So, everyone's sitting far back, which is okay. We'd like to welcome you all to the Management of the Athlete's Knee, I'm Latul Farrell, and I'm joined here by Dr. Cassandra Lee and Dr. Jacqueline Brady. And this is the first annual Management of the Athlete's Knee conference, so thank you all for signing up. I know this is a tough time of the year because many of us are ending our football seasons and rolling into the other athletic seasons. My high school and college, they're not very good, so we're done playing. As well as my kids, so it was easy for me to make it here. And certainly, this is going to be a great conference in terms of the way things are laid out here. We have some, obviously, talks to begin today, but tomorrow, as you can see from the agenda, which is kind of choose your own adventure. And I know sometimes we're kind of, at these meetings, we're kind of pigeonholed into doing certain things that may or may not be what you came to see. But here, we have some flexibility for you to be able to really explore some options with respect to different techniques surrounding the knee. For those of you who had the opportunity to look online preceding this, it has some great talks and techniques. Certainly, that gives you some information that you can use, evidence-based, kind of up-to-date, innovative things that we're all doing to better manage the care of our athletes. Certainly, I want to thank all of our instructors for taking their time out to be here and give such excellent talks. I want to thank the staff here at AOSSM and the Learning Center for all that they do here. And actually, certainly, we can't do this without them. But hopefully, this will be a successful conference for you. Please, please, please ask questions. We have some experts in the field here who, certainly, it's great to have them in this very intimate environment where you can kind of get our ear and see exactly what we do. And so, I'd like to give Cassandra and Jackie. I don't know if I have very much more to add from being on both the AOSSM side as well as the forum side. I'm going to leave the forum introduction to Dr. Brady. But from our standpoint, I think, yeah, we want this to be as interactive as possible. We have experts from all levels of athletic training, if you will. So, we have up to the pros, collegiate, semi-pros, high school. So, the hope is that we can help you guys learn about how to treat the athlete no matter what the level of play is. And then, as Latul kind of mentioned, tomorrow's day is going to be a lot of kind of name what you want to learn and take advantage of all the experts that you have here because this is your chance to really work in the lab, try to work on newer techniques. And then, also, as you make mistakes, take advantage of the people that are here that probably have made those mistakes before you and then see how to get out of it. So. All right. Hey, everybody. Thanks for coming. So, for those of you who haven't heard of the forum, it's a group of women in sports surgery. So, for the women in the audience, if you aren't part of the forum, if you haven't heard of the forum, please consider joining us. It's not just women who do sports surgery. It's women who support other women who do sports surgery. So, it's a wonderful group of people. It's academics. It's private practice, docs. We sort of run the whole gamut in terms of team coverage as well. And so, this is a great collaboration between AOSSM and the forum, and we're glad to have the people who are participating on the faculty and in the audience. Thanks. And as with everything we do, we cannot put these conferences on without industry support. So, I'd like to thank our sponsors, Arthrex, ComEd, Limvitec, DePue Synthes, JRF Ortho, Miak Orthopedics, Smith & Nephew, and Veracell. Please be sure to visit the exhibitor booths outside and kind of see what they have to offer in terms of some of the things that they brought for us to see here today. So, we're going to get things started off. I know our first speaker is not here, so we're going to swivel a little bit, and we're going to still present some meniscus stuff, but also some other talks here. But we're going to go to the bottom of our first session here, and we're going to have Rachel Frank come up, and she's going to speak about repairing stage four OCD lesions. All right. While the slides are coming up, I want to thank AOSSM and the forum for having me. It's great to be back in Chicago. The heat doesn't really get you too much. It's more the humidity this time of the year, so hopefully everyone's doing well and packed their bathing suits. My background is I'm a sports medicine and knee surgeon at the University of Colorado. I help take care of our CU athletes, and I'm our head team physician for the Colorado Rapids, which is, for anyone who doesn't know, it's the soccer team in Colorado. So, we have a lot of experience with cartilage and knee and ligaments and whatnot, and so hopefully we'll have a good chance to interact today and tomorrow during the lab as well. So, we'll talk a little bit about OCD lesions, are you too good for your home, advanced techniques for repairing OCD lesions. I do have disclosures, none of which are directly relevant to this talk, but certainly can be found online. How do we evaluate these patients? Like anything else in the world, we've got to do the basics, so history, physical examination, diagnostic imaging, and certainly diagnostic arthroscopy. A little plug for needle arthroscopy. This is an emerging technology, but certainly not new. It's been around for over a decade with different systems. This is one system that I happen to use, but this is a way, especially for patients who can tolerate it in the office, to really stage an OCD lesion or a cartilage lesion or a second look scope for meniscus and cartilage restoration and determine what they might be a candidate for. And in particular for OCD lesions, determining if they're stable, unstable, getting your probe in there, you can do this right in the office. In addition, for lesions where you're not sure if you want to repair, but you want to be able to offer an option for them at the time of definitive surgery, you can certainly get a look or a feel in the office, not waste precious surgical minutes and surgical risk, and get a feel for how the patient's doing, and then potentially order a cartilage graft or some other type of cartilage transplant procedure that you wish to do. So needle arthroscopy is a great way to diagnose and understand these lesions. If your patient's not a candidate for this in the clinic because they're too nervous or you're worried about pain, you can certainly do this under local with a little sedation in the operating room. This is a stage four OCD lesion that ended up not being repairable just because there's no defect or there's no lesion left. It's just the defect bed itself, but the classic lesion along the lateral aspect of the medial femoral condyle toward the notch. But doing this allows me to let the patient walk out of there with no narcotics, no stitches, and then figure out my definitive plan. So just a plug for using needle-based arthroscopy, and again, a variety of companies offer this. What do patients really want to know when they have OCD lesions? Well, often in this age group, it's the parents. And what they really want to know is how long will the surgery last for? Will their future All-American lacrosse athlete get back to sport, or is their career done? And without surgery, will things get worse? And the key for us as surgeons is to manage the expectations, because as we all know, even though we can execute a perfect technique and the patient can have a perfect recovery, not all of these lesions will heal, even with a perfect repair. Critical considerations for all of these things, you have to understand that the cartilage and the bone is not the only problem. If you don't understand the alignment, even in pediatric and adolescent patients, any repair that you do is likely going to be doomed to fail. We can have a little wiggle room in the pediatric patient population. We don't necessarily have to rush to osteotomy, but certainly we can do guided growth to help turn a varus knee into a straight knee and protect that medial femoral condyle. We have to think about the knee as an organ, the joint as an organ, and think about the biology. We have a lot of restoration options if repair is not a viable option, but my task today was to talk about repair. So what about repair? How can we do it? So traditionally, we have a lot of different tools in our toolbox, but none of which have been very successful, especially in the adult patient population. In kids, many things heal no matter what we do, but we want to increase our odds and we want to make sure in kids and adolescents that these things do heal. For me, it comes down to two factors, really. If the lesion's repairable, it's really about what is the age of the patient and what is the quality of the defect. Is there bone? If not, is there viable cartilage or is it fragmented? And ideally, the patient should be young. So these are the tools in our toolbox. We can do this arthroscopic. We can do it open. We can use screws, traditional metal screws or bioabsorbable screws. We can use headless screws. We can use regular