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Platelet-Rich Fibrin Clot–Augmented Repair of Horizontal Cleavage Meniscal Tear

  • Christopher Kowalski
    Affiliations
    Department of Orthopaedics, Bone and Joint Institute, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A.
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  • Robert A. Gallo
    Correspondence
    Address correspondence to Robert A. Gallo, M.D., Bone and Joint Institute, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, 30 Hope Drive, Hershey, PA 17033, U.S.A.
    Affiliations
    Department of Orthopaedics, Bone and Joint Institute, Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, Hershey, Pennsylvania, U.S.A.
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Open AccessPublished:October 30, 2017DOI:https://doi.org/10.1016/j.eats.2017.08.004

      Abstract

      Although horizontal tears of the meniscus have historically been treated with partial meniscectomy due to poor vascularity within the tear, evidence suggests that repair of horizontal meniscal tears may be advantageous to partial meniscectomy. Furthermore, the addition of platelet-rich plasma has shown promise in improving meniscal healing. We present our technique of platelet-rich fibrin clot–augmented repair of horizontal cleavage meniscal tear.

      Technique Video

      See video under supplementary data.

      Meniscal tears account for an estimated 400,000 ambulatory surgical visits each year in the United States.
      • Cullen K.A.
      • Hall M.J.
      • Golosinskiy A.
      Ambulatory surgery in the United States, 2006.
      Mounting evidence shows that partial meniscectomy is associated with radiographic and clinical osteoarthritis within 2 years after the index procedure.
      • Roemer F.W.
      • Kwoh C.K.
      • Hannon M.J.
      • et al.
      Partial meniscectomy is associated with increased risk of incident radiographic osteoarthritis and worsening cartilage damage in the following year.
      As technology and instrumentation improve, meniscal repair has become increasing popular in the treatment of meniscal tears.
      Horizontal cleavage tears, which extend from the inner free margin of the meniscus into the outer meniscal substance, divide the meniscus into superior and inferior laminae. Because of technical difficulty, suture failure, and diminished blood supply thought to impair healing, these tears have been historically treated with partial meniscectomy and not repair. Recent evidence shows that repairs may lead to improved outcome compared with meniscectomy and equivalent healing rates compared with the more common vertical and bucket-handle tears.
      • Kurzweil P.R.
      • Lynch N.M.
      • Coleman S.
      • Kearney B.
      Repair of horizontal meniscus tears: A systematic review.
      Furthermore, platelet-rich plasma (PRP), growth factor, and fibrin clot supplementation have shown promise in promoting meniscal healing.
      • Ionescu L.C.
      • Lee G.C.
      • Huang K.L.
      • Mauck R.L.
      Growth factor supplementation improves native and engineered meniscus repair in vitro.
      • Kamimura T.
      • Kimura M.
      Repair of horizontal meniscal cleavage tears with exogenous fibrin clots.
      Therefore, our purpose is to show a technique for platelet-rich fibrin clot augmentation in repair of horizontal medial meniscus tear (Table 1).
      Table 1Pearls and Pitfalls
      PearlsPitfalls
      When creating an anteromedial portal, ensure that the localizing spinal needle can touch the tear. This step shows accessibility of the tearInadequate centrifugation time during clot solidification may result in a fibrin clot lacking adequate structure for passage and implantation
      Identify the need for platelet-rich fibrin clot augmentation as early as possible during the procedure because the clot requires up to 30 min to prepareFailure to use a cannula through the anteromedial portal may lead to the fibrin clot getting caught within the fat pad during passage
      Knee-specific Arthrex Scorpion suture passing device (Arthrex) self-captures the suture passed through the meniscus and has a lower profile and allows easier passage through the knee joint than larger suture passage devices

      Surgical Technique

      Preoperative assessment is critical to identify those who may benefit from a biologically augmented meniscal repair. Those with horizontal cleavage meniscal tears should be considered for repair if the tear has adequate tissue quality and extends into the red-red or red-white zones, the medial compartment has minimal to no chondrosis, a perimeniscal cyst is present, and/or the patient is less than 50 years old and/or is willing to undergo the necessary weight-bearing restrictions postoperatively. Because most facilities do not stock PRP kits nor store centrifuges, coordinated planning must occur before the day of surgery to ensure that the equipment needed to create a platelet-rich fibrin clot is available.
      Patient positioning for the procedure is flexible but must accommodate 2 important conditions: (1) ability to generate adequate valgus stress and (2) assess to the posteromedial aspect of the knee. To obtain these requirements, the patient is placed supine on the operative table and a stress post (Mizuho OSI, Union City, CA) is placed at the level of the tourniquet. Although some circumferential leg holders may satisfy these criteria, others may limit the passage of needles through the posteromedial aspect of the knee.

