Grant Garcia MD, Seattle with Prof H Gopalan

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[00:00:00]Welcome all of you to this live program at orthopedic principles. Today our guest of honor is Dr. Gran Garcia from Seattle, United States. Dr. Gashia is a boardcertified orthopedic surgeon with subsp specialy certification in sports medicine and advanced fellowship training in shoulder surgery. Dagashia earned his undergraduate degree from the Brown University and received his medical degree from the University of Pennsylvania followed by orthopetic surgery residency at the hospital for special surgery in New York. During residency, he completed many shoulder fellowship in France and then completed sports medicine and shoulder fellowship at Rush in Chicago. Dr. Gashia is actively involved in surgical innovation and works with leading authoric companies on the innovation front. His roles include product development, FDA testing, medical consulting and surgeon education. He's authored over 80 peer-reviewed publications. If you've noticed, Dr. Dr. Garcia has delivered a lecture on a channel which has already reached a huge audience and today is my great honor to bring back Dr. Grant Garcia for this wonderful live program to Grant.

[00:01:02]>> Thank you so much for having me. So we're going to go right into it. Uh another unique topic. So meniscus transplants talk to about my practice and then the indications. So thank you again for having me. So again the big thing on miniscus transplants is not only you to have to execute the surgery well but you have to indicate properly.

[00:01:19]So the key for this is a biomechanically absent meniscus but the big key is really pain and swelling right no meniscus no pain not a great indication for a miniscus transplant. There is some indication in the sense of you have an ACL tear and you have miniscal deficiency it can improve the stability by adding the transplant. Um you want to make sure you have some correct coorbidities. So BMI under 35 is key.

[00:01:42]Alignment is very good as well. We'll talk about that in a second. The ligaments need to be stable around it.

[00:01:47]cartilage and then the number one in my practice and in many of your practices if you start doing these is going to be patient expectations. This is not a return to professional athletics even though we will show that it has has happened. This is a functional improvement that you that you currently have reducing pain improving stability.

[00:02:07]So this is just a really quick little slide and also a shout out for my podcast. Uh but you can see here the big one is on the right. So Lonzo Ball, he is the first NBA player to ever have a meniscus transplant. He had obviously taken a few different surgeries before he got to this. Uh but this is indication that this is now becoming even more cutting edge in the in the professional level because this is sort of the last effort for these patients to get back to the their level of athletics. And so far he's done quite well with it.

[00:02:34]So again, I love this this slide from Dr. Cole. Uh the key here is there's really pillars, right? You're not going to just do a meniscus transplant and not think about anything else because they will fail and I have seen that. So the goal here is to make sure that the knee is in the perfect environment. So your alignment's been adjusted whether it's an osteotomy etc. your stability's been adjusted and then and only then if those things are good then you start correcting the miniscal deficiency or the cartilage deficiency.

[00:03:02]So this summary slide is also really nice. I really like these from arthoroscopy because they're colorcoded and they're really nice for new surgeons or people reading it to understand better. So again, the indications we've talked about there are contra indications. The key for cartilage damage is you if you have a contra indication in terms of you have a cartilage hole as well, you can correct that if you correct the hole, but you don't leave the hole and do the meniscus transplant. There are three main types.

[00:03:27]There's soft tissue, bone plug, and bone bridge. I do some soft tissue. I tend to lean more towards a bone bridge and bone plug depending on the side of the knee.

[00:03:35]And this is just a really quick summary on the outcomes which we'll review in a second. So the sizing and matching is important. So we use MRI, we work with different companies. So we'll have a I have a coordinator. They'll submit for it. They'll submit all the notes, submit for the insurance approval, and then submit for the match. And then I'll get a thing labeled such as this one below.

[00:03:54]It's actually one of my patients that I just screenshotted. And you can see the match of the size. You want to get as close to the size as you can. The nice thing about this compared to the previous lecture we had on cartilage transplant is these graphs are frozen.

[00:04:06]So you get a match faster because there's a higher inventory and you don't have to have a weight list or worry about the match not coming in because it's a a fresh graft.

[00:04:16]So again, this is a different technique that you use for an X-ray as well. So you're looking at an AP and lateral X-ray and then they measure the length.

