The patient is a 41-year-old male. Coronal view imaging revealed loss of the lateral meniscus, thinning of articular cartilage, and cystic change with bone edema in the proximal lateral tibia. We present a combined technique for lateral meniscus transplantation, articular cartilage paste grafting, and bone grafting of the proximal tibial lesion.

At arthroscopy, the lateral compartment showed meniscus loss, exposed tibial bone, and femoral condyle damage. The residual meniscus was shaved, and a backbiter used on the anterior horn created a stable rim for transplantation, reducing allograft subluxation risk. A spinal needle was used for alignment, and a trough was prepared with a shaver and burr. A custom meniscus transplant guide is placed with a spoon on it to catch the penetrating drill pin. Drilling is conducted from anteromedial to posterolateral, away from the neurovascular bundle. A 4.5 mm drill is used to drill over the drill pin with curette placed over, a stitch is passed up the suture passer, and sutures retrieved through the anterior portal.

Posterior quarter fixation was performed similarly, recreating meniscotibial ligament attachments. Ideally, the graft is provided with intact meniscotibial ligaments, but this varies among tissue banks. We emphasize requesting that tissue banks not skeletonize the meniscus, as our goal is to recreate these meniscotibial ligaments in surgery. An oscillating saw is used to create a bone block and an osteotome is used to separate the donated meniscus. The bone is 5mmx5mm, preserving the meniscal tibial ligaments. Sutures were placed first in the posterior quarter, with an umbilical tape safety stitch for any necessary repositioning. Preserving the bone block maintains circumferential hoop stresses of the meniscus tissue. Suture tapes were used for smooth fixation on meniscus and bone block.

The bottom surface of the meniscus was marked, pulled into place through a widened anterior portal, and seated into the trough (first the posterior corner, then the bone block), ensuring stitches are not twisted. Sutures were tied at the anterior tibia and backed with a suture anchor. All efforts are made to make the new meniscus abut squarely against the meniscal rim. Sutures are passed on both the inferior and superior surfaces through small portals on the side of the knee. We no longer make large posteromedial or posterolateral incisions for meniscal transplantation, as these incisions risk neurovascular irritation more than a small portal that is subsequently widened with a curved clamp. Generally, the meniscus is sewn into place from posterior to anterior, attaching bone block sutures first to ensure the block is in the trough, and then tying peripheral sutures. Two to three small portals typically suffice for suture fixation.

The anterior horn may require a suture anchor. An all-inside device ensures the posterior horn is approximated to the capsule, placed carefully away from the neurovascular bundle. Final inspection confirmed a stable graft.

Articular cartilage paste grafting was then performed. A core of cartilage and cancellous bone was harvested with a 5–8 mm trephine, processed in a Cartilator to preserve cell viability, and impacted into the prepared tibial defect through a cannula. Prior to impaction, the underlying area has been bloodied through morselization with an awl; clot formation secures the paste into the defect. This technique, used for over 35 years in hundreds of patients, allows biologic cartilage restoration.

For the tibial cyst, a trephine created a canal into the lesion, which was then bone grafted using autograft from the proximal tibia.

We believe biologic knee reconstruction- restoring meniscus, cartilage, and bone, and reconstructing ligaments as needed- offers patients the potential to return to sports with a biologically functional knee rather than an artificial replacement.