Good morning, everyone, and thank you very much for being here. Thank you, Lee Pace, for giving this group some inertia and helping us pull off this from the ground. We're going to talk a little bit about meniscal radial tears. I'm going to try not to include too much background information. This is a 35-year-old male with medial knee pain, catching and swelling, with no prior trauma. He was pretty much going down the stairs, had, like, a little jump at the last step and felt a pop in his knee. Poppable effusion, range of motion 5 to 125, positive McMurray, joint-line tenderness, medial pain with terminal flexion. These are his x-rays, and these are his MRI images. You can see in the coronal plane, you would potentially call this a complex tear. Full disclosure, this was a live case that we were doing, which is not a great idea. But you can see that there's a medial meniscus tear there in the posterior horn that may extend a little bit more to the body. The things that I want to discuss are pretty much the same that Kirk was mentioning before. So timing for surgery, who would go in, who would treat this conservatively first, who would use an unloaded brace. If you do surgery, and considering this, of course, is a radial tear, which type of technique would you do? And are these repairable or not? Does it make sense in a 35-year-old to make a radial tear repair? Let's discuss that, and we'll reconvene in five minutes. What? Can you see the MRI? So that's a tear. And I can show you, that's, you can see the arthroscopic view of the tear there. It's like a posterior horn radial tear of the medial meniscus. Can you guys see it there? Okay. Good, let's discuss. Okay team, so let's, let's get a couple of questions for the group. So who would not repair this tear in a 35-year-old? Please raise your hand. Would anybody not repair this tear in a 35-year-old? Brian Cole is not here, he would have raised his hand. Who would do an all-inside technique, and who would add a centralization stitch? Vern, would you? So three millimeters of extrusion, 35-year-old. Brian, 35-year-old, radial tear. Would you repair that tear, or do you think a meniscectomy would be best for this person? Let me show you the x-ray and the MRI. Just in time. So this is a live case, 35-year-old, potential radial tear. Thoughts on repairing this versus debridement and unloading? Neutral axis. Is there a mic? Get a mic right here, Brian. There's all these intangible variables that we think about, right? So, if the patient is behaving as a painful tear versus, hey, my meniscus is no longer functioning, which can be tough to do in and of itself, because a radial tear is just like a metastatic by its name. So, it depends on how they present, that's the first thing. I think we can all pound our chests, like we used to do with Rotary Cups, say, I can repair a new Rotary Cup, there's no such thing as an irreparable tear. Anyone, which you're about to show us, can repair this tear, right? And it's gotten easier and easier. So I think the challenge is, you gotta talk to your patient. I will tell you that I think this pendulum has swung, in some instances, based upon your patient population, that just to repair everything, as opposed to save the meniscus, I saw a new MediThing this morning that came out, it was Seth, you know, repairing everything. We can all do it, right? That's the podium conversation. But when you're in a situation where they fail two and five times in certain sports, or three and five times, arguably, that there may be room for a meniscectomy. So I think in this case, I don't know the other background noise, how this patient is presenting, because I think it's very relevant. I think age is relevant, too, but obviously, the lateral side radial tear is the most threatening one. I wouldn't blame anyone for saying I think it's important to repair it, but it's not as straightforward as, yeah, I can repair it. It's why you're repairing it, and what the patient's presenting it with. So I know it's a little philosophical, but what would I do? I would have to ask 100 questions, and I'm coming at 9th hour, so I can't tell you, I'll watch how you repair it. I, um, I asked that question purposely, because we talk about this all the time with Brian, and I think, you know, those are all great points. Sometimes, we wanna be heroes, and try to repair everything there is, and sometimes, you know, we're not doing the best for the patient. So I think a good conversation with the patient, understanding what the limitations are, potential complications after surgery, and potential for going back. Remember that repairs have three times more failure rates than a meniscectomy, but it's important in cases like this, in a young patient with good jawline, that has good meniscus tissue, to be able to repair this pupil, or this type of tear. So this is what we did. I usually like to add a centralization stitch, very low threshold for an MCL pie crust, and they heal every single time. This centralization stitch will do two things for me. One is, we'll bring the meniscus back to the joint, and the second thing, deliver bone marrow elements from the tibia, into the repair site. I go from bottom to top on one of the leaflets, and top to bottom on the second one, and you can see how that brings the meniscus back in again. And after that, you can do whatever you want. You can do an inside-out, you can do an all-inside technique, depending on how much help you have in the OR, but you will see that this meniscus will come along together very nicely, and the borders