All right, thanks for joining us this morning. And the title says it all, what we're going to talk about this morning. And by way of hands, who has either treated patients with a meniscus tear or have had a meniscus tear themselves? So pretty much everyone in the room. So this will be relevant for you, which is great. So it says point-counterpoint, which suggests maybe there'll be some contention. But we'll see if there's fireworks or not. Hopefully, we're in agreement with the evidence here. So we'll get into it. So our format will be, I'll be the moderator, we'll give introductions in just a little bit. We have a non-surgeon, so a sports physiatrist perspective, as well as an orthopedic sports surgeon perspective on this very important topic. So let's get into it. No disclosures here. And this is our distinguished panel. So I am Alexis Tingen. As I said, I will be moderating. I am the division director and sports medicine fellowship director at Jefferson University in Philly. One of the themes you'll see here on the panel, we all have a Philly connection of one sort of the other. And I'm also on the program planning committee for APM&R. So very conveniently, if you don't like this topic or this session, you can complain to me afterwards. So willing to take suggestions. So our sports physiatrist is Christian von Rickenback. And she is an assistant professor of rehabilitation medicine at Columbia University. She is dual board certified in PM&R and primary care sports medicine. Dr. von Rickenback grew up in Philadelphia, there's your Philly connection, completing her undergraduate degree at the University of North Carolina Chapel Hill and medical school at the University of South Florida. She completed her residency in PM&R at the New York Presbyterian Columbia Cornell program where she served as chief resident during her final year. She then went on to complete her fellowship training in sports medicine at Harvard Spalding Rehabilitation Hospital. Dr. von, as she prefers to be called, runs a busy non-operative musculoskeletal practice out of Columbia University Medical Center and is actively involved in the medical education of the residents. She was named teacher of the year for the 2022-2023 academic year. Dr. von also serves as a team physician for the City College of New York. Welcome, Dr. von. And our distinguished surgeon is Dr. Misty Suri. He is a fellowship trained board certified sports medicine orthopedic surgeon at the Ochsner Sports Medicine Institute. He is an accomplished surgeon, clinician, educator, and researcher. Dr. Suri is local here to New Orleans, having graduated from Benjamin Franklin High School in New Orleans. He received his undergraduate degree from the University of Pennsylvania, another Philly connection, and he attended medical school at the Chicago Medical School at Rosalind Franklin, graduating with a master's in science and pathology as well as an MD degree. Following medical school, Dr. Suri returned to New Orleans to complete his orthopedic surgery residency at the Ochsner Clinic Foundation. He then completed his surgical sports medicine fellowship at the Stedman-Hawkins Clinic of the Carolinas in Greenville, Spartanburg, South Carolina. Dr. Suri is the co-director of the Ochsner Sports Medicine Institute Sports Medicine Fellowship Program. He is the head team physician for the University of New Orleans. He is a chairman of the Louisiana State High School Athletic Association Sports Medicine Advisory Committee. He is also a past head team physician for the New Orleans Pelicans and a team physician for the—and a past team physician for the New Orleans Saints. So I think they know what they're talking about. All right, so this is what we want you to leave with, and we'll talk about the format in just a little bit, but Dr. Suri will give us an introduction to the pathophysiology of meniscus tears as well as the surgical approach. And so, of course, we're not going to replace his years of training, but we want to be able to really understand how he thinks about these type of injuries. Dr. Vaughn will present our non-surgical approach, and the idea here is to be evidence-based. So of course we have our own practice knowledge, but we really want to explore what does the evidence say about these injuries. And very importantly, and this is why we do what we do, yes we research, yes we give talks, but we are physicians that treat our patients. So how do we best treat our patients, and also how do we best communicate to them about how to treat the injuries that they may have. And so this will be our outline. So again, Dr. Suri will give a brief presentation. We'll have a case presentation, after which Dr. Vaughn will talk a little bit about the evidence-based non-surgical, non-operative approach to meniscus injuries. And then we'll have a Q&A, and this will be our discussion portion, where the audience views, so it's meant to be interactive, both here live, but also online, asking questions about the case. Asking questions about how Dr. Vaughn may think about it based on the evidence. Asking questions of Dr. Suri, how he may think, Suri, sorry, based on the evidence. And then we'll do the same for a second case. So with further ado, we'll move on to the surgical approach given by, and the pathophysiology given by Dr. Suri. Oh, I'm sorry, what did you say? Thanks, guys. Thanks, Alexis. I don't want to go that way, but definitely want to make it interactive. So Alexis gave me this task, and Dr. Vaughan is my counterpoint, which I look forward to discussing things with her. And we want to talk about meniscus, right? So what do we do with these things? We repair them, do not repair them, present the evidence, and maybe a little sort of thoughts on how we do things in reality, in addition to sort of theoretically. So this is a classic tear. This is a root tear, and we'll go through this case later on in our time together. But this is a classic root tear on an orthopedic surgeon, actually, that we decided to repair. And you can see that that little medial meniscus there, that little medial fragment there ended up being very, very sort of friable. It was really just sort of Swiss cheese. And it wouldn't hold any suture. So basically, those stitches there in the right picture basically brought that anchor down to the medial meniscus to restore the hoop stresses of the medial meniscus to hopefully preserve the knee for as long as possible for this surgeon patient. And so the task for this patient is, in our decision making, and we'll go through this, is, OK, well, now this guy's got to do all this rehab. So as we go through this, we have to keep in mind, if we're going to repair something, the patient's going to have to do the appropriate rehab. So it's a much more involved situation for the patient. So again, you've got to keep these things in mind. It's all great to talk about how we should repair it and preserve the meniscus, preserve the knee for longer. But if that guy can't get back to work, and then he doesn't have a job, well, then that's a problem for the patient. So keeping the context of what the patient needs, I think, is very, very important, probably the number one thing, at least in my hands. I can thank Dr. Hawkins in the middle there, who I trained under many years ago, who kind of basically taught me everything I know, essentially. So just a little sort of in-training exam questions, potentially, and subspecialty questions that you may get on your tests. But in terms of the biochemistry and biomechanics of the meniscus, it's mostly water, as you know, type 1 collagen peripherally, type 2 collagen centrally. And the proteoglycans are very important, of course, in the sort of cushioning with the negative charges and the water going in and water going out with the application of pressure to the meniscus. So super important to have this appropriate sort of biochemistry of this meniscus. And when you alter it with a meniscectomy, things change, as we know. So again, when you do clean up the knee with a meniscectomy, things do change. Shock absorber, it's elastic. As we get older, that compliance gets less. That's been well described. The compressive forces is what we're trying to sort of disperse with the body weight and the various things that we're doing in terms of impact. Proprioception is a very important stability. This contact area that we want to have is sort of as big as possible. With preserving of our tissue, with meniscus repair, keeping that contact area as big as possible, of course, disperses that to the largest area possible, which is kind of what we want, rather than a centralized focus of stress, which can lead to spur formation and degeneration of the cartilage. So when we, this number of four millimeters, when we increase this tibial translation, can it get increased when we do a meniscus resection immediately? This can get important in a situation where you have a patient with, say, a lax ACL. Say they have a partial tear ACL. Say they're not really a super high demand patient, and you potentially resect this meniscus. Okay, well then if you get a little more increased translation in the knee, that knee may go from a stable knee to maybe potentially unstable knee. I never had that happen. Actually, one of the first