Complex Horizontal Cleavage Tear Repair of the Lateral Meniscus With Fibrin Clot Augmentation

Abstract

Background:

The menisci are critical for knee stability and cushioning and tears of the menisci have been linked to the acceleration of osteoarthritis. Horizontal cleavage tears split the meniscus into a top and bottom portion and are notoriously difficult to repair due to their localization in the avascular zone of the meniscus. Repair augmentation techniques, including fibrin clot and bone marrow venting, have been reported to increase meniscus healing.

Indications:

The use of a fibrin clot is indicated when there is a complex horizontal cleavage tear of the meniscus. There must be a clear separation of the top and bottom leaflets that can hold the fibrin clot inside.

Technique Description:

The horizontal cleavage tear is first identified, and a shaver with the suction left off is used to roughen between the upper and lower leaflets of the meniscus tear. A rasp is used inside the horizontal tear to roughen up the edges and expose the entire tear. Inside-out sutures are used in a hay bale technique to surround the tear. Thirty milliliters of blood are stirred until a fibrin clot is formed. This clot is stabilized with a circumferential Vicryl stitch and shuttled in between the leaflets of horizontal tear using a suture tied around the fibrin clot. The previously placed hay bale sutures are loosened to allow for placement of the fibrin clot. All sutures are tied at the end of the procedure.

Results:

A study by Nakayama et al reported a clinical success rate of 18 of 24 patients undergoing medial meniscus horizontal cleavage tear repair with fibrin clot augmentation. All patients with failures were in significant varus alignment. Another study by Kamimura et al with 10 patients reported increases in postoperative patient reported outcomes and a healing rate of 70% on second-look arthroscopy.

Discussion:

This fibrin clot interposition technique augments the repair of a horizontal cleavage tears. Due to horizontal cleavage tears being localized in the white-white avascular zone, augmentation including using a fibrin clot can help induce healing. This repair can help restore the stability and cushioning of the meniscus to slow the progression of osteoarthritis.

Graphical Abstract

This is a visual representation of the abstract.

Video transcript

This is a video presentation depicting a complex horizontal cleavage tear repair of the lateral meniscus with fibrin clot augmentation.

The disclosures of the senior author are listed.

Background

The menisci are critical structures for the stability and cushioning of the knee, with tears of the meniscus being reported to accelerate the progression of osteoarthritis.^5,8 Horizontal cleavage tears are tears of the meniscus that split the meniscus into top and bottom portions.^1,6,9 These tears are difficult to obtain healing after a repair due to their localization in mainly the white-white avascular zone of the meniscus.^1,2 With a push to improve outcomes for meniscal repairs in this avascular zone, new techniques including augmentation with a fibrin clot interposition and bone marrow venting have been used. ⁹ These techniques attempt to stimulate healing by providing the meniscus with localized growth and healing factors. ³ Previous studies have reported improved patient outcomes and healing rates for patients with horizontal cleavage tears with fibrin clot augmentation.^4-7

Indications

The patient depicted here is a 31-year-old male who presented to clinic due to right knee effusion. He had a twisting injury 10 months ago that resulted in significant pain and swelling. He initially attempted conservative treatment first with rest and icing which improved symptoms. He was able to temporarily return to light weightlifting and basketball. However, 7 months after the initial injury, the patient noted increasing pain and swelling. He presents with a desire to return to full activities.

Examination of the patient demonstrated 1 cm of heel height to 140° of flexion on his right leg compared to 3 cm of heel height to 140° of flexion on his contralateral side. He also had a trace effusion of his right knee. His Lachman, pivot-shift, and varus and valgus stress were all normal.

Radiographs were normal with no joint space narrowing, and long leg standing radiographs demonstrated neutral alignment.

Magnetic resonance imaging (MRI) taken 9 months after the patient’s initial injury showed a complex horizontal cleavage tear of his lateral meniscus. The tear extended from the anterior third of his lateral meniscus to the posterior root attachment. In addition, there was evidence of localized grade 2-3 chondromalacia of the lateral femoral condyle.

The findings of the patient examination and imaging are suggestive of a lateral meniscus horizontal cleavage tear. In addition, there are signs of grade 2-3 chondromalacia on the lateral femoral condyle. The patient likely had a meniscus tear with his initial injury, and the chondromalacia in the lateral compartment was due to continued activity after the initial tear. The plan for surgery is a horizontal cleavage tear repair with a fibrin clot augmentation due to the large size of the tear.

Technique Description

The patient was brought into the operating room and induced under general anesthesia. A high right thigh tourniquet was placed which was well padded. He was given 2 g of Ancef for prophylaxis against infection.

Medial and lateral parapatellar portals were made and the joint was insufflated with saline. The patient had some mild synovitis throughout his joint. The articular cartilage of the trochlear groove was normal.

The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) were normal. The medial compartment and his medial meniscus were normal.

