Thanks, Aaron. So we're going to run through some difficult cases now. So we've got a great panel up here. Going down the line next to Aaron, we have Mary Mulcahy from Tulane. We have Austin Stone from Kentucky, Derek Jones from Oshiner in New Orleans, Seth Sherman from Stanford, David Flanagan from Ohio State, and then my co-moderator here is Brian Waterman from Wake Forest. So let's jump right into it. My disclosures are available online. So here's our first patient. 39-year-old female did a deep squat, felt a pop in her knee, had increasing pain and swelling over the next few days that then persisted for a long, prolonged period of time, mostly lateral joint line pain, infusion on exam, positive meniscal test. X-ray is pretty nonspecific. Here's our MRI. So look at the lateral side particularly. We just heard from Aaron. So Mary, what do you think in there? What do you see in there? Tell us what your first initial gestalt and thought process is based off this pretty basic history in MRI. So this history is pretty characteristic of a root tear in this patient population. And we see that on the MRI too. Her X-rays aren't terrible in terms of arthritis. I mean, mild arthritis. But yeah, I mean, that's what I'm thinking here. And talking to her, and I'm sure we're going to go through this, like all the different options. But it sounds like, and certainly we want to get more history too, did she have any preceding pain? But if not, then we can definitely attribute it to this recent incident. Yeah, so I think she maybe had a little bit of preceding pain. And then maybe some of this incident in Europe. That's a great point because I think she did have some probably some preceding pain and some symptoms. So when we go to the diagnostic scope, this does extend over a little bit. But this is probably primarily more of like a horizontal cleavage tear, at least in this particular case. So it's near the popliteal hiatus, and then it extends over. So Austin, kind of tell me what your thought process here. You kind of already see what's happening. But tell me what your thought process is with these horizontal cleavage tears. We already saw some data today that these are somewhat difficult to deal with, and especially at the popliteal hiatus and the lateral meniscus. So what are you thinking when you see this type of tear? Yeah, so I think that the horizontal tear has a degenerative component. So I'm a little bit worried about the biology. So I try and get in that cleavage. I'll use a meniscal rasp. I was glad to see that earlier. My fellows don't know what that is. And I start to try and stimulate some healing. And then I'll do more of a hay bale compression. You do risk, on the lateral side, over-constraining it. But I think that's certainly better than meniscectomizing it. So Derek, talk to us a little bit about meniscal-based versus capsular-based repair, maybe some of the quick differences, and then where your approach for that is in a horizontal cleavage-type tear. Yeah, that's a great question. I don't hesitate to still use an inside-out technique in something like this if I have trouble getting, particularly in more anteriorly-based type extensions. But all-inside techniques can be effective. I think this certainly is one where you'd want to augment this with some type of an injection therapy to try to augment this healing potential. But an inside-out technique is certainly something to consider in this configuration as well. I like what you're doing there. You're pulling it together. But I do worry about the degenerative nature of this and preexistent history. One of the things you want to do is protect that. And I don't hesitate to use an unloaded brace in these situations as well to help that healing process. I think that's a great point about that being degenerative. We'll get back to that in a second. Seth, you showed a great video and picture earlier in your biologic augmentation talk, putting a fibrin clot in a horizontal cleavage tear. Would you add a fibrin clot or some sort of biologic augmentation to this type of tear? I think of all the tear patterns, this is the one that would be most amenable to putting something inside that pita bread sandwich and then doing that circumferential compression. So I would consider adding fibrin clot or PRP or the like. But I think it's still low-hanging fruit to do the marrow venting as well. I don't think you burn any bridges by doing both in these scenarios. David, what do you think about this? We put a bunch of knots in there. Is that a problem? Do you like all those knots? Is it too many knots? Do you do this type of repair? Tell us about the knots. Do you put them above? Do you put them below? Are you worried about that? Are you worried about the knots being above the meniscus? I'm the only person I'm not really worried about the knots. I think they synovialize and don't really give it trouble. You really want to make sure you have enough suture that you really can't put a probe in between. These can cause cysts. If you don't do that, a lot of times a cyst can be recreated. Question, though, how long did this patient have symptoms? Two months. Because one of the other things, for horizontal cleavage tear, these are definitely degenerative process. You can always offer them something like a PRP shot. There's obviously been a randomized controlled trial overseas. It can decrease their chance of going towards surgery. So I think there's always other conservative options that you can also give them prior to surgery as well. And I know what Seth's going to say. Her alignment was actually good. So we high five, a lot of high fives. We thought we got a pretty good repair right. The fellow is telling me you should tweet out hashtag save the meniscus when we leave the OR. But about 10 months later, she starts having pain again. This is her MRI one year later, looking at the lateral side again. What do you think now, Aaron? Can you see it very well? I mean, she has a little bit of