from Denver, Crystal Perkins from Atlanta, gonna go over their pearls on meniscal transplant. And again, we have that available for you guys if you guys want to. So again, if you guys just wanna take a break and watch about meniscal transplants. Kurt, can you guys hear us okay? Perfect. We can use that, yeah. Yeah, if you wanna. Kurt, you're there. Thank you so much, Henry. Appreciate it. Yeah, so we're here on a left knee. Crystal and I have done some preliminary preparation here. We've resected most of this meniscus to make it look like a patient who would need a lateral meniscal allograft transplant. In our population, this kind of young athletic or pediatric population, the majority of these patients are patients who have a discoid meniscus, who have had already surgery, often a subtotal meniscectomy or an unsalvageable meniscus. And they have essentially complete or near complete meniscal deficiency. You may already be seeing some cartilage changes. Or in some cases, it's this common complete radial tear that was irreparable and they're left with a functional meniscal loss. So here in the prep work, what we've done so far is we've resected a rim. We'd like to leave a little bit of a rim. You're not trying to get all the way to the capsule. So there is some meniscus left here peripherally, ideally, posteriorly. We can come around and see a little bit of meniscus left here in the body region. And as we look anteriorly, there's just a little bit of meniscal rim remaining. And so what we went ahead and have already done is we have created our tunnel. So obviously there's some debate on techniques for this. I'll show you what I'm familiar with and what I've been trained on, which is to make two independent anatomic tunnels in the root locations. So in the posterior root, what we used here was a tibial drill guide. I don't know if we have that drill guide actually available. We don't. It's okay. We use a tibial drill guide in this location. Here it is actually. Yep. And so we've already done it, but I'll kind of take you through the steps here. So we have a tibial drill guide and we use the RF wand to mark out our location of the posterior root laterally. See a little figure four, I think we're good there. And held the guide here, the posterior lateral bundle of the ACL can be a good reference point, but more importantly, we really do just see the meniscal anatomy. There's usually some remnant posterior root. We're just trying to recreate that anatomy. So we put our drill guide right in that location. We've used a device to retro ream this tunnel. We can see down this. In this case, about a seven millimeter diameter, but only need to go to a depth of about eight, maybe 10 millimeters. You don't want to have this too far because you can end up having too much length and countersinking the root in that location. So we clean that out and we've subsequently passed our suture. There's a suture coming through this. And an important reference point, we can show this on the external camera we see here. We'll just show in here is our reference for this posterior tunnel, which is a slightly more distal. And we referenced the PES tendon. So if you can go just above the PES, that's where this will start and go to our posterior root. And we want to keep about a one centimeter to 15 millimeter bone bridge where we ended up making our anterior tunnel. So that's kind of a two person job here. The person creating the tunnel and doing the drilling needs to make sure there's a bone bridge here because we ultimately will end up tying these two root tunnel sutures over a bone bridge. And then we've created our anterior tunnel as well. And again, we can see the native anatomy of the lateral meniscus and use those fibers as a reference, but also the ACL can be a good way to reference that as well. So we once again made a seven millimeter tunnel here anteriorly to a depth of about eight to 10 millimeters, cleared this out. We've intentionally not passed the suture yet in the anterior tunnel. We want to wait until we pass these other, the posterior horn first, just in our experience, that can be a little bit of a suture management tangle. And then the last thing we did is we used a spinal needle through the body region, just anterior to the popliteus tendon back here. We can open that up. Sorry. It's okay. We're just anterior to the popliteus here. We've passed this, and this is a device to pull in an additional suture that's just for a graft passage purposes. And then this is a cannula here, which I think this is a little small detail, but can help is we actually use a 12 millimeter cannula here, a 10 millimeter cannula can work, but it can be a little tricky just getting the graft through. So 12 millimeter seems to open it up just enough that much more to have a little bit easier time, hopefully getting our graft to come through here. And so we can show you what we've done in terms of graft preparation here. It's a left meniscal allograft. We're hoping this fits this patient. Typically this was the size matched based on preoperative x-rays. And then we use mostly MRI to measure this. So we're getting a size match graph. We've cut the bone block off mostly. We've left small dowels of bone in the posterior and anterior roots. I've marked this before we started on the superior and posterior portion, just so I don't get mixed up as this. It can actually flip and you can be, get a little lost. So I think it's nice to mark this. Then we've passed this, this a PDS suture, which we'll use through the retrieval passer here that we've used. So I think we're ready to go ahead and pass this thing. What we'll do now is we'll, we have our posterior root here. Perfect. And I think it's fine to go ahead and actually pass the sutures first. So we'll get these through. So we're working with those sutures here and then we can pass our PDS suture through this here. So we're going to use this outside-in meniscal passing device here. Come around to the other side and pull while you're loading. Yep. And so we'll, now we're, now we've got two good