Hi everyone, this is Stephanie Meyer from the University of Colorado. Thanks so much for joining us for this course, we're very excited to present all of this to you. I will be speaking on radial meniscal tears specifically, which we feel is a necessary repair in these adolescent patients. This is my one disclosure, which really is not relevant to this talk. As you know, the medial and lateral meniscus are made of type 1 fibrocartilage and they're organized mainly in a semicircular ring, which is between the femur and tibia, which is there to dissipate the hoop stresses within the joint. At birth, the entire meniscus is basically vascularized all the way from the capsule to the inner surface, and by about age 10, the vascularity seems to have reached basically an adult pattern, as you see in this cross section here, where essentially the outer third is vascularized, and that's how we get the terms red-red zone, and red-white zone meaning the junction between the non-vascularized areas, and then the white-white zone being all the way towards the inner surface. This has a lot of implications on how you might treat meniscus tears, particularly in adults, but in kids, this also can have some implications on how you might treat especially younger kids under this age of about 10 or 11. By about age 3, the collagen is mainly oriented in that circumferential pattern that we described just a second ago, with also some superficial radial fibers acting kind of as railroad ties to tie them together, and this circumferential pattern essentially dissipates the hoop stresses that come from the tibiofibular joint, and as you can imagine, radial tears completely disrupt this pattern and render that meniscus essentially non-functional. Other meniscus tear types that you will also be hearing about include vertical, horizontal, complex, parrot beak, and bucket handle tears. We'll be focusing on radial tears in this talk, which makes up about 10% of pediatric meniscus tears that you might see. These are two MRI examples of how you might diagnose a radial tear, both on a sagittal and axial cut, and as you can see, it essentially completely divides the meniscus, and the two portions typically separate by some millimeters and basically render that hoop stress dissipation non-functional, as I just mentioned. Here are another couple of views of a radial meniscus tear, both in situ and an arthroscopic image, and also as we scroll through, the sagittal cuts of that same radial tear that we just saw, and as you can see, all the way out to the periphery, essentially, in this radial tear, that meniscus is cut all the way across. The options for surgical treatment of these radial tears is just like any other tear, with basically debridement or repair as your two options. For a pediatric or adolescent patient, we feel that this is kind of a necessary repair to at least attempt, as these patients might have a little bit of a higher propensity to heal the tears, especially in our really young patients, but also because of the outcomes that we'll describe in a couple of slides of the possible radiographic outcomes and osteoarthritic outcomes that may come from a debridement, especially of this magnitude. This was a really nice meta-analysis done by Dr. Beck, also part of our faculty here, on the operative treatment of isolated meniscus injuries in adolescent patients, and those are two things that are hard to come by, meaning the outcomes of isolated meniscus injuries and those not included with ACL injuries, and also really teasing out adolescent patients. Despite that, this still includes heterogeneous tear types, so the data that we're presenting here does not just apply to radial tears, but overall, the point of the next slide is that the results of meniscus debridement is a little bit alarming, particularly in these young patients. In all of these outcomes of these studies that I'll show you here, at anywhere between five and then up to about 16-year follow-up, there's a significant amount of patients that were adolescents when they had this meniscectomy that ended up having either persistent pain, functional limitations, effusions, difficulty with certain activities, but even more concerning, in my opinion, is that they had x-ray changes so frequently of osteoarthritis at such a young age. So because of that, we feel that repairing these, even these radial tears, is a really important thing to attempt, and in the worst case, you end up with a debridement, but in a lot of cases, you may really have a successful outcome more than you might expect. In otherwise pretty healthy tissue quality and pretty simple radial tear patterns, the most simple options for surgical treatment would be either a side-to-side stitch, meaning just to simply tie the meniscus together in an all-inside fashion with some of the all-inside passing devices that can pass suture vertically, both up and down through the meniscus, and just tie that right over the top or bottom of the meniscus tear. A horizontal mattress and a couple of layers of that sometimes with an inside-out technique is also a very simple and reproducible way to provide a repair. In some of the newer papers over the past couple of years, there have been some very elegant and more complex patterns of repairs with some horizontal mattress and inside-out techniques such as the one in this slide here. This is another diagram description of a pattern of repair here, and one last repair option here, which I've zoomed in on to show the final product. There really aren't any studies that have specifically teased out adolescent pediatric patients with their outcomes of radial tears only. They seem to be mostly lumped in, as we saw in that meta-analysis earlier, and so most of them are going to be heterogeneous ages as well as tear types. However, for otherwise pretty simple patterns of tears, the outcomes for clinical success seems to be somewhere between about 70 and 80 percent. This goes down with more of a bucket-handle tear type or a complex pattern. So somewhere between 30 and 40 percent of patients are going to be undergoing a revision. So in summary, there are some concerning outcomes for sure, both in a functional limitation perspective but also a radiographic perspective with a lot of patients undergoing outcomes that are consistent with osteoarthritis with meniscectomy. And that plus the potential for healing in these younger patients makes a repair of even these radial tears worth the effort in the pediatric and adolescent needs. Thanks so much for your attendance, and if you have any questions, my email address is there and I'm happy to answer anything that you might have.

radial meniscal tears

hoop stresses

vascularity patterns

repair

pediatric patients