recurrent internal signal there. It's not terribly extruded. But yeah, likely worry about recurrence. So here's her second diagnostic scope. This is the same patient, actually, believe it or not. So now what do you think, Mary? Did we do a good job the first time? What didn't we do right? What would you change now? Would you just cut out that superior leaflet? Historically, with these horizontal cleavage tears, we were always kind of taught you just cut out whichever leaflet is smaller and hope for the best. But this is a lateral meniscus in a female close to the popliteal hiatus. What are you going to do differently now? Yeah, it's a very challenging situation. Certainly, we know the lateral compartment is critical. We want to do everything we can to save the meniscus, especially laterally. I mean, the one thing that wasn't done, potentially, augmenting this time with a fibrin clot, or PRP, or a microfracture in the notch. I think you look like you had a great repair previously. And still currently, her cartilage actually looks really good. So I still do everything I can to save that meniscus. And we know it's written about extensively in the literature. Yes, we can take out one of the leaflets, but it doesn't restore functions. It doesn't make that meniscus function normally. That's a great point. Austin, are you going to do anything different? Derek mentioned maybe a short fuse for going inside out instead of just an all-inside or meniscal-based repair here. Are you going to change your approach and go inside out? Are you going to try and involve the capsule more? Are you going to do something different the second go around? Especially in a revision setting, I'm definitely going inside out, using a lot of small. I preference a suture tape. They have 1-millimeter tape. And I think that is a little bit more tissue-friendly there. So inside out with suture tape. All right, that's awesome. So we're going to go on to the next patient. 16-year-old female player, twisted her right knee in a game, felt a pop, had swelling. Later that day, she tried to keep playing basketball but couldn't, had persistent pain and swelling. Lateral joint line pain, McMurray's again. X-ray is really non-contributory for the most part. Her alignment is actually good, too. Here's her MRI. Derek, what are you thinking here, looking at that lateral joint line again? Besides not being real excited about seeing that? Yeah, that was a quick view, but. Sorry. How about this? I'll give you the scope view. And then after you pick your heart up off the floor in this 16-year-old female athlete, now tell us what you're thinking. Yeah, obviously, a radial tear. We've got to, the hashtag configuration would be with consideration to try to pull it together. But this is one, the rehabilitation for me is really slow. Unloaded bracing, for sure. And I would definitely do a hashtag. Seth, so Aaron just talked to us about the tie grip technique. What's your approach to these big radial tears, almost a complete transection of the meniscus? It's hard sometimes, especially in lateral ones. What's your approach? How do you approach this from a technical standpoint? It's very challenging. I think you don't want this in the early or mid part of your flip room day. I mean, this is going to take you some time. This is this kid's knee's life. So you really want to appropriately have time, have your A-team. I tend to use a mayo stand on the opposite side. I make that higher than the knee so I can apply varus because you need to get really good exposure. I don't really have any experience with pie crusting laterally. But if it's tight, that might be something to consider. I like inside out for this, but you could use meniscus-based sutures as your rip stops. And I think you really go slow, slow, slow with the rehab. I may not move them week one. Then I definitely keep the weight bearing off six weeks. I'll do marrow venting only, not really other augment. David, you talk a lot about the hashtag kind of repair for these radial tears in similar technique to a tie grip or a cross grip. Kind of tell us about your thought process in terms of in your experience. You published a lot on that in terms of the hashtag technique and crisscrossing the meniscus. Yeah, so these are honestly dreaded tears. They're really something you really need to dress and dress well. I think for this, especially as they gap more and more, the most important thing, Aaron kind of alluded to this earlier, is really to get an anatomic reduction. And sometimes, and what we've found is actually having a traction stitch can be very useful for that. And so you can actually put one of your first vertical mattress, usually through a suture passer, in that posterior limb. And with that, you can now reduce that anteriorly. So now when you're putting your sutures in, you're actually going to the capsule in a reduced format, which is really important. So that way, when you're moving the knee later, you're not putting stress on the actual repair. But the hashtag configuration is really the game changer for these. And so you really need to get used to doing those vertical and horizontal mattress sutures. So Aaron, talk to us maybe a little bit about the tie grip. But then also, I think Dr. LaPrade's published some different things for these different types of radial tears, even doing a trans-tibial technique or a single versus two tunnel trans-tibial technique. You showed doing the tie grip technique, which is more meniscal based and not trans-tibial necessarily. What do you think about those different two types of techniques? And do you employ one versus the other in certain settings? Yeah, so we've definitely gotten away from the trans-tibial technique. Biomechanically, tie grip and hashtag have been shown to be equally as strong, if not better. So I don't think you necessarily have to worry about it unless you can't physically co-opt the two ends of the meniscus. And to Dave's point, when this posterior leaflet