[00:04:23]The MRI is kind of more the gold standard now, but it's just important for to touch base on this polar technique. So this is important too because you know people always again ask right it's a hard surgery to do so. So you really have to see the benefit of it because it can be something where the surgeons are swayed away from it just from the challenge of the technical aspect of it. And we have newer techniques that are improving the speed and the um the ease of doing the surgery. So in intact meniscus you can see here the contact pressures are really spread out. If you do a mintomy you basically have this contact pressure focalized there. You can see the high red focus right there on the tibial plateau and that's a problem. And that's when we start to get overload, cartilage damage, and that's kind of the beginning of sort of an arthritic knee. Now, if you add a slot technique medially, and this is what Dr. Cole does, you can see here the contact pressures are not exactly the same as the original meniscus, but they're a heck of a lot better than that middle image.

[00:05:16]So, how about again another discussion on this contact pressure? So, the side of the graph does have significant effect on the contact pressure. The key here for Matchy is you really don't want an oversized graph. That can increase the contact pressure. And if you undersize it, you'll increase the forces of the miniscus, more likely for it to tear. A correctly sized one really matches the best. And again, you can accept a 10% mismatch. And as you do more of these, there's some tricks that you can do. If you get it in there and you think it's a little bit too large and you have a slot, you can lower the slot a bit. If you're doing bone plugs, you can actually adjust that as well and deepen how much you pull it in. Um, and if you're doing soft tissue, it's a bit easier to take care of.

[00:05:52]>> So, this is an example of one. This patient had a I was doing a scope because I was already doing another part of their a different surgery for them.

[00:05:58]They had had a meniscus transplant and you can just see it's really hard to tell that this is a meniscus transplant.

[00:06:03]I'd say, you know, overall I was pretty pleased with this. He ended up going on doing really well. Um but the interest here is just to show you that it's really hard to tell once these heal uh if it's a transplant or not. You can see that it's completely integrated in. So just as hard it's good to see a second look. So again, does age have an adverse effect? So here the age cut off they put is 43. Again there's other there's other studies that look at 50. Um so when you're controlling for cartilage status there's no difference in older and younger and I have done up to about 52 53 for these. Again age is just a number. It's really that cartilage status and the health of the patient. Um the age related proxy factors are more of an issue. So it's obviously if they have good cartilage and alignment with the most recent in minisctomy don't just go off the age go off how their knee looks right. you know, you see those MRIs, we're like, "Wow, your knee looks really young on MRI." Um, that's a good patient for this scenario.

[00:06:57]And again, we're going to touch on the less than 50. So, this is 38 patients, 3.5 years, mean age here, uh, 30 years old, 89% improved, 77% pain-free with low impact. So, again, not an incredibly high impact procedure, but we will get to that in a minute. Now, we have had patients return to very high level, but that's not the promise we give our patients. The key to obviously a good surgery, especially a surgery like this with its complications is you want to set an expectations appropriately.

[00:07:27]So again, this one I like this because again this is does it prevent OA because people always ask that question and again we want to be careful because obviously you want to show enough studies but we don't want to oversell a product or oversell a surgery. So this is 24 studies all one level one some level threes and level fours. So there is no evidence needed for aftercintomya.

[00:07:47]Now we successfully did improve outcomes though which is important. The overall failure rate was about 10 to 29% return to sport almost 85% of the patient. So patients do well after this if done well. Um now in this thought the final conclusion though was that it may prevent progression of cartilage damage in the long run and we have seen that now with some newer studies. So this is important this protective effect. So I like this study because it's it does the uh the row imaging on MRI. You can see here now again that's not common for all the facilities to have this imaging stuff but it's really nice to see that they're able to do it. So again this is I think this is the Korean data and they do a lot of good meniscus transplant work. Um so they did T2 mapping pre and post a lateral meniscus transplant. This is actually the more common one I see in isolation. So this is a good one to do.

[00:08:33]31 patients almost 8.9year follow-up. So really good follow-up. So they looked at the femoral all the segments improved in ephemeral side and in the tibial plateau the posterior segment improved and I would say that's the side that gets affected most with these lateral meniscus transplants. You tend to see cartilage wear in the femur in this posterior lateral aspect of the tibia and sometimes you can cover that with the meniscus transplant and still get away with it but it's important obviously to know um whether this is improving with the transplant itself or whether it doesn't degrade. So you can see here there is some contra protective effect of adding the miniscus transplant.

[00:09:08]How about return to sports? So again we're going to get to more studies on this but this is one of the earlier ones. 13 patients you can see Cole Sherman a lot of big names on here. So almost 20 years old these patients were 3.3 year follow-up. Some professional varsity athletes college they had a 77% return to sport which is quite good because this is again a salvage procedure. 23 required further surgery.

