Meniscal Transplantation

This is a distressing complication - early meniscal allograft extrusion at 4 months suggesting graft failure despite apparently ideal patient selection and surgical technique. I need to approach this consultation with empathy, honesty, and a systematic plan. First, I would acknowledge the patient's frustration and validate that this is an unexpected outcome given that she was an ideal candidate and followed the protocol perfectly. I would explain that meniscal allograft transplantation has a 70-80% success rate at 10 years, meaning 20-30% of grafts fail even in ideal circumstances - unfortunately, she appears to be in that group despite everything being done correctly. Graft extrusion (radial subluxation beyond the tibial margin) is a recognized failure pattern, occurring in 15-20% of MAT cases, and is a poor prognostic sign associated with return of symptoms and accelerated arthritis. I need to determine why this occurred and what can be done. Step 1 is to systematically review potential causes of early extrusion: (1) Sizing error - though operative note states within 5%, I would re-measure the graft dimensions from the pre-operative scans and compare to her native meniscus to absolutely confirm - even 1-2mm oversizing can cause extrusion; (2) Technique issues - was the graft seated properly at the time? Was there any peripheral detachment? I would review the operative photos/video; (3) Missed malalignment - though pre-operative films showed normal alignment, I would repeat full-length standing films now to confirm mechanical axis is still neutral (sometimes subtle varus was missed or has progressed); (4) Root fixation failure - though MRI shows bone bridge healed, was the initial position anatomic? Non-anatomic root position (too anterior or posterior) can cause extrusion; (5) Peripheral detachment - sutures to capsule may have pulled through or failed, allowing radial extrusion; (6) Biological failure - graft may have failed to integrate/heal to the peripheral capsule, or patient's biology may not support graft incorporation (this is idiopathic in 10-15% of cases). Having explained these possibilities, I would outline management options: (1) Observation with conservative management - accept that the graft has failed and manage symptomatically with activity modification, physiotherapy, analgesia, possible corticosteroid injection; acknowledge that she is back to post-meniscectomy state; this may delay but not prevent eventual arthritis and possible future arthroplasty; (2) Revision MAT - technically possible but has significantly worse outcomes than primary MAT (only 40-50% success vs 70-80% primary); requires removing failed graft, re-preparing meniscal bed (which may be scarred), obtaining new size-matched allograft, and repeating surgery; only reasonable if a clear correctable cause is identified (e.g., definite sizing error, or missed malalignment now corrected with HTO); high risk of repeat failure; (3) Arthroscopic graft debridement/partial meniscectomy - if graft is partially extruded but portions remain functional, could arthroscopically debride degenerated portions and leave viable tissue; temporizing measure, not curative; (4) Acceptance and plan for future arthroplasty when symptoms warrant - at 38 years old, she has time before arthroplasty becomes necessary; may get 5-10 years with conservative management before considering TKR. I would recommend repeating full-length alignment films to absolutely exclude subtle malalignment, and reviewing all pre-operative imaging and operative details to identify any correctable technical factor. If no clear cause identified and alignment confirmed neutral, this likely represents biological failure (poor graft incorporation, peripheral detachment due to poor healing) which is a known risk that occurred despite optimal surgery. In this scenario, I would favor conservative management initially - accept the graft has failed, manage symptoms, and defer decision on revision MAT vs future arthroplasty until symptoms dictate. Revision MAT at 4 months is premature and unlikely to succeed without identifying correctable cause. I would provide regular follow-up, symptom management, and counsel that she will likely need some form of intervention in future (revision MAT vs arthroplasty) but timing depends on symptom severity. This is a difficult conversation but honesty, empathy, and systematic approach are critical to maintaining patient trust despite poor outcome.