sutures. And this is, this is a two, a two person job. Again, to me, it's sort of a push pull. And what we want to do is Crystal is going to kind of keep the slack out. I don't know if we can show this here. Well, you sort of just do enough to keep up with, with my pushing it in. That makes sense. So you got this here. And now let me go ahead and get our large flat grasper. Ideally use kind of a rotator cuff for large flat grasper here. Oh, he's got it. Look at that. Perfect. Okay. And then now this is one of the tricks is sort of, how do we hold this? So you're using that to guide your posterior root in? Yes, exactly. Yeah, we're going to kind of push the posterior root in. And, and it seems like it's a little 60% push, 40% pull. So we'll have you kind of keep the, if it's not going, we just sort of regroup. It shouldn't, it shouldn't be forced. And let me sort of get our visualization here. So I'm going to start kind of introducing this. It seems to be going. And then. My leg's moving a little bit. So we're, yeah, in the joint. And I'm almost going to go past the cannula. I'm going to come off. Now, Crystal will go ahead and just gently pull the posterior root, a little gentle there. Yep. Now pull on your Chia gently. Okay, good. So we're, we're relatively in here. Okay. So, and now we just got to tweak this a little bit. Now, again, I'm not sure this was sized. It's looking a little short, to be honest. It was a pretty small meniscus, but let's. Re-pass our anterior roots, you sure? Yep, exactly. So we can kind of seat this posteriorly. Okay. So that's relatively seated, actually, posteriorly now. And then that's looking like a meniscus, seated posteriorly. Just go ahead and put a clamp on this for the meantime, against the bone, so it's relatively taut here. Yep. So that's taut there. We've pulled the Chia in. We can, you can kind of do the same thing here. Although I think it's fine to leave that free. Now, this graft is going to be in the ballpark of the right size, actually. And now we've intentionally waited to pass our fiber stick suture. So let's see if we can find that site. Yep, she's got it there. So now, take a crab claw. We're going to go ahead and retrieve this here. Okay. Yep. We obviously already have our anterior root suture coming out of the anterior portal. We're going to pass that through. And so you waited to pass this second to avoid the suture mess? That's right. Yeah, you can do it all at once, but I think it's so easy to find that why deal with that suture mess. It can just cause some problems at this step. So now we've got that in, and now she's going to just tension that a little bit. And that actually nicely seated there. I think this graft is a little small, so it's kind of, if we sink this too much on the anterior side, it's sort of pulling the whole meniscus in. But that's a reasonable position there. I really like the posterior one, how it's positioned there. It's got the little bone. It's got a small piece of bone entering the tunnel in the anatomic location. We can see this body region. And then anteriorly here, this is coming in. So that's, my one critique is that it's probably a little bit small. And so it's pulling in the body, but we can work with that. So let's, next step would be, let's go ahead and tie this over the bone bridge anteriorly. So we can leave everything else. She's going to come off there. I'm just going to watch this as you do it, since there's two of us here. Go ahead and just throw like three knots in that for now. So that's nice. Pretty good? Yep, perfect. And then talk a little bit about what your repair strategy would be then for your anterior horn, body and posterior horn after we've tied over the bone bridge. Yeah, I think it's kind of dealer's choice at this point. Whatever, at this point, we're kind of just, it's a lateral meniscus repair, essentially. And so this looks really good here with the root. And just with the roots alone, we're saying that's a reasonable position for this meniscus. We'll just get a little figure four on that so we can open this up. And so there's our PDS suture. One thing I've learned with this is you don't want to do a lot back here. This excursion in the lateral meniscus is pretty normal. We don't want to just pin that up to the peripheral capsule on this lateral side. So I'm actually not going to do a lot from about here back. Maybe one, if we really feel like it's got a little too much excursion. But just what I'm seeing right now, I'm probably going to leave this alone. And our meniscus repair is generally going to be from this body location anterior to that. You know, maybe anywhere from five to eight sutures approximately. And this is where I would say it's a dealer's choice. We've done inside out and we've sort of moved to outside in. And one of the reasons I like that is you feel like we can really control the position of where we put each suture. We can do a combination of vertical, horizontal mattress. And I like that it's safe too. You know, we know exactly where the fibular head is. I know exactly where the perineal nerve is. Really minimizes any neurologic injury risk by doing the outside in technique. So that's sort of what we've done. There's certainly some dependencies that we've had to make. There's certainly some debate around how you can do this, but at this point we've got the roots relatively well fixed. The other thing we could do, which is a little bit optional is to add an anchor here. So she's tied over a bone bridge. There was about a 15 millimeter bone bridge between the two tunnel locations. What we could do is just dunk this into an anchor here, which would just provide some added stability. I don't know that we need to do that for demonstration purposes, but you'd simply just put an anchor a little bit distal to the distal tunnel site. So now what I would do is go ahead and begin our outside in meniscus repair, which is simply, did they give us a spinal needle? Yeah, I think that's the spinal that that CHEO fits down. So we have a spinal needle here and we can keep everything in and so we