Hello, this is Jeff Kneppel presenting Pediatric and Adolescent Meniscus Repair Meniscus Capsular versus Meniscus Only. Is there a difference? So I'm going to tell you yes and show you why meniscus only repair options are a useful addition to your toolbox. So here are my disclosures. Pediatric and Adolescent Meniscus Repair, we certainly want to push the limits for repairing meniscus to restore function as well as use options that can limit any traumatic components to access. Interestingly, the meniscus isn't something that people talk about a lot, especially compared to the ACL. Here you see differences in PubMed publications, but the meniscus is really critical to outcomes. We've published a couple of articles in JBGS that show at five years repair still fails in about 25% of techniques. So how can we get better? Some of that may be improving technology. The commentary after the first publication mentioned the Save the Meniscus Society, and I think as pediatric sports providers, we should definitely be members of that society. Outcomes of meniscus treatment play a key role in pain as well as eventual arthritis. So again, arguments for saving the meniscus whenever possible. So you really need to choose the best technique in your hand for a given meniscus tear, and I think for most people that means having several different options in your toolbox from traditional inside out repairs. For me, that's a bucket handle meniscus that I'm typically treating inside out these days. All inside options are becoming more popular with recent data showing their equivalency to inside out options. Most of that published literature comes from one type of anchor, the fast fix, while other newer options have tried to emulate that. Outside in repairs less commonly used for those more anterior components to the tears. And I'd argue that all inside meniscus only suture passage with the circumferential compression stitch utilizing the Nova stitch, which is the current main option, which allows you to do this is really a useful addition to your toolbox. And I'll show you why that is. So this is that technique, a passing device that's well made for the knee to allow us to pass sutures around the meniscus peripherally. Here's a longitudinal tear in the mid substance. Traditional inside out and all inside options get differential compression. So here's an example of an all inside placed on the top of the meniscus. You get compression at the superior surface, but you get gapping at the inferior surface. So it really takes another anchor in that situation to balance that repair. With circumferential compression sutures, you get balanced tension. So this is tied on the top of the meniscus and in theory gives you compression at both aspects of the tear, which in some settings I think is a useful addition. So this is what this looks like. This is the Nova stitch adjustable jaw. We can go in with this flat, then allow it to curve limiting trauma. The undersurface jaw then is deployed. So that relaxes around the condyle, the undersurface jaw, and there's a suture in there that's going to pass in this cartridge. That's a slightly older version of this, but we can pass peripherally, relax the tension and needle, and then come centrally second pass. So both these sutures going from the bottom of the meniscus to the top, and then we can tie that on the top and get nice balanced compression across the tear. So pros of this approach, it gets circumferential compression. It's a very small needle compared to our other options. And the lateral side, it can avoid the popliteus tendon, which is nice. Cons you have to tie knots, but this is a fairly easy as well. For me, ideal tears are those lateral meniscus tears really give you lots of room to do this. Some complex tears as well, horizontal cleavage tears can be very useful where our traditional options might harm that tissue more and lead to the issues with fixing that. So here's tying knots. We get the two sutures passed. We're going to tie this knot as peripherally as we can. I use a simple under, under, over sliding knot. So we slide this knot down. We've got a nice knot pusher. This is in figure four position. There's two of the throws. I catch that third throw, tighten that down. And then we're ready to go with a couple backup sutures and a nice compression on both sides of that tear. So a couple of cases to demonstrate this. Here's another lateral sided tear, sort of two tears in one. This would be a challenging one to fix with some of these other techniques because it may just tear through the tissue. So this is for me, a nice one for this approach. It's right at the popliteus tendon as well. Does the popliteus matter? I don't think it's clear tethering the popliteus probably certainly is less than ideal unclear how many people have issues with that though. So let's fix this with this approach so we can see getting that jaw in coming. We're coming across the knee here. We're going to fire that peripheral suture and then come back in with the central one. Central ones are actually harder. You can see how it wants to spit out our watermelon seeds. You really got to get the right bite here and slowly deploy this with forward pressure. There's a little guide on the top where that's going to come out. So I like that there seems stable. We'll go ahead and fire. And then we've got both of our sutures passed. We can deploy the under jaw to get this out again, put the upper jaw flat to avoid hitting anything. And there's our finished repair after tying those knots. You can see the compression on the bottom and the top with a single device in this kind of complex double-sided tear that seems to heal pretty well. This is a fast fix for comparison. So here's another longitudinal tear. We'll go into the central part of the meniscus. We're going to deploy the pledge it off the back. And then we're going to come up getting above the meniscus into the capsule or that peripheral meniscus for our second bite. And this, as we tension, it's going to give us good compression on the superior side. But we're going to need to balance this out on the inferior side, or you're going to have a gapped meniscus on the inferior side. So you end up using more