Arthroscopic meniscus repair and augmentation with autologous fibrin clot in Indian population: A 2-year prospective study

Abstract

Introduction

This study was proposed to evaluate the efficacy of fibrin clot augmentation in meniscal tear using inside-out meniscal repair.

Methods

A total of 35 patients with meniscus tears were operated on with inside-out meniscus repair and fibrin clot augmentation. Patients were evaluated preoperatively and postoperatively with clinical criteria, Lysholm knee scoring system, and MRI.

Results

Out of the total 35 cases, 5 cases were lost to follow-up. Clinical improvement was observed in 29 out of 30 patients (96.6%). The mean Lysholm score improved significantly from 67.63 ± 6.55 points preoperatively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 3 years follow-up. Follow-up MRI in all patients revealed complete healing except in 1 case where the patient presented with recurrence of symptoms such as pain and locking which resolved with partial meniscectomy. Paraesthesia in the anterior part of the knee was observed in 2 cases. (6.6%).

Conclusion

We conclude that fibrin clot augmentation is a good cost-effective modality of treatment for repairable meniscus tears to preserve the meniscus and decrease the point contact pressure on the condyles which may prevent the early occurrence of osteoarthritis.

1. Introduction

The meniscus helps in load transmission and shock absorption of the tibiofemoral joint in the human knee.¹,² It also acts as a secondary anteroposterior stabilizer of the knee joint, which further provides proprioception of the knee joint, lubrication, and nutrition supply to the articular cartilage.³

Meniscal tears are one of the most common knee injuries and are found in patients of almost all ages due to various causes: degeneration, trauma, and discoid meniscus.⁴ In the long-term follow-up studies, increasing degenerative changes have been noted after the excision of torn menisci, especially after total meniscectomy.⁵

Most of the studies show that patients on whom meniscectomy was performed end in long-term articular cartilage degeneration.² In vitro studies have shown that the excision of 16%–34% of the meniscus resulted in a 350% increase in contact forces.⁶ Also, according to the bio-mechanical studies peak contact pressure increases by up to 235% after total meniscectomy and by up to 165% even after partial meniscectomy.^7,8 In contrast to meniscectomy, the contact pressure after repair of the meniscus decreases almost to the intact level.^4,9 So it is beneficial to preserve meniscus especially in cases of young active patients.

Many augmentation techniques have been used in past such as synovial rasping, vascular access channels, platelet-rich plasma(PRP), fibrin glue, fascial-sheath coverage, the rasping of the intercondylar notch which helps to increase the success rates of meniscus repair.8, 9, 10

In our study, we tried to evaluate the clinical course of patients having meniscal tears augmented with autologous fibrin clot in an Indian scenario with an inside-out repair method.

2. Materials and methods

This was a prospective study that included 35 patients operated by a single team of surgeons in a single tertiary centre.

Inclusion criteria

• •Physically active patients within an age limit of 60 years
• •Isolated meniscus tears in the red-red zone (Miller, Warner, and Harner classification) like radial, bucket-handle, horizontal and longitudinal tears
• •Meniscus tears with associated anterior cruciate ligament tears
• •Less than 3-months after injury
• •Patients willing for post-operative rehabilitation

Exclusion criteria

• •Patients with inflammatory arthritis/synovitis
• •Rheumatoid arthritis
• •Infection
• •Degenerative and complex tears
• •Multi-ligament injuries
• •Meniscus tears associated with any ligament injuries other than anterior cruciate ligament.
• •Meniscus root avulsion
• •Abnormal alignment of the lower limb

Clinical criteria were a history of knee pain and locking symptoms, joint line tenderness, positive McMurray's test.¹¹ Meniscus tear was also confirmed on MRI. The preoperative Lysholm score was calculated. Tests for associated instability like Lachman's test, anterior drawer test, pivot shift test were done to rule out associated ligament injuries. Patients were operated on from June 2017 to June 2018 and were followed up until September 2021 at our Institute. Follow-up of all patients was done with similar clinical criteria at an interval of 3, 6, 9, 12, and 24 months. Rehabilitation protocol was the same for all types of meniscus tears and concomitant ACL reconstructions which is nil weight-bearing for 6 weeks and full ROM for one month.

