Treat a wide range of meniscal pathologies with the latest innovation in meniscal repair—all-inside meniscus repair using FiberStitch™ all-suture implants. In this procedure, soft all-suture sheaths replace traditional hard plastic PEEK anchors to provide a secure repair. Four different FiberStitch needle configurations are offered to address various tear patterns. Arthrex techniques and implants that address meniscus pathology include inside-out meniscus repair using the ZoneNavigator™ system with 0.9 mm SutureTape; meniscus-based, all-suture repair with the Knee Scorpion™ suture passer; all-suture meniscus ramp lesion repair; the Meniscal Root Repair System; and additional techniques for meniscus extrusion.

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A product of relentless innovation, the FiberStitch 1.5 implant features a new, low-profile delivery needle, resulting in less tissue morbidity and smaller implants and providing stronger fixation compared to previous FiberStitch implants.1 The proven superiority of FiberStitch all-suture anchors for all-inside meniscal repair is evident when compared to traditional PEEK implant systems.2 Made with 2-0 coreless FiberWire® suture, soft anchors provide secure arthroscopic all-inside knotless meniscal repair.
References
 
1. Arthrex, Inc. Data on file (APT-06136). Naples, FL; 2023.
 
2. Bachmaier S, Krych AJ, Smith PA, et al. Primary fixation and cyclic performance of single-stitch all-inside and inside-out meniscal devices for repairing vertical longitudinal meniscal tears. Am J Sports Med. 2022;50(10):2705-2713.doi:10.1177/03635465221107086

Arthrex presents the FiberStitch™ 1.5 implant, the next-generation all-suture, all-inside meniscus repair system with a 1.5 mm diameter delivery needle.

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FiberStitch™ 1.5 All-Inside Meniscus Repair

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FiberStitch™ 1.5 All-Inside Meniscal Repair

A product of relentless innovation, the FiberStitch™ 1.5 implant features a new, low-profile delivery needle, resulting in less tissue morbidity and smaller implants that provide stronger fixation compared to previous FiberStitch implants.1
The implant is available in multiple configurations, including a straight option, a 12˚ up curve, a 24˚ up curve, and a 12˚ reverse curve. Made with 2-0 coreless FiberWire® suture, soft anchors provide secure arthroscopic all-inside knotless meniscal repair with proven superiority when compared to traditional PEEK implant systems.2
References
1. Arthrex, Inc. Data on file (APT-06136). Naples, FL; 2023.
2. Bachmaier S, Krych AJ, Smith PA, et al. Primary fixation and cyclic performance of single-stitch all-inside and inside-out meniscal devices for repairing vertical longitudinal meniscal tears. Am J Sports Med. 2022;50(10):2705-2713.doi:10.1177/03635465221107086

FiberStitch™ 1.5 All-Inside Meniscus Repair Surgical Technique

Fiberstitch. All-inside. Meniscus repair. Determine the depth of penetration using the laser lines on the tip of the FiberStitch and set the depth. Stop accordingly by depressing and advancing the tab to the desired setting. Penetrate the tissue to the desired depth. Roll the deployment wheel backwards to the hard. Stop to deliver the first implant role, the deployment. We'll forward to the hard stop to load the second implant. Advance the needle tip through the tissue in the desired location, and roll the deployment wheel backwards to the hard stop. Roll the wheel forward to complete delivery of the second implant. Upon removing the device from the joint, a suture loop and a loose end of suture will be outside of the portal. Outside of the joint, pinch all the sutures and gently pull to set the implants. Identify the suture loop. Use a probe or similar device to pull the loop suture to compress the suture anchors. Tighten the repair construct by pulling the single suture to reduce the tissue. Introduce a suture cutter to cut the suture at the tissue.

FiberStitch™ 1.5 Implant

2.75 mm Mini Suture Retriever, Straight

Suture Tensioner/Cutter for 2-0 and 0 FiberWire Suture

Knotenschieber und Fadenabschneider, FW #2-0 und #0

2-0 Suture Cutter, 2.75 mm, Straight

Suture Cutter, Straight, 2-0 Suture only, Ø 2.75 mm

Pinza cortadora de sutura, recta, solo suturas de calibre#2-0, Ø 2.75 mm

CORTADOR DE SUTURA 2-0, 2.75 MM EIXO RETO

Fadenabschneider Ø 2.75 mm, 15° aufgewinkelt

Suture Cutter, 15° Up Curved, 2-0 Suture only, Ø 2.75 mm

Pinza cortadora de sutura, curvada arriba 15°, solo suturasde calibre #2

CORTADOR DE SUTURA 2-0, 2.75 MM, CURVADO 15° PARA CIMA, REUTILIZÁVEL (130MM X Ø2.75MM)

Child (D)

The ZoneNavigator™ System revolutionizes inside-out meniscal repair with single-handed control of needle placement. Use the ergonomic handle to advance and retract 2-0 SutureTape with meniscal repair needles in 1 cm increments. Cannulas attach to the handle to efficiently target specific zones of the meniscus.
Use the needle catcher to guide needles away from neurovascular structures. The concave, curved retractor efficiently retracts tissue and directs the needles for easy retrieval.

Aaron Krych, MD, (Rochester, MN) discusses the importance of re-establishing anatomical function of a damaged meniscus using the new ZoneNavigator™ system for inside-out meniscal repair. He also discusses using the Knee Scorpion™ suture passer for meniscal root repair and the meniscal root drill guide for transportal and transtibial root repair.

