Thanks, Julie and Sommer. So my job, I guess, is to call the correct play on Fort Down, following up on Aaron's analogies. So this is our current technique for meniscus root repair, and I want to acknowledge my colleague Aaron for all his contributions. These are my disclosures, which are also listed in the book. So we've already heard the dismal prognosis for a root tear. We know that they progress rather rapidly onto arthritis, which is a very ominous finding when you first see these patients, and that non-operative management doesn't work. In fact, it's associated with poor clinical outcomes and progressive arthritis in oftentimes a very short time span. In addition, partial meniscectomy provides no benefit whatsoever, with similar outcome scores and total knee arthroplasty rate when compared to non-operative management. Therefore, number one, we need to recognize these tears. We all need to train ourselves to evaluate the axial, sagittal, and coronal MRIs for these findings. It's not a clinical diagnosis. It requires MRI and arthroscopy. In the correct circumstances, which Aaron went over, we should repair it. Our prospective study of 47 patients along with colleagues at University of Missouri showed an 87% failure rate compared to 85 after repair. Six-month MRIs showed excellent healing, but actual increased meniscus extrusion. We looked at 10 additional patients where we got an MRI immediately after their root repair and found that it did not cure the extrusion, and in fact, it actually got worse. So this is our current preferred surgical technique, which is undergoing clinical validation. First, we centralize the mid-third of the meniscus, hopefully to reduce and then eliminate further extrusion. Secondly, we repair the root with a posterior horn socket and trans-tibial suture fixation. Step one, make sure you have an adequate exposure. Perform an MCL fractional lengthening, a grade 2 MCL sprain approximately with a single stick with a spinal needle through the skin, but multiple, multiple perforations to open the medial joint space. You can also perform a reverged notchplasty or medial tibial spine resection as necessary. You have to see. You have to be able to instrument. Second, you may have to release the meniscus tibial ligament to ensure proper meniscus reduction and to eliminate the extrusion. And this can be done with some type of an elevator through the ipsilateral and contralateral portal. And you'll notice after you do release the scarred meniscus tibial ligament, it actually improves the mobility of the meniscus and maybe reduces some of that strain on your repair. Third, you create a high accessory anteromedial portal and then insert a knotless suture anchor. We've been working with different techniques. We're trying to simplify this. And this accessory portal makes this knotless suture anchor placement quite simple. You'll notice the entry site is on top of the plateau underneath the meniscus, not on the side of the plateau, which could actually increase extrusion as you tighten that suture. You then retrieve the repair suture through the inferior lateral portal and you place it through the meniscus. Then you insert a passing suture with a loop in a horizontal or vertical configuration. Often it's oblique. And you shuttle the repair suture back through the meniscus. So here you can see the repair suture being placed at the meniscus synovial junction. That is then retrieved with the self-retrieving device through that inferior lateral portal. We then take a looped passing suture and insert that with the same device and retrieve that through the inferior lateral portal. The repair suture is placed in the loop. Then that is pulled through the meniscus, creating this vertical, horizontal, or oblique mattress-type suture. Next, you tension the suture within the anchor and cut off the excess. Once it's centralized in the proper anatomic location, you proceed with a transosseous root repair, which I think all of you are familiar with. Here you can see a classic, complete radial tear right next to the root attachment. You want to identify the anatomic location. We prefer to use a retrocutter device, typically a 6 millimeter by 8 or 10 millimeter socket. You can also remove some of the cartilage. We like to pass three sutures, a lead suture in the edge and two additional sutures. I find this helpful. I tension a lead suture and I fix the other two sutures to the tibia. Then you can tie that lead suture to the other two sutures so you have triple suture fixation. Quick example, six month follow-up MRI of a medial meniscus root repair before and after showing healing and improved extrusion. So in conclusion, number one, make the diagnosis. Don't miss these. Scrutinize your MRIs. Look through the notch at the time of arthroscopy. Next, you should choose repair or non-operative management. There is no value in partial meniscectomy. Perform centralization to reduce meniscus extrusion and hopefully prevent additional extrusion. Ensure an anatomic socket placement and secure suture repair with your technique of choice. Thank you. So while our next two speakers are coming up, just a question for both of you. I guess I would call this a meniscodesis because basically you're tacking the meniscus to the tibial plateau. Do you worry at all about the loss of meniscal motion, which has been shown to be so crucial for proper functioning of the meniscus when the knee goes through a range of motion? That's a fabulous question and that's why we're not currently using this technique on the lateral meniscus. For the medial side, we do think it's going to be helpful, but again, Julie, we need to clinically validate this.

meniscus root repair

root tears

surgical technique

clinical validation

Aaron