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In this two-episode limited series, Christopher Adams, MD, leads a discussion with surgeons Aaron J. Krych, MD; Travis G. Maak, MD; and Patrick A. Smith, MD, about meniscal pathology and the latest biomechanical research on meniscal repair. The group also reviews a study, published in the American Journal of Sports Medicine, in which the FiberStitch all-suture all-inside meniscal repair implant performed significantly better than hard PEEK implants and inside-out techniques.

FiberStitch™ Technique Biomechanical Research

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Christopher Adams, MD (Arthrex Sr. VP of Medical Affairs), leads a discussion with Aaron J. Krych, MD (Rochester, MN), Travis G. Maak, MD (Salt Lake City, UT), and Patrick A. Smith, MD (Columbia, MO), on a recent biomechanical study published in the&nbsp;American Journal of Sports Medicine&nbsp;supporting the&nbsp;FiberStitch™ technique for all-inside meniscal repair. View the&nbsp;<a href="https://journals.sagepub.com/doi/abs/10.1177/03635465221107086?utm_campaign=ajsm-scientific-graphic-relief-displacement-vs-initial-load_arthrexli_fiberstitch-ajsm_2022-11-28&amp;amp;utm_medium=organic&amp;amp;utm_source=linkedin&amp;amp;journalCode=ajsb">study abstract</a>.

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Videoaufzeichnung einer Podiumsdiskussion mit einem Chirurgen oder Chirurgin zusammen mit entweder einem Produktmanager oder Produktmanagerin, einem Mitglied des Medical Education-Teams oder anderen Chirurg:innen.

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FiberStitch™ Implant Biomechanical Research: The Results

Hello. Today we're going to be discussing meniscal repair. In a recent biomechanical study published in the American Journal of Sports Medicine, we have with us in the studio, Doctor Aaron Krich from Rochester, Minnesota, doctor Travis Mack from Salt Lake City, Utah, doctor Pat Smith from Columbia, Missouri. Gentlemen, thank you for joining us today. Thank you Chris. Thanks, Chris. Thank you. So, Travis, can you please give us a brief summary of the paper? Sure. I'd be happy to. This was a biomechanical study. Looking at all inside and inside out devices. There were three peak implants for the all inside device, as well as fiber stitch and all suture based, all inside device, and then suture tape and basic suture for the inside out. And it looked biomechanically at pull out strength. Total load to failure, gap formation and relief displacement, and tried to evaluate which one had the better and worse characteristics. That was a great summary, Travis. Thank you. Now, Aaron and Pat being the authors on this paper, can you please highlight the key results for us specifically initial load in relief displacement. Well, Chris, the initial load, what we did is we set all the repairs at a standard intraoperative tension of 50 newtons on the instron. And then what happened was we released the traction. So at that point, you knew exactly what was left that the device was holding the repair at. And that's the initial load. And then what we did is took the instron and took it down to two Newtons to unload it, to start our cyclic loading. But when you unload the construct there is stiffness from the repair itself. So we could determine which one had the greatest relief displacement based on that unloading effect. So Aaron, why are these results important to the repair and ultimately the patient? Yeah, I mean, the bottom line is we want the meniscus repair to be successful. And we have a lot of choice as surgeons. And we want to choose an implant that really has high primary fixation strength that's going to provide adequate compression at the repair site to allow that repair to heal. Thanks, Aaron. Now, we all know that optimal healing is best achieved when the fixation secures the two tissues and resist gapping. Pat, can you please share the importance of testing the gap behavior during