patients I had in practice actually was just like that. But he ended up being fine. The PT did well, and he did not need any ACL. So just keeping things in mind that when a resection does occur of the medial meniscus, that may increase your meniscus, your knee translation, increasing your forces on your ACL. The two shapes of the meniscus, basically we've got the medial and the lateral. The lateral shape, you know, it's, they're sort of crescents. They're concave superiorly with the femoral condyle, and they're inferiorly, they're flat with the tibial plateau. And they, sort of a wide, sort of thick periphery with this sort of taper towards the center. If you have a discoid meniscus where that center doesn't go away in utero, I kind of describe that to patients as an Oreo cookie, the middle of the Oreo cookie. It never disappeared. But that's, you know, that's the normal variant that we see in a discoid meniscus. But if you have an oral meniscus like in this picture, you know, that obviously goes away. The zones are there. You know, the most common location for the tearing is that zone four of the medial meniscus, the posterior horn medial meniscus, classic area to tear it there. And the lateral aspect has a few more zones there. And again, the posterior tears are most common for the lateral meniscus as well. So the medial side is, as you can see, so this is the right knee. In the bottom left, we have the medial, sort of the medial meniscus there. It's a C shape. The lateral meniscus is more O shaped. The lateral meniscus is more mobile. And you can see it's very wide and it covers more of the plateau as opposed to the medial meniscus. The medial meniscus has less coverage of the tibial plateau surface as opposed to the lateral meniscus. And it's much more fixed. It's much less mobile than the lateral meniscus. So this is a good axial cut of the sort of anatomy of the lateral meniscus versus medial meniscus. Very different looking structures. And keeping in mind, and we'll see some videos later, but surgically when we're in the knee and we're probing the lateral meniscus, you've got to keep in mind that it does move more than the medial meniscus. So it's not potentially torn. You may get fooled thinking that there is a lateral meniscus tear while you're pulling on it and probing on it because it moves more than the medial meniscus. But in actuality, it's a normal lateral meniscus mobility. So this is an interesting picture of sort of a macro slide of a cadaver of an extruded medial meniscus. And on the right picture, you can see how that meniscus is shifted out. It's shifted out medially towards the MCL. And on the left picture, that meniscus is providing some cushioning there. But that extruded meniscus on the right picture is not doing anything because it's no longer between the two surfaces. So this is a phenomenon that can happen with a diminutive cleaned out meniscus, especially if there's a repeat scope. That meniscus gets extruded, and then it's no longer functional. It's literally not doing anything. So in terms of blood supply, and this kind of gets into the concepts of repair versus meniscectomy and potential healing potential, the genicular arteries is kind of what supplies the meniscus. And it penetrates 2 to 3 millimeters from the lateral, from the sort of, sorry, from the peripheral surface into the sort of in the middle of the meniscus. And then the middle part of the meniscus gets the nutrition from the synovial fluid through diffusion. The red-red zone in that sort of peripheral area is sort of the direct blood supply that we just talked about. And that has the healing potential that is more sort of robust versus the inner parts. So in the white-white zone, which is avascular, in the intermediate area, the red-white zone is sort of basically the middle part between the two. So that is good blood supply in the inner part of the meniscus. So this kind of shows these sort of cross-sectional pictures there in the coronal plane, the left picture of the blood supply. You can see the red-red zone, you know, diffuse, lots of blood vessels there. The middle part, the RW, has kind of a little bit, and then the white-white in the inner part is relatively avascular. So much, much different in terms of healing potential. And also that comes into play when you're talking about repair versus meniscectomy. So if you've got a tear in the white-white zone, number one, you're not, if you have to do a meniscectomy, you're not taking as much out, which is good. But on the other hand, you know, you're also not going to heal it. So putting sutures in a white-white zone is probably not going to help you too much. So maybe we can, we'll revisit that on our cases later. So in terms of the contact pressure, so if you look at this picture on the right, you can see the circumferential collagen bundles there, as well as the radial fibers there on the bottom right. So it's kind of like a radial tire. If you ever looked at a cross-section of a tire, it's got these sort of, it's got those steel bands in the tire, and it's very similar to how the meniscus works. So if you imagine the compressive force and the meniscus is sort of, the circumferential fibers are held together to disperse that force nicely through that, through those radial fibers and circumferential fibers. So that's kind of how it was designed, and it's very, it's a great design by nature. So 70% of the lateral load is transmitted through the meniscus, and when you clean out the, when you take out the meniscus, you've got this much higher increase in contact forces in the 200 to 300% increase in contact stress, and contact surface area is much, much decreased to 40, 50%. So decrease in area, which is not good, increase in force, which is not good. So you've got the double whammy of those two things affecting you if you take out, if you get a complete meniscectomy. And then in the medial side, it's about 50%. So it's slightly less on the medial side, and if you think about it, you remember the picture of the cross-section, the lateral meniscus covers much more of the plateau, so if you take it all out, you would have more force towards the plateau as opposed to the medial side. So 70% laterally, 50% medially. And again, that hoop stress is the conversion of the axial load to the tensile force distributed throughout that meniscus, and that's due to the orientation of these radial fibers. So as we age, the elasticity and compliance gets less, so that's sort of one of the downfalls as we're all getting older. You've got these active patients that are physiologically very young, but their meniscus is not physiologically young, it's however old they are. So the cellular elements change, this non-collagenous matrix proteins, they decrease from this 22% dry weight as a neonate, and then it decreases to the adult age of 30 to 70 to 8%. So significant decrease in these matrix proteins. The fibrous tissue increases, and the vascularity decreases. So definitely, these are the sort of normal, inevitable age-related changes. Excuse me, sorry. I've got to cough for six weeks for my kid, yeah, if you don't mind. So it's common, you know, 61 per 100,000 males, discoid meniscus, as we talked about. The ligament laxity also is an issue. Chronic ACL tears, so chronic ACL tears will have more of a medial meniscus tear chance, as well as when you have an acute situation, it's more of the lateral meniscus. So again, acutely, lateral meniscus gets teared, torn more easily, more frequently I should say, and then if you've got the chronic situation, the medial meniscus gets affected. And then as we get older, in terms of the degenerative tears, non-traumatic things can cause these things, just walking can do it, squatting, obviously, you know, fall, those are the sort of standard clinical scenarios that we see. But then in the young athletes, it's usually a traumatic thing with a twist or change of direction, as opposed to the sort of community trauma that the older patients get. Sorry about that. So again, MRIs, we have these all the time, as you guys know, you can see this is a large horizontal tear. It's a horizontal tear in that medial meniscus there, you can see it with that large, large perimeniscal cyst forming, that's just basically a joint fluid going out of the tear into the adjacent tissue. Very sensitive, very specific MRIs work great to see meniscus tears. Now root tears, not as good. It's hard to see root tears on all the cuts, really, I mean, you can get lucky and get an axial cut to see a root tear, but root tears are much harder to see, I would submit on an MRI. So you can see the arrows there for the case examples there for the meniscus tears, very classic, you can see the flipped over tears in the very right picture for a bucket handle, so very classic meniscus tears for those pictures. One's very common, as you know, in the acute meniscus, they're almost always swollen. Classic physical exam maneuvers, basically joint line tenderness. The inflammation from the capsules, it's very sensitive. Range of motion, now force extension, force flexion, Dr. Hawkins always used to tell us force extension was his favorite test to diagnose meniscus tears, and also, you know, force flexion with the McMurray's as we rotate the tibia. An