will be pretty much in touch and in contact, and you will have all the bone marrow elements coming from below, from the tibial side. Some people advocate for taking that white, white area. I like to repair it, because we've seen in MRIs at six months, that they actually do heal. Would anybody do anything different in this case? Charlie, I know you've advocated for clots. Would you do that in this case? I'd add a fitting clot, and then I would use sort of a hashtag of a tiger repair. But yeah, I think it comes together better than you think. So, but yeah, good case for it. Lee, what do you do? Would you do a centralization stitch in this case, or no? I mean, if there is concern for extrusion, I think that that's reasonable. Personally, I would do all meniscal-based side-to-side. I think the biomechanical literature, which is all we have for some of these radial tears at this point, or at least for that type of construct, shows that that construct is better than anything else. So I would try to get two or three side-to-side, all meniscal-based stitches where I'm tying knots. That's what I trust the most. But I have done hybrid stuff as well. Tom, how do you rehab a repair like this? So this is a medial side. So I think you gotta really respect the biomechanics. I mean, it tore when he came off a stair. So his history, the way you present it, it tells you everything in reverse. You have to protect him from anything above half of his weight-bearing, and it goes for at least six to eight weeks to give it a fighting chance. The sutures are in a horizontal pattern that are in line with the radial fibers. So their propensity to pull out toward the tear and loosen over that six weeks, if you keep pounding it and just actually let him do what I'd love to do, full weight-bearing and knock them extension, if reasonable, not in this case, not in radial tears. Partial weight-bearing for six weeks, zero to 90. Don't go past 90, because you shear it apart as well. One other issue on the rehab I think is really important. I work in the Middle East, and kneeling and squatting and praying is critical to the population there. So you have to tell all your meniscal repair no deep flexion for at least six to nine months. That's really important. Otherwise, it's just a, it's fuming too. So Charlie, can you clarify flexion with and without weight-bearing? Like, what do you, how do you make the distinction of what we allow with or without weight-bearing in terms of the degree of flexion? So normal flexion without weight-bearing, first four would be zero to 90, and then we do the rest in normal. Weight-bearing, squatting, kneeling on the floor, I'd tell them six months before they do it. So they pray and shear. Yeah, because we got the good thing. If that's important to the patient, then it's the weight-bearing. Otherwise, it's just extremely fuming. Rib stop, you were talking about rib stop, but also the chronic pain. Yeah, I think that's a great thought, mostly for the lateral side. If you have bad or non-optimal tissue, a rib stop is a phenomenal technique just because you can avoid any issues with the sutures pulling through. On the medial side? You certainly can do it on the medial side. On the medial side, I like to bring it in with one of the stitches that I showed, but you can certainly do that when the meniscus tissue is not optimal. One last question for Wayne. Wayne, is there a rule for an unloaded brace after those first six weeks? So, if you're going for the insurance, there's gonna be an adjustment rule case ending with the brace, so if you're asking. Correct. I definitely think there'd be a rule for protecting, especially, you know, if preoperatively, we were just talking about the fact that a line was built, whether it's embarrassing or not, trying to unload that area might be to protect you a little bit more. Also, I think the brace kind of serves as a nice little reminder that they still start feeling pretty okay, and then all of a sudden do something stupid, so having that brace on there, it may be a good reminder. Brian. Yeah, I think the challenge is that the normal line knee or elbow is in that part or vice versa, and if you're not in weight-bearing early on or heel touch, I'm not sure the value of the brace. People talk about it a lot. If you look at Andriachi studies and others, in terms of the real ability to reduce that duction moment, in that kind of knee, I'm not sure it does a whole lot. That being said, to Wayne's point, it does remind the patient. It just may be an expensive reminder and they're not always that comfortable. So, it just, everyone talks about, not everyone, many people talk about it. I'm just thinking, if we drill it down to what we're really doing, in the early post-op period, does it really make sense if we protect them in a normal knee that's aligned with the other side, I don't know what it's gonna do. So, just thoughts, if you can say, well, put it for the four months to protect them, yeah, it's not gonna hurt them, but just talk to a patient. They're not crazy about it either. I think mostly the roots, you know, those are people that do have some cartilage damage to begin with, so if they are in various, even in neutral, and you repair those, protecting them after six weeks for up to six months, I think, can yield better outcomes, just because you're also not protecting the meniscus, but also the cartilage. So let's, in the interest of time, let's keep going. Thank you very much, Jorge. Thank you. So, hopefully we can.

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