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DVD-1077 | A | Dovetail Technique for Lateral Meniscal Allograft Transplantation

Thomas R. Carter

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Dovetail Technique for Lateral Meniscal Allograft Transplantation

The dovetail technique enables you to visualize the entire preparation of the bone, but at the same time, by having a dovetail orientation, it maintains the bone within the trough. The very first thing that's vitally important is proper position of your portals. You have to make the portal opposite that of the side of the meniscus first. You have as close to the patellar tendon, if not coming through the patellar tendon, so that that way you can see the posterior horn of the meniscus. Once that's been achieved, the contralateral side, you make sure that the posterior horn of the meniscus is directly aligned with your portal. After you've completed your portal site, the next step is to debris the remaining meniscus that is present. You have to make sure that there's excellent vascularity, otherwise you don't have a tissue to which the meniscus will heal subsequent to this. You go ahead and prepare the knee for accepting of the bone for the dovetail technique. You make certain that there's adequate space between the intercondylar notch and that of the horn attachment. So that way you're certain that the graph will fit to make sure that the graph fits easy and does not make the reduction difficult. The next step is the confirmation of communication from the anterior horn to posterior. So you can see that's straight on as we'd like. So if there's any question in regard to the height of this accommodating, you can take off a little portion of the tibial spine. So if you are going to do this completely through the arthroscope, you can use the Pin. Or you can put this in directly coming straight along the pin, or by looking through the arthroscope to see exactly where the blade is inserted. And this is a point that I will typically do it dry. You then can insert the osteotomy. Follow that by looking outside the knee. You can see the orientation from a sagittal plane. The marking tells you the height. The tibial slope is approximately ten degrees. If you come flat when you insert this, you can see that it's going to skive upward, and then you're not going to have the proper height for the insertion of the graft. So by doing it through the scope, you can see that the height is parallel to the articular cartilage. And by looking outside you can see can see that the angles ten degrees approximately, and by making certain that it does not rotate that way, you'll make sure when it goes in, it also is now 90 degrees to the articular cartilage. And typically you want to stop just a few millimeters away from the back wall. Your arthrotomy made the tourniquet up. You now take the guide off the osteotomy and just do it gently, even though it's embedded within the tibia. It should stay secure. This slides over the osteotomy and makes sure this fits flush with the tibia. After having this completed, you will use the first drill, which basically just takes off the top of the remaining bone so that you can see exactly where your tunnel is going to be and stop just short the posterior horn. You remove the initial guide for insertion of the drill. You then put the second one, which is below the level of the first, for depth preparation of the dovetail. The second one is an eight millimeter drill. It's two millimeters greater and obviously of lower depth when using the rasp where the final sizes, you need to make certain that your proper one one is on the right and one is on the left. Flat side is the one that follows the osteotomy. So when you turn these to insert them, make sure the flat side goes near the intercondylar notch. One can use inside out suturing technique, which is what I prefer to do. Other people use outside in, but as I frequently say, one needs to make the meniscus fit the knee, not vice versa. The next step is to go ahead and prepare the graft and do so on the back table. Here's the graft. The meniscus. When you first start, I'd recommend just gently, basically kind of roughing the edges from which to have the clot heal. So on the very first things that you do is to identify the posterior horn. And sometimes soft tissue will make it appear as if the horn is further back than it truly is. The horn is here, so you can make a cut first to mark the posterior horn in the same for the anterior horn, cut initially perpendicular to Perpendicular to the horn attachment. It makes it much easier to prepare the graph, so it is a true dovetail. Typically you do not have to make any adjustments in regards to the cuts. Cuts on the inner border. Since it already is perpendicular to the horns, the sizer actually is a dovetail. As you can see, you have perpendicular and a blank so that there is a little more than two millimeters difference between the top and the bottom, which helps the graph fit snugly within its trough. Go ahead and use this as a template for the marking of where you wish to cut the narrow portion on top. The greater portion on the bottom 90 degrees will be near the intercondylar notch, the greater will be at the bottom, the narrow at the top. And that gives you as a fairly good reference point for how you would like your graph to be prepared. So by using that template, you have a very good reference point for how to place the meniscus. It's obviously upside down. You make sure this is snug so it does not rotate. The nice thing about this system is we have three cutting devices and they're numbered. So you have cutting jig number one. And that is to make certain that your cut is exactly perpendicular to the meniscus. So if you do this properly, it should go straight up and down with the line in which you prepared. So one is more of a confirmation than anything. Cutting guide number two to cut the meniscus at the proper height for the dovetail. So this is exactly the same height as the height you wish to have the meniscus. Now it's important that you put this on proper orientation. If you come across this angle, you're not going to have it in the proper. It should be opposite from where you're perpendicular placement is. So the smooth edge of the bone, you put this on the same side. It's cut such that it's deeper on the bottom and narrower on the top. And once again I prefer to use a longer saw blade so that it goes all the way through and follows that all the way down. Obviously, you wish to keep the meniscus out of the way. You can either use a grasper or your hand. Once it's finished, you'll go ahead and place a reduction suture through the posterior horn of the meniscus and placing it in the knee with once again this being done through the arthrotomy, one can use inside out suturing technique, which is what I prefer to do. Other people use outside in, but as I frequently say, one needs to make the meniscus fit the knee, not vice versa. And by have direct visualization of where the meniscus should go, the inside out technique is a little easier to confirm this position. So here's the reduction. Here's all the way back. You can see it's all the way back here. The horns all the way back to the back wall. So here's our meniscus right here. That looks great. After I have two sutures placed in the posterior and medial side for exact position of the meniscus. Then under direct visualization, I'll repair the anterior horn using probably 2 or 3 sutures. Because there's such an excellent vascularity, I'll probably only use about a total of 6 to 8 sutures, and I've not had any problems whatsoever in healing because of the vascularity of the meniscal capsular rim, the arthrotomy is closed and then completion of the meniscus performed.

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