anterior drawer test, of course, for your meniscus, I'm sorry, for your ACL. And I don't really do the aptly compression test, but it's a very good test as well. In the different types of tear, in terms of respect to what it looks like, you know, you've got these, this is not super important to know all these, but when we've got a bucket handle tear, we tend to try to repair those to preserve those fibers, if at all possible. When you have a bucket handle tear, most of the time, many times, it's a red-red zone or red-white zone, so you can get that repaired nicely. So typically, in terms of non-op, a pretty standard non-op, degenerative tears with no mechanical symptoms, that's non-operative in my hands, and degenerative tears with arthritis, also non-operative in my hands. But now, when we get to this radial tears, the white-white zone, stable partial tears, stable longitudinal tears, maybe that's not non-operative. Maybe we need to address those with surgery or not surgery. I think that's debatable. I don't think we can talk about that. So historically, this meniscectomy has led to this increased rates of arthritis and acceleration of the knee degenerative cascade towards a total knee. So this classic operative indications, daily life affected, blocked knee, substantial mechanical symptoms, and the failure of non-surgical management. Pretty standard stuff there that I think we all would agree on in terms of what needs an operation. You want to do the case now? Yeah, so you can do the repair kit. Okay, perfect. All right, so this is kind of the, that's, I apologize for my cough, this is that case that we talked about earlier. So this is a 58-year-old male orthopedic surgeon, a partner of mine, tripped on a curb. And his history was that he had bilateral over-the-top ECL reconstruction done in the early 80s. He was a soccer player at that point. Very classic exam, joint-line tenderness medially, laterally, swollen, a little decreased range of motion, forced extension, forced flexion, and positive memories. His ACLs felt good in terms of his, in terms of exams, his, excuse me again, sorry. So just right knee there, you can see some, go back here, you can see some mild degenerative changes, mild to moderate degenerative changes to his right knee. But he's doing fine. He doesn't, he wasn't living, swollen at all. He was sort of carrying on, and he did a lot of exercising and biking, non-impact work, and his knees were doing great for many, many years until this episode. So we can see this MRI here, and you can see that ACL, tibial tunnel there, and the ACLs look fine. But we've got a medium meniscus tear and a lateral meniscus tear, a medium meniscus root tear with a peripheral lateral meniscus tear. You can see that medium meniscus root tear right over there. If we go scroll through that maybe again. Let me scroll through that again here. So it's right here. Here's the root tear coming up right here in a minute. Right there. Right there. That's the root tear right there. So okay, what do we do, right? So here's the situation. Here's the axial cut. You can kind of see this. Actually, this is, we got lucky here and got a good view of the root tear right here. So that's, you can see, that's that little, small little piece that we saw earlier in the first slide. And then this is the rest of the meniscus right here. So that's the root tear of the medium meniscus. So we went to the operating room. Not really a non-operative candidate here because we wanted to preserve his root tissue. So this is what the medium meniscus looked like. So we can probe it here. That's that little stump of tissue there of the root. That's what it looked like. His ACLs were hanging in there. You know, not doing much. Just cleaning out a little scar tissue off his ACLs. This was the lateral meniscus. So in terms of options, now what do we do? Any takers? Surgery? No surgery? Obviously surgery, but repair versus meniscectomy? Show of hands. Repair? Meniscectomy? Nobody? Nobody? Wow. So we ended up repairing it, obviously. So this is sort of a luggage tag. If you imagine you're putting your little tag on your luggage with that little plastic thing, that's kind of what this looks like. So we call it a luggage tag stitch. And then we passed one already, and then we passed a second one a little deeper. And then we pull that luggage tag down, get that tension nicely, which we'll pull here right here in a second. You can see that luggage tag getting pulled down. And then we pass another one in that right picture. We're passing actually another one into the better part of the meniscus. We'll kind of move that over a little bit. So this is an attempt here to try to get, you can see that in the left picture, we're trying to get those two sort of edges of the meniscus together right there. So we've got, and we're trying to see if that's going to come together or hold, and it ended up not. So I tried actually several times to get a stitch in that left part, in that little root stump, and it ended up not holding. So we ended up abandoning that, which was not surprising because that happens a lot where that root fragment is not very good. So then we have our tibial tunnel, which we drill right there in that left picture. And we can see that drill coming through there. We expand our drill there, and we kind of retrograde a little socket. And that socket, you can see, is a little anterior on purpose because we want to pull that meniscus anterior because the tendency when you do these repairs is to have it a little too far back because you want to preserve those hoop stresses and move that root a little anterior to its normal native area. So that's what that looks like. And then we do our retrograde drilling here to make a socket, get the stitches out of the way. I'll just expand our drill here. We'll just turn it on here in a second. And just make a little socket there. So that's where the root is going to heal to. Pass our little stitch there with that little red plastic straw-looking thing. And then we pull the repair stitches down into that little tunnel or that little socket that we made. And we tie that down on the tibia with a small, like about a centimeter and a half incision. So that's where we pull that stitch down, those three stitches down through that tunnel, and that's what the repair looks like. So that's the finished product on the right. All right, yeah, there we are. So then we'll go do a little bit of, in terms of evidence here. So yeah, so evidence versus repair versus meniscectomy, right? So in this, this is, we'll go through a few studies here. So 81 patients had this repair versus meniscectomy, so there was no osteoarthritic progress was detectable in 81% of the patients after repair, compared with 40 after meniscectomy. So pretty stark evidence there that the repair does better. We know that. That's, many studies bear this out. And the meniscectomies do better, do worse in terms of their return to pre-injury level, so the repairs do better. So another one here, decreased re-operation rate with the meniscectomy versus the repair. So this is the other side of the coin, right? So if you're going to do a repair, you got to do the rehab very well, you got to have a compliant patient, and they got to be okay if it fails. Because if I'm scoping Alexis's knee and he gets mad when the repair doesn't heal, he gets mad at me, well that's not going to be very nice for him or for me. So the patient has to understand that if this doesn't heal and he requires another operation, he's got to be okay with that. If he's not okay with that, then you got to have that discussion. So that's the key. We can all talk about how, in theory, the repair is better. It is better. But if he's got to get back to work and he's a laborer, he's got to get back to work in two weeks or a week or whatever he's got to do, then a repair is not going to work. So that context, again, has to be discussed with the patient. Super, I think, important to keep that in mind. So the repairs here in the very bottom here had no evidence of radiographic degenerative changes versus the 64% of the meniscectomies. So the repairs did better in terms of the degenerative changes, and there was a decreased reoperation rate laterally versus medially. This is one of these large database studies here. The meniscectomies were more likely to undergo a meniscal surgery or total knee arthroplasty or meniscus transplant. So the meniscectomies needed more work later on versus the repairs. The repairs did sort of better in terms of their long-term outcome, again, same theme over and over again. This was 58 patients with medial meniscus root tear. The radial repair group had better scores, less joint space narrowing. Again, the same thing, again, we see the repairs did much better in terms of their outcomes. In the very bottom here, the medial meniscus repairs were more likely to fail than the lateral meniscus repairs with a failure rate of 36% and 5.6%. So medial meniscus is harder to deal with in terms of a repair versus lateral. So it's not an insignificant failure rate. So again, we can talk about fixing these things, but the patient has to understand that it may not heal, especially, obviously, we're not talking about a pediatric patient, we're talking