Well thank you for all being here. If you're still here you care about the meniscus so I appreciate you. So we're going to be talking about all soft suture anchors and a comparison between peak and inside out. Here's my disclosures. So we all know some of the clinical data, right? So inside out meniscus repairs long been the gold standard. Still a great technique, okay? I use it every day almost in the OR. But if you look there's been a really good systematic review where they did inside out. They had several hundred patients and they showed there was no difference with failure rate inside out versus you know any of these other ones with all inside. And then also with respect to patient reported outcomes no difference. But you know there might be some differences if you look at when they combine all the data with nerve injury, higher complications with inside out. And that makes sense, right? So if you cut down on the one of the sides of the knee and you do an approach you're potentially going to cause some nerve irritation, nerve issues. You're tying knots on the side. So we all get that. We understand that. And then potentially there's less operative time with all inside devices because again you don't have to do the operative approach. And so the study bears the studies bear that out. But we already knew a lot of this because about 10 years ago there was already a systematic review and they showed that that if you look at the mean follow-up time of about 38 months so this is this isn't just you know 12 months that this failure rate was about 17% for inside out, 19% for all inside. And then also excellent patient reported outcomes. And then again a little bit higher nerve irritation for inside out versus all inside. With something of note with this study is the older rigid implants were included in this. A lot of errors were included in these studies and they're associated with chondral damage. So if we talk about the biomechanics of all inside repair you know there has been some differences. So if you look there's higher failure rates or higher failure load with inside out and there's less gapping with all inside. So there's a lot of potential reasons for that. If you look on average the inside out gapping is about 1.7 and about 1 to 2 millimeters in general gapping. Okay so what this is really about is just looking at the traditional peak which are now you know this used to be new and cutting-edge but really now this is what we call the traditional all inside anchors which are peak. And then the newer all soft suture anchors which I think a lot of people in this room probably use. They use a suture sleeve that expands when you deploy it and then pull on it. So the purpose of the study was to compare the biomechanic performance of two different all soft suture anchors all inside devices and compare them to peak anchors and then also to compare it to an inside out meniscus repair which has long been the gold standard. Our hypothesis was that the all soft suture anchors would have comparable biomechanic properties to peak based anchor and that's because if you look at the data most of the failures occur through the meniscal tissue. So because we already all use these sutures right so we use you know fiber wire whatever your preference is typically a lot of these implants utilize the same sutures we already use so that the failure is probably gonna be at the meniscus. So a little bit about the methods. So here's our four different groups. This is zoomed in. You got the jugger stitch and the fiber stitch where they all suture anchor devices and then the FasFix 360 which was the peak anchor and then the inside out repair which was the max braid. So we had 20 human cadaver knees which were dissected and then we divided them up into 40 meniscus so there are 10 in each group okay and those are randomized. A couple things of note each meniscus was inspected. We made sure there were no tears in them. There are two anchors per meniscus and biomechanical testing was performed and the engineer that performed the testing was blinded to which group and honestly they even if they looked at these they wouldn't know which was which okay and then we measured the force to reduce the tear and then last but not least the anchors replaced posterior to the capsule. So some of these studies these anchors are really designed to go behind the capsule but in a lot of these studies they'll cut the capsule out and just do the meniscus only so something of note and then this is our setup. Everyone understands how this works. We put it in the Instron and then we measure the failure load. We measure the gap measurements and this was done by high resolution photography and then we measured three different points and then we averaged the distance. So if you look at the results with the meniscus dimensions this is just to make sure we kind of have homogenous groups. There is no difference in the size of the meniscus among the four groups. There's no difference in the specimen among the age of the specimen among the four different groups. Of note the fiber stitch we actually measured with a dynamometer the force to reduce the meniscus and it took a little bit of extra force and we just did that to kind of really know how much force we were pulling on when we reduce these. If you look at gap formation no difference in gap formation like a lot of these studies about one millimeter one to two millimeters on average. And then failure load this was kind of the most significant finding the jugger stitch failure load had a higher failure load than the peak on side and the inside out. No difference compared to the fiber stitch though. Stiffness no difference in stiffness among the four different groups and then if you look at the failure modes no difference no significant difference among the four different failure modes and those are all the different types of failures that you typically see. The anchor pulling through the tissue the sutures popping or cutting and the really the big one that we see a lot of times is suture cutting through the meniscus. And then here's one on the end where there's a suture slippage so that's what that's with knots that were tied. So in conclusion the two soft suture devices had comparable failure loads to each other. The jugger stitch all inside device had higher failure loads than the peak on side and the inside out device for longitudinal meniscus repair and there are no differences found among the four devices with respect to gap formation and stiffness. Thank you.

meniscus repair techniques

soft suture anchors

peak method

inside-out method

biomechanics