Hi everyone, my name is Megan Bishop. I practice at Rothman Orthopedics in South Jersey. I want to thank Anna for having me as part of their course this year. Today I'm going to be giving my talk on meniscal root repair, role of releases, centralization, and osteotomy. These are my disclosures, none of them are relevant. Meniscal root tears are relatively common tears. We see them in 10-21% of meniscus tears. When we think of meniscal root tears, we think of both our medial meniscal root tear and our lateral meniscal root tear. These are actually pretty different tears. The medial meniscal root tears are the ones we see more commonly in practice with our older patients, oftentimes more obese, more associated with degenerative type tears. Our lateral meniscal root tears, while they can be degenerative, a lot of times we see these associated with more traumatic injuries like an ACL injury. How we approach these is somewhat different, but also the way we treat them is somewhat the same. I would say that today I'm going to focus mostly on the medial meniscal root repair as that's what we see most commonly in practice. A meniscal root tear is defined as an emulsion of the insertion of the meniscal attachment or complete radial tears that are less than one centimeter from the attachment. We're going to treat these tears that are less than one centimeter from the attachment similar to a root tear. Biomechanically, these are important because they disrupt the continuity of circumferential fibers so that the meniscus now will fail to convert axial loads into transverse hoop stresses, and you can get rapidly progressive arthritis in the knee. This is just an arthroscopic picture example of a meniscal root tear on the medial meniscus root. How do we identify meniscal root tears? Once you learn how to identify meniscal root tear in MRI, this is something you'll really be able to pick up at any time. You want to look at this in all three planes, the coronal, the sagittal, and the axial. On the coronal, you're looking for a high signal indicating disruption of the root here, so you actually see where this error is pointing. You can see your dark meniscus, and then you can see white where the tear is, and then this is just off the root as you see a little stub of root left here. You want to look for meniscal extrusion outside the joint over three millimeters on a coronal section. You also can look at the axial cut as well. You can see your C of your medial meniscus, and then again, you can see the disruption of the meniscal root here. And then finally, you can find your pathomonotic gosine that you see on the sagittal where you can see absence in the normal black triangle that you see at the posterior root attachment of your meniscus. You can actually see gray or white showing absence of the meniscus there. Why are meniscal root tears important? Well, we do know, again, it disrupts function of our meniscus, so you can get arthritis in a much faster fashion. This was a good meta-analysis that looked at a cohort of 55-year-old patients that presented with meniscus root tear. They did not have osteoarthritis at baseline. Over a 10-year period that they were followed, they found meniscus, looking at meniscus repair versus meniscectomy and non-operative treatment, they found that those that had the root repair had a 53% rate of osteoarthritis, while those that had a meniscectomy or non-operative treatment had 93% and 95% rates of osteoarthritis. And looking at total knees, only 33% of the repair group went on to total knee versus 51% and 45% of the meniscectomy and non-operative treatment. So repairing a meniscal root can change the natural history of the knee and be able to slow down developing that arthritis. When we look at clinical factors that are associated with successful root repairs, what really what you want to know is what's associated with poor outcomes. So this was a systematic review that looked at five studies and had 179 patients, and they found the risk factors for poor outcomes with the root repair was pre-existing high-grade chondral lesions or outer bridge three or higher, as well as varus alignment over five degrees in the medial tears. Interestingly enough, they found BMI and age in the majority of studies were not associated with worse outcomes. So when you're evaluating these patients for really who not to perform surgery on, you want to look for those patients that have those high-grade outer bridge three or higher chondral lesions, patients that have varus alignment over five degrees. BMI and age generally are not always a cutoff for these. Some patients, especially if they're younger and they have a root tear, even if their BMI is very elevated, you still want to fix it. However, I do caution that you want to make sure these patients can follow the post-op protocol. It is a little more difficult for older patients as well as heavier patients to be able to maintain and it can non-weight-bearing status or be able to use an assistive device to walk for or wear a brace properly for the time period necessary. So let's go through the trans-tibial meniscal root repair steps. So there's a number of different ways to repair root, but this is the most common way, and this is how I like to do it. So obviously, always beginning with a diagnostic arthroscopy. First, I usually like to pie crust my MCL just when doing a medial meniscal root repair to be able to get better exposure to the root. It allows you to be able to breathe the root better. It allows you to be able to just essentially work better back at the root because that can be quite a tight space. So to be able to do this, you take a spinal needle and you come either just above the body of the meniscus or just below the body of the meniscus, and you don't have to come out of the skin, but you can just move a number of different places through the MCL and have a gentle valgus force while you're doing this. You should be able to feel a real pop in that MCL and it'll open up. After you're able to get that exposure, you can do your debridement and releases. Then you want to go ahead and place your passport or cannula. You'll drill your tibial tunnel and pass your shuttling suture. You would use a meniscal scorpion or some kind of suture passing device for two to three repair sutures through the root. Plus or minus at this point, you can place a centralization stitch and then you can complete your tibial fixation. So looking at releases, so chronic tears may be scarred to the capsule and require release of the meniscal