Good morning. Hi, I'm Pat Smith from Naples, Florida. Thanks for being here bright and early this morning. We've got a great All-star crew for you to talk about meniscus repair to replace So what we're going to do is we'll have our five speakers kind of cover the gamut Of what we're going to talk about with meniscus and at the end. We've got some cases to show so Want to be interactive if you have questions, please, please let us know We're gonna start out With Ashish Bedi from the University of Michigan who's going to kind of talk about our basic science and set the table So Ashish Good morning, I'll get kind of in many ways the most basic and straightforward part of these presentations But it's to sort of set the stage of the complexity that's to come I don't have any Conflicts related to this and it's a bit to review the anatomy the function and then a little bit of what literature is out there On biology and biologic augmentation of meniscus healing as you then start to hear about these complex tears We all know about the anatomy But I think it's just important to keep reminding ourselves that again a lot of this is incumbent on this meniscal capsular Junction where we have the vascularity of the meniscus coming from the capsule into the periphery We recognize that that battles only that much more difficult on the lateral side where there is that hiatus in the area of the of the popliteus tendon Remember as you're looking at the meniscus tissue It's the medial and lateral superior and inferior genicular arteries that create these perimeniscal capsular plexus and those vessels are oriented in a radial direction If you go back even to the initial literature from Steve Arnosky and others in canine models This was the concept behind trepanation to improve this vascularity and increase perfusion from these these peripheral vessels These are actually some of those drawings from that initial work at HSS with Russ Warren and colleagues that shows that peripheral vascularity and interestingly Despite all the new attempts at biologic augmentation. We haven't had any change in terms of that Angiogenesis or ability to change that healing potential yet Our repair constructs have allowed us to push out of this red red zone into the red white zone Which you will see more and more today are probably a little aspirational still for the white white zone We all know these critical functions of the meniscus which are low transmission shock absorption joint stability and then of course Lubrication and joint nutrition important to recognize that again The vast majority of meniscal tissue is water and it does have all of those principles that interact both with with the synovial fluid But also with the biomechanics of the meniscal tissue. I Think one of the critical studies that of course is highly cited is this study from Amos and colleagues and it was this Recognition in conjunction with Fairbanks that of course Meniscectomy even so-called partial meniscectomy in focal locations can have a dramatic effect on contact pressure and mechanics You can see this here with of course the historical dreaded radial tear where you see these grade four changes in the joint and these Peak contact pressures that develop relatively quickly This of course was a tear in the past that we would have little option for but I think you'll see today Most of us would be treating radial tears if at all possible with repairs with new constructs that allow us to to approach them We recognize there are some differences in the different compartments of the joint the medium meniscus carrying about 50% of the load Whereas the lateral side carrying about 70% of the load again This reflects the geometry of the joint where the lateral and the lateral compartment has two convex surfaces And the meniscus is critical to restore that concavity to convexity relationship So even more critical each Respective portion of meniscus that much more critical when lost on the lateral side Again, these are the historical charts that you'll see in terms of healing and healing potential If you look in the red red zone fully vascular excellent healing potential red white zone a border of the vascular zone But again with all of our modern approaches This also now has excellent healing potential and I think that's a little bit of a change from the past We still struggle with these white white zone tears But this is often where a hybrid approach of trimming in that location and repairing more peripherally has become more common Just reviewing a little bit of that literature. What does this look like and where did that come from? This is Dill Cannon's old work here You can see as meniscal rim width increases the incidence of the repair failure increases and that's important to again recognize that principle of Vascularity, but if you start to combine that with some of the other factors that were recognized such as ACL reconstruction This is some of the studies that pointed out concomitant ACL reconstruction Improve the rate of meniscal healing now that may be a few different factors That may be the biology of reaming and some of the bone marrow elements that egress from those tunnels But it also could be that ACL tears are happening in younger patients Probably with more high quality meniscal tissue and tear patterns that are more traumatic rather than degenerative What about biologic stimulation at the repair site? We all have recognized even though oftentimes our tendency is to immediately go to Repairing that much like a fracture you do need to prepare the site It turns out if you look at the basic science literature many of the stem cells that allow for healing Often live in this pericapsular synovium Rasping in that area and mobilizing those cells can actually improve your healing response That's the principle of that so-called rasp that you often see in your trays But also micro fracture or marrow stimulation at the notch has been published by Rob LaPrada and others as Augmenting meniscal healing similar to that of doing associated ACL reconstruction So for those of you that are treating an isolated radial tear or bucket handle meniscus tear It's become more common than not to do something in addition to stimulate biology even something as simple as notch micro fracture What about fibrin clot on this was popularized some years ago by Tom Wicowitz and others and published by Bill Cannon and Steve Aronofsky The simple concept here that you could aspirate blood Even from the IV line place it in a mortal and pestle which would stimulate some clotting of that of that blood This was those initial studies in 1990 that reported a significantly improved healing rate with a fibrin clot Compared to failure in its absence But it turned out that if you looked at that in the setting of a stable ACL there were significant differences Kind of hearkening towards the idea that there was some value to augmentation But not entirely clear in which scenarios and when so if you look at least in the literature for level 2 evidence This is where you might see biologic augmentation having a role Isolated meniscus repairs as we talked about either marrow stimulation or fibrin clot or both Complex tear patterns radial tears root variant tears that you're going to hear about here shortly And then of course this a vascular zone where it's probably very difficult to get the meniscus to heal like a white white zone So this is just an example of those types of tears and how things have changed for me This is a case just recently from spring football at the University of Michigan where it's a complex radial tear just adjacent to the lateral Meniscus root this was actually a radial tear and the flap was displaced into the lateral gutter We reduced this and brought this back together with these ripstop stitches and side-to-side repairs This may or may not heal but certainly it's for me in 2025 is an attempt at a repair in an otherwise young person's Knee aiming to play football How do you prepare that clot lots of different ways and of course fibrin clot being the first generation of this? But you'll hear about platelet-rich fibrin matrix and other approaches. What's the real critical nature of repair? Remember just in terms of the fundamental biology on the orientation of the collagen within the meniscus are these Longitudinal fibers of collagen but brought together by these radial tie fibers And that's why when you're placing your repair constructs whether they're all inside inside out or outside in You're wanting to have these more vertical or oblique mattress stitches that are working around those longitudinal fibers This is of course what makes radial tear patterns difficult and why you'll often see these type of hash mark or other Constructs. Well, how does this fit as I conclude a little bit with with what? What should we add in at the time of our meniscus repair now that we understand this biology? Well, I think our challenge with regenerative medicine and meniscus repair is all of this. There's a lot of appeal to the patient There is a rapid growth in this area But probably the basic science and benchtop science probably is a little further along than the clinical outcomes and there's a financial conflict These are cash pay procedures. So there's an incentive to deliver them at the time of surgery It also makes some conceptual sense right to the patient and to the doctor. You're bringing growth factors You're theoretically bringing stem cells, but there's this need to balance how much of this is conceptual versus in fact proven So I would just point out some standard principles that I think are important to think about We know that meniscal tissue is a little bit behind the eight ball. It sees high biomechanical loads There's compromised or decreased vascularity to that peripheral 50 or 60 percent And if you talk to basic science colleagues to get that tissue to heal you need two of the three of this healing triad You need cells a scaffold and growth factors or cytokines at least in the case of meniscal tissue You would do have a scaffold but you need at least growth factors or cells or ideally all three for success So what does that tell us at least in terms of meniscal repair and biology today? If you look at this level of evidence pyramid PRP or cellular therapy for meniscus repair probably lives at the bottom of this chart It's in the level 3 for evidence area There isn't randomized control trials that I have seen that have shown platelet-rich plasma or cellular therapy improving meniscal repair That doesn't mean that there's no promise here. It just means that we need a higher level of evidence to study it This is our challenge and I think this is a very good paper from Scott Rodeo and Suzanne Maher to look at this What's our challenge with meniscus tissue it's that to actually study it you require several different models So on one hand you need patient based studies because that's fundamentally what all of us are doing in this room But that's longitudinal studies with serial imaging that's challenging on the other hand The biomechanical models are often studied at time zero in cadaveric studies in vivo animal models are where we start our basic science But we also know that these types of models and small animals such as rats have a much higher healing potential than humans Of course, probably what is the most powerful is our new approach with finite element analysis and statistical shape models But of course that still has to go from theoretical to real So why is that challenging