about an older patient. So in the very bottom here, this was 53 patients with an open total meniscectomy without any other pathology. So the degree of radiological RSC arthritis in the tibia, in the tibia femoral joint was much different between the operated and the non-operated knee. Obviously, if you take out the meniscus, it's going to do worse. Pediatric patients here, the meniscus, they do much better. But again, 17% failure rate at a mean time of 17 months after the initial surgery. So again, it's not a third or 40%, but it's still not low at 17%. So over 10 years, this is the root repairs versus non-operative management here. So we've got meniscus repair, meniscectomy, and the non-operative treatment. So those were your three groups. The osteoarthritis rates, you can see they're at 53% for the meniscus repair, 99% for meniscectomy, and then 95% for non-op. So obviously, the repairs do much better. And the rates of total knee, 34% for meniscus repair, 52% for meniscectomy, and then 46% for non-op. So again, much, much, much, much easier and better to do for long-term follow-up for the repair. Now microfracture on the meniscus tear healing rates. So on the very bottom line there, 15, so 65% of the meniscus tears with the microfracture completely healed versus only 12% of the meniscus healed without the microfracture. So the hypothesis of this study is that releasing these marrow elements or stem cells, native stem cells, into the knee at the time of meniscus repair may help in healing that meniscus. So we know that meniscus repairs with ACL reconstruction do better than isolated meniscus repair. So then we do this sort of microfracture or sort of notchplasty to vent out those stem cells, native stem cells, into the knee to help the meniscus heal. And that does help. So no significant, in terms of augmenting these with ACL reconstruction, there was no significant difference in the failure rates between the cohorts here. So these are my three little ones. These guys have little kids too, so we're all in the same boat here. And just trying to get these guys awake and fed every day, basically, is what we're doing. Thank you. That's amazing. You're my savior. Thanks. That's a very motherly gesture there. Mom bag. Yeah, that's right. Mom bag. We only have wallets. We don't have much to go with. Yeah. Okay. All right. Well, we'll get to the fun part. That was really just to give us a background, and some of that literature, I know we went a little bit quickly through it, but as we go through our discussion, we're going to reference some of that literature that Dr. Suri mentioned for us. The case that he presented was an easy case. It was a straightforward operative case. The cases we have here are meant for disagreement, so hopefully there is some when we get to it. Okay. This is our first case. You'll see it here. 44-year-old male, six weeks, twisted his knee, dancing at a wedding, dropping it low. I think some of us have seen that on Isaac by the Shout when you have to go down. I've actually had more than one patient with an injury like that. He's been mildly improved over the last six weeks, importantly, no mechanical symptoms, no prior injuries or procedures, and he works as an attorney. We see his exam on here. Of course, I don't have to read it out completely to you. I would say the important aspect of this is that he is entalgic, so it is causing some dysfunction for him. His knee flexion is not bad, but somewhat restricted. He has a classic palpation along the medial joint line, and we see our positive test, our special test there. And briefly, the MRI, this is the read. We'll take a brief look at the MRI. Actually, let's see. Here we go. Yeah, we will take a look at the MRI here in a little bit, but he has a medial meniscus tear, an oblique undersurface tear with a meniscal cyst, and mild chondrosis in the medial compartment. And very importantly for us as sports physicians, we think about what does a patient want to be able to do, either for an elite athlete, where they are in their calendar, or a recreational or active person, what they have coming up. And so he has a country club golf tournament, attorneys with all their time to play golf in eight weeks. So this is their MRI. We won't belabor it, but we see on the left here the medial meniscus, that undersurface tear both in our coronal and sagittal view, as well as the parameniscal cyst. Okay, so we'll now turn to Dr. Vaughan, who will talk a little bit about the non-operative approach here. All right, so I'm going to keep it casual and keep sitting down for this. I also have a cough from children, so bear with me. So you know, this is our case, and I'm going to talk a little bit longer than I will for case two of what I would do non-operatively, just so I can talk about what I do for this specific case, and also just how I think about patients in general who come in with this. So we have this 44-year-old male. He has this oblique medial meniscus tear. He has the associated parameniscal cyst and the Baker cyst, as we know. So before I even get an MRI, and based off of his review of symptoms and how he presents this injury of dancing, I'm going to talk to him about the potential of having some sort of intra-articular pathology, and likely a meniscal tear. I like to talk about this with the patients before I even get the imaging, one, because it kind of sets up that when we get the imaging, they're going to already be aware of what is potentially going on and what they might need to do, and two, I really don't like surprising people, so I think that that's the best. If I already know, I might as well tell them. And so we're going to start there. Once we get the MRI, we're going to re-review our symptoms, his exam, make sure it still correlates with how he's presenting today and what we see on the MRI. And then in the vein of shared patient decision-making, we're going to start with a very simple algorithm. It's best to start simple and then get into the weeds from there. So the first thing that we can always do is do absolutely nothing. Plenty of people come in, they just want a diagnosis, they want to believe that their pain actually equals something, and in this case, we have an answer for him for what his pain is coming from. And he may want to do nothing and just kind of continue on with his life. It's already been six weeks, his pain is starting to improve, and so we could just wait and see what happens. He can come back in a week, a month, never, it doesn't really bother me either way. What he chooses to do, he has his diagnosis now and he can make that decision. The next is that we can always do non-operative management. That's why a lot of people are seeking out physiatrists, is they know that I'm not a surgeon, I'm not going to try to cut them open, I'm just going to give them the facts. Maybe I'll put a needle in their knee if they let me, but I don't have to do anything interventionally with them. So that's where my expertise comes in, and we'll talk a little bit more about the non-operative management in a bit. And lastly, I always like to discuss surgical options if I believe there are some. I'm not a surgeon, so I can't go into the details of surgeries, but I do talk to patients about whether or not I believe they'd be a good surgical candidate, things like what kind of recovery they might want to expect from it, when they would be able to get the surgery done. And having those conversations with them early often gives them that opportunity to really think about whether or not they even want to meet with an orthopedic surgeon. For most of my patients, I want them to meet with an orthopedic surgeon. I want them to talk it over with someone who would actually be doing the surgery so they can get all the advice directly from them. But I do like to start the conversation early. So while I'm doing this decision tree with them, I'm also stratifying all of my patients. So I'm really thinking about what factors are important for them. So I'm thinking about their age. He's 44. So in terms of his knee health, he's about middle age in his knee health. So I do expect him to be able to recover from a meniscus tear, whether he has surgery or not. I'm thinking about comorbidities. This patient doesn't have any, but does he have any heart disease? Is he on a blood thinner? Things that might make him a good surgical candidate or not surgical candidate. I'm thinking about his activity level pre and post. So does he want to continue running, playing golf well into the rest of his life? Or are those activities that he's actually kind of coming off of? Those are important. And when does he want to get back to his activities? Some people are kind of like, oh, well, you know, I golf here and there, but it's winter and I'm not going to be golfing anytime soon. So these are things we think about in the north. I don't know. It's as big of a deal down here when it's nice and warm all the time. Then I'm thinking about the mechanism of injury. Is this an acute injury as it is in this patient's case? Or has he had some knee pain that's been going on for months or years? Mechanism of injury matters more to me and also makes me think of, is this some sort of degenerative process that's also causing some of the pain? And then