capsule junction in order to achieve anatomic repair and reduce stress on the repair. So you can come in and use a shaver. You can use arthroscopic scissors and really try to release that scar tissue around that root, especially in your more chronic type tears. Coming in with a grasper to be able to pull that back over will show that you won't have too much tension on the repair that is going to fail. After you perform your releases, you can come and do your drilling and suture passage. So I like to use a point-to-point guide here and a flip cutter I use. So I'll come in with the flip cutter through your tibial tunnel and come back about 10 millimeters after deploying the flip cutter. This allows to have a kind of a bony bleeding bed for healing, as well as a passage to be able to dunk the meniscal root in. You'll pass your passing suture and then you can come in with your meniscal scorpion repair device. I usually use fiber loop sutures, three of them at the root insertion here. Suture management sometimes can become a little bit of an issue here, so I actually usually like to keep my shuttle and suture outside of the cannula until I'm ready to dunk and pass all the sutures that you did, as you can see I did here. So the next, if you do want to perform a centralization stitch, you can form your meniscal centralization stitch at this time. So we know that persistent excrusion of the meniscus is bad, so even after fixing a meniscus root, if there still is extrusion, these are associated with worse outcomes and still having progression of OA. So we want to do everything we can to be able to prevent that persistent extrusion. A biomechanical study from AJSM 2019 showed that a root repair with meniscal centralization may help reduce this extrusion and protect the repair. And then Critch in arthroscopy in 2023 looked at 25 patients who underwent medial root repair with centralization and followed these patients for two years. They found that 88% had subjective improvement in learning outcomes, none went on to TKA and none went on to secondary surgery. They found no radiographic progression of OA as well. So being able to do a meniscal centralization procedure is an important supplement, especially in your younger patients that you want to be able to have the best outcome possible. So this is an example of performing a meniscal centralization stitch. So this is that same patient as before, we've already placed our root repair stitches, but haven't fixed them yet. Using a spinal needle to localize underneath the meniscus of the meniscal body onto the medial tibial plateau. I like to use a knotless 1.8 suture, excuse me, 1.8 fiber tack anchor. So moving percutaneously under the meniscus with the fiber tack anchor here. If you want to place more than one anchor, I would recommend placing them before you reduce the first sutures down. As once you reduce this down, it actually ends up being a pretty tight bit, so it's much harder to place additional anchors. So I placed your first, I've already switched my scope into the medial portal and now I'm retrieving sutures off the lateral portal here. And the blue suture is the repair suture, which you're going to load into your scorpion and deploy at the meniscus capsular junction. And this is going to be passed in a horizontal mattress like fashion. So in order to do that, the next stitch you're actually passing is the loop stitch that you're going to pass your blue repair stitch through to shuttle through the anchor eventually. So then you're taking the last stitch at the bottom and using that to reduce your repair stitch, the blue stitch in that horizontal mattress fashion. So that's shuttling through. And you can see the horizontal mattress stitch hanging down that meniscus capsular junction. Reduce extrusion. So yeah, like I said, you can throw one of them, you can throw more than one. I think one does a pretty good job of reducing that extrusion as seen here. And you can also see that there still is good mobility to the root to be able to repair. I like to do the centralization stitch prior to it because I don't wanna loosen up my repair after it's done. So I always do my complete my tibial fixation after doing the centralization stitch. And so finally you finish with your tibial fixation. It's the other choice which how you wanna do this. You can load the sutures into an anchor such as a swivel lock. You can tie over a button. If you're doing more than one bone tunnel, you can tie over bone tunnels. You wanna confirm your reduction arthroscopically and fix the knee in 30 degrees of flexion immediately and 60 degrees of flexion for your lateral meniscus root tears. And the question is, is there a role for high tibial osteotomy in conjunction with performing a medial meniscal root repair? We know that three to five degrees of tibial varus alignment can increase peak adduction pressures and ground reaction forces by 50%. And as we said before, varus from five degrees is a risk factor for failure of medial meniscal root repairs. From our Asian colleagues, they've done a number of studies on these which are mentioned here, looking at HTO with medial meniscal root repair. And they did find greater healing rates of the meniscus and some better regeneration of cartilage on second look arthroscopy. However, they found no differences in clinical outcomes in these studies. So really I think the role for high tibial osteotomy at this point is pretty low in conjunction with medial meniscal root repair and less very special circumstances and potentially very young patient that may have so good well-maintained cartilage but have some kind of significant varus alignment. So in summary, meniscal root tears or common tears are all gonna approach these very frequently in your practice. Fixing them is important to restore biomechanics of the meniscus and help slow osteoarthritis progression. There's worse outcomes associated with outer bridge three and four as well as knee varus over five degrees. You know, we still will repair these in older patients as well as more obese patients but you wanna make sure they're able to follow the post-op protocol. Releasing your MCL and your meniscal capsule scar tissue is important. You can use centralization stitches to be able to help reduce residual extrusion and help improve your outcomes. And at this point, HTO is generally not necessary in most cases. These are my references. And thank you very much.

meniscal root repair

medial meniscal tears

lateral meniscal tears

MRI identification

osteoarthritis prevention