and Cassandra will probably be coming from that as well, but I'm Matt Tao from University of Nebraska Medical Center, so helping to moderate this session, and Jocelyn Wittstein will be doing some cases with me at the end, but I'd like to introduce our first speaker. It's a meniscus-focused session, Adnan Saithna presenting on behalf of the Santee Group on ramp lesion failure and risk factors to predict that. Good afternoon, everyone, and welcome to the session. Thanks to Matt and the faculty for allowing me the opportunity to share our work. I'm talking about risk factors and failure rates of meniscus ramp lesions performed at the time of ACL reconstruction. I'd like to acknowledge my co-authors, especially Bertrand Sonnery-Cote, who's the senior surgeon involved in this study. Do we have a laser? Ah, here it is. All right, so the background to this study is basically that ramp lesions have been recognized for a long time, since the 1980s. They're essentially longitudinal tears of the meniscal capsular junction of the posterior horn of the medial meniscus. Their importance lies in the following key characteristics. Firstly, they're associated with a high rate of misdiagnoses. That's both on MRI and arthroscopically, and that's because they lie within a blind spot in the knee behind the femoral condyle. So what that means is that if you do a standard anterior portal viewing of the anterior compartment only, you're probably gonna miss these lesions. They're not typically visible from standard arthroscopic techniques. You have to do transnotch or post-remedial compartment viewing to be able to visualize them and avoid misdiagnoses. The other important point is that they occur frequently in ACL-injured knees, nine to 40%. It's a broad range. In the largest published series on this, also from the SONTI study group, in 3,000 patients, we found that the incidence was 25%. So they're common. They're also associated with abnormal knee kinematics. What that means is that if you have a ramp lesion, you do an ACL reconstruction, but you ignore the ramp lesion, there's high rates of persistent anterior, internal, and external rotational instability, or laxity, rather, I should say. The healing rate of ramp lesions after repair through a post-remedial portal is superior to that of ramp lesions left in situ without a repair. And also, if we fail to repair a ramp lesion, we know that there's increased rates of secondary meniscectomy and also tear progression, resulting in more serious types of meniscus tear, including bucket-handle lesions at long-term follow-up. So these key characteristics all support a systematic approach to transnotch visualization of the post-remedial compartment in every knee that's undergoing an ACL reconstruction. However, the failure rates associated with doing this and repairing these identified lesions is not defined, and that's really the purpose of this study. So specifically, the aim was to determine the failure rate defined by secondary meniscectomy of the posterior horn of the medial meniscus. So failure rates of ramp repair performed during, or rather performed using a post-remedial portal suture hook at the time of ACL reconstruction and also to identify risk factors for failure. Based on the existing literature, we hypothesize that patients who underwent a ACL reconstruction combined with a lateral extra-articular procedure would experience significantly lower rates of secondary meniscectomy compared to those undergoing isolated reconstruction. So this is a retrospective analysis of prospectively collected database data. All patients undergoing ramp repair at the time of ACL reconstruction performed by Bertrand Sonnery Cote between 2013 and 2020 with a minimum follow-up of two years were included. The only exclusion criteria were non-eligible meniscal tear types, so that means all other types of medial meniscus tear or lateral meniscus tear were included, but the medial meniscus were not if there are other patterns other than ramp. Concomitant multiligament reconstruction or osteotomy surgery. Patients either underwent isolated ACL reconstruction with hamstring tendons or BTB or combined reconstructions, and those combinations were with ALL reconstruction or a modified LMAIR. This is the surgical technique, and we're going to just follow through those figures starting in the top left. You can see post-remedial compartment trans-notch viewing there, and you can see a ramp lesion, a needle localization of a post-remedial portal, and then a shaver is put in there to freshen up those tear edges, and then we use a suture hook to pass sutures through that post-remedial capsule, meniscotibial ligament, and the posterior horn of the meniscus. Rehabilitation was unchanged from standard ACL rehabilitation regardless of which surgical technique patients underwent. The only change was that we restricted patient's range of motion zero to 90 degrees for six weeks, but that was brace-free, full weight-bearing, and immediate progressive range of motion within the restricted range. Return to sports was six months with pivoting non-contact sports and eight to nine months for pivoting contact sports. We determined the study endpoint to be March 2023, and final follow-up for each patient was defined by the last patient follow-up recorded in our prospective database. Secondary meniscectomy rates were defined. Again, that's specifically of the posterior horn of the medial meniscus, and we evaluated the findings with standard statistical tests including time-to-event data to account for the fact that this is a retrospective study, so that was Kaplan, Meyer, and Cox proportional hazard. Our main findings are that we had 1,000 patients included with a mean follow-up of 72 months. I'm going to skip over most of this slide, but the key finding here is that our failure rate or the secondary medial meniscectomy rate was 7.7%. The mean time between ramp repair and medial meniscectomy was 31 months, range three to 107 months, and in multivariate analysis, we analyzed all of these factors, age, gender, pre-injury tegna level, delay between injury and surgery, and whether they had an extra articular tenodesis or not, and the latter was the only factor that was significant. So, overall, we demonstrated that with this approach, which is basically, for those who missed it at the beginning, a standardized approach of a systematic trans-notch post-traumatic compartment evaluation in every single patient undergoing ACL reconstruction and repair of ramp lesions, we found that the overall failure rate was only 7.7%, so that's exceptionally low. Patients who underwent an isolated ACL reconstruction were at twofold increased risk compared to combined reconstructions. However, we'd caution that these findings cannot be extrapolated to other types of ramp repair, for example, an all-inside device, and the reason for this is illustrated in the slides at the bottom. With a hook, we can capture that menisciotibial ligament, highlighted in orange. I don't know if I can show it down there, but anyway, with an all-inside device, it's very difficult to capture that menisciotibial ligament. So, in conclusion, the secondary meniscectomy rate after ramp repair is very low. Patients who underwent isolated ACL reconstruction were at higher risk of secondary meniscectomy, and we didn't identify any additional risk