Tough act to follow is a good talk, but I just don't have any disclosures for this, although some of the images that I do use in here have some devices that people may recognize. I try to keep it across the breadth of the market so as not to create any bias. So again, some acknowledgments to my mentor helps me with a lot of this stuff. So I think it's important to be clear what we're going to talk about today. There's obviously different types of meniscus tears, degenerative, traumatic. We're going to focus more on the sort of traumatic reparable tears. We're going to try to focus on tears that are typically repaired with a longitudinal bucket handle, or even displaced ones, and stay away from even the radials. I think the zone of injury is a good point brought up by the previous lecturer, and I would argue that I think the biology dictates the repairs that we're going to do, not necessarily the suture technique we do, but I do think that the newer technologies are expanding our ability to do this. Certainly the tear patterns are important when we think about these things. We're going to stay away from root repairs as this is a hot topic and great techniques have been developed. This is not what we're going to talk about today with the focus of this inside-out technique. To set this up, we'll take a case example of a 20-year-old basketball player with an acute injury, landing on a rebound, restricted knee range of motion, stable knee, he's got this bucketed, displaced bucket handle tear. After reduction, your goal is to fix this thing. Now you have a couple options with this. You could use all-inside fixations, you could obviously fix it with a combination, or fix it with inside-out, sort of classic or standard techniques. As a guy with a mentor published on this a long time ago, there are definitely some still challenges with these devices. There have been significant improvements over time with these. They come in all forms and styles, but there are still difficulties and some glitches with the deployments of the fixations. And again, we're stabbing through the knee and deploying in a variety of zones that can put harm and risk to neurovascular structures as also putting this within muscle bellies or even tendons behind the knee. That said, there is well-described issues with this in terms of hardware irritation, cyst formations. The prevalences have been reported in the range of 30 to even 40%. A lot of these require a secondary surgery to address this. Some of them are asymptomatic but still present. The cost is a real issue, so given the example of the case that we just made, these are just numbers that were pulled from our institution at the University of Connecticut. I put ranges on the proprietary instruments, but the reality is, is let's say you do five stitches with this, the cost difference of this repair is real. Maybe not a big deal, but it's something we have to consider when we're talking about what kind of device we're using. So if we have a simple tear, maybe two or three sutures, maybe this is more straightforward or something like this, but I think this, even in this situation, leads to debate. And this one, I agree, is something within a more red-white zone. I still think that biology is the biggest deal and you can use whichever fixation you're more inclined to do. And I believe that the biomechanics, although similar, the previous studies looking at some of the older generations definitely showed that the outside-in sutures were still the best overall biomechanical constructs. Some of the newer generations, true, the biomechanics are definitely improving. And even after 100,000 cycles, the study up on top in AJSM in 2014 said that they were pretty similar in their load to failure. That said, in a recent meta-analysis, they ultimately looked at 41 studies. Their conclusion was still that the suture repair remains the gold standard. They looked into suture orientations and thought that they're vertically oriented. They did note that the second-generation repairs were approaching better biomechanics in this situation. So again, we're talking about the blind stab. So there is a risk to neurovascular structures. So we have to be aware of this. I think the trajectory is obviously important. Depth of penetration has been looked at. However, as we're putting it in, the blocker that's on these systems sometimes doesn't work and you can even go through that and skive. That said, this study looked at 14 millimeters as a quote-unquote safe zone. And there was even a study in the pediatric population looking at the angle in which you take, which I think is certainly important to use alternative across-the-knee trajectories to get to the zone you want to be into. So again, you could always avoid this by just making an incision. And I would argue that this is the best way to avoid neurovascular structures. If you get all the way down to the capsule, there should be nothing between you, your needle, the meniscus, the capsule, and then anything else is metal that you've put back in there. So for me, I think some of the concerns that I've heard is people are nervous about making an incision or approach. They haven't done this in a while. Increased time, arguably true, but there's also increased cost to that. It's labor-intensive. I need another set of hands. Actually, you really don't need another resident fellow and you can just use your scrub tech or an assistant. And I think a lot of these home run tears, they're small, they're usually on the periphery. I agree. You can run for it all inside, but wait, maybe, especially if associated with ACL, these are ones we just leave because they're stable. So a setup is all about exposure. The incision is pretty small, three centimeters. You want to angle it below the joint line so you can really take the angle of your incision. Really it just takes going through the fascia. Your cob typically finds the window. It opens up deep to the, on the medial side, deep to the medial head of the gastroc. You can put your instrument in there and actually the skin typically just holds it in there so you don't even need a scrub tech. All you do is you pass your needle and he or she will help you retrieve the needle and you can tie it. It actually really doesn't take a large amount of effort. So in the reality as mentioned, these are all zone specific. So I do think that you need to have all of them in your armatarium. The far posterior I think is actually a great idea for all inside. However, we do have to be wary of the neurovascular bundles behind there. I think for the large amount of tears, I typically still think that the outside in technique is the most tried and true and I can get a better repair with that. And obviously the way anterior, you can sort of stretch the limit with the inside out but the outside in is your mainstay in that zone. So I think it's better to just be prepared for all possible endeavors. So my final thoughts, I think the cost difference is real. I think there's a limited ability to reach the middle and anterior zones. I think there's still some inferior biomechanics but I totally agree that the second and potentially third generations are improving and I think the new sort of miniscule stitcher devices that the previous guy talked about is fantastic development. There are still some difficulties with deployment in all of these systems and the zones need to be aware of. And you can do this with a tech or a PA and maybe these simple tears that we just throw one or two in really don't need to be repaired at all. Thank you.

meniscus tears

traumatic reparable tears

zone of injury

fixations and sutures

neurovascular structures