All right, so root and ramp lesions, the other two R's after radial. So the three R's, we're going to cover the last two of them. So we know the role of the menisci, we're not going to really cover that, it's important. It's radial hoop stresses are important, and as Dr. Logan just told us, it's critical to recapitulate those hoop stresses, either with a radial tear repair, or what we're going to talk about now, the root, which is the root of it all, with the bony attachments. We're going to focus on root and ramp, and then we've obviously covered all these other ones throughout this morning's talk. Extrusion is important. You know, it's something that we've talked about as a word of late, we all see it, but it's a problem we have to take care of. I mean, when we do weight bear, we have to worry about the extruded meniscus, and it's more chronic, it gets fixed extruded, so we have to relieve that extrusion. Sometimes we have to do meniscocapsular releases to get that darn thing back in the working part of the joint, and act like the chalk block that it is. But disruption of the meniscotibial ligaments is assumed when patient presents with limited meniscal pathology, but greater than three millimeters side-to-side extrusion. So most of us don't get side-to-side MRIs, we've counted on the literature for that, but when you see it, you kind of know it. And three millimeters is the cutoff, or a change of at least two millimeters side-to-side. Can't get this to advance, there it goes. So meniscal extrusions and root tears, specifically. Root tears are strongly associated with extrusion. You know that either it's an acute ACL-related root tear, that's the early cohort of younger patients, and that second cohort may be pre-arthritic, but still shown by the Mayo Clinic to give us good, better results, and decreased hastening toward the total arthroplasty clinic if we do root repairs in the right second, older subset of patients. The severity of cartilage damage is independently associated with extrusion, as well as varus and valgus alignment. So we always got to think about alignment, too, especially in that younger cohort. What other forces are we fighting against? There's no evidence of meniscal extrusion associated with neofusion or higher BMI, and that's a good thing. I'm in San Antonio, and BMI is our middle name. Higher BMI can lead to other degenerative joint changes that can cause meniscal extrusion. But I have a second cohort of patients that, I would say all of them, have an elevated BMI, and they actually do reasonably well with our technology now to get a good root repair done expeditiously. So what does a root tear look like? Well, when you see it like this, it's pretty obvious. When they're attenuated or more of a juxtaposed to the insertion site or radial tear variant, they're more challenging. But they're a challenging injury in general because they don't always happen in the easiest part of the knee. It's in the back corner of the abyss. You have to have good visualization, but we know they're important to recapitulate the hoop stress distribution. And securing the meniscus in the small bone socket has been proven to be an effective and reproducible technique with like a pull-out suture, if you think of it. But they usually are permanent sutures, at least in my hands. So root tear repair. It's an arthroscopic evaluation and preparation. We know that you can't always count on the MRI to completely show it. There's a couple studies that say that sagittal and coronal images are the best way. But you have to identify the location on the plateau to which it goes back to. And that's best done after you do kind of a notchplasty, if it's medial root, below the posterior medial bundle and the eminence you can take down so you can see, just like you're doing a meniscal transplant. And I do a lot of those. So if I think like preparation and visualization, you have to tape off the room to make it doable, and then you can get it done. You can use RF or a burr to kind of take care of this and do a modified notchplasty, if you will. But you have to see to do. There's all sorts of guide systems out there. And this is a long traverse from the low inferior tibia. If you're doing an ACL, it's down and behind your tibial tunnel. You don't want to crisscross them because you'll have suture disasters. But you use some sort of aiming device, and a lot of companies make them. And you can either use offsets or point-to-point guides, whatever you are comfortable with. If you've got a great guide, though, and it's point-to-point, you can target where you want it to go. Sometimes you can see the root tear off and the bleeding in an acute case. But you want to just make a socket or drill hole and be able to get a passing suture and just pull down your grasping sutures. And that's simply what we're doing. So that's what we're doing. You have to have control of the sutures, just like a shoulder case. There can be a lot of sutures flying around. There's these luggage tag sutures and all these fancy suture configurations. But first is do no harm. So don't ruin the cartilage trying to get a fancy stitch. And just get a grasping stitch and co-apt it to the darn bone. And that's our goal. And that's how you secure it. And then with rehab, obviously, we control the