All right, good morning, everyone. It is 7 o'clock, and we're just going to get started. Appreciate everyone coming. We did the course last year, and I thought it was a huge success, at least for me, because I learned from this amazing panel. And I hope you'll have the chance to learn some good tricks today, too. There are really some great videos you'll see and great talks. This thing is finicky, by the way, so I'm going to just move the arrow. So yeah, some disclosures. They're all on the website. So here's the panel. So Andy Sheehan is from San Antonio in Texas. And he's going to talk first. And then David Flanagan from Ohio State and Aaron Critch from Mayo Clinic. So thanks, guys, for being here. And with that being said, we're going to get going with Andy, who will talk about tips and tricks of meniscus repair. Let me see if I can help load your talk up, Andy. Start. And we can ask some questions afterwards, and then hopefully we'll have some time for discussion after. Thank you. All right. Good morning, everybody. Excited to be back here, running it back with this esteemed group of surgeons. Learned a lot last year, and I'm sure we're going to continue that trend this year. finicky What if we do this button? We'll do that. Okay Here are my disclosures that are available on the website. So Just to set the stage for this session, you know I think it's important that we acknowledge how high the stakes are in terms in terms of what we're doing and We acknowledge the fact that there's a strong and valid contemporary emphasis on meniscus preservation But we have to get these things, right? We have to have techniques that are correct We have to understand and know our indications and appreciate the fact that to be quite honest Not all meniscus tears are probably best treated with surgery or with a repair I should say But nevertheless over the next 90 minutes or so we're gonna do everything we can to optimize those techniques and so much of what we know in terms of the pitfalls of These repairs that don't go well Has been taught to us by the moon group who has showed us over and over again and in very compelling fashion that the number one risk of significant knee pain after ACL reconstruction absent a Revision reconstruction is a subsequent surgery related to a meniscus And so I think it's in that it's in that context that we can proceed and understand that we're here talking about today's really really important I thought I'd start by Emphasizing something that is ubiquitous throughout orthopedic arthroscopic surgery regardless of whatever joint we're in It's the importance of seeing what you need to see if you can see what you need to see you can diagnose what you need to diagnose and you can treat and fix an instrument what you need to deal with and If we're thinking about visualization with respect to meniscus repair, I think that most of us tend to Struggle with visualizing the medial compartment more so than the lateral compartment And so we'll talk a little bit of now about how to best see that that medial compartment here a couple representative case examples here of a before and after on the left in terms of Using the MCL release to see what you need to see in the back Mark Miller has been a staunch advocate for the Utility and the wisdom of trephonating or pie crusting the the MCL He's published a nice technique paper in which he uses the palpable medial epicondyle brings his spinal needle About a centimeter posterior above the joint line to to work on that and to open that up And so we've got a representative case example here This is a left knee viewing and you see a relatively tight medial compartment Even with an appropriately positioned lateral post external rotation strong valgus stress all the things that we teach But you can't really see what's going on in the back and so the way that that Mark describes it we bring the spinal needle in above the meniscus there and And you and you make a series of pocals there to trephonate that all the while holding that strong Valgus force to titrate what you need to see if you don't hold that strong valgus force You can end up with a little bit more of an unstable situation If you haven't titrated to that effect, but here's kind of the end result of it here and you see what happens We're already starting to see a little bit more of that Radial tear in the back and then a fairly gratifying pop I like to warn the OR staff beforehand that they very well might hear an audible click But you can see that you've done a good job there. You see everything you need to see in the back You see that meniscus actually floating up a little bit and then you can get there and do what you need to do We ought not worry too much about the morbidity associated with this technique Miller's group has shown us in a systematic review. There are significant not significant differences in terms of stress radiography Patient-reported outcomes or iatrogenic damage to the saphenous Vein and nerve and so I think in 2024 for me. I have a very low threshold to do this to see what I need to see Just to review a little bit about the neurovascular anatomy in the back of the knee this is something I always look at when I'm particularly when I'm interested in focusing on or anticipating tears in either the posterior regions of the medial and lateral menisci at that horn root junction I want to know where the popliteal artery is relative to that Lateral root horn junction. We'll talk a little bit about the common perineal nerve as well Here's a couple easy to digest anatomic studies that have focused on the proximity of these structures relative again to the lateral meniscus These basically zero in on the fact that you're at your your risk is lowest in terms of an iatrogenic Injury to the neurovascular bundle if you're instrumenting from that medial portal as opposed to the lateral portal of the all inside devices Probably best to set those depth stops between 14 and 16 millimeters and then similarly Admittedly though less of a concern with a perineal nerve injury You're gonna have less of a risk of injury coming from medial to lateral as you work more around to that posterior horn mid-body junction Angles matter just like an arthroscopic surgery elsewhere Whether or not you're viewing from a medial lateral portal or instrumenting from a medial lateral portal I do like to use those portals Excuse me interchangeably in order to access the various zones of the meniscus to put my instruments in the right spot Here's a representative case example of a lateral meniscus oblique radial tear initially viewing from that medial portal You see what you need to see there and there's different ways to fix these I know some authors have previously advocated for an all inside Technique in which you're doing a mattress stitch to either one of those leafs I actually prefer putting the camera in the other portal and instrumenting from that lateral portal and using the anti-grade suture passer To pass the stitch on either side and then you can tie those arthroscopically But the point being here is that that anti-grade suture passer is is is best inserted through that lateral portal And so even though you know The convention is to start viewing lateral and then instrument medial have a low threshold to change the portals in which you're instrumenting. I Also think it's important to If you need to to use an accessory portal, this is something we do in shoulder surgery all the time This is a route that initially I had a hard time getting to we could Cast some stones about maybe I should have been more aggressive about truffling that medial meniscus But these these root tears sometimes the visualization can be obscured by a relatively prominent tibial spine. And so making that accessory portal and working through that Puts you in a better spot to pass your stitches stitches where you need to and then Put that guide where you need to in order to drill your tunnel trans osseous tunnel anatomic position if that's the way you do it Transition now to talking about inside-out repairs. I think that there's still a realm or excuse me a role for this in my practice Particularly with with meniscus transplant surgery, but I borrowed a term that's ubiquitous throughout aviation In situations in which there's a lot of lot going on a lot of moving parts and it really belabors the point About the emphasis emphasizing good communication, particularly if you've got trainees or maybe inexperienced technicians It's important to before you get started. I found to let everybody know who's doing what who's catching the stitches Who's going to be visualizing the back of the knee who's going to be holding the cannula? So you've figured all that stuff out before you get started and you can progress in a seamless a seamless fashion There are a number of devices available on the market that have streamlined this process somewhat from the standpoint of basically Having a single-handed needle insertion. It kind of removes some of those moving parts, but still having really good communication The team is seldom the wrong answer The Using these inside-out techniques obviously you want to be comfortable with Approaching both the posterior and medial and posterolateral aspects of the knee. This is an oldie but a goodie in arthroscopy text Technique paper by Kevin Bonner published about 12 years ago now But nicely defines where those incisions should be placed where the neurovascular Structures are and how to keep things safe And I think the point here is and the mistake that I've seen in the past is these is these incisions if you bias them Too far superior. You have a really hard time because the trajectory of that needle is from a relatively superior to inferior direction And so I really really emphasize with our residents that that incision should be one-third above two-thirds below the joint line In order to put that retractor in the best spot and here's just a representative case example here of a posterolateral approach again that incision biased Inferiorly, I like this s this s shaped retractor They get back and see what you need to see retracting the lateral head of the gastroc the biceps and the posterior capsule there anteriorly I'd also think it's important to emphasize using supplemental balancing sutures and oftentimes Especially for the larger bucket handle tears as you go through and you're placing your meniscus stitches repair stitches Superiorly not uncommonly or invariably actually that meniscus will start to flip up. And so as you go around Acknowledge the fact that some balancing stitches are generally speaking Advantageous or to bring that back down to an anatomic position and then don't forget about the