And then again, this format is just for two minutes, quick presentation of the history, physical exam imaging, then we'll go into small group discussion, then we'll do a quick solution. So this is a case of a 25-year-old medical student sustaining the injury while running. Her pain was medially more than anteriorly. Pain was an 8 out of 10 associated with catching sensations. Her knee range of motion was 3 to 130 degrees, and her point tenderness was about the postermedial joint line. Actually, these were normal, and ultimately, I confirmed a neutral alignment. Here's the MRI, and you can see the meniscus tear there. It's hard to tell. I kind of thought this might be a routine meniscus tear, like repair, but it's always hard with the pixelated kind of Super Nintendo graphics of an MRI, seeing with any confidence what's going on. Here's the arthroscopic view, and it was not routine. There were tears of different ages, multi-directional. Parts of it were just shredded. 85% of the medial meniscus was involved for a 30-millimeter longitudinal component. It's after the partial meniscectomy. The rest of the knee looked healthy. I carefully reviewed the findings with her. She attended physical therapy, but she had continued medial-sided pain. So my assessment was medial meniscus deficiency after a partial meniscectomy. Of note, normal ACL, normal articular cartilage, neutral alignment. Now we can discuss this at the tables. What would you do next? We'll take five minutes on that. How long post-op is she now? How far post-op? Three months post-op. Our table had some good discussions about waiting a bit, letting the bone remodel, maybe an unloader brace for a little bit. You brought up a good question. How much time is enough to wait after a partial meniscectomy before throwing in a talon and meniscal transplant? Or how much time after a chondroplasty if the patient's going to choose to do ACI? What's the soonest you allow a patient to judge their knee after an arthroscopy? Anyone from the audience want to entertain that? I think you've got to ask the patient are the symptoms different, are they the same? Because there's a lot of variables. There's people, Jorge made that point, they go back in a month, they start having pain. Sometimes people just don't tolerate early return to sport. So I'd want to know the character and nature of her pain if she's swelling and so forth. And then I think a new MRI will probably be helpful to guide your decision making here because if the character and nature has changed, you're starting to think, is this post-meniscectomy? This is a very rare phenomenon to have in a young person who didn't live with their problem for a very long period of time clinically. Maybe that pathology was there for a longer time than she was clinically relevant looking at it. But it's very rare to have persistent pain after a meniscectomy acutely. I bet that people who see a lot of meniscal tears in this room who do meniscal transplants can count on one hand the number of patients they've done transplants on that have been their own patients who underwent a meniscectomy. That is really rare. So I think we've got to first figure out what's going on with this patient. It may not be so obvious, or it might be. All right. Well, she and I talked about, and ultimately at the six-month visit, we wish to proceed with a medial meniscus allograft transplant. And then how many people in this room, if they were to do a meniscal transplant, would do it with bone? And how many would do it all soft tissue on the medial side? Let's do bone first. How many would do it with bone? And how about soft tissue? I think that's pretty typical. It looks like about 75% do bone or more and 25% soft tissue. From an expert consensus statement from 2015, the experts accepted there's no superiority of one technique over the other, bone versus soft tissue. There's been three systematic reviews. The first one showed no proven superiority of one method over the other. And the second one found that the soft tissue suture and bone fixation groups were similar in terms of allograft tear rates, failure, lysome scores, VAS scores. Even meniscal extrusion was similar, which was interesting. I thought that might be one category where bone fixation would win. And then the third systematic review showed things were similar again. The only difference was the soft tissue fixation group had a higher post-op IKDC score. So these are some photos on the area. This is my soft tissue technique. Again, this is just one of many, many techniques that would be successful for this. First step, I leave a one millimeter rim of native meniscus. For preparation of the allograft, I put some non-absorbable grasping sutures in the posterior horn and some absorbable suture in the body. For the posterior horn attachment site, it's similar to a root repair. Move the cartilage with an angled curette. I place an ACL targeting guide and drill to the point. And then for drawing the meniscus into the joint, I pass a couple loops of suture to draw on the body. I triple the portal length. If my finger can get in, the meniscal allograft can get in. I look in the middle when I'm looking just to make sure there's no tangling. Sometimes a suture will get wrapped around or there'll be like a suture bezoar in there. I like to look and just make sure it's just a nice, simple connection there. And then I evaluate the fit and tie the posterior root suture over a metallic button. On the left there, that's an on-side repair of the posterior horn. And then for the body and anterior horn, I'll just kind of hold the meniscus in place. I like doing an outside in for the body and anterior horn. For the anterior horn, for the anterior root, I'll use a biocomposite anchor. And then I'm sure we've noticed the anterior horn sometimes is just kind of too thin to really fit a vertical mattress in or even an oblique suture pattern. Often then I'll put one through the meniscus, one through the capsule, and then I'll assess the circumferential stability of the seven points of repair. Postoperatively the patient attended physical therapy as directed. She used brace, crutches, motion limits for six weeks. At the 18-week visit she had no pain. And I carefully reviewed the function of transplant tissue. Like it typically holds up to activities of daily life. It's not your native meniscus. It might survive more. And I often will review the first office note if they're really anticipating jogging, running, contact, collision sports and stuff. Because I reviewed whether she might return to that meniscal deficient state. Some of the technical things, the middle one, fixation with too many fixation points, we've sort of talked a little bit about. I moved from 10 or 11 points to more like 6 or 7 to minimize the risk of postage stamp tearing. For decision-making, always assess alignment, correct unfavorable malalignment. We've brought that up a little bit. Replace like with like at the same time. And the next case will highlight a more complex case in a patient with arthritis. I think that reviewing the patient ahead of time, the problems with meniscal transplantation is important before you put it in. The healing rate, long-term survivorship is not greater than 85% in a decade. I'm unaware of any study that shows it's higher than that, even in the best-case scenarios. I try to assess the structure whenever appropriate with MRIs and arthroscopy just to learn how they're healing and assess their function and patient-oriented outcome measures, especially at 5 and 10 years. I have a low threshold for second look arthroscopy. This is a different case, but I like to look for the healing. Is it fresh or frozen? So these are kind of like a hybrid, they're like fresh-frozen, right? They're frozen. Fresh-frozen is frozen. Frozen. By fresh, I mean by or increased by itself. So frozen. And you let her run? You mentioned money. You let her run? Yeah. I did. I did let her. I wasn't a big proponent of it, but yeah, she's been jogging fine. Now she's like three years in or so.

medical student

knee injury

meniscus tear

meniscectomy

medial meniscus deficiency