Thank you very much. Good afternoon. I'm going to share some tips and tricks with you, then my disclosures. I think we don't have to belabor the fact that the meniscus should be repaired. We've all done this in the last couple of years, more than we ever have. And since the ESCA panel is sitting right in front of me, I thought I'd put this slide in here. They had, two weeks ago, the big meniscus meeting in Luxembourg, pointing to the repair and don't do meniscectomy if you could. Also a very nice review, this is the only two papers I have in here, recently done by Justin Ahn and Rachel Frank, about all the different meniscus repair techniques. So here are our different techniques, all inside there on the left, most commonly used these days. But don't forget the old school outside-in technique, and sometimes inside-out is still used as well. So I have just four cases I want to show you. This is a 13-year-old male, quite mature already, but we did a ACL reconstruction over the top in the Zaffarnini technique. And then they had a medial meniscus vertical split tear. And so here is sort of how we think about these meniscus tears. So that black line is the tear in the red-white zone. So our plan of attack would be releasing a bit of the MCL and placing four vertical mattress sutures and maybe a fifth one on the bottom. And so here is the video that goes with it. This is a quite simple technique. You see there is a tiny bit of radial split that we just trimmed out. Then we rasp the meniscus periphery there, you can see a little bit of a horizontal split in that periphery. We just freshen that up. I also use a stepman awl and poke some holes for vascular access channels. And then with a shaver without suction, again, just rasping this area up and preparing it to receive our repair. And so vertical mattress is obviously the key. Don't use horizontal mattress. So in that case, the MCL release will give you the appropriate exposure. And so here are the first two stitches being put in through the capsule here. And then when you tie the suture, I think it's very important, you can definitely over-tension this if you just tie it to get the slack out. And that's about it. Don't over-tension it. And then the last stitch is underneath. You can see here from this ante-medial portal, I can't quite reach what I want to do. So I included that just to show that we switched the portal, a nice little trick I'm sure all of you use. And so now we have better access. Moving on to the next case, this is a quite, I would say, crazy case. But there's a 25-year-old girl who received a revision ACL meniscus transplant six years prior, but now comes back with recurrent bloody effusions. And our assessment was based on the MRI that there's probably a partial root tear of the transplant and she also had a lateral meniscus radial split tear. So something like this, where about half of this posterior root is still intact. The other half was off, also as visualized by this dotted line, that she had quite a deficient transplant there already. And then on the lateral side, that radial split. So here's the video. You see this meniscus looks pretty beaten up, yet because the root is torn off, we thought we could give it a try and maybe repair the root. Now in this video, the preparation of the root insertion was already done. In this particular case, we did medialize a little bit her root insertion point, although you preferably don't do that. You rather go anatomic, as Aaron has explained to you. We put two of these loop sutures in here and then drill our tunnel and pass with any really suture passing device, the sutures down in the transosseous tunnel. I think transosseous tunnels work well. You can use anchors as well. And obviously you can also use cannulas if you need to. On the lateral side here, you can see a radial split through all three zones. So this is quite significant. The meniscus is pretty beaten up. In this case, we used a all inside horizontal mattress type of device that delivers a 2-0 braided suture. And then that gets then tied like you would in the shoulder with a suture, not pusher. And we did this here twice. I'm going to move on to the next case. This is a relatively mature 13-year-old girl softball player. And she had a complex lateral meniscus tear with a radial split about 80%. And then a vertical split going towards posterior and a flip fragment, so a quite complex situation. With a tear as seen here in red. And our attack would be two sutures in horizontal mattress across the radial split, followed by a vertical suture and also a fibrin clot. You can see here, we used these devices that are bendable. This is quite helpful in this particular case. And then a fibrin clot on that lower picture. You can see here, trying to understand the tear and reducing the flip fragment. Here again, we're trying to use this horizontal mattress device, but the purchase didn't work since this device is not bendable. So I ended up removing the suture and switched my technique to the bendable all inside device. And with this, we did two horizontal mattress sutures, closing the radial split. And then we left the sutures untied, prepared a fibrin clot from the patient's own blood, delivered it through like a seven millimeter cannula, then tied the sutures down capturing the clot. And then finally used this horizontal mattress device and closed the vertical split posteriorly. This all in a very tight knee, where obviously on the lateral side, you can't release the So this is not the easiest case. And my last case here to show is a ramp tear. And I think recent literature is quite controversial whether you should use an all inside device from anterior or make a posterior medial portal and use a shoulder type of device. So I can show you here a 19 year old ACL tear that had a medial meniscus ramp lesion, much like this. And so the first step here is going through the Gilchrist portal with your camera and assessing, assuring that you in fact have this ramp lesion as you suspected on the MRI. As you know, MRI is only about 70% or so sensitive on this. But here indeed, you can see a quite large ramp lesion, pretty fresh too. This is a case where we got in probably within four weeks of the ACL tear. I do use a posterior medial portal only to insert a needle and see how mobile this is and where I do want my posterior capsule to come and lay, which is obviously quite depressed right now. So if we extend the knee, we can then go from anterior and just simply use a fast all inside device as you will. And I use a horizontal mattress suture here, and we do this twice. And you just have to trust the fact that the capsule reduces in extension. But once you deliver these two sutures, you can then go back through Gilchrist, which is now a little bit harder because the capsule is closed. You can see how the defect is closed down. So those are just a few of the tricks. This is my last slide. So summary, don't do a meniscectomy, at least an ACL reconstruction, I would say ever. Change in those joint motions will go and change the forces and get to further injury. Repair, really even complex tears as shown, and also as Aaron showed, root tears have very good outcomes as well. So thank you very much.

meniscus tears

repair techniques

meniscectomy

vertical mattress sutures

root repair