outside in repair This is a transplant situation obviously But but you see that you see two spinal needles coming in in the capsule and then through the meniscus on that superior Aspect of it for those tears that are coming around more towards the front or the necessity of repairing in the front There's a number of commercially available devices here on the left You see that little night and all wire loop coming in if you don't have that It can be as simple as putting two prolene or monofilament stitches in retrieving those out tying those and then using that suture link To shuttle your stitch back in here and here's just an example of that again at the end of the case You're just making a small incision between those two stitches Opening that up retrieving those stitches and then and then tying that stitch over the capsule and that really nicely Re-approximates that meniscus tissue to the capsule again as you're moving around more anteriorly, which is outside of the zone, which is comfortably accessed by either an all inside or even a far biased anterior zone specific cannula and Just to round things out Sorry about that We'll talk a little bit about these post remedial capsule injuries the so-called ramp lesions and their significant management Volkers taught us a lot about how to acknowledge these things or how to see them on MRI to see what you're looking for There should not be that hyper intense signal between the capsule and the meniscus Posteriorly and that bone bruise also too is something that should raise your index of suspicion I think that sometimes that we see this amongst our residents They see a post they see a posterior tibial bone bruise and they're scrolling through those MRIs quick and they immediately attributed that to the Pivot shift bone bruise and this is actually medial. So you see that bone bruise you see that signal you should be thinking about it Depending upon what series you read these these these injuries have been reported as high as 52% from a prevalence standpoint What are the biomechanical implications of these in the lab? There's a number of compelling studies that would suggest that that these studies can destabilize the knee they can potentiate anterior tibial translation in the setting of an ACL reconstruction They can result in increased insight to forces in that graft predisposing it to failure And so I think it's there's certainly a biomechanical of it evidence to support paying attention to these What about whether or not we should be fixing them? The definition or the description of these has been described as unstable and stable I prefer to think of these more in terms of the chronicity and the propensity for healing here two different examples That we've dealt with in the past on the left. You see more of a chronic situation. You see synovial eyes tissue And so this would be one that I would be more inclined to fix to be quite honest with you as opposed to the Right here where you see a lot of hemorrhagic tissue in a fresh one, and I think there's there's there's strong Rationale to leave these alone. I do think some of these heal particularly as acute ones But in situations which they're associated with MCL injuries or anterior medial rotary instability I do think it makes sense to have a lower threshold to fix these How do you fix them some of the best clinical information that we have out here would suggest that while there's both? There's different techniques different ways to skin this cat all inside versus alternative techniques the suture hook technique or an outside in lasso based technique is has been shown to have a lower likelihood of failure if You're gonna do an all inside I think it's important to try your best to reduce those capsular tissues that tend to fall either to the level or just below the the plateau It's difficult for me to imagine a situation in which that all inside device is able to get through that meniscus tissue through that capsular tissue in an atomic fashion And how do I do it it all starts with making a good posterior medial portal that tends to be more proximal Posterior and a little bit more medial I think than people want but it really gives you a nice angle of attack again We come back to the emphasis of angles So I've come in with that medial portal and then I try to turn it into I do a lot of shoulder surgery I try to try to turn it into a Bankart repair and so I bring a lasso in from the outside and make sure I get that bite of tissue and that capsule bring that through The meniscus and then and then you can shuttle a a monofilament in there and tie it. So in summary We're all arthroscopic surgeons and we were taught to that visualization and visualization is really important You got to see what you got to see Angles matter so set yourself up for success respect the neurovascular anatomy Particularly working in the back of the knee use all the arrows and the quiver Don't forget about the outside in techniques and I think that for the ramp lesions having a general understanding and appreciation for why their Consequential is important in terms of informing your decision to fix them. Thank you Thank you everyone for being here so early in the morning It's Truly an honor to do this talk One of the things I love the most is meniscus repair and my topic is to talk about some of these that we don't like To talk about so we're gonna go through some of these difficult tears Arrow These are my disclosures, so why why is this important? Well, we're gonna kind of go through this that all tears are pretty significant. We really need to repair The meniscus to restore the mechanics of the meniscus when we look at a lot of these outcomes Of these different more difficult tears We know that they are comparable to some of the standards that we have in the literature and in today's world We have a lot of improved techniques So the first one we're going to start about is the radial meniscus tear. So these are quite significant We all know that there's been great data over the years that have come through we're gonna kind of go through some of that data But we know that it kind of disrupts that meniscal hoop strength And so basically once that happens it really increases the peak pressure you get some medial shift and tibial rotation Which also increases the peak pressure and we know that partial meniscectomy for these Really are bad and we're gonna kind of describe some of that Once we can repair it we can restore those Pressures to normal levels and that's really best with some of the contemporary techniques that we're gonna go through So why are these so bad? So it really doesn't matter where you cut it for a radial tear This is a great study looking at the mid portion kind of post here then towards the root It really doesn't matter where that tear is They all are significant and it's going to dramatically increase those contact pressures on the cartilage as you can see here It's obviously worse for the root, but it really doesn't matter where it is. All these tears are bad And we think about these tears well, what if we just have kind of a partial thickness tear Even those are quite significant and we're gonna go through a couple of these biomechanical studies But it shows that once you have that tear and it gets into that red white zone You're gonna slowly get some propagation over time and you're gonna get gapping and as that gapping occurs That's we're gonna see that contact pressures of the cartilage increase And so we need to kind of think about this as kind of a continuum as these tears are starting to happen They're kind of small. They're gonna get bigger and they're gonna finally propagate to the full thickness Another great study here again showing about these partial thickness tears and the gapping that it can occur and again the contact pressures that we're going to see in the cartilage once you repair that you restore that to normal levels and Similarly in this study Really showing again not only that gapping that can occur But what happens is these tears kind of propagate and as they finally Get to that red red zone is you're gonna get extrusion of the meniscus and that's a very big concept, especially when we think about root tears, and I know that Dr. Critch is gonna talk about that in his discussion. But this is why these tears can be so bad. It really is this cascade of events that's gonna cause a significant chondral load, and this is what we're trying to prevent, right? So in the lateral meniscus especially, radial tears are 50% of these, where if we don't take care of them, we know that there's this risk of rapid chondralysis. And many of us have probably seen that in our practices where they've had a radial tear, maybe it wasn't fixable, maybe it came as a referred and someone's already kind of trimmed out some of it, and that knee has gone downhill. And now you're having a very complex issue. Are you doing a meniscal transplant, Carlos Restoration, osteotomy? And so we're really trying to prevent, hopefully, some of these catastrophic issues. And here's a great example. This is my case. So this is a 16-year-old who felt a pop in his knee while playing football. And you look at that MRI, and this is one of those, oh my goodness, what am I gonna do with this, right? This is significantly gapped. It's about a centimeter and a half, two centimeters gapped. And you're like, wow. You know, you get all the things you wanna get ready, and you think about how you're gonna fix this, and I'll tell you how I fixed this. And this is a little bit earlier in my career. And I did it the standard way that we can think about, right? We're gonna place some horizontal mattress sutures across this. Bring these and co-app these two areas together. And you can see I had one anchor in there that I went to the capsule. And that was truly, I think, the tools that I had learned of how to fix these type of tears. But I will tell you that some of the ways that we did things were not always the best. And this is what happened. So when we see about cheese wire, and you hear about people talking about cheese wire, this is it. So what happened is these just pulled through the meniscus. You can see that there's some scar tissue there, but this is really a non-functional meniscus. That meniscus has elongated. You can see now he's got significant cartilage issues. So this is really that kind of catastrophic knee that we just talked about. And I'll tell you some of the problems with the traditional techniques and just a horizontal mattress by itself. Remember, we don't have many radial collagen fibers in the meniscus. So if you think about the strength of your repair, it's usually not great with just a horizontal mattress suture. But