You guys, can you guys hear me okay? All right. So, as you guys remember, we talked about yesterday. Our day is gonna be filled with live demos. They're gonna be recorded. This morning, we're gonna focus first on the meniscus, and then we're gonna focus later on the afternoon about pediatric ACL reconstructions. So, about every 20 minutes, we're gonna have some live demos, so feel free to take a step back, watch the demo. If you guys wanna continue working a little bit and listen to it, that's fine too. We got all day in the lab, so this is just purely education for you. Right now, we're gonna start with two different versions of a meniscus repair. Pete Fabrikant's gonna start us off and talk about his techniques, tips, and pearls for a root repair. Pete, can you hear us? I can hear ya. All right. You hear me? We can also hear you. Good. So, this is a non-pediatric knee. It's extraordinarily arthritic, which is unique for us. But Cliff and I here created a root tear. You can see there's a lot of cartilage wear, but we created a root tear of the posterior horn lateral meniscus. And so, step one is just making sure that your portals are in such a way that you can get to it from both portals. And then, what I tend to do for a posterior lateral root is tend to work through the lateral portal. So, I'll switch my scope over to the medial side. So, you get a better look at it. And then, do we have a... So, let's see the... Let's just see this. So, what you can do, you can prep your landing zone. So, you can use a curette and just kind of work the back here. This is very friable bone and cartilage in this specimen. So, we'll be gentle. Work that. You want to prepare your edges. Have a nice area for repair, healing repair, biological healing repair. Okay, so we're gonna use this root repair guide. Lots of companies make a similar device, but essentially it's... I don't know if you guys can see. I'll put it in the camera. It's a root repair guide. This is designed to hook over the back of the tibial plateau. And then, you can pick which line you want to hit. So, we'll get this set. Which line do you find most reliable and useful? Yeah, I find that depending on your trajectory. So, a lot of times you're kind of coming at this from a shallower trajectory. So, I usually put it on the five millimeter, the one in the back. So, I think that if anything, these tend to miss a little anterior. And then, just let me set that up, yeah. So, we already kind of, just to save time, found our landing zone here. And, there's a couple different ways to do this. You can use, like in the Arthrex system for instance, you can use a flip cutter guide or you can use a retro cutter. This, in this case, we'll use a slotted drill pin. So, we get this down on the tibial metathesis. Cliff's gonna drill it. And again, you kind of, sometimes you tend to lose the markings there, but as long as you're kind of hooked onto the back of the tibia, you should be okay. All right. So, he'll get that started. In the middle. I think we're done. Yeah, okay. So, once he's hitting metal, we'll tend to take this off. Take this off. Nice. And then, we can advance it a little more. I'll try to wiggle the scope back there. There we go. Yep, so there we are right there, okay? So, if there's any debris there, you can kind of shaver that out. But, I like that spot. Perfect. So, what we're gonna do is, you can actually see really nicely here, there's a little central tip there. And so, you wanna unscrew that? Yep. So, let me get back up here. So, when he unscrews that, it's cannulated, and what we'll do is take a Nitenol guide wire and advance it up. And do you have the retriever? Perfect. Yep. Perfect. So, in your first thousand, what are your pearls? Thousand minutes or thousand cases? Yeah, so I think one pearl is just making sure you have good portal placement, making sure that you have excellent access to the spot. For a medial route, we talked about this yesterday, for a medial route, we will trephonate the MCL to get us some working room. So then, once we do that, I like to back this, the other pearl is, have your assistant hold that, back this out by hand if you can, or with a needle driver. If you spin it, you can hurt the Nitenol wire, and then we'll kinda clamp that together. So, that's our landing zone right there. And then, as far as the suture repair, I wish I could say I came up with this, but actually my rep showed this to me. Essentially, we're gonna use a meniscal scorpion or a meniscal suture passing device, and it's a luggage tag suture, so it's a loop, and we'll put that on the barrel of the scorpion, and then we load it like we normally do. So, what we're gonna do is pass