Meniscus Root Repair and Inside-Out Repair Techniques

Well, thank you to Reinhold, Chris Adams, the entire NE team for making meniscus a priority. My name is Aaron Critch from the Mayo Clinic in Rochester, Minnesota. And we're going to talk about meniscus repair pearls and innovative inside out repair techniques. I'd also like to acknowledge my partner, Doctor Michael Stewart, as we've developed some of these concepts together. So our preferred meniscus root repair technique is the trans portal Transtibial pull through technique, in which we create an anatomic socket with the FlipCutter 2 to 3 sutures using the FiberLink and tibial fixation using a SwiveLock. So what have we learned in the past two years of using this technique? Well, what was once a silent epidemic is now becoming common. 10 to 21% of meniscus repairs presented to our clinic are in fact, root tears. We still see the rapid progression of chondral degeneration with an untreated meniscus root tear. And now we're recognizing more and more with this publication by Freddie Fu and Ajsm this month that the lateral meniscus posterior root tear increases knee laxity in the ACL deficient knee by one plus grade, while the medial root is easy to see on MRI and visualize, the lateral meniscus root remains a challenge. 1 in 3 cases at our institution was missed on preoperative MRI. Therefore, with the lateral root, it's often an arthroscopic diagnosis. Take this an acute ACL tear and a seemingly normal lateral compartment until the posterior horn root is probed and you can see a complete traumatic avulsion. So you always must be prepared in these cases. In my opinion, the best way to be prepared is to have the root repair kit available. You're circulating nurse can open up one package. You can very efficiently perform your root repair in ten minutes later, be on with other parts of the surgery. So some pearls. First you need to create a space on the medial side. You often have a very tight compartment. We don't want to destroy the cartilage we're trying to save. So in this case we perform an MCL lengthening by placing the knee in valgus and perforating the femoral side of the MCL to create a grade two opening. Taking this from mission Impossible to something that's very accomplishable, we've also been using the PoweRasp to perform a reverse notch plasty the medial femoral condyle, and resecting the medial tibial spine. You can't fix what you can't see. It also creates a working space for us, and it also provides bony bleeding biology at the repair site. It's important to hit the target. If you don't restore the anatomy, you won't restore the biomechanics. We prefer the route repair guide, its advantages being the concave design to get it underneath the condyle. The marking hook hooks the back of the tibia. Adjustable pin placement allows for patient variation in anatomy. The swivel handle avoids torque and coalescence when performing concomitant procedures, and reliable two point fixation allows you to hit the target. So here's an axial cross-section of the tibia. The trans tibial root guide is designed to hook the posterior aspect. If you're coming more anterior into the PCL fossa, then your guide is also going to have a pin that's placed more anteriorly. So again, hook the posterior aspect of the tibia. You'll hit the target if you're coming forward in the PCL fossa your pin will be anteriorly. So here's what it looks like on a sawbones model. We hook the back of the tibia. We tamp down the step guide. We prefer to use a 3.5mm pin first and you hit your target. This is the typical posterior hook. If you come anteriorly into that PCL fossa, then your pin will also come anteriorly. And we hear this as a common issue. Avoiding coalescence is easy with the trans tibial root guide. Once you hook the back, you have complete degrees of freedom, both based on the angle as well as the as the swivel handle to avoid coalescence. That allows you to do cases like this. Here's a 25 year old with acute ACL tear, lateral meniscus, and medial meniscus root tear. Here we perform lateral meniscus transtibial pull through root repair technique. Same on the medial side and reconstruct the ACL all in the same setting. Here's a patient that requires a valgus producing proximal tibial osteotomy with the iBalance ACL reconstruction and medial meniscus root repair. Again, all in one setting. Because the swivel handle allows you to avoid coalescence. We place easy cinch sutures using the new Scorpion with old FiberLink. If you place the loop on your knee Scorpion first, it's a very fast and efficient way to pass your sutures. We just finished enrollment in our prospective multicenter trial with 45 patients all getting the same technique with the anatomic socket with the FlipCutter, 2 to 3 simple cinch sutures and tibial fixation using the SwiveLock. Here's six month MRI follow up on one of our patients where you can see the bone edema, mild extrusion of the lateral side before and at six months resolution of the bone marrow edema, and actually improvement in some of the extrusion we're seeing on the lateral side. Here's SOS data on those 45 patients at one year. Improvement in scores. Improvement in Litcham scores and improvement in pain scores. So for the medial meniscus or for route repair in general, you need to simplify the transtibial repair technique by making the diagnosis. Be prepared. Have a route kit available. Make a space. Hit the target using the Transtibial guide. Avoid coalescence using the swivel technique and enjoy the results. We're going to move on to Innovation with inside out meniscus repair. I think it's important to take a step back and ask what's essential for the meniscus to heal. And that's anatomic reduction, biologic preparation and circumferential compression, or what I call the ABCs of meniscus repair. If we look at circumferential compression when we typically place the all-inside device, we're compressing the femoral side of the meniscus tear. Oftentimes, we're gapping open the tibial side of the tear, which allows ingress of synovial fluid. And you get MRIs that look like this where you can't tell. Is it torn? Is it healed? It's probably only partially healed. In this case, we use stacked vertical mattress sutures as a way to provide circumferential compression in this vertical longitudinal tear. Here's a follow up MRI that shows complete healing. We all know the advantages of the traditional inside out technique being smaller perforations with the needle greatest strength of any meniscus repair technique, the greatest flexibility and versatile you can provide any stitch configuration. The disadvantages are that you often need two assistants and it can be time consuming. Fortunately, that's improved with the ZoneNavigator. The ZoneNavigator is an ergonomic needle advancement handle. One other advantage is that you can rotate these 360 degrees to very accurately place needles through your inside out incision, allowing a very efficient repair. The second advantage is you can hit all zones of the meniscus. So here is a lateral meniscus from the ChondralDrill portal with a post of a cannula. You can see access from the root all the way across the posterior horn of that meniscus. With the anterior cannula, you have complete access to the anterior horn and body of that meniscus, making it very simple. I think about traditional meniscus repair devices. Being able to do one thing inside out allows you to do everything. Stacked vertical mattress. Horizontal mattress. Circumferential compression complex. Radial complex. Multi-planar teres. Here's a case with a isolated bucket handle tear that involves all zones of the meniscus. So you could perform all inside outside in a variety of techniques. But why don't you just perform inside out for the entire meniscus? So it's important to anatomically reduce that meniscus. Your first stitch is your most important stitch. And with inside out, we can stack vertical mattress sutures. Access the as the tibial side, so you get circumferential compression all the way to the anterior horn of the meniscus. And here's a one year follow up MRI. Complete healing. Complete return of function. Here's the ZoneNavigator placing stacked vertical mattress sutures. Again, as you advance the needle one centimeter with each button, click. Another advantage is the small perforation. So you only have a one millimeter perforation using your meniscus needle. And these are loaded with many SutureTape. So that allows a very precise very anatomic placement of your needles. And the SutureTape provides dispersion of forces across the repair site. So overall a very large advantage. You can then dial in your tension by simple knot tying up through your incision. Typically it was very difficult to place sutures on the tibial side of the meniscus, but with inside out it's very simple. We looked at our clinical results at 17 year follow up. So long term follow up, 72% success rate and An excellent Icdc scores. What about radial tears? We all know that radial tears are particular bad actors because as we go through the peripheral circumferential fibers, we lose our ability to resist hoop stress. Here's a football player that presents with a full thickness radial tear. And here's a simulation in the lab showing what ZoneNavigator can do for this repair type. So first of all, you can provide very precise placement of your suture needle. Again a one millimeter perforation. In this case we're going to perform a cruciform or crossing stitches across our radial repair site. The other advantage of small perforations is that you can provide many sutures across the repair site. So we'll place sutures both on top as well as on the bottom of this meniscus repair. Here you can see with knot tying, you can dial in the amount of compression you want across your repair site. Again, that first stitch, most importantly to get that anatomic reduction and allow for that circumferential compression. So here we're finishing the femoral side. Again each button click is one centimeter of needle advancement. You can also back up the needle if you wish. But again it allows a very precise placement. And in this case you get a nice circumferential compression of that repair. Here's the MRI comparison showing complete healing with nice resolution and restoration of that circumferential rim. We looked at our clinical results. We compared 24 of our radial repairs to our traditional bucket handle tears. And we found that at three and a half years there were no difference in pain scores return to function and overall return to sport. Here's a little bit more of a complex case. If you have a radial tear on the lateral meniscus, what happens is that posterior leaflet will spring back through the popliteus hiatus because of the absence of capsular attachments. So in this case, even when you pull on it, there's significant tension. So here we'll use a hybrid construct. We're replacing ripstop two sutures using the Scorpion. We'll then perform circumferential compression using our inside out technique. So you can see our final repair construct. And we also restore the cartilage in this case an osteochondral allograft. Similar case of meniscus radial tear at five weeks. Again you see gapping at the tear site. Here we'll place our ripstop sutures and we're using the mini SutureTape in order to get our circumferential compression. In closing, I'll just say how do we define success after meniscal repair? Here's a nice study looking at 295 meniscus repairs. 19 of these repairs failed. However, 75% of these cases they actually removed less meniscus tissue than they would have with index meniscectomy. So, in conclusion, it's important to save as much native meniscus as possible. Remember your ABCs of meniscus repair with anatomic reduction biologic preparation, circumferential compression inside out repair has always been the gold standard for meniscus repair, but the ZoneNavigator now makes it easier. Thank you.

