Hello, everyone, thank you for joining us to this advanced municipal repair solutions and need preservation webinar in 2025. We have a esteemed panel of panelists and speakers that will speak about a broad range of variety of municipal tears repair techniques and need preservation will be all find it very informational and enjoyable. We're going to have several talks, and then at the end, we'll have a q amp a session. So some important information, there is CME available, and please make sure to use the q amp a feature. During the webinar we'll, we'll try to get to as many questions that we can and do some cases at the end as well. I'm shaking my body from the University of Kentucky, and I'm honored to be here today, and hope you all hope you all have a great webinar great hour. So faculty myself in the University of Kentucky. We have Arvind Thivaram from the University of Chicago. These are all our disclosures what you'll find. And then, moving on to other panelists. These are learning objectives, Christina. There we go. The other panelists on the moderator from the University of Kentucky, we have Armando Vidal from the University of Colorado School of Medicine at the Stedman Clinic in Vail. We have David Bernholt from the University of Tennessee Campbell Clinic. We have Shannon Moskovsky from the Druszynski Sports Medicine Institute, the Cleveland Medical Center, Seth Sherman from Stanford University, and Dr. Arvind Thivaram from the University of Chicago. So with that said, I'm going to start and talk about meniscal ramp lesions. Those are my disclosures. We can find disclosures for myself and all the panelists in the other slides in the intro to the webinar. So what is a meniscal ramp lesion? So basically, the proposed mechanism of how a ramp lesion works, basically an ACL tear leads to an increased anterior tibial translation, the meniscus becomes wedged between the femur and the tibia, and then the semimembranosus contracts along the posterior capsule. So for ramp lesions, importantly, it causes an increased anterior tibial translation, which is bad rotational laxity. The incidence in the concomitant injury with an ACL tear is anywhere from 16 to 42%, depending on the literature you read. And there is evidence in multiple articles for improved outcomes following repair. So we want to repair these, it's important thing we want to recognize, we want to repair these. So some techniques to repair these, we can use all-in-side devices, we can use an all-in-side suture hook and any types of sutures we want, and then we can perform an inside-out repair with posterior incisions. In terms of clinical outcomes, repair is superior to leaving a ramp tear in situ without repair. And however, there's no consensus on the best repair technique. So an MRI, it's important to be proactive and try to recognize these lesions and that'll help us in planning for our operative phase and what we're going to do in the OR. Typically, we find these on a sagittal MRI, there's fluid signal in the posterior aspect of the meniscus. We need to be careful. In young patients, this could actually be a vascular channel and not a ramp lesion. And then the saying that we've all heard, right? These lesions have seen us more than we've seen it. I think surgical setup and exposure is important in terms of accessing the medial meniscus, the posterior medial capsule and making a posterior medial portal. Here shown, obviously, we're operating on the right knee, the left lower extremity is in a stirrup. But moving that non-operative leg out allows us about 130 to 150 degrees of access to the operative leg and predominantly the medial and the posterior medial aspect of the knee for these ramp lesions. So in orthoscopic repair, first, we must look right. We need to have an index of suspicion, excuse me, suspicion. And then we need to be proactive and try to plan for these intraoperatively. A transnotch view with multiple posterior portals can work. And then a Gilchrist view is also good for accessing the posterior medial corner and visualizing ramp lesions. And I'll talk about that in a bit. I think MCL trephination and release is very important in terms of opening up that medial compartment in the knee. And then a posterior medial portal for either passing sutures or for good visualization. I think we can fix all these orthoscopically. We can use suture passing devices or we can use implants and tie knots. So this is an example of a meniscal ramp lesion fixed with sutures. There you see a posterior medial portal. I think the advantages of all-inside repair with just sutures alone is it allows for an anatomic repair. There's no posterior incisions other than the posterior medial portal. We can place vertical sutures. We can really use any suture we want. It's cost-effective. There's no implants. We don't have to worry about iatrogenic cartilage damage from using an implant from an anterior portal. And then we don't have to worry about implant failure or loosening or any of that. So talking about the posterior medial view with a 30-degree scope, here again on a sagittal image we can see increased signal there in the posterior horn of the medial meniscus and rupture of the posterior medial meniscus capsule or junction. And then there we see, again, we see the condyle to the left and then we see the medial meniscus and we see the posterior meniscal tibial ligament. The Gilchrist maneuver allows us good access to the posterior medial corner. We can go from an anterior portal and slide between that medial firma condyle and the posterior crucial ligament. And that allows us great access to the posterior medial corner and the posterior medial aspect of the knee. So here we see the differences, right? So we start with a 30-degree scope and there's outside the knee and then inside the knee. And then we put our candela in from posterior portal. And then on the bottom left there you can see the ramp lesion, the medial meniscus ramp lesion. But then when you put the 70-degree scope in, you can really get good access to look right down on that ramp lesion to allow for us to anatomically fix this because we want to reduce this and fix this anatomically. And then with the 70-degree scope, it also helps us make that posterior portal with the spinal medial initially. That particular tear was fixed with some proprietary all-inside devices. And you can see here it's reduced pretty well. And then added a fibrin clot here to add biology to the meniscus and the repair. It's one thing to fix the meniscus, another thing to get it repaired. Dr. Thieverin will talk about that here later in the session. So on repair with an all-inside meniscal device, I think it's important to again release the MCL, trephonate the MCL. That allows access to the medial compartment. It avoids any iatrogenic cartilage damage. I think we need to rasp and debride the area. That adds biology and biologic factors to allow for good healing. And then another tip for all-inside repair using proprietary devices is to aim the curved needle downwards towards that posterior meniscal tibial ligament. I think that allows for a good reduction in the anatomic repair. And then we can use oblique mattress sutures. Thank you. With that, we will move on to Dr. Armando Vidal, who will talk about meniscal root and lamort tears and repairs. All right. Good evening, everybody. Shetu, thanks for the invite. Thanks for the intro and for moderating. Thanks to ASSM. Super fun to be here with a bunch of friends. So I'm going to share my screen here, and we are going to talk about medial meniscus root tears and lamorts. All right. I have five minutes to