the needle, and when you take the instrument out, it'll create your luggage tag, so you don't have to worry about passing your stitch there. So, we'll go in. The other thing, sorry, the other thing is, is because of that, because of how the needle passes from bottom up, another pearl is if you can, if you have the room, actually pass it upside down, and then what happens is it makes the stitch lock a little better, and I'll show you what that looks like once we get it. This is a bit of a tight knee, so we'll try to make it work. Can you pull a little valgus, maybe? Or varus, I guess. So, let's get this out of the way. Yeah. Good. The other thing is always grab more tissue than you think you need. It's always too small of a bite, if anything. So, I'm gonna get way far back there. Grab the meniscus. I'm gonna turn the device so that we're not shooting it right into the tibial plateau, if we can. Deploy it. Retrieve. Pray a little bit. There we go. It worked. Okay, good. So then, I'm gonna release that, and then what we'll do, and a lot of times this tissue can be a little bit delicate, so I don't like to just kind of yank on the suture. We'll kind of go down slow, and then I'll use a standard knot pusher to kind of, here we go. You mind holding the scope for me right there? Perfect. We'll use your standard knot pusher to just do some of the work on cinching down your stitch so you don't put too much stress on the tissue. Good, and then, so what I was mentioning before about deploying it upside down, if you deploy it upside down, then, you can't see with this, let me show you with the probe, actually. If you deploy it upside down, then what happens is the loop, the loop orientation is such where you can see the loop is underneath, and then the stitch is gonna go down and lock on the loop. If you do it the other way, then the stitch is kind of coming up and then has to go over the top and down, and it doesn't kind of cinch down as well. We can throw, you wanna throw another one? Temp fate? Maybe in the interest of time, I want Cliff to have enough time for his radial repair. We'll just kind of pass this. So, just hold the scope for me for one sec. So, step one is gonna be making sure we don't have a soft tissue bridge. So, I'm gonna take my loop grasper, go into the knee, grab, oops, sorry. Turn my eyes here a little bit. I'm gonna grab both the suture and, kind of going in the same way, suture and nitinol wire, and then just kind of pull it out so that we make sure we don't have a soft tissue bridge, which we now don't. You mind holding the scope one more time? And then, this nitinol wire has a looped end, so we're gonna shuttle our stitch. We can, I'll let you do the honors area. Perfect. That's a good view there. We're gonna shuttle our stitch down, and then you'll see that kind of pulls it down nicely there. Again, you can do two, you can do two, you can do three. If the tear extends along the meniscus capsule junction, you can, once you secure and set your tension, you can do an all inside repair and inside out repair there as well. But, I find that doing, again, the Pearl, doing this upside down probe, sorry, doing this upside down gets you a really good, and Cliff, pull down on that if you don't mind, gives you a really good, you know, lock stitch that really doesn't slip, and if it goes the other way, sometimes there's a little more play in the system, but that tends to be good, and then we'll put it down to an anchor, and that's the end. So if you have an ACL tear and a root tear, and you're doing the reconstruction, what's your sequence of ACL reconstruction and tunnels and avoiding the tunnel? Yeah, it's a great question. So what I'll typically do is clear out my notch just for visualization. I'll prep my root, I'll pick my spot and pass the guide wire, but I won't switch it out for the night until after I drill my tibial tunnel just to make sure that we don't have converging tunnels, and then fix the ACL, sorry, pass my ACL, fix the femoral side, retrieve my root stitch transosseous, and then fix the root and the tibial fixation for the ACL. Yeah, I think that's great. Yeah, leaving the pin on while you're drilling your ACL tunnel just in case to protect it versus a suture that would get wrapped and damage the roots, a great pearl as well, so nice. For sure. All right, we're gonna move over to Cliff now. He's gonna show us his technique for a radial split. All right, so we've created a radial tear of the medial meniscus within the body, and I think a few pearls. One is on the axial MRI, it's easy to see the radial split in most cases. Sometimes if it's minimally displaced, you may be more difficult to see in the sagittal