Thank you for the opportunity to present today. This is Dr. Challa from Midwest Orthopaedics at Rush in Chicago, Illinois. I was tasked to talk about meniscal radial repairs and radial tears and how do I repair them. And this is a very exciting slide for me because we know that the trends are increasing towards the repair more than the meniscectomy. But still, meniscectomies are the most common procedure performed in America, and why? Because of multiple reasons. It's easy to perform, it has a fast rehabilitation, it has very low morbidity, at least initially in the first few years. Furthermore, if you look at the return to sport, meniscectomy patients can go back to sports as early as four weeks, whereas when you repair a meniscus, the mean return to sport date is about eight months. The revision rate is significantly lower also for meniscectomy with 7%, whereas repairs have 18% of revision rate at least at five-year outcomes. With that being said, there's a special subset of tears, like root tears or radial tears, where there's a loose of hoop stresses. And this will create a significant amount of pressure on the tibiofemoral compartment because of the load that the femur will generate on the tibia. And this is more common than we previously thought. Up to 20% of all meniscus tears will be radial or root tears at the attachment or at the body of the meniscus. We have called this a silent epidemic because we have seen this for many years, but we have failed to identify these tears. And we say this because we've published this article on AJSM looking at those people that we thought previously that had an AVN, and 81% of those had a related SONC, related to an insufficiency based on a meniscus root or radial tear. Furthermore, some of our colleagues from Korea have published that a radial or root tear were the main cause of a total knee replacement that was unidentified before in all the patients that they had a knee replacement before the age of 60. And this correlated with a degree of osteoarthritis. And why is this important? Because having a root or radial tear is the same thing as having a meniscectomy. And you can see in a patient where we treated this conservatively, at 3, 6, and 9 months, all the joint line basically disappeared, ended up with a partial knee replacement. And we clearly don't know exactly who are those people that will end up with a replacement, but we know from the work of Critch and others at Mayo Clinic that 3 out of 10 patients will end up with a total knee replacement within 10 years. And we know that when you repair this, a root or radial tear, this is a cost-effective treatment because they won't end up with a total knee replacement down the line and therefore it's a cost-effective procedure. What are the outcomes? Usually, we have pretty good functional outcomes with less joint space narrowing when they heal and less conversion to total knee replacement. But specifically talking about radial tears, this behaves very similarly to a root tear. They're similar to a total meniscectomy as we previously mentioned. It's more common in active patients and more frequently with ACL tears and multiligament injury cases. In the MRI, you can see the truncated triangle sign. You can see a cleft sign, a marching cleft sign, and or a ghost meniscus sign when that cut of the sagittal plane does not involve that portion of the meniscus. Historically, this has been treated with partial or subtotal meniscectomies that provide a short-term relief, accelerated the cartilage wear, and high reoperation rate between five to ten years after because of how much arthritis these patients had. There have been new described techniques of tight-grip suture that consists of our initial vertical sutures on both limbs of the tear and then horizontal sutures outside of vertical tears to avoid the cheese-cutting effect that the sutures can have in a more degenerative meniscus. In this article published in 2012, 27 patients with second-look arthroscopy, 19 of those have completely healed. But therefore we decided to create a novel repair technique because the current techniques did not reduce the edges and why not treat them like two root tears with criss-cross sutures in each end, at least for the medial side, so to allow for centralization of the meniscus, avoid an extrusion of the meniscus. So when performing biomechanical studies, we found out that there was two times less gapping and stronger failure loads for the ones that had a trans-tibial tunnel fixed into the anteromedial tibia. And to illustrate this, we're going to go over a case. This is a 30-year-old male that had a bowling injury, buckling an instability of his knee with significant swelling and no prior treatment. Physical examination, he had a palpable effusion. Range of motion was pretty much normal, 0 to 125, positive MacMurray, joint-line tenderness over the medial side, and medial pain with terminal flexion. We got AP, PA, and long-limb x-rays that showed a neutral alignment. You can see there's mild narrowing of the medial joint space, but pretty much normal x-rays. The skier's view looked pretty good, as well as the sunrise view. On MRI, we can appreciate some increased signal over the medial side of the medial meniscus that can be correlated