forces. We don't want to walk on most root tears initially. It's just like a minuscule transplant, except now we don't have a bony plug. We just have soft tissue to bone. And this is just kind of diagrammatically what we're doing. It's the same drill guide in most of our hands that you use for whatever ACL technique and company's products you're using. But the concept is deliver a passing suture, pass your locking sutures on your meniscus, and pull at least two down into the hole. Two, I guess, because one's probably good enough. And if one ruptures, at least you still have something else hanging on. And all we're doing is co-apting. It's not a super strength stitch, because a lot of times they're a little tenuous. So you have to protect them with rehabilitation. All sorts of devices to do it. And then distally, you have these sutures, and you're tying down the flagpole, the meniscus, down to the bone. And that's how I'll cleat it off. You can do that with an anchor. You can do it with a button. One of those two techniques is kind of standard. And there's not that much elasticity if you use the right kind of suture with less than 10% of give. It's about a 40 millimeter length from insertion to bony fixation on the distal tibia below your ACL external socket, if you will. So here we are placing with a suture passing device an auto cinch. That just means I have a loop suture that looks like a lollipop. That goes over the shaft of the passing device. And then when I bite the tissue, I pull through that loop, it auto luggage tags that suture that you see on the left. And I'm passing the second one deep and posterior to it. And then we just rope it down. Here we are with the sutures deployed. We give it a little tug test to make sure two's enough. If one pulls out, it can always have room for another one. I kind of try to stagger them as best you can. But in reality, I get two into good tissue and pray, right? So that's all we do. I mean, because it's not like we're working in the mid-body. But there they are passing the sutures. You got to almost capture it on video, because if you get a still, if you're not the one shooting and someone in the room helping as you miss it, it happens so quick. And that's if you've prepared it correctly and gotten rid of all of the debris and can see it. So here's the setup for centralization. Now many authors, including Mayo, Dr. Stewart, our friend and colleague, have talked about centralization. Can we just hang our hat on attaching that meniscus to bone? Sometimes maybe not in the chronic setting. So the chronically attenuated, still-extruded meniscus, we can help it on the medial side with a centralized meniscus-to-bone junctional implant or repair. And that's what we're talking about in this paper. This is kind of the setup for that, having accessory portals that come in with either an all-suture anchor of choice, and then we simply pass the sutures around the meniscus and we're just kind of helping. It's a helper suture is the way I think about it. You want to over-constrain it, especially laterally. You can't really get away with this laterally because there's so much anterior-to-posterior play. But medially, it's been shown, at least early on, not to wreck the compartment by decreasing translation in the anterior-to-posterior plane. But it does stabilize and bring the meniscus into the game. And we know that root repairs versus partial meniscectomy, people say, I don't want to put my patient into the hassle, but the VAST scores in global outcomes and the COOS scores in the outcomes for meniscectomy and repair are good, and they're equivalent. So we know it's better long-term to keep our meniscus, so it's in that realm of save the meniscus. And here's the global VAST as well, and then followed by the global COOS ADLs. It shows reasonable regaining function all the way out to two years, and that's where we have enough data. Now, switching over to ramp lesions, who's seen a ramp lesion? Who was surprised when you got in the OR and you looked back with your Gilquist maneuver through the notch and saw this meniscal capsular tear? Sometimes you don't see the tear, but you see the tibial plateau, and you're like, that's odd. Why did I see shiny tibia? I'm not supposed to see it back there. And that's often the giveaway, because in about 20% to 30%, depending on where you are in the acuity of your MSK radiologist, you miss ramp lesions. So ramp lesions are said to occur upwards of 20% to 30%. We'll talk about a paper out of UConn, my old fortress that I hung out in after West Point. I think Edgar and RCO and our group there showed a propensity in acute ACLs up in the 30%. And this is Dr. Leprod's paper that said, to rule out a ramp lesion, you have to look. You can't always just hang your hat on that bad MR of an acute knee with blood in it and tissue, and it looks like a Rorschach blot test back there. You have to look. Once the calmness of the arthroscopy occurs, you can see that tear, either with a 30-degree scope coming across the notch or a 70-degree scope coming around and seeing more around the meniscus capsular body junction. So here we see an incidence or prevalence, rather, of 3.1% to 16.8%. So I lied. It wasn't 30%. It's more like closer to 15% to 20%. And that's out of a large cohort. The MRI sensitivity