similarly, as you think about what Andrew just kind of talked about with an outside in, you're coming through a big area of the capsule, and you're trying to then co-opt a very thin portion of that meniscus. And what happens is you have so much tension there at that capsular area that you're gonna finally fail. And that's what happened in this case. And this really kind of enlightened me as to what we need to do, how do we need to kind of think through this differently, and how can we get a better repair? And thank goodness, the literature has some great examples, and a lot of people were thinking about similar things at the same time. And there's a lot of different things that we can do to strengthen our repair of that lateral meniscus or medial meniscus radial tear. And we're gonna kind of go about these three different concepts. One is the circumferential compression stitch, the rip stop, and then any type of trans-tibial repair. So when we're talking about a circumferential suture, so instead of kind of doing a horizontal going through the capsule, you're really doing a horizontal mattress going across the meniscus. So you're co-opting those two portions of the tear to where you get it really to seal well. And that's been shown that that can lower displacement, there's a higher load of failure, and it's a stiffer construct. So concept one is trying to have some of these circumferential sutures as much as you can. And concept two then is really starting to think about these tie grip or rip stop sutures. So again, our radial fibers of the meniscus, we don't have many of them, they're very small, they're not very strong. So what you're really trying to do is make a very strong radial fiber within the meniscus, and then using those as that tie grip or rip stop sutures with your horizontal mattress kind of spanning across that. And it really doesn't matter how you hash this, right? So we wanna hash it up. So you can do a cross hash, you can do just a normal hash tag. But if you can do this type of configuration, you're gonna greatly increase the strength of your repair and decrease the failure of that. And that's been shown in multiple different type of biomechanical studies. So our third concept then is, what about those that we really need to kind of maybe get a little bit further strength? And that can be with some of the trans-tibial repairs. Now this was really popularized by Dr. Leprade, especially on the medial side. So the medial side doesn't necessarily move as much as we know the meniscus is not as mobile as lateral side. And so you can actually do these trans-tibial fixation to help anchor that meniscus so it doesn't displace. In some other further follow-up studies though, shows that that type of technique compared to some of our cross hash or hash tag type of repairs, they're pretty equivalent. So I think if you can get a good repair with a hash tag or cross hash, you don't necessarily always have to go to the tibia. These type of repairs, not only as we talked about, help strengthen the repair, but also can decrease that extrusion that we saw in some of those biomechanical studies. So if we can, again, co-opt this, repair it, we're gonna prevent some of that extrusion that can happen with the meniscus with these type of tears. And we know that patient reported outcomes are quite good with this. So if we look at all these clinical studies, and these are two systematic reviews, that you improve their Tegner scores, their Leishman scores, and you have healing of partial or complete in roughly 90% of them. And Aaron's team and others have looked at this compared to other tear types, and you have very equivalent results. So you have two-year follow-up here, similar patient reported outcomes, and similar re-operation rates of about 20% at five years. But again, looking at the literature, it's really important to think about the biology. So we all know about red, red, red, white. The more that you get to those vascular zones, the higher chance that you are gonna have of success with these type of tears. I'm not necessarily advocating repairing a white, white tear, but again, if this is going into some of those vascular zones, we have techniques that can help augment that. And if we get there, we know that we can have, again, that close to 90% partial to complete healing. And again, lots of different techniques that can augment that to where you can improve the biology, and we saw some of that through Andrew's talk as well. You can rasp the area. You can use vascular access channels, which I use often for a lot of these type of cases. Marrow venting, which has been popularized, very easy, cost-effective, where you can just use an awl. You can even just use your shaver in the notch to allow some of that bleeding to occur. Fiber and clot, and there's some more and more simple ways that that can be done. And then, something that I've used a lot is PRP. So all of these can help augment that healing response to give you a better chance of complete or partial healing. So I'd like to now move into that next kind of type of tear pattern that many of us have seen in our clinics, in our surgical suites, is these horizontal cleavage tears. And these are very, very common. And they're more common as we age, but we're also seeing more and more of these in young, active patients. And so something you need to be really aware of. So if you think about many of us in this room who might be in that 40 years or older, about a third of us are gonna have these type of tears. And so why are they important? We're gonna talk about these four main concepts of why they're important. So first and foremost, it's going to increase the peak pressures. And a great study here is showing that as you have these, the peak pressures go up, the contact area goes down. It's worse with knee flexion. And again, this can be a mechanism for some of that cartilage degeneration over time. It also deforms and propagates with knee flexion. So this was an interesting study. It's a 3D computer model, but they did this with using MRIs on patients at different knee flexion angles and then put it into their computer model. And what they found is that as these get larger, they actually deform, propagate more with knee flexion. And then this is very related to the patient report outcome. So basically these can get bigger and they're gonna actually open like a fish mouth when you flex your knee. And then similar to what we see with roots, these also can cause a lot of meniscal extrusion over time and it can be up to three and a half millimeters. It's worse as they get more complex. And as we know with a lot of the stuff from root tears, the more extrusion you have, typically poor outcomes and also more arthritis. And so another reason why if you have to excise these, these can be potentially quite poor outcomes. And then lastly is increasing chondral damage. So again, horizontal cleavage tears and complex are often kind of lumped together because a lot of complex tears have a horizontal cleavage component. The incidence again is usually one of the highest. As you can see here in these type of patients as well, you're gonna have more significant chondral disease and often are gonna have more lesions. So again, these are not an uncommon tear pattern as we see as we get older. So we think about historic treatments. Many of us have done this as well. We often are going to see that tear and we are going to do a partial resection of either that top or bottom leaf. Unfortunately, if you do that, you've really not helped that patient when you think of biomechanical aspects. And so if you repair this though, you really bring this down to close to intact levels. So the big concept here is to try to save these meniscus as much as possible in the appropriate patient. And we know from a lot of different studies out there, you can have about an 85% success rate. And this has really been shown in our ASSIST-MAC review as we summarize all this, about 11 to 12% reoperation rates, so anywhere from 10 to 15%. So it can really restore the function of these patients. So how do we do this? And this is a video of one of the techniques. And so we often are going to see some tearing within that white, white zone. You want to remove any of those unstable flaps. Obviously that's not something that's going to really repair well. And so often you're going to be doing some sort of a partial meniscectomy in that central portion in the white, white zone. And once you do that, you really want to prepare the meniscus as best as possible. Obviously, this is going to improve the biology. And so you see here an aggressive rasping. We're actually using some of the Shaver 2 to get some synovial abrasion. And again, this is going to stimulate from the biology of this, usually that kind of panus of tissue over the meniscus to help with the healing. This one had a cyst as often you can see with a lot of these horizontal cleavage tears. And as was discussed by Andrew, we really need a straight shot. So access is so important when we think about meniscal repair. So if you don't have the right portal, stick a needle in there, making sure that you have the right path. And there's lots of commercially available suture passing devices. This can be used to kind of make these circumferential compression sutures. And these are all arthroscopically tied. So you're closing that fish mouth, co-opting that. And it's important to also place these pretty regularly. So if you think about the more access that you have in between these sutures, if it doesn't seal up really well, there's a higher chance that you can get cystic changes or a potential propagation again down the road. So after we do this as discussed by Andrew as well, you need to have lots of different techniques. You need to be familiar with it so that you can repair that in areas where maybe your all inside device can't reach. And so here's again shaving and allow some marrow venting as well. So finally, we're gonna talk about complex tears. So complex tears, and we've all seen it is really just like, oh my goodness, what do we have here? It's a kind of a little bit of everything, a mosh pitch of everything. And complex tears, again, are very common. We'll see these often as we get a little bit older as well. And if you look at this kind of repair versus meniscectomy, it's kind of interesting in the literature that if you do a meniscectomy, all of them had a worse outcomes. And so sometimes we see these and we're like, is this something to repair or not to repair? And again, that's something we have to kind of see how does that joint look? Is this something that we can actually get a potentially good repair? But we know that if you