cyclic testing? Well, Chris, we want to make sure that our repair stays together and it stays compressed. And that's important for us in our postoperative management of patients with knee range of motion when you start weight bearing. So the cyclic loading part of this paper was to determine which device gave us the best compression through that cyclic loading. And that translates directly into care of our patients post-op. That's very interesting, Pat. Now, Aaron, did anything surprise you when you tested inside out versus all inside techniques? Yeah, I think, you know, for me, this is one of the first Apple to Apple comparisons trying to simulate real life not only with repair in the operating room at time zero, but also with rehab. And clearly All Inside did better than inside out for both of those categories. And specifically the all suture based all inside construct constructed the best for both of those. And what did you think about the inside out difference between suture tape versus regular suture? Yeah. So for inside out, I think it's really dependent on the strength of the knots. And when we're tying knots with the suture tape, I think it was clear they both had a higher fixation strength and resisted that gap formation a little bit better than standard inside out suture. So we all know the one test that can't be overlooked is ultimate strength. Erin, can you share these results with us? Yeah. So after we put the meniscus through its cyclic loading protocol, we then did an ultimate pull to failure. I think that allows us to assess really the weak points in each of those suture and repair constructs. And what we found was that the all inside all suture did best. We found that the peak implant sometimes broke. Sometimes the peak implants actually pulled through the tissue. So having that broader backstop of the all inside, all suture was superior. That's interesting. Now, Travis, it was mentioned that ultimate stiffness was measured simultaneously with ultimate strength. What did you learn? So I think one of the biggest concerns with all inside techniques is that the implants will not hold themselves well under ultimate cyclic loading. And what we found here, interestingly, was the all inside, all suture based fiber stitch not only resisted gap formation, so stiffness was improved, but also it did not pull through. So ultimate strength was the best as well. So it actually was effectively the best of both worlds. So gentlemen that was a great discussion of the study. Any final thoughts. And we'll start with you, Pat. Well, Chris, I think that, you know, fiber stitch came out on top here. And I think it really has to do with the design of the construct. You know, this is an adjustable knotless tensioning device. So I think the fact that we have two sutures that we can adjust decreases the overall friction. And I think that's what allowed us to get these good numbers in terms of compression and less gap formation. Travis. So I think the two suture based, what Pat was just talking about, allowing you to dial it in and get perfect compression of the meniscus was a very important takeaway from this study. But for me, also the ability to put an all suture based implant into the capsule, have it have have the highest pull out strength of all, which is the big was the biggest concern for me was really the biggest take home. Yeah. And for me it comes down to, you know, the successful meniscus repair. We want good compression. We want resistance to gap formation and biomechanically. The fiber stitch really did the best job here. That was great. Again, thank you again for joining us today. Thanks, Chris. Thanks, Chris. Thank you. So this has been a great discussion on the importance of meniscal preservation in the impact of this agsm biomechanical study. Now, if you haven't had a chance, we encourage you to watch our other episode where we discuss the importance and principles of meniscal repair. Thank you for joining us.

