speak at this. And my conflicts of interest are disclosed here. And this is going to be two minutes of history, physical exam imaging, five minutes of a small group discussion, and three minutes of surgical solution, although we could shrink the middle section if needed. So here's our case, a 25-year-old medical student. She sustained a knee injury while running, pain medially more than anteriorly. And the pain was associated with catching sensations. She had a little limp. She lost some extension and some point tendons about the posterior medial joint line. Here's some of her x-rays showing her joint space is well-preserved. Ultimately, I did check her alignment, which was neutral. And here's the MRI. And of course, you can see that tear there. This is what it looked like arthroscopically. This is one of the rare ones we were talking about, where I really couldn't find anything to repair. It's just complex, multidirectional tearing, shredded tissue. It looked like different ages of tear. Some of it was rounded. Some of it had sharp edges. 85% of the meniscus was involved for about 30 millimeters of longitudinal component. Rest of the knee looked good, ACL and other compartments. So I reviewed the findings with the patient. She attended physical therapy as directed. She had some continued medial side of pain, which was a little different than her preoperative pain, but in similar location. So my assessment was left knee medial meniscus deficiency after knee arthroscopy in the setting of a normal ACL, normal articular cartilage, and neutral alignment. So this is the case where everything else looks pretty normal. So why don't we discuss briefly if you would entertain a meniscal transplant, and if so, some of the technical aspects of it, like how you're going to prepare the meniscus, and what you're going to do with the posterior root, the anterior root, and the soft tissue in between. All right, well, at this point, we'll return for the surgical solution, or one approach. And we'll spend three minutes on this. So I hope you've discussed at the table the shared decision-making process you'd undergo. How many decided that they wished to do a meniscal allograft transplant on this patient? Raise your hand. And how many decide they did not wish to do it? Good. And we discussed at our table, in the setting of this meniscal deficiency, you may want to follow them for a little bit, give it a chance to settle down, maybe an unloader brace, entertain it, but close follow-up, following their symptoms. I wanted to present one piece of expert opinion and three systematic reviews about techniques, because I know you've talked about the techniques at your tables as well. This International Meniscus Reconstruction Experts Forum accepted there's no superiority of one surgical technique over another, although 74% of surgeons prefer to use bone fixation compared to 26% preferring soft tissue. The first systematic review, they actually predate that a little bit, showed no proven superiority of one method over the other. That was 2014. One from 2017, a meta-analysis, had 485 meniscal transplants that were soft tissue, 489 that were bone fixation, and they had similar tear rates and failure rates, which were around 15%, similar Lysholm scores and other patient-oriented outcome measures. Meniscal extrusion was high in both groups, 40% in soft tissue group, 43% in bone fixation group. So these are things you should prepare the patient ahead of time for seeing extrusion and failures. And the one thing from 2019 showed, again, these are very similar, although soft tissue fixation groups showed a higher post-operative IKDC score than the bone fixation group. So I'm going to narrate this case, but I want to emphasize, again, this is only one possible approach. This is a soft tissue fixation. So the first step, I leave about 1 millimeter rim of native meniscus. I place non-absorbable grasping sutures in the posterior horn and anterior horn. I place absorbable suture in the body. I remove the articular cartilage with angled curette or shaver by the posterior horn. Do an ACL targeting guide, as we saw earlier, for the root repair. Drill to the point. Pass two loops of suture to draw on the body. In the center, I'll triple the portal length to allow passage of my finger. Then I know the meniscus will fit. Ensure no tangling of suture, because this could be a suture bezoar if you're not careful. And evaluate the fit. Tie the posterior root suture over a button or an anchor. That's a great word, bezoar. All inside, repair the posterior horn. Hold the meniscus in position. I still, like outside in, repair the body anterior horn, although I've dabbled with inside out. And then I do a biocomposite anchor for the anterior root. Sometimes the anterior horn gets a bit thin, so I can't do a vertical mattress or even an oblique suture. So I'll do one through the meniscus and one through the capsule, like I've shown in the center. I've moved from doing about 10 points of fixation, about seven. And one by the posterior root, one or two in the posterior horn, the one in the body that drew it in, I'll tie over the capsule. And then two or three by the body and anterior horn. Then we have that anchor for the anterior root. This patient had physical therapy. And I did have the brace, crutches, motion limits for six weeks. At the 18-week visit, she had no pain. But I carefully reviewed the function of transplant tissue with her. I said, typically it holds up to activities of daily life. I even sometimes will return to the first office note to show them, remember how you were? Do you want to get back like that? But she gradually increased her activities, even jogging a bit. So for the three technical pearls, I'll focus on two and three. Fixation with too many fixation points may lead to postage stamp tearing. We've seen some meniscal repairs already today that had some tearing through the sutures. I think the oblique suture pattern seems to work pretty well, more vertical than horizontal. For decision-making pearls, assess alignment, correct unfavorable malalignment. I like to replace like with like at the same time. So you're placing a meniscal deficiency with a meniscal allograft. Cartilage defects with cartilage restoration, ligament deficiencies with ligament reconstructions. I avoid meniscal transplantation in compartments with arthritis. We all know the difference between explanation and excuse is timing. The healing rate and long-term survivorship are not greater than 85%. I tell them that before the surgery, as well as to expect some extrusion on future imaging. I try to assess the structure with second look arthroscopy and an MRI whenever appropriate, and assess function and patient-oriented outcomes, especially long term. Here's one, a second look, just showing how the tissue integrates. All right, thank you. Thanks, Jim. All right.

knee injury

pain

tear

meniscal allograft transplant

soft tissue fixation