can repair them in the appropriate patient, you often are gonna have better outcomes than if you did a partial meniscectomy. And so if you look at some of these results, failure rates of anywhere from 15 to 25%, so very standard within the literature, a return to sport about 91%, improvement of patient reported outcomes, and good maintenance of those results over time. Now, we haven't talked about this, but all the key concepts that we think about, even with like cartilage restoration, what's your alignment like? What's the cartilage like? All those do play a role. So if you think about a significant varus knee and you have a complex medial meniscus tear, if you're gonna repair that, you should probably think about also restoring their alignment so that you can take the pressure off that inside part of the knee. So let's go through five kind of tips for successful repairs. And this can be used in any aspect, whether it's repair or complex. So first and foremost is always be prepared for repair. And I think this is a concept that's really important. You can see here to the right, this is my meniscus cart. This goes from room to room with me. It has every type of meniscus repair tool that I need to have success. So all inside, inside out, outside in, it's all on that cart and it can kind of go from room to room with me without any issues. And be comfortable with lots of different techniques and be comfortable with lots of different types of devices. So there's lots of things out there. Go to our industry hall. You're gonna see different things that are gonna work well in your hands. Use those tools because these are the ways that we can repair this. Second is the ABCs of meniscus repair. And Aaron has really did a great paper on this. And I think it's such a great concept to think about. So first and foremost, we need to have anatomic reduction. It's just the same concepts that we have with fracture care. You need to reduce that meniscus. You need to co-opt it so it's in the right place so you can have the best chance of success. Second thing is always think about that biology. Think about how you can augment it, how you can improve the biology so it can heal. And then you wanna have compression across that tear. So if you don't have compression, if there's gapping or anything else, you're not gonna get that to heal. And then lastly, I would like to really kind of, the concept that I've been really trying to think about and push is a tensionless repair. So we talked about that failure of the case that I had earlier. This is something that we developed then is this traction stitch to allow us to reduce this in an anatomic position. Once it's reduced in an anatomic position, now we can place those ripstop sutures in the capsule in an anatomic position, and we can do our cross horizontal mattress sutures, so making our hash tag. And if you do this now, you can see I am ranging this knee and there is no tension on this repair. And this is what we really wanna have with any type of our meniscus repairs is a tensionless repair, so it can really heal and do well for that patient. So I hope you've learned something. We've got great techniques now, we've got great outcomes, and I wanna encourage you all to repair some of these meniscus. Thanks so much. Okay, good morning, everyone. What a privilege it was to hear those first two talks. Absolutely masterclass, I learned a lot. So thank you, Andy and Dave. So we're gonna switch gears a little bit and try to focus just on the root tear. You know, for us, I think we're hearing a lot more about these different types of tears. I think for a long time it was just a degenerative or a traumatic tear, and now you can just see a higher level of precision and a higher level of care for our patients. Okay, so our you know, really we've been on a journey with meniscus root injury It's really a short journey since 2008. I think we really started to appreciate the existence of these tears We then began to recognize them and diagnose them in our own patients We understood the natural history, which is poor and I'll highlight that in a couple of studies There then was a really explosion of technique innovation So then you had all of this reporting of results which were largely good which then led to widespread adoption For repair in these patients. So the question is where are we now? And where are we going? So with root tears, what's the natural history? I think we all clearly understand now the natural history is poor for these types of tears Dave showed you why? The ability to resist hoop stress whether it's a root tear radial tear is so important for contact pressures So we took a group of patients that had serial MRIs with non-operative management and you can see within five months They went from grade 2 to almost grade 4 chondromalacia And it's oftentimes surprising how quickly these can progress in your practice When we looked at kind of five-year follow-up in a group of 52 patients overall 80% 87% of them failed they either rated their knees as severely abnormal or went on to knee replacement We actually just looked up that data and published in Anna this year At 15 years 95% of these patients had knee arthroplasty. So clearly the natural history is for progressive arthritis Still we will hear occasionally. Why not just perform a partial meniscectomy and for me it just never made sense that we would remove more of a structure that is not functioning as a way to Relieve pain in our patients and the literature really bears out that that is a way to fail actually faster than any other treatment option So if you look at these 52 patients that were treated with partial meniscectomy even if you compare it to non-op an even higher rate of Arthroplasty and when you look at all these risk factors for root tears in terms of you know Clinical poor outcomes. It's females. It's increased BMI It's meniscus extrusion sometimes alignment and those are really all risk factors for bone overload with without the function of the meniscus So should we repair any of these roots and the answer of course is yes And I certainly need to acknowledge our colleagues in Korea This is professor Jin Goo Kim who published some of the first comparative studies on root repair compared to partial meniscectomy And clearly there's an advantage for repair in these patients and multiple papers since that time have have shown that So when you look at our kind of multi-center prospective data These were 47 patients that would have been repaired with kind of standard techniques that we have What's striking is how significantly better these patients can get after surgery? These are some of the happiest patients that I take care of in clinic when you look at their IK DC score Almost a 40 point increase. So that's almost four times your MC ID And part of it is they start so low. I mean they come into clinic. You've all seen these patients. They have pain They're limping. They're absolutely miserable When we look at structural outcomes I think it's always important to look at structural outcomes to assess what we're doing with our repair techniques The good news here is with the traditional trans tibial pull-through technique. We're getting 98% healing That's prospective six-month MRI data. So really a large proportion of these heal we can have confidence in that technique however The extrusion at least in our hands actually increased So we looked at their baseline MRI to their six-month MRI and we actually saw an increase of extrusion So we were kind of left scratching our heads, you know Did we overcome the extrusion and then as they walked on it for six months? Did it get worse? We didn't really know but at the end of the day the extrusion was worse Why does that matter? Well when you look at a group of patients we present data overall They do very well, but when you start to drill down on the individual patient, you know doc will I get better? How much better can I expect? We looked at age. We looked at alignment. We looked at sex of the patient We looked at cartilage status the one factor that mattered most in terms of how they responded was Extrusion and if they had extrusion less than four millimeters They responded very well if they had extrusion four millimeters or more They were less likely to respond and you can say well, yes extrusion is kind of a sum total of cartilage where alignment BMI a lot of different factors and I I would agree with you Others have also shown this again. If you look at Jin Goo Kim's long-term results Total knee percent total knee arthroplasty percent failure Is higher when there was that critical extrusion greater than three millimeters? So just when you think you've kind of reached the finish line now, there may be a second mountain for us to climb So what is extrusion you heard it from? Dr. Flanagan? You know, it's essentially meniscal place Displacement beyond the border of the tibial plateau and this is not a new concept if you look at these publications 1997 Extrusion was recognized as an independent predictor of cartilage loss and subchondral bone edema So, how are we measuring it currently? Well, there has been more of an emphasis on Dynamic ultrasound in clinics and I think this is a great option I think for a lot of us though It's just it's really a burdensome workflow to try to get the patient to have ultrasounds With that, you know MRI remains the gold standard I think as a surgeon the vast majority of our patients are coming to us in clinic with an MRI So really we're measuring on that mid coronal view looking at extrusion of the body So is extrusion correctable? Well, it depends on really why there's some extrusion in the knee I think this is a great study that highlights the role of alignment or malalignment in causing extrusion So these were patients that underwent a valgus proximal tibial osteotomy for a varus deformity of the knee And they didn't do anything to the meniscus But when they looked at MRIs at two years and four years, they found that extrusion was less so clearly that overload That was mentioned by Dave with you know, malalignment plays a substantial role in the meniscus. So can we link? You know, is there a primary fundamental cause for extrusion, you know in our patients and I think it goes back to the anatomy We really look at the meniscus tibial ligaments at least on the medial side Are the coronary ligaments as they've been called we looked at a series of MRIs These are patients that did not have a meniscus tear and they did not have arthritis But we tried to identify patients with extrusion and what we found was that if they had greater than three millimeters of extrusion 100% of those patients had meniscus tibial ligament Abnormalities