All right, there's my disclosures. So what's an ideal meniscus tear? I would love to see these only in my practice, small vertical tears, vascular acute tears, stable knee, no mild alignment in young patients with the setting of an ACL. However, this is more like what I see, radial transections, large bucket tears, double bucket tears, red white tears, horizontal cleavages, and then that revision repair. So this is a young athlete that is a isolated radial transection, no ACL tear, no other injuries. And this isn't the most updated version, but that's okay. So I tried to repair this with an all-inside device, just trying to get re-approximation of that radial transection. The first anchor went in posteriorly and tried to pull it to the meniscus capsular junction, trying not to over tension that aspect of the meniscus tear. And you can see that I did get pretty good approximation of the meniscus capsular junction. Here's the second anchor, first in the anterior leaflet and then the posterior leaflet, again just trying to re-approximate that and getting it to a point of stable fixation. Just like everything else, prior to putting in the implant I did do meniscal rasping, which does that work or does it not, that's always a discussion. But I think it's low risk. And then also I microfractured the notch as well as put in some PRP in this particular case. So happy to say a year out that athlete did do well, got back to playing sports. But we know that meniscus repair outcomes definitely could be improved. If we look at the literature, this is a systematic result looking at all comers. And basically there's a failure rate of 20-25%, looking at large all-inside bucket handle tears anywhere from 29% and at longer follow-up probably a higher rate. The MOON cohort has told us a lot about ACL patients' meniscus repairs. And there's a 16% failure rate here. So overall a 10-30%, not awful, but not great. I think we can do better. So how do we conquer the healing challenge question of the meniscus? I don't know the answer. I'm not here to say I do. But I think definitely the low-cost aspects of rasping, inducing synovial ingrowth, inducing hopefully stimulating repair tissue, inducing cytokine expression. We can microfracture the notch, which is very easy to do, especially in the non-ACL type patient that doesn't have sort of bone marrow venting already occurring. Trepanation, this is something that I'll do for my horizontal meniscus tears, especially when they have a small meniscus cyst with vascular access channels. You can either do this inside out or all arthroscopically. But does it compromise tissue biomechanics? And then what about the biologics? So there's fiber and clot, which I think is an option. We call it sort of a gummy bear solution in the OR. However, my difficulty with this is sort of the clot localization. And the same with PRP. Where does it go after you take the camera out and finish the case? With PRP, ACP, BMA, BMAC, adipose, all these things are definitely having initial studies that are encouraging. And they're studies that are ongoing. As we know, the PRP is the blood plasma with a two-times concentration above baseline levels. But some of our literature, as we know, have different systems, different preparations, and ultimately have different concentrations. So it's really difficult to understand what's exactly happening. And just like most things in the literature, we can find things that say, well, there's no difference with PRP. And the exact opposite, that we have lowered our failure rates with PRP. So I think the study looked at a case control of 162 patients with an ACL and meniscus repair. And this one said that they did not improve the outcomes and maybe PRP increased the rate of postoperative stiffness. So all things definitely to take into account. I think this is an exciting future in the years to come about how we can improve meniscus healing. But there's multiple techniques with variable favorable results. We can rasp. We can marrow vent. We can add biologics. But we need the more evidence. And we need better delivery systems. Thank you.

meniscus tears

repair process

PRP

healing outcomes

future possibilities