Hi everybody. I'm Dr. Vonda Wright. I'm an orthopedic sports surgeon and president of the Houston Orthopedic Southeast Division in Orlando, Florida. And today the forum has asked me to speak about root tears of the meniscus. So let me share my screen with you and we'll get started. So management of degenerative meniscal root tears. I don't think anyone needs reminding about what the meniscus is or what it does, but we'll briefly go over that. We'll discuss operative versus non-operative care, briefly touch on the techniques for surgical management, as well as something that is very important in my practice, which is treating the whole person. So briefly, the meniscus is fibrocartilage wedge-shaped structure in the medial and lateral compartments of the knees, forming a three-quarter ring bounded posteriorly by roots implanting into the tibial plateau and anteriorly the same. As you know, it contains longitudinal fibers, converting compressive forces to circumvential hoop stress. These roots that we're talking about today are vital for anchoring these longitudinal fibers. And without them, frankly, it is equivalent to a total meniscectomy. This is a brilliant dissection published by LaPrade recently which shows the relationship between the various structures in the central portion of the knee. Notice the relationship between the posterior portion of the medial and lateral root to structures like the medial tibial eminence or anteriorly notice the relationship and actual interdigitation of the ACL and the lateral anterior root. These structures are all aligned within a very small space. And so as we correct the tears and deformities that happen, we are not affecting the knee in an isolated way, but as a group of structures working in concert. So diagnosis of root tears is not easy. Root tears comprise 10 to 21% of all meniscal pathology. And frankly are underdiagnosed as they sometimes are not medially apparent on physical exam or even MRI. Lateral root tears are most commonly disrupted in sports or trauma due to deep squatting with a rotational component. Approximately 80% of the time, they are associated with an ACL tear and they are most commonly found in young males. I've actually had two of these lateral root tears recently and come to my clinic, two young athletes. One was a jujitsu athlete who was down on the mat in a very deep squat, hips on heels and twisted to the side and actually dislodged both of his lateral roots. And the other is a young wrestler who was hit from the side while he was going down on the mat. So that is the picture of the person with a lateral root tear. Medial tears, however, are seen in more low energy situations with 70% of people having absolutely no recall of the inciting event. They're sometimes associated with midlife and osteoarthritis in females and tend to be degenerative. So we're gonna talk about this type mainly today but both types also. On physical exam, root tears can present with pain with a loaded deep flexion squatting or a McMurray's but these are pretty nonspecific. The gold standard for diagnosing a root tear is MRI or even diagnostic arthroscopy and probing each of the roots. Because of new technology that I'm actually using now, nanotechnology or needle scoping, we can do these diagnostic looks actually in our office without having to go to the OR. So the gold standard of diagnosis is the MRI with 77% sensitivity and 73% specificity. And you will often see what is described as the ghost sign or compared to a normal triangular root with no signal intensity within the body, you have a fluid-filled or empty space as indicated by the arrows here from LaPrade's paper. The other cynical known of this injury is edema and subchondral insufficiency fracture around the posterior root. Now, this is described as spontaneous osteonecrosis but actually that's a misnomer and is more accurately an impact or insufficiency fracture from the forces applied in the rotational portion of the mechanism. So what is the definition of a true root tear? A root tear is an avulsion of the attachment or complete radial tear within one centimeter of the root attachment to the tibia, either posterior or anterior. It is associated with meniscal extrusion, increased joint contact pressures. Without this anchor, there is rapid development of joint space narrowing due to osteoarthritis and can present with the painful subchondral insufficiency fractures I'd previously described. So LaPrade describes five types of root tears with the first being type one, which is a partial stable root tear. Type two, which is the most common, is either a complete radial tear or can be subdivided by how far it is from the actual root insertion. 2A is less than three millimeters, 2B is three to six, and 2C is six to nine from the root center. These distances make a difference in terms of repair. Type three is the disaster, the deep flexion, hyper-twisting injury that results in not only a complete root tear, but a bucket handle tear in addition. Obviously, you can tell that this kind of meniscal injury leads the compartment completely unprotected. Finally, type four is an oblique tear with the root attachment. And finally, type five is bony avulsions. So what are the treatment options for root tears, specifically degenerative, but all in general? And I've placed this question on a slide with pictures of my actual patients. In my practice, as in yours, you probably see lots of master's age athletes who happen to have a high chronologic age, but physiologically are very youthful. So as we think through what to do with these meniscus tears, remember that the goal is preventing the development of osteoarthritis and restoring normal joint contact forces and kinematics. I put this here to remind you that we cannot simply see the number on the page as you look at your patient list and decide we're just gonna debride this thing, right? These athletes that I take care of, and I'm sure you do, want restored function because they compete either recreationally, in life, or in true competitions and want to do so for many years in the future. It takes a mindset change for us. So what are the non-operative management of root tears? Well, at this point, the pendulum has swung and there are very few indications for non-operative care in vital active people. Because remember, our goal is whole person care. So in the environment of severe cartilage damage, obesity, or extreme elderly, non-operative care is an option. The goal being pain modification, continued activity of daily living. So we do that whole person care with anti-inflammatory, not only medications, the typical things we go to, the NSAIDs, but dietary. There's a big movement now within the health industry to pivot diets to non-inflammatory diets, which is more green leafy, vegetables and fruits, and high levels of protein, with carbohydrates in the form of fiber. If you are not equipped to do this kind of counseling in your office, it is perfect to have nutritional consultations that you easily give to your patients. Your patients will not know how to do this themselves, and yet it's critical. The second is metabolic control or load management. Notice I do not specifically say lose