[00:09:29]So this is not a surgery you go into and tell the patient I'm never going to see you again. There are a lot of these patients that come back either just to have their knee evaluated and or eventually need another surgery. So one had a revision, one had a repair. In high level athletes you can return patients to high level sports but again you have to properly set expectations.

[00:09:48]Another return to sports. So a larger cohort you can see here 89 patients 38.5 years. I'd say this is sort of more to my average in terms of the ones that I'm doing this on. Uh 4.2 two years. So 74% returned to sport at 8.6 months, 49% at the same level, 12% underwent a new surgery and only age really affected the outcome. You can see here again these are not football hit classes. You can see the the sports are doing are a little bit lower impact. So it's important for people to understand that return to sport means you can go back to some of your daily sports but maybe not the super high level activities.

[00:10:22]And this is a really important slide. So this is from Dr. Drago. Uh you can see here so the elite athletes can return to sport but it's only about 50%. I have another slide on this from cartilage the cartilage is in the 80%. So again, this is a long recovery, so you have to be really careful, right? Mid-season athlete can't get back without a miniscus transplant. They're going to be missing almost two seasons with this.

[00:10:43]And Lonzo Ball took him almost a thousand days. So this is not a small procedure you're doing on somebody.

[00:10:49]Another good study. Okay, so this is when you combine it with carage transplant. I'd say almost half to more of my carage trans my meniscus transplants I do a carage transplant with as well. So 100 patients again 31 years 4.9year follow-up more medal condiles and later from so assuming more medial meniscus transplants there is no difference in failure rate when you add a cartilage. So if you're doing a cartilage trans if you need a carage transplant do it add it to the miniscus transplant you'll get similar outcomes.

[00:11:14]So 86% survival rate at 5 years when you add them together again 86% and almost 3.1 years and you can see the cap and meers curve there. How about if you add it with an ACL? Again this is a harder surgery. I do a fair number of these but this is a much harder procedure technically. So we want to know whether it's worth it and whether it improves stability which we mentioned previously from some studies. So it's ACL with miniscus transplant versus isolated ACL.

[00:11:39]So again most of those are medial meniscus which is most commonly a lateral meniscus transplant with these is very challenging. I do it but that's that's why they have less of those and it's less common. It's mostly the medial meniscus you're usually replacing um versus 46 regulars. And there were some soft tissue ones in this scenario especially. It's a lot easier when you do it with an ACL. So again, no real differences. The no difference in the graph retailer rates or the level of return to sport. The level of sport you can see here, while not statistically significant, a little bit lower, 69% versus 78%. Majority of the ACL miniscus return to some sport and low risk of retire. And again, I would say that these actually are one of my highest success procedures because you're adding both the stability of the ACL and you're adding the meniscus transplant.

[00:12:24]Um this is a really interesting study.

[00:12:25]So this one it shows at HTO with meniscus better than in either isolation. And so the important part here is you really want to correct the alignment. And if you can almost overcorrect again the goal here we don't want to we'll talk about osteotoies another time. Um but you don't want to overcorrect too much but actually overcorrecting or getting someone in neutral unloads this compartment and really protects the meniscus transplant.

[00:12:46]I always tell patients once you've got that osteotomy unloaded the meniscus is sort of the extra credit uh scenario.

[00:12:51]These patients do well. Again, this is still a technically challenging procedure. Uh but you can see the biomechanics of this. So there is some thought that say you know we think about this in the sense of you know we don't want to do frivolous osteotoies but if someone's even on the borderline you should probably consider osteotomy because the contact pressures are so much less on their knee if you correct them appropriately.

[00:13:12]So here's another good one. So older than 50 again pushing I think this is an Italian study. So 26 older meniscus, so over 50, 26 younger meniscus over 50. So you can see on the right hand side there's still some excellent outcomes.

[00:13:25]Not as high as a younger patient, but remember we're not having a discussion with the patient saying, "Well, I wish you were younger." The patient has no other option, right? It's a knee replacement or probably not even ear replacement, they're just in pain. They have miscus deficiency. So even some good results to me is a positive when I'm in having that conversation with a patient. You always got to remember there's most of this this is important all these studies but it winds down to a patient conversation in the office. So mean followup 7.3 years both improved higher failure rate in the older patients which I would agree. The challenge is if you do a good job or the the benefit is you do a good job on these and you do them efficiently complications can be pretty low in terms of intraop complications or afterwards.

