I think all of you agree that it's a great summary of everything that shows that we've had a long way to go. Fiber cloth has been used for many years. A lot of exciting things coming down the road, but we definitely have to learn a lot more. It's great to have people like Scott, who's a scientist, but also a clinician that can put both of those together. So now we're going to learn how to deal with complex cases. Catherine, go ahead. All right, so good morning. I appreciate all of you who got up probably at 6 or 6.30 to make it in for this. I know it wasn't easy for everyone. So I'm going to talk a little bit about complex meniscus tears and particularly kind of innovative ways, hopefully, to start repairing them and hopefully repair them successfully. Oops, sorry, a little delayed action on the... But anyway, no disclosures. So when we talk about meniscus, we kind of have to have a common vernacular. And mostly what we talk about is whether that meniscus tear is vascular. So is it in the red-red zone, the red-white zone, or the white-white zone? And secondarily, we talk about sort of the orientation or the shape of the tear. And we have a number that we'll talk about, and this kind of encompasses most of the ones that we'll come to in our day-to-day practice. Traditionally, on the right side, we had very tight indications for meniscus repair. They had to be moderate to large-sized tears. They were in a vascular zone. They were generally vertical. Patients were young, less than 40, good mechanical access, acute tears, and ideally a concurrent ACL tear. But if we meet all these criteria, we're probably addressing less than 10% of the meniscus tears we see in our daily practice, possibly even less than that. And there's been increasing recognition that if we're debriding all of the tears that don't meet these criteria, we're removing a lot of meniscus in a lot of young patients. So today, I'm going to talk about the other tears, the majority that we see day-to-day and that might be amenable to repair, or where repair should at least be considered. And those are going to be radial, horizontal, and complex tears. So why expand our indications for repair? So number one, there's no going back. Once we take that meniscus out, of course, we'll hear a little bit about hopefully some upcoming alternatives in the future. But once that meniscus is gone, it's not coming back. And so we need to be good stewards of our patients' needs and really do the best that we can to preserve that meniscus, but in a way that gives good outcomes and good long-term results for those patients. Second, there is certainly reasonable but not perfect evidence that successful meniscus repair leads to improved clinical outcomes, particularly over the medium to long term, compared with meniscectomy. We hope that this prolongs athletic activity. Certainly there's good data in the NFL and other athletic populations that meniscectomy, particularly extensive meniscectomy, shortens careers. If we can preserve that meniscus, we may be preserving that athlete's ability to stay on the field for a longer period of time. Next, we think that repairing the meniscus successfully reduces the risk of osteoarthritis. Again, this data is not perfect. Most of our long-term clinical outcomes are a little bit tough in orthopedics and particularly in sports, just because we have a variety of very mobile patients without as much follow-up as we would like. But there's certainly that suggestion that a successful meniscus repair reduces the risk of future arthritis. And finally, we have better techniques. As the techniques have gotten better, as the implants have gotten better, our opportunity to really address these tears in a successful way has grown exponentially. So what are the cons of expanding your indications for meniscus repair? Well, number one, you're going to have higher revision rates. And I put revision here instead of failure, but those terms sort of go hand in hand. If we expand our indications, we're going to have more failures. And that's a discussion we have to have with our patients. And they have to understand that we're taking a little bit of a risk trying to repair this meniscus, but with an eye to the future health of their knee. Second, we're going to buy longer rehab times for these patients. And that may not be an opportunity for every patient. We certainly have patients who work in construction who have athletic schedules that they're not willing to miss, where we may feel that they're appropriate for a meniscus repair, but that may not be in the cards for them. And then finally, we're going to see a higher complication rate. And these tend to be nerve injuries. These tend to be implant-related complications, sometimes stiffness. And of course, revision or failure often gets wrapped into that higher complication rate. So let's talk a little bit about radial tears. And I think this is when you're moving beyond your repairs of longitudinal or vertical tears, I think that radial is kind of that gateway into some of these additional meniscus repairs. So radial tears traditionally were really thought of as irreparable. But in the past decade, there's really been a lot of increased interest and published data on repair for these types of tears. There's this