All right, this is a radial tear case presentation. This is a 35-year-old male with medial knee pain after an abrupt pivoting event, catching and swelling of the knee. Physical exam, palpable effusion comes two weeks after. A range of motion is somewhat limited in extension. joint-line tenderness, and some medial pain with terminal flexion. These are the x-rays, and this is the MRI. And I'll show you guys, well, let's go back and let's just discuss the case, what would you do with this case, if you would repair it or not, and then we can go back and see what we did. Okay, we'll take five minutes to discuss at the tables. So who would repair that tear in a 35-year-old recreational athlete? Most people would, okay. So this is a classification that we propose that has an algorithm for treatment as well. You know, we have a type one that only involves the white, white zone. Those are ones that we usually trim. For type twos, which mean a radial tear that goes almost to the red, white zone, then you can do a side-to-side. If you have a type three, we do this so-called hash tag technique, where you have rip stops that can allow for better biomechanical control. Type four is when you have some displacement in which I usually put a reduction stitch first to bring them together, and then you can do the hash tag. And then the type five, when you have a chronic, very retracted radial tear in which you have to release the borders in order to make it come together, then you do the reduction stitch and the hash tag. In the medial side or on the medial side, if you have significant extrusion, you can also add a centralization stitch. So this is the tear. You can see it's a radial tear that goes all the way down to the capsule. We were just talking with Adam about a paper by Ashish Beedi where if you have more than 70% of a radial tear that goes all the way down to the capsule, you should probably repair those because they change biomechanically, quite frankly, a fair amount of what the knee does, mostly in A to P position. You can see even in a 35-year-old, there's a fair amount of cartilage changes already in there. Brian, what would you do in this case? Would you remove it or would you repair this? I guess I'd love to know a little bit more about the patient, you know, because looking at a video and all this is just half the story. This was a definitive acute situation. This guy didn't have any sort of diathesis or any problem with his knee before this? No problem with his knee before. He said he had this pivoting event, locking sensation, acute edema, and pain. Yeah, I mean I think I would, I think his biology is not going to be great. The biology and part of that tear is not great. And you want to also understand why is he healing. Is he healing because he's got a painful, is he painful because he's got an acute tear or is he painful because he's functioning like a meniscectomized knee? We don't know for sure in a setting where he's already got threatened cartilage. But I would want to encourage repair in this situation because of the state of his joint. But I can also understand people saying this looks like hell and it's not likely to heal in 35 and the joints, and that's an older than 35-year-old joint. And people say let's just trim it and get him better because we think his pain is coming from his meniscal tear. So again, I just, I'm willing to put on the table and say there's no one right answer for this, for this type of patient. How many people will vote for removing this or resecting this? Matt. You know, Jorge, these worry me extensively. And you had some clues on your MRI that you've really scrutinized it. And this is why we have to look at every MRI closely is you've already got edema, you already got some cartilage issues on both the plateau and the femur. This is already going in the wrong direction. It's even potentially partially extruded by a millimeter if you really scrutinize and look at that capsule and how it's interacting with the medial meniscus. So this is already going down a path. And if you choose to repair it, this is one that can fail very easily. I usually tell patients when you look at, you know, the reviews on meniscus repairs, this is not a final procedure, right? This is a bridging procedure. This will take you hopefully 10 or 15 years. And if that's the case, that's great. We saved your joint for another 15 years, you're 35. If we were to remove this, there's a plethora of data showing that you can progress to arthritis pretty rapidly. Gladly, this patient had a neutral alignment, which, you know, in our defense probably helped some with the outcome of the patient. So this is what we did. You know, when I try to do this ripstop sutures, this is an inside-out technique, I try not to go all the way down to the white, white zone because I'm going to end up resecting some of that white, white area, mainly in a patient like this where you have some fraying on the white, white zone. We were just talking in our table and potentially it's okay to leave them there if you have a radial tear in a very young patient that doesn't have any fraying, but I usually tend not to. So we're going side to side using the ripstops in order to create that improved biomechanical environment. So we put a more proximal one on the red, red zone, another one