[00:14:05]I mean the worst complication most common one is usually a retire the meniscus. It's not that big a deal in the sense of if you can help some of these patients, I still think it's worth it in the right patient. Again, insurance approval can be challenging over 50. So, that's another port portion to discuss. The survival rates were almost the same. So, they had a little less, I'd say, a little worse results if you're older, but still significantly better than what they had preop.

[00:14:31]So, survival rates are important, right?

[00:14:33]People are like, well, great. They're, you know, I have a 17-year-old that just did recently. He's like, how long is this going to last me? So, it's important for us to understand that. So, 185 patients, seven-year follow-up, they were failure-free, so 80%. Now, again, there's a mix of different outcomes as to what you're looking at, right? Is it a retar? Is it complete removal of the meniscus? Is it a new cartilage lesion?

[00:14:52]Um, obviously, cartilage damage, age over 25, and BMI over 30 were some increased risks. And we're going to talk about this in a bit more with survival rates. So, how about all suture, right?

[00:15:02]Because this is becoming really popular with some newer implants. So 334 patients they had 184 suture fixation 150 bone fixation again 80.9% failure free and they had a mix again here. So there was no difference in all suture versus bone fixation long-term data is needed and again you have to realize generally when all sutures being done is by someone who's an expert in that area and the bone plug in that area as well.

[00:15:25]So it's kind of can be hard sometimes to do apples to apples when you have a different surgeon doing different techniques.

[00:15:32]How about revision? Not as common. I do a few of these. Obviously, Cole is one of one of the highest volumes in the country and if not the world. So, 11 patients, four-year follow-up, pretty good satisfaction in no revision, no progression to OA. Again, these patients generally tend to be younger because they had one at a very young age and then tore in that timeline of six to seven years.

[00:15:52]How about again, revision versus primary. So, an updated study from that last one. So, again, 22 revisions, mean age about 30, 10year follow-up. Um 32 uh were matched. Again, no age difference, normal follow-up, 81% lateral meniscus, no difference in scores. The failure rate was slightly higher, but again, it's a revision. But overall, pretty good numbers for a revision scenario, a hard surgery. Overall, we can see good success rates. So 92 90% at two years.

[00:16:21]Key here is really 10 years. That's what a lot of patients ask. So they do fail a bit sooner in terms of 63%. Um but still I mean 63% of patients were doing quite well with a revision miniscus transplant. Again a very hard and a very niche procedure and 92% for their primaries at 10 years which is a really really good number. I usually quote patients 75 to 80%. I like to keep my expectations low for these patients.

[00:16:45]So surgical techniques. So let's just show this. So this is with an ACL. So it's obviously a little bit harder procedure. So see here we have the bone plug and then we're going to pass some of the sutures and I used to be a bone plug on both sides for a medial meniscus transplant. In an isolation I will do that but in a ACL surgery that plug can be very very very very challenging to putting in the front and the main concern is damaging the meniscus damaging the ACL tunnel and you can blow into it which is a problem. So, this fixation technique again, I'm coming from a lateral portal and I'm actually going to dunk this and I can also set the tension a bit better. Um, and the ACL tunnel is right behind it, which you may or may not see in a second. Um, and you can see now we've fixed the root in the front. And overall, you can see right now we fixed that root in the front. That's really anatomic of where it was set. And you can set your your tunnel. The key here is to make sure that you do your root fixation first before you finish all your sutures because you want to appropriately set your tension, especially in sort of the soft tissue bone pluck hybrid.

[00:17:48]And then this is a workhorse for me. I I trained with Cole. This is this surgery when you get it really good and you do a good job. The the key here is that you can do a really effective lateral meniscus transplant. So I will not do bone plug. I do not do soft tissue. I dovetail uh for all my low meniscus transplants which can be a bit harder in an ACL surgery. So the key here obviously is to make sure you make your slot low enough.

[00:18:11]Uh so I use the guide system here and I'm doing a dovetail. So again this is a um this video is important but I do do under fllororoscopy. So I will go halfway through and then I'll do it under fluo because obviously the artery is right behind there. So you want to be really careful. And this is a power rasp. I really like this to sort of make my slot. And then we're going to dilate it up. And again, the dovetail is really nice because, you know, you can do a slot technique where you just have it slide around. Um, but I do like the dovetail because it usually locks in.