or pathology if they didn't have extrusion the meniscus tibial ligament was essentially normal So why does all that matter? Well, it matters because if you don't you know If you don't have a meniscus that can resist hoop stress You won't have a meniscus that can function for chondro protection or as a secondary stabilizer. I love this study You know, it's still controversial to meniscus transplants. Are they chondro protective or not? This is a 10 to 14 year follow-up study What they showed was that if they had three millimeters or less of extrusion those meniscus allografts were chondro protective Beyond that with major extrusion the allografts or the native of meniscus for that matter simply does not have any chondro protective effect So going back to those patients we treated in our study looking at their six months MRIs Again, we didn't know whether we initially improved extrusion and then it got worse as they walked So ten of these patients I'll thank them Bravely got into the MRI scanner a week after their surgery and when we looked at time zero We found that essentially we never improve extrusion with a traditional trans tibial pull-through root repair of our patients Then we got to ask ourselves. Well Is extrusion an effect Do you have the root tear and then extrusion happens or could it be the other way? So we were fortunate to have these patients in our series of 63 serial MRIs patients that initially presented with medial sided pain Extrusion but no root tear and then subsequently developed a root tear They had that terminal event where they felt that pop in the knee So we feel that this is the current understanding of the pathophysiology of a degenerative medial meniscus root tear So you have abnormalities the meniscus tibial ligament for whatever reason the alignment BMI, etc That places more stress at the root and then the patient gets up off a low chair and feels that pop I think this makes sense to a lot of us in the room because before you know you'd see a patient like a week after this pop event and you're looking at the MRI and you're like gosh look at All these chronic changes this plastic deformation, etc. And the answer is yes, all of these findings are chronic They lead up to the terminal event of the root tear So the analogy I like to use with patients is you know, the meniscus resisting hoop stress is like that suspension bridge So if you're walking on that suspension bridge, you will get elevated because it can resist hoop stress This is a bridge that has lost and has extrusion. So this is one where you walk across it It's just not going to give you that suspension. And then this one is, you know Finally had its root tear and won't get you to the other side there So what about? Centralizations we presented a technique on centralization about five years ago where we brought the meniscus back in. Where are we? conceptually with that and clinically with arthroscopic centralization, so Andy alluded to you know, stealing some concepts from our shoulder surgeon and taking them to the knee I'm gonna do the same So if you look at shoulder instability, you have your Bankart tear and then you have your Alps a lesion with your Alps a lesion What are we taught? We're taught to release retention and repair in order to restore Tension in that seat belt if you will and it's the same concept in the knee It's just we're now doing this fundamentally with the meniscus tibial ligament in the extruded meniscus. So this is our current Algorithm if you will, so we do see patients that have painful knees with an extruded meniscus with an intact root Yes, we are performing centralization on those patients. They actually do quite well It does take that tension off the root if they have a concomitant root tear We're certainly performing root repair and then you've heard now from several speakers if there is that malalignment You have to think about that in osteotomy Recognizing that all of these patients are not osteotomy candidates So just a few Technical things about the technique. So one is you do need some sort of accessory portal In order to place anchors This typically is either high medial or a high lateral portal depending on where you're placing your anchor And then you can see in this case, you know, this meniscus is completely out of the joint So we're gonna actually do a fairly aggressive release of the meniscus tibial ligament Around the body and the posterior horn to the medial meniscus and you'll see some of these plastically deformed ones that you can't bring back Will now have increased mobility, but you really need to bring that root back to its origin We then kind of line up our root repair sutures Dave highlighted very nice the importance of the ripstop and we've gone to ripstop sutures for all of our degenerative root tears And I'll give you some biomechanics data on why that's important So then once that is set up we place our anchors for our centralization Procedure if you will and then once everything is set we then do our final tensioning at the root So we do our final tensioning for centralization Now this video is about four or five years old and I'm going to show you what we do differently today than we did back then This worked clinically, but what I worried about was over constraining the meniscus replacing a lot of holes and degenerative meniscus And you know, you just worry about going through that tissue multiple times So what have we learned? Well, the fundamental change is we've gone back to you know addressing the path of anatomy So we're trying to tighten that meniscus tibial ligament and not so much the meniscus when you look at this We're actually attaching the suture anchored down to the capsule or to the meniscus tibial ligament rather than the meniscus itself When we do that, it clearly brings in the meniscus We'll be publishing our arthroscopic classification of extrusion very shortly But you can see clearly it changes the position of the meniscus then without the tension on there Dave talked to you about these tension sutures Well, it's the same thing with the root now that you centralize the meniscus You can just bring the root back to its origin more in a tension free state than with the extruded meniscus This is what the final repair looks like Typically we'll use two or three of those centralization anchors kind of as again spot welds to try to Bring in that meniscus tibial ligament. The nice thing about this technique is it's now generalizable the lateral side the medial side Meniscus allograft transplant. So here's a case where we perform the centralization first of the meniscus tibial ligament And then we'll put in our meniscus allograft second So hopefully it doesn't have as much extrusion and over the long term can be more counter protective This is our biomechanics study that will be impressed very shortly Basically the two main findings are it restored the extruded Meniscus to intact levels compared to the native meniscus. The good news is there was no over constraint in any case with this centralization technique Just a little bit about ripstop sutures in root tears So this was recently published so when you look at different suture configurations definitely root root repairs with Ripstop sutures did a better job. They resisted cyclic displacement more less of a tendency for that meniscus To leave its origin and really you want to continue that compression at its footprint. So what about clinically? You know, the results are really in the patient So we just published 25 patients Minimum to your follow-up and these are your average root patients that walk in 50 years old mainly female BMI of 33 Extrusion greater than three millimeters grade two chondromalacia and three degrees of varus malalignment. So how did they do it two years? Well, they had substantial improvement in pain scores both at rest and with function when you look at their IK DC scores They improve from 46 to 70 when you look at their coup scores, they improve substantially and they maintained if not improved Kind of their activity levels. So in conclusion, I think we really have to at this point in 2024 consider that the degenerative root injury also includes pre-existing extrusion in many of our patients Root repairs are successful in the right patient and we can get into some discussion of patient selection But I would consider centralization to address the critically extruded meniscus greater than three millimeters. Thank you very much Thanks Aaron and David and Andy very great talks Okay, so meniscus transplant Maybe Okay, okay So All these techniques of course apply to your transplants as well And I thought I'd give you just a little overview of when and how to do meniscus transplantation something that we've done in Pittsburgh for Oh probably 30 years now, so show you some outcome studies as well my disclosures So I'm not gonna belabor too much the function of the meniscus because we just talked about all this But looking at a graft at the back table It's just really nice and enables you kind of study a little bit the anatomy and especially when you look at the lateral side You realize how much of the tibial surface is covered by the meniscus? So that's quite impressive and Then obviously the meniscus is there for low transmission shock absorption Lubrication and it also it's a secondary restraint For your NTA translation and now it becomes very interesting whether you sometimes dare to prophylactically transplant meniscus I'm going to show you some data on this Because we don't do that very much, and I just thought I add this slide I'm proud to say that my meniscus addiction My repair addiction is getting more and more and I have you can see on this curve done less and less Meniscectomies over the years. It's really hard to to do this right because you get the Patients referred to you by other surgeons and they're set up for their meniscectomy and you have to talk them out of it Talk them out of Meniscectomy, that's what this slide tells you and on the other side. We've done much more repairs now over the last couple of years So why why do we need to transplant well if the meniscus is gone very clearly you you know that So I just doesn't project very well with the color That the forces increase the contact pressures increase, and you do get OA. It's just a fact, and so you want to prevent that. And that's when meniscus transplant comes in. And so it can prevent early OA, but with very strict criteria. This is a nice slide from Brian Cole that basically tells you what the ideal candidate is. Who is it? It's somebody that has definitely a lower BMI. That's for sure. It's a younger patient. He lists under 50. In my hands, I have rarely done this over the age of 