screws that have heads on them. We can use suture anchors or darts. We can also just use sutures. And trochleoplasty has really helped us understand how to use sutures to repair cartilage. And then certainly, you can consider bone grafting. This is one technique that I've started to do for these more pure cartilage lesions or cartilage with just a little sliver of bone. And these are for those stage four unstable lesions. Sorry, we were supposed to mute. I asked them to, but here's some theme music. So great, great theme music. OK. So here's a defect. This is of not a traditional OCD of the medial femoral condyle, but an osteochondral fracture of the trochlea after a patellar dislocation in a 14-year-old boy. This was a defect that I really wanted to repair. And I asked my team to bring everything in the kinshin sink over to the surgery, including screws. But when I got there, I didn't like the bone. And I don't know about you guys, but I just don't love putting screws into cartilage-only lesions, although I know you can do it. It just doesn't make me feel good. So in this case, I used two knotless suture anchors and placed those each into the bed of the defect spaced about one centimeter apart. I then shuttled these sutures through the defect itself, again spaced one centimeter apart, and then interlinked the two sutures using the knotless mechanism of the anchor. And then here you can see we're pulling the fragment down, and we use the probe to make sure that the sutures didn't rub on the actual cartilage. And then we cut these flush. And you can see, again, we hope in a 14-year-old boy, anything will heal. But we don't know if it will heal. And so in this case, the father was a physician. And I begged him to let me take this kid for a second look scope, because I had to know if this suture was going to be abrasive to the cartilage surrounding the area, to the synovium, to the meniscus. And you can see here at four months, it looks great. You know, it looks totally healed. It's stable to probing. You can see the little bit of the suture left, but it's really synovialized. And I bet in about a year, this will be completely synovialized. No irritation, no inflammation, no fibrillation to the surrounding carticular cartilage or meniscus. And so this is a new tool for me in my cartilage repair toolbox, in terms of being able to use a suture-based construct for more cartilaginous-based lesions, including OCD lesions, where the bone is just so thin that I don't feel comfortable with screws. What about rescrews? So this is a case I had my first year in practice. And this is a trochlear OCD lesion, kind of an interesting lesion. You can see it. Now, this isn't a 30-year-old guy. He's had acute pain, but he's had chronic pain for years. If I were to see this case now, I would just have taken this out. But first year in practice, I attempted to repair, because I was trying to repair anything and everything. So here you can see the defect. You can see it being unroofed, classic stage 4 lesion. And we go ahead and we look at it. There's a little bit of bone there, so I feel comfortable with screws. I used bioabsorbable screws in this case. I now only use metal screws when I fix these for this exact reason. And this guy does great till he doesn't. And then three months later, he has some pain. You can see the MRI. The cartilage looks okay. At three months, I don't think we can say that there's any problems. But he had mechanical symptoms, effusions, and pain. So I took him back, and this is what you see in the scope. It just never healed. Now, maybe it was never going to heal, but again, screws are an option. But for those really kind of chronic or acute on chronic lesions, I don't know that they're the best option when there's minimal to no bone behind the defect. What if repair is not possible? I have to plug this in, because anytime I give a cartilage talk, I have to talk about my favorite cartilage procedure, which is osteochondral allograft transplantation. This is a great option, particularly for stage four OCD defects that cannot be repaired. So this is a tool you should have in your toolbox. It's a precious gift. We have to really honor and thank the donors and their families for making the decision to have their patient or their loved one become a patient that we can actually use to help improve the lives of other patients. This osteochondral solution treats the osteochondral problem with fresh highland cartilage, type 2 cartilage. We really like that. And for those classic medial femoral condyle defects where the contour is just so hard to match, this is a really great option because you can really make your graft as big or as small or as round or as oval as you want to match the defect. The outcomes are terrific. We've looked at this. Avs have many others. And osteochondral allograft for OCD lesions that cannot be repaired have an excellent survival rate, high return to support rate. So this is really a great procedure for those lesions that cannot be repaired. I was going to go through a case example, but just for the sake of time, I'll skip that. But again, I think for OCD lesions, the technology is emerging. Do you want me to present the case? Oh, okay. So here's the case. So this is an 18-year-old female. She's a hurdler and a sprinter in college. She's at one of the smart schools in Colorado. It's called the Colorado School of Mines. For anyone not familiar with that, that's for the smartest people in the country. It's like an engineering school. So she comes in with a laundry list of questions about her cartilage defect and what we're going to do for her. She had swelling, mechanical symptoms. We non-opted her as long as we possibly could, and she just could not compete, and she was there to compete. She really wanted to compete. So in her case, she was actually that one of those needle scopes that I showed you before, the second one. That was her knee and staged her for this future procedure where we did an osteochondral allograft transplantation. You can see this is the classic location for a medial femoral condyle OCD. One-fourth to one-third of this defect is contained by the PCL as opposed to actual bone. And for any of the younger surgeons in the room, please don't be afraid of that. You can certainly put in an osteochondral allograft without having 360 degrees of containment. You can even do it with 180 degrees of containment if you're feeling a little risky. But in this case, felt very comfortable doing this, fashioned a nice plug for her. She developed a little bit of arthrofibrosis, which about one-third of patients after undergoing cartilage transplantation do develop. And so we had taken her back for a second look scope. You can see that everything has healed beautifully, thank goodness. And she was able to get back to sprinting and hurtling. It took her about a year, though, to get there. So not the easiest or quickest recovery, and again, requiring a secondary surgery. But this is something I think we'd all be happy with at the end of the day. So if not repairable, restoration is certainly an option for these. So this is my algorithm. We didn't talk about it, but debridement is a very viable option, particularly for in-season athletes or those with mechanical symptoms, and especially adults. And if the defect's not repairable, drilling, again, not my task to talk about that right now, but let's not forget about drilling for OCD lesions, particularly those stage 1, stage 2 lesions that happen to be symptomatic who have failed non-surgical treatment, particularly if their growth plates are open. Repair we've talked about, and then reconstruction is my backup, but honestly my go-to for so many of these, because we often see them more in the chronic setting when the defect, even if it's there, is not repairable. Thank you very much. Thank you. Thanks, Rachel. Obviously, I've known Rachel for quite a long time, and I think that was the patient that I sent to you, right? It was. Yeah. So that is awesome to see the outcomes with that. That was fantastic. Sports medicine is a very small world, indeed. And I keep telling Rachel at some point I'm going to want to see this dog in person, because I see this dog all over Twitter, and so one day I want to meet the dog. So cool. So next up, we're actually going to go to Dr. Kevin Shea's talk, and it's a pre-recorded talk. So Kevin's a good friend of mine who's obviously one of the preeminent sports medicine people that deals with cartilage and other pediatric and adolescent knee issues. There's two Kevin Sheas in sports medicine that I know of. This is the Stanford Kevin Shea. And again, Kevin, again, doing a lot of great dynamic things, and so we're going to present his pre-recorded talk. Thanks. Hello. I'm Kevin Shea, and we're going to talk about insight to management of OCD lesions, or letting the sleeping dogs lie. All my disclosures are up to date on both the Academy and AOSSM website, and I have no relevant conflicts with regards to this talk. We're going to review stable versus unstable OCD lesions, and also talk a little bit about the importance of a healthy bone bed. This is very important for insight to fixation, and also review some implant options and considerations. When I think of a stable OCD, I think of this as a minor apple bruise, if you will, that has