Those are always the fun ones. But hopefully when you go back after this talk, you'll save more meniscus, which I would love to see each and every one of you do. So these are my disclosures. And so why repair? I think we're definitely at the time in our profession where we need to consider that all these tears are significant. We have a lot of tools at our armatarium at this point where we can really effectively repair them. We know that the repair restores the mechanics. We know that in a lot of these different tears, the outcomes are comparable. And so my encouragement to each and every one of us in this room is to really use some of these improved techniques to repair as many of these tears as possible. So the first one we're going to talk about is radial tears. And there's a little bit of crossover between myself, talk, and then Dr. Critch's with the roots. We know that these tears are quite significant. Not only do we have just that disruption of those hoop stresses, but we see a tremendous amount of increased peak pressures. This leads to cartilage damage obviously. And if you remove some of that meniscus, it actually makes things worse. If you repair it, you can really restore some of those mechanics to near-normal levels. This is a really great article, and this is on the lateral meniscus. So just kind of showing basically wherever you have a radial tear, it's bad. Whether it's in the mid-portion, where it's in the posterior portion, or at the root, all these type of radial tears are going to cause poor mechanics. You're going to see the increased contact pressures. And that's going to lead obviously to some cartilage damage. So they're all significant tears. And here's an example for this. So you can see the MRI image on the top right. Sixteen-year-old felt-a-pop, you can see the amount of displacement of that lateral meniscus. I mean that's gapped about two centimeters. These are really, in my opinion, some of the most difficult and challenging tears that we see from a radial perspective. But of course, we try to fix it. And this is my own learning curve with some of these radial meniscus tears. So similar to many of us in repairing these, we would think of an inside-out or outside-in. And these are horizontal mattress sutures. And I thought I was really good because I did a couple of vertical. These are not rip stops. You were just trying to tag it back to the capsule, thinking that we did a good job. But unfortunately this is what we see. And this is subsequently about a year later. You can see that all those horizontal mattress sutures just cheese-wired through the meniscus. You have elongation of that meniscus. It's really a non-functional meniscus at this point. So it really retained that previous gapping. It just filled in with scar tissue. You can see the further cartilage degradation. You can see the popped suture from some of the vertical mattress in the back. So this, in all essence, we were thinking we were doing the right thing. But we were using some of the wrong techniques, I would say, some of our older techniques, to try to repair this, and it failed. And why would something like this fail? And I think that this is really conceptually what's happening with some of our older techniques for some of these difficult radial tears. We're trying to do an outside-in or inside-out, and we're kind of going in the direction exactly what Andy was just trying to share. But we're actually pinching a large amount of the capsule to try to reduce that space that we see intra-articular. So we have just a huge amount of tension on that capsular area that really cannot sustain the repair. It's going to fail. So how can we do this better? I think that there's really, I would say, three main concepts of where we've gone with radial repairs that really can help us to have success with these types of tears. So first and foremost are circumferential compression sutures. And we're going to show some of the biomechanics of this, but can we take sutures now from an all-inside perspective to allow some compression over that site? The second main concept is really these rip stops or tie grips. So if you think about it, we do not have many radial fibers within our meniscus. We are now trying to provide a very robust radial fiber within the meniscus that we can utilize to help those horizontal cleavage tears and maintain the reduction. And finally, and this is really from LaPrade, which we'll look at as well, is that in some areas, more in the medial, not in the lateral, you can think about trans-tibial tunnels to in essence stick the meniscus right in that spot in that reduced fashion. So these are really, I would say, the three contemporary techniques that we can think about. So let's dive into that a little bit more. So we think about these circumferential sutures, and this was really, I would say, the first biomechanical study. We can now compare to an inside-out. You can see that if you can do these circumferential compression sutures all inside, you can have lower displacement, higher load to failure, a stiffer construct. Then we move to that next step is these tie grip or rip stops. So again, you're placing these in a vertical mattress fashion within either side of the meniscus and now taking your horizontal