Christopher Adams, MD (Arthrex Sr. VP of Medical Affairs), leads a discussion with Aaron J. Krych, MD (Rochester, MN), Travis G. Maak, MD (Salt Lake City, UT), and Patrick A. Smith, MD (Columbia, MO), on meniscal pathology, the ABCs of meniscal repair, and how they influenced the recent biomechanical study published in the&nbsp;American Journal of Sports Medicine, which compares all-inside and inside-out meniscal repair devices. View the&nbsp;<a href="https://journals.sagepub.com/doi/abs/10.1177/03635465221107086?utm_campaign=ajsm-scientific-graphic-relief-displacement-vs-initial-load_arthrexli_fiberstitch-ajsm_2022-11-28&amp;amp;utm_medium=organic&amp;amp;utm_source=linkedin&amp;amp;journalCode=ajsb">study abstract</a>.

FiberStitch™ Implant Biomechanical Research: Meniscal Pathology

Hello. Today we're going to be discussing meniscal repair. In a recent biomechanical study published in the American Journal of Sports Medicine, we have with us in the studio, Doctor Aaron Krich from Rochester, Minnesota, doctor Travis Mack from Salt Lake City, Utah, and doctor Pat Smith from Columbia, Missouri. Gentlemen, thank you for joining us today. Thanks, Chris. Thank you Chris. So, gentlemen, let's start by talking about meniscal pathology in general. Pat, what is repairable or potentially not repairable with present day techniques? Well, Chris, as a knee surgeon, I think our goal is to always repair the meniscus. And now we have the techniques available to do great intra articular repairs all inside. Plus we also can do side to side repairs such as with the knee scorpion. So I think the devices have really helped us expand what we can repair. Now Aaron, you helped lead the charge for meniscal preservation. Why such a strong focus on this lately. Well, the meniscus is just critical to the overall health of the knee and knee function. And we know if we remove meniscus tissue, it's really the beginning of the end. And as Pat stated very well, we have more techniques. We're saving more meniscus tissue, which will lead to better outcomes. So once we've decided the meniscus can be repaired we consider the ABCs anatomic reduction biologic preparation and compression. Travis what are your anatomic considerations? So for me the most important thing is reestablishing the biomechanical integrity of the meniscus. Circumferential fibers, if compromised for example with a radial tear, need to be restored. Pat mentioned the meniscus scorpion. A great option for that route repairs as well. Establishing the attachment to the tibia. And last but not least, the circumferential when torn in a vertical fashion, reestablishing the repair to the capsule and minimizing any sort of displacement is also increasingly important. Good points. Travis. Now, Aaron, how are you preparing the meniscus to elicit a biologic response? Yeah, the B for biology is extremely important. And as a surgeon, we certainly don't want to overlook that step of the meniscus repair operation. So we really need to spend a lot of time rasping not only the repair site, the surface of the meniscus, the synovial area around the meniscus. We're learning more recently that a lot of progenitor cells live in those areas, and we really want to stimulate those cells to begin the healing cascade. Aaron, are you doing anything else biologically like Trephination or anything else to stimulate that healing process? Will your repairs? Yeah, that's a great point. So certainly if tears are extending into the avascular zones, then Trephination I think is a great option anytime you have an isolated meniscus repair without a ligament reconstruction, I think doing some marrow venting, stimulating the notch bone, I think it can be very helpful. Thanks, Aaron. That's definitely an important step. Pat, now that the meniscus is ready to be repaired, let's talk about stitch configuration and tissue compression. Well, I think tissue compression Chris is critical for healing. And we know the vertical mattress suture is the strongest construct. But I think it's important to understand the anatomy of the meniscus in its triangular shape. So if you put a vertical mattress just on top, you could actually separate underneath the meniscus. So I think it's critical to put a divergent vertical mattress above the meniscus and then come underneath meniscus and put another vertical mattress divergent there to close that gap to make sure you have full compression at the tear site. Okay, so Pat, you and Aaron were co-authors on this paper. What influenced you both to put this type of biomechanical study together? Well, I know from talking to Aaron, because we both were able to get the fiber stitch in our hands very early on how excited we were to have an adjustable tensioning device for meniscal repair, which hasn't been out there. So we wanted to compare that to what the gold standard of today was in terms of other devices for meniscal repair. Okay. Now, there have been publications in the past that have compared all inside meniscus repair to inside out repairs. Pat, why is this study unique? Well, I think the uniqueness is what we looked at because we other studies have really concentrated on gap formation or maybe ultimate load of repairs. We actually looked at the strength of the device and compared that to really show how it can help gap formation based on the quality of the fixation, initially to optimize compression for healing. That's great. Thanks, Pat. So, Travis, can you dive into the methodology of the publication for us? Absolutely. So this study looked at three peak all inside implants as well as the fiber stitch suture. All suture based, all inside technique, as well as two inside out techniques using standard suture and then suture tape. And really it looked at both cyclic loading with 500 cycles as well as initial displacement and pullout strength, and looked at which of the anchors and which techniques were better or worse, which had better biomechanical parameters, which had worse. Travis, that was a great summary and a great discussion. Gentlemen, thank you once again for joining us in the studio today. Thank you Chris. Thank you. Absolutely. So this has been a great discussion on the importance of meniscal preservation in the impact of this agsm biomechanical study. If you haven't had a chance, we encourage you to watch our other episode where we break down the results of the publication and highlight how the paradigm is shifting to all inside meniscal repair with all suture fixation. Thank you for joining us.

In this two-episode limited series, Christopher Adams, MD, leads a discussion with surgeons Aaron J. Krych, MD; Travis G. Maak, MD; and Patrick A. Smith, MD, about meniscal pathology and the latest biomechanical research on meniscal repair. The group also reviews a study, published in the American Journal of Sports Medicine, in which the FiberStitch all-suture all-inside meniscal repair implant performed significantly better than hard PEEK implants and inside-out techniques.