ZoneNavigator™ System

Walter R. Lowe, MD, (Houston, TX) demonstrates an inside-out meniscus repair, including placement of a posterolateral needle catcher, using the ZoneNavigator™ system.

ZoneNavigator™ System Posterolateral Exposure for Inside-Out Meniscus Repair

So what we're going to look at first is the exposure on the lateral side. So we'll do inside out suture repair. Landmarks are the fibular head here which I've drawn out already. This is the joint line biceps sitting below. Always important to remember peroneal nerve is down here. But joint line here. Biceps below it. Band above. And I'll make the incision a little bigger here. But I would take it along that junction between the IT band and the biceps over the joint line and down to the fibular head. So that would sort of be the, the typical incision for the lateral side. So then we just want to find that interval between the biceps and the IT band. There's not a whole lot to see until you get through the sub-q fat here. And then you'll see the IT band fibers heading up towards the hip and down below. You'll see this interval and can start to see muscle, the muscle fibers of the of the biceps femoris coming directly in into the fibular head. So that's the interval that we're going to want to develop. And this is a totally safe plane. And so now we have the biceps femoris down below us. I'm lifting the IT band up. This is the lateral head of the gastroc. And so now we have the lateral head of the gastroc here. And the capsule here is really thin putting posterior sutures in. We have to get our retractor underneath the biceps. So I'll typically do it just like this. I'm pushing into the tendon of the gastroc. I'm not trying to come here because you'll go right into the joint. I'm pushing into the tendon of the gastroc as I spread. That will give us our plane between the gastroc and the posterolateral capsule. Now that we have that plane. So here's the lateral head of the gastroc. This is the posterolateral capsule. Now I'm going to put the army Navy underneath the lateral head of the gastroc. And just make sure I have enough room to get my popliteal retractor in. Now, we've made the lateral exposure. We've developed the plane between the biceps femoris and the IT band. We've spread that, and then we've dissected underneath the lateral head of the gastroc. And this Army Navy retractor is retracting the lateral head of the gastroc that we need to be under to get to the posterolateral part of the capsule. And so now I'm just going to put the retractor in that will catch our sutures. And now this retractor is underneath the lateral head of the gastroc. And you can see I can push in and turn the corner and be all the way around in the back with the ZoneNavigator. I've already loaded the needle and brought it all the way down to the tip. So once we're in the joint, we can just push a little of the needle in and then that's how you use it to. So when we get there, you always want to come and work through the portal on the side of the meniscus. So we're on the lateral side right now. So we'll view through the Anteromedial portal. And then we're going to work through the lateral portal. Now in this cadaveric Specimen where in just 90 degrees. Typically this would be in the figure four position I'm in with the ZoneNavigator. This will pass the 0.9mm FiberTape I've introduced a little bit and I'll use it to. So I'm just going to choose the under surface because I actually would balance the under surface with the superior surface, really to get the any large vertically oriented tear reduced anatomically, you do have to have vertical mattress sutures on top and sutures underneath. And so we'll just take this, since that's what this specimen is showing us. You always want to sort of look at your outside clues and say, you know, the bend of your needle. You know where your retractor is, is it shooting towards it? It looks like it is. You should have felt it hit. And you can just keep advancing. Now I can just pull this out and you always want to keep. And I think this is a very important point. You always want to keep your needle holder on your needle. And don't let go of it until you cut the suture, or you're going to stick somebody or stick yourself with the needle. And it's a very important point of inside out meniscus repair. Now we'll just load the second suture. Same thing down the base of the ZoneNavigator. Just until you feel resistance. And when you feel resistance, you're right about down at that curve. And so same thing. We'll back up. I got just a little bit of the needle out now. And then just pull on your suture. I'll look outside. And I think our cannula will need to come down here a little. Here it comes. As you can see the needle advancing. And we'll take it out. And again grab it with the needle holder. And just go ahead and pull it the rest of the way through. I'll remove the ZoneNavigator. Like I said, I'll hold on to this because you can see how spring loaded it gets. So you never let go of it until you cut the suture, and then you can pass it off. Now, you know you can reduce and then tie your suture. Out here.

ZoneNavigator™ Inside-Out Meniscal Repair System

Inside/Out Meniscal Repair

Mini Suture Retriever, 15° Up Curve

MINI RECUPERADOR DE FIOS COM CURVATURA 15º PARA CIMA

The ZoneNavigator™ System revolutionizes inside-out meniscal repair with single-handed control of needle placement. Use the ergonomic handle to advance and retract 2-0 SutureTape with meniscal repair needles in 1 cm increments.

The low-profile 3.2 mm Knee Scorpion™ jaw allows the passage of 0 and 2-0 FiberWire® suture in tight recesses of the knee. The one-handed, ergonomically designed suture passer is offered with reliable FastPass technology. FastPass Scorpion™ technology allows passing suture through tissue and capturing the suture in one simple pass, eliminating the need for the extra steps of suture retrieval and suture shuttling. Multiple different suture configurations are possible using the Knee Scorpion suture passer.

Vic Goradia, MD, (Richmond, VA) demonstrates the use of the Knee Scorpion™ Suture Passer in conjunction with the Micro SutureLasso™ suture passer for an outside‐in repair of a radial meniscus tear.

Radial Meniscal Tear Repair Using the Knee Scorpion™ Suture Passer Combined with an Outside-In Repair

We've got a radial tear here of the medial meniscus kind of cleaning that out. And so what we're going to do is a little side to side repair, to see if we can give it any chance at all of healing, because if it remains as a radial tear, then that significantly increases the hoop stresses and is equivalent to not having a meniscus at all. So we're going to go in with the knee Scorpion. We're going to get in under this meniscus to the back here, and we're going to turn it slightly. Now we're going to load the second limb and pass that through. Okay. So that shows one side to side stitch in here. Now we still have the rent going back into the capsule. And what we're going to do there is come in with a outside in fixation to get that sewn down. So we're going to do that with the micro SutureLasso. All right. So we've passed the first lasso through the tear and grab that suture. Pull it out through our cannula here. All right. So we're going to make a second stab through here. Now we're going to insert A2O FiberStick I'm going to pull that through our passport cannula. And now we're going to take the loop and pass the free end of the stitch in our loop. We're going to shuttle that through. So now we've got both ends coming across here to tie this down to the capsule. And that's going to give us a nice fixation. We make just a little stab incision. We'll pull our two sutures through. Okay. So now we have a nice horizontal mattress stitch placed in a outside in fashion. So it's securing the radial tear to the capsule here. That gives us a nice fixation.