factors. Thank you. All right, perfect. Thank you very much. We'll pull the next one up. This is Paul Allegra from Oklahoma City talking about a biomechanical analysis of medial root repairs and loading those at an early time point. Good afternoon, everyone. It's an honor to be here. I'm going to talk to you about my fellowship study looking at the integrity of meniscal repair subjected to physiologic cyclic loading. Sorry. I have nothing to disclose. A little bit about medial meniscus tears. They are very important. They comprise about 20% of all meniscal tears, and they're important because they lead to increased joint forces and rapid progression of osteoarthritis. It's comparable to a total meniscectomy. So, the goal of repair is prompt diagnosis and to restore joint contact pressures, kinematics, and delay the development of osteoarthritis. There is no universal post-operative protocol, and while some authors advocate for immediate partial or toe-touch weight-bearing, others, including LeProd, have advocated for up to six weeks of non-weight-bearing with a graduated return to full weight-bearing thereafter. So, our study, we sought to evaluate the integrity of medial meniscus repairs performed using an inlay transosseous single-tunnel technique, and to provide objective data so that we could give better recommendations regarding post-operative weight-bearing protocols. This is our study design. We took 15 fresh frozen cadaveric knees, and of those 15, 11 met criteria. We then placed metallic tracers within the medial tibial spine and the mid-substance of the posterior horn of the medial meniscus and used a mini C-arm in order to document the relationship between those metallic tracers. Each specimen underwent loading in four unique conditions. The intact meniscus was loaded, the cut meniscus was loaded, and then the repaired meniscus was loaded. Additionally, the repaired meniscus was cycled and then loaded. All of these knees then underwent subsequent fluoroscopic evaluation. Here is a photo showing our study design. All of the knee specimens underwent a repeat knee arthroscopy after testing in order to assess the clinical integrity of those root repairs. And post hoc measurements were performed between these tracers in order to calculate meniscal displacement in the different scenarios. The root was prepared by detaching the root from the insertion site, the posterior root, using arthroscopic scissors. And the repair technique was performed using the following. Here is a photo showing our repair technique. And you can see the meniscus root repair being prepared and eventually being performed in four and probed. And you can see that there's desirable tension and restoration of the footprint. So when we look at our results, we compared the ratio of the difference between these markers with the entire medial tibial plateau for each image. And we compared the intact and loaded states to the cut loaded, repaired loaded, and repaired loaded cycle states. And what we found is what you may expect for the intact loaded and cut loaded, that there was a statistically significant difference, meaning when you load a cut meniscus, it displaces. But what we didn't expect was that when we load a repaired meniscus, it also displaces. And when we loaded the repaired and cycled meniscus, it also displaced. The repaired and cut states closely mimic each other. So all 11 specimens demonstrated intact repairs. We thought, okay, maybe the sutures would pull out, maybe the sutures tore. Well, when we went back inside the knees, every construct was intact with stable probing. So there were no catastrophic failures, but there was an unacceptable amount of displacement. You may ask, was the root repaired in a non-anatomic position? But the root was repaired with direct release from its anatomic position and then repair in the same location. We also performed measurements, comparing the intact and unloaded meniscal roots to the repaired and unloaded meniscal roots, which indicated that the repair was nearly anatomic without load, but displaced whenever load was applied. So really what this tells us is that this technique does not withstand immediate simulated physiologic cyclic weight bearing. I wish I had better news. The repair construct allows for unacceptably high amounts of creep, resulting in meniscal displacement that rivals the cut state. And this research is really tracking with other research that's been published recently. There are new implants. Direct aperture fixation, I think, would perform better. The analogy I've used is comparing a bridge plate construct, which I think this mimics, to a compression plate construct where you're looking for primary healing in the trauma setting. I think these aperture implants will function like compression plates, and that's what the meniscus needs. So we recommend a period of non-weight bearing and restricted range of motion, like LEPROD, before initiating any weight bearing. Thank you very much. All right, just to remind the audience, if you do have any questions, please do put them in the app, and we'll try to address them at the end of our sessions. Next up, I'll ask Zachary Burnett to come up to talk about evaluation of outcomes at a mean of 2.75 years after repair of lateral meniscus oblique radial tears during ACL reconstruction. Thank you. All right, thanks for having me today. I'll be talking about some of the research we've done at Ohio State, looking at how comes after repair of lateral meniscus oblique radial tears during ACL reconstruction. My co-authors and my disclosures are listed on the website for the meeting. Lateral meniscus oblique radial tears, or L-morts, commonly occur in the setting of an acute ACL injury. Previous studies have shown us the incidence of L-morts in the setting of an acute ACL tear is approximately 12 to 15%. Additionally, biomechanical investigation done by Patrick Smith and his colleagues demonstrated L-morts result in increased anterior tibial laxity and pivot shift in the setting of an ACL tear. And this persists even after ACL reconstruction if the L-mort is left untreated. However, repair of the L-mort restores baseline stability of the knee in terms of this anterior tibial translation. So taken together, these results demonstrate the importance of L-mort repair to restore knee stability during an ACL reconstruction. Dr. Critch and his colleagues also recently described classification system for L-morts, including four different types of tears based on their severity and their distance from the posterior meniscal root attachment. Type 1 and 2 tears are partial and complete tears respectively and are less than 10 millimeters from the posterior root attachment. Conversely, type 3 and 4 tears are also partial or complete respectively, but are greater than 10 millimeters from that posterior meniscal root attachment. And in terms of overall incidence, type 3 and 4 tears are much more common, making up over 75% of L-morts. So given the biomechanical data that we just talked about, this study aimed to examine the clinical and functional outcomes following surgical repair of L-morts during ACL reconstruction. Outcomes included the need for subsequent knee procedures, meniscus repair failure, postoperative complications, and patient-reported outcomes. We identified patients at our institution who underwent meniscus