thank you to AOSSM as well as the forum for the invitation to present to you I apologize that I couldn't be there in person but my topic is don't cut it out strategies for the so-called unsavable meniscus. here are my disclosures which some of them are relative regarding the products that I show in some of the videos regarding my consulting income as well as my research support. we'll briefly look at the meniscus function as well as the biomechanics. we will so called talk about the unsavable meniscus tears and then when can we push the limits. as we all know functions of the meniscus is multifactorial but load transmission, mechanical stability, shock absorption, proprioception and looking specifically at load transmission, the lateral meniscus transmits 70% of the load in the medial 50%. this also varies by position with 50% of compression load being an extension and 85% of compressive load inflection. this all affects regarding meniscectomies in the decreasing contact area with significant increases in contact stress with a hundred percent on the medial side and 200 to 300 percent on the lateral side which ultimately we could see and radiographic findings you know five to fifteen years down the road. looking at five-year outcomes with x-rays after meniscectomy, a partial meniscectomy shows a 10% reduction in joint space and subtotal meniscectomy shows a 24% reduction in joint space. historically speaking I would say the previous unsavable meniscus tears were complete radial transections, horizontal cleavage tears that we would historically take out the top leaf for the bottom leaf and then also root tears which as we know are more readily recognized as well as treatment options. so I would now say that this is now savable meniscus tears which will sort of touch upon you obviously have many other great lectures that touch on these individually as well. so recognizing radial tears on MRIs you'll see a truncated triangle as well as a cleft sign or a marching cleft sign. this is one of the many studies that supports biomechanically attempting to fix these unsavable previous radial transections. this is looking specifically at the lateral meniscus and comparison of the contact pressures and contact area with the intact state and increasing radial tears of the lateral meniscus and looking at repair of the radial meniscus tear significantly improves both the contact area and pressure. the contact pressure was not significantly different from the intact state but the contact area was significantly different. so this does sort of lend the hand to attempting to repair these when possible. here's an example from arthroscopy techniques regarding a side-to-side repair of a radial transection. here's an example from a young athlete I treated with an isolated radial transection and felt that this definitely deserved an attempt at repair. here's a video demonstrating here I used a all-inside device, one on each leaflet of the radial transection and as the video progresses you can see that this was then tightened but trying not to over tighten this and over reduce it. and here is that meniscus capsular side-to-side repair and a second suture was also placed. here's the second suture being placed And with probing, this was eventually stable and did have an excellent outcome regarding healing and allowed the athlete to get back to sport. This was a systematic review looking at an OJSM regarding 9 studies looked at 215 knees with a lateral meniscal root tear and either repaired with a side-to-side repair technique or a pull-out repair. And overall they reported a 90% success rate in the setting of an ACL regarding healing of this meniscus tear. As we all recognize the gold standard for meniscus repairs and what most studies compare to are inside-out techniques. So this is a study from Ohio State looking at a systematic review regarding alternative repair types from all-inside as well as trans-tibial and they have found that there may be alternatives to traditional inside-out horizontal repairs for radial meniscus tears. And that is all-inside vertical techniques that reinforce with a suture parallel to the tear instead of the standard inside-out type repairs. So trans-tibial two-tunnel augmentation may increase the strength of radial meniscus tears. So shifting the focus to horizontal cleavage tears, I like to call these and describe these as the PETA pocket. And historically it's either benign neglect or resection, removing one leaflet, usually whichever one looked worse. But recent biomechanical studies have definitely shown that resecting one of these leaflets may be as detrimental as a partial meniscectomy. And then cadaver studies showing that repairing horizontal cleavage tears can restore the biomechanics of the joint close to the intact state. So this unsavable meniscus has now transitioned to a more savable status. And new instrumentation has obviously facilitated this with all-inside vertical compression type stitches or all-inside devices. This biomechanical study looked at the horizontal cleavage tears with inferior leaflet resection, a double leaflet resection, as well