on the red, white. I'm going to put another one inferior to that. I take the AO principles for fractures the same way that you think about fractures for the meniscus. So trying to be perpendicular to the line of the fracture, trying to use multiple stitches is probably better than just using one or two. The good thing about the inside-out technique is you have a very small puncture in the meniscus. It's very reliable. It allows you to place multiple sutures and this is the final construct. You can place sutures on top or on the bottom. Remember the synovial fluid is not conducive of repair, it's not conducive of healing. So the more that you leave portions open, if you just put sutures on the top, the fluid can come from the bottom as well. So you want to close both the top and the bottom and then augment it with anything you've got, either a microfracture of the notch and or, you know, PRP or any other biologics. This is a paper that we've published with Rob, a 3.5 years follow-up. The outcomes after these repairs can improve. This is for patients that had a radial tear that were repaired also with a centralization stitch or a transdival approach. Thank you. Okay. I assume this patient had some amount of varus, just by definition. He had neutral alignment. 50%? He had probably to the, yeah, in between the meniscus. Okay. It's something that absolutely worries me though with these patients and so I'd encourage hip to ankle for any of these risky patients. We get hip to ankles on basically everyone just so we know, as you know, it just makes the discussion easier and a one or a zero and or something down the road. So these are the ones I'm very worried about from an alignment standpoint as well. Matt, if let's say that this patient would be on the medial tibial spine, would you recommend an HDO? No, but they're, I'm telling them they're going to need it down the road. So would you, what would you do in this case? Basically exactly what you did. But the discussion's there because this is a very bad actor. It is. And because of the edema pattern, that cartilage injury is predicted, all the, this has already gone down a path. The dye has been cast for this patient, unfortunately. And this is certainly a conversation, as you all said, you know, to Brian's point, you know, this actually fails sometimes and as they were showing before, there's a 30% failure in back and handles. I would say it's probably similar or even higher for this radial repairs mostly when you have some cartilage damage. So it's a conversation, you know, can I bridge your knee another 10 or 15 years? I think that's reasonable if patient understands, you know, there's a meniscectomy is also non, it's not a for free treatment, right? Sometimes I was telling, you know, my table that I had this MLS player that had a previously failed meniscus repair. I did a partial meniscectomy only where the repair was and he went back to play in the MLS four weeks later in the playoffs, played okay, but developed this massive bone marrow edema on the tibia. Gladly they lost and, you know, he rested for the rest of the season and he went back and he's doing okay. But I consulted with Brian and my other partners and they had another similar case like that. So I think it's also important to tell a patient that sometimes a meniscectomy may have a faster return to sport, but may overload the joint and may need some time to recover. I was going to ask you that question related to why do you think these hurt? Like in the acute setting, why do you think this guy is in pain? And I also be interested in Aaron's thoughts just for all the root discussions, you know, why does an acute root tear hurt? Because they don't get better typically when you just trim them and they get better we think when we fix them. So why does this guy hurt? Because he has a meniscal tear or because he has increased load across a joint that's not so great? I think it's a change in load and the abrupt change in load. So I think when you, you know, we are doing this randomized clinical trial now that hopefully will shed some light into, you know, root repairs and how much or how beneficial they are. But I think it's a change in load. So I'll be curious to see what Aaron thinks. Yeah, I think it's a good point in terms of are these meniscus positive or meniscus negative symptoms? So if they have meniscus negative, i.e. they have symptoms because their meniscus is not functioning, then going in and removing more of what's not functioning is not successful. Right. Yeah. You have to recognize that as a clinician with a lot of clues, you know, where their pain is. Do you have pain or any pain? Those sorts of things. Right. But you have to define that up front in order to be successful in treating. Yeah. Lee, another thing to keep in mind with people, one more question, one more answer a question. When people come in, when you have root repairs and things like this, if they have bone marrow edema, cutting it out is not going to change that. So keep that in mind when you're faced with these type of tears. You try to fix them or at least do something rather than cut them out if they have edema because they're not going to get better. They're just going to get worse.

radial tear

medial meniscus

treatment options

ripstop sutures

cartilage damage