repair from 2017 to 2019, specifically those that had an L-mort repair during an ACL reconstruction. We included those patients with type 3 and 4 tears, as these are typically repaired with an on-site technique, and also type 1 and 2 tears are much less common and also overlap significantly with root tears, are typically repaired in a similar trans-tibial fashion. So we were looking only at these tears a little further away from the meniscal root attachment. For repair, we utilized an on-site technique using an arthroscopic suture-passing device to span the tear and anatomically reduce the margins of the tear. We then evaluated postoperative patient-reported outcomes by collecting Q-scores, MARDS, and VAS. We were able to identify 25 patients during this time period who underwent an L-mort repair during an ACL reconstruction. Demographics of those patients are seen here. They tend to be young with an average age of 21 given they occurred with an acute ACL tear. Mean clinical follow-up for these patients was 33 months, and 28% of the patients did have bilateral meniscus injuries requiring repair at the time of their initial ACL reconstruction. In terms of postoperative complications, there were no reported failures of the L-mort repair during the follow-up period. Twenty-eight percent of the patients in our study did undergo secondary knee arthroscopy during the follow-up period. However, these were all done for indications other than their initial L-mort repair, including postoperative stiffness or re-injury to their ACL during the follow-up period. However, these repeat arthroscopies gave us an opportunity to evaluate the prior L-mort repair and evaluate its healing clinically. So during this secondary procedure, we noted that all of the L-morts that were repaired during the first surgery appeared healed. Patients were then contacted postoperatively to collect patient-reported outcomes at a mean of just under five years from their initial date of surgery. The mean Q score was just over 86 with the subscale seen here, marks of 7.1 and a VAS score of 2.1. So this study is one of the few studies so far examining clinical outcomes following L-mort repair. But similar to prior literature, we were able to show low failure rates with no reported failures in our study. These prior studies have utilized either a postoperative MRI or second look arthroscopies in order to evaluate healing after an L-mort repair, and they each showed greater than 90% healing of this L-mort. In conclusion, our study provides additional evidence that surgical repair of L-morts results in low failure rates, low complication rates, and favorable patient-reported outcomes up to almost five years postoperatively. Given the high rate of success of the L-mort repair and the previously published biomechanical data that we discussed showing the importance of L-mort repair following ACL reconstruction, we believe routine repair of these tears during ACL reconstruction can help to preserve the meniscus and reduce strain on the ACL graft. Thank you again, and these are my co-authors, and I appreciate the help completing this project. That was great. Thanks, Zach. I'll invite Aaron Critch from the Mayo Clinic up to talk about midterm outcomes following meniscal transplant. Good afternoon. Thank you for the opportunity. Certainly, we'd like to recognize my co-authors as well, and this is taking off on me. I apologize. Let's just back that up. Okay, so meniscus allograft transplant, as we know, has really been in use since the 1980s. We have a lot of data, mainly meta-analyses that have demonstrated improved outcomes at medium and long-term follow-up, and overall graft survival at about 10 years has been in the 60 to 80% range. However, current studies on transplants are limited by small sample size, heterogeneous patient populations, and what I would consider poorly-defined clinical endpoints. Therefore, the purpose of this study was to report clinical results, graft survivorship, and a strict definition of failure rate at a larger cohort of meniscus allograft transplant procedures, and then second to identify radiographic, surgical, and patient-specific risk factors for failure and secondary surgeries. We included all patients that underwent meniscus allograft transplantation with minimum two-year follow-up. They had to have been performed with bone plug. We excluded soft tissue fixation, as this was a minority of procedures, and those patients with less than two years follow-up. And really, these were all comers, so we accepted anyone who got a meniscus transplant, so all age, all arthritis grade, all concomitant procedures. So we tried to define failure strictly, so we used three different criteria. The first was anatomic failure. I think you can think of this as just re-tear of the meniscus allograft. We then looked at clinical failure. I would think of this as patients who were struggling that had a revision procedure, and then subjective failure as well. These were patients that were not doing so well, but did not elect to have further surgery. So we included 157 patients. You can see 93 men and 64 females. Average age, relatively young cohort of 25. Average follow-up of seven years, but up to 16 years of follow-up. Fairly equal distribution of both medial and lateral meniscus transplants. And then you can see about three-quarters of the group underwent concomitant procedures, osteochondral allografts, osteotomies, ligament reconstruction, and about a third had grade three or four changes in the affected compartment. So what we found overall was a 91% survivorship at the average of seven years. Again, up to 16 years of follow-up. So 9% of these knees experienced clinical failure. When we looked at subjective measures, these are baseline to post-operative scores. So both for IKDC and all domains of COUS, they had substantial improvement. And 81% of these knees had excellent outcomes. If you looked at anatomic failure, again, this is a graft tear. About 16% of knees at this follow-up experience anatomic failure. And then finally, subjective failure was approximately 8% of patients that reported a Leisholm score of less than 65. When we looked at predictors for failure, we did not see a difference of medial versus lateral-sided transplant. When we looked at cartilage, you're going to see a theme here. The cartilage did predict failure. So those with less cartilage damage, outer bridge grade zero to two, had a higher rate of success. Those with more substantial cartilage degeneration had a higher risk for failure over time. When you look at osteochondral allografts, that was another risk factor. So those treated with osteochondral allograft indicates they had more severity of cartilage disease. And just like grade three and four changes, they did worse over time. This is hard to see, but when you looked at both radiographic and clinical factors for failure, you'll see a theme of cartilage again. So those treated with osteochondral allograft, those with high grade, grade three and four lesions at the time of arthroscopy, and those with radiographic changes prior to surgery all did worse and had a higher risk for failure. So in the literature currently, there is a variable definition of success and failure following meniscus allograft transplantation. If we use the definition of survivorship, we had 91% at seven years, which