intact skin, and these overall have pretty good healing potential. And here's an example of such. On the contrast, though, if you have a larger lesion or things that involve break in the skin of the apple, if you will, these are lesions that are more unstable and I think have much worse or much poor healing potential. For example, this trochlear groove OCD, which is delaminated. Operative treatment indications for non-healing stable OCD lesions, sub-colonial bone drilling is a very appropriate treatment. But if lesions are less stable or have significant instability, you may have to do something, one, to ensure that the bone bed is healthy and not necrotic, and you might need some bone grafting with or without drilling to help in these cases to get them to heal. So keep that in mind when you're doing insight to fixation. Once again, the consideration of the cartilage quality is important. If you think your fixation on this fragment is going to provide at least 60 to 100 percent of coverage of the lesion, I think reusing that cartilage fragment makes sense. You want to make sure, though, that cartilage bone size is of adequate size and tissue quality to justify fixation because in some cases, the cartilage tissue has degenerated badly enough that you might think about another approach. And you also have to make sure that the tissue that you're going to reattach will hold the fixation that you use. The ROD Group has developed what I think is a pretty helpful arthroscopy classification system including stable or immobile lesions, and we call these the cue ball, the shadow, and the wrinkle in the rug. The other are the unstable or mobile lesions, including the locked door, trapped door, and the crater. With regards to these stable and immobile lesions, isolated drilling will work in many of these cases, especially young patients who have significant growth remaining, two, three, four years or more. If the patients are closer to skeletal maturity, you might have to consider drilling plus fixation and in some cases, bone grafting might be advantageous as well. Obviously, for more advanced lesions, drilling and isolation is not going to be enough and keep that in mind in older, more complex cases. The wrinkle in the rug classification is an unstable lesion, so in some of these cases, fixation might be necessary. For these unstable lesions, fixation is almost always going to be necessary, including locked door, trapped door, and the crater type lesion. So here's an example of notch drilling technique for OCD. In addition to drilling through the lesion, you can actually drill off the side of the lesion through the notch to obtain additional subchondral bone stimulation and healing. Here's just the anatomy of the medial femoral condyle. There's the PCL organ and its fibers. We'll just quickly show you a video of the OCD notch drilling with a marker pen. You can see this drill here off the interchondral notch just off the edge of the reticular cartilage can be used to obtain additional drilling without traversing the reticular cartilage. This has advantages as it's more of a retroarticular drilling technique rather than transarticular drilling technique, which may have some advantages. You can frequently place these three, four, or five millimeters apart to further stimulate that subchondral bone, try to create a fracture healing environment to produce healing of that subchondral bone to save the OCD. Once again, a third drill hole is placed here in a retroarticular, non-transarticular drilling fashion. I think you'll find this a helpful trick. We use these 0.45 and occasionally 0.625K wires, which are a little bit stiffer. Fixation options, you can use metal, including headless compression screws. These work great if you can put them deep below the subchondral cartilage or into the subchondral bone below the cartilage. There are some flat head screws that can be used for more superficial fixation, which the thickness of the bone may be limited. There are some bioabsorbable options that we use increasingly. There are different types of pins and suture anchor bridges, and there are some bioabsorbable screws. Although many of the OCD study group members have abandoned the bioabsorbable screws because of reaction and cyst formation with some of these devices. So here's an example of blue, rather purple being the cartilage surface and orange being the bone. If you have cartilage with significant bone and you want to make sure you try to countersink the screws into this bone as possible, get them below the cartilage surface. These won't work with headless screws. If you just have cartilage or minimal bone on the cartilage, the screws will cut right through and they won't actually give you the purchase if you're trying to recess these more deeply. So you have to come up with an alternative. In addition to screws, there are also some implants, bioabsorbable pin type implants that have sort of a threaded barb that can also be used in a similar fashion. Once again, you want to make sure you've got cartilage and bone such that there's enough bone that you can countersink into the bone if possible. Once again, keep in mind that screw fixation may be better in cases in which you have significant bone just because of the biomechanical strength of a screw, especially headless screws that have variable compression on the two different pitches of the screw. Once again, you have some bioabsorbable pin options and some people will use these in cases where there's cartilage with no bone or minimal bone, but keep in mind that these minimal bone things probably give you a little better fixation than those with no bone at all when you're dealing with these bioabsorbable pins. A couple of different companies provide these, and we're not advocating for one or the other, but there are some reports of success, but there are also reports of these backing out, so keep that in mind. You probably need to get them recessed adequately to make sure they're not going to back out and create problems later on. In cases in which you want to use screws, and there are advantages and disadvantages to this, but there are some low-profile headed screws, and they might be used in cargo with no bone or minimal bone, and these screws you can actually countersink in the surface. There's a small countersink device that allows you to recess these below the most superficial aspect of the cartilage surface, but not cut through that cartilage and still obtain adequate fixation of the bone. A technique that I've been using more and more recently is suture bridge fixation. Ted Ganley, Todd Lawrence, and others have described this, and I'll just show you some diagrams. This is an example of a diagram. Assuming this is a femoral condyle, you can put four sutures or suture anchors on the periphery, and then you can have a series of sutures pass through these suture anchors, and there's various different constructs, and I suggest you go into labs sometime and play with this. There are simple cruciform constructs, and you can also cross limbs and basically combine what I call a crucifix with a diamond, and you can also put a suture anchor in the center of these as well. There's a lot of different constructs you can use. Here's an example of a cartilage lesion that we recently fixed with such a construct. In this case, we used zero-vicral sutures, obtaining quite good fixation for these cases. Here's another example of another cartilage case in which we used a series of sutures, including a central suture anchor, to obtain good compression and good stability with dissolving sutures. Keep in mind about subcondral bone drilling. We typically do this if it's transarticular with a 0.045 inch K-wire, and put these at four to five intervals, four to five millimeter intervals, to help with healing and stimulating that subcondral bone. Orthoscopic placement of these screws is quite, you know, really a good option today. You don't necessarily need to do arthrotomies in many of these cases now if it's a relatively stable lesion. And I'll just once again outline the anatomy here. Here's the medial formal condyle. You can see that circumferential outline of the OCD lesion. It's been probed and determined to be a relatively stable lesion. These are the 0.45 inch K-wire holes, about four to five millimeters apart. And here's actually the guide pin with a threaded tip that you use for a cannulated screw. So we'll just quickly play this video of placing this screw. And so you can hear we're going to advance the guide pin, the threaded guide pin. It's always good to advance these perhaps a little further than you think so that when you're drilling, you don't back these guide wires out. And you can see the blood coming out of that adjacent hole indicating that you've drilled into the appropriate level of healthy bone to produce bleeding. Here's the use of a depth gauge measurement. We'll use these screws anywhere from 14, 16, sometimes as much as 22, 24 millimeters of length. Keep in mind, you don't want to go too deep if you're going to be approaching the growth plate. Here we're drilling in partway. You're only drilling in the first, you know, 10, 15 millimeters of screw. You don't necessarily need to drill this all the way because the subchondral bone is soft enough in most cases that it'll self-tap as you