The low profile and anatomically designed device will facilitate suture passage in tight areas of the knee.
• Low Profile: Pass suture in tight spaces with the Knee Scorpion™ Needle (AR-12990N) • Versatility: Accommodates 2-0 and 0 FiberWire® • Efficient: Pass and retrieve suture in one step through one portal • Anatomic: Angled jaw engineered for the knee joint

Knee Scorpion™ - Simplified, Single-Portal Suture Passing and Retrieving

Mini 0.9 mm Wide SutureTape FiberLink™ Suture and TigerLink™ Suture with 2-0 Suture Tails

A list of scientific articles pertaining to a product or procedure.

Eine Liste wissenschaftlicher Artikel zu einem Produkt oder Verfahren.

Wissenschaftsupdate

Lista de artigos científicos referentes a um produto ou procedimento.

Atualizações científicas

Lista de artículos científicos relacionados con un producto o procedimiento.

Actualizaciones científicas

Scientific Updates

All-Inside Meniscal Repair Scientific Update

Meniscal All-Suture Repair

2-0 FiberStick, 2-0 FiberWire, 50" (blue) one end stiffened, 12"

FiberStick #2-0, mit 30.0 cm gesteiftem Ende, steril

The Meniscal Cinch II technique offers a linear deployment mechanism to provide ergonomic handling and simplicity. The low-profile cannula allows flexibility in tight locations in the knee and the crimped cannula supports active implant deployment. The 1 mm × 5 mm PEEK implants are secured by 2-0 coreless FiberWire® suture with a pre-tied, modified Weston sliding knot that tensions easily and facilitates secure, low-profile vertical or horizontal suture repairs.

Patrick A. Smith, MD (Naples, FL), demonstrates a cadaveric all-inside meniscus repair with the Meniscal Cinch™ II system.

Meniscal Cinch™ II System

This is a left knee. We're going to place a suture in the lateral meniscus. And so I have the scope positioned laterally. I like to use a skid to make easy placement of the meniscus. Cinch two into the joint. So again my scopes lateral. Here's my medial portal. Here's my skid. So here's the meniscal cinch two device. And I want to point out first of all there's two buttons one and two that we will deploy. But I want to show you one is advanced further than two initially because it's preloaded. The other thing is I like to use a depth stop. And typically I like to go to 18mm. You can set anywhere from 12 to 18 by two millimeters. Works like this where we pass the black depth stop over the meniscal cinch two. It locks into place. You can see the 18 right there. And there's the 18mm exiting out the depth stop. So with my skid in place we bring in meniscal cinch two directly over the skid and remove the skid. So now we're in the lateral compartment. We're going to pick my spot here for my first deployment. So now here we're coming to the lateral meniscus. We're going to place our suture. So I kind of find my spot within the meniscus. And I'm going to go to go ahead. One's already preloaded, so I'm going to pass through the meniscus to the depth stop of 18. And then I'll deliver number one to a hard stop. And then I bring number one back to where it matches up to number two clicks in place. I've got my first implant deployed, so I'm going to come up to my meniscus for my second implant. But first thing I'm going to do is I'm going to bring number two down to the speed bump. You can see there's a little raised area on the device right there. It stops. So I bring number two down to that speed bump. And that just brings extra suture into the joint, which will make securing the knot much easier. So now I'm going to come to my next chosen position right here. I'm going to come through the meniscus again to my 18th depth stop 18mm as so. And then I just bring number two all the way down hard. Stop there. So let's bring it back to match up to number one. And there was a click right there. So this is all one handed use of the meniscus cinch two. So now I've got my second implant deployed. And I think it's think it's very important. I don't do any setting of the knot at this point. The first thing I do is we want to pass through our our knot pusher combination suture cutter. And what I like to do is I like to hold the scope. And I like my assistant to pull directly in line of the shaft of the knot pusher to get the slack out. So we'll pull back a little bit. You can see here coming out nicely. Then I like to end up toward the first implant position. So you can see. Then I come to number one spot here. We'll do our final tensioning here. So you can see it's nice and tight. And then we just cut it off right here with our knot cutter. So there's our final suture in place. So we've got excellent tension. You can see here we've excellent tension on the suture. All one handed. Very simple to use. Very pleased with that.

Meniscal Cinch™ II Implant

Meniscal Cinch™ II Implant Competitive Matrix

The Meniscal Cinch™ II implant delivery system provides an efficient and reproducible method for all‐inside meniscal repair with small tissue perforations and low‐profile PEEK implants secured with 2‐0 FiberWire® suture.

Meniscal Cinch™ II All-Inside Meniscal Repair

The meniscal cinch to implant delivery device for All-inside meniscal repair delivers small peak implants, which are secured by 200 FiberWire suture. The meniscus is measured using the laser lines on the tip of the meniscal cinch two needle. The depth stop is set according to the measurement by rotating to the desired depth, with the desired number facing upwards completely. Advance button number one to deploy the first implant, retract button number one until it is in line with button number two. Advance button number two forward to the indicator. Advance the needle through the meniscus to the desired depth and advance the button completely. Fully retract the button so that it's in line with button number one. Advance the knot pusher suture cutter towards the second implant. Apply tension to the suture while using the knot pusher to advance the sliding knot towards the first implant. Countersink the knot and sever the suture.

Meniscal Cinch™ II Technique

Ramp lesions, which are commonly associated with ACL injuries and are often misdiagnosed,1 disrupt the meniscotibial ligament and the posteromedial meniscus in the meniscocapsular zone. Disruption of the posterior horn of the medial meniscus could lead to excessive forces within the knee joint and surrounding structures.
The QuickPass™ SutureLasso™ suture passer is preloaded with a #2-0 FiberStick™ suture, and is available with a left or right 25° curve and 1.5 mm tip.
Reference 
1. Peltier A, et al.&nbsp;&nbsp;Arthroscopy. 2015;31(4):691-698. doi:10.1016/j.arthro.2014.12.003.

Walter R. Lowe, MD (Houston, TX), demonstrates a cadaveric ramp lesion repair of the medial meniscus using a FiberStitch™ all-inside meniscus repair implant through a standard anterior portal approach.

Meniscus Ramp Lesion Repair Using an Anterior Approach and the FiberStitch™ Implant