mattress sutures across them. So these are called hash tags or cross hash, and we'll see some of these different configurations. But just having that, you're going to improve, again, the stability of your construct with higher load of failure and lower suture cutout like you saw in my case. And so this is where I would call hash it up today. So we have the ability now with all these different techniques where we can place these tie grips. We can place these sutures across it, and you can do different configurations, cross hash or just a normal hash tag, but you can see that the mechanics of this is really far superior than just going across where there's just a cross by itself or with the horizontal mattress. And now we have all these different types. You know, you have cross tag as an option. So again, all these different suture configurations have really improved the stability of our construct. And as I said, Rob LaPrade really kind of paved the way, the thought process of these trans-tibial tunnels. This is very similar, same type of instrumentation that we use for our roots. You can make some tunnels within the tibia coming right at the area of the radial tear. I would recommend this more on the medial side, not necessarily on the lateral side because of the motion of the lateral meniscus. But interestingly enough, in another one of LaPrade's articles, if you look at this type of technique compared to using the hash tag type of configuration, there's really no difference. So in my practice, I would say it's very rare that I have to use now a trans-tibial technique if I feel like I can successfully do a hash tag type of suture. We also know that these type of tears have a high rate of extrusion, very similar to what we can see with root tears. And if we can repair it, we're going to improve that extrusion. And again, if you can kind of keep that meniscus mobile in a normal way, you're going to allow the normal amount of mechanics where you see some of the meniscus move in a standard way. These tears can have success. So we know the patient-reported outcomes for these type of repairs are very high and very similar to other types of tear patterns. You can improve their activity level. We'll see how the healing can be effective, especially with where it is located. So Erin, as with LaPrade, looked at these type of tears compared to bucket-handled tears. You can see again, similar patient-reported outcomes, reoperation rates were similar by 5 years. So we know we can have success with these type of tears. And again, I encourage you with our current techniques to try to repair these. But how far this tear goes to our peripheries also makes a difference. I think this was a really good article showing how much the biology is important for healing. If you have tears that are going towards that peripheral zone or all the way complete, you're going to have a higher chance of full healing or partial healing. You can see if these are truly just small tears within that white, white zone, you're really going to potentially struggle with a successful repair in this area. That being said, I think Jorge Chala has shown that there is some vascular potential even in those white, white zones. But if we're going to do any type of repairs that are more of those partial thickness, I think we really have to augment it in some fashion or form. We have multiple techniques, Andy kind of shared in his talk, that we have as tools. I would say for most of my repairs, I'm utilizing three of these techniques standard. And so be comfortable with that. Our RASP is a great tool. Make vascular access channels. There's great, great literature, long history of how this can definitely help with meniscal repairs. And then I think you have all these other three options that we have tools now to help improve some of the biology within our knees so that we can actually have success with these type of tears. I'd like to move into another kind of concept of, I would say, more difficult tear patterns, which is the horizontal cleavage tear and then finishing with the complex tears. And if you look at this, and it gives a conglomerate of a lot of literature, but horizontal cleavage tears are actually one of the most common tear patterns that we can see. And there's lots of different reasons for this. And part of it is because we all get older. But we're also starting to see this in a lot of our younger patients, some of our high-level athletes where the meniscus is degenerating at an early age and are starting to form these type of tears as well. So why are these important? We'll kind of go through four main concepts. But just similar to what we saw with the radial tears, we know that these type of tears are going to increase our contact pressures. So very similarly it's going to lead to some arthritic changes over time. We also know that these will deform and propagate with knee flexion. This was a really great computer model where they looked at these type of tears and a different knee flexion. And what happens, the larger it is, it actually books open and it will actually start to extrude. So these tears are very significant as far as their mechanics as well, especially as they get larger. We also know, similar to other type of tear patterns, you can