give you five things that everybody should know, so I'm going to do my best. In all likelihood, I'm going to run over a little bit here. So all my disclosures are on the Academy website, and were shown on the first slide. So point one is that oftentimes we think of these as two sides of the same coin, but I will argue that these are apples and oranges. I think medial and lateral meniscus roots are very different injuries. Medial, they have different demographics. They have different natural histories. Medial tend to occur in older patients. They're more degenerative in nature, typically female. If you look at the literature, it's, say, five to one. In my clinical experience, it's about 20 to one, female to male. Again, they occur often in early degenerative knees and often patients with borderline or high BMIs, and they have very aggressive natural histories if left untreated. Lateral is a totally different beast. It's a younger patient. It's an active cohort, typically in association with an ACL injury. It does have impacts on joint reaction forces and ACL biomechanics that we'll talk about briefly, but a much less aggressive natural history. How about point two? Point two is the medial side is very, very aggressive. When I was a fellow at Pittsburgh 20 years ago, Chris Harner was one of the first to talk about medial meniscus root tears. He showed us that the biomechanical consequence of a root tear is the equivalent of a total meniscectomy. A lot of us saw these cases early on in our careers that we called spontaneous osteonecrosis or subchondral insufficiency fractures, and they were probably unrecognized root tears. We take it for granted now that we recognize these all the times, but I'll tell you, in the early to mid-2000s, these were getting missed by radiologists and by orthopedic surgeons all the time with significant impacts on our patient outcomes. And we often saw cases like this with a true subchondral insufficiency fracture, significant subchondral edema, and meniscal extrusion. This was a nurse of mine. She was an OR nurse. They missed it at the time of her surgery. They told her that she had a conventional meniscus tear. They did some debridement. This was in six months of that scope, and I'll propose to you that at the time of her scope, her articular cartilage surfaces were pretty normal. And you can see those large geographic areas of grade four damage on both the femur and tibia. So these are bad actors, and they can progress to arthritis very quickly. A lot's been written about this. The Mayo Group has probably published on this the most. This is Erin Critch and the group at Mayo. They looked at the natural history. They took 52 patients. They followed them for about five years, plus or minus. 30% of them went on to total knee arthroplasty at an average of 2 1⁄2 years. The interesting thing is if you look at the patients that didn't go on to total knee arthroplasty, you would think that those were a success, but most of them reported poor knee quality of life patient-reported outcomes. And they argued that almost 90% of their patients failed non-operative management, either because of their PROs or conversion to total knee arthroplasty. Several authors have written about this. The group out of the UK has looked at this, and they show that repair is superior to non-operative management at 12 months. They all can have some progression of OA, but it's better in the repair. And the predictors of outcome that we're going to discuss on point three, extrusion, varus, and the extent of pretreatment OA. Once again, the Mayo group has looked at this. They had a really interesting matched cohort group that took 15 non-operative management, 15 debridement, and 15 repair. Similar to their previous study, four out of 15 in the non-operative management went on to total knee. I often tell our fellows that debridement is worse than non-operative management. I would rather leave it alone than debride it. And the majority of the patients in their debridement group went on to total knee. And that's been my clinical experience as well. And none of the patients in their repair group went on to total knee. Jorge Chala looked at this. He did a systematic review. Again, meniscectomy, two thirds of those patients went on to OA progression. And less than one out of four in the repair group with similar numbers, about a 4x multiple for conversion to total knee arthroplasty. So it just gives you an idea of how aggressive the natural history can be. So what affects, point three, what affects our prognostic factors for repair with medial meniscus root tears? Well, it's a variety of things, and these are all tied. And I often tell our fellows these aren't necessarily independent variables. And we'll talk about how they're all tied. But acuity, alignment, specifically varus, the presence or absence of osteoarthritis, and BMI. So let's look at these individually. How about acuity? The group out of Korea has looked at this. They found a cutoff of about three months led to a significant deterioration of radiographic and clinical outcomes. But these things are all tied. So the longer you wait, the more extrusion you have, and the more OA you have. So all these things are tied. And this is how I help counsel my patients when they come in with a month of symptoms and acute medial meniscus root, and they ask, can I wait three or four months? And I often tell them you can, but the challenge is you may impact your long-term outcome in the success of surgery because of the effect of chronicity on extrusion and OA progression. How about alignment? A controversial topic, but much has been written about this. In general, it's accepted, but I think, again, there's controversy here that greater degrees of varus lead to worse clinical outcomes. We've looked at this as well. We published on this. This was right when I got here to Vail. In essence, if they had higher Kellgren and Lawrence grades, so worse OA, they had worse post-operative PROs, and alignment greater than five degrees of varus led to worse WOMAC scores. The interesting thing is we looked at a sub-cohort of this that had HTOs, and it was unclear that those patients did better. I just had a conversation with Jorge Chala. They are looking up their series now. They're about to publish it, and it was unclear that osteotomy significantly improved those outcomes, so stay tuned for the impact of osteotomy on these outcomes. I personally think that it does help, but I think we need to prove that with clinical outcomes. How about OA and BMI? BMI over 35, higher risk of repeat surgery, and higher degree of OA progression, so you're getting some sense of the natural history of beetle meniscus root tears and what's going to affect your outcome if you endeavor on repair. Point four, Lamorts, very different beast. These are common with ACL injury. Once again, the Mayo Group has published on this pretty extensively. It's anywhere from 12% to 15% of acute ACLs will have a Lamort lesion, and they classified it along these four different classifications. This group and others have written a lot about the biomechanical impacts. It's kind of an interesting topic, so if you look at it, they published on this. Essentially, they found that untreated Lamorts increase anterior translation, pivot shift, and meniscal extrusion after ACL, and they highlighted the importance of repairing Lamort 3 and 4 lesions at the time of ACL. What I will propose to this group is you need to be critical when you look at these papers, because if you just look at the summary and the abstract, you'd be convinced from a biomechanical perspective