compares favorably to other studies. I think there's more data emerging that shows advantage for bone fixation over soft tissue only. Preclinical biomechanical studies and meta-analysis is bearing this out. And then when we look at outcomes following meniscus transplant, we're really not surprised to see they're multifactorial. And a lot of factors are non-modifiable, including patient age and cartilage status. But in general, the earlier you can do the transplants, the better the outcomes will be. So in conclusion, in this study, meniscus allograft transplants showed good to excellent clinical results with 91% survivorship at seven years. A lower cartilage grade was associated with higher clinical and anatomic survival rates. And then finally, patients with concurrent osteocondroallograft transplantation are at higher risk for failure, but they still did benefit from the procedure, including those with grade three and four changes. Thank you. Fantastic. Thank you, Erin. That was great. Can I ask, I'm going to ask a quick question, and then I'm going to introduce Dr. Seil to come up to do his video. But so looking at your data, Erin, can you almost make an argument to move towards, if patients do better with ICRS grades one and two versus three and four, and then no KL changes, is this almost an argument to almost prophylactically treat patients with the meniscus allograft transplant? My question is, like, the patients do very, the ones who do very well, lower risk factors for, at survivorship for your allografts. Is there maybe some evidence pointing us towards more doing a prophylactic meniscus transplant if we do septal meniscus after being a young patient? Yeah, thank you. Yeah, prophylactic is hard. I think patients are truly completely asymptomatic. I don't think we're there yet. Certainly insurance companies would not approve it. But I think you have to follow these patients extremely closely and especially a young patient who has any signs or symptoms of meniscal deficiency. At first sign, I think clearly the best option is to transplant the meniscus. I think we have to also take into account that this will not be their last surgery. And I tell patients all that, that this is a bridge. We're trying to buy some time, give them some clinical benefit and protect their cartilage. But we don't have a perfect solution. But certainly I don't think we're at the prophylactic stage. But any early signs or symptoms, and they're a good candidate, you should go ahead and do it. All right. All right, next I will introduce Dr. Roman Seil coming from Luxembourg showing us how to repair a meniscus ramp lesion. Thank you, Cassandra. Hello, everybody. It's a great pleasure to be here. And thanks for the invitation. No? Doesn't want to come up? There we go. Yeah, perfect. Okay, thank you. So, meniscus ramp repair. You have heard extensive arguments previously by Adnan why you should do these ramp repairs. And you see a nice publication from the Lyon Group that it works best with, if you use suture hook repairs, actually. There are different ways of doing, different ways of getting to Rome. The most frequent one being the intercondylar portal, the Gilchrist portal. Then you could use the hypostromedial portal or transeptal portal, especially if you have very narrow, very tight knees. And you need to secure, of course, some of our time, decide on the approaches, identify the lesion, debride, reposition the tissue, and then do your repair, which is close to what you do in shoulder arthroscopy. The problem, if you go with the second best portal, which is the Gilchrist portal, is that you have blind zones. You cannot see around the corner. You go underneath the PCL, of course, but if you have a 30-degree scope, you cannot see around the corner. If you have a 70-degree scope, you see a little bit better. But the best is if you do a post-remedial portal to have the visualization. This has been described some years... many years ago by Professor Ahn from South Korea. And he did these two post-remedial approaches. And you see here on the picture on the right that the two approaches are pretty close together. And that can be annoying during surgery. That's why Cécile Toanen came up with a very nice cadaver study, which had a bigger distance between the two portals. And you see the viewing portal on the right and the working portal on the left. And that's what we applied. Now, if you put your scope posteriorly and you have a look at the ramp lesion, very often you are really surprised that it is much bigger than you would have anticipated through the Gilchrist portal, and that it is nicely covered with synovial tissue, as you see here. Now, and then what you can do, again, appreciate from posterior is, again, the medial lateral extension, the gapping of the meniscus in extension or inflection, as you see here in these two cases. You see if the ramp moves or not. And finally, you can get a glimpse of the capsular tension, which is very often really loose and not tense. This is then classically what we do. Here you see the video. You see here the viewing and the working portals. We operate at a 90-degree hanging knee. Then you get in with your... with your knife proximally to this synovial fold. It's very important in order to have no mismatch with your working portal. Then you bring in your switching stick. And then the... this... you can use it to palpate the ramp lesion, if there is one. And then you get a nice view from posterior. Actually, you can really see that this lesion extends from medial to lateral. And you do your working portal. This is pretty unusual if you start doing it. So, you need to train a little bit, ideally on cadavers. And then you get in with your instruments just to debride the lesion. And then you start, you see here again. If you bring the knee into extension, you see that there is a gapping. So, if you fix it from anterior, you can see that the lesions are lower and that they will not grasp the posterior tissue. Then you do your suture repairs. You would do, for instance, a bank cut repair in the shoulder. This is pretty similar. We use here in these cases a 90 degrees angle took and then do usually two to three of those repairs And that's that's and how it works at the beginning It's you have a steep learning curve But at the end you do that routinely pretty easily and you see here the capsule if you look from posterior after after the repair that sometimes it's it's really tense and Here, of course, you can do you can extend your indications. This wasn't an acute knee where we did then and Basically and double row repair where we fixed the meniscus t-bill ligament first you see it here we use we don't use a tourniquet and You see again We put two stitches on the meniscus t-bill ligament and then two stitches on the capsule Over it in order to have really an anatomic a nice anatomic reconstruction And Then we discover sometimes some new lesions and risk we discover regularly in usual lesions This was what we call the bipolar ramp lesion, which was at the meniscus But also at the capsule on the superior gastrocumulus attachment Sometimes you can go underneath the capsule can visualize the tendons underneath So this is pretty nice once you start working with this and you discover really nice and stuff But probably what is most more important than the technique that I