Good afternoon. Thank you to Anna and to Dr. Bonner for the opportunity to give this talk here at the OLC. I was asked to give you all some of my tricks and tips on a meniscus repair. So I will be quite honest, I don't have much literature to back up what these tricks and tips are. These are more some of my own personal tricks. Although one of the techniques I have specifically is well documented in the literature now and I think most of the seasoned vets in the crowd will back me up on tip three. In fact, I learned tip three here at the OLC and it's arguably been one of the major game changers for me in meniscus repair and near arthroscopy in general. But before we get started, when you're doing a meniscus repair, bear with me, you need to know what type of tear you have. Because some tears, even though some people will repair every tear, personally, I try to be a little bit more pragmatic. I like to know if my tear is in a zone like the red red zone or red white zone that I think will have some blood flow versus the white white zone. I typically do not repair tears in the white white zone unless I'm a true pediatric patient. But I also like I prefer a vertical tear or a bucket handle type tear versus let's say a radial tear unless it's a young patient again, you can do the trans-tibial technique. But I think you need to know what type of tear orientation you have. I know many more of orthopedic surgeons are repairing horizontal cleavage tears. I think most of us would agree that a vertical tear in the red red zone is likely going to be your tear that's going to give you the highest success rate of healing. That doesn't mean that other tear patterns will not heal. But knowing what tear pattern you have, if possible, will one help you have a better conversation with the patient and hopefully help set expectations a little better postoperatively. One other thing I would like to say about this talk is I'm not going to go into detail on how I do meniscus repairs. My other colleagues aren't going to details on different techniques. These are just some of my tips on how to get better exposure and how to orientate yourself better with the repair of the meniscus. So when it comes to the decision of a meniscus repair, this is one of my decision making trees. Typically, I'm going to do a debriement on someone over the age of 40, a higher BMI, maybe someone with mechanical symptoms is a little more chronic, less likely to heal, maybe an athlete mid-season because I know if I do a repair in mid-season, their season's over. Again, any tear in the red, excuse me, any tear in the white, white zone, a horizontal, a complex tear in nature, whether it be horizontal or radial, and sometimes I do a combo. Maybe I'll debride a tear to an extent and then come back and repair the remaining aspect. My meniscus repairs are typically going to be any pediatric patient. I don't care what it looks like. I'm going to try to salvage it. Patients under the age of 40, athletes out of season where they have the time to rehab, minimal chondral changes, you know, I don't want to do a repair on someone with grade four chondromalacia typically. Red, red zone tears, I like the bucket handle, the vertical, the root tears are typically going to be your best healers, but I will do other tears if necessary, depending on the patient. Then as I said earlier, I will do sometimes a combo debridement. So tip number two, you need to have a plan, then you need to have a contingency, and then you need to have a contingency for your contingency, as we say in the military. Basically, you need to be prepared for everything. So you need to tell your rep literally to bring everything. I do that with all my meniscus repairs. I tell my rep to bring everything from the ACL reamers, to the arthroscopic suture passers, to the inside out guides, to the all inside repairs, to the malice anchors, to the buttons, to the suture passers that I use for labrum. I don't want to have any hiccups in the OR, and I don't want to have my rep say, oh, I forgot to bring that. So as you can see in the top left corner, those are your zone specific inside out cannulas. On the top right is your all inside repair, and on the bottom right is your arthroscopic suture passer, which many times you use for rotator cuff repairs, and there are some companies that have more meniscal specific suture passers, but as you'll see with tip three, as long as you get good exposure, you can use any company's suture passers. Some are deceitful than others. But basically, even though you may have an idea of what you're getting into and what your plan is, sometimes you get in there and the MRI is off, or the pathology is different, or if you're doing it in the setting of let's say a multiligamentous knee or an ACL, there may be more damage and you actually appreciate it on MRI, so you need to be prepared for everything. So have them bring the inside out needles and zone specific cannulas, the all inside repair sutures, the reamers, the retro reamers, whatever it is you want to use. And also finally, set enough time aside for the case. You know, I don't ever book these like a standard knee scope. I always give myself an extra hour if I get done early. So I didn't get an extra case in that day. But at least my staff's not running around like a chicken with their head cut off. Everyone's working calmly. And that way, if I do get behind in the case, I'm not anxious about meeting the time deadlines throughout the day. Tip three, percutaneous MCL release. This is the game changer. This is the one I picked up here at the OLC. I like to use an 18 gauge needle. I put a valve distress on the knee and I basically pepper the outside of the knee until I get to release. Sometimes you'll get it within three or four pokes. Sometimes it takes 30 or 40. You go, holy cow, am I ever going to get it? But this technique will allow for better visualization and repair and less chondral damage. And in fact, even in my cases where I'm doing a municipal debridement, I will use this technique to sort of damage the medial primal condyle or the medial tibial plateau during the municipal debridement. I remember as a resident sometimes doing some of these municipal debridements and going, oh my gosh, I do more harm than good because of the damage I did to the medial primal condyle and medial tibial plateau. So don't hesitate to release the MCL. You do not