if you superimpose as Suzanne and Scott show here those? Challenges of having to use six or seven models even to study a meniscus tear and then add on these factors Every one of these tears is different. They're different if they're in the medial compartment in the lateral compartment You can see those plots on the right scatter plots show how heterogeneous these tears are Even though they're often grouped in studies as quote-unquote meniscus tears So when you look at bio biologic strategies for meniscus healing and you look at the literature both this year and beyond Think of them in these categories here. Some of them will be focused on cell recruitment Some will be focused on increasing vascularization Others will be focused on time zero mechanics such as glues or other materials to augment poor quality tissue And you want to start stratifying those in your mind, so they're not just all lumped into biologic augmentation But what was the specific goal of the biologic augmentation? So let's just briefly review the literature as I finish up what's out there on this actually a good study I'm from from Rachel's colleagues and and and the group at University of Colorado Eric McCarty They did a systematic review looking at augmentation of meniscal repair with platelet-rich plasma These were all the studies that met the criteria for inclusion where they looked at with or without PRP In their particular study when they looked at all different outcomes both PROs as well as failure rates requiring a take back to the OR They did not notice any significant difference with augmentation and platelet-rich plasma That's been studied as well by this group in arthroscopy in 2020 They also noted an insufficient amount of evidence to suggest PRP augmentation at the time of meniscal repair There are new products on the horizon that you'll see It has in our past been a challenge to deal with the partially resected meniscus We all think about subtotal meniscectomy as meniscus transplantation We then think about partial meniscectomy as wait and see what happens to that knee until it's a degenerative change and knee arthroplasty Either uni or total. These are types of structural scaffolds that you'll see now to potentially treat the segmental defect This happens to be one which is based out of a bovine meniscus Utilizing that as a scaffold with or without delivery of biology The anatomy and biomechanics of this have just received FDA approval and again has a narrow indication of use at this moment predominantly in the medial meniscus Significant meniscal loss in the setting of otherwise a well-preserved knee But future studies will tell us that the animal studies translate into healing This is what you can see for example in terms of tissue in growth These are scanning electron microscopy that shows the porosity that allows for in growth of native Adjacent meniscal tissue into the scaffold and then the corresponding histology studies in an animal model that show in growth of that to fill in with some reasonable meniscal tissue time will tell whether these types of segmental transplants either with human allograft or these types of Reprocessed bovine allograft can actually allow us to achieve those results. Thank you Great job. She's now Travis Mack from University of Utah is gonna come up and tell us how to do it Travis. I Think I'm gonna more suggest options I think she should talk to you or at least has taught all of us about Different reasons as to why we should be repairing these in different areas in which we should repair. I think meniscus repair has gone through a large transition from Thinking we could take out a lot of meniscal tissue to understanding that we should try to repair as much as we can Especially with the radial tears and other circumferential fiber compromising types of tear patterns Looking a little bit at the data Meniscus repair outcomes greater than five years suggests that all inside techniques and inside-out techniques all have very good healing rates the early generation all inside had a very high failure rate subsequent innovation and Progress has demonstrated all inside techniques with the newer Implants have demonstrated similar failure to all inside and inside out The key is to repair what you need to repair and do it in a hybrid model if you need to The key is use what's good in your hands, but repair what you can interestingly a sheesh directly stated early outcomes with concomitant ACL repairs Demonstrated higher healing rates and there were there are questions as to why that may be And she's just taught us all that perhaps maybe This may have to do with the more acute types of tears and I would suggest that's probably true subsequent data like this Suggested ACL really didn't have any distance difference in failure rates. Maybe that there are other confounding factors But again, it may not necessarily be the concomitant ACL, but rather the tear pattern or acuity so Putting my own cases to highlight these different types of tear patterns and how I prefer to repair these This is a 39 year old recreational football player He has an MCL tear but also a bucket handle meniscus tear which I think most of us would suggest should be repaired Of course when you get into 39 or in my time even in my my mid-40s You start to think that perhaps age may play a role, but interestingly that doesn't seem to play out in the literature So for me, this is a repairable meniscus tear, but unfortunately, it's a medial bucket But now you have a medial capsular injury with an MCL that may present a difficult scenario to repair You can see the medial capsular compromise and so putting a meniscal capsular repair stitch may be difficult So for me, this is a hybrid technique that posterior side can be difficult to repair So I start with an inside-out technique going both above and below the meniscus as Ashish just showed us I think making sure that you have good stability of both the superior and inferior Aspects of the meniscus is important to ensure good stability, but also getting a good Opposition but also repair of the meniscal capsular junction in this case is an inside-out technique because of that compromised MCL and also the capsule I then go into an all inside technique in the posterior aspect This can be done also with inside-out. It really doesn't matter but from my perspective this lent itself to an all inside technique posteriorly because the meniscal tissue in the The meniscal capsular junction the back did not have compromise of the capsule So for me an all inside technique posteriorly was an appropriate approach in this case The patient ended up doing well from my perspective meniscal tears I'm really not feeling good until they're outside the one one and a half to two year mark Most of my meniscal failures occur within nine to twelve months So once they get outside that twelve month mark, I start to feel a little bit better This is a study by Aaron Critch in his group looking at the potential complications of all inside versus inside out again I would say there's no way no right way to do a meniscal repair only that you should do it to the best way You can using the input instruments that you have at your disposal Interestingly, there were no complications with all inside 10% minor complications worth inside out Most of these were nerve irritation without any significance So I would suggest both are reasonable approaches and as you saw in that last repair I use hybrid approaches very commonly Continuing with highlighting patients that demonstrate to us what we should do This is a patient of mine a collegiate tennis player and you heard Ashish talk about the dreaded radial tear This is what we found here so this is a lateral meniscus tear with complete obliteration of the Circumferential fibers in a young male who's going to be using his knee to it in a very highly competitive position So this is what you see when you come in and you could argue that this looks almost chronic But in this case the history does not support that and he has an acute chondral defect on his lateral femoral condyle So this is a need it's not going to end up well So from my perspective, this is a meniscus that I would consider repairing and in this case I did again There's a radial tear that goes from the red red all the way through the white junction and it's a very difficult repair But using different techniques and instruments that we have at our disposal this time I'll initially use a cruciate technique But also a side-to-side repair to initially anatomically reduce and then stabilize Aaron's taught us a lot about the different ways of appropriately reducing and then Stabilizing meniscus tears and this is how I approach this So initially closing the gap and then stabilizing to the meniscus and meniscal capsular junction to both provide an anatomic repair But also a stable one biomechanically This is him after we went back to fix the cartilage and you can see even in a repair that you would think Would not heal this is him at approximately eight weeks out So there's good healing already even in a white white extended junction radial tear you can get healing even through that meat White white junction in an acute tear pattern How do these do so clinical outcomes of inside-out meniscus repairs Rob LaPrague groups which Ashish talked about before Demonstrate really good results here the highlighted points here for me. It's not so much the ACL It's the acuity of the tear and so this leads me to counsel my patients in a very fairly strong fashion when they ask Can I wait for a few months just because this isn't good in my life my life right now I have a tear of my meniscus Can I wait for a few months because I have a trip plan or something of that nature or I'm in the middle of my Season because I would can I wait till the end of the season? It's shared decision making of course But we have literature to back up that shared decision making on our end and at the end of the day the answers repair These early Rob LaPrague's group taught us that less than six weeks out You have better healing rates better outcomes doesn't mean you have to do it. But at least it allows you to counsel your patients So meniscus tears come in different shapes and sizes. This is a 24 year old male Olympic rock climber Again flipped meniscus not a good outcome. It portends this person obviously has a locked knee that you're gonna take this early But again, this can be a difficult complicated meniscus repair This is the lateral meniscus that flip but what I would draw your attention to is the posterior aspect of the meniscus You see that meniscal tissue coming in It's not a complete meniscal tear and there's a rim of tissue that you'll see in just a moment The meniscus is flipped into the front. But again, don't forget about the meniscal tissue in the back There are meniscal tibial ligaments that we also can use to help ourselves So this is the meniscus and in the back you see a rim of tissue in the back Which is a remnant of the meniscus at the popliteal junction We can use this to repair the meniscus in fact, and it has a very good structural stability to do so So for me, this is an all-inside technique, but not the way we typically think we're not using implants But rather we're using the peripheral rim of tissue to stabilize the meniscus Initially preparing the meniscus in the standard fashion as Ashish just taught us but then using an all-inside Circumferential stitch to effectively baseball stitch this but not all the way around the meniscus