So today we're going to show a all-inside repair of a meniscal ramp lesion. This is a left knee I'm viewing through the anterolateral portal. And you know, to see ramp lesions you need to sort of have this trans notch view. Obviously I've cleaned this up a little bit. So coming underneath the PCL along the medial femoral condyle. And as you pop into the back of the knee you can look down. And it gives you a very good view of our ramp lesion. So this is the very posterior part of the medial meniscus. So the rim of the medial meniscus along here obviously the posterior capsule here. And this is that meniscus capsular junction where where we have made a ramp lesion previously. But this is how the ramp lesions will look when you view them through the through the anterolateral portal portal, through the trans notch approach to the posterior compartment. If you pull the capsule away, you see down to the tibial plateau If we look more in here at the meniscus, then we can see that posterior rim of the medial meniscus here. So very classic findings in this cadaver of what you would normally see clinically. Having previously made the Posteromedial portal, you can rasp your ramp from back here to get it to good healing tissue, or I'll show you in the front a second. You can usually ramp some of these from there. So just showing sort of preparing the ramp lesion with the rasp. And then we're ready to repair it. So this is really important to see because it's what makes doing a all-inside repair with the FiberStitch feasible to repair a ramp lesion. So again very classic ramp lesion. This looks just kind of how they'll look when you find them. And I just want to show you this when you take the knee from flexion into full extension. See how that ramp lesion reduces. So using extension to reduce the ramp lesion when you are placing the FiberStitch is very important to be able to grasp that capsule in an anatomic location and repair it back where it goes. So just a second picture. There's the ramp and flexion. And as we come back into extension it reduces. And that is the angle we're going to repair it at. Right now the knee is in about you know 15 degrees of flexion. And you know put the skid in to help protect us as we introduce the FiberStitch. So we have multiple different angles to work at. We have a 12 degree up. We have the zero degree. We have a reverse. We have a 24 degree. And on these you just have to make that game time decision of what what angle gets you where you need to get to place your FiberStitch anchor. So now the FiberStitch is in, I'll take the scope back and I want to get ready to put the first part so you can see flex a little bit for me. You can see the ramp kind of move away. Way back there and then come back. And so for this example, I want to get way up here and I like to position it here. And so I'm just engaging the meniscus. If you saw that little move. And then I want to come up into full extension. And I'll just slowly push through the capsule. This makes might make you nervous, but really you're very safe here because we're aiming very posterior medially away from the neurovascular bundle. This would make me a lot more nervous if we were in the lateral portal doing this. So now it's there. We'll deploy the FiberStitch. And so here's our second stitch. Same thing on this one. I'm going to choose a transverse approach to get the most superior portion of the capsule back up against the meniscus. Same thing. Kind of engage the meniscus like I just did and then extend. And then I'll push in through the Posteromedial Remedial capsule and deploy the second part. And that worked beautifully. And then I'll just remove it. And I'm going to back up my view a little bit so we can see that. So just grabbing the anchor. I'll always give it I mean just grabbing the loop of this, I'll give it a little tug to make sure I'm headed down in the right direction, and I am. And then with a probe through the loop outside here, will, you don't have to do anything. We'll we'll tighten the loop. Good. And then we'll just set the second part of the suture. Okay. And then we'll just cut this. So now you can see with the FiberStitch you know deployed in, you can see how the Posteromedial capsule is pulled up adjacent to the posterior horn of the medial meniscus.

Walter R. Lowe, MD (Houston, TX), discusses medial meniscus ramp lesions, including an all-inside repair technique using the FiberStitch™ all-suture implant.

All-Inside Meniscus Ramp Repair Using the FiberStitch™ All-Suture Implant

Hi, I'm Walt tho I'm the chair of orthopedic surgery at Uthealth McGovern Medical School in Houston, Texas. Today we're going to talk about a meniscal ramp All-inside repair with the FiberStitch. So defining a meniscal ramp, it's a vertical tear, the peripheral posterior medial meniscus capsular junction. And it's often often associated with an ACL injury. It's present in 9 to 17% from the literature. And it's called a hidden lesion because it's very difficult to see if you don't go look for it because it exists, right, in that very most posterior medial part of the medial meniscus. That's hard to visualize. And knees that are fairly tight in the medial compartment. Ramp lesions do cause symptoms. They can cause pain. They cause dysfunction. And they certainly cause altered kinematics that I'll go into later. They're very difficult to diagnose on your MRI scans. Most radiologists miss them. I think as we are seeing them more and paying more attention to it will get better at that. A hint as opposed to your medial tibial plateau bone bruise that you can see, and I'll show you one of those. And that exists because of how they happen, and they happen because the semimembranosus is attached in one of the wings of it in this area. And when the the athlete's knee goes into hyper flexion and the semitendinosus fires is sort of how this meniscal capsular avulsion, if you want to call it that, happens, the diagnosis is still best made by viewing it and probing it through the arthroscope. And you need to view through a trans notch approach, where you place the scope between the medial femoral condyle and the PCL. Sometimes you need to debris a little of the synovial covering of the PCL to get through this. And if you'll gently rotate your scope from right to left while pushing posteriorly into the posterior Compartment, you will drop into the posterior compartment. And if you look straight down, just with your 30 degree scope, at that point in time, you have a very clear view of ramp lesions if they exist. This is the classic EMR that I think should clue us in. And you see the blue arrow, the little fluid line between the capsule and the medial meniscus there. The little red arrow is showing you the very subtle but present posteromedial bone bruise. Those are the hints that you may find a ramp lesion when you look at it. So why do we repair ramps? And so biomechanically the medial meniscus, you know, obviously contributes to load transmission to joint lubrication, to proprioception, to cartilage nutrition. And it is definitely a secondary stabilizer of the knee. When you do not repair a ramp, it increases the forces in the ACL. It may increase rotatory instability of that knee and cadaveric studies have shown that when a ramp exists, it increases both translation and external rotation in the ACL deficient knee, and this is not restored just by reconstructing the ACL. If you reconstruct the ACL and you repair the ramp lesion, then this increased anterior translation and external rotation is restored to normal. So today we're going to talk about meniscal ramp all-inside repair with the FiberStitch. And the advantage of this is this is all done through the traditional anteromedial and anterolateral portals. And so I think the technique of this makes this very, very doable. So there are non-surgical options. You know, I don't think they're the right thing to do anymore. Now that we're understanding more and more about how not repairing these ramp lesions can lead to trouble down the line for for many things in the knee, inside out was the typical way we started doing this. But now I think all-inside repair is something most of us can get very comfortable with. You see a very classic example of this on the two scope pictures. Same patient, where you see the FiberStitch place before it's tightened up and then tightening up on the right. You see how it advances that posteromedial capsule up to to the rim of the medial meniscus. So like I said, we we have the inside out kind of classic repair. There's lots of options to repair this through a posterior medial portal using SutureLasso. But today I really want to talk about the all-inside repair through standard anterolateral portals using the FiberStitch. So so this is a good view of the FiberStitch. You know, if you haven't seen it. It's a very ergonomic device with multiple curves that allow us to access different parts of the meniscus. So we have sort of the traditional one that's been out with the slight up angle. We have a reverse, we have a 24 degree up. And that will let you address really, you know, superior surface. Inferior surface what? Even in tight knees where you have to reach up over, over the or under and then over the meniscus, all of them. The different angles allow us access to the parts of the meniscus. But like we're showing here that this is going to be a repairing the ramp with the FiberStitch. So first of all, you have to identify the ramp I usually use once I'm viewing through that trans notch portal at 18 gauge spinal needle. If they're subtle to probe and decide whether you have a ramp, sometimes they're really obvious. Actually, most of the time they're really obvious. You can rasp the ramp, getting ready to repair sometimes just through the the intermediate portal, sometimes through a posterior medial portal, which I generally do not use cannulas back there. And then, as you'll see from when we're repairing it from the anteromedial portal knee and extension, getting the best view you can of that root posterior area of area of the medial meniscus. Where these ramps exist, the FiberStitch is advanced into the superior portion of the meniscus, and then your assistant comes into hyperextension, which reduces the ramp, and then you place the FiberStitch through the capsule in and deploy it. The same thing is repeated for the for the second suture. So this is showing just grasping that ramp lesion. You can see it pretty easily there. Luckily this was a knee you could view posterior medially pretty easily. And so just grasping that lesion getting ready to repair. And then in this video just what I just described, you positioned the FiberStitch bring the knee into extension, push it through into the capsular part of this and repeat that. And you'll see as I start to tighten this up at the back there, you see the capsule being advanced up to the rim of the medial meniscus. So we're going to I'm just going to show a little short case presentation here of what we see. So this is a 16 year old football player. So a contact type ACL injury that included this ramp lesion that I've shown you before on on the MRI. He had a very loose knee from from an ACL standpoint. He had a sort of grade two medial collateral exam but no joint line tenderness. And that's often the case with the ramps. There's not really a good clinical exam for a ramp lesion. This is his exact tear on the left. You see the defect and the little hematoma between the capsule and the posterior horn of the medial meniscus. And then the repair using this technique that I talked about of, you know, a positioning the FiberStitch and then hyperextending the knee to get it to grasp that posterior capsule. Here is the original Mr.. That you've seen a couple times before on this presentation with the blue arrow showing the ramp, the red arrow showing the posteromedial bone bruise, and in him you see the ramp healed on the on the right there with the green arrow showing that area between the posteromedial capsule and the medial meniscus is now healed and intact. If we're just looking at how do we rehab these? That's always a question. If it's an isolated ramp, but honestly hardly ever see an isolated ramp, I would treat it like I would a meniscal repair from a rehab standpoint in in conjunction with an ACL. I do not change anything over the typical ACL rehab, so I don't protect weight bearing or range of motion after the repair of the ramp lesion other than what we do for ACL reconstruction. Thank you.