and repair technique were talked about in this exhibit way back at the Academy in 2016, so six years ago. So this is one of those things that I look back at old scope pictures from Tripler when I was a resident in the 90s, and we had ramp lesions, and we had nice pictures of them, but we didn't do anything to them, so maybe we had inferior results because of that. So it's a poster medial cannulated portal that you can make. Everyone's kind of made that portal probably less often than we'd like to admit, but you can either do it all in the back or other ways, or if you think about it, get a helper device back there, a poster medial portal, and just a probe. Lift up that capsule that falls away from the meniscus, and then you can go from front to back and put an anchor in, or you can work in the back. If you have a spacious enough poster medial space, you can work all in the back, and we're going to show you a different technique here in a second. So in their results, translation and strain returned to near baseline in all their samples, and it works out good. If you see it, you should repair it. This is one of those things, like the meniscus is whole, and your MSK radiologist will say there's no meniscal tear, but they didn't say there wasn't a ramp lesion, so it's up to us to really confirm that, because the ramp is at the junction of the meniscal and capsular junction, generally speaking, from a definitional standpoint. So pre- and post-repair, this is in their study, just looking at what it looks like obviously open. You can do these open. I think they're more difficult, actually, because it's more technically demanding. You've got to have more risks of nerve and vessel damage, perhaps, but all our technology allows us to do these very efficiently arthroscopically. But this is what it looks like. This is what we want to recapitulate. It's like the argument of open Bankart versus arthroscopic Bankart. You can definitely get it done, and hopefully the results are similar. So in conclusion, repairing the lesion at time of ACL reconstruction is important in restoring knee biomechanics. So if you see it, and there's a prevalence of about 15% to 20%, that could really be hindering our results if we just blow them off. So if you see it, because it's definitely seen us in the past, take care of the business and figure out a way to fix it. Come on thing. We've got no advancement. Can you guys? There we go. So here's what it looks like on an MRI, if you happen to get it. I like the coronal view, which I don't have, I don't think. But here we see the ramp lesion diagrammatically. It's in that dark spot in the back of the knee. Here's the meniscal capsular junction, what it looks like. And if you can pull the meniscus away, and you don't necessarily, the plateau, because it could be a young person with a really thick meniscus, you don't quite see it. But this is kind of real-time what it looks like in a 32-year-old male with a complex posterolateral meniscus tear that's repairable, and here's an ACL. And then we don't want to overlook this. There's a little blood bath back there. We've created this lesion. If it's actively bleeding, you can be assured, all you got to do is co-opt A to B, it's going to heal, because that's a mini blood bath, and that's under pressure of about 35 millimeters. So here's an all-suture technique, doing a ramp repair with all inside, you can see the gap closed down there, that little clot. That's nice. I don't need to add any biology in this one, because I'm about to do an ACL on top of it. But doing biology can help. You can do inside-out repairs. This is a medial meniscus with a capsule, or you can do this ramp technique that we'll end with. I've used a little silicone cannula back here, because it gives you more play. It safely gets you in and out, and you can control sutures. And I brought in one of my modified rotor-locking sliding knots, so I don't have to do a lot of manipulation back there, and I use this little special kind of curvilinear corkscrew type device to pass the hardened suture, and if you use the company's hardened suture, you can just go suture, direct the suture, retrieve your ends, and do a sliding locking knot in the back like that. It's very simple. Practice on a cadaver model first, but once you get the access and develop that view on the right inset picture, it's very doable, because you've got the pliability. I used a hip skid before, a one-third kind of hip skid to get in there, and you can just back it out. But you have to have access if you're going to do this, and you have to have reproducible access and safe access. So all-inside meniscus repairs, they do good. The all-inside meniscus repair with the ramp lesion, it gets good KUS scores. And in conclusion, ramp lesions constitute a common but often missed entity with ACLs. Ramp lesions produce significant anterior tibial translation, and once we repair them, you can get it back to normal. MRIs have a low sensitivity, so be skeptical and always look, and at present, it's highly recommended to repair these lesions to avoid previously mentioned unwanted biomechanical consequences. Thank you very much. Thank you very much. Enjoy the rest of your meeting.

ACL reconstruction

root tears

hoop stress distribution

meniscus extrusion

ramp lesions