have a good amount of meniscal extrusion. This is quite common as they become larger. And as you see, the more extrusion they're going to have, the poorer outcomes as we can expect more arthritic changes. And similarly these again, horizontal and complex, the incidence is one of the highest. And as you can see with that, you're going to have higher cartilage damage and typically more lesions within the knee. So some of this obviously can be an aging phenomenon, but they're also pretty significant tears. Historically our treatments have been pretty poor. So if you look at here, if you have a tear, how this is increasing your contact pressures, if you remove the meniscus, this is what many of us have done for many years, you remove a leaf. There's one more unstable leaf, I'm just going to remove one leaf. You haven't changed anything for that patient. In fact, if you remove all of it, you've really made it worse. But you haven't made necessarily that patient better. If you repair it, you can actually get this to near intact levels. So from a lot of the literature and systematic reviews that we've done and some of the recent studies, we know that we can get successful repairs about 85% of the time, restoring the function with a lot of our contemporary techniques. So just to kind of go through what does this look like today, how do we approach this? So one of the key concepts is always remove what is truly unstable. It's not going to be able to be repaired. You can look in this case, there's some unstable flaps that are within some of the white zone. You remove that, you get to your good meniscal bed, which is really the remainder of that peripheral meniscus. And so if I remove some of this at this point, or if I remove a leaf, again I've really in essence not done this patient any good. So we want to keep as much of these hoop stretches as possible. You can see now I'm just using the shaver but no suction to really kind of use that as a meniscal rasp to get some good synovial irritation. Many of these type of tears are going to have a meniscal cyst. A lot of times you can decompress those both intra-articulately. If there's a large multilobulated one, you may have to do a small open incision. When you're approaching these type of meniscus tears, you really want a straight shot. We now have many companies that have an all-inside suture device, which is really, I would say in a lot of ways, revolutionize how we can approach these type of tears. When you're placing these hay bale sutures and you're making these, tying them and placing the knots, you really want to make sure that you've grabbed through that peripheral tissue. You want to make sure that you are placing these and gapping these to where you cannot necessarily place your probe in between, because you're really wanting to make sure you seal this fish mouth. For the open, you're going to need to utilize multiple different techniques. So as you move more anteriorly, you're going to have limitations sometimes with the different tools that we have from all-inside. And so being familiar with inside-out, outside-in so you can have a successful repair. Again, always think of any type of biologic augmentation at the same time. So finally I want to cover the third meniscal type, which are these complex lesions. So complex lesions and horizontal cleavage really kind of overlap in a lot of ways. And we're seeing more and more complex tears as patients get older. And what's interesting when you look at the literature, it's a little bit sparse, but there's some really good nuggets of information here. If you do a meniscectomy for these complex tears, they actually have the worst outcomes. And if you can repair them, actually you can really improve their outcomes, their scores, their function. And so if you look at again some of the literature here, failure rate pretty similar to what we see with other type of tear patterns, anywhere from 15-25%. You can get good return to activity, good improvement of the patient-reported outcomes and maintenance of these results over time. But maybe not for everyone. Obviously if they have some significant malalignment, this can influence some of the results as well. So what are my five tips for some of these complex radial and complex tears? So always be prepared for repair. So I have this meniscus cart. This was a brainchild of one of my scrub techs because of how many meniscus repairs I do. She made this cart. It has every tool that I could ever imagine for any of my meniscus repairs. And it's all there and it goes between my rooms, from one room to the other. So really kind of having all access to all the different types of tools you may need is really important. Dr. Critch has also taught us about the ABCs of repair. And so anatomic reduction is really important, making sure you have some biologic augmentation and then compression around the tear site as well. So we really need to think about this very similarly to fracture management, right. We want to have as an anatomic as possible reduction of this. We want to co-opt those to really have a good compression across there as well. And again, think about that biology. But if we can keep these main tenets, I think again we can have the best chance for success. And then lastly, I