is he having any mechanical symptoms? So in this case, he's not having any locking or clicking or catching. But if he is, that is going to be a quick, I want you to see someone surgical. Because those are the types of things that are going to continue to inflame over time. So mechanical symptoms are very important to me. So once I get to the non-operative part, this is kind of where our physiatry stuff kind of shines. So most of this is basic, but I'm going to start from the most basic things, because I know that we're all coming from different levels of training here. So first is activity. So I think this is one of the things we really should be stressing, is what is their activity now and what have they modified over the last six weeks? So in this patient's case, he was dancing. I mean, I assume he's not a dancer all the time, but maybe he is. So I want to know, are you still dancing? Are you playing golf? If you're playing golf, are you walking or are you using the golf cart? Are you doing nine holes? Are you doing 12 holes? How frequently are you doing it? Because all of that matters. Someone might say, oh, I injured myself and it hurts when I play golf, so I stopped golfing. Well, what about running? What about basketball? Is he still doing these things? I don't know how many patients have told me that they've pulled back on their sport that hurt them, but yet they're waking up at 6 o'clock every morning and running seven miles and are confused as to why their knee still hurts. So actually digging into their activity modification, what it means they are doing and aren't doing is important. Then at the same time, I also don't want him to just sit on his behind, right? He needs to keep the range of motion that he has. I don't want him to become stiff, so I want to make sure that he's still doing something, just hopefully something that's not overly provocative. Next I'm going to go into is some sort of medication options. I like to start there because I want to bring his pain level down. I want him to be able to tolerate activities. I'm a big non-opioid person, so I don't prescribe any opioids to my patients. If they want that, they can talk to my pain colleagues. But I always start with NSAIDs. So NSAID research really comes from the emergency department. Most research on terms of NSAIDs and analgesics is the lower dose is just as effective as higher dose. So starting with ibuprofen, 400 milligrams has been shown to be just as effective as 600 or 800 milligrams in terms of pain relief. I typically prescribe more meloxicam or long-acting NSAIDs mostly because, one, it can be covered by insurance. And for a lot of my patients, they can't actually afford a lot of over-the-counter medications. And two, because I think of patient compliance. So I want them to be taking this around the clock. And if you're asking someone to take a pill every four to six hours, it's not as easy as once or twice a day. Second thing I'm going to add on is acetaminophen. So Tylenol, a lot of patients will say, oh, Tylenol doesn't work. Well, research does show that Tylenol at 650 milligrams isn't actually that good at pain relief. But when you bump it up to 1,000 milligrams, it's more effective with analgesic effects. So the combination of both Tylenol or acetaminophen at 1,000 milligrams plus some NSAIDs is usually a good combination for most patients. And a lot of people haven't tried both at the same time. So if you give them those facts, they're more likely to try. And I think they're more likely to get some sort of pain relief from it. I do remind them though that this is just medication for pain relief symptomatics. It's not going to cure or treat any of those things. It can help with inflammation, but it's not going to heal this meniscus tear. Next we'll go into is any options for modalities or aids that they might be able to use. If they haven't been using ice or heat, I will always recommend those things in terms of myofascial pain and some anti-inflammatories with the ice. Bracing is an option. I'm not the biggest fan of using any large cumbersome braces. But I think that a compressive brace is always a good idea. So some sort of sleeve, an ice bandage, something that's going to help with some of that extra fluid that he has in his knee. And also it's a nice proprioceptive reminder of, you know, your knee is injured. And it tells the world around you, hey, watch out. Don't kind of push me on the subway. I live or work in New York. So I'm always telling patients, you know, you want the outside world to know that something's going on so they don't, you know, push you over while you're walking. And the third or fourth is going into therapy. So, you know, long-term outcomes in terms of physical therapy when it comes to meniscus tears, the research is a little bit off in terms of this type of case specifically. But it shows that when you compare meniscus tears to physical therapy, most of the research is comparing physical therapy versus partial meniscectomies. And so in the short term, if you do a partial meniscectomy, you might have improved pain or patient outcomes early. But there's a study that came out of the Netherlands called the ESCAPE trial. I think it was around 2018. And they showed that up to 24 months, actually, patients that had just did physical therapy or did physical therapy plus the partial meniscectomy actually had the same patient-reported outcomes at the end. So their pain was the same as somebody who had surgery. So what I tell my patients is that if you don't want to do surgery and you want to just try physical therapy, there's a good chance that your pain may be improving by a year to two years. Initially, it might not improve as quickly. But research does support physical therapy for it. And then from there, that was, you know, a one- to two-year follow-up. There's been numerous studies that actually go out to five years and show that five years after a partial meniscectomy, your patient-reported outcomes in terms of pain and function are the same as someone who's done physical therapy during that time. So it really shows that that physical therapy can have a long effect for the patients. And as non-surgical physicians, obviously, I'm trying to keep them away from the Dr. Surrys of the world, if I can. And lastly, we talk about injections. So, you know, a lot of my training has been doing injections, and I love to put a needle in anything that I can, but it's not going to be the first thing that I offer to any of my patients. You know, I kind of stratify the two different options, one being an intra-articular steroid injection, and then two being anything that's more towards the biologics, so your PRPs, your BMACs, your MFATs. And so, you know, steroids have been proven to give you that short-term pain relief. A lot of patients just need that pain relief in order to, one, be able to actually tolerate any physical therapy, and two, it might give them enough pain relief to get over that inflammatory state that they're in in order to just slowly heal on their own, and they may be able to avoid surgery altogether, or at least delay surgery. So I think intra-articular steroid injections in this type of case is a completely reasonable approach and one that I would offer a lot of my patients. And then lastly, if you're thinking of a biological, I offer them to all of my patients. You know, we have to talk about a lot of risks and benefits, and one of the risks is that it does nothing, and it's a decent out-of-pocket expense, PRP and the likes. But there is some suggestion that they might be able to help a little bit longer term in terms of your pain relief. So Melanga actually had a pilot study that came out about injecting MFAT directly into meniscal tears. And while there wasn't any imaging that showed improvement or healing of the meniscal tears, it did show that those patients had longer-term improvements of pain after directly injecting the MFAT into the tears. So there is some hope and potential for using these more orthobiologics in our cases. All right, so great, Dr. Vaughn. Thank you. We're joking with Dr. Suri. You're outnumbered here, non-surgeons and surgeons, but we still want you to be able to feed your kids, so we do give you cases sometimes, but we try to keep our patients away. Okay. So now for the fun part. Dr. Vaughn, so you talked about your approach to this particular patient. I think we covered it pretty well. Dr. Suri, this patient shows up in your office. What do you tell them? I tell them to do whatever Dr. Vaughn said. Good answer. See? I'm not as dumb as I look. I'm not as dumb as I look. So I think, as Christian mentioned, in terms of the decision-making, in terms of, okay, is this eight-week golf thing, is it that important to this guy? Is this guy a big-time golfer, or does he really want to get back to this thing at eight weeks? Because if he wants to get back to this thing at eight weeks at all costs, then you can't do a repair. I mean, clearly, that's not going to work. In terms of an injection, certainly reasonable to do, to try to get him through that. Maybe that could help him get him through that process to be able to participate in this golf thing. So the other side of the injection is that, okay, well, what happens if he does