But instead preserving the triangular structure of the meniscal tissue to that posterior rim and these have a very very high healing rate So this is typically my go-to technique for those posterior meniscal tears of the lateral meniscus. Now, this is technique does not Lend itself to a medial meniscus repair for obvious reasons. We don't have that popliteal hiatus that we can go circumferentially around This person's six months out. I told you I'm not happy until they're two years, but so far so good Ashish or Aaron has taught us a lot about the Elmore pattern So an Ashish alluded to it earlier the lateral meniscus oblique radial tears These are almost always seen in ACL tears However previously in my early years of practice I would just resect this and think it's fine because there's a meniscal femoral ligament and that should be okay Turns out I was wrong. Like most decisions I make that don't have data to back them up As a result, I've now gone to repairing these because Aaron and others have taught us the importance of this The outcomes of these do better when they repair and in Aaron's study of over 600 patients They had no ACL retears. No meniscal retears with the Elmore repair. And so following his lead This is how I typically repair these this is an Elmore lesion as a she showed us a beautifully repaired one This is how I do it There are obviously different tear patterns But this is a fairly typical type of Elmore that I see This one had some extension into that meniscal past the meniscal femoral ligament. So initially again, we're reducing Anatomically reducing in a side-to-side technique compressing at that meniscus radial tear junction, but this also went circumferentially And so this one I also went baseball stitch around to catch that posterior structure But also provide a rip stop and again which stitches you place are really up to you But providing rip stops for those side-to-side repairs can be helpful to ensure that you don't have the tears tear your meniscus repairs tear through How do these return to sport? Well first menisectomy unquestionably gets back to sport sooner But unfortunately the outcome of the knee may not be quite as good especially in young people females lateral meniscus tears I really do try to go to the mat on these the younger the patient the more compromised their circumferential fibers, the more adamant I am about repairing these, and I think the data has taught us that getting back to sport may not necessarily be the reason why we should do a certain type of surgery, but rather preservation of the knee and the patient's future is probably more paramount. Vertical repairs come back a little bit slower. Complex repairs even further out than that. What about athletes? In a second study by Lee and his group demonstrates meniscectomies return to sport very quickly, but of course this does not portend well for the knee long-term. Repairs take about five to six months, and meniscal allograft transplants that Rachel's about to teach us about take much longer, but I would say don't use these numbers to compare the patients, but rather think about what you're trying to accomplish for the knee. Thank you. Thank you, Travis, and got a real treat for you. We've got the world's expert on lesions, ramp repair, who came from Luxembourg. It's the travel ward. Romain and Sal, thanks, Romain, for making a long trip to educate us. Thank you very much, Pat. Good morning, everybody. So I have no disclosures because no one is really interested in ramp repairs, right? So actually here you see this big hole. This was an ACL-injured patient, and from the anterior you couldn't see that there was any lesion in the back part, so we went through the notch and looked at that and discovered it partially, but only partially. And now you will ask me, why didn't you repair it from the front? Because it's very difficult. In some of those cases, you cannot really open the medial side, the medial part of the knee. They kind of turn around and subluxate. So this is then when we go posteriorly, and we have this nice posterior medial view and see this big hole where you have a direct view on the tibia. On the top is the meniscus. On the left, the PCL, so the notch, and on the right, the MCL, and the capsule and the meniscus tibial ligament just hang down. Here again, the anatomy, two structures that are really important here, the meniscus tibial ligament and the meniscus capsular ligament, nicely published by Etienne Cavagnac and Robert Proud's group. Now, one of the questions we had over time, and I've been thinking of these lesions for 15 years now, is how do they occur, actually? And this video, coming from the Italian First League Football, published by our friends from Bologna, they are just an eye-opener, because you see here that in the medial compartment of the knee, you have a dislocation, like in the shoulder. This is a banquet lesion, and this has been nicely described also indirectly, so the indirect signs with the bone marrow edema and the signs of this, the calculation of the displacement in the medial compartment by Obujiu Akiyo in the AGSM some years ago. And now, bringing it all together, we wanted to understand the context. We know that the prevalence of ramped lesion is roughly 20%, 20 to 30%, depending on your recruitment pattern. And then we developed this type of score, which is made from MRI data and from arthroscopy data. And we put the information together about ligament, meniscus, bone and cartilage, and maximum score was 12 points. We called it the ACL injury severity scale. And here's the distribution of ACL injuries. And you see here, there's a big variety, big diversity from just simple ACL injuries to really complex ACL injuries that we call achilles grade three, and they account for roughly 20% of the cases. And in these cases, we see that the bigger the injury gets, the more the damage, the associated damage moves from the lateral to the medial compartment, and also the B meniscus lesions. The 80% of the B meniscus lesions are in the achilles three categories, and 75% actually of the ramp lesions. And that's really showing us, it's a proof to us that these ramp injuries do not occur in just simple ACL injured knees, but in complex ACL injuries. So the medial compartment involvement and the ramp lesions are signs of severity of an ACL injury. That was a lesson we learned from that. And we have found some indirect signs in the years before. We found, for instance, that the direct trauma to the knee increased, so it increased the association with ramp lesions. We found a higher degree of pivot shift in these patients who had ramp lesions, and we found that there was a frequent associated with lateral root tears, you call them L-morts. And actually, if you have a ramp lesion in 80% of the cases, you also have a lesion to the lateral meniscus. So again, testifying the energy, the importance of the energy of trauma. And then we looked at the prevalence again, 25% in this series that we published in K-Star five years ago, which is more actually than the lesions in the medial meniscus body, so in the posterior horn. What about the classifications? This is the most popular one published by Mathieu Tonard from Lyon in France. And you find that the type one injuries are found in 48%. We recently came up in the Green Journal with a new classification with Robert Pratt's team published by Luke Tollefson. And there, we kind of included the kind of dynamic proportion to this, as you have seen from my first video. Can you diagnose them on MRI? Well, the sensitivity is not really good, so it's more or less a guess. There is an increased precision or specificity if you have an associated bone marrow edema on the posterior medial tibia. That's again, an indirect sign of a major trauma in your knee. If you have time and technical possibilities, you can also do an MRI in the flexed knee position as these Japanese colleagues here, then you can increase the precision of the diagnosis. How do you find them? Actually, arthroscopy is the gold standard, so we usually go through the intercondylar portal, the Gilchrist portal, but you can also do, as I showed you previously, a hypostromedial portal, or you can go through the septum, the transeptal portal. This is then what you find if you go to the intercondylar notch. In some cases, it's very easy because it's a big region that extends towards the notch, but in some cases, they are more medially placed, and then you have the problem with the blind zones here on the medial side. You can improve this with a 70-degree scope, but it's not perfect, so to me, the best way is to have really this posterior medial view showing you very nicely this Bankhat lesion, actually, of the medial meniscus ramp. This is a type I lesion, again, with a three-centimeter extension from the notch, basically, to the MCL. Then we develop these post-medial portals. We published that also in the Green Journal some years ago, and I do actually a two-portal approach with a viewing portal and a working portal, which is a little bit more distal and a little bit more posteriorly. If you do that, well, and if you decide to go for repair, for posterior repair, you really see then, and also here dynamically, that some ramp lesions really do not reposition themselves. Even if you put the knee into extension, if you put, then, a device from anterior, it will not grab the capsule posteriorly, and you see how nicely the ramp is moving in some of those cases. This is how we do the repairs. You need to secure 20 minutes OR time, decide on the approaches, then identify the lesion, debride it, reposition the tissue, which is not always that easy, as you've seen in some big cases before, and then you do the repair, and for that, we use shoulder instruments, and you need to be proficient, of course, doing arthroscopic knot tying, and we use resolvable sutures, so in this case, PDS1. See here how you debride it from posteriorly, again, this posterior view, and then we use these hooks. You have different angulations available, and then you just repair it. And one interesting feature that we regularly find is actually that you are able to tension the capsule, the posterior capsule, again, if you bring it into extension. We don't really understand what this means, but I guess that this will increase the laxity or decrease the laxity in the postoperative phase. So should they be repaired? You know, it's a controversial subject, but there is growing biomechanical and clinical evidence that they should be repaired. They should be recognized as in vitro data, in vivo data, and also some clinical results showing that increased ankyrolaxity in non-healed ramp lesion can be found, that the repair reduces secondary meniscectomies. That's probably the most important thing. You can save these meniscus in the long term and prolong the career of the athlete then. Non-repair increases secondary meniscus injuries. It has been shown nicely, and also that the suture hooks repair is superior to the repair of all incited devices. Many publications come from the Lyon group around Bertrand-Sonnery-Cotet, many of those clinical publications. So we have to give him tribute for that. Take-home messages, identify the lesions, understand their context, most important thing. Ramp lesions are a sign of severity of an ACL injury. Get familiar with either one repair technique and take the time to repair them. Your patients will thank you for that. My personal preference is an anatomic direct suture hook repair with two post remedial portal. This allows for perfect visualization. It's challenging at the beginning though. It's just like adding a banquet repair to an ACL reconstruction, but you get proficient in that by repeating it. And again, ramp repair for severe ACL injuries probably leads to a better outcome in the long term. Thank you for your attention. Thank you. Great, thanks Romain. So Aaron Critch is gonna come up now and talk to us about root repair and the role of centralization. Aaron. Well, thanks Pat for organizing an outstanding group. I always learn a lot from each of these speakers. So this is our typical case we get asked about. 