QuickPass™ SutureLasso™ for Meniscus Ramp Lesion Repair

Orthobiologics

Influence of Sutures on Cartilage Integrity: Do Meniscus Sutures Harm Cartilage? An Experimental Animal Study

Meniscus Ramp Lesion Repair

Meniscal root avulsions are a challenging injury causing meniscal extrusion and loss of hoop stress distribution, which can lead to the development of knee arthritis.1 Arthrex offers multiple implant systems for meniscal root repair.&nbsp;
The SutureLoc™ implant allows for direct tibial fixation of the meniscal root. The 2.4 mm cannulated drill pin leaves more bone intact while delivering the SutureLasso™ wire directly to the footprint of the meniscal root. Once the anchor has been passed, the 2 repair sutures can be passed through the tissue in a variety of stitch patterns. The knotless implant is retensionable, allowing surgeons to dial in their repair. Traditional transtibial implant systems using a FlipCutter® II reamer and multiple fixation options are also available.
A complete system for meniscal root repair includes the meniscal root marking hooks and the Knee Scorpion™ suture passer. Two meniscal root marking hooks are available, so surgeons can choose their preferred hook.&nbsp;
The point-to-point guide allows surgeons to directly target their drill location at the meniscal root footprint, while the over-the-back marking hook sits securely over the back of the tibia to allow stable drilling tunnel preparation. Use the low-profile Knee Scorpion suture passer to simplify suture passing in tight recesses of the knee.
Reference:
1. Pagnani MJ, Cooper DE, Warren RF. Extrusion of the medial meniscus. Arthroscopy. 1991;7(3):297-300. doi:10.1016/0749-8063(91)90131-g

Aaron J. Krych, MD (Rochester, MN), demonstrates the point-to-point meniscal marking hook for use in meniscal root repair. Dr. Krych highlights the many benefits of the marking hook, including point-to-point precision targeting and the variable locking mechanism.&nbsp;