30. So it's really the younger patient where this works best. Now, can you do it on somebody who's 65 and has an arthritic knee? Sure, you can do that, but I'm not sure that's going to work for very long. Some people do that, but not me. The alignment is absolute key, so it has to be neutral alignment. And if it is not, then you have to make it neutral. The knee has to be stable. And again, if it's not stable, it's concomitants. It's very rare that I do an isolated meniscus transplant. And then also the focal cartilage loss, you'll work on that as well. So everything is about alignment in these cases. So somebody whose weight-bearing axis goes right through the compartment where you transplant, you better do the osteotomy. And in fact, if you do the osteotomy, you may do two stages and realize that you'll never get to that second stage, because the osteotomy is clearly more powerful than a meniscus transplant. So that's key to know. And in Europe, when they do osteotomies, they never even scope the knee. Now, this is a really good study, again, from Korea. Aaron cited some Korean studies as well. 190 transplants, and if the lateral transplant is done in a knee that has a slight varus, it ended up being protective. I wouldn't go as far as varus-aiding a knee that is neutral into a varus state. I have never done that. But this is just saying if the patient natively has a varus alignment, it's protective. Contraindications in my hand is clearly if they have advanced OA. In fact, if you have more than grade two changes in that compartment, you'd be hard-pressed to say that this meniscus is going to last in there. You can do a concomitant osteochondral repair procedure, but that's a contraindication, advanced OA. Osteophytes, arthrofibrosis, if the knee is stiff, it's not going to work. A previous infection is very difficult, and of course, inflammatory arthritis. Now, there are many different techniques. There are bone block techniques. There are slot techniques. And then there are all soft tissue techniques. And this all started in the 80s. And then in Pittsburgh, they started that in the early 90s because there's a lot of transplant surgery that was going on as well. And then in 1999, that technique that Dr. Fu described we kind of still use, but slightly modified. I'm going to show you that. And then in 2011, some all-inside technique, which is what I'm going through at this point. Now, the indications, unicompartmental pain. Very clearly, it's pain in one compartment. And pain is the main indication. Vision ACL with meniscus deficiency. Again, if there's no pain in that compartment, I'm not going to transplant that usually. And then articular cartilage repair in a meniscus-deficient compartment. Here's some questions that were asked in this IMREF group. And so the first box is, would you do a realignment procedure? And of course, you would if there is malalignment. And then the second box is, would you do this in an asymptomatic knee? And most people say no to that. And that includes me. So some people talk about chondroprotection of a transplant. And so again, very rarely would this be the case. You all know the cases that come to you, and they ask, hey, I was just being meniscectomized. Can you just put a new meniscus back in? We usually don't do that. We follow patients instead and wait until symptoms arrive. Now, the sizing is absolute key. Now, the sizing is absolute key. It's very simple. With this Pollard method, undersizing will give you trouble. And that's what this paper says. I personally find it very hard in my studies to even find out if the meniscus that were failed were indeed undersized, because it's just about how you document this. So unless you do this prospectively, it's hard to say. But meniscus, the rule of thumb is that you accept the size that is about 10% or so bigger than what was measured in that knee. Never transplant something that is smaller. The way the meniscus is processed, this is usually fresh frozen. That's what that first box says. You can do it in a fresh state or cryopreserved, lyophilized. They're all different methods. But fresh frozen is the preferred technique. I want to show you this slide, just two very bad cases that, unfortunately, I had to learn from, because they're my own cases. But my point here is, before you transplant a meniscus, you better look at the graft on the back table before the intubation happens. At least, that's what I do. On the left, this was supposed to be for a 16-year-old kid with two previous surgeries. And I just didn't feel comfortable transplanting this sort of hypoplastic meniscus. It wasn't too small or anything, except there was just, overall, the structure kind of sucked. This is what I would like to transplant. It's the same size, except a better specimen. And the same thing happened again in a different hospital with this lateral meniscus, which is paper-thin, two millimeters thick. It's just not something I want to put into a young patient with four or five previous surgeries. So lesson learned. And that's maybe my biggest takeaway for you. Now, for the surgical technique, there are probably about 15 steps or so that you go through. And here's a video. Let me see if this works. What I do now is, so it's the 1999 paper by Freddy Fu. But what I do is I don't take the meniscus sharply off the bone anymore. I actually osteotomize it away. And so that enables me to keep a slightly longer graft. And also, it enables me to keep a little bony sliver still underneath the root. And I think it helps with healing. I put a number 5 sort of modified Brunel stitch into each of the two roots. And then I mark out where my sutures will go. Usually, 8 to 12 sutures go in. And so I don't have any more of the posterior peripheral sutures in there. But rather, I use all inside. And so here's a case. This is a 21-year-old. You can see the high slope, the failed ACL, with about an 8-degree varus alignment, totally unstable knee, and pain, very importantly, pain in the medial compartment. And so they're very young. They're still athletic. And now your decision has to be joint preservation or return to sport. But those are two very different things. And I discuss that with the patient, explain to them. We can do some revision ACL that's going to fail later, and then do joint preservation, or just go for it. And that's what we did in this case with two stages. We found this chondral defect, which we also fixed with an osteochondral procedure. He had an opening red osteotomy on the medial side, and also helping a little bit with the slope at the same time. Then a revision ACL, and a second procedure then had the meniscus transplantation. And so here, we basically put the meniscus in through the dilated anterior medial portal. You make the portal as big as your pinky finger. And that's roughly how big the meniscus is. I make a posterior root tunnel, bring the meniscus in. I will not perform any anterior root tunnels at first, but wait until the meniscus is fixed everywhere. And then just see where the meniscus, the anterior root, comes to lay. And that's where I will place the tunnel even, if it is slightly non-anatomic, because it's just the anterior root is just there to give you the hoop stress. And then here is also the osteochondral procedure. So pretty big surgery for the guy, but he's doing very well with this. This is the osteochondral graft right here, in addition to the meniscus. OK. So this guy is doing well. Hardware is removed, and it's doing OK. Here's another case I want to show you. This is a 18-year-old patient. They had two previous meniscectomies, neutral alignment, pain over the compartment, and full range of motion. And interesting is the meniscus transplant was done. At the time, still used the posterior peripheral sutures, a posterior medial incision. And over the years, when you do that MCL trepanation, I just did too much of it and didn't really realize that. So she was doing OK, came back to the office for the yearly follow-up, but wasn't doing great. But it wasn't very demanding either. Anyway, eventually, I figured out what I should have done much earlier, stressed her, just listened to her a little bit more, and realized that my trepanation was too much, lost the MCL a little bit. And once I gave her an MCL reconstruction, also enabled me to do a nice centralization, just the way Aaron just showed it, except I did it in an open way. It really stabilized her knee and made her a much, much happier patient. So it's something to realize that your trepanation there sometimes can actually fail. Very rare, but I do so much of it that eventually, if you do enough, you will realize failures that will come too. And then here's one last case to show you. This is a 37-year-old. They had a meniscus transplant done, kind of kept having pain, and had a root tear of their transplant. Again, this happens relatively commonly. It's not a complication-free surgery. And so at that time, we did a valgus-aiding osteotomy and a root repair of the transplant. It actually worked out quite well. So here are some outcomes, very sobering outcomes. This is our own study we published recently on, not true, this is Dr. Amendola's study. Sorry, the next slide is my study. But it shows similar sobering, at least 23% of the patients underwent subsequent surgery. And you can see it's either failure, root tears, some chondral damage, there's some stiffness surgery, implants that hurt, or ACL that's injured. So there is plenty that can go wrong with these types of procedures. This is our own study. So there's 140 patients. And they had all 10-year-plus follow-up, which is really a nice study, I would say. But you can look at this list on the right side, all the different things that can happen. And they will happen to you if you do meniscus transplants. You have to really carefully select your patients. Again, the sizing is absolute key, because I think some of these root tears can be prevented by sizing correctly, using centralization type of techniques, and maybe with bone blocks as well. And here you can see, obviously, those meniscus transplants that had tears, they survived, of course, at a much lower rate than those that ended up being tear free. They have actually a quite nice survival. Up to 20 years, they're 70% still good. So that's very nice. What defines success? I'm getting to the end of my talk here. It's really been, so Tim Spalding published a very nice series that an isolated meniscus transplant really has similar IKDC and outcomes to an ACL. But of course, very rarely do we do isolated meniscus transplants. So in summary, very careful selection of your patients. Pain is the number one indication for meniscus transplant. They