So we're going to change this up a little bit, because we decided that with everything going that way, we'd do more of some cases. Rob and I are going to sort of argue both sides, and we'll get a raise of hands on how people would treat these different athletes that we're all dealing with in our clinic. So we just sort of changed it up a little bit from that. So first case is a 35-year-old Olympic-level marathon runner. She's getting progressively worsening deep medial side knee pain. She reports no injury associated with this. She gets mild swelling with her long runs. She is slightly off her times if she's close to it. Olympic trials are six weeks away, and she has a chance. So we get imaging on her, and as Aaron was showing us before, and Mike was showing us, we have sort of the ghost meniscus sign there. If we look at the chronos, which is the best place to see it, you can see the root tear here that's well-demonstrated. And so just try to get a show of hands just sort of seeing this. Aaron just told us we should fix these because they're going to get worse, but this is an Olympic-level athlete. So who's going to tell her her Olympic dreams are over and fix it right now? Okay, we have a few back in the back. Their arms went down real quick afterwards. Who's going to let her try to run on it and see what she can do? The majority there. Rob, your thoughts? Well, again, I think these are interesting cases. Obviously, the concern is for her knee, and as our esteemed colleague from Mayo have shown, the degree of which she can get rapid degeneration. But obviously, if you do that, her shot is gone. So long discussion with her. Trying to run. She can't do it. So this is what we're seeing inside. So anything on these findings that you're looking at? So we see a little bit of early cartilage wear. Tibia looks pretty good. Here's our root tear in this area. Rob, what are your thoughts? Again, from the knee standpoint, I don't think it's a no-brainer. The social athlete issues are where it gets into a challenge. But from a knee standpoint, fixing it now gives her the best longevity and health. Yeah, I think for the long term at this point, if she's already gotten to that point where she can't compete and the Olympics are over, that's one of the big questions. Do you take that away or not? Aaron, Mike, thoughts that you guys have dealing with your Olympic athletes? Well, I would say one of my contraindications was having a willing patient to undergo the rehabilitation. So she's got to decide as an athlete, if I can't run, then absolutely fix it. You should be validated seeing that cartilage wear that you're glad you're there now and not six months from now. Yeah, I think you go through the shared decision-making process. I would predict this athlete probably would try to compete if possible. Now, obviously, if she can't compete, you do want to fix this. Yeah, so on her, when she wasn't able to compete, started going into the root repair. Similar to how Mike and Aaron started doing it, although we didn't put any of the centralization sutures on that. When would you let her return, Rob? Well, I think I err on the side of going slow with these. So I mean, I don't think she's thinking about running until at least close to six, eight months, and that's just starting to do some low-impact short distances. I mean, I think for her, if she was younger and still had a shot at getting back to competition, I think it'd be closer to a year before she'd actually be reaching the mileage she'd want to do if things went well. All right, so we'll go on to the next case. So we're going to keep it in the athlete population again. So this is a 20-year-old, Division I, power five defensive back. Injures knee during the fifth game of the season. So we have seven games to go, bowl game. We're not at Alabama. We're not going to go to the national championship. Medial side knee pain. X-rays are normal. Got an MRI on it. This is what we're seeing. So those that can see here, we have a vertical meniscus tear. Probably red-white zone versus white-white zone, depending on how you're going to talk about it. Not a huge tear. He's symptomatic. He couldn't treat non-operatively. What are you going to do with him, Rob? Well, again, I think from the side of repairing it, you're looking for his long-term knee health. You're looking that if he's got a chance to heal this, it probably gives him both long-term knee health as an individual and potentially greater durability as an athlete if he heals. But again, you're looking at the downtime in terms of that longer recovery. So who's going to fix it? This kid has an NFL shot. How about the kid needs a senior year to get an NFL shot? Still going to fix it? Not going to fix it? So what do you think the chances are it's going to heal? Mike, you have? Well, I think there's some options. I need to palpate it myself. But this might be a case where you could do some trepanation, some vascular access channels. If you're going to fix it, I would caution you against putting multiple all-inside suture devices which have a large bore open needle that will do more harm than good. So a couple sutures looks fine. I think these are fun to put in and they're easy to put in. But please, don't destroy the meniscus as you're trying to repair it. Yeah, I think being careful on that. But then this is, we talked about before, shared decision-making with the athlete. So the athlete, you're treating him, say he's a Ram player when the Rams were in St. Louis. You're treating him, contract year, he says, Doc, I don't want it fixed. What are you going to talk to him about? Well, I mean, I don't think it's any different in that scenario. So again, it's looking at short-term versus long-term gain in cost and weighing where they're at. And at the pro level, that's going to depend on where they are. If it's a younger kid with a long potential career versus an older vet who's just hanging on, you're going to take that into account, as well as if they've got a shot that year at success at a postseason run versus a team, what we got used to, not doing very well at all, just trying to limp along until the season's