Meniscal Root Repair Using the Point-to-Point Marking Hook

My name is Aaron Critch and we're very excited to demonstrate today our technique for medial meniscus Transtibial route repair. So there are a few features of this guide which really make the procedure more safe and more efficient. So one is the shape. When you look here there's a cutout to go underneath the femoral condyle. So this is very low profile. It's designed to work in tight spaces. A second feature that we like is the ability to have variable angle. So this is spring loaded on the back. And you can rotate 40 degrees in either direction. Traditionally when you use an ACL guide for medial meniscus route repair, the problem was the guide would often torque. So in order to get your spot in the knee and to line up on the anteromedial face of the tibia, you had to talk through the guide. And what happened is you missed with your guide pin in the back. And best case scenario, you missed anatomically in the bone. But worst case scenario, you can miss in the back of the knee where there are important neurovascular structures. So we'll show you on this knee today how this variable angle can be very helpful and beneficial. Lastly, I'd like to point out this is designed to have a little bit higher angle of entry. So you can notice that we're coming in almost perpendicular to the subchondral surface. So there's two advantages to this. One is if you use an ACL guide you're going to come in at a very shallow angle and you're actually going to undermine the subchondral bone when you're drilling. The second advantage here is that we're often doing combined procedures, whether it's an ACL reconstruction. So the higher angle allows you to be co-linear with your ACL tunnel or socket, which reduces the risk of coalescence in the tibial bone. We have a right knee here and we're looking through standard portals. We have our camera in the anterolateral portal and I have a probe through the Anteromedial portal. And this is probably a typical route patient. You can see some damage of the condyle and the And the tibia. And then at the meniscus here you can see a medial meniscus root. So this is a radial tear near the root that we've created in this cadaveric specimen. So I think there's a few important visualization tips because you can't fix what you can't see. So what we've done is we've lengthened the MCL. So we've taken a spinal needle and crusted the femoral side of the MCL at about 20 degrees of knee flexion and valgus. So you can see we have a little bit more opening here than normal. We're not trying to create a grade three but maybe a grade two MCL opening. A couple of other things we've done is I've taken the PoweRasp, and you can see I've taken down the medial tibial spine. So I think this does a few things for you. One is it provides some visualization to the back. Number two is it provides some bleeding bone and biology. And then number three it helps your guide sit just a little bit flatter so you don't have that big upslope of the tibial spine. We've then removed a little bit of this PCL synovium. And then here we've taken just a little bit for reverse notch plasty. This isn't often necessary with the Arthrex tools that we're using for this case, but something you can keep in mind if you have an osteophyte or tight space. But all of these measures really give you a nice view and allow us to safely perform our work. So we're going to introduce the point to point Transtibial root guide. And you can see for this right knee, we're going to go from the medial portal to the anteromedial face of the tibia. So I've actually rotated this. You can see 40 degrees to the right. And I'll show you when we introduce this into the knee what happens with that. So here again that laser line really helps visualization. You can see our point. And then you can see the anatomic remnant or the origin of exactly where we want this root to be. So with the point we simply are going to find our spot. And you can see how removing a little bit of that tibial spine, the guide sits nice and flat. And with the ability to rotate, we can really achieve our target on the anteromedial face of the tibia without creating talk. If we didn't have that rotation, you'd really be talking the guide. But here the guide stays nice and flat in the joint, and we're able to advance our guide just to see where we are in the skin. You want to be about a finger breadth medial to the tibial tubercle. In cases where you have combined, procedures such as an ACL will be obviously aware and trying to avoid coalescence. But in this case we'll just plan a small incision just one finger breadth medial to the tibial tubercle. So one of the great advantages of this transtibial root guide is when we're performing concomitant procedures. What's nice is as the surgeon, you have complete degrees of freedom. So if you want to avoid your ACL tibial tunnel, you can certainly do that. If you have an uncommon case of both a medial and lateral, you can really change your angle, change your position, really avoid that tibial coalescence without having to compromise the anatomic origin of your route. So we'll just line this up. We'll just make a small incision here on the skin. And again, the goal with this guide is we really want that point to point accuracy. So we're going to double check to make sure in the joint that we're exactly where we need to be. And then with the ratcheted guide, what we'll do is we'll actually just tap that fully down. So we have that nice point to point fixation. Good. So now you can really see that laser line where exactly where we want in terms of our anatomic target. So now we'll have our assistant introduce the FlipCutter into the joint. And we'll feel for that first cortex. And then we'll really feel that second cortex. And then our FlipCutter will hit the undersurface of our point on the guide. Perfect. So we've beautifully hit our target there. I'll just show you here. It's right underneath. So we're in an absolutely perfect spot. So I think if you're confident that you've hit your target, which this guide does, then at this point we can really remove the guide and decorticate to make our socket to create some biology. And you can already see even in this cadaveric specimen, how you can see a little bit of these osseous elements here. So then we're just going to slowly introduce the FlipCutter. And you can see that really hits our target. Well. And we've got great visualization back here. So now under the direct visualization of our FlipCutter we're going to open that up. And then here we're just going to go about five or so millimeters in. We really want to decorticate that bone. So that really creates some nice biology that you can see. So that looks great. And then at this point we can bring it back in. So then we're just going to flip it and come back out. And before we come back out what we'll do is I'm going to take this guide out and we're just going to take a mallet, and we're going to just pound this guide in just a little bit to make sure that we can get our shuttling suture in the correct spot. So what I'll do is I'll hold this guide. We'll come out with the FlipCutter and then we'll bring our shuttling suture directly in. So we're going to bring the lasso directly up through. And we've got a good visualization of it coming through. So then we're just going to take a grasper and fish it out the medial portal. Now you have to remember we're going to be passing our sutures through the medial portal. So this is something that I will initially grab through this medial portal. So we're going to do is we're actually going to bring this over and park it in the other portal. This just does a really nice job just keeping keeping things tidy, keeping everything out of our way. So at this point, we can remove the sheath. And we'll just snap these together, and we'll have that for later. Suture passage. So then at this point, I'll just clean up that remnant a little bit more with our shaver. We'll just make sure that we're getting nice bone contact with our meniscus repair. So that looks great. You can really. I'll just show you where this is coming in with that point to point guide. This is just I mean, it's really dead on accurate. You can see that's exactly where we'd want to restore the anatomy. So this this looks great. And you can see the decortication here. So then we'll put our passport cannula in to the Anteromedial portal. This is an eight by three passport that for most knees is going to be Adequate. And for passage of our sutures, we'll use the NE Scorpion. And I think, you know several advantages I really like with the NE Scorpion. So one obviously it's self retrieving. The second is that with this needle you have a very small perforation into this meniscal tissue. Oftentimes this is degenerative meniscal tissue. We looked at the biomechanics of this several years ago, different stitch configurations and really found that the just the simple cinch stitch was the best in terms of ultimate strength, as well as reducing or resisting cyclic displacement with rehabilitation. So we really like the simple cinch sutures with the old FiberLink suture. So we have our NE Scorpion loaded. So we'll just simply introduce our NE Scorpion with our FiberLink through our passport cannula. And sometimes it's easy to kind of get around this meniscus. Other times it's a little bit down. So what we'll do is we'll just turn that Scorpion upside down, and then you can barrel roll to really help placement with the knee Scorpion. And we'll just come into a little bit more extension. Perfect. So you need just enough room for clearance. So I'll kind of place that posterior stitch first. Here you get a great view of the trap door and you can see very precise placement. And then one trick I found is that instead of directly coming back through the condyle, if you just kind of come through the notch, you'll have a little bit more clearance, a little bit more chance of that suture retrieving. And then we'll just hold our passport cannula so that stays in. And then with our loop already loaded, you can see this is just a very efficient way to pass our sutures and get good control of that meniscus. Typically if the if the meniscus quality is good we'll pass two of these sutures. So now we have our O TigerLink that will bring in as our second stitch. I think for this one we'll place it a little bit more here on the on the inside. We really want a good span between the two here. We can really have good visualization. Really got captured some good tissue there. And again with the simple cinch. Works really nicely to capture. So now we have both sutures in really good control of that posterior root. So at this point we'll grab our wire shuttle that we had parked in our lateral portal. So we'll just take a little retriever or grasper and grab it through our passport. At this point, we can make sure that we have no SutureBridge and we can shuttle Transtibial into our socket. So we'll just pull those on through, and then we can directly visualize our tensioning with this route. The nice thing here is we have only two sutures with different suture constructs. You might have four suture strands, which are a little bit harder to tension here. With just two sutures, you can see really great tensioning, a nice anatomic repair back to where we wanted it. So then one thing we did find in our biomechanical studies that there definitely is some creep or some cyclic displacement. So what I'll do is I'll actually cycle the knee just holding tension on these sutures from about 0 to 90. And I'll do about ten cycles or so. And then once we are confident, then we'll perform our fixation with our swivel lock on the anteromedial face of the tibia. So we'll typically do this in about 70 degrees of knee flexion. So we'll come in. We just want to make sure we're distal to our sutures and nice and perpendicular to our tibia. We go down till we have the positive stop. And then we'll load our swivel lock. We'll make sure we have good tension so tension so we can directly visualize the joint as we're doing this. So once we confirm that we have a good direct reduction, then we'll fix it with our SwiveLock. And we'll just take a mallet and tap this in. And then I typically will back this up with tying a knot at the SwiveLock. I'll make sure that it's low profile. So then when we go back into the joint, we'll just make sure that we really have a nice reduction that you can see here. If we're doing a concomitant procedure such as an ACL, typically we'll fix the root last once we have the ligament reconstruction complete. But here you can see really a nice anatomic repair. You can see our transtibial guide point to point. Hit our spot in really nice fixation for this medial meniscus tear.

Travis G. Maak, MD (Salt Lake City, UT), discusses the critical function of the posterolateral and medial meniscal roots, including the need to address this pathology, and unique techniques for repairing disrupted posterior meniscal roots.