that? What happens if you inject him? Dr. Vaughn does her perfect injections that she does, and he feels better, and then he goes back to this golf thing, and then he hurts his knee again, and then it gets worse, and his tear's bigger. Okay, so then you've got to deal with that, right? So as long as the patient understands that these are all the risks, that this tear could get worse. He may feel fine, but, okay, what if he's walking on the course and has a twisting injury or whatever, and the meniscus tear gets worse, and then you've got to deal with that, potential complications of having a bigger tear, bigger, more extensive repair, higher chance for failure, or not being able to repair it. So I think as long as you cover all these spaces, I think it's reasonable to do. In my hands, if that's me, I'm six years older than that, but if that's me, and I have to play in this golf tournament, I'm a very serious golfer, but I'm not professional, so I'm not that serious, I would say I would probably go for either an injection or a scope to clean it out immediately. That would be my choice. A cortisone shot. A cortisone shot to get through it and see how that goes, or a meniscectomy. Is there anything in this case that, oh, before I get to that, so you said meniscectomy, and you detailed very well the meniscectomy versus repair. Is there any consideration to repair this individual? I think the tear doesn't look too big, so I think if it was a giant tear, then that would be, I think, a different discussion. The tear didn't look too big, so maybe cleaning out of the meniscus would be a small meniscectomy, which would be favorable. We'll move on, actually, to the second case, and I think what we can do is we'll do a Q&A at the end. We'll do the second case, but, of course, as you go along, you have questions about the first case, we can go back to it, questions about the second case, we can go back to it, but again, we can have a robust general discussion about our approaches here. That first case, that's an easy case. I think I threw a bone to Dr. Vaughn and didn't throw a bone to Dr. Suri because he doesn't get to eat in that case. He's got to feed the kids first, right? But this next case, I think, is a little bit more challenging in terms of how we would approach the patients here, so this is a 59-year-old male, sudden knee pain four weeks ago, doing the sport that keeps us, sports medicine physicians, in business, the infamous pickleball. So symptoms have not been improved. He has new mechanical symptoms, and he's a semi-retired real estate agent, living the best of both worlds. So we see his exam here. He has a little bit more refusion than the first case, a little more restriction of range of motion in his knee, and then you see the palpation and the special test results there. His MRI is here, which we'll take a look at briefly. We see the important components here is that he has an extrusion, which we'll see. Dr. Suri talked about that in the gross anatomy section, part of his talk. And he has these undersurface tears in the lateral meniscus, and then also has, again, we talked about the medial meniscus, but very importantly, he also has tricompartmental arthritis. So these are his functional goals, again, very important for us as physiatrists. And he wants to return to sport, but he has a very important functional goal of a wedding coming up. So what do we do? His MRI is here. Again, we won't belabor it. Coronal cut on the far left, showing the extruded fragment, extruded meniscus there. We also have some arrows pointing to, I'm sorry, this is the medial meniscus here. So we also have some arrows pointing to the chondrosis that's there. Now we see the medial meniscus sagittal cut here. And again, we see in the posterior horn our meniscus tear. And then we have our lateral cut on the far right. Okay. So this is a case. Dr. Vaughn, what do you think? What's your opinion here? So, you know, this is a patient that I feel like we see often, and I feel like these tears and presentations always seem to happen right before a wedding or a big event that they have coming up. So I feel like this is a pretty standard conversation that you have. And so in this patient's case, he wants to walk his daughter down the aisle in eight weeks. And my goal is to do everything possible to see if he can do that, or to make sure that he can do that. So what I wouldn't do is probably offer him a steroid injection that day. And the reason I would wait is because it's eight weeks away. And I don't want to give him something that might be really helpful today and for the next couple of weeks that wears off before eight weeks. I would start him on the ibuprofen and the Tylenol, as I mentioned before, and see if he can tolerate any physical therapy, and make sure that he can kind of get into some sort of program, whether it's a home program or something more structured immediately. So we can get that pain down. He had mild pain to begin with prior to his injury. So my goal would be just to get him back to basically that level. I can't make all of his pain go away. The next thing I would talk to him about though is those mechanical symptoms. And so if he's having continual mechanical symptoms, especially if it's daily, multiple times a day, I'm going to remind him that anything that I do is going to be symptomatic. It's not going to stop that mechanical symptom from happening. And five seconds before that wedding, he might trip or kind of get locked or stuck, and there's nothing that I can do about it. So because he's having those mechanical symptoms, I'd want him to talk to an orthopedic surgeon as quickly as possible, because there is the opportunity that he could have surgery, recover from it, and be ready to walk down the aisle within those eight weeks. But you also have to think about what is his life, he's semi-retired, so he probably has the time to get the surgery done, but does the surgeon have the schedule to be able to get the surgery done in time? So those are things that he needs to be thinking about. In terms of injections, I would definitely offer him a steroid injection, but probably closer to the four weeks before the wedding. I want him to, one, recover from the steroid injection, and two, hopefully still get the benefit from the steroids. Research shows about five to six weeks after a steroid injection and these more complex tears, the pain might start to come back. So I want to be shooting for a window before those five to six weeks. Great. Dr. Suri, what do you think? I think that's a pretty reasonable plan. I think the other thing is how much, one thing I would add is, does this effusion bother him, right? So I would potentially drain the knee at that visit if it was bothering him. If it wasn't bothering him that much, and his motion's restricted, but if he's not complaining, his quads are working, then I think that would be sort of reasonable to leave that alone and then aspirate it when you do the injection at the four-week point from that visit. So I wouldn't offer, I wouldn't, and more likely than not would not scope the knee right away just because you can get him through this point, through this event with the injection, and then potentially scope it afterwards if you need to. Go with the conservative management first, do the injection, potentially an aspiration. And the other thing is that, is his quad shut down too, right? So if his quad shut down because of the effusion, because of the pain, I think therapy would help to work on that in terms of the quad and the hip core muscles to keep the sort of biomechanics and kinematics of the lower extremity good and so that he can sort of get through this whole time and hopefully not need an operation, but he might. Yeah, and let's say the timescale, so it was not two months here. Let's say it was six months. Would that change your decision-making with him, the mechanical settings? Yeah, it would. I mean, I think for that, at that point, I think an injection certainly is reasonable to do first. I think that's actually a very good idea because it may help him. What if it helps him for a year? Then he'll carry on and then do another shot in a year. I think that works. Many patients are like that, as you guys know. But the only thing with the injection is that he may need another one before the wedding. However, if the mechanical symptoms get worse, then you run into the issues of potentially an injection not helping as much in four months or five months or six months. And with this particular patient, you would still proceed with a scope, even in the setting of the osteoarthritis? With his mechanical symptoms, yes. Yes. And tell me a little bit about the, tell us a little bit about the conversation you would have with the patient. Because you said you're going to relieve his pain, are you going to relieve the mechanical symptoms? What are you going to do? Yeah, so does your pain come from cartilage damage or does it come from the meniscus tear? It's hard to know what comes from what. I think anyone who tells anybody that they can figure out 50% of your pain comes from, it's all over the board, right? Because there's patients that have arthritis and have arthritis that's fairly significant and they've had no pain before this event and they have done great for many, many years. We've had many patients like that. And so then, okay, so does this event sort of trigger a sort of cascading of an inflammatory process in that knee that leads them down a downward spiral of effusion, of poor quality joint fluid, of quads shutting down, so then that now you're biomechanically in a bad place, biochemically in a bad place as well. So then, okay, what do we do? Then potentially, you know, visco-supplementation might help because we want to improve the quality of the joint fluid to allow them to get that pain down, to allow them to get stronger, so that hopefully then they're kind of okay managing their knee with this meniscus. Yeah, and one final question before we get into our audience discussion here. Let's change a little bit the profession of this individual. He's a younger, he's an elite athlete, and he, sorry, let's, sorry, we'll go back to our first case here. This patient is an elite athlete. He could be a 44-year-old professional pickleball player. And he has, and let's make the timescale, three months is a big championship tournament, right? 