can kind of see it coming and obviously it's not secured yet. That's a good look actually how, actually I'm gonna have you hold this a little, give us some tension here, but this clearly needs some fixation over here. Go ahead and pull that in a little. Yeah, give us some tension. And as we do that, usually once you get one or two in, you can really stabilize this. And so ideally I'd like to have this come through a little bit of this rim of the meniscus. Let me start this one a little more anterior. We can see this coming in. What additional considerations do you give in kids aside from meniscal deficiency when you're considering treatment for them and their alignment and other risk factors, their activities? Yeah, good question. It's for the CHEO. There it is. Yeah, certainly every single one of these patients is getting an alignment x-ray. Obviously in the lateral side, which most of these are lateral by the way, at least in the population. We see occasionally you'll have someone who's had a failed meniscus repair or irreparable meniscus repair on the medial side. So it's not uncommon to see this on the medial side, but way more common on the lateral side. So we're looking at alignment. Obviously patients who are in significant valgus are gonna overload the lateral compartment. So if someone still has significant growth remaining, that may be a good opportunity to do guided growth, which we can definitely do put a medial A plate on. Actually at the same time, we'll just take a braided suture, yep. We can do that at the same time as a meniscus transplant. If they're still, if the feices are closed and they're in significant valgus, that's a different conversation. But whether you do a distal femur osteotomy at the same time or stage it, those are definitely considerations. You clearly want, go ahead and hold that suture here. I'll just pull this through. Yep, good. And now we'll do one more. And you clearly want the patient to be ligamentously stable, so in my experience, more of these patients are kind of your discoid or isolated meniscus patients. They're not, they could certainly be ACL, associated with an ACL tear, and goes without saying, but the ACL would need to be fixed as well. So those are the biggest things. In dealing with this population, one of the things we've come across from time to time is patients who have open growth plates still with clear meniscal deficiency, and what do you do for them? And we tried to look at this, Kevin Che was, led this study, but looking at a CT modeling of how much of the physis you would actually violate with this technique, and using the retro drilling technique, the seven millimeter reamer, we can actually avoid the physis. You stay proximal to the physis with your tunnels. And so, so I would feel comfortable actually doing this in a skeletally immature patient. That's not the best placement. I can do a little better job there. So yeah, all considerations, but alignments definitely key. And then, what about if they have associated cartilage pathology? That gets a lot more complicated quickly. In the outcomes we know, when there is associated cartilage changes already at the time of meniscal transplant, the outcomes are not likely to be as good. So to me, this can be a preemptive strategy in a known meniscal deficient patient, with or without symptoms, with near complete meniscal loss. But that's the gray area that we're trying to figure out. And then do you limit their activities or recommended sports postoperatively, or are there patients that you would just consider guided growth or an osteotomy and wait for a meniscal transplant? Yeah, you know, a patient that has a subtotal meniscectomy, we know the natural history of that, especially in the lateral compartment. So I'm not afraid to recommend meniscus transplant for the right patient. It's certainly a conversation. I think you can give them all those options and the risk factors, but we know from a lot of the adult studies that near complete loss of lateral meniscus is near guarantee of osteoarthritis in the lateral compartment in a relatively short period of time. So that's, let's just do this one here. Oh. Yeah, that tail. Yep, so we'll give us a loop. Kurt, I appreciate it, man. That's a lot of great tips. Do you have any kind of, any final comments as we wrap this up? No, I think, you saw sort of some of the pros there. We did get one suture in, and at this point in time, it would just be a matter of going around and doing whatever repair technique you like. That's just one outside-in suture. We'd make a small incision. So this ends up being just an arthroscopic procedure. We have the portal incisions, about a 15-millimeter incision for our two root tunnels, and then a small transverse incision here to tie these over the lateral capsule. I'd say that the keys are, obviously, anatomic root identification, suture management. You saw how we did that in a stepwise fashion. And little things like a 12-millimeter cannula, the push-pull that we showed. Those are the things that can really hang you up in getting in the joint. But yeah, at this point, if we were gonna complete this, we would just go around and put in probably six or seven more sutures, tie this over the capsule, and reassess if we need any more fixation. Great, thanks so much. And again, there's a great video, a technical video that Crystal has put together. This will also be available for you guys. A lot of meniscal transplants are not common, but you guys do have them available if you want to learn how to do them in the future. We're gonna transition this morning from the meniscus. If you guys want to do a meniscus transplant, we've got the tissue to do it. We're gonna transition this morning into the ACL. So we're gonna just switch the cadavers around and we're gonna go straight into pediatric ACL techniques. So you guys may want to transition your station, start talking to your reps, start figuring out what equipment, what.

meniscal transplant surgery

pediatric patients

anatomical tunnels

ACL surgeries

sutures

cartilage pathology