of these type anchors to balance this out, which has probably a little bit more cost there. You can see the buckling of the meniscus as we're nicely compressed on the top, but not the bottom. So a balanced repair, we would go back and put one on the bottom as well to get that to balance out with all inside options. Inside out certainly has a place too in complex tears, bucket-handled tears, we can get lots of sutures for me, 10, 12 sutures is pretty common with a bucket-handled tear that I'm not going to do that with an all-inside device so we can get all of these sutures to maximize our healing and hopefully minimize the risk of another failure, which in a bucket handle is sort of catastrophic compared to some other tears where it may be leading to a partial meniscectomy and some of these cases would lead to a total meniscectomy. Horizontal cleavage tears are a nice use of the NovaStitch so we can freshen this tear up. Taking back either one of those leaflets is going to leave you with a pretty small meniscus. So this approach I think is nice for this so we can freshen that up and then we're going to use a single suture passage or more of a hay bale technique. So we're going to pass that peripheral suture, here we're just in front of the poplitea, so we're going to go all the way around the meniscus and then just tie it centrally. So we don't need that second pass if you aren't passing it through tissue again. If you tried to go through any tissue there I think you'd be unlikely to add anything. So here's again that same under, under, over, sliding knot, we get the first two down, that other knot's waiting for us, we'll just back up, grab it, and finish with nice compression keeping the knots as peripheral as we can so that we've sort of hay baled that back down and I think the literature supports that those can heal as well. Another case, another complex meniscus tear again, the two cleavages is a great example where I don't think you're going to necessarily do this other ways and sometimes trimming out that central issue is a problem too. There's a risper rip in the back here too where the meniscal femoral ligaments starting to come off so a nice case for using this for me. We can pass this all the way around the back right at the popliteus tendon without tethering it and then get a central bite as well and tie that down and then we're going to work our way back all the way through the meniscal femoral ligaments. So there's our sutures and we can go, I think we sneak to the back here for this last passage so we're going to catch that risper grip as well all the way to the back. You can see our needle come out at the top of our device there and we can tie that down nicely as well to get a good zone all the way back. We can use this in small knees that we see as well. Here's a six-year-old with a tibial spine fracture. We can adequately get this with the NovaStitch. It's very important to get your portals prepped enough so you're not getting hung up on the tissue. Younger patients, the tibial spine can be an issue too where you may end up coming straight at the tear rather than across the knee. Once that's ready, there's our tibial spine and then here's our meniscus tear. So a six-year-old meniscus should have a really good chance to heal this. This is pretty mobile that I think the Soterix gives us a nice option for getting this. Even in a small knee, we've got enough room to use this sort of adult type device, certainly looks a little bigger, but we got enough laxity and figure four position to wrap this tear up just like we did for the younger ones or for the older ones. Here's the central bite again, avoiding watermelon seeding is the key and I highly recommend trying this out in the lab as well as a great chance to use it. So then we can tie this and we get nice compression on the under and upper sides as it comes into view here. You can see the compression that we would not get with an upper surface repair all inside traditionally. So the medial meniscus, we can do this as well on the medial meniscus. You need some space. So trepanation of your MCL I think is important. You can also do this in sort of bucket handle tears as well. You've got enough access. That's a good tear that pretty amenable to this as well. Here's a displaced bucket that if you pass a suture under the meniscus to get the periphery and then you can come back and grab that slightly displaced fragment with the upper with your second pass and both sutures are coming from the undersurface of the meniscus. If you do that, it doesn't wrap it up and you can tie that down and start to get that suture to aid in your reduction. So there's kind of a final look at the start of that repair. So pearls for meniscus only options, you really need to have good portal trajectory, probably true of all meniscus repair, ensure that it passes easily into the joint. That second pass is really your challenge to make sure you get a good bite. In some cases, it's fine to go around the meniscus, that hay bale technique. But if there's a lot of meniscus there, you'd like to get into that. The simple sliding knot works very well for this with the peripheral limb being your post. Ideal tears for me, mostly lateral, sometimes medial. If you've got enough room, these longitudinal tears are very nice to repair. Pedicular techniques certainly apply to root tears and radial tears as well. If we look back, the initial concerns at this were the suture prominence. If you ever look back at any of these, I've had a chance to see a few of them, the sutures are really synovialized that you can hardly see the knots and the sutures have never seen any abrasion of the condyle from this. So I think that's less a concern, the more experience we have with this technique. So in summary, we certainly need to push the limits for meniscus repair. Tear type and location will adjust what you're going to choose to do with that tear, so having this as a part of your toolbox, especially for those lateral repairs, is a nice addition. Thank you for your time.

Pediatric and Adolescent Meniscus Repair

Meniscus Capsular versus Meniscus Only

All-inside Meniscus Only Suture Passage

Nova Stitch

Balanced Tension and Compression