44-year-old professional pickleball player, three months, big tournament. Is that changed how you think about maybe doing a meniscectomy on the patient like this? Yeah, in my hands, that would be as immediate, scope as quick as possible, and get him back to rehab so he can get back playing in three to four weeks. Yeah, good. And in terms of your patient, in terms of how long does it take to get back after an operation, just to touch on that real quick, different patients are different, obviously, in terms of their resilience and how quickly they can bounce back. We've gotten guys back to playing college basketball and pro sports in two weeks after a knee scope. And again, but not everybody's like that. You've got athletes that are just, whatever you say, doc kind of athletes that'll just get back and have a little discomfort, and also may have an infusion that you may have to drain, or you have ones that don't only wanna come back when they're 100%. So those aren't gonna come back in two weeks. Those are gonna come back in six weeks. So that, figuring out what kind of patient you have is also, I think, super important for these, at the elite level or athlete level. Great, thank you. Okay, so we'll have some time for some Q&A here. And we also have some questions from online, but invite the audience who's here with any questions. Oh, I wanna ask Kirsten a question, too. Yeah, go ahead. In the patient that we just brought up, would you potentially inject, number one, would you potentially inject? Number two, what would you inject? Case one or case two? This guy. Case one. Case one, I would probably inject the one who's trying to do his golf tournament. I'd probably inject him with a steroid. And I would probably also, obviously, I would try to drain either of their effusions, case one or case two, with the steroid injection. For case two, just to, I know this wasn't your actual question, but I'm gonna just say it. For case two, I wouldn't drain right away. The reason why I wouldn't drain his knee right away is because he already had mild symptoms prior to this more recent injury. And I would assume that he had some sort of effusion ahead of time. So if I'm just draining, but not putting steroids in at the same time, I might expect that fluid to just reaccumulate pretty quickly. So in case two specifically, I would only aspirate if I was also going to put steroids in. In this case, I might aspirate first if he wanted to just try that without steroids, because it's more acute. We can see how much of that fluid is bothering him. But for the most part, I would inject with steroids for both of these patients as my initial starting point. Thank you all for that. This question is directed to Dr. Vaughn. You mentioned steroid injection and the PRP injection, and you mentioned another one, MFAD. Could you maybe speak on that? Sure, yeah. Lipogens is one of the brand names of MFAD or the aspiration of your fat cells or adipose tissues. And so adipose tissues have a higher level of, I'm gonna say stem cells and put it in quotes because we're not allowed to call it stem cells. But it's taking the fat from your own body and you aren't manipulating it because again, that would be illegal, but taking that product and trying to augment healing processes. So there's two different ways you can do that. One of them is using fat and the other one is using bone marrow aspirate. And both of them come with pretty high costs. So in the thousands, so it's out of pockets, neither are covered by insurances unless maybe you're a professional athlete. And so these are ways to potentially augment the healing process. Research is still up and coming with actually proving it, especially proving it on MRI. So when we look at the injection, we can see improvement in pain, improvement in function in our patients, but we haven't actually seen the healing on imaging for the meniscus specifically. A lot of these products are being used for other musculoskeletal injuries. And I mean, you could put them in hair loss and there's a lot of other applications for them in medicine in general. But I think it is something that is worth trying for any patient that is against surgery. And here is my mentor who taught me how to do all of those wonderful injections and procedures. No pressure. I just want to thank you. This is a really interesting and relevant session. You know, I struggle probably every day with that 59 year old patient. Sometimes x-rays, you know, see with weight bearing how much cartilage they really have left. But even in the presence of mechanical symptoms, I think some of the old studies from Jeff Katz and the METEOR trial and, you know, sort of the operation on meniscal tears and the setting of moderate to advanced arthritis may not do the patient great in the long run. They still may end up with arthroplasty. So I just wonder, you know, Christian, and also to our searcher, like how do you think about those? And, you know, there's some surgeons will operate, some won't, but that sort of moderate to advanced arthritis, superimposed meniscal tear, but the meniscus is kind of trashed anyway. And, you know, how you decide who might benefit from a surgery and who not in that setting. I'll take it, I guess. So I think, it's a hard question and a very good question, thank you. I think mechanical symptoms are key, right? So if they're not having mechanical symptoms, I'm not touching it most of the time, almost always. So if they're not having mechanical symptoms, I think conservative management is exactly what should be done, in my opinion. If they are having new mechanical symptoms after an injury with moderate arthritis, right? That's very classic patient that you're describing, which is difficult. And they were doing fairly well with previous to this. Those patients in my hands do pretty well with a scope, not always though. And so I have to give them that disclaimer of every now and then we'll have someone, you know, handful of times a year that declines into arthritis. So that has set forth this cascade of sort of decline into total knee situation. So then I got to send it to the total knee guy. So the biomechanically and biochemically that knee is sort of down, it's just not coming back. And that happens sometimes. And there may be some superimposed bone edema as well. And that potentially may be treated with a potential, it's another discussion, but potentially treated with a bone substitute potential injection to that area. But barring that, I think that if you have that discussion of, and certainly conservative management is certainly reasonable to do, but, and then when that fails, then you potentially scope the knee at that point. But the problem with that is, has the knee progressed down further to make that potential scope sort of too late for that? So I think it's a tricky situation, but if you have a patient that has new mechanical symptoms from a traumatic event, that may not be a big trauma, it may just be walking or getting up or something, I think it's reasonable in my hands to do a scope on that knee if conservative management has failed. From a surgeon's perspective, what are the buzzwords the patient is gonna use for their mechanical symptoms? Because a lot of them come in, they're like, all of a sudden it's kind of buckling on them, but once you- Yeah, most likely that's the quad, right? Yeah, exactly. Because the quad is shut down. So you gotta really, that's a great point, because you really gotta pin them on that, pin them down on that a little bit. Okay, is it worse going down steps? Does your knee give out? And they have to, I can make them get up and describe just exactly what you're doing with your leg, kind of letting that knee go into flexion. Is that all that it is? Because if that's it, then that's most likely the quad right now locking, catching, and you gotta kind of go down that rabbit hole a little bit with them because they don't really know what that is. So does it feel like there's something inside your knee? Does it feel like there's a piece of something in your knee that is catching, that is sticking, that your knee kind of doesn't move sometimes, and