that all these lesions need to be repaired, and we're going to talk about this in point five. What is interesting is when you look at the outcomes and the biomechanical impact, it's about a millimeter of translation, so it's still unclear if all these Lamorts need to be repaired and if the one millimeter of increased translation warrants surgical intervention. The other thing that's interesting is when you look at some of these biomechanical papers, if you want to be critical, this was done by the late, great Freddy Fu, who was one of my mentors. They cut the meniscal femoral ligament, and I'll propose to you that that's not an injury that I've ever seen in nature. Every single Lamort lesion that I've seen has an intact meniscal femoral ligament. Lastly, if you look at the stabilizing role of the meniscal femoral ligament, it does not lead to increased joint reaction forces or increased translation, so I think you need to be a little bit skeptical and critical of literature as you interpret these biomechanical studies and its impact on your clinical treatment. Lastly, is that there is controversy about optimal treatment for Lamorts. I would say that if you go to any sports medicine meeting, in general, you'd think that every single one of these need to be treated. I would say that for me, just informally querying my friends that are in academics, it's probably about 50-50 who feel that these need to be aggressively treated. I do err on the side of repair, and I'll explain why in a minute, but Leo Pinchenski had a really interesting paper. They looked at almost 500 patients with 15-year follow-up with Lamorts that were treated non-operatively, no difference in outcome between an untreated lateral meniscus post-root tear, and no injury when they compared it to a cohort without injury to the meniscus. It was interesting because a similar group put in a rebuttal, and they said, we acknowledge your clinical outcomes, but the biomechanical evidence that I presented earlier supports repair of these injuries, and I probably saw the most interesting rebuttal I've ever seen in a journal, which is Leo Pinchenski's remark. He said, nothing ruins a good operation like clinical follow-up. Again, 15 years of follow-up on 500 patients is pretty impressive. We looked at this in the MOON cohort. I will argue that we weren't super critical. We weren't talking about Lamorts in the era that we collected this cohort, so these were a variety of different lateral meniscus tears, but we looked at essentially 208 lateral meniscus tears that were left untreated and in situ at the time of ACL. Presumably, several of these were Lamorts, and only 2% of these required reoperation. In general, had very little reoperation and good clinical outcomes. I do tend to repair them, and why? We can talk about these in the cases. I do all inside repairs, but not with an implant. I use an all suture device to repair it and tie it down using arthroscopic knots. Why do I do that? I do it because it's technically easy. I don't want to trim any lateral meniscus because I think the lateral compartment can be very sensitive to meniscus deficiency. I think right now the data is conflicting, and we do have a little bit of friction between the biomechanical data and the clinical data, and I don't restrict weight bearing, so it doesn't meaningfully impact my recovery after ACL. In general, these heal amazingly well. This is a patient that I went back for a Cyclops, and you can see that healed a Lamort, and it's amazing the healing capacity of that lateral meniscus. That was a quick whirlwind. That was Lamort's and medial meniscus, five points in five minutes, and I look forward to the cases, and I'll pass it on to the next speaker. Thanks. Thank you, Armando. That was fantastic. Next, we have Dave Bernholt talking about all inside versus inside out bucket handle tears. While he's pulling that up, I just want to get to one question for you, Armando, from the audience. Could you please touch upon how you approach an acute root tear versus a degenerative tear in an older patient? If younger, but unwilling to do the rehab, how do you approach that? Sorry. Younger with an acute... If it's an acute tear, I'm pretty aggressive about recommending surgery because I think the biomechanical consequence of that injury, if we're talking about medial specifically, is pretty clear. I think that the biomechanical data, the clinical data, all is concordant. I think there's nuance and shared decision with the older patient who's degenerative because your options range from allowing them to just continue the degenerative process and get a total knee. You get some patients that can't comply with non-weight bearing and all the recovery. I think it's important that you have a conversation with patients about what the impact is of leaving it alone, what the impact is of waiting, and how willing are they to undergo a total knee arthroplasty if this progresses along that degenerative curve. I think it's shared decision-making, and I think it's a nuanced answer, but I think you just have to have that conversation with patients and explain them the fate and what their options are. But in general, pretty aggressive with a recommended repair. Okay. And then real quick, what about centralization for roots? Ah, great question. If they have extrusion, I try to do some sort of centralization. I typically do a meniscal tibial ligament tenodesis. I make a little incision medially, and you can use knotless anchors to essentially anchor that down. There's some evidence that that extrusion sometimes even occurs before the root fails. We've looked at that biomechanically. Aaron Critch has published on that. So if there's extrusion on MRI and certainly if there's chronicity, and again, those things are tied, I am more apt to add some sort of centralization either through a drill hole or meniscal tibial ligament tenodesis. Great. Thank you, Armando. All right, Dave. Thank you, Dr. Malampati, and thanks to the AOSSM for putting on this great event. So no disclosures. We're going to attempt to answer the question of all inside versus inside out meniscus repair for a bucket handle tear. So anytime you're trying to answer a clinical question like this, it's always good to turn to the data. What does the data say? And I'm gonna highlight two studies here that were both published in the last six months. The first is a study out of the Mayo Clinic looking at 10-year minimum outcomes. So long-term comparative outcomes between all inside and inside out repairs. And the punchline here is there was no difference. 