put your questions in, you can do it on the app. There are also microphones here for people like me that aren't app savvy, so if you have questions, come on up. I'm going to start with Dr. Gershoff because I think this is probably the most controversial subject that was in this series of papers. I appreciate all the authors getting their papers in on time and allowing us to review them. One thing in the paper that is not in your talk was the reoperation rate. Can you discuss that please? There was a fairly significantly high reoperation rate that was in the mid-30%. However, when you look at that, we need to weed out several factors. During the study, we did change and improve some of the surgical technique, which then lowered the amount of knees for revision. Some of those reoperations were due to patients having traumatic events where they displaced the meniscal implant, such as a fall on a flexed knee or so. There was a separate group that when we tweaked out also were very non-compliant. One of the dangers, I think, with these patients was that they felt so much better after their surgery that they, as most patients will, pushed themselves a little bit further. So I think in looking at that, I think when we critically look at that and revisions that have been made, I think we'll see a decreased operative rate. And I think the other factor that after the submission of the ZAPTRACT that we've been doing is carefully looking at the morphology of the femoral condyle and the patients that have failed and found that there are certain characteristics that are common to all the patients that actually had implant failure that was purely implant failure. And these patients would probably not be indicated for the procedure. So revisions in the design of the implant or revisions in technique or both? Revisions in technique. So another follow-up question that came in from the audience is, what kind of activity restrictions are placed on the patients after a new surface implantation? So I think that's a great question. I think we don't want people, you know, again, the implant isn't designed to last forever. And we're trying to maintain or bridge that gap in these patients. So I think in general, they can get back to normal activities of daily living. I would not encourage them to, let's say, take up a marathon running or, as in one patient of mine who I discouraged from skiing, double black diamond moguls, who insisted on doing it and he destroyed his implant. So I think modified recreational activities would probably be the best. One more follow-up question, as I'm sure most are interested. What do you see as like the horizon in terms of it being introduced into the United States for more widespread use and in terms of cost? So those are two great questions. One, the implant is presently being used in multiple countries in Europe. Right now, we're in discussions and negotiations and back and forth with the FDA about getting approval for this implant in the United States. We're hoping that in the next three to six months, we'll actually have approval for it. I probably couldn't comment really on cost because I don't think it's going to be established, but I think hopefully it's going to be in the type of frame that's probably less than like an allograft tissue but more than just a screw. All right, I have a couple other questions for the panel. So Dr. Vesey, meniscus tibial ligament repair, is that what the next step is? I think that that's certainly a question and it's something that's arised by our study. So I think our study highlights three things, namely that there's certainly secondary restraints to the meniscus root and those restraints go out prior to the root failing, at least in most cases. And perhaps in the future, we will be repairing that ligament prior to the root tearing and we can better restore native anatomy by not having the rest of the native anatomy tear. And certainly it also raises the question, which is currently evolving, of at the time of root repair, it has been shown by other authors, such as Chung et al., that residual extrusion leads to inferior midterm outcomes. And therefore the question is how do we address residual extrusion and what leads to it? And certainly a meniscus tibial ligament repair would be one of the possibilities along with meniscus centralization and other techniques that are currently evolving. One question for Dr. Ding. So I have parents in the Kaiser system and I, you know, I'm always left kind of wondering when that studies come out of the Kaiser system, why more information can't be gleaned to include in the studies. So I'm just a little bit confused in terms of when you talk about someone having had a repair and then a subsequent meniscectomy, are you able to actually say that the subsequent meniscectomy was on the repaired bucket handle tear or could it have been a separate lateral meniscal tear? I just want to know how much can we kind of rely on this information since so much information is unknown. Right, so we did do a chart review of some of our analysis and most of the people who got, at least the ones who were reviewed. Sorry, I have to push it. You're right on that. Maybe this won't work. I seem to be having technical difficulties today. Right, so you're right. A lot of stuff is a little bit nebulous. We did review a certain proportion of our patient population and the people who got the surgeries afterwards, we obviously had the correct side and the correct laterality and the correct medial or lateral. We didn't review all of them, so there's obviously a possibility that some of them could have had a subsequent meniscectomy on the lateral meniscus and a bucket handle repair on the medial meniscus. Yeah, so you obviously have to live with that data and that limitation. I just want to make a comment. Dr. Kaplan's study was very good at acknowledging the COVID effect on research in his study and the fact he could only get 10 people to come back for his MRI, so I commend the people who continue to do the research in spite of the difficulties we'd struggled with over the last year and a half. Any other questions? So, let's see, I'm just trying to go through the ones that came in right now. One person, I guess this is to the group as a whole, has your indications for root repair changed since failure rate seems to be high in terms of MRI worsening changes, ICRS, etc.? So, to consider that, you just have to consider the alternative. So, the alternative being non-op or a meniscectomy. So, the guys from Mayo have done a lot of good studies. So, Dr. Critch in 2018 had a KSSA study, no benefit of partial meniscectomy. They had another one, a significant progression of non-op. Bernard et al. from 2020 in AJSM, also the same group, did a match cohort study. They showed that repair did better than non-op or partial meniscectomy, both in pro scores and cartilage status. Roe in 2020 had an arthroscopy meta-analysis that showed the same thing. So, it's not that repairs are great, but it seems like they're doing better than the current meniscectomy or non-op. So, I don't know that you would stop doing them because it's still the best option, but it's just like we were saying before, we still have a long way to go. Great. So, let's move on to our talk by...

meniscal implantation

reoperation rate

surgical technique improvements

FDA approval

root repair