Lateral roots, not ramp lesions, sure. And so when, how and why should we repair them? Okay, so disclosures haven't changed. So why are they important? Well we know that root tears have an impact on defunctioning the meniscus and so we do see a change in contact mechanics in the lateral compartment and that's particularly important when you're dealing with the lateral side with the the convexity, unconvexity, so that essentially that challenging morphology in the lateral compartment. So from a point of view of just joint preservation you've got one strong argument to try and restore normal function of your lateral meniscus. We did a study looking, not looking at contact pressures, but wanted to really look at the understanding of kinematics associated with lateral meniscus root tear. We find that in angles closer to extension that the addition of a lateral root tear to an ACL deficiency increased rotatory laxity and so, and that was also shown by Hideko Koga's group in Japan, showing that the lateral root aided in control of anterolateral rotatory laxity. So really important from a point of view of thinking about repairing these in the ACL deficient knee. So how common are they? Well what we see in most studies is about an 8% prevalence and certainly we saw that we had about 6%, 6.2% in stability of lateral meniscus root tears. Okay and this was our cohort. Now we also looked at this in terms of a number of studies looking at MRI scans. I'm just going to show you some of this data of the impact of lateral meniscus repair within the stability trial. We had a number of patients that came back one in two years for quantitative MRI and not only did we look at lateral meniscus healing but also look at the articular cartilage. What we saw was that there was a pretty good healing of the lateral root repair. We only had one that was classified as failed on the MRI and this was some earlier data that we have more updated data with an increased number of patients. We see some very small minor changes in the quantitative MR and the more anterior aspect of the articular cartilage but we're not sure if it's clinical relevance but certainly it's something that we have to be aware of. So this is a really interesting study that came out recently Journal of Arthroscopy and this study from Leo Pincheski who looked at a series of his ACL reconstructions with what he described as having a stable lateral meniscus root tear and these were not repaired and he found that they really didn't have an impact on outcome and I think it's really challenging to interpret this particular study in terms of what they described as a stable lateral meniscus and essentially when they drilled down looking at patient-reported outcomes they didn't see any differences but when you look at actually the ACL graft rupture rates it's really not powered to look at graft rupture and I think that's an important finding here is that I would argue that I do a lot of lateral root repairs to try and reduce my failure rates rather than thinking about patient-reported outcomes. So it's certainly something that we need to be aware of. How do we perform a root repair? We'll have a number of different options in terms of sutures within the meniscus root itself as well as the technique that you use. These studies looking at both simple cinches and luggage tags really not showing a significant difference. The double tunnel trans-tibial seems to show that you have a greater load to failure by using a double tunnel versus a single tunnel but when you actually look at the numbers the question of whether or not this is clinically significant again is not hasn't been answered. This is more just a study looking at the medial meniscus posterior root in terms of where you place your sutures and that's what you don't necessarily want to pass it into the root ligament the stronger position is in work at the transition and body and that's really and also the use of tape has been shown to have a higher load to failure so certainly I've moved more to being using tapes rather than a simple sutures. So if we take a patient this is a 26 year old revision ACL reconstruction, high-grade anterior laxity, high-grade rotatory laxity and here's just an arthroscopic image classic position where the roots off the tibial plateau still got some attachment of the meniscal femoral ligament but essentially that lateral meniscus is now defunctioned you can already see some of the chondral changes on the lateral femoral condyle so for me this is certainly a patient that I would wish to repair. And so the first step you can see I've already drilled my ACL femoral tunnel with the suture sitting in the femoral tunnel but the first stage is to debride the insertion point so using a curette and shaver really get down to good bleeding cancellous bone and then using a root guide I can pass a 2.4 millimeter pin and then I over drill the pin with a 4.5 millimeter drill so a candidate drill and so I'm using a single tunnel technique and then you can see passing the suture tape with a proprietary suture passer and you can do this in a number of manners this is just using a simple suture configuration in a mattress sorry a mattress suture but you can also pass it in a luggage tag type fashion but that's just a simple suture so pass one and then I'll pass another over the top of that in a simple suture configuration which which creates a bit of a ripstop type technique and get a really good hold of that lateral meniscus. So once the sutures are in place then it's just a matter of shuttling those sutures down into the tibial tunnel and there are a number of different devices that can be used actually tend to use just a simple PDS meniscus suture passed up backwards it's very easy one thing about just the suture management is I just take that suture manipulator through the portal on the sutures to ensure I don't have a soft tissue bridge so I don't need to need don't need the use of a cannula and that keeps the cost of the procedure down a little bit better then once the suture tapes you pull down in through the tunnel I can tie those over a button but certainly I tend I tend very rarely to use an anchor on the tibia first tied over a button. This is just some nice images from colleague Dr. Charlie Brown the UAE just showing this high-grade pivot pre-operatively at the time of examination under anesthesia and this patient does have a lateral meniscus posterior root tear and this is after the root has been repaired so the ACL reconstruction tunnels have been drilled but the but the the graft has not been fixated and so essentially that posterior root repair has an impact on controlling rotatory laxity even before doing the ACL reconstruction. Rehabilitation for the first six weeks I tend to keep them touch weight bearing with a range of motion limited from 0 to 90 degrees from 6 to 8 weeks onwards it's a full range of motion and full loading but just no squats past 90 degrees and then at 12 weeks for onwards full range of motion and if using for this is just an unloader brace more for that from the point of view of a medial meniscus root tear rather than a lateral. So in summary we have already talked about medial roots but the lateral root tears compromise rotatory stability they are commonly found with ACL tears you've got to look for them and the posterior root repair it optimizes meniscus function improves knee kinematics and potentially can improve patient outcomes following ACL reconstruction. Thanks very much for your attention.

lateral root tears

knee

meniscus function

rotatory laxity

meniscus root repair