2.1. Surgical procedure

The procedure was performed under spinal anesthesia. After diagnostic arthroscopy, tears were identified, and associated ACL tears, if present, were treated beforehand to create a stable knee and then reparable meniscus tears (red-red zone according to Miller, Warner, and Harner classification) were repaired, and irreparable degenerative tears in the avascular zone were debrided. Fig. 1 shows the types of reparable meniscal tears and the meniscus repair instruments.

Fig. 1.

Bucket handle tear(A), Radial tear(B), Horizontal tear(C), Protector meniscus suturing set-Arthrex (D).

Exposure of the posteromedial capsule: A 2 cm vertical incision at the posteromedial joint line was taken. After identifying the saphenous nerve and dissection of the sartorius fascia, an anatomic triangle was identified made by the posteromedial joint capsule, the medial gastrocnemius, and the semimembranosus which bounds it anteriorly, posteriorly, and inferiorly respectively [Fig. 2]. A bent tablespoon was placed in this interval to act as a retractor, protecting the popliteal vessels and receiving the outcoming needles from the joint.

Fig. 2.

Isolation of Saphenous nerve.

Posterolateral approach: A longitudinal incision was made posterior to the fibular collateral ligament. After the posterior border of the iliotibial band down to Gerdy's tubercle, a transverse and oblique incision was taken over the lateral joint line. The common peroneal nerve is located posteromedial to the biceps femoris tendon and should be carefully avoided. Next, blunt dissection was performed toward the fibular head, and an interval was created with the lateral head of the gastrocnemius superiorly and posterolateral joint capsule anteriorly. The gastrocnemius muscle was dissected off the capsule bluntly in a similar fashion as in the medial approach. Once again, a bent tablespoon can be used in this interval to act as a retractor for the neurovascular structures.

Meniscal Repair: Viewing through anterolateral portal freshening of the periphery with shaver and microfracture awl was done till pinpoint bleeding was seen and excision of avascular meniscus edges was done. Pie crusting of superficial MCL was done with an 18G needle to open up the tight medial compartment. The tear was anatomically reduced and inside-out sutures were passed through the zone-specific cannula with long flexible needles. 2–0 polyester braided sutures were placed from both the superior and inferior surfaces of the torn meniscus to avoid eversion of the meniscal edge. Colour coding of threads with methylene blue was done to avoid confusion while tying the knots (Fig. 3). Patients having concomitant ACL tear underwent ACL reconstruction with the hamstring graft. Tibial fixation was carried out after meniscal repair.

Fig. 3.

Preparation of peripheral rim(A), Needle through cannula piercing inferior surface(B), Needle through cannula piercing superior surface (C, D), Final repair (E), Colour coding of threads (F).

The radial meniscus tears extending into the peripheral vascular zone were selected for repair. Radial tears in the inner 1/3rd zone of the meniscus were excluded from the study as they were trimmed till stable rim. Precaution was taken to suture the radial tears robustly in a criss-cross fashion and the patients were protected from weight bearing for 6 weeks. Horizontal meniscus tears which extend into the periphery and form parameniscal cyst were selected for repair as they extend into vascular outer 1/3rd zone of the meniscus. Capsular abrasion along with abrasion of torn edges of meniscus was done to augment healing.

2.2. Fibrin clot preparation and usage

While the meniscal repair was being undertaken, 60 mL of venous blood was drawn from the upper limb under all aseptic precautions. An assistant stirred the blood with the reverse end of the 4.5 mm arthroscopy reamer for approximately 15 min to assure adequate clot formation. The clot was transferred to a sterile surgical sponge (Fig. 4). The clot was washed with a lot of normal saline to remove excess RBCs. After washing, the clot was soaked in wet gauze. With the help of the scalpel (No. 15), the clot was cut and shaped to best fit the meniscal lesion.