springs, it can scar down very quickly. So these are tears you can't wait on. You've got to get them the OR the week that you see them in clinic. Because if you get to them at five, six weeks, it's just incredibly difficult to try to completely anatomically reduce this. But if you get to them quick, use the techniques that everybody talked about. They heal at a very high rate and patients can do well. Seth alluded to it. Mary, what's your post-op protocol on these radial tears? Let's say you feel like you got pretty good fixation. We feel we're taking the knee through a range of motion there, the meniscus we think looks pretty good. We feel like we have a pretty solid repair. What's your post-op, immediate post-op and then rehab protocol for these? Yeah, so I would put the patient into a hinged brace, knee range of motion zero to 90 for six weeks, non-weight bearing for the six weeks. I don't use an unloader brace, but I do think using a standard knee brace is important. And then starting them, I mean, they can start working on range of motion immediately with physical therapy or whatnot, but they're not really starting to move forward with PT until they're starting a full range of motion at six weeks and they can advance their weight bearing. Great, quick show of hands from the panel, who is doing an intercontinental or notch microfracture in all or almost all of their isolated meniscal repairs? Who is doing some sort of adjunct biologics, whether it be a patch or a blood patch or PRP or something in most of their isolated meniscal pairs? How about a show of hands, intercontinental or notch microfracture for most people, biologics for isolated meniscal repairs, some sort of PRP injections for quite a few less people, but okay. So this is her at a little over four months out. She's back to playing basketball and is pretty happy. Got to work on her, maybe jump skills there, but she's doing pretty good there. So the last patient we'll try and blow us through this, 17 year old male elite soccer player, twisted his knee and fell in a game, felt a sharp pain, pretty similar history, pretty similar physical exam to what we've seen previously. In interest of time, we'll keep going. I'll kind of blow through his MRI. It's going to be pretty tough to see on his MRI because you'll see it's a relatively small tear, at least as the way it shows up on the MRI. But then when you go to this diagnostic arthroscopy, what do you see here, Austin? What are you thinking about this? And again, lateral compartment in a elite soccer player. That's ugly. Yeah, so large complex flap there. You know, you're in that white, white zone. Here, I would definitely have a, well, I would go inside out because I'm going to try and put as much suture in that as possible and hope for the best. I think you may need to trim that flap just enough where you don't have something that is prone to a mechanical catching during the repair. And then I'd reinforce it too with another all meniscal suture, more medial as well to help offload that. So here's the all meniscal suture that you're talking about, a little bit more medial to that flap tear. And then, so once we put that in, then you can still see it's a pretty big flap tear there. So Derek, are you taking the same approach? Are you going straight to inside out for this? Do you think that maybe there's an all inside, there's a role for all inside here for a portion of this? What do you think? I'm old enough to know that I'm going inside out every day of the week. Seth, you showed a good video similar to this actually. I'm pretty sure this is my patient, not yours, but we could have crossed over, who knows. But you actually showed going inside out repairing this type of tear. And you've had a great success with a lot of different all inside, excuse me, you showed all inside devices. Would you do this all inside for this type of flap tear? I think you're never faulted for doing inside out, but I think I can tackle this one with a all inside using hybrid devices, one meniscus based, and then one that's not meniscus based using circumferential compression on the horizontal component. And then that can act as a ripstop suture to bring that flap component back to the base. And I think that can work well. Yeah, so that's a great point. I think it's a good example. I elected to do as a couple of the other members of the panel said, and just go straight to an inside out given just the proclivity of the tear. And so there you see the small, you can do this through a relatively small laterally based incision, and then taking a little bit more of a horizontal component after the meniscal based component. What do you think, David? What would be your approach? All inside, inside out? Would you hashtag this in some way? What's your thought process? Yeah, I would use still a hashtag in this, and I would use a hybrid technique using both some all inside and the posterior portion and the horizontal cleavage component and using inside out more for that anterior component. Aaron, change your rehab at all in this, change your rehab protocol. What would be your rehab protocol after this? Yeah, I think this scenario is tough because maybe you weren't expecting as much of this tear in the office, but I think a good in-clinic discussion really wins or loses the game here. So you have to sit down and give them the heads up that this meniscus recovery will be six weeks of really non-weight bearing. One tip I've used as we confiscate the shoes of that side, so they can clear their foot. In Minnesota, it's pretty much cold year round, so they don't want to put their bare foot down on the cold ground, so. Very good. So here's him a little over four months out of repair, and he's back playing soccer and hoping to get some offers from some of these D1 schools. He does have some pretty good offers actually already. So, okay, thank you.

panel of experts

difficult cases

meniscal tear repairs

repair techniques

diagnosis and treatment options