study from Jeff Abrams back in 2013. And he was looking primarily at CPT data. And they saw from 2015 to 2011 a doubling in the CPT codes for meniscus repair, particularly isolated meniscus repair, so not just in the setting of ACL. They didn't see a huge decrease in meniscectomy. But a follow-up study to that published in 2000 saw that those meniscus repair rates had continued to go up somewhat, and the meniscectomy codes were dropping down. And so what we are seeing is we are seeing changes in practice pattern where people are starting to address some of these additional tears. So why has that changed? I think there's an increased risk, excuse me, recognition of the significant biomechanical consequences and osteoarthritis risk related to radial and other tears. And so people, I think, really start to think more carefully about what the result is in the long-term, not just the short-term patient satisfaction. And I can say personally in my own practice, I have more patients coming in asking about repair. So I think when patients go and Google their meniscus tear, they really get more information about what does removing the meniscus mean, what is the consequence to my knee, what's the risk of my development of arthritis. And although internet searches are not always helpful to us when the patients kind of undertake them in an extensive way, I think in this case it actually is helpful when patients come in and they're already on board potentially with saying like, OK, this may be a longer recovery, but maybe this is the best thing long-term for my knee. So what's our technique going to look like for radial tears? And this is really being an evolution. I think the steps have not changed, but some of the techniques with regard to suture placement have certainly evolved over the last decade. So first, we're going to identify the tear. We need to get good visualization. We need to see the depth of that tear. We need to have appropriate opening in the joint space. And for me, that may mean doing a release of the MCL or a trephination of the MCL on the medial side, particularly for the patients who might be in their 40s or even a little bit older. They're having softening of their cartilage in many cases. And if we're causing a lot of articular cartilage damage in our quest to repair the meniscus, we may be kind of fighting against ourselves, kind of a one-step-forward, two-steps-back situation. I'll often prepare the meniscus, try to increase bleeding, particularly in our isolated meniscus. As Scott was just discussing, we really need to improve the biology and the vascularity. The more we can do to do that, hopefully the better chance we have of healing. We're going to make a decision regarding inside-out or all-inside repairs. And I think a lot of this comes down to surgeon preference. I don't think there's necessarily a best way. We're going to place and tension our sutures and then potentially augment biology. So number one is really kind of where I think a lot of radial tears started, was just placing two horizontal mattress sutures across the tear. And this is a fairly simple pattern. This is generally trying to stay in the red-red or the red-white zone. These sutures often will go out through the capsule and be, particularly with an inside-out device or with an all-inside device, your fixation is going to be on the capsule. But most of this is just to re-approximate the two leaflets of the tear. And this is kind of where things started. This does get you back to the stability of kind of your time zero prior to the meniscus tear. Some people will actually continue to bring that repair all the way out to the white-white zone. Typically if that is done, that will be done with a side-to-side suture that does not go through the capsule. And the reason for that is if you keep going with your white-white sutures all the way out to the central part of the meniscus, when you tie that down, if it goes through the capsule, it's going to tend to displace the meniscus. So our more peripheral sutures are going to go out through the capsule. Our more central sutures, if we plan to place them, are going to be through and through sutures that are circumferential through the two leaflets. So once people started doing these parallel horizontal mattress, they then went to a crossing pattern, thinking that this may give a little bit more stability. And biomechanically, it does seem fairly similar. It again gets us back to that time zero state. My personal experience with this is that I have found this technique a little bit difficult because I think it's hard to balance those two leaflets appropriately, and you tend to get a little bit of crossover or a little bit of malapposition of the two fragments. So those are kind of our early ways of doing these radial meniscus repairs. And what's really changed, probably over, really, it's 10 years since this was described in Japan, but I feel like in more common use, maybe over the last five to seven years, is this idea of a ripstop repair and sort of what's come on beyond that. And basically, the idea is you're not necessarily just trying to re-oppose the leaflets. You're trying to attach the leaflet of the meniscus back to the capsule and have that be a lot of your stabilization. And so what