[00:18:39]And if you have it loose, what you can do is just add uh sort of a swivel lock or any sort of small anchor to that inside. And then we're going to push this in. And you can see overall fairly small incisions. You can make these even smaller now with some newer techniques.

[00:18:54]And then you'll impact it. Obviously, the key is a really well-made dovetail because if it's too tight, you obviously are in a big problem and you have to flip the meniscus. And then what we'll do is we'll pull it, push it back as far as we can. That can be kind of a challenge. You want to make sure you do a nice job there. And then usually we do some sort of um all- inside device in that posterior aspect or that posterior capsule. Um and then we'll pass our sutures all the way around. Usually in this case we'll do two in the back and then we'll do about five above, three or four below and then fix the anterior side as well. And you can see this actually this patient went on to play really high level soccer. Uh and then we do a little notch plasty. So we're going to use a microfar the notch here as well. And there you go. Thank you.

[00:19:44]>> Thank you Grant. Are we done with the presentation or you have something more to say?

[00:19:50]>> I have nothing. I I can always say more but that's I'm done with the presentation.

[00:19:54]>> Okay. Thank you because I thought it was just abrupt. So I'll just take few questions. Grant. So Grant there's the tendency to use menuscll scaffolds.

[00:20:03]Right.

[00:20:05]So men where do you place menuscles scaffolds with respect to mencal transplant? Do you do that or what is the trend in the US?

[00:20:14]>> Yeah. Yeah. So the trend in the US is still transplant mainly because scaffolds there's limited FDA approval.

[00:20:19]I know there's some coming down the line. They've tried um one of the implants I can't remember the name of it. Uh had an FDA trial on just placing that this sort of gelatinous implant in um the results for the those gelatinous implants has not been as good for us.

[00:20:34]And then the scaffolds are very hard uh to get because most of them aren't FDA approved. So, I know in Europe and and maybe in other countries, um, they're more frequently done. Um, but we're just not there yet, uh, in terms of the approval rate. I think it would be great. Obviously, it'd be easier for availability and the idea is that if you could grow in new meniscus that's your own tissue, um, that's obviously more ideal. Uh, and then segmental implants also are a topic of conversation. The challenge is buyin and the challenge is, you know, there's some thought process of like, well, if you're going to replace only a segment of the meniscus, how is that going to grow in? I mean your highest chance of growth as we know when you repair meniscus is from the roots right so if you're not if you're having the old roots you're just trying to get meniscus to meniscus to heal I I don't I don't see that I think the scaffold's a bigger market um but obviously there's also cost right because if the companies are when they come to the US the prices go way up so the the concern is that is it is it going to be feasible for our patients >> yeah so even if it's not FDA approved I'm sure there are a lot of surgeons are doing it off label right so do you have presentations in the AOS meeting or the AOS meeting with the scaffolds from the US.

[00:21:40]>> I mean there are people that talk about it briefly.

[00:21:43]The challenge is not the off label. It's if you do an off label market thing and something happens there's a high liability uh for us. Um and you know unfortunately in the US it's a bit latigious uh and so and the other the other caveat is we keep bringing up cost but these you know this is an expensive surgery for the insurance company because the miniscus transplants are are fairly expensive. It's just why it's why some countries challenge even get the grass right. Um and then the second part is uh if they're not approved and you do this anywhere they where they manage costs generally you won't get it reimburseed but the idea of the scaffold is great and a lot of people are talking about it or they're it's generally not like here's my case series of scaffolds under the conversation when we have it like AOS as etc. they're showing here is another option that's coming down the line and then they'll talk briefly about scaffolds or they'll show the European data um on the scaffolds. So yes, so they're there but it's just they're they're not trying to oversell it and it's they also may be not allowed to say it too much because if it's not fully FDA approved we have to be really careful about what we're putting in our powerpoints.

[00:22:45]>> Thank you Grant for that. And Grant, what is the uh comparison between medial and lateral miniscal transplants?

[00:22:52]Which one do you do more often more often and how are the results like compared which is better? Which one performs better?