as a repair. And you can see very nicely in this graph that the repair status significantly decreased the mean contact pressures as well as increased the mean contact area. So this is definitely something to consider as you begin to see these more commonly. Looking at the horizontal cleavage tear, the aim is to repair the superior to inferior leaflets, obliterate that horizontal cleavage, and prevent the intra-articular fluid from collecting into a perimeniscal cyst. Here's one of my patients that's a 35-year-old female with localized joint line pain with this horizontal cleavage tear that you can see here in the video. Historically I probably would have chose one of the leaflets to resect or at least trim back to a more stable rim. However now I choose to do a circumferential type suture to try to close down that horizontal cleavage. I think we can all agree that meniscal root injuries are definitely more readily recognized as well as treated, but these are the radial tears located within one centimeter from the meniscal attachment or a bony avulsion. Biomechanically these are really comparable to a total meniscectomy and compromise our hoop stresses and we know will ultimately lead to meniscal extrusion and ultimately the development of early arthritis. So meniscus extrusion can definitely happen when you have a meniscal root injury, but also it can happen with just meniscotibial disruption that results in extrusion and loss of the meniscus function even when you have an intact root. So can you just debride these? Well looking at 52 patients with an average age of 55 years with a partial meniscectomy versus non-op and five years follow-up, they really had similar outcomes and a 54% rate converted to total knee arthroplasty. Here's a patient of mine with a root tear. My choice fixation is a looped type construct. I put two sutures in the root. I drill a socket of about six to ten millimeters and do a trans-tibial pull-through type technique and fix it on the tibial cortex. This is a 26-year-old male with a chronic ACL who also had this chronic bucket handle meniscus tear that was obviously flipped and incarcerated into the notch. So this really asks, you know, when can you push the limits? And that's also with the tear types that you can repair, but also with the techniques that we choose to use. In the setting of isolated meniscus tears, I think we all know and believe that complex tears are going to have less clinical success than simple tear patterns, but what I think it's really important to keep in mind that these complex tear patterns, although may have less clinical success when compared to simple tear patterns, when treated with meniscus repair, they were definitely better from a patient outcomes perspective than a simple partial meniscectomy. In saying that in a slightly different way, you know, at the time of ACL reconstruction, complex and bucket handle tears are a negative prognostic factor with regard to patient reported outcomes, but clinical success rates of meniscus repairs of those complex tears were higher in the setting associated with an ACL versus isolated meniscus tears. So again, this is an idea of pushing the limits and looking at meniscus repair for bucket handle tears in the setting of ACLs showed lower pain scores at long-term follow-up for the repair group. So back to my 26-year-old patient, this was a chronic bucket handle meniscus tear that traditionally you could definitely make an argument for inside out, but I do think that our strength of repair has improved with vertical mattress type sutures that I felt comfortably marching from the posterior horn out to more anterior horn. Some of our devices are now more flexible and can get into positions of the meniscus that historically we were not able to reach arthroscopically. So pushing the limits, we are not only talking about the type of tear, but also the ways in which we fix it. So historically, the gold standard of this would have been inside out, so I think having an open mind with looking at some of these newer devices, being able to repair tears that historically were treated in a more invasive manner, as long as our strength is appropriate, it's something to consider. Recognizing radial tears and diagnosing these are important as radial tears are associated with greater extrusion than non-radial tears, so this is one of the areas that you should probably push the limits to try to get a repair. Radial tears have a 5.92 odds ratio for development of osteoarthritis compared to controls. All inside and inside out techniques significantly decrease tibial femoral contact pressures compared to partial meniscectomy. All inside, side to side repair constructs demonstrate a greater load to failure than traditional inside out. So all things to think about as you push the limits on radial tears. So here, my topic started out with unsavable meniscus, but now hopefully you have a few more skills to save the meniscus, don't cut it out. Thank you very much for the opportunity to participate.

unsavable meniscus tears

load transmission

mechanical stability

shock absorption

proprioception