Hi, Tom DiBerardino from San Antonio. We're going to talk about root tears, and there's a lot of folks in the room here that have added to the literature already. Basically the shortcut is, if it's fixable and it's reasonable, fix it, and there's so many techniques we'll talk about. There's the disclosures, they're already out. Meniscal repairs, we've talked about them all. We're going to talk about root tear specifically now. We call it the silent epidemic, and you've got to realize how anterior, when you're looking from the front, that lateral meniscus root is. It's in the middle of the damn knee. So when we're putting it back, if we're going to put it back, we don't want to put it back iatrogenically extruded. All we're doing is securing the problem, we're not fixing the issue. So we've got to make sure we get it right. There's some classifications out there, they're complex. We've seen them all. The hardest ones are the ones that aren't a type 5 or a type 4, kind of almost a Lamort type. They're kind of oblique, juxtaposed to the root. Is it a posterior horn or a root tear? Well, they're hybrids. Everything in our life is a hybrid. They're not one. They don't ever fit into these categories. They do when you stratify them in big cohorts. So it is a silent epidemic. Diagnostic difficulty. You know, unless the patient comes in and it's your neighbor, and that's the case I'll present verbally because it didn't get loaded up for some reason. So my neighbor, she's 60, but she's walking, I see her walking the dogs all the time. The dogs are actually walking her, they're big dogs. I saw her fall off the step, the curb, this big tall curb, and I saw her hold her knee. And I walked out, I go, did you just hurt your knee, Lori? And she said, yeah, I heard a loud pop. I go, this is weird, but you need to come see me at the clinic. And she's on the books for next Tuesday. That's the case, but she doesn't have arthritis. But I mean, that's the kind of presentation you love to get. I actually saw it happen. It was like watching a football game in video, except I was the videographer. I'm like, I just saw Lori pop her knee. And she did. Diagnostic difficulty is otherwise very difficult. You can't feel the posterior hornoval meniscus. They feel it. They kind of feel like fullness in the back of the knee. They have recurrent effusions when they go walking or do whatever they do. A lot of these aren't athletes. We'll talk about the dichotomous spread. But they can get a rapid progression of OA. If we don't jump on these and figure this out early, the window of opportunity closes. And lots of studies have shown us that. They account for a good chunk of all the tears out there. And we don't know how many are out there, because we don't know how many are being missed and walk right into the arthroplasty clinic and get a uni or a total without ever seeing one of us. So in JBGS, this current concept just came out. Basically, it said in yellow, surgical repair of the meniscus roots whenever possible. So if it's possible, there's data out of Aaron's hospital where he is that says, you know, fix them if possible. Because the opposite, not fixing them if they're symptomatic, is a rapid road to the arthroplasty clinic. And that's the point. So root tear timeline, negation of the normal hoop stresses. It's a meniscectomized knee. It's out the back. You get extrusion secondarily, because it's just like there's nothing hanging on. There's no basis of support. The tent is floating in the wind. Altered load distribution immediately, right? So that's pounding on the knee. Increased contact pressure secondarily and insufficiency fractures. Sometimes they come in and they're like, oh, my knee is killing me. And you point at their tibia. And that hurts more than the joint. But you have to work it backwards with the MRI. You don't want to operate on a lot of subchondral fractures and do meniscectomies, because you're missing the boat. This is what we see on MRI. And our musculoskeletal radiologists have caught up with this. It took about 10 years. But ghost sign, the coronal images, and the extrusion that we've all heard about. Three millimeters or more, as Jorge told us, that's the cutoff. But you know, you see normal knees sometimes. If you get an MRI on the opposite knee, sometimes they look partially extruded. So you're like, is that an attenuation in continuity? I mean, are these not all acute tears with a loud pop? Some of them attenuate, attenuate, and they just have extrusion. And then the pop happens. So that's the hybrid nature of it. So you've got to watch out. These are out there. We just have to look for them very diligently. So what have we learned? Dr. Lerprad's biomechanical studies. It's a meniscectomized knee. And there's lots of techniques to do the repair with anchors or drill through. Again, the dichotomous presentation. Don't blow off the older patient, because that's a large chunk of that 20% of all meniscus tears. The younger patients, they present with the acute tears. It's just part of like, you know, an ACL injury, getting the lateral root, or some sort of L-mort tear that Pat Smith is talking about just yesterday in one of the talks across the hall. Older patients present chronically more often than not. They're often following a degenerative process. The posterior medial root tears commonly occur in isolation, whereas the lateral root tears are the ones that happen with an ACL in a major rotatory mal