[00:22:59]>> That's an excellent question because that's a really really important I didn't I was going to bring it up and I think I sidetracked myself. So medial meniscus isolation is very uncommon. we do it and they do pretty well but they're not usually the ones I'm as most excited about because a lot of times if it's a isolated medial they're in varys and so you're doing the osteotomy and I find the osteotomy is more effective than the min men miniscus transplant most of the medial meniscus transplants we do are ACL's so it's an ACL with a medial meniscus transplant they tend to feel really good but they're not as satisfying from a like they do really well but like the person's in a much different situation right you're doing an ACL and you're doing a medium miniscus transplant. So they it's not like that the transplant dominated the scenario. Now a lateral those are where the money's at in terms of my the ones that I really enjoy doing the most with the highest satisfaction because that's the one where you can just see the meniscus itself did such a good job. The number one complaint for lateral is I feel unstable because they feel that the niche opening up like this as they go by this loss of cushion. So when you replace that lateral meniscus transplant they're very pleased. Again, not 100% success, but the laterals, in my opinion, do better in isolation. That's what Cole does a lot more of. You know, if we training with him, we did a lot more laterals in medial meniscus. Um, but and the other thing is laterals, there's a lot less stuff you can help them with, right? If someone has a lateral meniscus deficiency, there's almost no other surgery you can do. If they're medial meniscus and they've fallen into veris you can do you know misha you can do an osteotomy you can do you know there just there's a few medial even if worst case they needed a partial knee replacement medial medial sided knees uh do better than laterals so the lateral ones are a bit more desperate and I think that they do a bit better because there's not many options for them and they know their expectations versus a medial side. So, but I I I like both, but I would say if I had a choice in isolation, the laterals would be the would be the way to go.

[00:24:55]>> Great. And when we talk about fixation methods, right, we talk about bone plugs and sutures. So, invariably, it's a combination, right? You need uh the slot as well as you need the peripheral sutures, isn't it? To hold >> Yeah. I mean, the challenge is I just showed you the hardest ones to do. So the I had a good conversation with a well-n named surgeon in California and he was saying, "Hey, I he goes, I know you do bone plugs and I know you do slots." So I benefit I have is my assistants make the graphs and they're very very good like top end. And so I have the luxury of like cutting my surgery in half. If you're doing this all yourself, this can take you three plus hours to do. And so that situation changes things. And so he made a good point of saying, listen, maybe soft tissue isn't as strong a fixation. Now again, there's some newer implants, so we're pushing our way that that it might still be equivalent. You saw the data on that, but is it better to do a soft tissue than nothing? And I would say 100% yes. Or if I can't teach a fellow with three or four of these how to do it with a slot because it's much more technically challenging, why don't I teach them how to do a little bit easier procedure with a soft tissue and at least now they can help people. And so those were really interesting points. So I would say in whatever whatever you can do feel comfortable with that's great.

[00:26:11]Um I personally love doing the slot for lateral and bone plug for the medial.

[00:26:16]I've done medial slots. They are much harder to do. So a lateral dovetail generally and medial will be either soft tissue or bone plug or a bone plug hybrid.

[00:26:28]>> Thank you Grant. And uh Grant most of these are done arthoscopically completely arthoscopically right. Is there a situation where you had to open up Excellent. No, actually I do do a pherommones open because the one thing I didn't show so Derek Jones showed me this video about a few years ago and again it sounds more archaic but to be honest with you the patients are so happy because you saw that lateral meniscus transplant. You saw that incision in the back. The same incision is on the medial side. It's just a standard inside out technique um when you do this. But that incision can be really uncomfortable which is very it's weird until you start doing these. So when I do a cartilage transplant, I just do a one big front incision and I'll go maybe another centimeter longer and I can sneak in the back with my spoon and do it all from the front. These patients actually are incredibly pleased and I when you pass the meniscus, you're doing it from a little bit of an open technique. So you are open uh because you're doing your cartilage transplant as well. They're a bit easier which is really really nice. Um but the key is that like when they when they wake up and they don't see that incision in the back, they usually have no pain. I mean, if you're going to get a I would say if you're going to get a small like wound in wound infection or something else, generally not the joint infected. Um, it's going to be even that back incision because that's where they're kind of that's where the crease is in the knee.

[00:27:42]Um, so that to me is like the ultimate.

[00:27:44]Like if I can do one of those, I really really like it because it just goes a bit faster. Like you can get one of those done in about two two hours and 15 minutes. Uh, so that that is my actual preference if I had one. Um, but I do lots of mini incisions as well. You saw that was the arthoscopic one. So I would say it's arthoscopic assisted right we do all the work arthoscopically then when we pass the meniscus after the transplant we just don't close the transplant site. So excellent question >> thank you grant grant I think that's all the questions that we have for the session thank you for yet another cutting edge presentation and really look forward for more the in the later part of this year.

[00:28:20]Thank you.