70% for all inside, 60% for inside out, no statistical difference. They did, of note, show medial meniscus bucket handle tears to be bad actors. That's been pretty well established in the literature at this point. So then this is the second study I'm gonna highlight. This is a recent systematic review put out by Jorge Chala. And they looked at 16 different studies. And if you compiled the data, the range of failure rates were very similar to one another. There's no difference in how these are performing. The last study here that I'm going to highlight, this was published a couple of years ago out of the UK. And this contrasts in the findings. And so there is a difference in the setup of this study. This is two-year outcomes in elite athletes. And so you could argue maybe the demand of these patients are higher, and that's what brought out this significant finding of all insides failing at a higher rate for bucket handle repair at 58% compared to 23% for inside out. But it's important to note that in this study, the all inside group, the repair construct only featured three sutures on average compared to eight for the inside out. So that then brings up the question, well, why would there be less fixation points? And so there's important to note differences with cost and access, as well as size with these devices with all inside meniscal repair, having much larger devices in comparison, almost double the size compared to many of the, or compared to a inside out needle. So inside out meniscus repair has classically been referred to as the gold standard. You can debate whether that moniker still is warranted, but when we're talking about all inside devices in 2025, I think it's fair to say we're moving towards making things more like inside out repairs. So what I mean by that is we're trending to become smaller and allowing better access. So there's now bendable implants and different curve options. So this video featured here shows different curves utilized to create mattress stitches, creating mattresses both on the superior surface as well as the inferior surface to reduce the meniscus. And you can achieve a nice density of repair sutures to better approximate what you can achieve with an inside out repair. It should still be noted that inside out remains smaller. It makes a 0.9 millimeter hole compared to ballpark about 1.5 millimeter, give or take, depending on which particular implant you choose to use. So basically the summary, the answer to the question right now, all inside versus inside out for a bucket handle meniscus, essentially this is a dealer's choice. And I use both of these techniques in my practice. I use them for different scenarios. The factors that most influence the decision for me are implant cost as well as OR resources. So depending on insurance status and whether the insurance will pay for implants or not, if you're talking about achieving the level, the number of fixation points we want to achieve with an all inside repair, it's going to become a fairly pricey construct. So that's something to keep in mind. In terms of OR resources, inside out repairs typically require more time. They also require a skilled assistant. Whereas if you're using a leg holder for positioning, it's fairly easy to accomplish a meniscus repair without an assistant. The other factors, the morbidity of an additional incision could be considered and then reliability. There is a learning curve to using these devices. They can misfire. And the effect of a misfire, if you're removing an implant, can cause iatrogenic damage to the meniscus. So that's something to be aware of. And then as mentioned before, there is a difference in access that can be achieved as well as size. Although those changes are becoming more narrow over time. Another key difference to consider as you start to approach the root and your bucket handle repair, the inside out and all inside have different considerations. With an inside out, it's going to be harder to catch and find the needles in this location. With all inside, this is where you have a higher risk of neurovascular injury. So be careful on the depth of penetration of your needle. Use the stops to set your distance to be sure if you need to. So now some take home points, things to ensure. So no matter which technique you use, get enough fixation points. So this is a study from about five years ago at this point. Now, this is not specific to bucket handle repairs, but they did show that meniscus repair failures were associated with less fixation points. I know it's not exactly a topic we're talking about all inside, inside out, not particularly about outside in, but as we're talking about getting enough fixation points, as you start moving anterior to the mid body, it's important to make sure you include outside in fixation points to ensure that you're getting adequate fixation of your meniscus. As I mentioned, I am a proponent of using a leg holder. It gives you excellent ability to open up the medial compartment during these bucket handle repairs. You can pie crust the MCL if needed. There's good data that shows the controlled partial release of the MCL does not lead to any inferior clinical outcomes. And in fact, this is a recent study that here at the bottom highlighted that showed, now this was for root repair and not bucket handle, but should improve clinical outcomes at minimum to your follow-up when pie crusting is utilized. So use it to your advantage to allow better access to help you get your repair. And then consider accessory portals. You can use a spinal needle to make sure the portal you're gonna make is going to have appropriate trajectory to allow you to get your implants in where you want to on the meniscus. And then we're not gonna go too in depth on this as this is a topic that's gonna be addressed later, but optimize biology. So take these patients to the OR quickly, use crutches in the interim to protect the meniscal fragment, repair the tissue with a rasp that was shown in the video on the side earlier. And you can use a K-wire or other techniques for marrow venting versus other biologic augmentation, which includes PRP, VMAC, and Fibrin clot. More to come on those, but these are very cost-effective, especially marrow venting, a very cost-effective means to increase your rate of meniscus healing after a repair. That's all I got. Thank you. Awesome. Thank you, Dave. Next, we have Dr. Shana Muscovsky, and she will talk about radial tears. Dave, there was a question about all-inside repairs for bucket handle, given that inside-out is the gold standard. You hit on that a little bit. What's your cutoff to all-inside versus then using inside-out? Yeah, I mean, I think it's arguable whether you really call inside-out still the gold standard based on some of the data that's out there. Now, we don't have good level one comparative data where fixation points are held similar between the groups. But if you look at the 10-year data out of Mayo, if you look at Jorge's systematic review, there's no difference in failure rates. So I think the key is making sure you have enough fixation points and just understanding the pros and cons of each. Like I said, I use both in my practice, depending on the scenario, depending on whether implants are covered. But I think they're both very viable options. And the data we have available does not suggest that one is necessarily superior to the other. And then another question, is medium risk of superior ever indicated patients over 75? Is there a risk of failure to heal? I would suspect that some of it depends upon the OA profile and the compartment and such. Yeah, I think that's dead on. There's no, as far as I'm aware, there's no data that can cleanly compare that. That's gonna be very hard to do. I will say my own personal practice, oldest age of a bucket handle repair is 67 and a gentleman with pristine cartilage who was active. And so, and of one at that age, I know that's not 70. I've never had a bucket north of 70, but that gentleman did well. But I don't think there's much data out there for that scenario. But if the cartilage is good, the meniscus quality is good, you're getting to an acutely appropriate ligaments stability. I would say I don't see any reason why you couldn't repair. Perfect. So thank you for the opportunity. I'm going to do the five things you have to know about radial tears of the meniscus. Five things I've learned. Also, I need a lollipop every time I see a radial tear because there are some issues that we'll go through that make them more difficult to treat. Next slide, please. Radial tears are special, not in a good way, unfortunately. They are oriented perpendicular