need to put them in a brace. You can still make them weight-bearing as tolerated if you're doing a municipal debridement. And there's a good article, I apologize, I can't quite off the top of my head, that did study patients getting this technique and showed no harm in allowing the patients to not wear a brace and to resume weight-bearing afterwards and no laxity. And I can say personally, in my practice, I have yet to encounter a patient with laxity six weeks after a percutaneous MCL release. But this is the big game changer for visualization. And like I would tell my residents who I have to teach, you know, just like arthroscopic surgery is no different than an open procedure. If you don't put your incision in the right spots, you don't get the exposure you need. If you don't put your portals in the right spots, you don't get the exposure you need. If you don't release the MCL, you're not going to get the exposure you need. And therefore, you may not see what you need to see and you may not do as quality of repair as you're capable of. Four, use all your portals. My mentor used to say a real arthroscopist can use every portal and visualize from every portal. So don't hesitate to change your portal. It will allow you to change your perspective and maybe even the trajectory of your implant. What I want you to see here is this is the exact same radial lateral meniscus radial tear of the posterior third. And in the top top right, I'm viewing from my medial portal, or excuse me, from my lateral portal. Scratch that. Yes, from my lateral portal. And on the bottom right, I'm viewing from my medial portal. And you can see my trajectory is quite different and allowing me to get a better purchase of the meniscus from my all inside repair. And don't be afraid to make extra portals or they're one centimeter. If you need to make a portal higher, lower, an extra portal, mirror lateral, it doesn't matter, get the job done, make an extra portal, make your life easier. So you can do a quality repair. This may especially be important if you're doing a arthroscopic outside in repair, like we do many times for the anterior horn tears. Also, if you can't see what you need, don't hesitate to change to a 70 degree scope. I use a 70 degree scope in every type of arthroscopy I do, whether it be a shoulder, an elbow or a knee. And a 70 degree scope, once you get comfortable with it is also a game changer in that it will allow you to have a bigger field of vision, and sometimes allow you to do a see your pathology a little better and as a result, do a better repair. Tip five, use your sled. The sled is used to help with all inside meniscus repair instruments. You can use a sled to help you reduce the meniscus tear itself. You can use a sled to help you guide where you want to put your all inside repair without damaging the cartilage. The sled is your friend and don't hesitate to use it to help you with your all inside repair. And I would recommend that regardless of what implant you use, introduce your all inside repair with bevel down. It's more of a chondro protective technique. So here's a video. I'll just cut to different aspects. But this is a ramp lesion of the medial meniscus with a vertical tear of the meniscus, as you can see right here. And so here I am, I'll come back, I'm introducing my sled. Here comes the all inside device beveled down. I end up flipping device over and going into the capsular tissue. This patient already had an MCL tear. So you can see the visualizations quite good. I deploy the device, then I come back in my appropriate trajectory. And I apply my first vertical mattress suture for this tear. As you can see, I have trouble maintaining a steady hand. Sorry if anyone's getting motion sickness. We'll fast forward to the second stitch. As you can see, I'll bring in my sled again and here again, I'm going to use my sled to get a bite of that posterior capsular tissue. The sled will prevent my all-inside device from getting hung up on a fat pad. It also allows me to use the sled to put my device exactly where I want it to go. As you'll see here, I've come in beveled down. I like my trajectory, so I just go right in. I don't even flip my bevel around. I introduce it, and I deploy the implant, and then I come back. Once again, in a vertical mattress manner, I get my second purchase here in the red-white zone, and deploy the meniscus all-inside device. Then finally, to complete the construct, I come in in a horizontal mattress manner and use my sled to introduce the device, again, in a chondroprotective manner with the bevel down to make sure I don't damage any of the cartilage tissue. Flip it up, and then I introduce it into the posterior capsule. In this horizontal mattress suture, after you've done your vertical mattress repair, we'll help flatten out the meniscus repair and bring it back into its native orientation. Then I use the arthroscopic knot pusher to tighten the knot. You can see the final meniscus repair here. In conclusion, know the patient. Know the personality of the tear. I remember in trauma, they'd always say, know the personality of your fractures. Know the personality of your meniscus tear. Know what you're getting into. Know what you're capable of doing and what will likely heal, especially given your patient demographics. Be prepared. Have the rep bring the kitchen sink. You know, I like different implants, and I like different devices from different companies. I'm not loyal to one company all the time, so I'll have more than one rep in the room, and it doesn't bother me, so I'm sure it doesn't bother them. If it does, it doesn't matter to me because I'm more concerned about my patient's outcome and what I'm comfortable with. For a cutaneous MCL release, that is a big-time game-changer, especially if you're in the medial compartment. Additionally, some companies' implants, especially for an all-inside repair, will have a higher angle, which will allow you to get around the curvature of the medial femoral condyle, so know your implants. Use all your portals. Don't hesitate to make new portals. Change your perspective. Change your trajectory. Use your sled, especially in all-inside repairs. It will help you with the reduction and proper device placement. All right, thanks. Thanks for the opportunity.

meniscus repair

percutaneous MCL release

surgical techniques

all-inside instruments

cartilage protection