So, how many of you have done meniscal allografts? Okay, all right, so I'll review this. I'll just show you a technique and then go over a newer method that we're working on for taking care of meniscus. So should be on Carter. Yep. Okay, my disclosure's on the website. So when you're faced with this, what do you do? We know that this popliteus, the chance of the knee deteriorating is really great, so you can go ahead and put the meniscus back in. Bob, it shows that the stress definitely makes a difference when you put the meniscus in compared to the normal meniscectomy and meniscal allograft. Now, which patients do you pick and how do you get there? Indications, they should be involved to the part that had the meniscus excised. They should not have diffuse pain unless there's a synovitis present. Make sure the symptoms are due to the meniscus excision. You can see that's more of a ABN entity that's gonna have medial compartment pain that had meniscectomy. If you try to put a meniscus in, it's not gonna work whatsoever. Chondromalacia, we talk about more arthritic knees doing well, but if you try to get authorization with your insurance company, just tell them there's grade two changes. If you tell them there's grade three or four, they're not gonna authorize it. If it's an isolated defect, you've heard enough today, I mean this weekend, about treating the isolated defects so they're still a candidate. As far as indications, it's 50 to 55 years of age. It's physiologic and chronologic, but again, insurance companies will say beyond 55, do other things. You have to obviously address other pathology, the cartilage, as I said, the ligament or alignment, and it's not a substitute for a knee replacement. This person, if you go and put a meniscus in, it's not gonna do very well because of the alignment, so do an osteotomy to transfer the forces over to the midline. You don't wanna do this like an arthritic entity and go to the opposite side. Right through the tibial spines is a good way to perform it. We talk about using bone or no bone, and I'll go over this. Bone has been shown to be of greater benefit. I'm doing a biomechanic study right now with soft tissue and using the centralization. I'll have a little bit more information in a couple months to let you know if maybe you can just do that with soft tissue, but for right now, bone should be used to stabilize it. And if you see the bone plugs, you can see that they have more of a substance to them rather than just a soft tissue, and at least for now, it makes more sense to make a socket, have bone-to-bone healing for the meniscus. I use a dovetail technique and a two-bone plug on the medial side, the dovetail on the lateral side because the horn attachments are very close to one another, only a centimeter apart. On the medial side, they're two and a half centimeters, and the attachment up front is varied quite a bit. When you suture these, please don't ever do this type of technique. I don't know how this guy ever stopped from getting these crossed over. I don't know if you two can do this, but I sure as heck wouldn't be able to do that. I don't know where you'd start either. So this is just, as I said, under dynamic loading, transosseous fixation with bone provides superior load after a meniscus allograft compared to suture only, and this is one of the reasons. You have the bone fixation. We talk about this extrusion factor, soft tissues, 36%, bone fixation, 26, and this is what we talk about. You'll hear people talk about clinical studies making no difference. Well, this is from Korea. You can see that early on, it does make a difference, but if you have more extrusion after about four to six years, it does make a difference as far as arthritic changes. So extrusion is very important. Fixation, determine which has less extrusion and use that technique. So this is just, again, to show you how extrusion, when we do these, not just for meniscus allografts, but any repair, you repair it in the back. You come across with a couple stitches up in the front, and then you secure it anteriorly. If you put front and back, then you have to make up the difference in the midpoint, and you can pull the meniscus out. So this is not just for meniscus allografts. If you're doing a bucket handle tear, do it in this manner. Stabilize it one or two in the back, middle, and front. We talked about extrusion, and this is what the hot topic is. As I said, we're doing biomechanics studies. This is from Mayo Clinic. Tom showed these, and you can see afterwards, if you do these properly, it holds it in place. The medial side, it seems to be a good idea laterally because lateral meniscus moves a centimeter front to back. Some studies have shown it rips them out. So if you are gonna do this, stick to the medial side at this point. In technique, it is technically challenging. You can see that this meniscus doesn't have a chance. You can see where they made the trough. It should be right in line with the anterior and posterior horns. Obviously, this is not in the right place, so it's meant to have extrusion from the get-go. Can you start the video, please? This is a basic, simple. This is also for root. You have the line straight in front. Use a spinal needle. Start the opposite portal straight in front so you can see exactly in line because if you're trying to get the instruments in through there, you can easily disrupt articular cartilage. So not just meniscal