advance the screw. And in this screw, you have a different type pitch on the front edge of the screw. And there's a different variable pitch on the other end of the screw, so you actually get some sequential compression. This device also has an external collar that allows you to compress the lesion as you place it in. And so now it's actually compressing the lesion into the bone. And this external collar is now threaded off the screw, and you get additional fixation as you advance this screw because there's a difference in the pitch advancement on the proximal and distal screws. So it's very important to sink these screws into the cartilage and actually pass the cartilage through the cartilage into the subchondral bone to make sure they're not going to scratch adjacent cartilage surfaces. And you can go back and forth and kind of look at the depth of these screws. In this case, you can see, we now see subchondral bone. So this screw is completely covered. Here's an example of three or four or five screws that you can place, and you want to make sure you're kind of probing with the guide wire to ensure the screws are into the appropriate depth. Once again, these screws are clearly below the cartilage level. One tip is I do recommend that you use subchondral screws that have a star driver, especially if they're titanium. Titanium is more MR-compatible than stainless steel screws. Allen head screws are more likely to strip. So I strongly encourage that, especially in these young patients with hard bone, a star driver is much less likely to strip, which is a real problem because you'd have to take that screw out if it's sitting proud. After putting the screws in, we tend to get multiple CRM images just to confirm that the screws are clearly recessed in the subchondral bone, and these images basically confirm that for us quite clearly. Here's an example of progression of healing over six months. The patient is treated basically percutaneously. You have complete healing of that bone interface between the parent and prodging bone over that six-month period. Just a little more detail on these screws. This is a hand set used for fixation of hand fractures, and the screw diameters are quite remarkable. You have 1.0, 1.3, 1.5, 2.0, and 2.4. This is a very low-profile cruciform head, much lower than you can get with an Allen head screw. You can also countersink these. They do have a countersink tool, and they're also made of titanium. Here's an example of these screws. I do typically remove these screws somewhere around four to six weeks because I do worry about them scratching the opposite surface. Keep in mind, you probably want to remove these if you don't use something that's dissolvable or absorbable, or if you don't use a suture bridge construct. Here's an example of a 14-year-old male who had a large condor delamination off the patella for a patella OCD, and we used three screws to get very secure fixation. Currently, I would probably do this with suture bridge instead of screws, but screws are an option in some cases. Just to summarize, the cartilage and OCD fragment fixation is clearly possible. The healthy bone bed is really important, and if you don't have a healthy bone bed, you may need to do some debridement. Bone grafting might be important in some cases. In some cases, you can do that with a retroticular approach and a retroticular drilling device. Fixation options depend on the fixation of the bone and the cartilage. Make sure you've got adequate tissue of bone and cartilage delaminated piece that's actually going to be able to hold screws or sutures. There's several different options, including metal, bioabsorbable, and suture fixation options. Thanks for your attention. If you have any questions, just send me an email at my gmail address listed below. Thank you. Actually, Kevin walked in midway through his talk, so he's in the back, and so he missed my wonderful introduction, but we're happy to have him, and certainly we'll be able to use his excellent skills tomorrow in the lab. Next up, we have Alex Calivas, who comes to us from UCSF, who's going to give our next presentation, looking at radial tears of the meniscus, a very complex and very difficult topic and hopefully change our thinking about cutting these things out and really trying to be a little bit more aggressive at repairing these, especially in our pediatric population because obviously, as much of the meniscus as we can conserve, the better. Thanks for being here. Thank you. All right, so we can get started here. Thank you, everybody, for being here. I ran a little late with the flight today, but I made it, and we're going to talk about root tears. I'm going to talk about root tears and radial tears today, and I'm sure we all understand that root tears have a functional total meniscectomy is the outcome, essentially, if you don't fix them. I think most of us are fixing these. I'm going to go through these steps, but I think the standard accepted technique for fixing these is really the leprod technique, trans-tibial technique, and I think most of us do a variation of this technique right now where you're essentially securing that up against a bony bed to reattach it. The steps are a diagnostic scope. You don't have to do these steps in order, but you have to do them. Read the root, test its mobility, put your sutures in, drill the tibial tunnel, prepare a good bony bed, I think that's key, shuttle those sutures down, and then secure the sutures over a button. So this is what it looks like, and let's see if we're running. So first you go and you do a diagnostic scope. You can see that this is an older patient with a little bit of some arthritis, but you clean it up, you test it, and I actually use a grasper for this little maneuver to see how much mobility we have and how difficult it is to move. Once we get that done, I next usually put some sutures in here, like suture tape rather than suture itself, two cinch sutures or luggage tag sutures using the tape, and then we drill. At the insertion, at the anatomic insertion, clean that up, and this is where I spend a little extra time to really make sure that I have a good bleeding surface there. I'll use a curette. I think a flip cut is an elegant solution here too if you have room in there, and just get yourself a really good, healthy, bony bed for that meniscus to come down onto. Then you can use your ligament passer or a fiber stick, whatever you like, and transfer that down, and then secure that down, and then the next key part is, of course, getting your tibial fixation really solid for this. So this is a relatively routine surgery that I think we can all be really good at, and I think root tears do well with these. I think on the lateral side, you're looking at a tear that's a little bit more difficult to diagnose clinically by MRI and even at the time of surgery, but really it's the same technique, and it's about as easy to fix. People ask me a lot about what suture you can use, what suture you use, what construct you use. I think a cinch is fine. I think a Mason-Allen suture is fine. I think if you get enough sutures and you use tape, you probably got a really good construct according to the biomechanical studies. If you have a little bony piece attached, make sure that you clean up both sides so you've got good bony air position on both sides, and then when you put that down, that's bone on bone, your suture's on the right. Little pearl is be very comfortable and learn how to do an MCL release. You don't have to do it extensively, but enough to be able to see. This is very key for any medial-sided work. It helps if you can't see, you can operate. My residents have all heard that many, many times from me, but it helps you with that and it helps preventing scuffing of the cartilage. There's a little discussion around what your tibial fixation should be. Biomechanical studies suggest button or post is the strongest, but I think do something that works well for you. I use a button and I back it up. If you don't have that tension, you don't have that meniscus pulled down onto that bony bed, it's not going to heal. I use marrow venting for all my meniscus repairs and I do for roots as well. Maybe you don't need it as much because you've got a tunnel there, but I still think it's reasonable to do. The tough ones are the delayed ones where you get to them late, the tissue's not very mobile or like a revision and it's too anterior of a tunnel and you've got that big gap there. Basically what you have to do is a lot of releasing and bring that back as anatomic as you can. So that's the root tear and then I'm going to go on to the radials. I think the radials are a tougher nut to crack because we're dealing really with a situation where the tear is different every time. You can't go in expecting to have exactly the same tear. I can talk for hours or days about saving the meniscus and how we should be doing more repairs. And since this is a surgical skills lab I'm going to say or talk, I'm going to really focus more on the actual techniques than what we should be saving. But I certainly try and repair and achieve repair on most of my radial tears at this point in time. So the radial tears I think, I like this quote that's coming up, which essentially outlines that you have to be prepared if you're going to do a