45 year old lower demand female gets up, feels a pop in the knee, a little bit of varus alignment, but the joint spaces look pretty good. And we see that root tear with extrusion. So what do we do in this case? Well, we can wait, but we're gonna show some data that shows waiting is not a good idea. Non-operative management has a very high failure rate over time. Never do a partial meniscectomy in this setting and root repair can work in the right patient. So this is a very nice study showing that if you're going to do surgery, do it early. Don't inject them, follow them, wait to come back because they're gonna wear their cartilage. If they're fixed after three months from injury, they do worse. They have worse functional outcomes, they have worse arthritis, and overall do not do as well. When you look at non-operative management, we just updated a 10 year follow-up, over a 90% failure rate at 10 years of non-operative management. So there were more patients deceased in this study at the time of follow-up than had a success from non-operative management. And this makes sense, right? She presented some good lab data, but this is how you create arthritis in a mouse model. You create a root tear and you watch the compartment be destroyed very quickly. So should we repair them? Absolutely. We just published this systematic review. Over 3,000 patients in repair when compared to non-operative management or debridement had less arthritis, better functional outcomes over time. So this is a study we did with Pat. It was multi-center, it was prospective. We looked at trans-tibial repair and 47 root repairs. What we found is overall good healing at six months after MRI, but we didn't really solve the extrusion problem. And when we looked at our outcomes, so we look at groups of patients, yes, they do well with root repair. The question is how does an individual patient respond? And when we look at all their factors, age, alignment, cartilage status, BMI, the one that matters most is how much preoperative extrusion they have. And if they have more than three millimeters, they do poorly with a standard root repair. This has been validated. Jin Goo Kim, certainly a pioneer, has taught us a lot on root repair, found very similar results. When they have substantial extrusion, they just don't do as well. So why does it matter? I really love this study. Rachel's gonna talk to us next about meniscus transplant. There's this debate, are they chondroprotective? Are they not chondroprotective? Well, if they're extruded more than three millimeters, they simply are not chondroprotective. That meniscus does not have function. So that's one of the key takeaways. So we convinced 10 of our patients, Pat and myself, to get back in the MRI scanner within a week from surgery. We wanted to see does the extrusion ever improve? And in fact, it does not, even at time zero. So we looked at could extrusion be the cause of root tears? The fundamental teaching was you have a root repair first, and then the meniscus is extruded. But we had 63 patients that actually had an extruded meniscus with symptoms, and then went on to have their root tear subsequently. So this is what we feel for the degenerative root tears is the pathophysiology. So they get abnormal loading, which causes abnormalities of the meniscotibial ligaments. That causes extrusion, which then leads to increased stresses at the root. So now a seemingly minor injury, getting up from a chair, going up a step, causes that root tear. And this makes sense to us because that MRI shows a lot of chronic changes. So I use this analogy for patients. Feel free to borrow it. So a normal meniscus is like walking across a suspension bridge. The meniscus is able to resist hoop stress and supports us. This saggy suspension bridge is an extruded meniscus. And then finally, the terminal pop, now we have the root tear, and this isn't gonna do anything for our knee. So what about centralization? Can we improve extrusion with techniques? Well, first of all, I think our techniques have significantly evolved over time. Really a credit to Pat and others in the room working together. But we do use rip stops now in all our root repairs. We'll show a couple of different techniques. Dr. Mehta, who's sitting over there, published on our rip stops, showing better footprint compression. So this recent paper, please take a look at it. We've really updated our centralization technique. We used to put a lot of sutures through the degenerative meniscus. Now we've gone back to focus on the problem. The problem is the meniscotibial ligament. So we really look at passing our sutures. You can see here just at the inferior surface of the meniscus. And essentially we're creating a suture staple. And that allows us to then centralize or re-tension the meniscotibial ligament. We typically use two anchors, one at the posterior medial and one at the mid-body. And I think this video demonstrates it very well. We think of extrusion in the coronal plane, but it's three-dimensional. So as we recreate the meniscus anatomy here, we're pulling it into the sagittal plane correctly and the coronal plane. And really, if we don't restore that anatomy, we can't possibly restore the function of the meniscus. So we have to think about extrusion as three-dimensional. So we did a lab study looking at this model. We were able to restore extrusion intact levels. Obviously there's some concern for over-constraint. We did not see it in this model. And I think that's allowed us to expand the technique. You're gonna hear again from meniscus transplant next. But I typically now centralize the rim of the meniscus transplant first, and then bring in that meniscus allograft second to avoid that time zero extrusion. There's another technique that's being developed called circumferential augmentation. You can see on the upper right, expansion to radial tears, some root tears, some complex tears, degenerative tears. Multiple groups are developing multiple techniques, but overall this circumferential augmentation, I think makes sense. Pat was kind enough to share this video with me. I won't focus too much on the technique, but conceptually it makes sense. I think about my belt this morning, kind of going through the belt loops and cinching up so my pants aren't sagging down over time. And it's the same thing with this meniscus. There are so many factors we control, and Rachel will go over them for meniscus transplant technically. But again, it doesn't really make sense that we're sewing this meniscus to a peripheral capsule and kind of taking it out of the joint. So the circumferential augmentation allows us to avoid that. And you can see Pat here, anchoring those circumferential fibers before doing suturing to the meniscus transplant. So here you can see the final product. And again, we have to have less than three millimeters of extrusion for these transplants to function. What about roots in terms of trans-tibial versus anchors? Again, when we started this 15 years ago, there was a debate. We kind of abandoned direct suture anchors just because of post-year portals and technical difficulty, and the trans-tibial became more efficient and easier. But really, ideally, you wouldn't fix something five centimeters away from its origin where it needs compression. So really, we've gone now back to suture anchor technology. There are some ways we can use trans-tibial approaches, familiar anterior portals, and do direct suture anchor fixations. I think in the last two years, this has been an absolute game-changer for our practice, and we are seeing some really great-looking MRIs and clinical outcomes. So here, again, we're going through a trans-tibial approach. We'll place a knotless anchor first, and then we'll pass our sutures for direct fixation. Here's the final construct. We do this slightly different ways, but again, I think it's very important to have that ripstop configuration. We want to restore anatomy. These are degenerative menisci. The collagen fibers and things, we don't want to pull through. When you look at this in the lab, this is 10,000 cycle data. Direct suture anchor repair, to no surprise, did better with compression of the meniscal tissue. And most importantly, it resisted cyclic displacement over time. That's how these fail. They loosen up. You get cyclic displacement over time. We then went to 100,000 cycles. This was just published. Again, the suture anchor technique compared to trans-tibial was biomechanically superior. So in 2025, my recommendation for root repair, I use a ripstop all the time, and there's degenerative tissue, direct suture anchor repair. And then if we have that critical extrusion more than three millimeters, we do add centralization to the construct. So what about clinical data? This was just published. So 25 patients with two-year follow-up. You can see these are the patients we all get asked about. 50 years old, female, they're overweight. They have some varus. They have some chondral damage. And what do we see? Well, we saw a substantial improvement in pain, both at rest and with function. Their IKDC improved almost three times MCID. Their KUS scores and their functional scores were all positive. So the takeaways for meniscus root repair in 2025, fix it early, make that early decision. Don't wait on it. They'll continue to wear their cartilage with worse outcomes. Just understand the degenerative root tear does include pre-existing extrusion in many patients. That's the pathology. Direct suture anchor repair and ripstop sutures improve the biomechanics. And again, we like to consider an emerging technique of centralization for that critically extruded meniscus. Thank you. Thank you. Great job, Aaron. Okay, so Rachel's gonna come and teach us what to do when we can't repair it and we gotta replace it. Rachel from the University of Colorado, thanks for coming. Thank you. I feel like every time Aaron mentioned the demographics for root repair, I took a personal hit as the female, elevated age and BMI. So thank you, Dr. Critch. As the slides come up, first, thank you, Pat, for having me with this amazing panel. I'm humbled and honored because these are the superstars in meniscus repair and transplantation. How many in the audience do meniscus transplants? How many do more than 10 a year? So about one a month. Not too many. So it's not super common, but it's something we need to have in our toolbox if we're gonna be meniscus surgeons. So I'll share a little bit about my experience and research with meniscus transplantation. No relevant disclosures, but all of my disclosures are available online. So as we all know, we need to consider the meniscus as part of the overall biology of the joint. And it's not just the meniscus, it's the alignment. You can't solve a meniscus deficiency problem in a malaligned knee. You can't solve it when you don't have good cartilage. You can't solve