allografts. Bring the bone plug through that straight on, or the instruments we talked about suturing it. You drill up through the back just like a meniscal root, usually six to eight millimeters for meniscal allografts, but root is just a couple of millimeters enough to have some bone bleeding stir up. And if you do this, you push the meniscus into the knee through about a 2 1⁄2 centimeter incision. You gently push the bone plug back in, and it's a very satisfying feeling once you get this to plop just as you feel when you have a bucket handle tear that you reduced. Boom. It's a great feeling, isn't it? So I have this reduced, and you've repaired. There's a root attachment. You go ahead and suture it around. You make this under direct visualization, and you go down enough that you can get the bone plug, and I personally just tamp these in. I used to suture these and take time to drill through the bottom and up. It's very, very cumbersome. So just go ahead. If you do it, just make a plug, push it in, and tamp it in that keeps it in place. Okay. So the allograft clinical studies evidence shows it does provide relief and improve function. That's what it's all about. 10-year follow-up. There's multiple studies and systematic reviews that show rate benefit of 70 to 80. The radiographics, as I showed you, if you prevent the extrusion, it has been shown to stop, it doesn't stop. It slows down progression of arthritis, and this is a publication I just did. Longest follow-up, at least for now, in the American literature. 20-year follow-up, 56% were still survivorship. And as far as arthritic changes, you see eight of these went on to arthroplasty, but the average time frame was 14 years. So most of these did last quite a bit of time if you take the time to make sure it's properly positioned and not extruded. So conclusion for meniscus allografts. Selection is incredibly important. It's not for the asymptomatic. People talk about asymptomatic. Number one, insurance companies aren't gonna do that. Number two is if you get an infection, arthrofibrosis, it's hard to justify putting a meniscus in, and it's not a simple operation, so it can occur. It's not for advanced arthritis. It's not a substitute for a knee replacement. It's for mild to moderate symptomatic patients. It's technically challenging, but if I could do it, then you should be able to if you take the time. And the ability to deter arthritis still needs further documentation. It is encouraging, but it's not scientifically proven enough as to how it would change long-term. So what would people do faced with this meniscus? You have the radial tear that was excised. You try to go ahead and replace it or suture it, it doesn't go anywhere. You can see the cyst going out. So yes, you can do a meniscus allograft, but I think all of you would agree that's quite a bit to fill in a small segment. So historically, you can use Menaflex. Hopefully you're at least familiar with this. It's a collagen first by Steadman, and it was drawn off, but it is back on the market. It's just a collagen. It grows into it, and there's an ActiFit implant. It's scaffold as well. You can see it's a polyurethane that degrades over five years. And you go ahead and you fill in these, cut out the area that I showed you, just if you had that radial tear that was excised, and you plop it back in. Problem is they don't look normal. Five years, you can see that's far from a normal-looking meniscus, and from a histologic standpoint, it doesn't fill in with healthy bone. There's more of the channels. So what do we do now? This is something we're starting to do studies on. It's something just to be aware of. We're doing segmental meniscus allografts, so ones that have less than 50%. We're starting to try to do this in just a video for completement's sake. Go ahead and start the video. This was done in conjunction with Pat Smith. Obviously, it's a Gandabra. You don't go and cut all this up before you work on it, but you cut it back to the circumferential fibers. You do not go beyond that because you want to have the hoop stresses. You go ahead and measure the length of the defect. Again, these are for less than 50%. If it's more than 50% excision, go ahead and do a meniscus allograft. Technique, you pull the sutures. So you have passing sutures out the front. You put them in into four quadrants. And it's technically, you have to keep these sorted out. Different cannulas have different portals. This one's four, so that way you can segment them so you don't get them crossed up. You'll go ahead and cut the segment of the meniscus to match the defect. We are starting to do little implants that you are pre-sizing so that you don't have a, it's more scientifically proven than just guessing. Put sutures in the four quadrants. So you see, by having different colored sutures, it's a lot easier to keep these organized. And then, as I said, you gently pull the sutures out. And then, as I said, you gently push it in. Do not pull it in so that it doesn't pull the sutures out. And again, the template we're working on instead of just free-handing it, so to speak. You tie them down just like you would an inside-out. And once you have it situated, you would do the same as a radial tear as you see here. If you have a little, small little snubbin up there in the corner, you would suture that further. This is just again for demonstration purposes. So that's, I think, the next thing that's coming