radial tear to look at that tear very carefully and decide what technique you're going to use. This is not a situation where you have one go-to technique that you use for all your meniscus repairs. You really have to be facile in inside out, outside in, all inside, circumferential, trans-tibial. You have to be able to do all of these well because when you get in there you may use one or two or three of these to fix these tears. This is what we're looking at. This is a relatively simple one. You can just do some circumferential sutures around it. You can do that all inside or outside in. These are usually the fresher ones that haven't undergone any kind of degeneration yet. Again, side to side probably works really nicely for these. I've had a lot of good success with that. Sometimes they have an associated tear, so be sure you fix that as well, a little vertical tear in the back there. But the difficulty comes when you get a tear like this that has some chronicity to it. You can see this patient's cartilage is good, good to excellent, and taking that tear out or resecting that is going to leave you with essentially a subtotal meniscectomy. So I approach these by looking at them really carefully. You can see there's sometimes vertical or horizontal cleavage components as well. Clean up all the poor tissue. I trephinate back there. Some of these I will use a fibrin clot as well and really get good surfaces there. And then what my sort of next step would be is to put in, I use a circumferential suture, I think it's fine to do all inside, and just see what I get. Just see what kind of reduction I get using the initial suture. If it comes together reasonably well, then I just add multiple either all inside or inside out sutures or circumferential sutures. And I think you've got to correct all the different angles, and I think you really want to put in as many sutures as you need. Probably more is better. It's probably a limit, but more is better than less. And get yourself a stable construct. Something that I've been using a lot was this rebar technique that was originally described a few years ago, now called the hashtag technique, where you put two vertical mattress sutures in there and kind of as a ripstop for your horizontal sutures that are crossing over. And that provides good support. There's studies to show that it's better and more secure for poor tissue than just a straight across or crisscross type of construct. And there's variations on the hashtag technique as well. You can do a straight hashtag or you can do a crossover hashtag. I think as long as you are prepared to do whatever you need to to get this repaired in a really strong manner is the way you want to do it. Again, the MCL release will help you here. You don't have to get a grade three MCL tear on these patients. Just enough to get you in there so you can really see what you're looking at. And more recently I've been using this technique, which I think is very helpful for some of these more difficult tears, where you're essentially using either a single or a double tunnel. Both are described. You're going to use a single tunnel typically. Essentially pass a shuttle suture through your tunnel here. And then you're going to use an all-inside circumferential device that gets you a good solid reinforcing and centralizing suture. The trick here is to turn the device upside down so you get around the tear. And then once you have that, you pull that down through your tunnel. You shuttle that down through your tunnel. And that gives you a securing suture that can help reduce this and hold it reduced. Once you have that in place, then you take either your all-inside device or an inside-out technique, whatever you're comfortable with and whatever you think is going to work. And you start putting that together. And your end result is a very solid repair. Arguably, you could say that this doesn't move very much. But on the medial side, you may not need it to move very much. But it's a very solid repair. I'm always asked about rehab afterwards. I think if you look at the literature, it's all over the map. But certainly for radial tears and any tear that you are worried about further extrusion under compressive load, six weeks of non-weight bearing remains the sort of gold standard and limitation inflection. And that's all I have for today. Thank you. Rachel and Kevin, we need you for the panel discussion. And we have microphones, obviously, they're just sometimes they can be a little finicky. Just remember just kind of to press down the mic button and hold it down if you have a question. So I want to thank all of our speakers for some excellent talks that were just performed. And so we have about 20 minutes or so to go through things and obviously pick the brains of the experts. So if anyone has any questions, feel free to chime in now. Jackie? I have a question for you guys. We've talked a lot about the MCL and how to get more room on the medial side. What do you do if the lateral side is tight? Do you have any pearls of wisdom of positioning or gathering your strongest residents or anything along those lines? Yeah, I'm happy to answer. Yeah, we're always up against that problem. I think most times I find the lateral side is clearly easier than the medial side. So you're in luck with anatomy there. But really, pushing harder is definitely an option. Also, have your resident or have your assistant move the knee through a range of motion in that figure 4 position. Because sometimes the position you think you're going to get with maximum flexion, you think you're going to open up the most, actually doesn't give you exactly what you need. And sometimes actually extending the knee a little bit, particularly as you get more towards the mid-body, can give you a little different access and help you get there. But it's tough. And there's no LCL release that I know of or I would recommend. I would agree. And I think one of the keys is if you're with a resident or fellow or even your PA or NP, just like was just mentioned, knee flexion extension is not the same as varus. And so we'll have our assistant lift the heel up while applying pressure on the thigh. And I think that seems obvious. But in the heat of the moment, often it's forgotten. That moment is forgotten. Because they might be using two hands to push on the thigh. So they don't have a third hand to lift the heel up. So I'm constantly reminding the resident or the fellow, what are we trying to accomplish here? And we're trying to get varus. And so varus is lifting the heel up. In addition, if you set your table up where you use a side post for the thigh, I use a side post for the thigh that you can push a button through the drapes and it pops down. And so I use that. So sometimes that thigh post can prevent you from getting the varus or hip flexion that you need to allow you to get varus. So working around what might be constraining you and kind of doing a discount double check. Like, what position are we trying to get the knee in to actually accomplish our goal? And I would say, especially with the older patients for meniscus repair, like 40s and 50s, if you push hard, you can really hurt someone. So I think there's a, the answer in ortho is always do more, push harder, be stronger. But not always, right? And so we wanna be cautious not to hurt their hip or the older men and women don't cause a fracture or something like that. Cause that, if you get too excited to open up your joint space, you might be fixing a hip later on. And not much to add, pretty complete there. Maybe just a few comments. Rotation as well. Sometimes you inward out, we rotate a little bit in addition to flexion extension can make a difference. You just have to kind of play and then reminding people that, hey, hold that position. That's a good position. I have a foot post that I use to hold the leg from in a certain flex extended position. And that foot post actually, when I'm in that figure four position, they rest the foot and ankle distal tibia on that. And then they can push down on the thigh, but that first post lifts the leg up a little bit, gives a little more varus opening. And I agree with your comment about don't push too hard. I tend to take care of a younger group as well, but you can fracture a growth plate. You can cause a distal femoral or proximal tibial growth plate injury, pushing too hard on a kid's knee for a varus or valgus. So keep that in mind as well. No. So in your case right there, to me, what else are you going to do? So you could inject him all day, you could put him in an unloader, but at that weight he's never gonna tolerate an unloader. It's never gonna fit on the thigh. He's not gonna go to an acute total knee replacement. So to me that's something where I tell the patient 50-50 chance this works, but if it works you're gonna be really happy, and if it doesn't we're probably gonna be no worse. So I think there's really good data to show that even in the setting of bipolar grade 4 chondrosis, medial meniscus root repairs do a good thing for the patient. So I'm aggressive. I would repair that. He was normal four weeks ago and now he's not. You can have an acute intervention on an acute problem. So that would be my bias, but I would tell him, you know, maybe I'm not the best surgeon, but these don't always work in my hands and