it if you don't have stability with respect to the ligaments. So you need to consider all of the different factors to making a knee joint healthy, including the meniscus. Now, the meniscus we learned yesterday, we all know from our practice, it's a really big deal in terms of its overall function. And we know that meniscus deficiency in some patients is inevitable. And despite all of the advances in repair techniques that you've heard about today that you employ in your own practice, there are certain tear patterns that simply cannot be repaired, or if they can be repaired, they simply don't heal. And so we're ending up in this state of meniscus deficiency. Not everyone with meniscus deficiency has symptoms, right? We have plenty of patients where we take out the meniscus or it's been taken out, maybe someone in this room, and they've had their meniscus taken out and they don't have symptoms. So not everyone with a deficient meniscus needs a transplant, but some people do. And so our options in 2025 in the United States include either allograft, which we're going to talk about, substitute or replace, and that's part of clinical trials. There's not any device right now that's commercially available, FDA approved, that can substitute the meniscus. But across the world, there are several devices that are available or simply watch and wait and kind of nurse the patient along. Taking a step back, what do our patients really wanna know? They wanna know these four questions. I use this slide in almost every single one of my talks about joint preservation because it's so relevant to what we're doing. And the key is to manage expectations. What they wanna know is if you do something, will they get better? If you do nothing, will they get worse? And if you do something, can they go back to their activities that they enjoy? Or are you simply going to put in a meniscus allograft for them to become a couch potato? So they want to know the answers to these questions, and our task is to manage the expectations. Meniscus allograft transplantation is designed to do these three things. Reduce pain, improve function, and improve quality of life. That's what it's designed to do, and nowhere here do we see run marathons, hike 14ers, ski in the backcountry, but that's what our patients want, so we have to try to give them what they want. In terms of indications in 2025, symptomatic meniscus deficiency is by far the number one indication, but growing indications include instability in the setting of chronic or recurrent ACL tears, particularly for the deficient posterior horn medial meniscus, and we may learn in the coming decade the deficient lateral posterior horn because of the rotational implications. Certainly with concurrent cartilage restoration, if you don't have a good meniscus and you think a meniscus might support the cartilage, then transplantation would be indicated, and I think the evolving indication is prophylactic transplantation, particularly for the patient with pristine articular cartilage, neutral or correctable alignment, and no meniscus should you get at them early and prevent the changes that we know will happen, or will you cause more harm than good by giving them a surgery they never needed. It's important to understand the surgical anatomy. This is something that I think as we grow in our practices, we sometimes stop looking at the basic science, we stop looking at the relevant surgical anatomy, but if you teach or you're involved with residents, fellow students, it's really important that you understand the relationship of the horns because this has implications on how you're going to do your surgery. We all know the medial meniscus is more C-shaped with a bigger spread between the anterior and posterior horns. This can create some challenging scenarios from donor to recipient sizing. The lateral meniscus is more O-shaped, covers more of the lateral tibial plateau, and the horns are closer together, which can create challenges with surgical techniques with respect to the ACL being caught right in the middle of those horns, and sometimes part of that ACL comes out depending on what technique you're doing when you're doing your lateral meniscus transplants. So speaking of technique, what are the technique options? This is the options that are available, and it's interesting in order of left to right, this is my evolution of my personal approach to transplants. I was trained in a bridge-and-slot approach for both the medial and lateral side. That's how I started in the first few years of my practice. I saw some of the difficulties with that, and with newer technology, doing bone plugs became more facile for me and my hands, and working around the ACL or with ACL reconstruction became a more viable option. But for anyone who's done bone plugs, sometimes you start with a nice robust bone plug, and then by the time it gets into the joint, it's not so much a bone plug, but a bone fingernail, and then after that, it's just a piece of soft tissue. So why not start with a soft tissue approach? And so I've gone in the last several years to all soft tissue approaches, and I've been very happy with my results. So when we think about the different options, the bridge-and-slot technique is, again, how I was trained. It's how many of us have been trained, because one of the highest-value meniscus transplant surgeons in the world, Brian Cole, has taught so many of us how to do this approach. As you know, this can be done through either a trough or a dovetail technique. The trough is more rectangular, the dovetail has a trapezoid fashion to try to stop the bone plug from backing out. The advantages to this are you don't have to worry about the relationship between the horns, because it's set for you. What you get is what you get. The other advantage is you get bone-to-bone fixation, which we all know is ideal, just from a general orthopedic perspective. The difficulty is that it's technically very difficult. If that bone bridge breaks, you have a problem, and if your horns don't match your patient's native anatomy, which can happen, you're gonna have a non-anatomic graft. This can be very difficult on the medial side, in particular, when you're working around an ACL. I actually find it very difficult around the lateral side when the horns are so close together, not violating at least the one-third of the tibial footprint on the ACL. So, bone plug technique, this is a nice technique that gives you the advantage of the bridge and slot with respect to bone-to-bone fixation, but you have two independent horns, and so you can work more easily around the joint and do this in a more familiar arthroscopic approach versus a slightly open incision for the bridge and slot technique. The disadvantages are, again, it can be difficult to keep that bone plug a bone plug without destroying the articular cartilage by the time you get it into the joint, and it can ultimately become a soft tissue graft, and then you do worry about that bone-to-bone fixation if there's no bone-to-bone fixation. Finally, my preferred technique, the soft tissue technique. So, this, again, is often the end result of a planned bone-to-bone fixation. It's the most simple technique. It's perhaps the most popular technique because of its simplicity. It's the most forgiving if you have a mismatch on size. The disadvantages, you're relying exclusively on soft tissue to heal. If they have bad soft tissue, a patchless capsule, it's a revision scenario, which most of these cases are. You could result in a beautiful transplant that's significantly extruded, and then what's the purpose of that? So, we need to be cautious with soft tissue technique. I think in terms of Pearls for Success, the keys are here. You've got to manage the expectations. That's number one. If you don't know before you go, they're not going to know before they're done, and so what I mean by that is, if you haven't told them the purpose of this technique is to reduce pain and improve their activities of daily living, and instead they're coming in thinking they're going to run a marathon, even if you execute a perfect transplant and they heal it 100%, they're probably not going to be very happy. So, understanding your patient and explaining to them what to do is critical. As I finish up in the last couple minutes, these are the three critical questions I think that I still have no answers to, but I'll try to give you as much supporting evidence as I can in 2025. Are the outcomes worth it? Is the juice worth the squeeze? And athletes, should we even consider this? And then what about prophylaxis? When you look at outcomes, this is one paper that we helped work on almost a decade ago. This is Dr. Cole's series, at this time 172 meniscus allografts, average patient demographics that probably match your practice. What I will tell you is, to sum up this paper, at the end of the day, most patients do well at five years. They've just published their 10 and are looking at their 15-year data, but the outcomes at 10 years dropped to about 78% good to excellent outcomes, and there's a high rate of reoperation and a high rate of concurrent surgery at the time of allograft, so you've got to do your indications appropriately to get these results. Those are all with bridge and slot techniques. This is another paper published out of Italy. They looked at 147 meniscus allografts at four years. They found that clinical failure was about 16% summary statement, 84% survival at four years, and again, I would surmise that these results dip down to the 70s or 60s at 10 to 15 years, like most of the papers suggest. What about return to sport? So this is, unfortunately, we're not dealing with the 50-year-old getting a transplant all the time. It's the 20- to 30-year-old, and they're not satisfied with just improved quality of life. They want to do the sports, so can we get them back to sport? There's a lot of different papers that talk about this, but what I would tell you is I'm going to summarize them all very quickly. Some patients return to sport, two out of three, three out of four, but the level of sport that they return to is very low. It's not nearly what it was in the majority of patients compared to before their injury or before their transplant, and that's the key to explain to them. I tell patients you'll probably get back to doing most of the things you love, but not at the level that you love them. Not every day will you go on your ski trip. You might go half days. You might have to switch from blacks to blues. You might have to reduce your activity level in some capacity, but you still can do the activity. That's kind of how I explain it to them, and I set the stage that way. This is another paper published out of the U.S. 230 military patients, mean follow-up of two years. These are very athletic patients in the military. Again, you're going to find 78% survival, so two out of three, three out of four, but the overall activity rate is lower in this highly active patient population. This is a paper from Dr. Cole's group, 13 high-level athletes, reoperation rate approaching 23%, and what you see is 77% return within two years, but under 70% at the level that they were at, so this is not a home run operation. This is one of my favorite studies to look at, and when you fear someone who just reads the abstracts, you may find that really good results in professional athletes. With this study out of Italy, they looked at 12 professional soccer players undergoing medial meniscus allograft transplants, and