really want to have this concept of a tensionless repair. And this is really important when it comes towards radial tears today. We want to make sure we don't have tension as we talked about across that tear site. So this is really important. We're using these newer techniques, these different rip stops or tie grips. So again you can see I actually placed a traction suture in here to help reduce the meniscus to its anatomic position. So now all the rest of my repair is with this in an anatomic position with the meniscus to the capsule. So I'm placing those vertical mattress sutures and then my hash tag across them. You can see motion here. There's no tension on that repair. And that's something that we really want to aim for these days. I can't get out of that. There we go. So finally I just want to say that these repairs do work. I think again we have a lot of better techniques and good outcomes. And we really want to encourage you all to repair more meniscus. So go home now, first day after a conference, and repair more meniscus. Exactly. Thanks so much. Very nice. Some really cool techniques. If I recall back in the day in Germany before I went to Pittsburgh, we did ACLs open. We didn't even look at the meniscus. Then I went to Pittsburgh. We looked at the meniscus, but we cut it out. And so now we repair basically every meniscus. How do you balance the stiffness that sometimes occurs when you—but your worst case scenario is an ACL with a medium meniscus, as far as stiffness goes. What do you do? Do you do anything different, knowing that they may become stiff? So I have found that—we haven't looked at this, but I would say anecdotally, if I have to repair both the medial and lateral meniscus on an ACL, those are the ones that typically have the highest chance of stiffness. But we're really aggressive with motion right away. I think if they have a more stable pattern of the meniscus, so for instance a peripheral tear, I'm letting them weight-bear right away with an ACL surgery. So they're getting their motion and weight-bearing on it. These more difficult patterns when you're having a radial, a root, a horizontal cleavage component where typically we are doing some weight-bearing restrictions, and that's where I think stiffness can be a little bit more of an issue. But it's just really communication with your patient and your therapist to really work hard on that. That's specifically what I wanted to ask regarding postoperative protocol for those complex tears because I try to save the meniscus all the time, and I do see in the medial lateral meniscus tear, I had a radial tear, went back in to do a lysis. I don't—I mean, anterior neural release for a patient, I don't ever really have to do that. But this patient went in and saw the meniscus healed. It was great. But we had to do a second surgery to release the scar tissue because I limited him. So what is your protocol for the complex? Yeah, that's a great question. Maybe how many weeks do you do non-weight-bearing for these complex radial splits when you repair them? So I become a little bit more aggressive with my motion over time in my rehab protocol. So I used to be pretty strict with bracing and weight-bearing restrictions for about six weeks, but really found that the stiffness was too high. So in these radial tears, they are not getting a brace, so they're working on motion right away. They are typically four weeks non-weight-bearing and then a progression where I let them fully weight-bear and off crutches by six weeks. And do you limit the range of motion how much, like zero to 60 for a couple of weeks or zero to 90? So I think the key here is this tensionless repair. I think if you can get a tensionless repair, I have no issues with them working on range of motion whenever they feel comfortable. So that's the key. I would say in some of the older techniques, I had to limit their flexion because we would get more tension on that repair with flexion. Any of you would go under four weeks for a non-weight-bearing? Four? Anyone? Weight-bearing is tolerated? Not really, right? I like to try to do that, but I really haven't either. As a follow-up to that, what is your weight-bearing restrictions, if any, for the one that you showed with the horizontal cleavage repair, if you're doing that isolated without any kind of ACL? Yeah, those are great questions. So I would say historically I used to similarly do between four weeks of non-weight-bearing up to six weeks of non-weight-bearing. But I think that these are truly stable tears. So now I have them, in essence, I have them on crutch use for four weeks just to make sure that they're not doing anything stupid. In my first two weeks, they're kind of a partial weight-bearing. They're weight-bearing with crutches for a total of four weeks and off crutches. Good. It sounds like we're getting more aggressive with the rehab. This is good. I'm going to shamelessly plug for the STAR trial. We're ending trial two here in the fall, and then you'll learn a lot more about a randomized control study talking about weight-bearing versus no, following multi-ligaments and including many menisci. So it'll be fun. All right.

meniscus tears

repair techniques

radial tears

hoop stresses

cartilage damage

postoperative protocols