showed you is to understand in which cases the ramp lesions to occur for that we did this study in order to Assess the magnitude of the whole tissue damage and we put MRI and atroscopy data together Retrospectively and we developed the score on that With a maximum of 12 points and here you see the distribution of the ACL injured knees and these were all acute ACL injuries Semi-acute injuries and we just divided this into three categories on the left You see this achilles for one to three and what we saw is that in the easy ones Actually, the most damage is on the lateral side and the more Tissue damage you get the more it moves to the medial side and in this achilles three category We had 80% of B meniscus lesions So both include involving the medial and lateral meniscus and the ramp lesions were mostly in this category so a ramp lesion is really a sign of severity of an ACL injury and that's basically the take-home message because You cannot compare this these two ends of the spectrum. This is really like comparing apples and pears So take-home messages anatomic reconstructions all the of all the inner structures is key identify all the meniscus injuries improve improve the repair techniques that's really mandatory and Then the double post remedial portal at least in our hands provides better view of the ramp and to repair is just something like an Modified bank at lesions if you want, so thank you for your attention Well, that was tremendous Cassandra and I were just saying we find these to be very difficult So not having audio on there eliminates the swearing and stomping of feet that typically occur in my cases So I like that visualization too. That was beautiful So Travis Decker from the United States Air Force is going to give us tips on repairing meniscal roots Thanks, dr. Toth dr. Dickens for putting on such a great program Just gonna hopefully share a couple tips and tricks I think I've learned more about how to fix a root from people in the room. And so it's just humble to be here and Hopefully walk away with a couple of simple things to make it a little bit easier And so This one All right so this is kind of my global technical perspective of how I'm looking at root tears as from a global perspective and First as we've briefly talked about is you have to find and identify that tear and how are we doing that? And then just kind of a revisit of the anatomy I think that oftentimes where we see that lifted off But if we're not going back and looking specifically where it's supposed to go is that are we actually identifying the tear? We'll go through my technical pearls of how I do this Then lastly just hearing from the research earlier We have to give these specific types of tears time to heal and we have to really counsel our patients on On some limited weight-bearing and some restrictions with when they're going to be able to return back to sport So first and foremost, we're starting with some imaging I think that we've been able to see that we can now identify this via ultrasound We see different signs that there might be a root tear what comes first. Dr Christian is group you continue to tease this out But identifying on all planes the MRI to have a high suspicion of a root tear I think is is key In addition, all of my patients are undergoing Alignment films is there had there been multiple biomechanical studies to show that root repair in the setting of asymmetric alignment It doesn't restore the tibia formal contact forces So this is going to be important specifically not only in the primary but even in revision settings and where these three mentors of mine were really key to tell me specifically about alignment and how key it is and Maximizing the outcomes for these folks in restorative procedures. Dr. LeProd and his group in 2015 came up with a tear Classification system for both medial lateral tears and then dr. Critch described this lateral lateral meniscus oblique radial tear to help really figure out exactly how you want to approach this when you're looking inside the knee and Then also with that the the 2015 Anatomy study by Dr. LeProd really found where these roots are And so if you take your probe and just go one centimeter posterior to that medial tibial eminence I found this to be the most reproducible for me to go and identify where that root is and then when you look at that Lateral meniscal root in a similar fashion. It's tucked up tighter under the ACL It's just one millimeter posterior to that lateral tibial eminence and four millimeters medial and so from there is how can we provide a repair that is reproducible and anatomic and With having a good plan knowing who it's in the OR with you to help And so this is General Patton and I think preparation going into the OR Taken too literally for the first one But it's it does pay off in the end if you have a good plan and then knowing what your tolerances are Going into the for the repair So I think everybody will agree that you first need to prepare that footprint That bleeding surface just with any surgery as if we're doing a rotator cuff repair Preparing that is going to optimize a healing surface Yeah by doing this this can be done with curettes. This can be done with reamers This can be done with in a variety fashion, but adequately preparing that healing bed For me I have slowly over time I've tried to take advantage of where the Circumferential fibers are of the meniscus coming in in setting of a unilateral tear and that within ACL tunnel for instance I like to drill from the contralateral face to pull in line with those fibers if you're drilling from that ipsilateral side, you're pulling 90 degrees from the angle of where the tear is and If your angle is too shallow that can undercut and anteriorly displace your meniscal repair I have had bilateral tears and doing this you can't be coming from the contralateral face because you'll cross your tunnels And so that does need to come from the ipsilateral face and dropping down the angle of the guide up to 70 degrees Out of Jorge Challa's paper showed that you're going to minimize the chance and risk of overlap Next One trick that I got out of the University of Utah. Dr. Burks showed that if you use a Drill bit instead of going in initially with the reamer I've always noticed that if you're off two to three millimeters And this is a game of millimeters in the setting of a root tear that if you're off by three millimeters That's functionally equivalent to that of not repairing it at all So this is the game of millimeters these drill bits can be more accurate as they're stiff and then if you get that of the same size or just slightly undersized of That of the reamer that you're using that allows for you just to introduce that by hand Next is determining whether or not you want to do a one versus two tunnel Biomechanical studies have shown no difference and for folks that have multiple hands drilling two tunnels can Can be beneficial and for me there's limited help in the OR So doing a single tunnel and trying to get an atomic right away has been the most reliable and then lastly How do we re-approximate or just oppose re-oppose the tissue and instead of diving it down? Diving it down. I know there are techniques where we describe of doing an inlay versus an onlay But I think one thing that is underappreciated in the setting of these meniscal root tears