to the meniscal edge. You lose the circumferential collagenous fibers in the periphery. And so essentially the meniscus can't translate the axial loads into tensile strains. And so hoop stresses aren't well taken care of. So unfortunately, the outcome of these can include meniscal extrusion, increased joint contact pressures, cartilage degeneration. And these outcomes are higher in the radial tear type compared to other types of meniscal tears. Next slide, please. Radial tears, another learning point, they lead to poor knee biomechanics. So unfortunately, large tears, decreased contact area, increases compartmental pressures and essentially creates a total meniscectomy. And in post-op patients with partial meniscectomy, you can see changes in the gait that you see in knee arthritis patients, including knee adduction and flexion moments. Next slide, please. Point number three, learning is radial tears. Try to fix them if you can. Obviously there are some relative contraindications to repair, that is if there's joint space less than three millimeters in the involved compartment, if they have very high KL grade three or higher classification if they have modified outer bridge grade three or higher conjural lesions in the area of the tear. You also have to watch out for genuvarum and genuvalgum as you may have to realign the knee as a treatment or in addition to trying to address the meniscal tear. In general, if it's in the white-white zone, theoretically there's less blood flow and so we would do partial meniscectomy in most cases. Interestingly, there's some recent literature out there that says there may be some progenitor cells in the white-white zone and so keep tuned that might change over time or indications. But when you do pick surgery for these tears and they have a good potential for healing, surgery is the option that is preferable. There are numerous ways of fixing radial tears. The main point is make sure you do the tear repair well, patient outcomes don't change. There's two classifications. There's an inside out repair, which is a more traditional repair that requires an open incision, has more neurovascular complications potentially. You also have to retrieve sutures and so needle sticks with your assistants are also a complication to be aware of. The other type is all inside repair and with newer implants. These have been found to be biomechanically superior and that there's displacement decrease, there's a higher load to failure and also a greater stiffness to the repair. And there's a number of ways of repairing, so the double vertical repair basically have a transverse portion of your suture coming perpendicular to the plane of the radial tear with a more vertical suture coming out with an anchor or a tunnel. Hashtag repair just refers to an inside out horizontal repair plus a vertical mattress ripstop suture, which I'll go through in a minute. The cross tag repair is a suture based all inside figure of eight type configuration to repair it plus a ripstop suture. So when you place your sutures perpendicular to the radial tear plane, the ripstop suture is placed actually vertically. So it's perpendicular actually to the circumferential fibers and it's placed on the edges of your horizontal suture. And the thought is it reinforces repair and prevents if your radial tear starts to re-tear, it prevents it from spreading. There's also some techniques that require two tunnel trans-tibial pullout repair where you do your sutures and pull them through a tibial tunnel and then use a device to fixate on the tibia. There's also a hybrid double vertical trans-tibial pullout with all inside horizontal repair. So there's about 21 different types that have been studied in large systematic review. And again, the particular repair technique you use doesn't necessarily matter in patient outcome. What I typically do is I use a curved suture needle that goes through with all inside suture implant based repair. I basically poke that limb of the radial tear that's extruded and try to push it and pull it back over to kind of meet the rest of the tear plane. And I do some way out of a ripstop suture to fixate it to the capsule. And then that takes a little pressure off my repair as I do my horizontally based sutures to fix the radial tear itself. Next slide, please. Point number four, with radial tears in particular, we do have to make changes in the rehabilitation after surgery. So non-weight bearing is key. Otherwise there's significant distraction forces. We also have to limit flexion to 90 degrees to release the first four to six weeks to avoid stressing the repair. Post-op hinge knee brace wear is usually longer after radial tear repairs up to seven to eight weeks. And full weight bearing again is delayed to about six to eight weeks depending on the severity of the tear. The one thing you have to caution your patients is that recovery takes a lot longer than other types of repairs. It can take up to six to nine months. So these radial tears are difficult. They're bad actors. You have to protect patients longer after you fix them. Next slide. The final point and learning point I would make is we need longer term hirable studies to evaluate radial tears in particular. So on second look arthroscopy, studies have shown 60 to 86% healing rate, which isn't bad. There's partial healing rates in one arthroscopic study in 90% of patients. So it seems to be worth trying to fix these radial tears. A recent systematic review show that patient reported outcomes, WOMAC, et cetera had no effects with respect to the repair technique used. And so again, be proficient, get good contact of your tear planes and get a stable repair and patients will do well. Repair seems to restore function activity, but unfortunately with respect to the athletic population in general, there's not a lot of data out there. So we need to do further research on that population particularly. Biologic and augmentation techniques do exist, but with respect to radial tears itself in that subgroup of tears, we still need more data. And finally, we're not sure if long-term this means 10 to 20 years down the road. If we fix these radial tears, are we preventing the joint degeneration over time? And those are my five key points for radial tears in particular, and I hope you enjoyed them and hopefully they help you out when you're treating patients. Thanks again for the opportunity to be part of the seminar. Awesome, thank you, Shana. Next, we have Dr. Seth Sherman and he will talk on meniscal allograft. Hi, Chai, can you hear me and see my slides? Yeah, you're good, Seth. Excellent, well, this is awesome. I've been writing down questions for my panelists if we have the time. My task is really to talk about meniscus transplant, giving you my tips in five minutes. The key take-home for me, and I'd love info from you all because there's room for improvement in meniscus transplant, clearly evidence-based humility. We published this 58% reoperation rate looking in a big database. So that's not just experts, that's all of us around the country doing these surgeries at a year. But fortunately, the early complications are low and the conversion rates to other interventions still remain low. It's really important for indications to recognize that MAT does not last forever. These are basically tire changes or space holders, and that truly influences in a lot of cases when and if we might offer it to our patient. There are many targets for improvement, patient selection, better meniscus tissue, improved techniques, biologic augments, as we'll hear about next, rehab, return to sport, just a ton