they found that there was significant improvements. Tegner from 8 to 10, but I would argue what's the difference between 8 and 10 in a clinically meaningful fashion, and 11 out of 12 return to professional soccer. This paper gets quoted a lot, and a lot of athletes come in who are educated saying, hey, we can do this, you can do this, and me and I'll get better too. I would ask everyone to interpret with caution. The vast majority of our patients are not highly paid professional soccer players in Europe. They have other motivations, including millions of euros to get back to sport, whereas our regular weekend warriors do not have those same intrinsic motivations. Finally, other papers about return to sport, again, highlighting the same things. Most people are getting back to light activities, but not highly athletic or high-level recreational sports, so the key, manage expectations. My puppy Murphy likes all that meat at the barbecue. In reality, what he's going to get is a vegetable. Fortunately, he's a dog and loves it all the same. In terms of prophylaxis, the last thing to talk about here, because this is a common question that we get, this is one paper published out of China, and they looked at doing meniscus allografts either immediately after meniscectomy in a delayed fashion or in a control group who just underwent meniscectomy with no transplant. What they found is that there was really no significant clinically meaningful differences in any of these groups, but some immediate improvements with VAS scores in the immediate MAT group versus the control groups and slightly higher IKDC scores in the immediate group, so I guess if you're going to do it, maybe don't delay, is what they're saying. But no power analysis in that study, so it makes it difficult to interpret. This was a nice trial by Tim Spalding and colleagues looking at using physical therapy versus meniscus allografts, and interestingly, they found that meniscus allografts had better outcomes at one year compared to physical therapy for the meniscus deficient patient. The question is, how will that hold up over time? And in the U.S., insurance companies are going to be really interested in understanding not one year, but ten year implications of doing physical therapy versus a $30,000 meniscus allograft. This was a paper looking at chondroprotection. I think Erin mentioned this patient already. Meniscus allografts do show some evidence of chondroprotection, so there is, I think, at least a spark for us to think about doing this for a prophylaxis, but it's got to be done well and we've got to minimize the extrusion. And then last question, what if they already have cartilage damage? My take-home is just like root repair. If you've got cartilage damage, you can still do a transplant, but make sure you correct the alignment if alignment needs to be corrected or counsel your patient appropriately. Finally, take-home points. The literature is reasonable, but I would be cautious with interpreting the outcomes. Most of the studies are done by the same groups, and so those patients may not be extrapolatable to your patient population. And I think the question I always ask is, are the results the combination of the transplant or the result of the transplant or the combined effect of multiple procedures? Because so many of these patients also have cartilage and alignment surgeries done. The last thing I'll tell you, and this is just a personal anecdote, I'm now 14 years almost to the date out from a revision meniscus transplant. Knock on wood, doing quite well, but my tegner is not a 10. And prior to my first transplant, it was a 10. I was a quote-unquote high-level athlete. So I think I understand what it means when you have these things put in and the reasonable expectations that we have to have our patients understand before embarking on the surgical journey. But with that understanding, patients can do really well. So I would keep this as a tool in your toolbox. It's certainly been life-changing for me. Thank you all very much. Okay, let's have the panel up. Some great work, guys. I'm gonna go through some cases. We've got about 20 minutes here, and we'll have time for some questions, too. So Shane, if you can pull mine up. Okay, so I recently transitioned to a new practice in Naples, Florida six months ago. And so actually these first three cases are ones that I just encountered in trying to build my new practice, which has been a bit arduous. These are my disclosures. So first one, 65-year-old female, tore ACL four years ago, guys. Treated conservatively, but was not happy. She's a dancer. She can't run. And then before she saw me, she re-injured a knee, complained of medial pain. So you can see her exam. So she is unstable. She doesn't have full extension. And here's her x-rays, which I would offer to you for a 65-year-old. Looked pretty darn good, right? Nothing too crazy. Kind of go through the MRI. Aaron, can you see that, what we got in the scan? So I see large effusion, displaced buccal anal tear of the medial meniscus, and a chronic deficiency of the ACL. Great. Okay. We won't belabor that. The saggels are here. Okay. So, got the diagnosis for me. So here's her scope. She's 65 years old. Kind of looks not really in the red-white zone. So, Rachel, what are you going to do with this particular patient? 65, no ACL, and kind of a white, white, almost bucket tear. I would tell you, I hope that my knee looks like that at 45, first and foremost. So I need to get some of these patients. Even in Colorado, where we have younger physiologic patients, this is amazing. I think, look, you're obviously taking her for surgery. You've had that discussion. She's failed non-op. That cartilage on the medial side looks pristine. It's not pristine at 65, but it looks pristine. I think I would attempt to salvage the meniscus for two reasons. One, you're going to protect healthy cartilage that's already healthy. But number two, to help support the ACL, to have that, you know, posterior horn medial meniscus repaired, I think would be ideal. And then I would do an ACL reconstruction. I typically do an allograft in this patient population, especially with running, dancing, age over 40, let alone age over 60. So I would try to salvage that joint with a medial meniscus repair and an ACL reconstruction. Okay, well, Travis, yesterday we had a meniscal session in the morning, and a bucket nail tear came up, and an athletic person, much less younger than this, and three of the four said, take it out. What are you, are you repairing this one? What are you going to do? I would repair this for the same reason Rachel just talked about, and it's obviously very healthy tissue. The meniscus tissue looks acute. The ACL obviously being chronic, this is a medial-sided failure and a secondary stabilizer. So everything that Rachel said is exactly what I would do. And data has taught us that age does not necessarily correlate with outcomes and healing rates, but rather it's the integrity of the meniscus and the biology. Aaron? I just want to make a quick comment, too. If you saw this patient acutely with a repairable tear, even though they're 65, you know, that is a role for operative indication for the ACL as well. So sometimes people miss that, but if you have a repairable meniscus in that age group, I would go ahead. Ashish, Romain, any other comments? Little to add other than I think this is a good example for as good as this knee looks, right? Age is just kind of a surrogate with the quality of that knee and the appearance of no reason not to fix that meniscus. Yeah, fully agree. I think we have a non-significant amount of colleagues who would indicate a knee arthroplasty for some reasons in that case. But no, fully agree. Repair and do the ACL. Okay, so that's our choice. Would you add biologics? Ashish? You know, probably in this setting I don't think, no, that I would, Pat. You know, again, I don't know that there's strong data for it. You might add a fibrin clot if you're concerned at 65 that there's some other comorbidities, but to be honest with you, if I was doing the ACL and fixing the meniscus, I'd probably just do that. Okay, all right. So that's what I did. I did an all-in-side repair. Here's a patella-formal joint. She had some counter-wear of her patella, but really the rest of her joint was, as Rachel pointed out, pretty remarkable. So I thought, you know what, I'm gonna put it back. We'll see how it looks. I agree with everything that the panel said. It's important, as Ashish taught us, you know, to really roughen up that calcifer junction of the meniscus. I like to go with just a straight all-in-side technique and put eight sutures in, top and bottom, as Aaron's taught us, for that compression, for the 360 compression of the healing for the meniscus. So here's what I did. Would you guys go inside-out as well? Which, you know, preference, Aaron? The data shows really no difference between the two techniques and, you know, if I didn't have a lot of help that I trusted, I would do this as well. Dr. Hankelman was just visiting us as a traveling fellow and, you know, having four people assist me in the OR is a luxury, for sure. Well, let me tell you, I'm struggling brand-new in Naples, Florida, with my help, so it was all-in-side for sure. Okay, so anyway, so she's doing okay. She's got like 160 degrees of flexion on her other knee. She's an ex-professional dancer, so she's not super happy with me that it flexes to 150 at five months. I mean, her other leg is like, I mean, it would break my femur. It's unphysiologic how much flexion she has, so that's her complaint right now, is, well, doc, you know, I can't bend my knee like the other side, so we'll see how this thing holds up, so. Okay, so how about this one? 26-year-old male, felt injury playing soccer, felt a pop. He tells me, hey, I'm going, I'm enrolled in the Marines in five months. Can you, can you help me out? So, here's his motion, not so good. He's got a lochman, can't really pivot him. Stable varus and valgus. Again, here's his x-rays, nothing crazy. Okay, Ashish, what are you seeing here? A minimum, at least a lot of edema. There's an ACL tear in the coronal view. It's hard to see a little bit in the back, the meniscal roots, but I may want a second look at those. Okay, here's some, if it runs through, let's go. Here's your sagittal images for you. It looks like an MCL injury. There's some undersurface on the medial meniscus, ACL is out. A little bone edema in that plateau, right? Okay, not too much there. So, here's what I've got. So, what are we gonna do with this thing? I've seen these kind of, you know, this is a, you know, this complex tear that has both a red-white zone, as well as a more peripheral red-red zone, almost meniscal capsular injury there. You know, I still think that this is one that you make attempts at repairing, and I've seen, you know, different techniques where you can incorporate both of those tears into your repair construct. You can repair that inner tear and then repair more peripherally, but I would make an approach to kind of work around both of those longitudinal tears and repair that. Romain, would you keep that longitudinal tear that's the white-white? What would you do? Yeah, I would keep it. Worst case is that you have to return a couple months later just to take it out, but I mean, generally, this has a high healing potential. So, given his age and activity profile, the fact that you'll stabilize him, the fact that there's a lot of biology in that