Specifically that of the medial meniscus root is that there oftentimes is tissue loss So if we're placing this back at the anatomic footprint We've lost tissue and you're bringing that back over to where it actually is supposed to go You're over tensioning the meniscus and likely increasing your risk of re-tear So just gently taking away Decorticating the bone and not drilling it too far back in order to avoid over tensioning of the meniscus And then lastly we talked about you need to give them time to heal you have to counsel your patients on the rehabilitation Specifically for root tears saw that paper about early weight-bearing and how they do displace with cyclic loading. So for me, this is a Rehab protocol that I got from dr La Prada with limited weight-bearing for six weeks and with limited range of motion for that five to six weeks But this really is a return to sport in five to six months And this isn't one of the ones that you're trying to rush back to sport So in conclusion, you first have to recognize the tear by doing this with preoperative imaging But also intraoperatively identifying the anatomic landmarks to where you can be more specific and clear about identifying those lastly do a repair that works for you in your hands and And then you have to be able to counsel your patients giving them time to heal Keeping them off of it for a while to optimize your outcomes All right, next up I'm gonna ask Nick Cullivoss from UCSF to come up and show us how to do meniscus radial tear repairs You Thank you to the organizers for this invitation, oh, yep, here we go. Okay, so No disclosures for this talk I'm going to talk about radial tears a specific type of tear about 10% of the tears we see they have a very specific identification and treatment plan for these because they are Traditionally difficult tears to repair and I think many of them weren't repaired I'd say over the last 10 years we've gotten better at repairing them we've gotten better at the indications for repairing them we've gotten better with the techniques and By and the addition of biologics. So now we're starting to see the results of these types of repairs actually improving In any sort of technique repair, I think on the medial side the addition of an MCL pie crusting or Controlled release or trepanation, whatever you want to call it has been a really significant improvement in the way We repair these we can really see them better We can really repair them better do less damage to the cartilage So in almost all of the medial side ones, I'm doing an MCL controlled release So The basic goal with these radial tears is to get two leaves to come together and I think for simple ones A simple surgery is probably fine, but I don't do this very much But I think if you have a simple tear you trim away the white white zone you then get compression sutures you can use the various oil inside devices including the suture capture devices get some compression across that tear and Essentially Repair it. So this is a patient of mine with a simple tear like this that the pieces come together It's a relatively acute tear and I think a few sutures across it will work But these sutures are in line with the circumferential suit Architecture of the meniscus and so there's a risk that these can pull out. So I think we've developed some more augmented techniques to help Really make this construct stronger I use this occasionally for those Tears that really I think can benefit from it Essentially wants you to breathe the tear you can see it gets bigger you put in a trans osseous tunnel here using your root guide equipment Suture shuttle and then you can use your self capture device to put one two or three as many sutures as you feel You need you can make these sutures mattress sutures. You can do two tunnels I just like a simple technique the trick there is to turn that upside down and get going from the top to the bottom And then that you will shuttle down into your tibial tunnel there and that gives you an augment suture or at least a suture that you can Use to help your repair once you have that you can then continue your repair with all inside devices or inside out however, you feel most comfortable and I use the that Augment to really tension the device while I put those sutures in your final contrast Construct is pretty rigid. So I don't typically use this on the lateral side because that's going to limit mobility But if it's way back near the root, I think a rigid construct like this is actually very effective I think we're moving now more to a Technique that's being developed over the last I'd say five five years or so Which is the rebar technique or hashtag technique? III do this on most of my radial tears now less less of the trans osseous repairs and this technique shown biomechanically to Have a superior construct better pull-out strength because essentially what you're doing is you're providing a rip stop For those sutures those horizontal sutures. So here it is in a relatively straightforward one and this is a good indications for repair here as a young patient or Relatively young patient with a radial tear fairly near the root here, but enough tissue to use For the for repair and essentially you're going to put in two vertical arms one on each side those provide the rip stop for you to then put your Horizontal arms so one and you can do all inside. Sorry the all inside devices here or inside out And this device this this technique essentially gets you a Vertical arm on each side and once you have those in place you can come from either side here's the first one the horizontal arm and then the second one coming in and you Come to the outside of your vertical arm and then back on to the outside wherever you've got good real estate You typically get typically get one. Sorry at least two maybe one sometimes It's good idea to get a long vertical arm if you can so you can get more sutures in there and then you tension that up and The final construct is is nice and strong and in this case actually ended up also adding a centralization suture to really Make that as strong as possible Now we can push the edge of the envelope a little bit here this is a little bit more of a difficult tear a sort of devastating tear and a young a very young patient that has a big gap and You know, that's a that's a big gap to really close So we are really pushing the edge of the envelope here What I do with these oftentimes is I will put in a reduction suture sort of like a traction suture to see if this comes together reasonably well. So side to side, just put that there. And if it looks pretty good, then I'll go ahead and do the repair with the hashtag technique. So there's the vertical arm going in on the one side, a vertical arm going in on the other side. And with this, this is an inside-out technique here. The kind of nice thing about the inside-out technique is you can tension everything at the same time. Whereas if you use the all-inside devices, you're kind of tensioning them as you go. I think this gives you a better tensionable construct. And in this case, you can see I'm able to put actually a total of three horizontal sutures in and get a really good sort of repair against that. And sometimes the knot that you use for your initial suture is actually quite large and interferes. In that case, I'll actually take it out, take that knot