that we can make better. We had a great consensus group. Most of the things I'll say here are from that group 10 years ago. We should repeat it. But MAT is really not considered routine in asymptomatic patients because the chondro protective effects are still controversial. Animal models show protection, but human studies show mixed results. There are more and more studies, however, including this one, showing longer-term chondro protection. Here's on the lateral side. This other study is both medial and lateral, particularly for anatomic and non-extruded transplants. So this is a moving target, but just doing something for the future at this point in 2025 has to be taken with a guarded recommendation. I looked at this with Kevin Shea, biomechanical study, and while we do a good job restoring contact areas and pressures, it's not a great job. And so these are imperfect solutions to tough problems. I think most of us, if you see this young girl with asymmetric valgus, lateral meniscus deficiency, a cartilage defect, are gonna throw the kitchen sink, including meniscus transplant, at her. But is that for everybody? What about asymptomatic patients with stable knees? What about the discoid lateral meniscectomized adolescent in Varus? What about a medial meniscectomized athlete who wants to return? And so it gets really challenging. Here we're looking at ACL-deficient knees. Certainly my indications are evolving. We know the medial meniscus is a secondary stabilizer. And in some cases of revision ACL without a medial meniscus, we're really doing the meniscus for stability and not necessarily for pain. These patients often have 3B Lachman's. Like this guy, he's 21. He's failed multiple ACLs. He has no meniscus. And so we do a repeat revision with his quad. We do a meniscus transplant. We add an LET. And he goes on and does quite well with a nice, stable joint. There's really no superiority of one technique over another. Here's that in systematic review. Anatomic placement, regardless of technique, really does matter. You can see failure rates higher non-anatomic versus anatomic. Extrusion matters, and we're learning more about that with roots. And we're translating a lot of the tools to our meniscus transplant techniques as well. My technique, and I think most of those who are doing these relatively commonly, I do 12 to 15 a year. It's almost all soft tissue now, a little bit of bone, anatomic bone sockets, hybrid fixation. Basically, this is technically easier than some of the older techniques, really strong fixation, real-time adjustment of graft mismatch. So here you're seeing just familiar tools we might use for roots. Anteriorly, particularly on the medial side, I use a low-profile reamer like you see here, because I really have to get up and over the anterior edge, whereas on the lateral side, I can still use a retro reaming device. I tend to fixate posteriorly with a rigid anchor. I use more of a hybrid technique on the front with a attachable button, as you see here. That way, if I make the anterior socket deeper, I can actually taper for graft mismatch, so I can really tailor this and get a nice anatomic fit. And so you can see, basically, I do my definitive anterior fixation at the end, so I can really pull that anterior part into the tunnel. That way, I'm not extruded at time zero, and I can get kind of the solid fixation for early range of motion that I really want. What about all suture root fixations? There are some perceived and real advantages here. There's just not a lot of evidence for things like this when we're talking about meniscus allograft transplant. So time will certainly tell, but I think these could be coming more familiar for our root techniques. Meniscus tibial has been a hot topic. It's really intriguing to do this, but Al's study here, really no reduction in extrusion with that specific technique. I tend to put these down to suture anchors. It sounds like similar to what Armando was describing with centralization. And I think on the medial side, I can get really nice meniscus tibial fixation. I'm more concerned on the lateral side for doing any of this. And I certainly think we can adopt the centralization techniques to meniscus transplant. I think Pat Smith might've just come out with a technique that did just that for this type of thing. Also being creative, circumferential tape augmentation. Look, we know that extrusion is a problem and we know that we need to find novel solutions. Lateral capsules is my solution on the opposite side. I basically bring the capsule to the meniscus and then I put the meniscus in. And this is better in my mind as described across the pond in Spain, than doing a meniscus down to tibia where it should be more mobile. And so it's basically like a remplissage procedure for the lateral side before the transplant comes in. And I'd argue that these look really good at time zero. They actually look good in stiff patients on second looks. I mean, the periphery heals, the roots heal. These typically tear over time in that white, white zone, probably a biologic phenomenon or a placement phenomenon with increased stress. And lastly, we really don't know about orthobiologics in these cases. And so we don't have great evidence to support it, but I do think there's obviously a rationale for biologics, perhaps even for viable transplants to improve our success rates. For rehab, we can talk about this. I tend to prefer delayed rehab, lower risk of extrusion, reduced arthrosis without differences in clinical outcomes. And then the group from Mizzou showed in their series the exact opposite thing. So clear as mud. We avoid caution. We have a lot of caution with return to contact sport, systematic reviews, really all across the board with return to sport rates. You can see as far as timing and which patients and what they did. You can quote 70 to 80%. You wouldn't be wrong based on the literature. You can see the relative times, nine months and change. However, nice, generous sports, I mean, this is 18 to 20%. So that's not a lot. And so this was a whirlwind, maybe a few more than five points in five minutes, but I did my best. There's certainly room to improve meniscus transplants. Indications techniques continue to evolve. We clearly need to optimize both biology and biomechanics to improve durability and ideally to influence and prolong the longer term outcome for our patients. And really a toast to the Mercure group, multi-center collaboration. We're gonna try to get big prospective numbers of our transplants and try to do this right to put some better science behind the thinking. And thank you very much, Chai. And I'll turn it back over to the group. Awesome, thank you, Seth. Next, we have Dr. Arvind Arthivaram, who will talk about biologic augmentation and meniscal repair. All right, hopefully you can all see my slides. You're good, Arvind. All right, excellent. So, as highlighted in this webinar as well, isolated meniscal repair has a much higher failure rate in literature compared to meniscal repair combined with ACL reconstruction. Studies have shown between 20 to 25% failure rate of isolated meniscus repair compared to less than 10% when meniscal repairs combined with ACL reconstruction. One of the thoughts for this is drilling bone tunnels during ACL reconstruction leads to a hemarthrosis that provides a rich environment with growth factors and fibrin clot. This promotes proliferation of meniscal fibrochondrocytes. Our challenge is to try to create the same environment without needing to do an ACL reconstruction. Obviously, with the time constraints, we can't focus on every biologic