had a previous meniscectomy. Neutral alignment, a stable knee, and intact articular cartilage address the concomitant pathology. There is a high rate of secondary procedures, so be aware of that and act appropriately. Allograft extrusion happens pretty much from day one, whatever study you look at. They're very good midterm and longterm outcomes. Again, if the graft stays intact, and improved pain, high satisfaction, it's really a salvage procedure. So in athletes, very rarely this is done. And then return to impact sports. Again, there are some studies on high-level athletes, but not in my hands. And there's some evidence that it's chondroprotective. So with that, thank you very much. And let us have some discussion. All right. Thanks. So maybe you guys can all come up. Can I, for the tech team, can I put my own laptop here? I have some cases I want to maybe show. Okay. All right, so you guys can come up to the microphone if you have questions. So in your hands, what is your minisectomy rate? Is it going down as well? Are you doing a lot of minisectomy still, or are you trying to avoid it? Andy. I mean, I'm- Have you looked at your own data? Not as closely as I should. But I think, like most of us here, we, and for all the reasons that have been talked about over the last hour or so, is that we try to be as thoughtful in terms of understanding the importance in fixing the ones that should be fixed. I have unfortunately been labeled a meniscus optimist, and I guess that means that I try to repair as many meniscus as possible. But I do think with saying that, you have to be real with not only what that tear pattern looks like, can you have a good chance of successful meniscal repair? Because if you think about the literature, about 20% of these are gonna fail, right? And so I think you really need to know in your hands, are you ready with all the techniques that you have to repair this meniscus, and put them in that realistic mix? Because subsequent surgery, as you pointed out, Andy, I do think that the more that these things fail, that knee is worse off. So you have to really consider that, you have to be thoughtful of it. I repair a lot of meniscus. My meniscectomy rate is lower. But there's some that you just can't repair. Yeah. Yeah, what you don't know about Dr. Flanagan is that all of the security codes in his house are 29882 and 29883 for his personalized license plate. So he takes the CPT codes for meniscus repair and owns them, so that's great. No, in all seriousness, I think, yes, definitely meniscectomy rates have gone down. You know, it depends on the context, whether it's isolated, whether it's with an ACL. I would say meniscectomy in a primary ACL is approaching zero. I mean, it is amazing now. I think the tears that we can address, and I think overall patients are happy. I don't think we should expect necessarily that 20% to change, though, because as techniques get better, we're pushing the envelope a little bit farther, a little bit farther, a little bit farther. So it would be interesting to look at our kind of bread and butter repairs. I would guess that that success rate has improved over time. But if you look at all comers that we treat with repair, I think that 20% number is a good one for patients. Yeah, it's, of course, very, very tough when you have the young patient with the ACL to have a meniscus tear. If you repair as many menisci as we all do, you will have to deal with the complication that is stiffness and that is failure. And you have to just explain that to the patient. Now, some parents will be very, very tough with you and say, I do not want that meniscus fixed, right? So how do you deal with that? Because it's a 16-year-old. You know that meniscus needs to be fixed, but the parents insist on removing it because they've had it fail in their career. How do you deal with that sort of conversation with your patient, Aaron? Well, I think you have to spend some time with them and unpack exactly what their concerns are, their worries. And I think for a lot of athletes, their worry is, gosh, I won't get back to sport. But then if you really have a detailed conversation with him, I forgot, was it one of you presented the rapid chondrolysis in professional athletes after lateral meniscectomy? Sometimes with these tear patterns, there's a bigger risk of them not getting back to sport after meniscus removal than repairing it. So I think after you have a really educated discussion, I would say most patients gain perspective. And ultimately, it's shared decision making. But I think a lot of them will come around, particularly you're really worried about that could have problems after surgery. I agree. I think these are tough discussions, especially with our athletes. And a lot of times, they have tunnel vision that they want to get back towards the sport as quick as possible. You have to be real. It is a shared decision making process. But you really do need to unpack what are those relative risks. What does that look like for them? Obviously, as they progress in their sport, whether it's in the college or pro level, there's a lot of different things that we're thinking about as well. So these are tough decisions, tough discussions. But you have to be open and frank with them. It's realistic expectations for their decision one way or another. Andy, so a classic case is ACL tear. And the lateral meniscus posterior root has some sort of oblique tear in there, maybe not a complete avulsion. In the past, our maybe mentors have talked about this being a stable posterior root partial tear. And we leave it alone and have a great outcome. It's actually a very phenomenal sort of discussion, editorial type of discussion in the arthroscopy journal, if you're interested in it. I think you were involved as well, right? I don't know, maybe you were not, because you're smiling. It was a bit of a battle back and forth. Sometimes these editorials are kind of fun. Anyways, in this situation, do you leave it alone? Do you fix it? What do you do? Do you know the sort of elements? It's hard, because in terms of the best data available, long-term prospective data, I think at best it's mixed as to how those do. I mean, the case example that I showed of that LUMWART tear, she was 16 years old. And so in that situation, in these types of situations, it's pretty hard, if not impossible for me, to say that this person has such a high healing potential to begin with. In the setting of an ACL reconstruction, put one or two stitches right there, co-op those tissues, protect them. And so I tend to fix those. I have debrided them. And in my older military patients that are in the twilight of their career, but I think a younger person like that with really good tissue and a robust capacity to heal, I tend to fix those. Volker, can I suggest a question that we can discuss as a panel? Absolutely. Because I'm sure that many of you in the audience were like me, and I love learning from my esteemed people up here as well, is, well, how do we take care of these patients after we do all these cool techniques, right? I think part of the challenge we have with meniscal repairs and have success is, how do we rehab them? What are our weight-bearing restrictions? What's our expectations for return to sport? And so maybe, Aaron, when you think about these different tear patterns, what's your weight-bearing restrictions? What are you doing initially post-op? Yeah, so I'll just back up, and I'll say that battle, if you will, is won or lost at that consultation visit. What I mean by that is, if someone comes in, they have that complex meniscus tear with an ACL. They're in the mindset that this is an ACL injury. I'm going to compare it to my teammate who was off crutches in two weeks, et cetera, et cetera. So you better talk to that patient, that family, up front first to give them appropriate expectations. And we don't always know, but I think we're at the point now we can predict pretty well what their post-operative rehab is going to be. And then I make it mandatory they have to see a physical therapist before surgery so they can lay out, OK, what does the first six weeks look like? So I think we're getting a little bit more tear-specific on our rehab. So certainly, if we have a radial or a root, for me, those still are toe-touch weight-bearing, protective weight-bearing for six weeks. I limit flexion to 90 degrees and have to counsel the patient appropriately. That is a longer recovery, longer to get your quad back, longer to return to work, et cetera. So the patient has to be quite motivated. If you have a tear that's stable with weight-bearing and full extension, like a bucket handle or a vertical longitudinal where it's compressed, as long as they're in a knee brace, then we're a bit more aggressive in terms of partial to full weight-bearing, still limiting that flexion to 90 degrees the first four weeks, but then progressing after that. But I think, really, it's up front, just giving the patient and family good expectations, having them meet with a great therapist. And I think they'll get it, and they'll be compliant and do well at the rehab. Aaron, when do you let those patients go back to run? Which patients? So two different patients. So patient A is the complex, the radial, hashtag it up, repair. And the second patient is the bucket that feels great that you let walk right away, when very different patients return to run. I mean, everything's milestone-based. But the radials and the roots and such, I'm not starting repetitive impact probably to five or six months, honestly. That cartilage needs time to just have a good homeostasis, et cetera. I think a lot of these chondrolysis cases where the meniscus is taken out, it's just the activity is too fast, too soon. Now, in the case of a bucket handle, if they do it with an ACL, if they're doing well clinically, they get to jog at three months, just like everybody else, as long as they're hitting their clinical milestones. I don't know. Dave, what do you? Yeah, I agree. I think the radial tears, root, radial, are going to be just a different bag. And I typically set that expectation for most of my patients. It's going to be closer to six months before running for those impact activities. And any of these other type of, even for like horizontal cleavage tears, I've kind of moved up to where, or back, or whatever I want to say. But most of my horizontal cleavage tears can be anywhere from three to four months post-op. They'll start running, progression. A stable peripheral tear is going to be based on their milestones, which is usually between three to four months. So I'm maybe slightly more aggressive, in essence, very similar to what you say. But we recently came