it may not work in your in this case. No, but I'm a simple person. So I think I was definitely gonna operate on this guy till you told me he had grade 4 changes and that really concerns me a lot. Even though the weight is not a, it's a relative contraindication, I agree with Rachel that we, you know, we're aggressive about these and we should be aggressive about these. I would have a serious conversation with the patient about their options. I wouldn't be, I would certainly offer them the surgery, but I think that with the grade 4 changes, we're, you know, we're really up against a hard wall there. So, but you know, to your point, the sort of one of the most important features of the story was that he was fine until that point. The ones that are sudden and acute episode, those are the ones that do well for obvious reasons. So I think that would push me far more towards surgery, but the grade 4 changes pull me back a little bit. Great points by both. I might just add that one, I think a recommendation that they get into the bariatric clinic at some stage and I mean that in all seriousness, I'm not being facetious at all, but I think the bariatric thing, it's part of the post-op plan, is pretty important. Obviously, that's not gonna help us preoperatively, but I think a patient-centered discussion about limitations, as Rachel said, about I may have a 50-50 failure rate, but if you have a success, that's a huge gain for someone put off a knee replacement and functional disability for maybe 5, 7, 10 years. That's also a kind of a poor candidate. The younger people are when they have knee replacements, results aren't as good as older people, and so if you could buy them 5, 7, 8 years, maybe 10, I think you've done them, done them a favor. And I also think of the risk of arthroscopy, the risk of a root repair, even an obese individual, is relatively low. They probably maybe have pre-diabetic and maybe, maybe even have diabetes, but the risk of arthroscopy compared to a total knee replacement, either hemming or total, is almost an order of magnitude lower. So I think the risk we take with arthroscopic things like this are relatively low and that maybe changes my calculus a bit. And just one last thing, I think along those lines, at least at University of Colorado, there's no arthroplasty surgeon in my group that will do an arthroplasty on this guy at this, at this weight, and so even if, if we milk him along and we do a steroid or a VSCO or, heaven forbid, a PRP and we try to fix this problem and it doesn't work, and a year later he's miserable but at the same weight, there's literally no option for him. So to me, this, the risk reward, just like you were saying, I, I hate risk and Jenna, one of my former fellows here, will tell you I absolutely hate risk, but this is a risk I'm willing to take if the patient's willing to undergo it. Yeah, I think these are injuries that we have a chance to kind of intervene for these patients and, you know, I'm in Cleveland so I don't think any of these patients in my clinic are less than BMI 35 and so, you know, we're not in Colorado and so, you know, so that's kind of the demographic. It's, and, and I think back to the first 10 years of my career where I basically, a lot of benign neglect and I, and there's, and now I feel bad at this stage of my career because I'm like, you know, it's so many patients that I ignored and kind of pushed them along and they just didn't get better with these things and, and I'm not gonna say this is my, one of my favorite procedures to do, but it is one of the things that I feel like I'm, had the most impact for my patients and something that's fairly simple to do is, it's become an easy procedure, especially with the trepanation of the MCL. It kind of makes this, you know, case pretty simple and great outcomes in general. Yes, so I mean I just did one this week in a 42 year old BMI around their acute medial root tear, no pain prior to that with Varus at about 11, I corrected her to 12 degrees and I did a root repair with the HTO. For me it's five degrees and if I'm doing it, I'm, and there's minimal data on this. I've asked actually Aaron Critch to look into this with his cases because he seems to publish more on roots than anyone else. But there's, so there's minimal data to say that we have to do it because again, they've been living in Varus forever so your root repair doesn't change the Varus. And if you do a good repair, ideally they go back to living in Varus but with now a healed root. But I'm aggressive and I do the osteotomy, I love osteotomies so that's also my bias. But five degrees or more for me gets an osteotomy. Was that opening wedge or closing wedge? Great question. So my experience is medial opening wedge but I've been moving closer and closer to converting to a distal femoral closing wedge just so they can weight bear and it's a more stable construct. But my training, I'm decent at medial opening wedge and I just don't have the experience on the tibia, on the experience on the femur with the closing wedge. So, but that's a tool that's growing in my toolbox as I get a little bit more confident with that. Can you hear me? There we go. I'd say not very often for the osteotomies but sometimes it's clear that there's just too much load on that medial side. I think that we're gonna be using osteotomies a lot more than we used to if we look at the broad spectrum of meniscus tears. You know, more repairs are gonna have to be unloaded over time is what I predict for the future. So I think osteotomies are gonna continue to grow in number. But for the root tears I have to say I haven't done a lot of them. I don't see enough patients with significant enough varus to really, at least in my practice, move to an osteotomy. And I will say I have a very healthy fear of osteotomy in the obese patient. Certainly, I just did one on a patient who had a varus thrust and had a post-traumatic corner injury and it was a lot of sweating and watching, waiting for this thing to heal. And that's why I asked about closing wedge because we did a lot of closing wedge osteotomies when I was a resident, but not something I felt comfortable doing. Lateral closing wedge on the tibia, not something I felt comfortable with doing, didn't wanna mess with the proximal tib-fib joint. But in these patients I would feel much more comfortable closing that down, putting the plate on, and I think being able to do the meniscal root probably a little bit easier with a closing wedge. But I have a very healthy fear of the osteotomy in the obese patient because if that fails, that's a disaster. If your medial meniscus root fails, it is what it is. And so I look at osteotomies in those patients the same way that I look at knee replacements for my joint colleagues. We have to lose weight before we go that route. But I think it certainly would solve the problem. So nowadays I'm doing my osteotomies using PSI, so patient-specific instrumentation. I don't know if we have any of those companies here, but if not, we should get them here for the next course. But when you do it using, and there's several different companies, but you can ask the company on the HTO or DFO guide, in this case it'd be HTO, to add an extra socket for your root. And so based on the CT scan, they can put a little slot, a three millimeter or 4.5 or whatever size tunnel you wanna drill for your root, or two tunnels if you wanted. They can build a slot into the guide, and all you do is drill your pin up, and based on the 3D planning with the CT scan, it goes to the anatomic medial root. And so then all the fuss of using a root guide by any company, which can be tough in these tight varus knees, goes away. Because you don't have to use a guide, because it's built into the HTO guide. So there's some advantages in terms of our ability to accomplish these tasks a little bit easier, whether it's opening or closing wedge. So upper age limit for our performance of these cases, roots and HTOs. So I'd say for your patient, do it. You know, if they've got good cartilage, they're well aligned, stable knee, acute incident, no reason not to do it. I've got, not a lot, but you know, some very happy 72, 73 year olds who've had root repairs. And if you've got all those things in place, then the age is just a number. Fix those because, you know, if you don't, you know that you're going to be sending them to your arthroplasty colleagues. I would agree. I mean, I'm biased in Colorado now, which is different from where I trained in Chicago, but people ski in their seventies and eighties and they don't want to stop. So I think it's a big discussion though with the patient, because I do put them on crutches for six weeks. And I also tell them, look, at this age, even if I get a great repair, it may not heal. You know, the blood supply is not great, will augment, but may not work. And if it doesn't work, I put you on crutches for six weeks. At that age, even if they're healthy and physiologically young, they're going to deteriorate a little bit. They're going to atrophy. Both legs are going to atrophy. That's going to take a hit on their body. So that's a long discussion for me, but I don't let age be the cutoff, but it's a much longer discussion about the potential downsides. Yeah, I agree. And I think the cartilage age, the physiological age, as I just