over. Yeah, we'll make, you know, if you're dealing with some of these high-end athletes, if you get the repair and you take them out for the year and they get the repair and the repair works, they'll be happy. If you take them out and the repair, you're going back in taking that meniscus out in four months and you cost them a contract year, that's going to be a big deal and they're not going to be real happy and that could be a negative. But I think this is that shared decision-making. Some tears like this, I think one thing that sort of emphasizing and Rob and I were talking about it, is when you look at these tears, really paying focus on your MRI, how far peripheral is that tear, I think we're very bad judges at looking at arthroscopically where the blood supply is and we look at it and say, oh I can fix that, but we've all seen meniscus tears, we've gone in and fixed, you come back later, they didn't fix and you found out a little bit more of a horizontal component to it. It was in the white, white zone and those are, you know, in the right patient, if they're in season, those are a patient that's not going to be happy if you fix it. And if you can get it to heal, it's great, but we have to be realistic on which meniscus tears will heal and which ones won't. So we'll go into a little bit more controversy on this one. So this is an 18-year-old senior football player, he's also a wrestler, tears his ACL non-contact, late October in football, we're in Wisconsin so football season's almost over. No meniscal pathology on his MRI, he's a top-ranked wrestler in the state, he's actually being looked at by our program. Patients and parents insist on delaying his ACL reconstruction until after wrestling season. He states that he is a good enough wrestler that he won't have to really use his knees until he gets towards the state level, wants to play college football. So what discussions are you going to have with him, Rob? Well, this is more an ACL discussion than otherwise. So obviously for his knee, you're highly concerned about a problem, you know, and you're concerned not only about the ACL but about a subsequent meniscus injury if he has another subluxation event. Yeah, so we'll go on with that. So they're insistent, so we let him go, brace him, try to get him through. He's undefeated, we're in mid-December, re-injures his knee, what we're all concerned about. Can't extend his knee, MRI, does show a bucket handle meniscus tear. Thoughts? What is, who's vote for repair it, do his ACL at this point? Okay, almost everybody, that's perfect. Who's going to trim it out? We're going to say it's a repairable meniscus tear. Good, that's what we want. Of course at this point, Kit is now still ranked like two in the state. He wants to keep wrestling, we make a deal with him, here's his MRI, you can see the bucket handle meniscus tear there, flipped over, we get the double PCL sign. This is his meniscus when we go in there and look at it, we see the bucket of meniscus, definitely acute injury, bleeding around it, reduces fairly well, cartilage still looks good. Repair the meniscus, inside out repair with a little bit of hybrid in the back, but the kid doesn't want his ACL reconstructed. So who would fix it at that point and who would leave it alone? Fix the meniscus, leave the ACL alone because the family doesn't want it? Rob? So, I mean, this is where in for a dime, in for a dollar in my book. I mean, if you're going in, you've got to really try to convince them, but the patient also has their choices. Mike, anything you, Mike or Aaron? I mean, the chances of this, so first of all, the native meniscus tore at the unstable knee, so the chances of this, first of all, healing and then sustaining its healing with an unstable knee to me just makes no sense whatsoever. So I agree with Rob that if you're going to go in, you have to do both. There's synergistic hand in hand. Meniscus is a secondary stabilizer for the ACL. The ACL stabilizes the knee for the meniscus, so. Yeah, so we had that discussion. They were still insistent, but they did let me fix the meniscus. Did well, gave me six weeks, allowed the meniscus to heal, went back to wrestling, conference championship. He wins conference, wins regionals, re-injures his knee at state. My athletic trainers at UW are covering state, so yeah, the kid's trying to get his knee unlocked during it, but re-tears on the MRI, bucket handle meniscus. We're at COVID right now too, so this is a bonus with all this going on. Thoughts on how would you treat this now? Wrestling season's over. Are you going to try to repair the meniscus again, or are you taking it out, Rob? Well, I don't think, I mean, this is a very interesting case. I would not go into this knee again until they agree to. This time they will let you do the ACL. Right, right. So that would be an absolute minimum. And then I, it's a relatively short time period. This probably failed because of the lack of an ACL. So as long as he hadn't demolished or done extensive damage to what was left of the bucket handle tear, I might be willing to try to fix it one more time. But I would probably be much less optimistic about it healing and succeeding. Yeah. So they, we unfortunately had to do this at a secondary hospital because of COVID when ours was shut down. But we did go in and reconstruct his ACL and do the meniscus. And right now he's playing college football and wrestling as a sophomore in college with that recovering. So you can fix them again, but again, all that takes place and you have to take a look at it. I think doing an inside out repair, as Mike was saying, those smaller needles when you pass an inside out repair work really well versus if you're doing with the backstops and everything else. Those things tend to rip through the meniscus too and they'll destroy it. So you have to be careful with those when you're doing that. They are fast. They are easy. But you have to be careful when you do those. So thank you very much. I think we're good. I think that, I thank you all for attending the session and enjoy Nashville. Have a great day.

discussion

athletes

knee injuries

meniscus tear

repair techniques