we do is we place a vertical mattress stitch anterior and posterior to the tear, and those are the first stitches that we're going to need to place. And then similar to in a shoulder rotator cuff, we're going to place a third horizontal mattress stitch that goes around those two vertical mattress stitches. And the idea is, number one, you're distributing the stress. So the stress is not just on the meniscus. It's on the capsule as well. And number two, you're reducing suture cutout. As we know, most of our failure is not suture failure. It's biological or soft tissue failure. And so if we can place some of the stress on these sutures instead of on our sometimes somewhat flimsy meniscal tissue, we're distributing stress more successfully. And in the shoulder, many of us have seen good results with that, and hopefully we'll see similar good results in the radial meniscus tears. What I will say and emphasize is that it's important to have the tear reduced before you place those vertical mattress stitches, because once you have those vertical mattress stitches in place, you're largely fixing where that leaflet will come off of the capsule. So think carefully about how you're going to reduce the meniscus first. If it is one of those meniscus that maybe needs a little bit of release or a little bit of encouragement to come back together, and that may be particularly true in your tears that are not quite as acute, and sometimes on the lateral side can have a little bit more displacement. So once we got through our ripstop repairs, we got modified ripstop, and then we got a rebar repair. And this rebar repair is basically saying, okay, we're going to use that ripstop concept. We're going to distribute our stresses, but we want to bring more of that leaflet together, and we're going to put additional sutures along the axis of the repair to re-oppose those leaflets. And those re-opposing stitches, those horizontal mattress stitches, they don't need to be overly tight. They're really just trying to oppose the tissue. They're not trying to, you know, compress it so much that we're displacing the meniscus. A lot of that stress with the ripstop or the rebar is really going to be at that capsule layer. And so with your horizontal stitches, you're really trying to oppose. You're not necessarily trying to overly tighten. Oh, you know, one last comment. And then the last technique that has been published by LeProd is a trans-tibial technique. And the idea here is that you're repairing those leaflets down to bone. And usually it'll be on that anterior and posterior side of the tear. And this does require a little bit more dissection. This requires a little bit more time. But it's also a very stable construct. There has been some mechanical concern that this might over-constrain the meniscus because it does reduce meniscal mobility. But that said, in terms of your fixation, it's among the strongest. Okay, so what are the outcomes of these different repair techniques? So when we think about our outcomes, we want to think time zero. But we also want to think with cyclic loading. So at time zero, most of these techniques are fairly similar in that they do get your meniscus back to its pre-injury state in terms of its mechanics, its ability to share stress and take load. But when we do cyclic loading, we do tend to see some differences. And particularly, as I was mentioning earlier, a lot of it comes down to the mode of failure. And the mode of failure for most of these is, again, going to be the soft tissue, just like it would be in your rotator cuff. And so if you can distribute that stress and you can put some of that stress onto the capsule, you're going to hopefully bear stress in a more distributed way, and you're going to have fewer failures. The second thing that we see, and we know this too from rotator cuffs, is that if you have more sutures, you're going to have more strength to your mechanical repair. And so again, your ripstop, your rebar, your additional suture-type patterns, those are going to tend to give you more strength with cyclic loading. In terms of the clinical outcomes, still kind of TBD. But that said, consideration of these distributed repairs, I think, should be within your thought process when you're looking at fixing these repairs or fixing these tears. So finally, what are your clinical outcomes? Well, it's still early days, but we're starting to get some additional data. Milleron, just last year, published a meta-analysis, 12 studies, 241 patients with radial meniscus repairs. And we get some good, almost demographic data from this study. What are people doing? How are they repairing these? It's fairly evenly balanced between inside-out and all-inside repairs. You know, we don't have a lot of information about hybrid repairs, but having those zone-specific cannulas and doing an initial stitch to reduce your meniscus never hurts, and I think that's a nice kind of tool to have available to you in these situations, particularly as you're starting out, making sure you get that reduced properly. About a third to a little bit more than that use biologic adjuvants, so there's definitely the thought process, hey, these are tears that maybe don't have quite the traditional ability to heal. What can we do to enhance