His lateral compartment had an area of grade 2-3 chondromalacia on the posterior aspect of the lateral femoral condyle, as well as grade 1-2 chondromalacia on the posterior aspect of the lateral tibial plateau. He had a very large horizontal cleavage tear of the lateral meniscus which started at the far anterolateral aspect at the junction of the anterior third and medial third, extending all the way to the posterior root attachment. The posterior root attachment had a radial flap tear with a portion that had detached. A shaver was used to gently shave within the edges of the tear, and a ball rasp was used to gently rasp the edges in preparation for the repair. During this step, the horizontal cleavage tear is assessed to determine if a fibrin clot should be used. The tear should be at least 20 mm in length and at least half the depth of the meniscus to properly position the fibrin clot within the leaflets. A third more medial portal was made for better access for the repair.

A probe was placed inside the joint and used to localize where the lateral meniscus repair incision would be made for the inside-out repair. A lateral incision about 8 cm long was made centered over the inferior iliotibial band. Dissection was carried down to the iliotibial band and a horizontal incision was made along the inferior aspect of the iliotibial band. The interval anterior to his lateral gastrocnemius tendon, posterior to the fibular collateral ligament, and above his biceps femoris tendon was entered. A spoon was inserted into this interval to deflect the needles from the inside-out repair.

Very slowly and meticulously, 13 inside-out sutures were placed in a hay bale technique with one further suture to hold the radial flap in place at the posterior aspect of the meniscus. For the hay bale technique, 1 suture is placed at the superior surface of the lateral meniscus, capturing the meniscus about a third of the way down from the peripheral rim. The same process is repeated on the inferior aspect of the meniscus; the sutures wrap around the meniscus and squeezes the horizontal tear shut. These sutures should be placed 3-4 mm apart. While placing the sutures, the fibrin clot is prepared on the back table. Thirty milliliters of blood were placed in a metal basin and was stirred with the frosted end of a glass syringe. After about 20 minutes, a fibrin clot of acceptable size for the tear had formed. The clot was placed on some sponges and flushed with saline to remove blood products which would interfere with arthroscopic visualization once it was inserted. A circumferential Vicryl stitch was tied around the clot to reinforce it.

One needle of an inside-out suture was placed in the midportion of the horizontal cleavage tear, close to the popliteal hiatus. The fibrin clot should be placed in the deepest portion of the tear and should be in a location that will hold the clot within the meniscus. Over time, the clot and the healing factors will disperse throughout the meniscus. The remaining needle on the other end of the inside-out suture was cut off and a 7-mm Clear-Trac Screw cannula (Smith & Nephew) was placed into the joint. The suture was pulled through the cannula and tied around the fibrin clot. Using the other end of the suture, the fibrin clot was pulled into the horizontal cleavage tear. Another inside-out suture was placed around the fibrin clot to hold it in place. All sutures were tied from the outside and it made for a very solid and secure repair with a fibrin clot interposition.

A microfracture awl was used to place 4 holes in the lateral aspect of the intercondylar notch for marrow venting to release blood products to promote further meniscal healing.

The tourniquet was let down and the deep and superficial tissues were closed with suture.

Results

This surgery is not without potential complications. This procedure requires the formation of a fibrin clot for the augmentation of the horizontal cleavage tear repair. Occasionally, there is some difficulty in forming a fibrin clot. The timing and the size of the fibrin clot is unpredictable and may require additional surgical time. In addition, there can sometimes be difficulties in reinforcing the fibrin clot prior to passing the fibrin clot into the joint and into the horizontal cleavage tear. There can be difficulty in securing the fibrin clot in the horizontal cleavage tear if the clot is not the proper size or the inside-out mattress sutures around the tear and clot are not in the proper positions. At least 20 minutes should be allocated for stirring the blood for fibrin clot formation and the inside-out mattress sutures should be strategically placed to hold the fibrin clot in place.

Another complication is potential damage to neurovascular structures. In any situation in which surgery is being performed near the neurovascular structures, care must be taken to ensure these structures are not injured. In this procedure, a spoon is placed anterior to the neurovascular structures to catch the suture needles from the inside-out repair; this helps ensure the needles do not injure the neurovascular structures. In addition, the knee is flexed when passing the inside-out sutures to ensure the needles avoid the neurovascular structures.

The patient will be nonweightbearing on his right lower extremity for 6 weeks. When he does initiate weightbearing, he should slowly wean off crutches until he can ambulate without a limp. He should avoid squatting, squatting with lifting, and sitting cross-legged for 4 months to protect his horizontal cleavage tear repair. The patient can return to full activity 5-6 months after surgery once adequate quadriceps strength has returned.

Discussion

A study by Nakayama et al ⁷ reported on 24 patients with horizontal cleavage tears who underwent repair with a fibrin clot augmentation. Of the 24 patients, 18 attained clinical healing. The 6 that were clinical failures all had a varus deformity, which was defined as having with a long leg mechanical axis line passing less than 30% of the width of tibial plateau from medial to lateral. A significant increase was reported in mean Lysholm scores between preoperative and postoperative values.