out, take that suture out. And then you're left with this construct with the essentially triple hashtag repair. I'm always asked about rehab for these. I think we've heard a little bit about how radial-type tears like root tears can be at risk with... I actually accelerate most of my meniscus tears pretty quickly. But root tears and radial tears, I do keep them non-weight-bearing for four to six weeks and limit flexion. So to summarize, I think radial tears are difficult. But you can get good results with the correct indications, excellent technique, and addition of biologics. Thank you. I'm personally enjoying non-wavering status myself right now, so, okay. Matt and I are just going to alternate some cases here. And we'll get the opinions of our panelists, so, okay. So first case I'm going to present here is a 38-year-old woman who's an active climber as her form of physical fitness. She had a fall from a wall, presented with knee pain and instability, positive Lachman's anterior and stable collaterals. Really no significant degenerative disease, neutral alignment on full weight-bearing films. MRI showed complete ACL tear and a lateral meniscus root tear. And this is what it looked like at the time of arthroscopy. So there is some focal chondral wear at the more central aspect of the lateral plateau, but the remainder of the cartilage surfaces look pretty good. Really a complete tear there. And she was treated with ACL reconstruction, a quadriceps autograft, and a root repair. But questions for the group in this scenario, I'd like for you to comment on sort of order of steps. Which tunnel do you drill first, ACL tibial tunnel or your root tunnel, and your preferred guide settings? And does your femoral tunnel for the ACL technique influence whether or not you prefer to prepare your root tunnel first, meaning medial portal folks who have to hyperflex as part of the ACL reconstruction? Travis, you want to start? Sure. In terms of the first question, ACL tunnels, which is getting drilled first, I will drill the femoral tunnel. I use an intramedial portal, which leads into that second one. But I drill ACL tunnel from the femur first, then I'll go and do my root tunnel and finish that up with the tibial tunnel and the ACL. I don't fixate anything until the end. And I have my guide, it depends on the graft, but I have my guide set for BTV set at 60. And then with that contralateral face of the tibia, or in this instance, it would be the medial tibia, tibial face for that lateral root. I'm aiming more medial on that face. And so... Yeah. Good. Okay. So you're a medial portal driller, so you're kind of influenced by that, because you wouldn't want to probably hyperflex the knee after you've done your root repair, I'm guessing. Correct. Yes, I'll do it at the end. Yeah. Okay. Yeah. All right. What are other folks' preferences? Any comments? Anything different? I'm sorry. Yeah, so I usually do the meniscus work first. And I use... Like, for this case, I would use the double tunnel technique, transosus. And the good thing with this is that you can leave the metal sleeves in place, become a little bit more from intermedially, and then there is usually no coalition with the ACL tunnel. So we do everything on the meniscus first, and then I go for my ACL. All right. Any outside-in tunnel preppers in our panel for the ACL? Yeah. I do similar, but I use a flexible remiss for my ACL, so I don't have to worry about medial portal and hyperflexion. Yeah. Good. Okay. So we'll sort of scoot ahead here. So this was repaired with contralateral facing drilling. I like the same technique as you, Travis, with single tunnel transosus and reduced after preparing the footprint with this ACL reconstruction done afterwards. So she did well, returns to the office four years later after utilizing a motorized scooter and attempted to break with her leg while going 20 miles per hour. Previously completely asymptomatic, doing great, no pain, no instability, and presents now with this recurrent ACL tear, recurrent root tear, slight extrusion, although similar on the medial side, which does not have a tear, little development of some interval chondromalacia. So this is confirmed arthroscopically. You can see there's sort of where her meniscus had previously healed to the tibia. That sort of bulbous tissue, what looks to be a new transection of the ACL near the root, but we've lost a little bit of tissue at this point. And so what are folks' strategies regarding whether or not you would repair this again or strategies for revising it with a new acute injury? I'll only take one comment on this and we'll move to another. So I think these revision roots can be tough. You can see the tissue there is not as good of quality. So in this one, we are combining ripstop techniques with our root repairs at this point with any degenerative tissue. So I would definitely consider that here. Other than that, I don't think you'll run into too many technical issues. In this revision setting, depends what you're kind of using for a graft. But if you're drilling a full tibial tunnel, you can certainly look up the tibial tunnel with your scope to make sure there's no coalescence. But the other consideration here would be, do you consider there's some debate about LAT? Does it over-constrain the lateral compartment? I think, Adnan, I'll ask your opinion on that as you presented on it. Thank you. I think there's a couple of issues here. Firstly, is if we look at the original repair that was done, I know a lot of us are kind of drilling these sockets with a retro drill and having a little socket there for preparation. And I just wondered that whether sometimes we actually over-tension these repairs and it kind of looked a little bit like that to me from the original repair image. And that might also be a reason why we've got some tissue loss here. But in terms of the specific question about LAT, I would always recommend to try and fix the root if we can. But there's a study from Japan, I can't remember the specific group, where they evaluated the role of LAT in the situation of a deficient lateral meniscus. And they found that that did offer some compensatory benefit in terms of knee stability. But it's not really the first strategy here. I think wherever possible, you want to repair that root. All right. So we want to get to another case here. So in this case, just wanted to move the attachment site a little bit due to meniscal deficiency. Didn't want to over-tension this into a tunnel. And wanted to kind of tension it just the right amount given the tissue deficiency. So this person had sort of the subchondral suture tensioning technique to have this revised in the setting of their revision ACL. All right. All right. Matt's going to give us our next case. We're running a little short on time. So we'll try to get through one case. Certainly if you have to leave, no problem. Feel free to bounce out. But we'll go a little bit of a different direction here. This is a six-year-old kid with a discoid lateral meniscus, which I find very challenging to deal with. It's a near-complete discoid. He has intact anterior and posterior roots. Has a tear of the anterior horn and body where it seems like they commonly are. So this is one that I saw four years ago. And I usually kind of lay crepe and say, hey, this is just not normal tissue. If we can, we want