this? Most of them restricted weight-bearing and range of motion for four-plus weeks. But I think the, you know, interesting thing to me is that we really saw pretty good clinical outcomes. So a number of these have either, these studies have second-look arthroscopy or MRI follow-up. In particular, on that right side, Suji et al. in 2019, they looked at 40 radial repairs and had second-look arthroscopy on 31, and they saw really good results, really exceptional healing. And although you see complete healing by imaging or second-look at 60 to 100 percent, if you included partially healed, you'd get up to 80 to 100 percent, so pretty high numbers. And the clinical outcome showed significant improvements in multiple scales and PROs, so clinically these patients were doing very well. I will give the caveat, most of these follow-ups are not longer than three years. The Suji study, which is three-plus years, is one of the longest follow-ups out there, so we have to see how these results hold up over time. And then finally, the reoperation rate is less than 20 percent, so it's fairly in line with what you see with vertical tears. And just to highlight this study up in the top right corner by Wu et al. in 2018, they basically created a cohort study where they looked at the outcomes of radial tears and the outcomes of bucket-handle tears, and I think this is really an attempt to kind of change our thinking. When we think meniscus repairs, we largely think of these radial and bucket-handle tears, but we know that mechanically the result of a radial tear is really just as severe, if not more severe. And what they found in their study is really equivalency between the two. So whether they were repairing a vertical tear, whether they were repairing a radial tear, they really saw similar outcomes, patient outcomes, clinical outcomes, radiographic outcomes. And so because of that, we should really start thinking of that same paradigm where our vertical tears and our radial tears are equally important and hopefully equally amenable to repair. So in summary, radial tears of the meniscus have a significant effect on contact pressures in the knee and likely on osteoarthritis progression. Radial tears show good mechanical and clinical outcomes, but data is limited. Biomechanical outcomes favor techniques with less risk of suture cutout. So these are a ripstop and rebar. We have multiple options that we need to have available when undertaking a radial repair. So really have your whole toolbox there. That may be zone-specific cannulas, all-inside devices, bendable inside devices, suture-passing devices, cannulas. Have everything you might need. It creates a lot less stress in the operating room. And then finally, those unanswered questions. What are the long-term outcomes? We really don't know. What is the effect of age? What is the effect of BMI? What about these white-white zone tears? Do we repair all the way up? What do we do with the popliteus hiatus? I think once we get that simple radial tear that has a red-white or red-red extension and we can get that repair down, that's sort of step one. But then we need to start addressing some of these other more complicated questions to better serve our patients. OK, so I'll do two more minutes on this. So horizontal cleavage tears, very significant number of tears, but generally not repaired. The techniques, number one, think non-surgical. Many of these patients really do not need a repair. When we are doing meniscectomy, we're going to try to resect the inferior leaflet only as the inferior leaflet is more likely to displace and cause mechanical symptoms. We have multiple techniques, but circumferential stitches are most common. Peter Kurzweil published the two-year results of his stitch study just last year, and they actually showed pretty good results, but again, about an 18% reoperation rate, but this was up into patients up to age 60. Finally, complex tears. Number one, know your tear. Look at all aspects of the tear on your MRI. Have everything available and really have a good plan if in doubt. And when you do have a root repair, excuse me, a root tear, fix the root first and then move on from there. And post-surgical care for vertical tears, we do think there's compression with weight bearing, at least partial weight bearing and extension. So consider letting those patients bear weight. As Scott said, for our radial tears, for our root tears, these are ones that you may want to have them stay off for a while. And in summary, preserve the meniscus when possible. Engage the patient in shared decision-making. They should fully understand the pros and cons of a repair, particularly when we're starting to push the limits a little bit on traditional repair. Evaluate your MRI carefully. Get standing alignment when needed. Consider additional instruments and implants. Consider MCL trephination. Consider biological augmentation. And think about what you're going to do with your weight bearing. Recognize that not every meniscus will heal perfectly, and so you're going to have some revisions or some failures and more studies needed in almost every aspect of this topic. Thank you.

complex meniscus tears

radial tears

meniscus preservation

repair techniques

clinical outcomes

shared decision-making