down the road for us to deal with meniscus substitutes. Again, less than half, more than half meniscus allograft. Oops, didn't mean to be doing that. Oops. So you go back to the one slide where I have a thank you. So that's a meniscus allograft that I did a second look on at six months post-operative lateral side. So they look pretty good. They heal very well. If you take your time, you can see the position is within the joint to act as a true meniscus. Obviously, not all of mine have turned out that way, but I have to show you a good one at least. Okay. So we have about 12, 13 minutes. I want to leave some time open to ask questions. Somebody out there has to have questions for, use our, I guess you call it experience. Yes, sir. So I had a question for Dr. Robertson about the radial tears. I generally stayed away from the rebar and ripstop methods or repairing those because of that need to have it reduced in advance. Most of the radial tears I see essentially look like these, and I don't know any way to reduce those other than a side-to-side suture that pulls it together, which is what you're supposed to do last. So I was curious if you had any suggestions on how you reduce those in advance. So what I would say is two things. Number one, I think if you have that one centimeter gap, I think pulling it together with the horizontal stitch and hoping that it stays together, that always makes me nervous because I think it's too much soft tissue tension. And so we probably should be releasing more around the capsule, kind of similar to what we've all seen about root repairs, where it's the same thing. If we're trying to reduce something under too much tension, it's going to struggle to heal. And so we're probably releasing along the synovial border, putting less tension on it. I actually think it's okay, especially if you're just doing an inside-out and just putting a stitch in just to hold it. That way, at least when you put your vertical mattresses in for your ripstop, you're attaching it to the right place in the capsule, because if you don't, then you're going to have an inherent gap, whatever you do with that horizontal stitch. So I think number one really has to be that reduction, and I think that's going to be on the capsule or synovial side. I agree, though. Some of these are really difficult. I wish I could say that, especially on the lateral side, that I was able to immediately bring that gap down. But I think we do have to focus on that, because otherwise I think we're not achieving a close-to-tension-free repair. Tom, you've done a lot of these yourself. Yeah, I was just going to make a comment, actually. So the releases, I think, are critical. The more chronic they are, if you see a gap, the radial hoop stresses, our horizontal stitches are obviously in line with those. They're going to pull out and attenuate. So getting it reduced simply first. It's like when we talk in shoulders. If the bank cart doesn't auto-reduce, the sutures are doing way too much work. They're just management stitches. They just should hold it all in place. So the horizontal finishing stitches, like we showed in the talks, are key. Getting it reduced easily at first. And there's other tricks we didn't talk about, because it's only an hour long, but you can do criss-crossing, not criss-crossing in the frontal view, but criss-crossing directionally, so that you go outside in to get a passing suture to pull the back leaflet toward the front as you tie it down. So you have to generate the force vectors that auto-reduce it. And that helps decrease the tension. But doing those rebar stitches that were shown are key. You hold it, and you anchor it to the capsule. It's like pinning a butterfly to the corkboard. And then you can do your easy work after that, the finishing work. But I think that's key. We don't want to use all inside sutures for these? You can. There's circumferential devices on the market that you can act like your internal sewing machine, and you can get the four quadrants that were talked about in your talk very nicely to get a good, balanced repair that tethers it to the meniscus femoral and the meniscus tibial aspect, so it's balanced and doesn't lip up or jump down on you. You want it to look and act like a normal meniscus, and you can do it with a combination. Usually in my hands, it's a hybrid. There's a lot of all inside, but occasionally some anchor stitches that are those rebar stitches that actually do the work of the reduction. You have to be careful. You have to be careful on the all inside because those anchors, some of those are 17, even 16-gauge needles. They're easy sometimes to tear out of the meniscus because it's sometimes very difficult to oppose. Just to give you a heads up, I think you should a lot of times use inside out to get these and then use what Tom talked about. Are you repairing the white, white radial tears that just go into the red, white zone that don't go into the circumferential fibers in the back, like on the natural progression one that you showed, the initial stage? Because I see a lot of those that are primarily white, white into the red, white, but don't seem to go further all the way to the capsule. Are you fixing those or are you still cutting those out? In a younger patient, it'll be a discussion where we talk about the pros and cons. I think there are people out there definitely repairing right into the white, white. I think if it was white, white