up with like three protocols, the radial split and the root tear being on the far end, but very conservative. But even in that case, I try to get them after four weeks sort of out of that brace, and not six weeks. But I don't know if that's the best thing to do so far. It has worked pretty well. But there's a particular, there's a scenario where, so every meniscus repair that I do, I'm dreaming of just treating it as an isolated ACL. And so if I have this stable, I hate to call it stable because I think it doesn't exist, but that partial posterior lateral root tear, I put one or two stitches in, I probably just treat them as an isolated ACL rehab-wise. Do you do that? Are there any tears where you just say, hey, isolated protocol? Yeah, I think so. But I still think the enemy of our meniscus repairs in the posterior horn is femoral rollback beyond 90 degrees. So we really have to avoid that loaded flexion. But if it is a stable repair, as long as they're in full terminal extension, I think that weight bearing is OK. Yeah. Agreed. If you have questions, please come up. Maybe use the microphone. Thanks for the lectures. It was great for me. I have two questions. One of them is regarding the lateral meniscus repair. Usually, the exposure in the valgus knee is not easy. And most of the patient that they have lateral meniscal injury or cartilage or something, the patient has valgus deformity. What technique do you use for better exposure of the lateral compartment? And which position do you pass the inside technique, the suture? And what do you think about the popliteal base repair of the lateral meniscus? Yeah, so what Andy showed on the medial side, obviously, is not possible on the lateral side, meaning the trepanation of the meniscus tibial or meniscus femoral, whichever side you want to go. So you can't release your LCL. I think the key is that when you do various, I mean, I have slight tricks. And maybe you have better tricks than me. The table has to be very low so that the assistant can really sit on that knee and give you various stress. One, two, a little bit of traction is actually helpful. So if you work, for some time, I've worked with an L-bar or something that keeps the leg at 90 degrees. But what that does is it compresses the knee ever so slightly. So if you have a setup where the knee is either hanging, like a hanging leg setup like Freddy Fu used to do, or you have a setup where you have a second assistant that can give a little bit of traction. So it's various in traction. But those are my tricks. And as far as portal placement, just like Andy said, if I use three portals, four or five portals, I don't care. I use as many portals as I need to get over there. And so if I make an accessory low portal on the lateral side of an accessory medial portal high enough so I can clear the spine, which is sometimes high, those are my tricks. Do you have better tricks? Yeah, the other thing about the lateral compartment, which I've found myself struggling, and I take a step back. And as you externally rotate the hip and flex, I think there's a tendency, if you can't see, it's to do more hip external rotation, more flexion. You actually lose varus. And so I make sure that the knee's not becoming too flexed. Does that make sense? Yes. Yeah, so I think that the position of the hip, too, can actually hurt you. You think that you need more, so you flex the hip. You externally rotate it more. You flex the knee, and it actually closes it down. So keep that knee relatively extended and really lean into that varus and have your assistant push on the thigh is something that I've found to be helpful. But the question is, in this angle, when you pass the suture, is there any chance to hit the pronal nerve or not? Because less flexion, this is my concern. Yeah, no, there is, and there's a higher risk if you're doing it from that lateral portal, for sure. So vary your angles and be mindful of those anatomic relationships like we talked about earlier. Yeah, go ahead, Dave. Yeah, I remember a study I did with one of our fellows, probably my second year in practice, and we looked at one of the all-in-sight implants. And this has been shown in other studies. But if you come from the lateral portal, going straight back posteriorly, you can be tickling many of those important structures, and you're within 2 to 3 millimeters. So always at risk. You want to think about coming from the contralateral portal. Obviously, some of the newer designs have different stops to try to prevent you from going that far, but you always are at risk. If you're coming from the medial portal or any other accessory portal, as you kind of try to get more and more interior with that, you typically are going to be away from any of those structures. You really have to go pretty far to get the perineal nerve, to be quite honest with you. And again, with some of the depth stops, I think there's lots of ways to protect yourself so that you don't over-penetrate to where you would get any of the important structures. Yeah, and I'll just say those are great tips for all-in-sight. For inside-out on the lateral side, you have to be careful. And the key is you have to get your retractor in front of the lateral head of the gastroc. And the problem is a lot of times we're seeing 11-year-old females with discoid lateral meniscus that we have to do inside-out on, and their lateral gastroc is paper thin. So it's very easy to put your retractor behind the lateral gastroc, which then puts the perineal nerve at risk because if you come out in two different spots, you can easily tie your knots over the perineal nerve. So I can't emphasize enough, put your retractor in front of the lateral head of the gastroc and just make sure those needles are coming cleanly through that interval. But I've taken care of at least three cases now where we've seen knots tied over the perineal nerve, and it's always been petite females. Yeah, let me ask the panel, too. Oh, did you have another question? Yeah, I have another question. About the centralization, what the post-op recovery do you use, non-weight bearing, partial weight bearing, and what do you think? Yeah, so that's the hard part, I think, for any of these root repairs with centralization. We do keep them toe-touch for four weeks, partial for two, and then full weight bearing at six weeks. Six weeks. But that's a little bit of selection because you have to have that motivated patient that's willing to invest that time. Thank you. Great. Great. Excellent. Thanks for the questions. So I'm going to ask you just two case scenarios real quick. You have a 18-year-old athlete. There's an isolated medial meniscus bucket handle tear. Do you go all inside, which we showed a lot in these four talks, or do you go inside out? Do you believe inside out is still the gold standard? I say do what you do best. There is no difference in literature. Multiple studies show. So what do you do? I would go inside out with that, or maybe a hybrid if I'm having trouble getting that posterior spot. I'll do one all inside there. David? Yeah, I've done both. So what is my preference? I don't think that inside out is the gold standard, as Aaron just said. There's plenty of literature saying that your results are equivalent. And so often, if it's truly peripheral and I have a lot of the meniscus, I would, a lot of times, just from the ease and sake of doing multiple rooms, I would do an all inside. If there's in the red-white zone, I would do inside out. Andy? We can maybe get two cases done at the military hospital. And so there's really no value in trying to hustle along. So in that case, I tend to still do the inside out. Very good. And my second case scenario is the typical patient comes in, 60 years old, a little bit bigger, and has an isolated root tear with a history, with a pop, that bad IKDC score that you said. Do you offer that patient a non-operative treatment? So I think it's changed over time. Unfortunately, a lot of these patients come to me after like five months of failed non-operative management. So there's multiple papers now, including our data, that shows if you're going to fix a root, do it in the first three months. So if they're a good candidate, I won't take them through a cortisone injection and all of that. If they want to go ahead with surgery, the sooner you do it, the better the outcome. Agreed. Yeah, I go through that same discussion. I mean, Aaron has done so many great papers on this. And I pretty much quote all those papers with my patients. And we have that discussion. I think if they're an appropriate patient, I'm really discussing surgery with them. Yeah. Andy, surgery, non-op, do you have equipoise? Would you enroll into a study? I always have to Google the definition of equipoise to make sure I understand it. No, no. But just real quick, the acute pop thing, I think that's pretty straightforward. But to Aaron's point earlier about these being the happiest patients, in my experience, it's been these people with these posterior root tears have been told, have been limped along by other people, providers, physical therapists, that there's nothing to do. And so these have been some of the more gratifying cases for me because you go in there, it's juicy, you fix it, and they love you. And they've been told that there was nothing to do up until that point. I agree. They do so well with it. And they're very, very happy patients. So I think we're at the end of our time. I would say it's a fantastic. I learn every time I'm at this ICL. So I hope you all learned a lot. Go check out the industry. There are a lot of devices. I think you should know inside out techniques. I think you should know outside in the old classic technique. And you also should know all inside techniques. All of them have a place here. Preserve the meniscus. Thanks very much. One last thing, if I can, before all you leave. I'm on a committee that's looking at how we evaluate these ICLs. So you should be getting, hopefully, some quick questions. But these are really important for us. And one of the last questions in there, I ask you to please, if there's something that you want to hear from an ICL for future meetings, please put that down. We really want to, as an association, make sure we are reaching you in the ways that you want to learn. So please fill that out and put any ideas that you would like to see in the future. Thanks so much. Great point. Thank you. Thanks, everyone. Thanks, Scott.

meniscus repair

surgical techniques

meniscus preservation

Andy Sheehan

David Flanagan

Aaron Critch

tear patterns

medial compartment

MCL release

circumferential compression sutures

meniscus root injuries

diagnostics

post-operative care