Fibrin Clot–Augmented Meniscal Repair

Abstract

Background:

Failure rate of meniscal repair can reach 25%. Multiple techniques have been used to increase meniscal healing, notably biological augmentation techniques. One of them is fibrin clot–augmented meniscal repair, which will be described in this video.

Indications:

This technique is indicated mainly for the lesions with a high failure rate. This includes large, horizontal, and radial tears and even for meniscal cysts, especially in a stable knee. This technique can also be used in revision meniscal suture when failure is no longer an option.

Surgical Technique:

Fibrin clot is prepared from sterile peripheral venous blood from the patient. A plastic syringe is used to stir the blood in a sterile glass container. The fibrin clot is then formed and washed rigorously with saline solution. Rolling the fibrin clot which is fixed to the syringe allows to give the fibrillar aspect of the clot. The formed fibrin clot is now solid enough to be manipulated and can be fixed to a vicryl suture thread allowing it to enter the knee and be fixed inside the meniscal lesion. The clot is wrapped inside the meniscal lesion with inside-out or outside-in suture technique.

Results:

We used this technique for multiple types of lesions, like bucket handle meniscal tear, horizontal meniscal cleavage, parrot beak tear, and even in lesions within white-white zone. The postoperative protocol is the same as standard inside-out meniscal repair. This technique has been used in the literature with promising results.

Conclusion:

The fibrin clot–augmented meniscal repair is a demanding but promising technique. We need further follow-up to confirm its effectiveness.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

In this video, we are going to demonstrate the technique of the fibrin clot–augmented meniscal repair.

Failure rate in isolated meniscal repair can be high, reaching 25% according to a recent systematic review by Zaffagnini et al. ¹⁰

In order to reduce this failure rate, multiple biological augmentation techniques were used, especially for the lesions localized in the less-vascularized areas of the menisci.^2,9 One of the techniques we can use is fibrin clot–augmented meniscal repair.

This technique is demanding, so we are going to describe it step by step with some tips and tricks.

This technique is indicated mainly for the lesions with a high failure rate. This includes large, horizontal and radial tears and even for meniscal cysts, especially in a stable knee. This technique can also be used in revision meniscal suture when failure is no longer an option.

Our case is a 26-year-old man, an active recreational soccer player. He has a history of left knee pain since 12 months without instability or varus deformity. In the physical exam, he had full range of motion, a negative Lachmann sign, and medial joint line tenderness.

The magnetic resonance imaging (MRI) showed this large horizontal cleavage of the posterior horn of the medial meniscus with a parameniscal cyst. On the sagittal view, the lesion reaches the femoral side of the meniscus.

The arthroscopic findings showed a normal anterior cruciate ligament (ACL). After medial collateral ligament (MCL) pie crusting, we were able to visualize the lesion.

As seen in the MRI, there was a large femoral-side opening of the lesion. The tibial side of the meniscus was intact.

Putting the probe inside the lesion allowed to evacuate the meniscal cyst liquid.

As the first step of the treatment, the lesion is aggressively abrased with the mechanical shaver until the peripheric part of the tear is reached.

To prepare the fibrin clot, we usually use between 20 and 30 ml of sterile peripheral venous blood from the patient. The blood is collected in a sterile glass container. A plastic syringe is used to stir the blood slowly for about 10 to 15 minutes with regular rotatory movements. Progressively, we will start to note clot formation around the syringe.

This newly formed clot has to be washed numerous times with saline solution. It is very important to wash rigorously the fibrin clot until the saline solution remains clear.

Afterwards, we dry it by rolling the syringe into a sterile gauze as shown in the video. The rolling of the clot gives its fibrillar aspect. We repeat these steps until we have a well-formed fibrin clot solid enough to be manipulated.

This is the final aspect of the clot. It can be manipulated quite easily and has some elasticity.

