All right. Good morning, everybody. I'm going to prove to you why you need to add centralization to your root repair to make it work in this patient and keep that osteotomy saw on the shelf. In the words of Al Bundy, Seth, let's rock. All right. So we're all paying much more attention to meniscus root tears due to its impact on load distribution and the potential to lead to the rapid development of progressive osteoarthritis. There are many studies out there that are demonstrating successful clinical outcomes and healing following root repair. But in the setting of a meniscus root on the medial side, pathologic extrusion can develop and increases with patient age, elevated BMI, and varus malalignment with five or six degrees being the threshold where you start to think about it. And even with a well-performed anatomic root repair, meniscus extrusion can persist and contribute to progression of the arthritis. So the addition of an arthroscopic meniscus centralization can help reduce extrusion and protect the root repair. So here's a short video. There you see the root tear. So we start off using a bank card elevator. We're releasing the meniscus tibial ligaments to allow us to mobilize the meniscus tissue through the anterior portal. We're going to insert a knotless tensionable all suture anchor from the opposite portal. We'll use a self grasping suture passer to pass a mattress suture with the repair stitch then shuttled through the knotless anchor and tensioned. I'll typically do one to three centralization stitches depending on the extent of extrusion that's present. So here you see the tensioning of that centralization stitch. We'll then turn our attention to the root repair, which in this case was done with a trans-tibial approach. Here you see our three luggage tag sutures that are then passed into the tibial tunnel at the site of the posterior root. We'll then go back and re-tension that centralization stitch, cut it, go distally, fix our root repair with an anchor, and we're on our way. There's literature to support this approach. There are biomechanical studies out there that show that augmenting a root repair with centralization will significantly reduce extrusion and reduce contact pressures in the medial compartment. There's also clinical support. Aaron Critch and his colleagues at Mayo, who've done a lot of work in this realm, published a study looking at 25 patients with a mean age of 50 years, and at two years of follow-up there were significant improvements in pain, function, and quality of life, in addition to satisfaction with the outcome of the procedure. In this study, there was no evidence of significant progression of the arthritis, no revisions, and no patients that went on to total knee. In a similar study out of Japan, there were 26 patients, as you see, two years of follow-up. There were significant improvements over baseline with respect to Lyshom and Kuh scores, and there was significant reduction in the amount of extrusion that was present. So meniscus extrusion in the setting of a posterior root tear can negatively impact knee kinematics and load distribution, and meniscus centralization techniques have been developed with clinical and biomechanical support for their use. So should you do osteotomy alone? Despite unloading, without a healed intact root, this young female is going to remain meniscus insufficient. A root repair with centralization is a much easier procedure with a more straightforward recovery. You can always do that HTO down the line if the root repair fails or if the OA progresses. So for this 46-year-old female and a little bit of varus with a relatively acute injury, let's just restore her anatomy, add centralization to the root repair to make it work, and keep the osteotomy saw on the shelf. Have at it, Sherman. Thank you.

centralization

meniscus root repair

pathologic extrusion

surgical technique

anatomy restoration