      Portal Creation

      Portal sites are selected to ensure that the posterior horn of the medial meniscus can be easily accessed through the anteromedial portal (Video 1). The anteromedial portal is established by passing a spinal needle at a trajectory such that the needle can easily touch the posterior horn of the medial meniscus. The anteromedial portal is created by directly visualizing an 11-blade scalpel passing through the capsule at the same trajectory as the spinal needle. Because the blade is often millimeters from the superior surface of the anterior horn of the medial meniscus, the scalpel is inserted with the blade directed away from the surface of the meniscus.
      The platelet-rich fibrin matrix clot (Cascade Autologous Platelet System, Musculoskeletal Transplant Foundation, Edison, NJ) requires at least 20 minutes of preparation. Therefore, the decision to perform a meniscal repair augmented with a platelet-rich clot should be made as early in the case as possible to optimize timing and avoid delays. The horizontal cleavage tear should be thoroughly inspected to ensure that the leaflets of the tear are adequate for repair.

      Fibrin Clot Preparation

      Once the tear is deemed reparable, the patient's blood is collected and placed through a series of centrifugations using the Cascade Autologous Platelet System. The first centrifugation, which lasts 6 minutes, separates the PRP from the blood cells. The PRP is transferred into another tube and is spun in the centrifuge for 15 to 20 minutes to create the fibrin clot. A longer duration of centrifugation time produces a more reliable and rigid clot. The clot is aseptically removed from the vial and placed onto the surgical field. Adsorbable polyfilament sutures of different colors, for example, dyed and undyed 0 Vicryl sutures (Ethicon, Somerville, NJ), are carefully passed through each end of the clot in a locking pattern (Fig 1).
      Figure thumbnail gr1
      Fig 1Two polyfilament sutures of different colors are passed through the platelet-rich fibrin clot to facilitate passage into the joint.

      Shuttle Suture Passage

      While the blood sample is being processed, the meniscus tear can be prepared. An 18-gauge spinal needle is inserted through skin overlying the posteromedial skin. The needle should be directed at the anterior extent of the tear and should enter the knee between the superior and inferior leaflet of the tear. Once the needle has been adequately positioned at the anterior extent of the tear, a 0 monofilament suture (Prolene, Ethicon) is passed through the needle and grasped using an arthroscopic grasper (Fig 2). Before retrieving the suture out the anteromedial portal, the needle is retracted from the joint to prevent the tip of the needle from lacerating the suture. A second monofilament suture is shuttled through the posterior extent of the tear using a similar technique.
      Figure thumbnail gr2
      Fig 2Right knee, internal view of the medial compartment using the anterolateral portal. An 18-gauge spinal needle is passed through the skin from the posteromedial knee and entering the joint between the superior and inferior meniscal leaflets at the anterior aspect of the tear. A 0 monofilament suture is passed through the needle and grasped using an arthroscopic grasper. A second monofilament suture is shuttled through the posterior extent of the tear using a similar technique. These sutures will be used to eventually shuttle the clot into the tear.

      Meniscus Preparation

      The meniscus tissue is prepared to create an adequate bed for healing. A meniscal rasp is used to debride the degenerative tissue often found within the tear (Fig 3). Debridement of the degenerative meniscal tissue occurs between the 2 sutures and should proceed until bleeding is encountered within the base of the lesion.
      Figure thumbnail gr3
      Fig 3Right knee, internal view of the medial compartment using the anterolateral portal. The degenerative tissue found between the meniscal leaflets is debrided using a meniscal rasp. Debridement continues until bleeding is encountered within the base of the tear.

      Clot Passage

      The joint is prepared for passage of the platelet-rich fibrin clot into the apex of the meniscal tear. A 5.0-mm-diameter cannula is inserted through the anteromedial portal, and the monofilament sutures previously passed through the meniscus are again each retrieved out of the joint through the cannula. Each of these monofilament suture tails is secured to one of the suture pairs passed through each end of the clot (Fig 4). The monofilament sutures will be used to position the platelet-rich fibrin clot into the center of the meniscus tear. Each monofilament suture is sequentially removed from the joint by pulling on the suture limb exiting the skin overlying the posteromedial knee, and, thus, the clot is slowly manipulated into the tear one end at a time. Once all polyfilament suture limbs are passed through the meniscus and out the posteromedial knee, tension is applied to both polyfilament sutures and the graft is further entrenched into position between the 2 leaflets of the tear (Fig 5).
      Figure thumbnail gr4
      Fig 4(A) The monofilament sutures previously passed through the spinal needles are grasped out the anteromedial portal, secured extracorporeal to polyfilament sutures that were previously woven through the fibrin clot, and pulled out the posteromedial skin. The polyfilament sutures through the clot are cut flush to the posteromedial skin once the meniscus has been repaired. (B) Right knee, internal view of medial compartment using the anterolateral portal. Thus, these monofilament sutures are used to shuttle the fibrin clot into position between the leaflets of the meniscal tear.
      Figure thumbnail gr5
      Fig 5Right knee, internal view of the medial compartment using the anterolateral portal. The fibrin clot is pulled into position between the 2 meniscal leaflets.