augmentation available, but we're gonna talk about fibrin clot, bone marrow venting, and plate-rich plasma, which all have some literature behind it. So fibrin clot, Dr. Malapati showed that briefly in his slide. So in this technique, you draw blood from the patient for about eight to 10 minutes, use a glass rod to stir it, creates a fibrin clot, place it on a gauze and incorporate it with suture into your meniscal repair. And this is thought to act as a chemotactic stimulus and scaffold for reparative cells. Retrospective case series have shown positive results in a study by Henning. In core, he showed isolated meniscus repair with fibrin clot had 92% healing versus 59% in his control group. Marrow simulation, again, very commonly done. So multiple different techniques to do it, also known as bone marrow venting. You can use a microfracture awl or other device to poke holes in the area of the bone where there's no cartilage. Typically, I'll do this. Just enter to the ACL for a lot of walls into collar notch. And the thought is that it introduces marrow elements into the knee. This is the study out of the Stedman group. They compared 37 patients with isolated meniscus repair with bone marrow venting and compared it to 72 patients with meniscus repair combined with ACL reconstruction. And what they found was that there was no significant difference in either reoperation or failure or their peer rows. So they suggested based on their results that bone marrow venting may produce a biologic malaria comparable to ACL reconstruction. It's a group out of Poland. It was a single center prospective double-blind randomized controlled trial. They compared 23 patients with bone marrow venting and 21 patients without. And again, this is for isolated meniscus repair. They did a second look arthroscopy at week 35. They found 100% healing rate in the bone marrow vented augmented group compared to 76% in the control group. All the peer rows that they looked at were all better in the bone marrow vented group. What about platelet-rich plasma? So the thought is that PRP leads to an increased release of growth factors, such as the ones you see listed, promotes the viability of fibrochondrocytes, increased cell migration, accelerated matrix formation. It also thought to have a local anti-inflammatory response and promotes chondrogenesis. This is a nice study out of Ohio State by Everhart et al. He looked at 550 patients and it was a prospective study. So they compared patients with and without PRP. Also, they looked at patients with or without combined ACL reconstruction. In their study, they defined failure as reoperation. What they found in their study was that PRP did improve the survival rate for isolated meniscal repairs, but had no effect on survival of meniscal repairs when done in conjunction with ACL reconstruction. This is very nicely shown in their survival plot. So if you look at the graph with the highest survival, this is actually the isolated meniscus repair with PRP augmentation compared to the lowest dashed line, which is the isolated meniscus repair without any augmentation. So quite a dramatic difference there. However, in the ACL reconstructed group, there was no difference with or without PRP. That same group out of Poland that conducted the other randomized control trial also looked at PRP. So they looked at 37 patients with vertical longitudinal meniscal tears with or without PRP, and they assessed healing either with MRI or repeat arthroscopy. At 18 weeks in the PRP group, that 85% healing versus 47% in the group without. And again, the PROs are all better in the PRP group. This is a meta-analysis by Lee in published orthopedic surgery research in 2022. Again, a large number of patients, 1,164. They found lower failure rate, again, with PRP, with odds ratio of 0.64, improvements in VAS and crew scores. So one of the main attractions of PRP is it does meet the FDA criteria for minimal manipulation homologous use as an excellent safety profile with other indications and it's easy to use. And again, there's some literature behind it that's coming out. Major cons is cost as alluded to. It's off labels and it's as such not covered by insurance. And we've seen that there may be other cheaper ways to enhance the biological milieu. And we talked about bone marrow venting. We also talked about fibrin clot. And PRP, again, there's a lack of standardization of formulations and applications. And even within the same patient, depending on when it's harvested, the exact sample that's coming out may be different. To answer the question whether or not, how PRP relates to bone marrow venting, we're actually part of a large randomized controlled trial that's across several sites. We're looking at standardized PRP formulations and post-op protocol. We're excluding, obviously, anything that could confound results such as root degenerative tears. And mainly looking at radial tears, vertical longitudinal tears, other non-root unstable tears. Our outcomes that we're looking at include PROMIS scores, re-operation, IKDC, Tegner, and MRI when clinically indicated. So stay tuned for the results from that. So in conclusion, biological augmentation for meniscal repair is an exciting future. We do need to enhance the consistency and determine optimal concentrations of blood components when using PRP. And again, try to determine what's the best method to augment meniscal repair. So again, more level one studies will be coming out in the future, so stay tuned for that. Again, thank you very much, Chetan and Ayoza, for the opportunity. Thank you, Arvind. That was great. Question for you from the audience. If you marrow vent or use PRP and the patient has a post-op effusion, are you draining it? If so, is there a timeframe in which or after you do so? So, yeah, I typically do not, I would not drain that, especially in that circumstance. I think typically, ice the knee, rest ice compression elevation, I mean, usually is most new effusions. But I would say by six weeks, it's still significant, which I've not necessarily seen in my practice, I would consider doing it. But I would say for the most part, I've not seen a large effusion that would necessitate early drainage. Awesome, thank you. Yeah, I haven't really seen that either, but great talk on biologics. For the panel, any questions for the other panelists? Hey, Chai, can I jump in and ask Arvind just a follow-up for PRP? Do you put it into the joint or are you putting it into the peripheral aspect of the meniscal capsular junction or both? And is there any data to support either of those two? Thanks very much, Seth. So when I inject it, I just inject it, so I take all the arthroscopic fluid out, close the other portal, and then just inject it inter-articularly we're doing a standard injection. Obviously, it's gonna move around, so I don't think that, I don't do anything special to localize it. I'm not familiar with any techniques to look, so I know sometimes, I've been described, but I've not seen any literature behind it yet. Yeah, I think I saw Don Buford talk to us and mention it, and I've been doing that now, localizing with a spinal needle more peripherally and trying to just induce the body's own cellular response and or bring growth factors that might be there and may not get swept away in the hemarthrosis. So I think we have to put some science behind it, but that's just my thoughts on that. Okay, thank you. Another question for Armando, how much arthritis is too much for a good result with a medial root repair? That's a good question. I mean, I think grade two and grade three changes are pretty typical with