Sequential Workflow for Integrated Biological Repair in Combined Four-Graft Knee Reconstruction

To describe a structured technical-conceptual workflow for comprehensive biological knee reconstruction, focusing on the coordinated integration of four independent allografts - femoral osteochondral, tibial osteochondral, meniscal, and anterior cruciate ligament (ACL) - performed in a single operative setting.

Multicompartmental failure involving bipolar osteochondral defects, meniscal deficiency, and ligamentous instability represents one of the most challenging scenarios in joint preservation surgery. Although individual reconstructive techniques are well documented, current literature lacks a widely accepted consensus regarding their simultaneous execution. In this context, three-dimensional preoperative planning and structured sequencing logic are critical for preventing tunnel convergence and preserving the biological viability of the grafts. Methodological Framework Description: A structured reconstructive strategy is proposed to optimize surgical exposure and avoid spatial conflicts and graft interference. The workflow begins with a systematic arthroscopic mapping followed by a wide arthrotomy, adhering to a "surface restoration-to-stabilization" logic, consisting of: (1) customized femoral osteochondral shell allograft transplantation; (2) tibial osteochondral transplantation using a cylindrical plug technique; (3) medial meniscal allograft transplantation with dovetail bone fixation; and (4) anatomic ACL reconstruction using a soft tissue tendon allograft. This specific sequencing allows stabilizing elements to be adapted to the already restored articular anatomy, minimizing tunnel convergence and protecting soft-tissue grafts from aggressive osseous surgical maneuvers.

This technical-conceptual work provides a structured roadmap to support surgical decision-making in highly complex reconstructive cases. By systematizing operative sequencing and the management of technical interferences, the proposed workflow enables a reproducible biological reconstruction strategy aimed at restoring articular homeostasis in young and active patients within a single surgical procedure.