Concomitant Arthroscopic Meniscal Allograft Transplantation and Anterior Cruciate Ligament Reconstruction  Bryan M. Saltzman, M.D., Justin W. Griffin, M.D., Nathan Wetters, M.D., Maximilian A. Meyer, B.S., Brian J. Cole, M.D., M.B.A., Adam B. Yanke, M.D.  Arthroscopy Techniques  Volume 5, Issue 5, Pages e1161-e1171 (October 2016) DOI: 10.1016/j.eats.2016.07.002 Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 1 Suggested preoperative radiographic imaging studies, including (A) extension anteroposterior (AP), (B) flexion posteroanterior (PA), and (C) mechanical alignment films. Old anterior cruciate ligament reconstruction (ACLR) hardware is shown in A. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 2 Arthroscopic image of the left knee viewed from the anterolateral portal at the back wall of the lateral femoral condyle after notchplasty was performed to allow for improved visualization. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 3 Arthroscopic images of the left knee viewed from the anterolateral portal at the back wall of the lateral femoral condyle after placement of the femoral tunnel guide pin through the anteromedial portal (A) and, subsequently, reaming over the guide pin with an appropriate sized reamer depending on graft size (B). Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 4 Arthroscopic image of the left knee viewed from the anteromedial portal up the femoral tunnel. The femoral tunnel for the anterior cruciate ligament (ACL) is created in the anatomic position with an appropriate sized reamer depending on graft size, with care taken to avoid posterior wall compromise. (Transp, transplant.) Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 5 Arthroscopic images of the left knee viewed from the anterolateral portal showing how the remaining medial meniscus is debrided (A) to a subtotal meniscectomy (B) (bleeding peripheral rim of tissue of 1-2 mm), with care taken to maintain the anterior and posterior horns of the native tissue, which will serve as landmarks for meniscal slot preparation. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 6 Arthroscopic image of the left knee viewed from the anterolateral portal showing use of an 18-gauge spinal needle for localization of the position for the arthrotomy to be in line with the horns of the meniscus. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 7 Arthroscopic image of the left knee viewed from the anterolateral portal showing the initial slot being made with the 4.5-mm burr at the site for medial meniscal allograft transplantation with instrumentation being introduced into the knee through the created arthrotomy. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 8 Arthroscopic image of the left knee viewed from the anterolateral portal showing the over-reaming of the guide pin with a 7-mm reamer at the site of meniscal slot preparation. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 9 (A-C) Arthroscopic images of the left knee viewed from the anterolateral portal showing how once the meniscal slot is reamed, it is then completed using a box cutter introduced through the created arthrotomy. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 10 Intraoperative photograph of the left knee looking at the posteromedial aspect of the knee. This image shows the placement of the Henning retractor through the posteromedial incision and capsulotomy to allow for easy needle passage during final meniscal allograft transplantation fixation. In addition, the surgeon has the arthroscope in the anterolateral viewing portal, with the tibial slot instrumentation through the anteromedial arthrotomy. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 11 Intraoperative photographs showing the preparation of the Achilles allograft on the back operating room table with whipstitching being performed with Ethibond suture. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 12 Intraoperative photographs showing the preparation of the meniscal allograft on the back operating room table by creating a 7-mm bone slot with a 1-cm height. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 13 Intraoperative photograph of the patient's left knee looking at the posteromedial aspect of the knee joint showing placement of the cruciate aiming device and tibial guide pin for the anterior cruciate ligament tibial tunnel with substantial oblique positioning so as not to affect the bone plug or slot placement of the meniscal allograft transplantation. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 14 Arthroscopic image of the left knee viewing from the anterolateral portal showing the cruciate aiming device and entry of the tibial guide pin into the joint at the native tibial footprint of the anterior cruciate ligament. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 15 Arthroscopic image of the left knee viewing from the anterolateral portal as the bone plug on the anterior cruciate ligament (ACL) allograft is being passed through the tibial tunnel toward the femoral tunnel position, being assisted in its orientation by a hemostat introduced through the anteromedial portal. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 16 Arthroscopic image of the left knee viewing from the anterolateral portal as the bone plug on the anterior cruciate ligament allograft is fixed within the femoral tunnel for an interference fit with a 7 × 20–mm metallic interference screw. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 17 Arthroscopic image of the left knee viewing from the anterolateral portal after the meniscal allograft has been introduced through the anteromedial arthrotomy. The meniscus in this image is flipped within the center of the joint and will be reduced within the medial joint space as the bone plug is seated within the slot. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 18 Arthroscopic image of the left knee viewing from the anterolateral portal showing the senior author's current preferred technique for bone block fixation within the tibia, using a SwiveLock screw at the slot-graft interface for an interference fit to guide in the graft. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions

Fig 19 (A-E) Arthroscopic images of the left knee viewing from the anteromedial portal showing the inside-out technique being used to place multiple vertical mattress sutures through the meniscal allograft to maintain position. Arthroscopy Techniques 2016 5, e1161-e1171DOI: (10.1016/j.eats.2016.07.002) Copyright © 2016 Arthroscopy Association of North America Terms and Conditions