event. So the presentation. Examination for pain on deep flexion. That's a giveaway, because they don't have that buttress back there. It's popping out the back, and it's dramatic sometimes, acutely. You can sometimes feel the extruded meniscus on palpation. But I'm not sure we're really feeling the meniscus all the time in a big, beefy lineman. I think we're just feeling the pain of it all. Some of it's subchondral pain, if you really get close with your index finger. And combination of findings, the hybrid. It's all hybrid. Fifty to sixty percent have been the school root tears. It's just kind of like, you've got to think of it. If you don't think about it, it's happening. So how do you do it? Identify the location. Position as anatomic as possible. Just recapitulating on the MRI in that first picture I showed, that the anterior, the posterior and lateral meniscus especially is way more anterior than you expect if you're not back there all the time. You've got to see. If you can't see, you can't do. If you can't do, it's like, why are we there? So you've got to tape off the room. It's like painting with my wife. If you haven't taped off the room, the cleanup's a disaster. And getting through the process of painting around the windows is painful. So you've got to do a notchplasty. You've got to do an eminenceplasty. Get the synovium taken down with an RF. Tame the knee so that you can get it done. Because if you can't see it, you can't nail the insertion site. It's like me shooting a bow and arrow. I can shoot it downrange, but I'm not hitting the target. So there's lots of techniques, lots of fancy guides. Aaron had a lot of help working on this. This one's out of one company in Naples, obviously. But you've got to have a point-to-point type guide so you know you're coming in oblique around a curved tibia, especially on the lateral side. Not a lot of real estate. Skiving's important. You've got to get a good direct hit. And less moving parts that lock down all the guides and all the different companies are adequate. But you've got to trust it. So use them in the lab because you've got to get within a millimeter of the spot. Then you're going to excoriate or drill a little hole to get some biology to heal it and anchor it to it if you're doing a drill-through technique. So the steps are, get a suture in the meniscus. That's like my test. In the 55-year-old wife of the dean of the hospital you work at, Tom, you're going to repair this. I'm going to try. But if the first stitch pulls out, no bueno. It's not going to work, right? So I put a suture in, and it's like my suture stress test. If that meniscus root is intact, in fact acute on chronic, and that first stitch pulls out, I don't care what technique you have. There's nothing left to repair. It's like in process. That's just the canary in the coal mine for a degenerative meniscus and degenerative compartment. You may not actually, don't waste all the widgets and open 10 things up on the back table only to find out that everything's pulling through. So figure that out right away. Passing suture, if you're going to do a drill-through technique, you've got to get a drill system up and some sort of passing suture or wire to pull everything down and anchor it on the front. And that's it in a nutshell. It's kind of, that picture on the right, that's the drill hole I make for a poster horn for a meniscal transplant bony plug. I excoriate it. You just want a bleeding bed, kind of like on the tuberosity for a cuff repair. We don't burr down the tuberosity to put a cuff back to a bleeding bed like we're planting corn. We're just planting seeds. We're just throwing the seeds down. So we've got to get a bleeding bed. Pat St. Pierre, one of our West Point fellows eons ago, told us that you just have to excoriate the surface to get biology to heal soft tissue back to that type of bone. So here we are passing it, tying it off. You can tie it off with a button or an anchor. I think it's been shown in the literature, an anchor gives less elasticity. It's actually going to tighten a lock down. So I've gone to anchors down there. Different toolboxes all around the system. This cinch stitch, auto cinch stitch, is what it's all about, getting a luggage tag stitch back there. A lot of companies have a suture with a loop on it, or you can use the loop suture. Pass the loop, and already have the loop on the device you're passing the suture with, and then you pull it down, whether you're using a cannula or not. That way it's all one pass, and you're going to lock down some soft tissue in the front and wonder what happened. And you get one or two of those in. It's been shown that it's teachable, it's reproducible, and it holds if it's holdable. You don't have to get any fancier than a luggage tag suture. One, two, maybe three, kind of stagger them, one deep, one shallow, sink them into the hole, and you're off to the races. So here is, not my neighbor, this is actually the lady across the street, younger, she's not a lady, she's like 17, bad looking knee though. So in the young, I don't have a case, I mean it's the cat's out of the bag, we said fix them all if they're fixable. So I don't really have a case, so I'm not going to waste our time showing a case to wonder what we're going to do. Yeah, we've got to make up some time. Okay, good. We don't need to go through that. Good, we're done.

root tears

treatment

diagnostic difficulty

repairing root tears

bleeding bed