to try to do everything to preserve and repair, particularly because we know how poorly people do with total lateral meniscectomy. So we did try to fix it. He did fairly well for several years. He comes back about four years later and says recently started to have intermittent issues. Nothing consistent, but intermittent sense of pain, mechanical-type symptoms. You can see even on the films here, obviously, he's still skeletally mature. He's only 10 years old. You can see changes in that lateral femoral condyle. He's progressively fallen into asymmetric valgus on this side. And he really has developed a more substantial OCD lesion of the lateral femoral condyle. I put the film from five years ago up on the upper right there. He had just a little signal on one cut. But it's a little bit more substantial now. You can see one small cyst, a little bit of fluid under that lesion there. So maybe, Nick, I'll start with you. How would you approach something like this at this point? He's still 10 years old, bad-looking lateral meniscus, asymmetric valgus, and an OCD. I think you've got to look at all of those pieces and put them together. The meniscus is not normal, the cartilage is not normal, and his alignment's off. So I think I would be talking about some kind of an alignment procedure as well as cartilage and potentially even an MAT. Because there's really not very much meniscus left there on some of those views. If you have an axial, oftentimes, you'll be able to look at that better. But the first thing you're going to tell the parents is this is a terrible situation. Because there's not a lot of good things that you see in this knee. I think if you're going to do something, you're going to try and have to do all of that. And the question about whether or not you wait a little bit of a while until he's more mature or not, I think, is open. Maybe Roman, I'll ask you, because we had that discussion, they were just shocked that he had a problem with his knee. They thought I was going to say, oh, it looks great, there's no problems, because he really had only had kind of intermittent issues the last few months. So Roman, how would you counsel them going forward as to kind of the path ahead? And I know Nick mentioned a few of those things. Well, first, I think the most difficult thing nowadays is to get the two parents together in order to discuss the problem with both of them. That's one thing. The second is then, yeah, I think you need to realign this limb. And if he's not symptomatic, because he was so poorly symptomatic, which were his symptoms, actually? I don't remember that. Yeah, he started to have intermittent pain and mechanical sensations. He describes kind of a locking-type situation. Yeah, so that's something that surprises parents often when they come and they see, well, there is a bigger problem than you would have expected, or you need to talk to them. Very often, they are not convinced at the first stage, they say, OK, well, we do kind of bracing to gain time, to play the clock a little bit, see them later. And then I think the essential thing at this stage is realignment, and it's not about meniscus problem. Well, I'll let you agree or disagree with what we did here. So that was essentially the same discussion I had with them. This is the first few of the meniscus when we went in. Not surprisingly, it looked terrible. There really was not much to repair. This is looking from the medial side over laterally, so you can see his body is essentially completely deficient at this point after the debridement. Just ballpark, the anterior horn probably had about a quarter of normal volume. The posterior horn looked the best, actually, but still probably only about 50% of normal volume there. So he's certainly, at least in part, meniscal deficient. If you look at that OCD by the rock classification, I would say this is a fairly stable cue ball type situation where you really couldn't see anything abnormal. I drilled it. I will say, as I was putting this together, I thought, why didn't I put a screw in that? So retrospectively, maybe we can talk about that if people have thoughts on that. But drilled that, and then I completely agree on the realignment. These folks were a little bit worried about this, but I think that's the beauty of dealing with young kids is that you have the ability to do something relatively easily where I like osteotomies a lot as well, but this is a fairly simple way to try to correct the alignment over time. So that's exactly what we did. He's still only probably three or four months out. We're following this. I am keeping him in a lateral and loader brace as well and kind of watching this going forward. But maybe, Aaron, I'll tag onto your paper. When's the right time to do an MAT on this kid? I think he's only 10, and so he's a pretty little guy, but it's hard to imagine he's not going to be symptomatic on this side at some point. Yeah, so you did the right thing. I have a lot of families of these discoid patients, and when they present that young, you just have to tell them from that first surgery, this is not going to be your last surgery. You're going to have multiple surgeries over the course of your lifetime. As far as timing of meniscus transplant, here, unfortunately, you have that significant squaring of the condyle. So the problem with meniscus transplant in these severe discoid cases is it almost immediately extrudes. So the Japanese have been innovative, trying to perform some reshaping of the femoral condyle and such. But at the end of the day, meniscus transplants do not perform very well in this patient population. So it's very reasonable what you did. Follow the growth and see if you remain symptomatic. You can do a skeletally immature meniscus transplant. This is the one time I use a bridge and slot technique, because you don't need to violate the physis. But I would just follow this family very closely. Maybe Travis, I'll end with you. Say we do a meniscus transplant at some point. You talked about root fixation. There's obviously different ways, like Erin presented, or I do an all soft tissue technique, which you could certainly do in somebody's skeletally immature. But one of the things that I learned from you, Erin, with the centralization, Travis, if you do transplants, what do you use for fixation? I mean, do you do any type of centralization or any special fixation for the roots? Specifically lateral versus medial? Either way. Putting more of the centralization stitches in the medial side versus laterally to make sure there's as much of the natural and normal mobility. And then doing traditional small bone slots, like Dr. Critch does, with vertical mattress stitches inside that repair. Good. All right. We're a few minutes over, so we'll end here. Certainly if you have questions, come up. We appreciate all you being here, and thank you so much for our speakers and the papers and the techniques. Thank you.

meniscus ramp lesions

surgical techniques

ACL reconstruction

transnotch visualization

biomechanical analysis

non-weight-bearing

meniscal allograft transplants

postero-medial portals

pediatric cases

knee stability

Cassandra A. Lee, MD

Matthew Tao, MD

Adnan Saithna, MD, FAANA

Paul Allegra, MD

Zachary Burnett, MD

Aaron J. Krych, MD

Romain Seil, MD, PhD

Travis J. Dekker, MD

Nick Colyvas, MD

Jocelyn R. Wittstein, MD