Fig. 4.

(A) Preparation of fibrin clot, (B) Fibrin clot, (C) Horizontal meniscus tear repair with fibrin clot augmentation.

A long hemostat was then used to introduce the clot through the portal for the respective injured meniscus. To fit the clot underneath the meniscus and have the best contact with the lesion, the meniscal sutures were loosened. To prevent the dislodgement of the clot, water flow was stopped and the clot was held gently with a hemostat to push through the loosened threads into the meniscus tear and threads were tied. The knee was then taken to 90° of flexion and the sutures were fastened down and then tied with a sliding knot.

2.3. Postoperative rehabilitation for isolated meniscal repairs

Postoperatively, all patients were kept non-weight bearing for at least 6 weeks. Physical therapy emphasized early quadriceps muscle activation and knee flexion from 0° to 90° restricted for the first 2 weeks and progressed thereafter. Six weeks post-operatively, weight-bearing was initiated. After 6 months, full flexion, squatting, and return to full activities or sports were allowed. The same rehabilitation protocol was followed for all patients irrespective of the associated anterior cruciate ligament injury.

3. Results

A total of 35 cases were operated and 5 were lost to follow-up. Of the remaining 30, 9 were bucket handle tear (30%), 8 were horizontal (26.7%), 7 were longitudinal (23.3%), 6 were radial tears (20%). Clinical criteria for healing were loss of knee pain and locking symptoms, absence of joint line tenderness, and negative McMurray's test which was observed in 29 out of 30 patients (96.6%). The mean Lysholm score improved significantly from 67.63 ± 6.55 points preoperatively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 3 years follow-up. A follow-up MRI done in all patients revealed complete healing. Sixteen patients (53.3%) had associated anterior cruciate ligament tear and fared better when compared with isolated meniscus tears. All patients improved clinically except one who had a recurrence of knee pain and effusion and on repeat arthroscopy revealed complex tear which was debrided in form of partial meniscectomy. Paraesthesia in the anterior part of the knee was observed in 2 cases (6.6%) which resolved in 6 months. Our results faired better in comparison with the previous literature in which meniscus repair without fibrin clot augmentation was done (Table 1).

Table 1.

Previous literature with meniscus repair with failure rates.

Authors	Repair Technique	Year	Failure rate (%)
Sommerlath and Hamberg24	Open	1989	21.9
Sommerlath25	Open	1991	24
DeHaven et al.26	Open	1995	21.2
Eggli et al.27	Inside out	1995	26.9
Johnson et al.32	Inside-out	1999	23.7
Muellner et al.33	Open	1999	16.0
Rockborn et al.28	Open	2000	29.0
Steenbrugge et al.34	Inside out	2004	0.0
Lee and Diduch35	All-inside	2005	28.6
Majewski et al.29	Outside-in	2006	23.9
Siebold et al.30	All-inside	2007	28.5
Logan et al.31	Inside out	2009	26.7
Noyes et al.12	Inside out	2011	20.7

4. Discussion

Most of the studies show that patients on whom meniscectomy was performed logged long-term articular cartilage degeneration.² Noyes et al. recommended the preservation of meniscal tissue whenever possible in both of his studies reviewing patients undergoing meniscal repair in the avascular zone with and without anterior cruciate ligament repair.¹² So it is beneficial to preserve meniscus, and therefore meniscal repair is cited as the preferred treatment of choice over meniscectomy, especially in cases of young active patients and for peripheral longitudinal tears.

There are different methods for meniscal repair each having its own benefits and drawbacks. The three main techniques used most commonly are inside-out, all-inside, and outside-in. Though the all-inside technique is being increasingly used, inside-out is still popular as the strongest meniscus repair.¹³ Additionally, inside-out repair allows more number of sutures to be used on both sides of the tear to avoid margin eversion in a bucket handle tear. In our study, we used the inside-out technique because of it is cost-effective and most of the patients in our setup have financial limitations and are non-affording for expensive techniques like all-inside meniscus repair.