alone, probably not. If I think there's vascularity in the meniscus, I think that placing some of those more central sutures also probably balances your repair. But I would not sew those into the capsule because I think that deforms the meniscus. And I would consider doing that with the PDS so that I haven't really burned any bridges in terms of, hey, I'm holding it together, hopefully it stays. If it doesn't heal, it's not the end of the world. There are certainly some small case theories where they published going straight through that white, white zone. And the results have been surprisingly reasonable. It's not five-year data. It's not comparative studies. It's not 300 patients. But that said, I think using an absorbable stitch, I think doing that on the right patient who probably has some enhanced ability to heal is quite reasonable and may somewhat balance your repair. There was a study done by Scott Brodio that shows if you just have those inner one-third nibbling away is okay. The problem is people start nibbling and then they keep going further and further. So there's where the inner third, isolated inner third, you can nibble those away. It's going further out, don't, and definitely don't go. You see any circumferential fibers, that's what you're losing. So that's, again, there's publications by him if you want to look that up. It's tough to get those little flimsy inside ones, the sutures, tear out, and then you get a partial meniscectomy. So inner third, isolated, it's okay to nibble them out if you want. Thank you. Any other questions? It's extrusion in general. Extrusion can occur with a root that's intact and attenuated. That older age group, it's kind of like a tear in progress, I guess is the best way to describe it. It's like early precept to arthritis, actually, because there's overload in that compartment. You got to think about alignment and overload and all the other things. But the extrusion prevention stitch that people are talking about now, popularized at Mayo. They've done some work on that. It kind of works together with a root repair that's chronic. You can't just hold that big meniscus down with just two good root stitches. The idea is to kind of share the load and share the work. In the mid-substance, mid-body, meniscotibial, junctional tissue, there are techniques now. I showed one. We both showed one on a recent paper that you can use an all suture technique or a suture anchor and just kind of hold it in place and prevent extrusion from worsening. We don't know that we negate it, per se, but we think it's better to keep the meniscus in the game. Don't be afraid to release some, because if these are chronic, you're going to have a gap and you try to suture, they're going to tear out. So in the very back, you can release some to mobilize that as well. Release at the undersurface of the meniscus? The whole back part, right in the red-red, so that you can pull it over to get it more anatomic. You've got to, but it doesn't matter, you've got to do it through the whole thing. Yes, sir? When you're releasing it, the meniscus capsule is done, aren't you creating a ramping? No, because it's just barely by the, you're not talking about a whole major segment, it's just a small segment. We do it centimeters at the most is what I do. If you try to, these ones that have a gap, if you try to suture it, they're usually already extruded outward. So if we, so that's debated, whether those are, do you leave that gap there and then use a centralization, stabilization stitch? But if it's that far of a gap, those sutures are going to pull out and you don't have a true posterior horn. So you try to bring that posterior horn back over to as close as you can. So that's, again, we're not talking about a major release, just a small segment. Anything else you can add to that? I mean, going back to, there's different reasons to do releases. In the radial tear talk, if it's a chronic, it looks like a Michael Spinks, you know, scapula lunate type, like there's missing chunk of meniscus. Is it really missing or is it extruded through the radial tear? If it's extruded through a tear, it's just chronic and it's attenuated because there was some capsular injury, maybe with an MCL and a radial meniscal body tear. You can imagine that it's like an absolution in the shoulder. That chronic tear doesn't go together because the hoop stresses want to dissipate and extrude it. You can't just bring it in. You still have a gap. So you have to release it at that meniscus capsule junction to be able to easily get A to B. And that's, it's, I mean, it's really just trying to set it up for success and decrease the forces through your horizontal finishing sutures. And you're drilling up through the bone. So the healing is much greater because you have the bone marrow elements up through when you do these, like at a root. So again, we're not talking about massive, just enough to make sure you get a grasp where you can get it over. Same thing with those sutures. Tom's talking about just enough to pose it without putting excessive tension on. Other questions? None? Come on. You have to have some, nobody's had any problems with any of their meniscus repairs or replacements. You still have two minutes. You don't want to see Tom dance, believe me. No, not at all. I'm bullied. Anything else you two want to add? I like to follow up on the question with the releases because when you look at the coronal