It's always nice to see standing room only for a meniscus session. So my disclosures can be found in the app and on the program. So when we look at meniscus root injury, it's been a remarkable journey in the past 13 years. We first had to find out that these tears actually existed. We then had to find out how to diagnose them. We then learned its natural history. Then we had an explosion of technique innovation. And now we're left with the questions why, when, and how. And hopefully you've heard from Mario a little bit about why. For me, you're going to hear about when. And then for my mentor, Mike Stewart, next you're going to hear about how we do it. So in terms of treatment options, these were alluded to. So non-operative management, at least over the long term, doesn't do well. There's a high rate of progressive arthritis. When you look at partial meniscectomy, I still get this question, it doesn't work. Actually the rate of arthritis is higher following partial meniscectomy. Offering more of a meniscus that doesn't function isn't going to solve that problem. Well, what about repair? Certainly repairs work. I credit Professor Jin-Goo Kim in Seoul as being a pioneer of the trans-tibial pull-through technique. If you look at his long-term results in 91 patients, 92% survival at eight years. Certainly as was alluded to, there's been some progression of arthritis despite the patients doing well. We had the first known match study, patient's age, sex, and preoperative KL grade. What we found was that the repair group did substantially better than partial meniscectomy or non-operative management. So we can almost ask this question in reverse. Who shouldn't we repair or what are risk factors for repair failure? And again, Professor Kim's work here, extrusion has a higher risk for failure in his hands as well as varus more than five degrees. When we look at, this is our unpublished data, 51 degenerative medial meniscus root tears at four-year follow-up. What we found, the two factors that mattered most, actually more than cartilage status, more than alignment, was the fact that acute events and less than four millimeters of extrusion did much better. They had far more greater improvement than those patients that had chronic tears or more extrusion. So the bottom line is when to fix and when to punt. I could go over this boring treatment algorithm for you, but we published it a couple years ago in JAOS. So we'll go through the five most common patients that we see in our clinics and how should we manage them. Case number one, upon further review, perhaps this is a patient that shouldn't have been repaired. This is a 58-year-old that had an acute tear. You can see the radial tear near the root, extrusion, subchondral edema, cartilage loss. And this is the outside arthroscopic debridement pictures, already grade three bipolar changes. Again, removing more of a meniscus that doesn't work is not a winning option. So not surprisingly, she came to us and unfortunately had developed subchondral collapse, formerly known as spontaneous osteonecrosis. There's really nothing spontaneous about this. We reviewed 28 cases sent to us following arthroscopy. The vast majority of these had either root or radial tears that were debrided. So I just don't recommend that as a treatment option. Case number two, fourth and 29 yards. That's a long way to go. So here's a 55-year-old female. She's sedentary, elevated BMI. She did have an acute knee injury and a pop, but that was 10 months ago. Unfortunately, she's gotten a few cortisone injections, struggling over time. Now she comes to you, she's already got some joint space narrowing, some varus malalignment. You can see on her MR, advanced changes, and one year later, she's bone on bone. So it's okay to treat that patient non-operatively. The question is, how do they do that if they go on to arthroplasty? We've looked at a MATCH cohort, 225 patients that ultimately ended up with arthroplasty, compared them to normal arthritis patients, and what we found was that the root patients that go on to arthroplasty actually have less severe radiographic findings at baseline, but they improve just as much as arthroplasty patients for arthritis. So I think it's a discussion with your arthroplasty colleagues, but certainly if they get to that point, they can benefit, even though they may not have as radiographic severe disease. Case number three, fourth and goal, the time is running out. We better go for it. Here's a 53-year-old male, acute pop and pain, well-aligned joint, no joint space narrowing. Here you can see the root tear, just minimal extrusion. Intact cartilages is one you better fix, and you should fix it now. The data, this is Dr. Moon's group, shows that if you repair them earlier, you have better clinical outcomes, less extrusion, and less progression of arthritis. So if you're going to repair these, get to them in the first three months from injury. Case number four, know your entire playbook. You have more options than just a root repair. So here's a 44-year-old, very fit and active gentleman that has a root tear extrusion, but already advanced changes of that compartment. Here you can see joint space narrowing and quite a bit of varus malalignment. So in this 44-year-old, sure, we repair the root, but more importantly, we take care of the alignment. Here you can see his x-ray at five years. He maintains the joint space that he has and overall is doing very well. What about alignment in root repair? This is a recent study published by Professor Moon, and he showed that at least in patients with normal BMI, varus alignment of five to 10 degrees had similar outcomes to those less than five degrees. So their conclusion was don't exclude those patients with mild to moderate varus alignment, at least with a normal BMI. And then the Hail Mary. In this patient, here's a 48-year-old female, elevated BMI and some varus. What are we going to do? Very substantial root tear. You can see that a meniscus is completely extruded. There's a gap. Under diagnostic scope, you can just see how much that meniscus is off from its root origin. And rapid cartilage wear, as we expect. So in this case, we are going to perform centralization to directly centralize the meniscus. You're going to hear from Dr. Stewart how we do this. Conceptually, to me, this makes sense. I think if you steal an analogy from our shoulder colleagues, a root tear without extrusion is like a Bankart lesion. You can probably get by with fixing that in situ. When you have an ELPSA lesion, what are we taught in the shoulder? Well, we're taught to release, retention, and repair. The same thing in the extruded meniscus that has a root tear. What we need to do is release, retention, and repair the meniscus tibial ligament in this case. And when you look at, this is some early work out of Japan, showing that extrusion ratio can improve up to two years following centralization of the extruded meniscus. So in conclusion, when to fix and when to punt. You better fix it if it's an acute injury and the cartilage is intact, grade two or less changes. And you better fix it soon, before three months. Don't wait and perform a lot of injections and non-operative management. If you have a lesion in the knee with malalignment, especially in that patient that's obese, you probably can accept a little bit of malalignment in the non-obese patient. And then finally, when to punt. My absolute contraindications, if there's obviously subchondral collapse, if there's diffuse joint space narrowing, diffuse grade three changes, or if that patient just is not motivated to undergoing the extensive rehabilitation with six weeks of crutches, I would definitely punt. Thank you very much. Thanks, Erin. Can I just ask one question as Michael Stewart's getting set up? So one issue and scenario that I run into a lot is the patient whose tibiofemoral compartment is relatively well maintained, but they have severe patellofemoral asymptomatic disease. So how do you deal with those patients? Maybe how do you counsel them? Are those people you punt? Yeah, that's a great scenario. So they probably had some chronic patellofemoral arthritis that's minimally symptomatic. I ignore it, essentially. I do warn that patient that their patellofemoral symptoms can get worse as we treat them non-weight bearing and they lose a little bit of their quadriceps function. But I find that if they present with acute medial-sided pain and their symptoms are from the root, I ignore patellofemoral arthritis in that setting. And next, we do have Michael Stewart, who is Dr. Critch's senior partner, who is going to give us the technique of how they do meniscal root repairs.

meniscal root injuries

treatment options

non-operative management

repair failure

contraindications for repair