these, at least in my experience. It's grade four, I think, is where I, obviously, I think the outcomes deteriorate. It's not infrequent to see some grade four at the most medial extent, the medial tibial plateau is that meniscus extrudes, that seems to be the pattern. I think when you bring that meniscus back, it covers that, so that doesn't make me as nervous. Grade four changes in the femoral condyle, I think is concerning. I think if it's a young enough patient and the rest of their knee is good, you can couple that with an articular cartilage reconstruction. I just did that on a friend of mine where we did an ocealograft. He had a neglected root, tibia was fine, we fixed his root, we did an ocealograft, his alignment was favorable. So I think grade four, you either need to consider a different intervention or you need to consider something to restore that articular cartilage, but that's pretty seldom. Most of these patients are a little on the older side, so typically by the time they have grade four, I think you're looking at probably arthroplasty. Armando, very briefly, if you're in there, are you guessed wrong? You have a little heavy patient, you have grade three to four, maybe on one or both sides with some extrusion and you were gonna do a root, do you do it or do you lay up? What do you do with that patient? I think, I don't, I mean, I don't know if there's a cut and dry answer. I have bailed. I mean, if that's the question, I've gotten into it because I don't want to put a patient through that. The surgery is easy, but the recovery is significant. Making somebody non-weight bearing for six weeks is cruel and unusual punishment. So I've had cases, I had one case that I can think of where I bailed and actually brought the patient back and did an osteotomy on them, like at a later date, but obviously you can't do that on the fly. I had another one where I bailed and just told them, unfortunately, this had progressed and there was a delay between the MRI and arthroplasty was their only option. Thankfully, that's pretty seldom, but it happens. I bailed with the ESCA traveling fellows in the room with DeJure there telling me to bail. Yeah, it was a great case. Well, if DeJure is telling you to bail, you feel like, you know, you've got some backup. Awesome. Another question for Seth. In the case of an elite young athlete with an irreparable meniscus, how do you balance the need for meniscus allograft transplantation with concerns about long-term durability, graft extrusion, and return to play timelines? Are there specific modifications in technique or rehab that you found particularly effective in this specific patient population? Yeah, it's a great question. I'll be brief and open up to other panelists to comment on this one as well, if you want, but I really don't have any significant role for Matt in the elite athlete, maybe in the aging elite athlete or the retiring elite athlete. I think the timeframes are too long. The IMREF group really wasn't for contact collision sports. So, you know, these are really big guys and they may tear it up. And so if I have like an ACL patient with meniscus deficiency, I'll do my best ACL graft plus an LAT, lay crepe, and then maybe do something later. And that's kind of where I am. If you have no other choice, it's the end of career, or you do a MAT, then yeah, of course I would do it. And I would just go 12 months and then go by functional criteria and hope. Anyone else have thoughts on that? No, I'm very much aligned with that, Seth. That's exactly why I think about it. I often tell our fellows and our patients like meniscus transplant's the least predictable tool in my joint preservation toolbox. You know, osteotomy is reliable, osteolograph, but transplants are tough and unpredictable. Yeah, same here. Great, any other questions from the panelists? We've got a couple minutes here. I can ask Dave, any tips or tricks for access lateral? I know we talked about pie crusty on the medial side, but what if you had maybe, let's say a bucket in a tight lateral compartment or something that you have to access, what do you do? Yeah, you know, I use a leg holder in almost every knee case I do, and I've never had issues with access on the lateral side. Usually the trajectory of the portal is more of the issue. I can get the space open enough, but sometimes I find myself making a second accessory, a separate portal from my standard AM to get a better trajectory. Yeah, correct, yeah. Anybody pie crust IT band or do anything different on the lateral side? I haven't, but I've considered it. I've, you know, I've talked to people about it. Do you do that, Seth? I've not. Yeah, me neither, but I mean, there's certainly, I've not had the same experience as Dave. I've had some that are so tight that, or ones where I've done a meniscus repair and I'm just praying I never have to go back in to do a transplant, because I'm not sure how I'd ever get it in there. Question for the panel, is anyone, when you have a concomitant ACL with a root repair, is anyone, when you talk about convergence of tunnels and all that, is anyone putting the root repair tunnel just lateral to the crest? Just getting it out of there on the intramedial tibia. Lateral to, you're talking about the aperture on the tibia? Yes, just moving it out, getting it away, just moving it lateral to the tibial crest. Yeah, I mean, I'm trying to think. So it's rare that I do them through transosseous tunnels. Occasionally you do though. I do move it lateral to my ACL tunnel and just posterior, and I just do it before I pass my graft. So I do my ACL tunnels first, and then I do that tunnel second. Sometimes you get a little bit of convergence, but it's on the periphery and you can still pass a graft adjacent to it. And I'll fix it. There are newer devices now that are aperture, they're at the surface, so you don't have to worry about convergence as much. So there are some technical things you can consider. As Armando said, the most common is ACL with lateral root. And for me, I typically can just go more posterior medial and get to the lateral root. And then my ACL would be more central and more proximal in that those tunnels are not in the same zip code in most cases. Revision ACL medial meniscus transplant or medial roots can get a little more challenging, but I haven't gone lateral. Would you do that for medial, Chai? For the medial root? Is that what you're saying? Yeah, for the medial root. You get these questions all the time. Well, how do I remove the tunnels? Can I just bring the tunnel just lateral to the crest? You're not even working anything there, right? I don't think there's any problem. I don't think there's a problem with it. I mean, I think that's reasonable if you need the space. I think the Koreans just published a study where they brought the tunnel to far lateral, like kind of near the head, which is somewhat different, but you just move it just lateral to the crest and don't worry about it at all. All right, for the sake of time, I think we have to wrap this up. It was fantastic. You know, I wanna thank all the panelists. You guys are awesome. Very informative, great webinar, great discussion and awesome cases. Please feel free to continue to ask questions or send to the Q&A portion and we'll try to get to them after the webinar is over as well. And then, and also thank you to our audience. Thank you to the AOS Assignment. Thanks for attending.

meniscal tears

biologic augmentation

repair modalities

MRI planning

patient selection

allograft transplants

platelet-rich plasma

evidence-based insights

elite athletes

surgical techniques