a lot of weight because what we actually want to do is lose fat while we gain lean muscle mass in order to support our joints. Number three is activity modification. If you have a patient who has lots of high impact activity and continually has knee pain, then help them understand the benefits of things like elliptical stair climbing, rowing as a means to remaining healthy and fit without having to do plyometric box jumps, running, jump roping, that kind of thing. And finally, we can use unloader braces or mechanical assistance in our non-operative whole person care. Physical therapy is critical in non-operative care, focusing on the glute strength, core, and quad. Overall fitness in older patients with degenerative meniscus tears generally and specific root tears can greatly impact pain function. But the truth is, is there is not robust research as to the role of physical therapy in degenerative root tears. Finally, given the root impact, it is suggested when possible, immediate surgical intervention with comprehensive physical therapy to follow to restore strength, function, and cardiovascular fitness. Here's the deal. If you sentence someone to sitting around for the next 20 years of their lives, their metabolic syndrome will increase significantly. Therefore, I am encouraging us to reconsider whole person care and keeping people mobile as a means of staving off chronic disease. So when we look at operative management, debridement versus repair, we see in this study that with meniscal repair, there still can be some significant progression into osteoarthritis in the future with 53% progression. However, there is nearly 100% progression with minisectomy or non-operative treatment. So how do we fix root tears? This is the technique that LeProd uses. I use a similar technique I'm going to show you next. Every company makes a set of instruments to do this, but basically we are reaffixing the anatomy, the posterior horn, the anterior horn, to its insertion site through tibial tunnels with the goal of restoring anatomy in its exact place. And that's why that dissection that I presented earlier is so helpful to see the relationships. We're restoring anatomic position of the root via sutures through the root core anchored to a prepared bleeding bed of the tibia. This can be onlay technique to a bleeding bed or actually through a small trough. The bleeding bed is prepared with a ringed curette or a retrograde burr. Two sutures in general are placed through lassos through the meniscal root, and they are then pulled through the trans-tibial tunnel. The sutures are retrieved, brought out the anterior portion of the tibia and fixed via anterior cortical fixation. No matter what system you use, these are the general steps. Prepare the bleeding bed, put sutures through the horn, tunnel through the tibia, pull the sutures out, docking or onlaying the meniscus to its native anatomic position, and then placing anterior cortex fixation. For best visualization, you can do things like do a small resection of the tibial spine. You can do a very small notchplasty to increase visualization. If the PCL synovium is in the way, you can debride that. Or if you have extreme difficulty getting to the back, you can trephinate the MCL. This is actually the technique I use. Again, very similar. I am preparing the tibial bed at the anatomic insertion site. I am drilling a trans-tibial tunnel using a tip-to-tip guide or over-the-top guide, putting two lasso sutures. You can also put modified Mason-Allen through the horn, and then pulling those sutures through the tibial tunnel to the anterior cortex and providing cordial fixation, either with an anchor or with some sort of metal button. Rehab following this procedure is critical. The literature suggests six weeks of non-weight bearing to allow the sharpie fibers to come up and grab the meniscus and hold it to bone. The first two weeks, you have passive range of motion limited to 90 degrees to decrease the stresses across your newly repaired meniscus. From weeks two to six, you gently increase passive range of motion to full. After six weeks, you progress from non-weight bearing to weight bearing as tolerated over a period of two weeks and really work on reestablishing normal gait patterns. No squatting beyond 70 degrees should occur until four months to prevent the kind of forces across the posterior part of the meniscus that could re-tear it. And then finally, when we get through the acute phase of rehab, we do a long return to sport for lower extremity strength, joint proprioception and postural stability as we move back to cardiovascular fitness. So what are the outcomes? Well, three studies I polled shows that in greater than 60 months follow-up, 41% had a radiologic progression of osteoarthritis. However, only 22% in the repaired group versus 61% in the debrided group. 21% of people in this study progressed to total knee arthroplasty. However, again, a statistically and clinically significant difference between the repair group in whom only about 10% progressed versus 36% in the debridement group. Another study in the British Medical Journal found that there was no significant difference depending on patient's age, less than 50, greater than 50, with both the Leisholm and the Womack scores improving in patients above and below 50 as an age group divider. And finally, in a meta-analysis of clinical and radiographic outcomes after posterior horn of the medial meniscus root repairs, it is interesting to see that medial meniscal extrusion was not eliminated. However, there remains significant improvement in functional and pain scores. So finally, what's the bottom line? The bottom line is that root tears are a silent epidemic and the pendulum has swung from simply debriding them all out to frankly fixing every single root tear you can. Only root repair will restore knee kinematics. Non-operative meniscectomy and non-anatomic repair fail to stop OA progression. Diagnosis can be difficult. We need not only physical exam, but MRI and sometimes diagnostic arthroscopy, which can be done with needles now in your office. But the key is to probe every meniscus, not just look at it with your eyes. You may see the ghost sign in addition to the regular increased signal intensity within the root. And you may see the fragility type edema in the bone commonly called zonk. And finally, peripheral extrusion. The gold standard is progressing to repair with anatomic trans-tibial pull-out technique with guided PT and meniscal repair protection for six weeks. And finally, once again, I am going to encourage you to not cop out to the ageism as seeing patients is only the sum total of their chronologic age, but consider the metabolic and functional age of your patient and their knee as you provide whole person care and get people back to the activity that they need physiologically and deserve as your patient. So thank you so much for joining me today. I hope that this information was helpful and I look forward to seeing you at the technical hands-on portion of this course. Bye now.

root tears of the meniscus

diagnosis of root tears

non-operative management

surgical intervention

rehabilitation process

positive outcomes