Thanks, Kevin. Good morning to everyone. I'd like to thank Dr. John Kelly, the program, the moderators, for putting emphasis on the root tear. We're seeing it more and more clinically and giving me the opportunity to debate the great Dr. Shelbourne. My disclosures can be found in the program. So in the words of Dr. Jack Houston, you may not have seen it, but it's seen you. And I think nothing more aptly applies than meniscus root tears. While once thought uncommon or unrecognized, now 10 to 21 percent of the meniscus tears to our clinic are, in fact, root tears. So why are they important? Well, we know biomechanically that a root tear is the same as removing the entire meniscus, will increase contact pressures, and will also lose that secondary stabilization effect of the meniscus. So we've all seen this patient that presents with an acute meniscus injury and at time zero, reasonable joint space, but just over the course of 12 short months, progression of arthritis to bone on bone, requiring metal and plastic. So the question is, does every root tear have arthritis? And I would submit to you, no. Here's our series of 141 root tears, and you can see on the medial side, a little bit older patient age, a little bit higher BMI, but a baseline KL radiographic arthritis score of 1.3. If you look on the lateral side, these are very young patients, 24, often with an ACL injury and essentially no arthritis in those knees. When you look at the ability to diagnose root tear, you have to carefully scrutinize and MRIs. The medial side, pretty fairly easy to see, but on the lateral side, we're still not diagnosing these prior to surgery. On 45 consecutive lateral meniscus root tears confirmed at the time of arthroscopy, our radiologists only diagnosed one-third of them, so you really have to be prepared. Here's a 17-year-old that presents with an acute ACL tear, MRI read as normal, you can see no arthritis, but in fact, this is a root tear only discovered when you do dynamic probing, so you really have to do this in every ACL and revision ACL case. The Pittsburgh group has also taught us that the root tear is important for stability of the knee. If you don't fix a lateral meniscus root tear, you'll have a one-plus increased pivot shift in your knee, so very important to recognize and treat on the lateral side. So we do that with a trans-tibial pull-through technique. You can see the 17-year-old, we get a nice anatomic repair on the lateral side. So the question is, what about the medial side? What's the natural history? We've looked at serial MRIs of untreated medial meniscus root tears, and you can see, alarmingly, two grades of outer bridge progression just over the course of four to five months from diagnosis. When we look at non-operative treatment, 52 patients, 87% failure rate if untreated, with overall a natural history for progressive RSD arthritis. So why not just perform a partial meniscectomy? I still get asked that question. Well, it doesn't work. We're not restoring any function to the meniscus. We looked at 52 of our patients, no difference compared to non-operative management, high rate of knee replacement. These are patients that I see in my clinic. These are the unhappiest patients. So here's a 58-year-old that was treated elsewhere. You can see a radial tear near the root, early subchondral edema. Here's her outside arthroscopy pictures. You can clearly see the root that was debrided. No surprise, she has worsening pain. On follow-up MRI, you can see a stress reaction that goes on to subchondral bone collapse. When you go back and look at the literature on this post-meniscectomy osteonecrosis, we now know that it's a subchondral fracture. We looked at 223 of our patients that were diagnosed with the classic sponk, which we now know, again, is the subchondral insufficiency fracture. Three-quarters of these had a root tear or a radial tear near the root. So the question is, should we be fixing any of these medial-sided tears? Well, if you look at Professor Jin-Goo Kim's work, he's shown that when compared to partial meniscectomy, there is an advantage to repair. We have the first matched series. This is 45 patients that were matched by age, sex, and their preoperative radiographs. And you can see the repair group at four years does well, no progression to arthroplasty. The non-operative group, 60% progression to arthroplasty, and partial meniscectomy, 80% progression to arthroplasty. So the repair group had significantly less total knee arthroplasty and progression of osteoarthritis. When we look at a meta-analysis with cost-effectiveness modeling, we know that the root pairs lead to less osteoarthritis and is cost-effective, and evidence supports root repair as the first treatment in good candidates. So the question is, who are those good candidates? Well, we published our treatment algorithm in JAOS this year, and we used the literature to try to help us define who should be operated on. This is Professor Onswerk from Seoul, and he found that if you repair in the setting of grade 3 chondromalacia or uncorrected varus more than 5 degrees, repairs simply don't work. So for me, my current indications in the traumatic setting, I'm always fixing the root with intact articular cartilage. On the degenerative side, indications are evolving. My contraindications are any subchondral collapse, grade 3 changes, uncorrected varus, or significant obesity. So here's a case of a 53-year-old, normal alignment, normal joint spaces. I think we can all see there's no arthritis in this knee. Acute root tear. We can see some early extrusion of the root, and in this case, we perform a trans-tibial pull-through technique. We've looked prospectively at 45 of our patients with Dr. Pat Smith, and what we found on the lateral side at 6-month MRIs, we're seeing resolution of bone edema and resolution of meniscus extrusion. On the medial side, these do heal. We see perhaps mild improvement of extrusion, but we're not overcoming ultimate extrusion on the medial side. So what about long-term results? This is, again, Professor Kim's work, 7-year follow-up, 91 patients, overall a 92% survival with excellent outcomes at 8 years. I think in the right patient, these repairs can do very well. So in conclusion, not all root tears have arthritis at presentation. The natural history, however, is for progression of osteoarthritis. Non-operative management's appropriate for knees that present with arthritis and root tears. For me, there's no role for arthroscopic debridement in my practice. If the cartilage is good, then repair is clearly the best option, and at long-term follow-up, the results can be excellent. Thank you.

meniscus root tears

contact pressures

loss of stability

prevalence of root tears

association with arthritis