mentioned, I think those are probably the drivers of that decision. If you've got an older patient, but their cartilage age is 30 years younger than their chronological age, I would probably go on that. I do think, in line with you, that I think the older people get, though, the rehab is harder. I think younger people recover quicker. They need less therapy and less time. And so having that discussion with the family that, you know, this is a four-month, six-month, you've really got to be committed to a rehab process to recover from this. That's the only comment about aging. I think they do rehab slower, even if their cartilage is in great shape. You guys all in line in terms of your rehab after, say, a root repair. What are you doing, Rachel, for your roots? Six weeks of limited weight-bearing. I let them go foot-flat. I just think it's torture to go strictly non-weight-bearing. I would say half are compliant. The big individuals are not compliant at all. I use a big T-ROM knee brace. And again, usually when they have these conical thighs, which so many times these root repairs do, they're not wearing those. I try to say, you know, no weight-bearing flexion beyond 90 degrees for three months. But again, the compliance level when they come back and they've been skiing is close to zero. And so, you know, that's what I tell them. That's what's on my protocol. But what they follow, I honestly couldn't tell you. It's a different beast in Colorado, because they, especially my boulder patients, they have to do their workouts 50,000 times a day, and surgery and recovery cannot interrupt that. Yeah, I think we see something similar to that in California. But last two years have gone to four weeks of non-weight-bearing if they can, touchdown if they can't. I think that our constructs are stronger, and I certainly haven't had any problems with that. I don't know how low we can go. But, you know, for root repairs that come together nicely, acute tears that are good, solid construct and repair, I think four weeks is okay. Okay, and then unloader brace? I use an unloader brace a lot. And if I have a patient who says to me, you know, I can't do the surgery immediately, I think we used to think of roots as an absolute emergency, you know, get it done immediately. But I think you can probably do now. It's clear you can wait a little bit, and I put those patients in unloader braces too. And I use them a lot for post-op. Yeah. I think the quality of the suture material, the placement of the suture material, the luggage tags and other things we have, I think using more rather than less is a good idea because I think a lot of our therapy goals are what I call aspirational. You know, we have cones of shame we can put around dogs so they won't chew their incisions. We don't have cones of shame to stop our patients from being full weight-bearing. And a lot of my patients are in the age of 30, most of them are, and it's really hard to limit their weight-bearing more than the recovery room because I've seen these kids out in the parking lot after surgery sometimes and they're full weight-bearing despite our recommendation. So I think the quality of the fixation, if you're gonna, if you think you wanna put another suture in, probably put another suture in, thinking your patient's probably gonna stress it. The other thing I'm doing now with Roots, I've started doing this for about eight months, is centralizing them on the medial side. So Aaron Critch has described this, as has Pauletta and others, but you can do it arthroscopically now. And I think from a rehab perspective, potentially getting one or two or even three anchors depending on how extruded that meniscus is to begin with, you are almost load-sharing your root repair with the centralization anchors. We don't know in terms of the long-term data on that yet, but the short-term data looks promising. So a technique we could certainly try in the lab if anyone's not seen that or wants to try it out. But more to come on that, but I think that might help us accelerate our rehab a little bit to ideally prevent the meniscus from squishing out once the weight-bearing starts. One question. You can use your microphone. Sorry. There you go. Just press it down and hold it. Or screen. Okay. Can you hear me now? Perfect. Any surgical pearls and pitfalls about tunnel placement with how much bony bridge you need or what you drill first, the ACL versus the root? Great question. So I think that if you look at the tibia, the antramenial tibia, you've actually got a fair amount of real estate. I always find it useful to get a model and hold it in my hand and kind of visualize mentally. I'm sure there's software that can do that for you too, but it's pretty straightforward. If you're gonna do an ACL and a root, you should be able to have enough distance. Remember, your guide also has the ability to go up and down on the angle so you can really get yourself a good gap with that and you have to be anatomic, right? Your tunnel's gonna go to the right place and avoid each other if you're anatomic. If you're not anatomic, you're probably gonna hit your tunnels. So I think that with that, it becomes a real challenge when you've got an ACL, PCL, MCL, root tear, then you sort of start running out of room, but you should be able to miss them by just sort of carefully planning where you're gonna go. So my tricks for that, because this is a tricky thing and if you haven't done it a lot, it can get really stressful in the OR and then you also can run into the situation where you've drilled one tunnel and maybe it wasn't as perfect as you thought and now you don't have room to do the other one. So to me, I think about what are the goals of surgery and if it's an ACL medial root, I drill my ACL tunnel, tibial tunnel first and then I do my root after that. I will cheat my ACL tunnel a little bit either more shallow or deeper just depending on where I think I'm gonna place my root, but I always do my ACL tunnel first to answer that question. Trickier with medial and lateral roots, trickier even in the revision ACL setting if you're trying to single stage it. Now remember, and Al Getgood taught me this, you can drill a tibial tunnel from the lateral side. It looks weird and feels weird and the angle's weird, but you can if you need to. So I try not to do that for my ACL tunnel. I've never done that for my ACL tunnel, but I will sometimes for my lateral roots do my lateral root tunnel there, medial root medially, ACL tunnel medially. When you have a PCL, I make my PCL tunnel as long as I humanly can. So it almost sometimes looks like it's in the proximal third of the tibia which makes me feel a little bit weird, but if I'm doing, if I have PCL tunnel plus MCL tunnel plus ACL tunnel plus a root, sometimes in those cases, I'll put the posterior root in the PCL tunnel or if it's a lateral root, the same thing. Not as anatomic as we'd like, but then we're starting to run into real estate issues when there's three or four different tunnels in the tibia. So that's how I do it. But I always drill my ligament tunnels before my root tunnels, because to me that's the critical part of the procedure. Just to, sorry, go back. The other thing is that when you drill your tunnels, don't do the ACL and then try and do your tunnel, your root tunnel. Drill your tunnels first so you can be sure that they're not hitting each other. Yeah, and yeah, I laughed when you asked that because that was my case yesterday. And so we had a ACL, BTB ACL with a lateral meniscus root. And I actually drilled my ACL tunnel more central and then I cheated way medial with my lateral tunnel. And what was said here is definitely drill the ACL tunnel first. So even with all that said, and I cheated way medial, my root tunnel just skived the back of my ACL tunnel, almost close to the aperture at the tibia. It's not a big deal. So I actually passed my ACL, fixed it on the femur. And before I put my interference screw, I pulled and reduced the meniscus and then fixed that on the tibia. And I put my ACL screw in last on the tibia. And as long as you're not right through the center of your tunnel, which I think is kind of difficult to get right through the center. I think if you're skiving off to the side, you got soft tissue at that point, or even a bone block that's skating by there, it's probably not a big deal. So, and I made sure the root was reduced before I put my interference screw in for my ACL. So all the things that were sort of mentioned is good. I think even having a saw bones tibia as part of your preoperative planning, just, and maybe even put the pins in your saw bones tibia, but really think about it. And I think the comments have been made about, the ACL entry into the joint on the tibia side doesn't really matter if it's got one angle or the other. Basically the entry point is what matters. So if you're a little more vertical or a little less vertical, because you're planning around your root tunnels, you're okay. It's the entry point that matters, not so much the angle of approach. So feel comfortable altering that angle of approach on the tibial tunnel drilling side to accommodate a tunnel or a root repair. That's just sort of the position that I think, you know, you essentially got the knee in. I don't see the reason to put it up to 90, which I hear about. But, you