with a complex tear with some horizontal cleavage component, as well as a cleft sign where the radial tear was. This was the arthroscopy, where you can see that there's a full-thickness radial tear at the body of the meniscus that basically went all the way down to the margin of the capsule. And this is how I repair these tears. On the medial side, I'm not scared or I'm not worried about creating a trans-tibial tunnel because that will centralize the meniscus. And as the medial meniscus is pretty much fixed through the medial tibial ligament to the tibia, there's not much excursion. It's about 2 to 3 millimeters, and therefore, fixing the meniscus back to the tibia will not give an abnormal motion of the medial meniscus. So I pass with this suture shuttling device a mini-tape from bottom to top on one side of the meniscus, and then I bring the same tape from top to bottom with a reverse basically technique here on the anterior portion of the radial tear. And then I'm going to shuttle this suture through a cannula through the anterolateral portal, and then through the trans-tibial tunnel that was created previously with the use of a root set that is basically the same one that we use for root repairs. We shuttle a needle and wire, and then we bring the sutures back down through the tibial tunnel. This will accomplish mainly two objectives. One is to centralize the meniscus to keep it together for our successive or consecutive repair, as well as provide all the marrow elements from the tibia that will go into the repair site and provide some biological augmentation healing for this repair to heal. We then proceeded with augmenting this repair with three only-side sutures. I start in the middle of the meniscus to try to bring that together. You can see that by using this cutting device as a knot pusher, you can actually reduce this tear pretty nicely, and once you've obtained pretty good tension on the repair, you can go ahead and cut it. Then we place our second suture in the most marginal aspect of the meniscus, on the white white zone, first on the posterior edge, as far as you can, posteriorly, so that even if the suture cuts through the meniscus a little bit, it will still be on that leaflet, and then go anteriorly on the most anterior portion of the meniscus. Again, we go ahead and get this meniscus back together with the use of a knot pusher or the cutting device, and you will see that all the white white zone will come together pretty nicely here. One thing to note in this meniscus repair is that the meniscus is pretty much centralized because we have placed that trans-tibial suture initially. Finally, we go to the red red zone, and we're going to put our last suture. It's critical here if you don't have good visualization to perform an MCL pie crusting, just because you will have a much better visualization, avoiding any atrogenic damage to the cartilage. This last suture will bring the meniscus together on the meniscus capsular zone, and once that's done, we can go ahead and cut that last suture, and then probing of the meniscus will demonstrate that it's a very solid repair. Sometimes crisscrossing of a meniscus can occur, but that will synovialize completely in second look arthroscopies, as we've seen before. As with any root or radial tears, I keep them non-weight-bearing for six weeks. They start PT on the next day with a range of motion that is not limited between zero to 90, emphasizing full extension. They get Norcos for three to four days, and then they will have an adductor block most of the time, so pain is well controlled over the first two days, and then they will go to an oral plan. The brace is locked in extension until they recover good quadriceps control, and they can return to sport at six months if they have hit all the milestones in the recovery. We have published on this 27 patients, 3.5 years follow-up. Litional improvement was from 47 to 91. No difference in comparison. Also for vertical longitudinal tears, which was the gold standard of repair, so this radial repairs that used to be treated with a meniscectomy can just do as well when they're traumatic and when they're repaired with transdibial sutures. Nowadays, I do a double horizontal mattress suture with a tight grip configuration for lateral tears, and I do a transdibial tunnel for the medial side. For the rehabilitation, as we said before, we like to have this periodization concept where we work on range of motion first with patellar mobilization to avoid stiffness and range of motion from zero to 90 and no-weight-bearing for six weeks, endurance and strengthening for six weeks with partial weight-bearing, stationary bike, no pivoting activities and leg presses to 70 degrees, and power can be started at four months when running progression agility exercises and a sports test at six months. In conclusion, for radial or root tears, you should always suspect them, even if you don't see them very clearly in the MRI with extrusion. MRI is not definitive, many on the lateral side. Fix them when the cartilage is acceptable, and you can expect to have really good outcomes and prevent joint space narrowing if they heal. Thank you.

meniscal radial repairs

radial tears

meniscectomies

root tears

trans-tibial tunnel fixation