This is the most common operation in orthopedics and we understand the importance of preserving the meniscus, but there are times when we can go too far. The slides are not advancing. There we go. So some case examples will help highlight those tears that may not be appropriate for repair. We don't want to submit our patients to a long recovery that's doomed to fail. 15-year-old, twisting injury, feels a pop, can't bear weight, can't extend his knee. We know what this is, right? This is a locked knee, normal x-rays, effusion, inability to extend. And we see that flipped bucket, flipped over in the front, locked. You see it in the notch. But you also recognize that on the sagittal view that there's an oblique cleavage tear. So that should alert you that this may not be a repairable tear. Think about the direction of the tear, even though you have the trapped piece in the notch. So a locked bucket handle in a 15-year-old, you certainly go into this surgery thinking repair, counseling repair. But this is what you find. So these are characteristics of a tear, in summary, that don't work well with a repair. So white zone, this is all white. There's no blush of pink. You see a complex tear pattern and multiple tear planes. You see a radial component on the medial side that does terribly. And you see that it's certainly very friable. And when you try to reduce it, it tends to be plastically deformed. So that's just doomed to fail. You can put a bunch of stitches in that, but that's not going to work. So especially the radial component on the medial side is just not going to work well with a repair. And a meniscectomy is better. So trim this, get back to a stable rim, preserve rim, preserve anterior and posterior insertions. This is your post-meniscectomy picture. That patient's going to do great. They're going to be back to activity quickly. They're going to appreciate that they don't have five months out of sport for a tear that's doomed to fail. So we've all seen this slide. This is Arnosky's India, Inc. Vascularity Study. And it keeps coming back in presentations because it's so important. But understand that your tear patterns are often oblique. You may see it peripherally on one side, but on the other side, if it's oblique, it's extending into the white zone. So that's going to be a setup for failure as well if you do a repair. It's going to be hinging on those sutures. Now radial tears tend to do very poorly on the medial side. But this is on the lateral side, the junction, the anterior horn, and the body. We see this tear often in basketball players. You can get this to heal. And it's important to go after this and try to get this to heal. Do a crisscross configuration pattern with your sutures. You get better coaptation and side-to-side compression. And you can get this to heal and change the outcome of this knee in a major way. We all understand the plateau anatomy matters a lot about meniscal deficiency. The medial side is dished. You get more congruency, shearing of load. The lateral side is more dumb, so be much more aggressive on the lateral side with repairs. Medial side is going to be much more forgiving. Here's another case. Here's a couple of tear patterns that may be unrecognized and can be a problem. So this is a 26-year-old, low BMI, very healthy, felt a pop while doing squats, basically normal x-rays again. And here you see a relatively oblique tear on the posterior horn, on the sagittal view. And you see less meniscal tissue on the coronal view. It's rounded off, and there's a flip fragment in the gutter. Those flip fragments go underneath the MCL. The MCL, for whatever reason, is loaded with nerve endings. Think about your people that get a grade one MCL tear and how much they hurt. You put this piece of tissue wedged underneath there, and they're very uncomfortable. Recognize this on the MRI and go after it surgically. It can be very difficult to see on first pass, but you need to be able to reduce it. Then you see much more readily the fragment, and you can trim it. In post-meniscectomy, they can do well. Here's another patient, a little older, but it also highlights another key feature of this tear pattern. So flip fragment, again, under the MCL. Here's another view. If you look at the far right picture, you see how it's rounded. So the meniscal edge will not ever look rounded if it's just a valse. This is a folded piece of meniscus, and it's, again, under the deep MCL there and very uncomfortable. So it's almost invisible when you get in there to surgery. And if you probe it and you unflip it, there it is, a large, large fragment that needs to be trimmed. Now understand, as you approach this with your biters, that the place where there's the most space for the instruments is right there at the junction of the posterior horn of the body. So as you trim it, it's very easy to go too deep into the rim and make this patient relatively meniscal deficient. So be cautious about that, especially if you're working with trainees. That's where the instrument's just going to fall, right in that corner where there's the most space. It's easy for one bite to go too deeply. So be careful there. So the other thing I want to highlight is on the lateral side. This has tremendous healing potential. In conjunction with an ACL reconstruction, these posterior horn lateral meniscus tears occur from getting pinched during a pivot shift. Once you've reconstructed the ACL, that tear mechanism is gone. They're not pivoting, and they have excellent healing potential. Very useful paper from Don Shelburne many years ago, titled Aggressive Non-Treatment of Lateral Meniscus Tears. It's worth a read. Don't poke them full of holes. You're just going to make them worse. The more you mess with it, the worse they look. You see these often on one surface only. The other side is pristine. If they're posterior to the popatiloidus, tremendous healing potential. Pay attention to what that meniscus looks like based on time from injury to when you get in there to surgery. A lot of times, you'll glance past it, not even see the tear. If you really go look, they're six weeks out from injury. You'll see what used to be a tear. It's very educational for the healing potential of this injury. So lastly, let's talk about a root tear. So here's a 50-year-old physician, female powerlifter, fitness fanatic. She gets a root tear. You see it right there. That knee is very different. You see the extrusion of that meniscus and bone marrow edema. Bone marrow edema hurts a lot. That is the driver for this knee. That is the main source of pain. Don't ignore that. You need to treat the bone. Think about bone health. Think about offloading. But she doesn't get to see the surgeon because she's trying to get better on her own for four months. And they come into your office, and they got this weight-bearing x-ray, it's too late. That's not going to work. Too much articular cartilage is gone. Too much extrusion. So relative exclusions for root repair. There's obviously a zone here, a gray zone. But extended and flexed weight-bearing to use. Male grade three that is global is going to be too advanced. Too much chondral loss, excessive varus, excessive BMI. Obviously a range of factors here. Age is not a factor, but I would recommend getting new weight-bearing x-rays within six weeks of your planned surgery because this disease process can move fast and carefully communicate expectations well and what the goals are. So it's important not to do a meniscectomy on these root tears. They do much, much worse. That is the worst outcome you see from Fawcett's paper here. Highest cost, worst onset of osteoarthritis, highest rate of conversion to total knees. So better to treat these non-operatively than to do a meniscectomy in the face of a root tear. Thank you.

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