knee. So, yeah, go for it. And we know that the medial tears don't heal as well as the lateral. This was, you know, for me, I was kind of like, okay, can I fix this thing? I knew he needed ACL reconstruction. So, I elected to do it again with this technique. We'll see how it goes. I mean, I just feel like it's important to try to save it. It's tricky. There's not much room there to try to bridge that small portion on the white-white side. You'll see it. I don't think it's, it's not perfect. I don't see what you guys think, but, you know, he's a young enough guy. He wants to go in the military. Carledge looks pretty good. He had one little ding, but otherwise it looked pretty good. So, this is what I did. Just trying to pull them both together, came back underneath it. You know, I think that's one of the advantages of these on-side devices, very fast, so you can have different angles and oblique it a little bit if you need to. So, I just didn't really want to get too close to the edge. I'm just thinking I would rip through that. So, I don't know. That's what I did. It's not perfect. It's got a little gap there. I don't know. I think it'll heal. Aaron, what do you think? Yeah, I think, again, this is with an ACL. We could debate if it was an isolation, but I think with an ACL, it's got a good chance to heal. What are you doing for rehab on this guy? Yeah, I kept him a little bit off. Yeah, that's a great question. I typically, you know, taught longitudinal tears. I let him bear weight in a brace. This one, I kept him on weight-bearing for the first four weeks. I don't know. What would you guys think? Aaron, what would you do? Yeah, I think, you know, if it's just like one or two on-side devices, I just do a standard ACL rehab, but I think this one I would be conservative. He's gonna try to go to the military in five months. I'm having that discussion with him that that's probably delayed. Travis. So, just to pull the panel, this is, you have circumferential fibers that are preserved here. You're gonna circumferentially go around with it on-side or inside-out, whichever you prefer. Why not let them weight-bear a locked-in extension? That should theoretically compress across the circumferential fibers. You have your hoop stresses preserved. Is there a downside? I'll just tell you, I don't trust this guy. He's not gonna listen, so if I don't have him in a brace and tell him at least something about protecting his weight-bearing and limiting inflection beyond 90, there's gonna be no chance, but again, Pat, see him in the office, but I know this patient type. Yeah, my concern, Travis, is that inner tear is really not perfectly reduced, you know. I mean, I wish we had meniscal glue and I'd be able to just put something on it. So, I was worried about that inner fragment displacement. It's quite absolute. Good question. Okay, so he's doing okay. He's just a couple months out, and this is all new stuff that I have, so. All right, so, question? So, that's a great thing. So, has anyone in the panel had two knee surgeries, emotionally? Because I hear it's a whole- Seven. You see, I'm in New York, and I offer two knee surgeries in the state of North Carolina. My only one surgery that I got out of the plane 20 years ago was a guy that I repaired who pissed. It didn't work out. He was a homicidal guy. So, I just think, you know, the technical military sometimes, I hear it, but I just wonder if it's cause that when you have the second knee surgery, I think sometimes we just have to really manage the expectations that I do have. I don't trust this guy, he's going to the military, but I understand why he's saying it, and it's my idea, but I think it's good therapy to have conversations with the military throughout your 20 years. Yeah, point well taken, Kev, for sure. Yeah, I think there's, I think KP's point is really pertinent, not just for meniscus surgery, but for everything we do, and especially in 2025, and if you're taking care of athletes in the U.S., there's also that possibility that you take out the meniscus because you think it might not work, and then they get upset because you caused arthritis, and that's in your hands. So I think my ACL conversations, one of my fellows was joking, he can give my spiel that I give to patients from heart right now, because he's heard it so many times, but we talk about risks, benefits, we quote them numbers on re-operation based on the historical literature and my own practice. We do the same with meniscus, whether it's repair or meniscectomy, same with cartilage, repair, replace, transplant, et cetera. So I think as long as you set the stage ahead of time that there's a chance for complications, no surgeon and no surgery's perfect, there's a chance for re-operations, and re-operation is not synonymous with failure. Re-operations like getting an oil change, not getting a new car, that I think that sets the stage ahead of time versus having to walk that back after the fact. Okay, let's just jump this one. This is like my second patient I saw down in Naples. 17-year-old tore his ACL seven years ago, right? Didn't get fixed because his growth plates were open and there was nobody down there that could fix him apparently. So a guy, multiple re-injuries, comes to me, mom is really intense, so here's his exam in the office. I'm stressed out trying to build this practice and this lady's all over me and I go, okay, I'm this kid, as you can see, it's got, in the office, two plus pivot, I mean, he's super unstable. X-rays look remarkably good. I want to kind of show you guys, jump through this. So he's ACL deficient, he's got meniscus going on, medial and lateral. Aaron, you're the one that never misses this. What else does he have besides his medial meniscus tear? Well, he's, yeah, he's got the medial undersurface tear, laterally, you know, worried about a root to root variant, especially with that chondral damage laterally. Aaron always finds the lateral meniscus roots on MRI that I never get to see on MRI, but he's smarter than me on that. So lateral roots, so guy's a mess, right? So look at this tear. So, you know, yeah, he's got that, but look at the, look at his root. So what do you think, Aaron? Am I crazy about that? What are you gonna do here? So I've seen a few of these tear patterns. It seems like that posterior root has kind of pulled off a little bit. You know, I know what you're gonna do because you've already lengthened the MCL there, so. Cheated a little bit. Actually, he was pretty loose already. I didn't have to do much. So, I mean, would you repair the root, guys? One quick rapid fire, yes or no? Yes. Rachel? Yes. Keith? Yes. Travis? Yeah, so it's just challenging, you know? So let's just go ahead. So, you know, I did. So I, you know, this kid, he had a lateral root. He has this. I got no help. I got brand new ACL. I'm like, what am I doing moving here to Naples from? So I'm asking for these devices and nobody knows what I'm doing here. This was a nightmare case, actually. So I'm trying to do this by myself, holding the leg, holding the scope with my teeth, trying to, this was a rough one. I'm not gonna tell you how long this surgery took. So I'm embarrassed. So I think the key is really trying to get it just, you know, as anatomic as I could. And as Aaron showed, this aperture fixation device has really been a game changer. And with the ability to suture in situ right there. So a lot of work. This was just the medial side. Then I had a lateral root. Then I had an ACL. And then I had a, he's got a full thickness condal defect. I did an osteocondyle graft and I did an LAT at the same time. So this took a while. So, you know, I put it back together. We'll see. He's doing pretty well now. A lot of suture, root back. So anyway, but you guys kind of get a feel of that one. All right, so let's kind of really, really quick. I want to show this one. This is something we're gonna see. So this is a 53-year-old female came to me with left knee pain. She said it bothers me with my kneeling walking. She's in the healthcare space. She's been seen by a couple other orthopedic surgeons, said an MRI said your meniscus is normal, nothing we can do, steroid and therapy. She has medial pain, tender, positive McMurray's test. X-rays look good, even her weight-bearing films. So look at this. She, you see much on this MRI? It's a hefty soft tissue envelope. Yeah, she did. So, I mean, did you see that? A little bit of like a postural medial chondral edema. Right, so, okay, so this is cool. So here's your scope. So she's got Aaron's lesion, in my opinion. You can see the roots a little bit up, but watch this. She does not have a, this is a meniscal tibial tear. The meniscus is not torn. I'm underneath the meniscus pulling it forward. So I think, Aaron, this is kind of what you're, what you taught us about how the meniscal tibial starts to fail. So I think this is really the exciting area for us. If we can find these patients before they tear the root. I did go ahead and reinforce the root. And I just wanna get your guys' opinion. Would you have done this? Would you have just left this? What do you think, Aaron? Yeah, I think this is kind of the next frontier of, you know, you have to spend time with this patient in clinic, but your history gave you a better idea of the diagnosis than your MRI did. So I think MRI, there's some subtle things, but here, I think that patient is usually right when they give you that history. And, you know, these are patients who've been treated and they get substantially better, you know, assuming, you know, the mal, you have no malalignment and other issues. Well, I did, you know, I centralized her because, you know, she had that just about a millimeter extrusion. I think my opinion was she had the lesion. And so I went ahead and centralized her as well as doing the root repair. So the interesting thing is she really, really did well. And actually, I saw her at a year. X-rays look great. So you can see, I just pulled it in, centralized her, all good. She came back at a year and said, do my other side. I had the same thing. So I did both of them before. So I did both sides. I think we're almost out of time. Let me just show one quick thing that I wanna just, one last video right here. Let me back up if I can. So I would say this about the lateral meniscus. I've got several of these. You know, I'm an old guy. I've been doing this a long time. Can that video, can you play that video, Shane? Will that play for you? Yeah, thank you. So just be really aggressive on the lateral side. Look at this tear. This is, you know, awful. She showed one similar. He repaired it much better than I did. But, you know, you have these terrible tears on the lateral side. Tempted to just take it out, move on, you know, go get your ACL done. So I came in and fixed this, you know, with a, you know, a meniscal-based repair. And, you know, it's not my best job. You'll see it here in a second. I just wanna make the point about what can happen here. So you get, you know, you got ties, knots. I mean, it's, you know, the fellow's looking at me, and you go, really, that's as good as you got? Okay, so I would tell you, do this. And look what happens. I've got 20 of these in my practice I'd love to put. Look it after my ACL reconstruction. Went back and looked at it. It's friggin' anatomic. So I think the lateral misc is just really forgiving. And, you know, just get that thing together, and I think when you put your ACL in, I think it has a good chance. Hey, Pat, the one comment I'd make, and this