I want to thank ESCA for being here. This is really great and really appreciate you coming over here and speaking to us. It's awesome, especially on our 50th anniversary. You're very special, so thank you. My question is for David and meniscal allograft transplants. Now, when I was traveling, they didn't seem to be quite as popular as when I was a godfather in 2018. The tissue banks, are they available in every country or only in certain places, or are they increasing in number, and how are they regulated? This is the big question, and this is why ESCA trying to promote huge work on the use of allograft and the necessity to be able to use allograft because there is a high diversity in different countries. And I would say, if I have to speak about France, it's very tough to get some allograft. If you go to Italy, I think it's more easy. If you go to Belgium or Germany, probably it's more difficult. Germany is difficult, and so it's very difficult. So it's still not very easy. So we have to fight, and we have to promote that, and that's why we, in this allograft initiative, was a very powerful tool to go to EU, and we still need to work on them to have the allograft that you have in your countries. I have been traveling for three weeks and a half in your country, and I have some sort of allograft. Can I just add that because some countries are so difficult and there's no regulation on the EU level, and this makes it quite hard for the doctors, and what we basically are trying with this initiative is not necessarily the health authorities telling, I mean, probably it's not to be the different tier, telling us what we have to do and what we shouldn't do. So we created the initiative to, first of all, find how much is the demand of getting allografts, and for instance, Fresh Fertil is not allowed in Germany, which has some of the best grafts in our country, and then, of course, with these results we got from the initiative, we have to go to the authorities in each country and try to convince them that we need to change that rule so that we are able to first get access, and then secondly, to actually treat the patient because it's still very long-winded and our meniscus is very, very poor. This is allograft, as we mentioned. Good, thank you. And a question for Thomas. If you have a knee with a meniscectomy and you have this lesion, do you still perform the articular cartilage procedure, or do you wanna do something to restore the meniscus? Oh, that was the last words, of course. Look at the whole joint. First comes the alignment, so if it's malaligned, you have to correct the alignment, then you have to do something about the meniscus, and if it's malaligned, the meniscus is missing or in any language there, it doesn't fail, of course, it's not working. No, very, very. Go ahead. Roll it. No, thank you for the symposium. I thought that was excellent. You know, I totally agree. When you have malalignment, you need an osteotomy to correct the alignment. The question was really for all of you. At what age, so say you had a root tear in a 50-year-old and they had various knee, when do you do the root repair with the osteotomy? If you have a meniscal deficient knee and they need a meniscal transplant, what age is the cutoff where you just do the osteotomy or you do both the osteotomy and meniscus transplant? And same for Thomas, for cartilage lesion. That seems to be the biggest problem I have, deciding when to just do the osteotomy or when do you add the other procedures? I should start. You know, last week, we had a meniscus meeting in Luxembourg and she addressed this at this point and it was, there is nothing in menisculature that you call... and some participants were doing only yoga. In Germany we have the difficulty to restore the meniscus because we basically have no meniscus allopaths. The synthetic meniscus are really not working. To remove the exhalation probably it's also the biological age, normally the age of 50. But if you think of the overweight 50-year-old lady, you know, the root channel virus, the joint will probably break in Germany totally in the after-fasting period. So we have to discuss it with the patient in the biological reconstruction. We must intervene, prepare and try to avoid it totally. Or say, okay, let's do a conservative and then probably we'll be able to support it. So there's no age cut-off. The medication is a bio-mechanic, it's a bio-mechanical. So the osteotomy will be definitely the key. And if you want to have a match, it might be, but you have seen that on the right. Hi, Ken Zasloff, David, first of all I want to just thank everybody for coming and I want to thank ESCA for their relationship not only with ICRS but also with AOSSM. You guys are great about working with other societies. We really appreciate your input. David, if you're trained in the U.S., most of us have been doing bone plugs or slot technique for meniscus transplant. Based on your data as well as Renee and Peter Verdung's data, clearly all soft tissue is just fine. Can you just tell us though, do you use tunnels for the roots when you do the all soft tissue with no bone plugs? But the same thing with the meniscus transplant, you use the same tunnel for the root or yeah? And on the anterior, do you use a tunnel or you just do suture on the anterior root? Thank you. You mean, sorry, well Aaron has started to show us, Critch, that for root repairs you need to consider that to prevent extrusion, is to try to centralize it. Is that what you're talking about? And then we do the same thing. Put an anchor into the tibial plateau and suture it. Yeah, we're starting to do that. It's pretty early. Yeah, I think there's some stability in there if you just fix it to the tibial plateau because it's not going to be as easy as it used to be, but it's not as easy as it used to be. Normally, especially on the lateral side, I do a meniscus transplant plus medial varus osteotomy. And on the medial side, it depends on the degree of varus malalignment, but I do, most of the time I do now in combined because why I have to leave the knee without meniscus if I have the possibility to put, correcting the alignment and to put a new meniscus? When there is a varus knee more than three degree, you should do it. And I have no limits of age. I'd like to make a comment about the ramp lesions. Also, this was an excellent, excellent symposium. And you've shown my American colleagues that in Europe, we really do good work. As a football doctor in Madrid, we don't see as much as I did as a ski doctor in Lake Tahoe, these ramp lesions. In a skier with an effusion, at least 10% will either have a root or a ramp lesion, even if they don't have a cruciate ligament tear. The first thing that tears in the skier is the poster medial corner with valgus abduction stress. And the problem is that most MRI will not show you that lesion on the poster medial corner. So, you must do an arthroscopy. You must look at the poster medial, poster lateral corners, and you must dynamically probe the meniscus to see if it's stable. And I think you've mentioned that, but I want to emphasize that, especially because in skiers, at least 10% will go unrecognized. If you're living in the city and you see a skier come in, the MRI may be negative and you will have a repairable lesion at least 10% of the time. But if you're a professional skier, if you're a pro footballer, alias, soccer, you still have those types of injury. Once again, as soon as you have a prediction of the mechanism involved in the mechanism, you should really have a high degree of suspicion. And if you have a player or if you're a skier that keeps posting you can play, even a couple of weeks after the trauma, I think you should get it. More questions? Burning questions? If not, since we are perfectly on time, thank you very much for coming.

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