view. So we can see our radial tear. I think when you're first assessing the radial tear as a candidate for repair or not, probe and check the tissues. I think sometimes it's retracted, and it's at first glance, arthroscopic grasper, at first glance it's easy to assume it's not gonna mobilize and be repairable. So put a grasper in, you can grab the tissue, and check its mobility to see if you can reduce it close enough. And then when we start passing sutures, we will use the inside-out technique, and the body often can pass the sutures and then make an incision afterwards to tie them over the capsule. When I'm passing the sutures, there's lots of biomechanical studies that have looked at suture constructs, and using, for the social media gurus, a hashtag-type suture configuration, which would be two vertical mattress sutures serving as rip stops, and then a horizontal mattress sutures, two of them spanning on either side of the vertical mattress to become the rip stop component. And so, as we, there are a variety of cannulas. This is a zone-specific cannulas. Why don't we push the needle out just a few millimeters? And we can use the exposed needle to manipulate the tissue. Okay, perfect. So now, our first is, you have to be careful. If you place your first suture as the vertical mattress, you're kind of, it's like an open internal fixation without a reduction to OIF. And so, we want to try to use it as a horizontal first to help reduce our tear versus fixing it in place. So, I'm puncturing through the tissue. I'm trying to displace it anteriorly. And now, we'll pass the needle, right? Yeah. So, our first needle is passing. Thank you. And then, we will load the next needle. So, in similar fashion, passing on the other side. And we're trying to leave enough space to place our vertical mattress sutures. So, piercing the tissue, trying to use it to reduce. Let's let it flex just a little bit. Yeah, perfect. Okay, and now, we'll pass. Okay. So, in essence, those are serving as our first kind of reduction sutures. Our next will be in a vertical mattress configuration while holding slight tension on our first set of sutures. We can slide through with our. Get a suture scissor. The suture scissor, Dean. Yeah, just want to make sure we get rid of these. Using an all-inside technique is nice because the small size of the repair needles, it's not damaging the somewhat friable tissue. So, next, I'm sliding in under. If we can apply a little bit of pressure to our repair suture that's already passed. So, that seems like an important distinction, right? You're passing it under so that it acts as a ripstop. If you're over top, then it's not really gonna help you that way. Okay, coming at you. Yep, good. I see it. Okay. Now, we will pass our second. Okay, back up this. Can you back up the needle slightly, Dean? Thank you. Excellent. Okay, now, same and pass. Perfect, I see it. So, trying to leave enough spacing in the vertical mattress so that our horizontal sutures can be protected with the ripstop. Okay, now, we'll complete the process on the same, the other side. So we're through the tissue, but not through the capsule, pulling the sutures. Okay, a slight flexion, okay, it's passed in. Nice, got it, okay. I think our muscle relaxant wore off. The anesthesia seems to be... Can you try to extend a little bit? Yeah, extend a little more. Okay, let's flex slightly. Let's vary the position. Maybe it's moving in the... Okay, try a little... Yeah, perfect. Okay. Okay, nice. Perfect, got it. All right, now we have one remaining suture to pass. Occasionally, we'll pass an undersurface suture. As I'm passing the vertical mattress, I'm trying to diverge the sutures so that we're spanning as much tissue as possible. Biomechanical studies have compared a hashtag-type construct with a ripstop component to simple horizontals and have shown it to be biomechanically superior in both cyclic loading and pull-out strength. So, trying to hug right against the vertical mattress. One more passage. Good, got it. One last one, push it through slightly, advance slightly, okay. What other tips do you have for getting access to this part of the knee? Yeah, sometimes it's tight, it was in this knee, so pie crusting, the MCL, can be useful. Using a spinal needle or an 11 blade, so we can see the general construct. I think it's also helpful occasionally in pediatric needs to use a smaller 30 degree arthroscope, viewing from the same side is helpful. And then, in this case, we would make an incision along the medial side of the knee, expose the capsule, and tie our sutures. When you're tying the sutures, it's important to tie the horizontal mattress sutures first because they