is just learn through folly. When you're doing these, I found it helpful to put the first stitch really close to the edge of each meniscal at the radial tear. It's not a very strong stitch, but it does anatomically compress the edges, and then you can put another one on either side of it, and it doesn't overlap the two ends. So I call it an apical stitch, similar to that, not that dissimilar from when you're doing a fracture reduction, but in a similar fashion. Just very small bites on your first one like you did there, and then take a bigger bite that's more of a strong repair so you don't overlap and you compress. And in regards to lateral miscus, Chris, run through the panel. Do you guys have any problems putting sutures through the hiatus to fix the lateral miscus tear? Oh, Romain, is he hitting the puppeteer step out of the air? Not on a routine basis, but in cases like those where it's your last salvage option, then yes, we do. Sheesh. Yeah, same, I'll try to avoid it, but if it's required to get some form of purchase for the repair, I'll do it. Gives you some stability, Travis. I would have gone around this one. You have a rim. I went around this one, but I'm saying, do you hesitate? In general? No, not appraisal. No hesitation. Aaron? I tell you, I pulled a lot of all inside, you know, probably the plastic out of the puppeteer's hiatus down the road. So I do think it's probably under-recognized. There's probably some issues there. But if you have no alternative, I think it's reasonable. Question? Yes, please. I would like to have some technical tips on dealing with ramp feet. So when you put a knee through a range of motion, the ramp opens up an extension, does it? In some cases, yeah. Not always. So then the follow-up question is, when you're repairing it, what's the knee position for the repair of the ramp? Hanging knee 90 degrees, which is my traditional one. I mean, if you have the patience of pine, you can do it in flexion. But you need to do it in flexion. That's when the capsule goes posterior. And then it's straightforward. Can I ask Romain a question? So is that PDS suit you're using, or is that a type of nylon? No, it's PDS. PDS 1. PDS 0 is not strong enough, in my experience. You break it, but PDS 1 never breaks. Can you give us your perspective? So looking at a lot of the US surgeon videos, we all tend to use a permanent type of suture in the meniscus. You use absorbable. Can you give us a little bit of your perspective there? Yeah, so in the beginning, we used non-absorbables, actually. And then in some cases where we had to do some revisions, when you look at the meniscus, then you have absolutely no healing around it, non-absorbables. And so we said, well, this is like a stamp, the small holes in the stamp. And we do try to avoid it, to have re-tears at that place. So that's why we moved to PDS. When I say we, it's actually Bertrand, Sonny Coté, and me. We worked a lot together on that at the beginning, years ago. And so now it's our standard approach. Question? Good morning. I'm Mohamed from Egypt. Thank you for this nice session. I want to ask you how to define physiological virus or constitutional virus, if you believe in such thing. And how does it affect root tear? Aaron, you want to take that? Yeah. Yeah, I would say it's an area of active debate. So I think for us, when we look at it, we kind of define 5 degrees as a threshold of overload. And it's bilateral and symmetrical? Well, again, it's not a problem until that root tear happens. And now it's an issue. So that being said, there is some good data out of Korea. They looked at groups that had basically 0 to 5 degrees of virus, 5 to 10 degrees of virus, and more than 10 degrees of virus. And in normal BMI patients, they still had pretty good results in virus knees. That being said, the way I approach it is, yes, you have to look at, and it's nice to get a long-legged standing x-ray, but I watch that patient walk. Because 5 degrees of virus is very different. So some people thrust with 5 degrees. And if you have shearing thrust across your medial compartment, gosh, I'm just not sure that our root repairs can hold up. Other people, that tends to be, I guess, more physiologic, and you don't see them thrust, and it's at 5 degrees, but it's still not affecting their mechanics too much, then I probably ignore it. Yeah, I think we get every meniscus. An ACL patient gets a long-legged alignment in my clinic for this reason. So the hardest one is when the alignment is just at the medial tibial spine, or just slightly medial to the downslope of that sign, and it's both knees. They were born that way. They're going to die that way unless you change something. But I think once you're addressing pathology in that medial compartment, then, just as Erin said, you really have to balance, is a root that's dead, because it's torn off, and you're not going to go fix it and hope that it lives again, is that root going to need some love? Is it going to need some support to offload, even though their normal is to live in varus? So when they're over kind of that 5 to 6 degree threshold, as long as they don't have significant comorbidities that I think get concerning for bone healing, I have no problem adding the osteotomy, because I think, if anything, that's going to be the most powerful solution, should my root repair fail, to preserve their quality of life. But I think this is one of the hardest decisions, because it's very easy to tell a patient, I'm going to take you for an arthroscopic procedure, even if you're going to be on crutches for six weeks, they can stomach that for the root repair. When you say, I'm going to cut your bone, they start to get a little bit antsy. But I think we have to make sure that we're doing the root repair for a reason, and if varus is going to contribute to failure, which it may, we have to address that. Not much to add. I would agree with all of that, but standing alignment films are part of the equation. It helps me counsel my patients. Severe varus, or the medial root, obviously is a portentous, not ideal outcome. And then later, you do osteotomy on the other side. No, not unless they're asymptomatic, or if they're symptomatic. So he has one knee straightened, and the other knee is. So it's funny that you mention that. I get this a lot in my valgus knees, where you're correcting for an osteotomy for cartilage or meniscus preservation, or lateral compartment disease, and they always ask, well now, will you do my other side? I would say most patients, outside of a 12 or greater degree correction, don't notice that their one leg is straight, and their one leg is still crooked. So I have never done a prophylactic, not to say that I won't, but I've never yet done a prophylactic osteotomy, just to make the legs look symmetric. I only do an osteotomy if they have symptoms. And I have not had anyone complain, even with up to 14, 15 degree double level corrections on one leg, having to do the other leg if it's not symptomatic. The only thing I'll add is, and I think your point's a good one, right, which is that some balance between protecting what you've decided to repair, which is the root or the root variant tear, and then the risk that somebody who's quote unquote physiologic or has mild symmetric varus is now concerned about a windswept deformity. And as we know, even if you add that osteotomy, and perhaps that root doesn't heal or doesn't look structurally healed on the MRI, you've introduced one other factor. So I think this is an area that's entirely unknown right now, particularly when it's symmetric or physiologic varus, you know, should you add in that osteotomy because it comes with a host of risks. And I may add that we need to differentiate between acute and chronic cases. So in acute cases, no extrusion and so on, I think it's a small virus, probably not necessary to add an osteotomy. If you're going more into chronic, having a virus you can correct. And if you do the osteotomy in these cases, I never over correct, which I would do, for instance, for medial osteoarthritis, then you over correct. But in these cases, I just put them to neutral and that's usually enough. Yeah, I would say to me, in my practice, obviously it's your decision making. But the problem is a lot of these patients we have in the US have big BMIs, they're big, heavy people. They have diabetes. To add an osteotomy at age 55 and risk complications, I don't do it. I say, I'll fix your root, give it a go. But I would accept the virus because of the risk of adding that, you know, doesn't make to me that much sense. And really, the study to me, you could do an osteotomy in a control group or do a root repair in another group. I mean, the osteotomy may be fine without the root repair, quite honestly. What's gonna work in that setting is, so I don't do it. And don't forget that patients in Korea, as Aaron told us, they are very disciplined, unlike us. Very disciplined. And very often they keep them for weeks in the hospital with a very, very strong rehabilitation protocol and so on. So keep that in mind if you read the literature. Any other questions? Getting back to the high-strain sutures, maybe you have, do you look at, I have two cases of a muscle handle that turned later into a radial turn because of one of my teachers. So I'm a little bit concerned in the paper from the San Diego to the Grand Mission. You know, around 4%, if I remember correctly, of a re-injury because the high-strain suture is acting like a cheese wire coming through the, so do you have any concerns? You say that, but you're gonna make everybody using high-strain sutures even for inside out. Go ahead, Rachel or Aaron, go ahead. So I've taken care of a number of iatrogenic and where I typically see it, it's an all-inside device. Won't get into company names, but it's people over-tension it, particularly in the lateral meniscus. Because that lateral meniscus needs mobility. So when they over-tension into the capsule, that's why I love the cases Travis was showing because he did a meniscus-to-meniscus all-inside technique. Soon as you tether it to the capsule and you over-tension, if you're seeing that puckering with an all-inside device, particularly that plastic one that concentrates forces, that's where I see those iatrogenic radial tears. Yeah, I kind of think of it as a, I also do shoulder work and kind of over-tensioning a rotator cuff and resulting in that type two re-tear. I totally agree. Even on the medial side, I think we can over-tension. So I think these devices are so good now and they're so strong that we have to be, I think that's the main issue. I've not been concerned even with inside-out about using suture tape or permanent suture material, but you really have to pay attention to that tensioning. The only thing I would add is anything we put in is a temporary fix. If it doesn't heal, nothing's going to work regardless of what suture you use. So if you have a dissolvable one and it doesn't heal, you're going to be taking the torn meniscus out. If you have a permanent one that doesn't heal, it will tear through. So everything, whether we put metal in, plastic in, or anything else, if it doesn't heal, it's going to fail. So from my perspective, reduce it anatomically, use permanent or dissolvable. And if it's going to heal, it will. If you do over-tension, then you're not anatomically reducing it. So that's an iatrogenic problem, but it's not an implant failure, it's a technique failure.

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