questions now while people are coming up to the podium. We actually have some questions from the audience. This one would be for Christian. Can patients return to high impact activity after the new surface surgery? I would add to that, how do you counsel your patients to their activity level, what they can and can't do after this type of implant surgery as well as just a standard meniscal allograft transplantation? What can they expect? This is different. For the new surface implant, the recommendation is for them not to return back to high impact activities. The fear here is obviously that the implant gets overstressed. That said, I can tell you I've had several patients who are actually ski patrols up in New England who ski 150 days a year with this implant. You can make that work. I wouldn't recommend that as the baseline, but this is a fairly durable implant per se. Now they can break. You saw an example that I showed you, but then you can actually put a second one in. I haven't had to take a second one out yet. The last one I put in was I think when the study shut down about three years ago. For meniscus transplants, this is different. Meniscus transplants, even in young people, I would not recommend for them to go back to high knee demanding sports, but this is not because they can't do it. In fact, actually many of them probably could if they wanted to and some of them do, but the fear here is that these meniscus transplants, as good as they are, they'll never really be a normal meniscus. They're essentially a temporary spacer that will deteriorate over time and this is a function of utilization, right? So if you ride it really hard, it won't last that long and that's the discussion that you need to have with the patient. Frank, we have one audience member. We'll take the front first and then the back. Yeah, thank you. You answered my first question about this at the activity level, but second, Christian, I have two questions and one for the Rush fellow. I forgot your name. I'm sorry, but what types of fractures have you seen with these? That one you showed was a clean break, but have they ever like kind of shattered? No, this is actually a very flexible material and these are more rips actually than that they are fractures and the underlying reason for that is in fact actually a technical reason that they have subsequently been able to change and that had to do with osteophytes along the medial condyle that basically dig into that corner over time and then cause these fractures and so these are not shattered implants or anything. In fact, you pull them out on the fracture and they come out in one piece. Okay, so do you shave down the little osteophytes then to kind of avoid that? That's exactly right, yeah. Okay, and then with the high preponderance of lateral meniscus transplants in females, what was the underlying diagnosis? Were those discoids or were those failed lateral meniscus repairs after an ACL reconstruction or both, which dominated? Yeah, it was both. I would say primarily it was failed prior meniscus repairs or meniscal debridements, but there were a couple of discoids, but it didn't make up the preponderance of that population. Thanks. Joe Nguyen, HSS. This is for Dr. Lowenstein. Did you look at any potential ceiling effects with your COUS outcomes because, you know, in some previous work that we've done, we found that certain arthroscopic procedures, like the COUS really hits like a pretty significant ceiling effect for those outcomes and if you looked at that and applied that to your weighting algorithms? We did not do that for this current study, but would definitely be interesting to look at. A follow-up question to that that I had and that an audience member had is that in only one scenario do you come out with a meeting a CI of less than 50% and so really the majority of patients are getting at least a 67% chance of meeting the CI. Although I don't seem to find that clinically in practice and from the previous data that's been published, so what do you make of that? I might pass that on to Dr. Atkins. That's fine. Yeah, I mean I think part of it is this population was almost 500 patients of all comers, so there were 30-year-olds and there were 60-year-olds, so I think it may be different, you know, if when we're thinking about more of these degenerative meniscal tears, but a lot of those patients aren't going to fall into the, you know, 80-90% range because they're going to have a KL2 or 3, you know, on the abbreviated score, but you're right. Only that one subset of patients had 40% chance of improvement and those were most of the KL3s. Dr. Harner. Chris Harner, Pittsburgh. I have a question for Dr. Quigley's fellow. Is that correct? Dr. Cole's fellow, yeah. Yeah. You showed a slide that there were 25% of reoperation rates in your population. I was wondering, probably a little over 50%, maybe two-thirds were done with other concomitant procedures. Did you get a chance to look at isolated meniscal transplants and the reoperation for that group? Was that the same? It seems like you have enough patients there to break out and look at that group and the results of that group. Yeah, that's a great point. We didn't look at that in this study. I know that the number of concomitant procedures was very high in this. So, I think we can certainly write up another analysis on that. I think anecdotally, I remember when we were putting the data together, it looked like some of the revisions were in isolated transplants as well. So, it wasn't like all of them were due to patients who had multiple procedures. I think that would be interesting to look at just the isolated transplants. For sure. Good point. Dr. Strauss, can we do one last question for Dr. Strauss from the audiences? Have you started to use these biomarkers in clinical decision-making? And if not, how far away from that are we from realistically putting it in the clinic? And I'll add one thing, Eric, as well. Have you looked at serum biomarkers instead of just intra-articular synovial fluid? Perfect. So, clearly a great question and the holy grail of all that we're doing. So, I don't think we're at the point where we can basically do that patient-specific determination based on the fluid levels yet. What we continue to see is indicators that there's likely something inherent to their innate immune response to injury that predicts their response to injury and thus their response to treatment. So, we're doing a couple, you know, our registry at this point has samples from about 1,400 patients. We're doing a lot of, you know, interesting things with genetics and proteomics. We have published a couple of things on looking at correlations between what's going on in the synovial fluid environment and what's going on in the serum. And unfortunately, the serum is just not as predictable. So, the key for us is what's going on in the synovial fluid environment and then we're going to start to, you know, factor in a few other things in our predictive model. So, I would say we're getting closer, but continued work needs to be done. Great. Well, I'd like to congratulate all the speakers and the investigators for a great first session. We're going to move on to our technique spotlight videos, and I'd like to invite up Dr. Amin.

panel of experts

high-impact activities

surface implant surgery

meniscal transplants

biomarkers