Management of Meniscal Root Tears

I've been charged with talking about the management of meniscal root tears, and I share some of the statements stated by my my former individuals who have been discussing things today about preservation of the meniscus. The meniscal root is a beast if you leave it because it effectively deems the meniscus completely incompetent. This has been shown by multiple studies. Doctor Levy, Doctor Stewart, as well as others. This is a very brief slide which most of you already know, that obviously the medial and lateral meniscus serve a very important role, and that's distribution of pressure forces across the tibial plateau. There are many types of root tears, specifically these partial complete radial root, complete radial root, tear off the ligament, oblique tears. The root avulsion fractures. All of these deem the meniscus incompetent. And there's a subtype which I'll talk about today, which Doctor Demartino beautifully described earlier, but I'll go into a little more detail. So this is an example of the avulsion fracture. Sure. Actually, this is a patient of mine, and the Arthrex FlipCutter offers a very good opportunity to actually dunk this in and do a true arthroscopic reduction internal fixation like you would a spine. What are the consequences of a root tear? Well, the consequences are significant in the medial meniscus, especially in the individual who has genu varum an overload on the medial compartment. They're very dependent on their medial meniscus and a root tear on the medial side that's not fixed is a disaster for them. We've looked at previous studies, have looked at the consequences of these root tears. And if you look at these, this of wow, this is going to be tough. So if you look at the actual pressure distribution in a root avulsion here, you can see a complete pressure increase in this specific area as opposed to an anatomic root repair, which demonstrates an almost complete reduction and elimination of the pressure distribution back to a normal anatomic state. I'm a big fan of case examples of what these types of things do. So this is a patient of mine, a 37 year old female CrossFit trainer. She had a direct axial load with hyperextension of her of her knee. She was able to train but had continued medial joint line pain. Here you see the go sign complete medial root tear. And this individual is not morbidly obese. She's a very high level athlete and she trains as a trainer, as a fitness. And that is her job. So in a female with this problem, this is a very significant issue. The in this case, this is what it looks like. And this is demonstrating the actual repair. And fortunately Arthrex has given us very a number of different instruments to allow us to treat this effectively with minimal intra-articular trauma. This is the meniscal Scorpion which allows me to put two close half sutures. Luggage tag technique. On the medial meniscus root. The medial root is very hard. If you saw many of my colleagues, a lot of the pictures you see are the lateral root repair because you can see it. Unfortunately, medial meniscus roots in this individual is very hard to see because the medial side is so close and tight. You can do a small opening percutaneous MCL release if you need to. And I do that not not uncommonly, but But in this case, we didn't need to. This is using the FlipCutter. It's a six millimeter FlipCutter with the over-the-top guide which Doctor Stuart and others helped develop with Arthrex, which gives us a very close anatomic repair with respect to the position of the drill followed by the FlipCutter, and that allows to dunk it and do a true anatomic repair. The and I use a technique with respect to a button on the anteromedial aspect of the tibia, although it can be done with a with a suture anchor as well. I find the osseous technique allows me to tension it better and improves my visualization. What about the lateral meniscus root? Well, evaluation of the lateral meniscus tear shows similar issues. Evaluation with three different signs the cleft, the ghost, and the truncated triangle sign, when used simultaneously, allows a very high specificity, specificity, and sensitivity. That being said, it still leaves 10% that are completely missed. And if you don't have a very good radiologist and are not meticulous in your evaluation, your MRIs, you can miss these. And if you don't pay close attention your arthroscopy, you can miss these. And I'll show you a unique opportunity to allow us to evaluate these in the office. What about the lateral meniscal root repair? Well, an ACL transition. Transected knee's transection of the lateral meniscal posterior root led to increased internal tibial instability, as well as which was most specifically at 60 and 90 degrees transection of the femoral ligament further increased the instability. So it produces an instability rotational decrease as well, and repair of that may reduce that. And this study suggested that it in fact did. So what about evaluation of these tears? Well, I would suggest this is a very good opportunity for the NanoScope specifically both for evaluating it as well as treating it. The medial meniscal route can be very hard to visualize in tight knees, as you see in this picture. This is the NanoScope visualized in the medial side, and I'll show that again in a second. It also bends. So as far as the cartilage damage that can occur, the scope trauma when you're trying to slide back into that to view the medial root, you can either percutaneous release the MCL or use the NanoScope. So this is an is an evaluation arthroscopic looking at the NanoScope using my scope and the NanoScope to show this visualization. This is the lateral compartment visualizing through the NanoScope. You can easily see the lateral root. This is the mu guide. You can also see the root guide. It's a very easy view. Now this is the medial side. Here's the mu coming through. And looking back that is the view you get of the medial root. You can't get that with a normal scope that's sliding all the way past the PCL without any scope trauma whatsoever. So augmented visualization can be helpful. Another case of mine. This is a semi-pro or excuse me, a pro skier. Heli skiing in Alaska. And I asked him how he had his injury. He said, I'll just show you. So he pulled out his phone and showed me the the injury. I was surprised he was coming in with a small injury that he had. And I used small in quotations given the mechanism. So this is a person who had a previous ACL reconstruction and he came in in addition to his ACL. He had a lateral meniscus root tear. And again these can be missed If you're not really careful in terms of evaluating them, it's harder to see this than it is the medial route. So what about a repair? Well, again, using the very minimally invasive techniques with the instruments that Arthrex has provided, in this case the meniscus Scorpion, two half hitch sutures, luggage tag technique are then placed in the root. And this is actually a ligament avulsion. So you can see the ligament side of this where it's avulsed off the root. In this case, because it's done with an ACL reconstruction. I'm not using the FlipCutter here because I don't want the tunnels to converge. Instead, I'm using the standard three zero drill with a nitinol wire, taking the suture retriever, grabbing them all and dunking it down, doing a direct osseous repair in a osseous technique, prior to which I repair that and follow it with the ACL reconstruction. So in both cases, you can do a very, very simple, easy, high, high strength construct both with and without ACL reconstructions. Last but not least, the lateral meniscus root tear equivalent. So Doctor Bernardino showed this briefly, but I would suggest this is a very. This is the equivalent of a root tear. Now, whether or not these should be repaired, I would suggest to you that they should. More studies needed here. What about the increase in contact pressure? Well, the contact pressure is significantly increased in this cadaveric study. And repair restored those contact pressures and restore the contact pressure area. This is what it looks like on MRI. So you see the split. The meniscofemoral ligament attaches to the lateral side of the meniscus, with the root being attached, but no longer contiguous with the remaining meniscus. How do these repaired again? Arthrex with the meniscus. Scorpion has given us a unique opportunity to repair this very easily. You can either do a rip stop technique or a side to side repair, depending on the integrity of the tissue. In this case, I'm using the Scorpion. I grab the the small nubbin which is attached to the root. It pulls the stitches away from my visualization. Then I go lateral to it again. Pass it, rotating them in a Scorpion because it's so small without any trauma, and then reduce it and tie standard knots on the root side so it's less articular in nature. I do two half hitch or two sutures side to side, giving a very tight and appropriate anatomic reduction of the lateral meniscal root. How do these patients do? Well, we can rely on our SOS data to look at that. Meniscal root repairs demonstrate improvement in the global Vas scores as well as the global Womac scores. Improvements across the board in reasonably long term follow up. I would suggest if this is a patient who is treated, 57 year old female BMI of 34 had a root repair and notch microfracture non-weight bearing for six weeks. She was seen at three months. She then moved to Utah and followed up with me. She was put in a medial unloader brace and sent to physical therapy, and came back to see me when she was not feeling better. This is what her X-rays looked like. She has medial joint space narrowing early osteo osteophyte formation. Her MRI demonstrates evidence of medial plateau overload. She has damage on the tibia and a complete rupture of her medial meniscal root repair. So I would suggest this probably should not have been repaired in the first place. That being said, we can debate about that on the panel. Thank you all.

This animation demonstrates the point-to-point marking hook, a device developed for meniscal root repair.&nbsp;