Meniscus repair is governed by several factors. Factors favouring repair include red-red zone, fresh tears, radial tears, and those which are deemed irreparable include complex, old, degenerative tears and plastic deformation of tissue. Many augmentation techniques have been popularised in the recent past such as fibrin clot, synovial rasping, vascular access channels, platelet-rich plasma,¹⁴ fibrin glue, fascial-sheath coverage, microfracture of the intercondylar notch which may increase the success rates of meniscus repair.¹⁵,¹⁶

Fibrin clot has long-term effects with slow polymerization, hemostasis, more healing factors, 10 times concentration of platelets, supports cytokines and cellular migration.¹⁷ It acts as a scaffold that helps maintain the elongated shape of meniscal cells and thereby helps in the healing of the meniscus.¹⁸,¹⁹ The fibrin clot gradually changes from fibroconnective tissue into fibrocartilaginous tissue and growth factors as well as reparative cells are recruited through chemotaxis and the stimulation of mitosis occurs around the fibrin clot.²⁰ This serial reparative process expedites the healing of the meniscus. Tying knots after putting a clot in the repair site creates a water-tight repair rather than the tying knots followed by clot formation which happens with simple marrow venting procedures. In addition, it can be prepared with less expensive equipment, shorter time, and effort with the use of autologous blood at the time of the procedure. Various animal models and human studies have concluded that the platelets in fibrin clots contain growth factors, which help promote cellular infiltration and healing.¹,²¹ Ho Jong Ra reported good repair results for complete radial tears of the meniscus with fibrin clot augmentation.²⁰

In a case series of meniscus tear repair with fibrin clot augmentation, Trommel et al. reported good healing in three of five cases, whereas the other two presented incomplete healing.²² Henning et al. repaired isolated meniscus tears and reported an 8% failure rate using exogenous fibrin clots compared with a 41% failure rate without fibrin clots.²³

The present results were excellent and equivalent to those reported previously for meniscal repair with an exogenous fibrin clot. In our study, on clinical evaluation 29 out of 30 patients had a loss of symptoms i.e. absence of locking, joint line tenderness, effusion, and negative MacMurray's test. The mean Lysholm score improved significantly from 67.63 ± 6.55 points preoperatively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 2 years follow-up. Follow-up MRI showed good healing of meniscus in these patients (Fig. 5). Amongst complications, paraesthesia of the anteromedial aspect of the knee was seen in 6.6% of cases. This can be avoided with meticulous dissection to avoid injury to the saphenous nerve.

Fig. 5.

35 years old male. (A) Preoperative MRI showing bucket-handle tear of medial meniscus, (B) Follow-up MRI after 2 years showing complete healing of medial meniscus, (C) Clinical picture of patient at 2 years follow-up.

The advantages of this method include cost-effectiveness both in terms of meniscus repair and fibrin clot giving equal results. Augmentation with fibrin clots has added a biological advantage in the process of meniscal healing.

Drawbacks of our study are a smaller sample size, not a randomized control study, and a relatively short follow-up. One case of failure in healing was detected after 6 months which underwent partial meniscectomy due to recurrence of symptoms. We have not done second-look arthroscopy in all cases for evaluation of the healing of the meniscus as it was not possible in the Indian scenario since most patients did not consent for second surgery as there were no symptoms.

5. Conclusion

As the emphasis on complete knee reconstruction increases and the significance of meniscal structure and function is further recognized, the indications for meniscal repair are escalating. This short-term follow-up result showed that arthroscopic repair of meniscal tears combined with fibrin clot augmentation attained clinical healing in the majority of patients. Our study shows that this procedure produces better results and is a promising cost-effective procedure for young and middle-aged patients, who wish to return to regular activities.

Declaration of competing interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.