Well, thank you very much. My disclosures can be found on the website and in the program. So really, we've been walking along this meniscus root journey in relatively recent years. Since 2008, we first learned of its existence. We then learned how to recognize and diagnose it in our patients. We understood the natural history. We've had an explosion of technique innovation. And now we really have the questions of why, when, and we'll try to cover how over the next eight minutes. So here's our patient, a 53-year-old male, presents with pain and acute pop. You can see a well-aligned knee. He's got a reasonable medial joint space remaining. The MRI clearly shows a medial meniscus root tear with a go sign. You can see truncation and extrusion of the meniscus. And overall, this cartilage looks pretty good. So how are we going to treat it? Well, we should be treating these with repair. This is our matched cohort study looking at repair versus non-operative management versus partial meniscectomy. We found that repairs overall did better in terms of less progression of arthritis and less arthroplasty. When should we repair them? Well, you better go early if you get to these within the first three months. Professor Kim has shown better clinical outcomes, less extrusion, and less progression of arthritis. So don't wait six months for non-operative management. You really have to diagnose these. This is a lateral-sided root tear that was read as normal on the MRI in a younger knee, anything but normal at the time of arthroscopy. We've shown that the medial side, you should make a preoperative diagnosis, but the lateral side remains elusive, really hard to visualize completely, especially in cases of revision ACLs. So you have to be prepared. On the medial side, I would highly recommend to do MCL lengthening. In addition, we also consider reverse notchplasty in some cases. Every case, I perform a medial tibial spine resection to allow visualization and biology. It also helps your guide to sit a little bit better, and I remove the PCL synovium. This case on the left, certainly we can do the diagnostic part of the scope, but that would not be a very fun time in the operating room. The image on the right is after we do the MCL lengthening. We remove the PCL synovium. We've taken down the medial tibial spine, and that's a much more enjoyable situation to work on that root. We then check the mobility. Again, the goal is to restore anatomy and hoop stress to the meniscus. On the medial side, sometimes we'll see some posterior medial scarring. As Dr. LaPrade has taught us, occasionally we need to do a little bit of a release here to get rid of some of that plastic deformation and chronic tissue. Remember your anatomy. Our goal is to restore the anatomy so we can have the normal function of the meniscus. We must hit the target. You really have to recreate the root origin. If we're five millimeters off, as Dr. LaPrade has taught us, we will not restore contact areas or contact pressures. How do you get there? I would really encourage you to use a specific root guide. Many companies have different guides. You have to use what works and is most comfortable in your own hands. Here's the example of the medial repair using a trans-tibial guide. This is an example of a lateral repair. Notice we're off of the articular cartilage. If you're making your socket on articular cartilage, you are not restoring the anatomy of the posterior horn. Really know your guide. If you look at the cross section of the tibia, avoid the neurovascular structures, of course, but it's going to make a difference whether you put your guide here or here. Guides don't tend to miss. It's more human error, so really understand where you're placing your guide. Is it a hook over the back guide, a point-to-point guide? You've got to be comfortable. Pat Smith, you've heard from. We looked and collaborated together on different suture configurations. We found that the cinch stitch was the easiest to pass, just one pass. It had less cyclic displacement compared to more complex patterns. I think if you have reasonable, healthy meniscus tissue, this is a very efficient way to place your sutures and overall very simple in terms of only one perforation of the meniscus. However, we do see a lot of degenerative tissue, so we have been adding ripstop sutures. This is a meniscal-based suture. I just passed two passes, essentially, using the self-retrieving device with 2-0 suture. Now I have a backstop where my cinch sutures won't tear through the meniscal tissue. So here you can see excellent footprint compression just with one ripstop and then a couple of cinch sutures. Looking at our final repair, again, we strive to restore Mother Nature and the anatomy. When we look at our clinical results, it's a multi-center prospective study performed with Pat Smith. And overall, we found excellent clinical results, almost a 30-point improvement in IKDC. Your MCID is 10 points, almost three times minimally clinically important difference. When we looked at structural outcomes, you can have confidence that these do heal, 98% healing in our study. However, we found that extrusion actually increased from baseline to six months post-operatively. So you might be asking yourself, does extrusion matter to clinical outcome? When we drilled down to our individual patients, we found that yes, it does matter. Patients that had less than four millimeters of extrusion did better, and it mattered more than cartilage status, age, BMI, and sex, as well as alignment. Professor Kim has also confirmed this in his work, showing a higher failure rate with more extrusion. So we introduced arthroscopic centralization as a technique to really overcome the extrusion and centralize the meniscus. Brief technical points, we place a very high medial portal that allows access to the posterior tibial plateau. In this case, you can see the meniscus is completely extruded, so we will release the meniscal tibial or coronary ligaments. Again, we really want to restore tension in that meniscus and re-centralize it. Once we've done this, we place our anchors. We'll typically use two anchors. We'll work in the posterior part of the knee, and then the anterior part of the knee second. And then it becomes an exercise in suture passage. We use the same self-retrieving device that we've placed the root sutures. Here the goal is just to really place either a horizontal mattress or kind of an oblique mattress suture. We want to place one throw at the periphery of the capsule and then one in the peripheral meniscus. Once we've done this, we can then tension the centralization anchor. So the nice part about doing this arthroscopically is we can directly visualize and see how we're affecting the position of the meniscus. When you look at this meniscus before, peripheral edge of the meniscus is completely off the plateau, and after you can see improvement. We've now changed our final tensioning sequence. So we'll tension the root. Here you can see we've passed both of our sutures from our knotless anchors. We'll then sequentially tension these to get the maximum amount of centralization. Again, two to three millimeters here will make all the difference in the world in terms of condor protection and clinical outcomes. So it's really important to work for that correction. And here you can see three points of fixation and our final knotless construct to repair the root as well as restore the extrusion part of the meniscus. So in conclusion, I would say it's important to recognize and treat root tears early. If the cartilage is overall good, then clearly the clinical data supports that repair is your best option. The goal is to restore the anatomy. I would encourage you to use a guide to restore the root footprint. Root stop sutures and degenerative tissue are becoming more common. I think we can have excellent clinical outcomes in the right patient. And finally, centralization is becoming more common to address our extruded menisci. Thank you very much.

meniscus root tears

treatment options

early diagnosis

surgical techniques

suturing techniques