      Meniscus Repair

      The meniscus can now be repaired. A self-capturing suture passing device (Knee Scorpion, Arthrex, Naples, FL) is used to pass a high-strength braided suture (2-0 Fiberwire, Arthrex) through both superior and inferior meniscal leaflets at the tear's midpoint and 2 to 3 mm from the central edge of the tear (Fig 6). The suture limbs are secured using a series of half-hitch knots on the meniscus' superior surface. Additional sutures are placed anteriorly and posteriorly to the initial suture until the edges of the tear are reapproximated (Fig 7). With the platelet-rich fibrin clot firmly entrapped within the repaired meniscus, the polyfilament sutures passed through the clot are resected as they exit the skin overlying the posteromedial knee.
      Figure thumbnail gr6
      Fig 6Right knee, internal view of the medial compartment using the anterolateral portal. A self-capturing suture passage device is used to pass a high-strength suture through the superior and inferior leaflets of the meniscus. The suture is secured to entrap the fibrin clot between the meniscal leaflets.
      Figure thumbnail gr7
      Fig 7Right knee, internal view of the medial compartment using the anterolateral portal. A series of sutures are passed through both meniscal leaflets and secured to appose the edges of the meniscus and complete the repair.
      Postoperatively, the patient is 50% partial weightbearing in a knee extension brace for 4 weeks followed by full weightbearing with the brace unlocked for the next 2 weeks. Physical therapy including gentle range of motion begins at 2 weeks with motion limited to 45° of flexion until week 4 and 90° until week 6. At 6 weeks postoperatively, full weightbearing without a brace commences and flexion restrictions are removed. No pivoting, twisting, hopping, jumping, and running are permitted for 3 months postoperatively. Light jogging is expected to begin at 3 months and return to sports between 4 and 6 months.

      Discussion

      Symptomatic horizontal cleavage meniscal tears have been typically treated with partial meniscectomy owing to the proposed poor vascular supply and impaired healing. However, recent pooled data suggest that those who underwent repair for this meniscal tear configuration had improved outcomes versus those who had a segment of the meniscus resected.
      • Kurzweil P.R.
      • Lynch N.M.
      • Coleman S.
      • Kearney B.
      Repair of horizontal meniscus tears: A systematic review.
      Fibrin clots have previously been used as a method to improve healing potential of repaired menisci. More recently, PRP, which can induce upregulation of biglycan, decorin, aggrecan, collagen type I (α1), and elastin, has been introduced as a biological augment to increase healing rates after meniscal repair.
      • Howard D.
      • Shepherd J.H.
      • Kew S.J.
      • et al.
      Release of growth factors from a reinforced collagen GAG matrix supplemented with platelet rich plasma: Influence on cultured human meniscal cells.
      • Ishida K.
      • Kuroda R.
      • Miwa M.
      • et al.
      The regenerative effects of platelet-rich plasma on meniscal cells in vitro and its in vivo application with biodegradable gelatin hydrogel.
      A commercially available system can facilitate formation of PRP clots that can be sutured and manipulated between the tear edges. Available in vitro data are mixed on efficacy of PRP to induce meniscal tears to heal.
      • Ishida K.
      • Kuroda R.
      • Miwa M.
      • et al.
      The regenerative effects of platelet-rich plasma on meniscal cells in vitro and its in vivo application with biodegradable gelatin hydrogel.
      • Kwak H.S.
      • Nam J.
      • Lee J.H.
      • Kim H.J.
      • Yoo J.J.
      Meniscal repair in vivo using human chondrocyte-seeded PLGA mesh scaffold pretreated with platelet-rich plasma.
      • Zellner J.
      • Taeger C.D.
      • Schaffer M.
      • et al.
      Are applied growth factors able to mimic the positive effects of mesenchymal stem cells on the regeneration of meniscus in the avascular zone?.
      Limited data exist to substantiate the clinical benefit of PRP augmentation in meniscus repair (Table 2). One study of 35 isolated meniscal repairs suggested no clinical advantage when PRP is used
      • Griffin J.W.
      • Hadeed M.M.
      • Werner B.C.
      • Diduch D.R.
      • Carson E.W.
      • Miller M.D.
      Platelet-rich plasma in meniscal repair: Does augmentation improve surgical outcomes?.
      ; however, although not reaching statistical significance, both Lysholm and International Knee Documentation Committee values were increased in the PRP-treated group compared with the control group. Other studies including only those with horizontal meniscal tears show an improvement in functional outcome and magnetic resonance imaging-documented healing when PRP is added to the repair site.
      • Pujol N.
      • Salle De Chou E.
      • Boisrenoult P.
      • Beaufils P.
      Platelet-rich plasma for open meniscal repair in young patients: Any benefit?.
      Given that PRP may improve rates of healing and outcomes after meniscal tears and the potential for limited healing with repair of horizontal meniscal tears, platelet-rich fibrin clots are a useful adjunct for the treatment of these tears.
      Table 2Advantages and Disadvantages
      AdvantagesDisadvantages
      Repair of horizontal meniscus tears can lead to improved outcomes compared with partial meniscectomyCommercially available platelet-rich plasma clot has increased cost compared with a traditional fibrin clot
      Improved healing milieu and healing rate after meniscus repair using platelet-rich plasmaRepaired horizontal meniscus tear has potential to not heal and may require subsequent surgery to perform meniscectomy
      Clot content and structure is predictableIntra-articular suture and knots may be abrasive to chondral surfaces
      Procedure can be performed using the all-arthroscopic technique

      Supplementary Data

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