shots with the extrusion, on those views, that's like the nine o'clock position. And if you're trying to do a root repair back at the posterior horn, you're going to release all the way from nine o'clock to the posterior horn to get it to reduce. If you don't, and are you going to repair that? It doesn't make sense to me. I'm not released that far. No, you're not. It's a segmental release because there's tether at the extruded point and there are different subset of patients, not the acute root tear. You don't need to do releases. The tissues pliable, they're not scarred into that position. The attenuated older subset of patients, you get attenuation of the root and you get scarification out in the extruded position because of the attenuation creates a functional lengthening of your meniscus and it finds a happier space, not being a chalk block anymore. So it extrudes, you just need to release it enough to be able to get your root back anatomically because in that attenuated situation, you know you're not missing a meniscus, but just fixing it in situ doesn't change that coronal MR. You got to change that dynamic and you do that with a little release. You have to remember, a lot of these occur in San Antonio with larger people that Tom keeps talking about. I'm in Phoenix, but they're everywhere. But you get a 50 year old that comes in and said, my knee's totally normal. And they felt a pop, now my knee's terrible. So you can't repair all these. You really have to, we talk about all these, but you have to be realistic that you're not going to be able to repair these if these are de-jammed tears that have been tissues been pulled on or the extrusion has been pulling on that attachment. So we talk about these, but you have to be realistic on fixing these. They're not going to all come back. They're not all going to hold the sutures. But you won't put any additional sutures in like you would a repair. You just do the root repair. You don't put additional sutures to structurally reinforced release area. You don't have to. It's a minimal release. It's enough. It's like untethering it. And it just springs back in. It's kind of like when you do an MCL, you just pie crust it to get it open, which we didn't really talk about. But do if you need to for transplants and for repairs. Anything else you can add, Kirsten? Just enough. I would say, some of this is still really early days. And so I think it's good that we're at least thinking about these concepts, particularly with some of the root and radial tears. I think that we were really kind of missing the boat and not addressing some of these. But I think what we're going to learn over time is who the appropriate patients are. And some of them are so chronic and so immobile, they're just not going to close the gap. And I think putting patients through a repair and a long recovery is probably not the right thing to do. I also think we're going to learn how much we release and when we release. I think that the reason that some of the release is hard to describe is because it's subtle and you go in and you're releasing with a liberator or whatever you're using, and then it starts to come and it's really an interoperative decision. And so it's not necessarily cutting the entire capsule or attachment at the posterior part of the meniscus. The other benefit of some of these releases, quite honestly, is that it's pretty much in a synovial abrasion as well. So I think you're not doing enough structural damage so that capsule is not going to heal, usually is they're not going to be weight bearing for a while, two you're adding biology, three you're taking tension from the repair. So I would say don't be too hesitant to do some of these releases because again, as you've heard a couple of times, I think if we don't do some relief to reduce these menisci before we repair them, I think we're likely not going to get that result that we want. And I don't want anybody leaving here thinking we're cutting this all the way open. We're talking about barely, if you have to, a very small segment, you can get a grasper and pull it over to see if you approximate it, but don't, if you have to cut like a two centimeter area to get that over, that's not going to do well. Because that means that meniscus is a degenerative one that's been up for a while, you're not going to get that back or it's not going to hold sutures. So please, please don't leave thinking that. The other thing is just a little trick since we're supposed to talk. There's a study that shows if you're going to do the pi crusting, go high up near the MCL. A lot of people try to do it at the joint or inferior. The study they did was very good. It shows they just were the inside where you can see right the MCL and do that because it heals, has very great healing capacity. Sometimes you get frustrated and start poking these right at the joint and then you're causing the capsule to separate when you crank on the leg. So just a tip and that's scientifically proven in the lab. Yeah, once you do it, you don't go back because it makes all the difficult repairs and the visualization, you cruise after that and then you're like, why was I doing this the last 20 years? And then you get extrusion on your repair because you have to pull it to meet the capsule out there. So, well, thank you all for coming.

meniscus allografts

newer methods

knee deterioration

patient selection

surgical techniques

meniscus care