When we have a large longitudinal tear, bucket handle tear or horizontal tear, the clot has to be long enough to cover the whole lesion. A shuttle suture thread is used.

The purpose of this thread is to transport the clot inside the knee. We start by fixing the clot on both ends. We use vicryl 1 suture with multiple knots, one knot per 5 mm. The purpose of these knots is to prevent the clot from slipping.

In case of a radial, oblique, small longitudinal tears and meniscal cysts, we can keep the clot in its circular form. We will just fix the shuttle suture thread on both ends of the clot.

Now we face the most delicate part of the surgery. The clot has to go in one block with minimal manipulation from outside to inside the knee without being lost within the Hoffa fat pad. For this purpose, we use a sterile tube to pass the threads inside the knee in both ends of the lesion. These threads will go outside the knee using the inside-out or outside-in technique.

Then, we make a traction on both ends of the shuttle suture thread, allowing the fibrin clot to reach its final location inside the meniscal tear.

In our case, we used the outside-inside technique using polydioxanone (PDS) 1 thread to work as relay wires, after making the postero-medial approach. The PDS thread is used to tract the vicryl already fixed to the fibrin clot.

Afterwards, we tract the vicryl thread, allowing the clot to enter the knee slowly until it reaches the meniscal tear. This is how it looks outside the knee. The clot enters slowly through the sterile tube without being trapped inside the Hoffa fat pad. During this step, the irrigation is stopped in order to facilitate the passage of the clot. This will allow the fibrin clot to stay inside the meniscal tear.

Afterwards, we use our preferred technique for meniscal suture, which is the inside-out technique. This technique has been described in another article published in Video Journal of Sports Medicine (VJSM) during 2022. ⁷ It allows us to make as many vertical mattress sutures as we need, both on the femoral and tibial sides of the lesion. It is also cost-effective.

And this is the final aspect of the repair.

We can use this technique for other types of lesions, like this large bucket-handle meniscal tear. We use a long fibrin clot fixed to the vicryl thread in order to cover the whole lesion. Again, we use the inside-out technique until we have a satisfactory suture.

The fibrin clot–augmented meniscal repair can also be used effectively in horizontal meniscal cleavage. Putting the fibrin clot and using the suture allows to make a sandwich-like repair.

We used this technique even in Parrot beak tear, allowing us to make a repair for meniscal lesions with a low potential of healing. In fact, the fibrin clot allows to make a fibrous scar of the meniscus that will help meniscus healing in the white-white zone.^1,8

The postoperative protocol is the same as standard inside-out meniscal repair. ⁷ We allow early weight-bearing for our patients using 2 crutches for 3 weeks, unless we have a radial meniscal tear. We authorize return to sports after 4 months postoperatively.

Henning, the father of the inside-out meniscal repair technique, repaired isolated meniscus tears and reported an 8% failure rate using exogenous fibrin clots compared with a 41% failure rate without fibrin clots. ³ Van Trommel et al ⁸ used this technique for radial tears of the lateral meniscus in the avascular zone, reporting a healing rate of 60%. Kamimura and Nakayama used the fibrin clot augmentation repair in degenerative lesions of the meniscus, giving 70% or more healing rate.^5,6 Kale et al ⁴ used this technique in 30 patients and reported a promising healing rate of 97%.

Again, with the systematic review of Zaffagini et al, ¹⁰ we found out that the use of fibrin clot can decrease the failure rate of meniscal repair from 41% to 8%.

In comparison to other biological augmentation techniques, the use of platelet-rich plasma allowed to have a failure rate of 9.9%. ¹⁰

The use of mesenchymal stem cells in meniscus repair had promising results in vitro, but literature is scarce when it comes to clinical studies. Overall, there is a need of further high-level studies in order to confirm these findings.

In conclusion, it is a demanding technique, but it can be helpful for meniscal healing of low-potential healing lesions. It is also cost-effective, but we need further follow-up for our patients and more studies to confirm its effectiveness.