All right, well, we'll end the morning with probably a more dramatic type of situation. And this can happen very often in younger people. They have a significant meniscus injury, wind up damaging the articular cartilage. So this first case, and if we have time, I'll show you the other one as well. But basically, a 22-year-old female college soccer player has lateral knee pain, preventing her from participating in soccer, develops a fusion. She's had treatments including braces, non-steroidals, injections. The significant thing here is that her past medical history is that she's had two previous arthroscopic partial lateral meniscectomies. Probably looking back, this was something that was sent to me, looking back at her previous records, what we saw early is that the first time, it should have been repaired. And part was taken out. She kept on playing, weakened it, tore more of it, and then she wound up in this kind of situation. Otherwise, really good health. Her knee is in good standing alignment and neutral alignment, so not a concern there. Our considerations here are what's the source of pain, whether there's any other non-operative considerations, and she's already expired a bunch of these. And I think very importantly, and I think what Jim was talking about is important as well, is that realistic expectations. You know, I think, you know, she ultimately wants to return to be playing soccer, and I kind of told her, I ultimately want you to avoid a unit compartmental knee replacement when you're 30. So very important to be realistic about that. So here's just select views of her MRIs, and you can see that there's basically no real lateral meniscus tissue, and she's developed that cartilage injury on her lateral femoral condyle. At the time of diagnostic arthroscopy, you can see this big area of chondral injury to her lateral femoral condyle, and just a rim remnant of her lateral meniscus. I guess we'll skip this table discussions for time-wise. Yeah, yeah, we can do that. We've got a few minutes left. So basically, so I guess general question, this 22-year-old, we have no option, right? I mean, is anyone not going to try to fix this person? Right? So basically what we do is go ahead and do a lateral meniscus allograft transplant and mace to her lateral femoral condyle. So in doing the procedure, at the time, we reevaluate the knee joint initially before we proceed with opening and doing any allograft preparation. Then we'll go ahead and prepare for the meniscus allograft. As you've kind of seen, on the lateral side, I prefer to use a bone bridge. So that will get prepared. I'll prepare the joint itself. We'll go ahead and implant the meniscus allograft tissue, then go ahead and do an arthrotomy to fix the lateral femoral condyle. We'll go ahead and prepare the lateral femoral condyle, prepare the mace graft, then implant the mace graft. The one thing I would do is I'll do some of the meniscus allograft, I'll do some all inside, sutures in the back, and then inside out in the rest. And I won't tie those down until after I put the mace in, but I'll want to pass everything so I don't wind up injuring the aspect of the allograft. So here you can see her lateral meniscus allograft in place. You can see she's already developed some congenalation of her lateral tibial plateau here. Here's her mace allograft. And you can see very nicely, here's her meniscus coming through the bone bridge. And when I use the bone bridge, I like to use like a small rotator cuff anchor to use as an interference screw to hold that bone bridge in. I think if you use a regular interference screw, you know, it's just too big. So these are about three millimeters. They hold it really well. And what's really nice is that you can use those sutures from it to kind of close over the anterior capsule and synovium. That's always a weak spot. And post-operative rehabilitation, I follow the guidelines of the mace in regards to weight bearing with early protected range of motion, progressing to full weight bearing by 6 to 8 weeks, then continue working on range of motion and gradually return to activities in 9 to 12 months. I can tell you her follow-up was she did try to return to playing soccer and could play, but just not at the level that she used to be, which was kind of frustrating. She was a D1 level player, and she just could not get back to the level that she really wanted to be, although she wasn't really having any knee pain, and she wasn't having any swelling. She just kind of couldn't get back to it. So that was kind of unfortunate for her. Yeah, so let's do this. Why don't we... I'll just wait. Yeah, so we're basically sort of at time, but I think as long as people don't have anywhere to go or if they want to stick around, we can just sort of entertain some general questions here. And my first question for Wayne or for the faculty is, with this, the MRI did not show like subchondral cysts on the lateral femoral condyle, so this was a surface-only lesion, so that's why you chose mace. How many other people would choose an osteochondral graft in this situation? Okay. And let's see, who wants to take a stab at explaining why they would choose a graft? We'll pick on Brian. Brian, Brian's... Or Scott, please. Go ahead. Tom, what would you do on this? Or Tom Carter, sorry. All right. And then anybody, as far as like Wayne uses a slot for the lateral meniscus, who uses something besides a slot for the lateral meniscus? Yeah. So two trans-tibial plugs? I guess that's what I meant, yeah. Yeah. Jim, are you all soft tissue on the lateral side as well? Yeah. Yeah, I'm all soft tissue as well. Other questions? Yes. All right, and then how many, to the other point that Wayne made was that he fixed 75% of the meniscus graft, then did the cartilage procedure, and then finished off the meniscus, basically to try and not pop a stitch, right? Yep, pop a stitch and not damage the graft passing needles. Yeah, well is that common here, where people just get the meniscus fixed all the way and just then do the cartilage? You don't want to hyperflex against your meniscus repair, so I agree with your approach to that, and that's important to think through the day before your surgery, the next morning, go through your steps, and let me know if you don't think you are the same, see what I do now. Brian? Yeah, I mean, I think mostly I just do two-thirds meniscal repair, near a closet, put the plug in, and fix the edge for a month, that's how I've always done it. I haven't seen a billion issues. I don't sew it down, I don't tie it down, I just place all my stitches. Do the upper arm, fix the graft, fix the front, close the upper arm, extend the knee, close the meniscus, capture sutures, everything. I haven't seen this issue otherwise. And are you doing these, are you going inside out with your repair stitches on all these? Inside out, I think it's cost-effective, probably the most balanced repair, you don't get as much buffer, you can kind of customize how you place your sutures, so I would prefer it on the top and the bottom, and less sutures than I would be able to do meniscus repair. And that's an interesting point, too. So a bucket handle meniscus tear, I will place ten plus inside out stitches. For a meniscus transplant, amongst the faculty, how many people are placing typically more than ten stitches? How many eight to ten? Probably like six. Yeah, six to eight. Six to eight, yeah. So roughly like maybe two to three points of fixation in each area of the meniscus, does that sound about right? It's interesting, right? Plus you don't want to over-constrain the meniscus. And then how many people, at least on the medial side, are considering some sort of anti-extrusion or prophylactic centralization type thing here? Jorge's raising his hand in the back. Aaron, would you guys do the little, the anchor on the peripheral rim of the plateau, pass it up through the meniscus like you do for a standard centralization in a root situation? Yeah, for me I try to get one by the peripheral capsule and one in the transplant. Kind of just hold it, hold it in place there. Would anyone consider anything on the lateral side in that regard? Or do you think it's too mobile? Excellent. Anything else we can think of? Questions? We're a little over time, but again, as long as everyone's... Awesome. Alright, thank you guys very much. Appreciate it.

lateral knee pain

meniscus damage

articular cartilage damage

surgical techniques

rehabilitation