know, I think what you have to do is really tension it. The other thing when I'm tensioning my root is I'm always looking at it. When I'm securing that tibial button and screw, whatever you're going to use, look at your root and make sure that tension is maintained because that's, I think, a very key part to the whole surgery. If you don't have that tension on there or if you lose that tension on there, essentially all your work has been for naught. Yeah, you know, I don't know how knee flexion extension affects root repair so much. Clearly, ligament position may matter more, whether it's MPFL or ACL or PCL, but I think of the tibia being somewhat, or the root repairs being a bit independent of knee flexion extension. But I do think your point about you want to make sure that you don't fix it loose, and so you've got play and the sutures are kind of pulling in and out. So I think that's a critical thing, and that's why I usually like some type of a fixed anchor on the tibia side. I don't typically tie them over bone bridges because I don't feel I can control the tension, but if I use a, I'm not sure if we're supposed to say device names, but if I use an anchor that goes into the bone, I feel I can very securely make sure I've got that root securely anchored, and it's not going to kind of weewaw back and forth on the sutures in the joint. I use buttons initially, and I've gotten away from that. I just use an interference fit twisting device anchor on the tibia. Yes, same here. I just don't, I can't name it, though. I've moved away from buttons as well because I think getting the tension just right on a button, if you make a big incision, it's easier with a button, but if you're trying to do it through a small incision, it's hard to get the button just right. But if you're using one of those, whatever he said, that type of anchor that we can't name, I think it's really easy to get the tension right through a small incision. And to echo that point, you know, in terms of flexion extension, I just, you know, again, I want to make sure I have the knee in some valgus so we're not, you know, kind of outpressing it out the way, but I figure I'm restoring anatomy, so, you know, certainly flexion does not matter as much. I want to be able to see it. That's a key thing. I'll pick a position that allows me to really see my root repair when I'm putting my anchor and just make sure it's clearly tensioned appropriately and dunked in the tunnel, if you will, appropriately. Question? Hi. Just had a question about radial repairs, and given the avascular zone of the meniscus, how do you rehab them differently than your other meniscal repairs, and do you do a second look so you don't have a nidus for a re-tear? I think my rehab is very similar to anything else I do. I mean, I'm hoping that my repair has restored the anatomy enough that the vascular supply is going to be effective. I often end up trimming the inner white zone out of those radial tears. You know, that's usually clearly non-viable, but don't really do anything other than, you know, our typical weight restrictions that I outlined, six weeks, non-weight bearing, no flexion, past 90 degrees for those. For me, radials, roots, and transplants all get rehabbed the same, and then verticals, obliques, kind of simple little ones, or even big buckets are in another category. So radials, roots, and transplants are like that, so strict, and then the others I let fly based on the status of the ACL and whatnot. I have second looked a few. I never second look except in your case that you referred me because I just had to know, but I never second look unless they have symptoms, but I've certainly gotten the opportunity to second look for, you know, for example, staged revision ACL reconstruction where I repaired the meniscus or radial tear at the first case, and that we could talk about all day if you prefer to do that at the first or second case. And knock on wood, even those white red zone Hail Mary repairs where you're throwing in cross stitches and you're just praying and hoping that something's going to heal, it's amazing. The lateral side in particular, it's going to heal. There's so much blood in the knee, and I think we're always taught that it doesn't heal, and take out the meniscus, and these things never heal, and there's a lot of blood in the knee. These things do heal, and it's amazing. So yeah, I would say don't be afraid of the lack of vascularity. In particular, if you look at the anatomy of the geniculate arteries in the back of the knee, along the lateral joint line, it's a much thicker genicular branch versus the medial side of the knee. There's some great dissections in the literature, but you could do it yourself too. And so it's a big fat vessel laterally, and that's probably why many of these lateral repairs do have a chance if you take the time to repair them. Radial tear is probably bothering me the most when I think about the rehab because many of our roots and buccal tendon tears and other things, when people put a little weight on them, in some ways they compress the meniscus tissue together. The radial tear is that bad situation where weight-bearing actually distracts the menisci. And so I tend to, if I'm ever going to put the fear of God in a kid about not weight-bearing, it's really with the radial repairs. I appreciate it. You're making me feel better. You're so enthusiastic about lateral repairs. But I'm still anxious just when I think about the biomechanics of that repair because I think weight-bearing tends to work against us. So that's the group where I really try to protect their weight-bearing for a while, knowing that, once again, these kids probably do what they're going to do. But lots of sutures. Sometimes I feel like I've made a meniscus out of suture when I'm done with a radial tear. And I do think some of these bad ones have actually healed at least two or three years later. They're doing fine, and they're not complaining of pain. And I'd love to do second-look arthroscopies, and maybe I need to do one of those in-office things where you can do it easily with a little local anesthetic. But I rarely do second looks, but I certainly would like to. It would make me feel better. But as long as they're doing well clinically, I don't feel the need to do it. No, I agree with that. I don't have that many that I've had to go back on. In fact, I can't recall anyone recently. I have gotten some MRIs on some, and that's somewhat disappointing sometimes. You know, the meniscus never looks good after a repair or after a transplant. They always look a bit funny on the MRI, so it's not very satisfying. I'd love to look at some more of them. But, you know, if they're doing well, it's hard to convince them. Cool. We have one more question, and then we'll go into our next session. Hello. All right. So, you know, we talked about the oldest age in which you might do a root repair, and I read some articles recently about in pediatric patients finding more root tears in combination with ACLs and things like that. But how would you manage a scaly, immature patient? Obviously, this is a much rarer case, but with a root tear, you know, in terms of managing the fices and things like that. I can take a stab at it. We've done some modeling work on not so much root repairs, but on meniscus transplants, how to put your tunnels. And basically, smaller tunnels and vertical tunnels are better than horizontal tunnels, so you want to injure as little of the fices as possible when you're doing those cases. So I think you can do them. I have done some in scaly, immature kids, and I haven't seen any problems. But I think smaller tunnels, and I'll kind of go in, and I'm not supposed to name any names, but it's a device where you put it in, and then you flip it, and you can back cut a little bit, but you can stop short of the fice. I didn't say what it was, but I think you can make very small tunnels, and putting suture across a tunnel I don't think is necessarily going to cause a— Ben Hayward tells me that the growth plate is stronger than a suture, and it's going to power right through that suture. So I would repair it just like adult, but I'd probably use more vertical tunnels and not drill a tunnel any deeper than it needs to be, just a few millimeters stay above the fices in that posterior area, and I think you don't have to worry about a growth plate problem. And no need to untether that suture at any point? I don't think so, but when I do tibial spine repairs, I still—especially in kids under the age of about 10, I still take the sutures out because I'm worried about that. But Ben Hayward tells me that he doesn't think you need it. He thinks the suture will be overpowered by the fices. Brian Haas is in the room. Brian seems to know a lot about this kind of stuff. Brian, do you have any thoughts about that question in particular? Brian, speak up just a little bit, you're saying some really good things. So Brian's saying he's comfortable with small drill holes across the FISUS and has not seen problems with sutures or growth deformity for those types of repair situations. Thank you. Thanks, Brian. So a round of applause for our expert panel.

knee injuries

root tears

radial tears

meniscus

sutures

tibial tunnel

repair techniques

bony apposition

MCL

rebar method

rehabilitation