you gotta kind of wiggle it free. Classic mechanical symptoms. So pinning them down on that is, I think, super important to make sure that it's true mechanical symptoms, not crepitus, right? That's great, thank you. Yeah. That's great. Yeah, and often I think of some of these mechanical symptoms as sometimes unpredictable, like the crepitus is reproducible. Every time I do this, I get this, or every time I go up and down the stairs, I do this, but versus all of a sudden my knee catches, I have no idea, you know, kind of what's going on. We have some questions online, and we'll get back to a live question here. The first one that came through, and I think it should be pretty quick for you, Dr. Seery, is how long can you, or should you, put off a repair of a bucket handle tear and still expect a good outcome? Good question about that. The answer is you want to get to it as soon as possible. Funny story. My first case, really, literally first case as a coming out of fellowship was a 16-year-old kid with a bucket handle tear with an ECO that had been bucket handled for six months. So it was in the notch for six months. Oh my God, geez. Are they all like this? Like, what's going on here? This is terrible. This is like literally terrible, first case. And his dad is a computer guy at the hospital. So interestingly, you know, this kid is young, so obviously, you know, good healing potential. So could not reduce the meniscus, had to actually snip the meniscus to get the, because it had contracted, right? So to get that back into the periphery, had to actually cut it and then repair it, and there was a gap of about six, seven millimeters between the two pieces. And sure enough, that was literally 15 years ago, and I see the guy's dad all the time in the hospital. He's kid's doing great. So again, in a younger patient, you've got more leeway, but you wanna get to it like ASAP. So meaning like, I don't think it has to be tomorrow. I think it can be within a week or two if the injury is, you know, last week. If it's six months later, you can have that contraction issue. You can have that non-reducibility issue, non-repairability issue, tissue's not viable. So that pre-op discussion has to be had with the patient that, okay, this may not work. You may need, you know, a meniscectomy. You may not be able to do this, and you may need a meniscus transplant in the future from one of our colleagues. So I think as long as you, you gotta sort that out ahead of time. I think, you know, the discussion about the meniscectomy, the mechanical symptoms, really pitting the patient down on the history, I think is super important. Yeah, thanks. Yep. Is there a role for visco supplementation in either of these cases? I think there's always a role for visco supplementation. I think that you were talking about it before about kind of improving the synovial fluid that's within the knee, especially when you're in this large pro-inflammatory state that they're both likely in because of a more acute injury. So I think that there's always a role. I think state by state though, insurance coverage of it is changing, and so it kind of goes into almost the orthobiologic, out-of-pocket, next-level treatment options depending on where you live. When I was going through my visco supplementation phase, it wasn't covered by insurance, but as a physician, they gave it to me. It worked great for about four or five years, but I've had other people go get it, and now in different states, it is approved. So did you get a repeat in series after your first series? Oh, I had them every three to four months for about five or six years in both knees, and then I had to have my knees replaced. So, and that begs the question, right? So, okay, so you did great with those injections, and you were able to get back to work and do your thing, right? So you also, you have to keep in mind that the patient, meaning you, if you can get back to work and do well with your injections, that's awesome, rather than just going straight to the total knee. So I think keeping that, that's important, that your patient's going back to work, and that's, he's productive, and he's doing his thing. I've gone actually to every two weeks now for my visco supplementation. Instead of every week, I've changed, actually about three or four years ago at the advice of one of my buddies who found that to be a little more successful to go with the 2CC injection once every two weeks, not every week. Every two weeks for how long? Three weeks. Oh, for three weeks. I mean, sorry, three series, three injections, six weeks. And do you think that's better than the single injections? Yes, in my hands, the single injections are too painful. We'll do one question from the chat, and then I think we have a couple here, and then we'll wrap up. Of course, we're available afterwards to talk, so I don't wanna keep you all from lunch. So I think this is a very interesting question. This is very important for us as we collaborate as operative and non-operative physicians. This question is, do you, Dr. Suri, have any concerns about performing arthroscopy following a recent injection of steroid or any other substance? And is it different when you're considering meniscectomy versus repair? Yeah, good question. I don't, I don't. Not for a total joint, you know, three months, some of the literature has shown, for the total knees, but for a scope, no, I don't have any concerns. Thank you. Yeah, thank you, this is a great talk. I feel like I see one of these patients at least once a day, if not multiple. So you mentioned PRP in some of these cases, and every time I bring up PRP to my surgical colleagues, they bring up, like, natural progression, and like, oh, this is gonna get better, and so how do you know your studies are, you know, making a difference, basically? What is our data for PRP in meniscus tears, and how, what level of evidence is that? I know for arthritis, we have pretty robust, you know, long-term data for knee arthritis, but what about for meniscus tears? For meniscus tears, I think that the research still needs to kind of be done, to be honest, and I think that the reason why it's a difficult topic to research is because the best patient to do it on is someone who has an acute meniscus tear and no arthritis, but most of the cases that we're seeing are these gray areas where they have arthritis, as well as the meniscus tear, and so research is really showing that it's not necessarily that much better, if at all better, than steroid injection, than doing physical therapy alone, or than doing a partial meniscectomy, so it kind of falls in that gray area. It does show that there is improvement in pain, but is it more superior than others? Not that I've seen in research. Yeah, great, I mean, I think, in many of our practices, it's shared decision-making, and you present exactly that to the patient, and you don't oversell these treatments. I think it's very important, too, setting expectations so that when it works, you look like a champion, and when it doesn't, you told them to go straight. All right, one more question, and then we'll wrap up. So kind of a specific scenario, but the patient that had a root tear repair in the past recovered, and then maybe has an acute tear again. Is there any consideration you make when you want to consider maybe non-operative management? Are you concerned about putting a steroid in their knee, or maybe using a biologic in a patient that had that repair? No, I think it's certainly reasonable to do. The only thing that's tricky in that situation is figuring out if the new tear is contiguous with the old tear. That can, more often than not, be an issue. So if the MRI shows that it's definitely not, and I think that's certainly reasonable, but I think if you're in doubt, then you gotta scope it and just actually look at it. But I have no problem doing exactly what you said. I think that's really a good plan. And the patient that you do want to scope, a young athlete, and you do a resection, is your conversation with them usually, you know, this is to help you get to this, whatever event you want to play at, but in the future, we're increasing maybe your odds of developing OA. Do you have that discussion? Sure, yeah. So, and that can be a long, painful discussion, as you know. The issue is, you know, a young person, say it's a small meniscectomy, right? They may do well for 20 years, and who knows what we'll be doing in 20 years. So that's kind of what I tell them, too. I was like, we're doing a lot of different things now than we were 20 years ago when we were taking out entire meniscuses, menisci. So I think in 20 years or 30 years when that patient has an issue, maybe we'll have other fancy things that Dr. Vaughn can just inject and we're all done. We don't have a job now. That's our goal. Yeah, moral of the story, get Dr. Suri out of a job, right? So, we're a big 10 in PM&R, so you're always welcome. All right, so that concludes our session. Thanks, all of you, for joining us. A big round of applause for our panel, did a great job.

meniscus tears

evaluation

management

mechanical symptoms

non-operative treatment

surgical treatment

activity modification

patient communication

shared decision-making

biologics

treatment plan