reduce the tissue, and then tie the vertical mattress ripstop sutures as your second set. Otherwise you'd essentially set the vertical mattress and not be able to reduce your meniscus. Now in what case might you consider doing a transosseous augmentation here? Yeah, so transosseous constructs have been also compared to a ripstop type construct and have shown them really to be equivalent. So where you're using two tunnels that are crossing, I find that useful in the posterior horn. You can see in the back of the knee it would be somewhat difficult to probe, to pass the sutures such as we just did in the back of the knee. So you can use a similar concept of the root repair, but think of it as doing two root repairs where we would, in essence, perform a root repair of one side of a radial tear and then a root repair on the other side. And then you can use either an all inside construct or an inside out to repair the remainder of the tissue, but using the transosseous component to repair the outer third. If we have time later today we could demonstrate that. It's been a really helpful technique in the tears that are too far away from the root, but typically in the posterior horn segment here. Last question for you. Do you have any specific landmark where you feel comfortable that it's anterior enough that you can percutaneously do your inside out sutures or that you're too posterior that you want to cut down first? Yeah, I think there are two components to that. One is it depends on the cannula that you're using. And so bringing the cannula in from the opposite portal and having enough curvature in the cannula that you're not diverging posteriorly. And so typically in the body segment for radial tears, that's okay, but anything in the posterior horn, I really think you need to make a posterior medial approach for protection. Cool. Cliff and Pete, thanks, and I'm going to put you guys on the spot real quick. We couldn't possibly give you guys a discoid meniscus, but a very pediatric problem. Can you guys each give us two pearls on your meniscal treatment for a discoid meniscus? Yeah, two pearls on treatment for discoid meniscus. I think one, and it's the thing that I tell our residents every time we're doing a discoid is you can always take more, you can't put it back. So the discoid meniscus can be a little tricky. You can think that you're resecting abnormal tissue, but if it's displaced anteriorly or posteriorly, you could be into normal tissue. So we take our time making sure that as we saucerize, for instance, we're checking, making sure that we like our resection and we can always then go ahead and take more. I think my other pearl that I'll just kind of pick off the top of my head is you always want to put the camera, like right now, Cliff has the camera in the medial portal and he's working through the lateral portal and that gives you a really good look at the front and you want to make sure you're not missing any flaps or abnormal tissue or tears in the front, in the anterior horn. Yeah, and similar, recognize instability. When the meniscus, the discoid meniscus, if it's detached from the anterior capsule, there's typically not a gap present at the time of arthroscopy. There will be a thin veil of tissue. So probing and assessing the meniscus capsular junction anteriorly. If you shave, you see the instability and you shave slightly, you'll realize it's just a small, thin layer of fibrous tissue against a recognized instability anteriorly, certainly posteriorly as well. And then when you start the resection, sometimes if you have a peripheral rim instability from the anterior capsule, the meniscus is displaced posteriorly. And so it would look something like this. And so you may inadvertently start your resection to anterior. So if that's the case, you can place a tag stitch and use it to reduce the anterior horn while you start your resection. But the one constant anatomical finding I find is that the posterior aspect of the root tissue, the discoid typically does not extend, the discoid component does not extend all the way to the root. So you can always find this anterior root attachment, the posterior aspect of the anterior root. So you can use that to help identify the root and make sure that you're starting your resection in the appropriate location. Yeah. That little axilla that's there usually. Yeah. That's great. I appreciate it. Thank you guys for the demo. Again, these are recorded. Catch them later. And in about half an hour, we'll come back with a demo for a meniscal transplant. Thank you.

meniscus repair

pediatric ACL reconstructions

root tear

portal placement

meniscal suture passing device

radial split repair