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Technical tips in orthopaedics: Meniscal repair with use of an in situ fibrin clot
Technical Note
Technical Tips in Orthopaedics: Meniscal Repair With Use of an In Situ Fibrin Clot Paul M. Sethi, M.D., Andrew Cooper, B.S., and Peter Jokl, M.D.
Abstract: The importance of meniscal preservation has become increasingly clear, and many authors advocate repair of the meniscus whenever possible, forgoing patient age and tear location. In accordance with the common goal of preserving meniscal tissue, we describe a simple technique to augment meniscal repairs with the use of an in situ fibrin clot. The site is prepared accordingly: the synovium directly above the tear site is abraded with a shaver, rasp, or small intra-articular banana blade. Next, the water inflow cannula is closed, and the outflow cannula is opened to vacuum suctioning, allowing collapse of the distended joint. Under these circumstances, negative intraarticular pressure is produced in the knee joint. This condition is maintained for a period of 1 to 2 minutes and induces bleeding from the abraded synovial site. The knee in a dependent position causes the blood to run down the synovial wall and into the meniscal cleft, pooling there and forming a clot adherent to the edges of the separated meniscal tear. This procedure has been found to be a simple and minimally invasive mechanism for clot placement. The exposed collagen of the meniscal tear provides an ideal surface for a relatively tenacious clot attachment. It provides the healing factors reported to induce successful meniscal healing. Key Words: Meniscus—Arthroscopy—Fibrin clot.
T
he importance of meniscal preservation has become increasingly clear, and many authors advocate repair of the meniscus whenever possible, forgoing patient age and tear location.1,2 In accordance with the common goal of preserving meniscal tissue, we describe a simple technique for augmenting meniscal repairs with the use of an in situ fibrin clot. The first meniscus repair was reported in 1885 by Annandal3; however, the utility of repair was not fully recognized until Fairbank’s landmark paper in 1948,4 in which he noted radiographic arthritic changes in 69% of patients who underwent meniscectomy. In
From the Yale University School of Medicine, New Haven, Connecticut, U.S.A. Address correspondence and reprint requests to Peter Jokl, M.D., Director of Sports Medicine, Yale University School of Medicine, 800 Howard Ave, Yale Physicians Building, New Haven, CT 06511, U.S.A. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 1526-3231/03/1905-3367$30.00/0 doi:10.1053/jars.2003.50164
efforts to reduce the negative consequences of total meniscectomy, procedures have progressed to subtotal meniscectomy, partial meniscectomy, and subsequently to arthroscopic debridement. Each of these techniques show with improved outcomes, but all are associated with long-term arthritic changes nonetheless.5,6 In 1981, DeHaven et al.7 and DeHaven,8 aware of the benefits of sparing the meniscus, described the technique of open meniscal repair. The 9-year follow-up showed a 79% success rate. Since the initial report, many specific repair techniques have been described, and these descriptions continue to evolve. These techniques essentially fall into 3 categories: inside out, outside in, and all arthroscopic techniques. All the methods include excision of loose tags or fragments, rasping of the torn meniscus, and rasping of the parameniscal synovium. The use of sutures, both vertical and horizontal mattress, as well as use of biodegradable fixation devices, has been described with great success.1
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 5 (May-June), 2003: E44
1
2
P. M. SETHI ET AL.
FIGURE 1. A standard extracorporeal fibrin clot with absorbable sutures before implantation.
In addition to fixation techniques and devices, several biologic adjunctive methods to enhance meniscal healing have been described. These include vascular access channels, synovial flaps, adding Hyaluron, and making a fibrin clot (Figs 1 and 2). The latter technique is the most studied. Arnocyky and Warren9 have showed the experimental efficacy of a clot, and this was confirmed by Cannon10 and later by Henning et al.,11 who reported a reduction in failures from 61% to 8% with the addition of a fibrin clot. The mechanism by which the clot works has not yet been fully elucidated, but it is presumed that the local delivery of growth factors enhances the ability of the tissues to repair themselves. There are few downsides to adding a fibrin clot. However, despite the low morbidity associated with use of a clot in meniscal repair, this technique is not uniformly used by arthro-
FIGURE 2. sutures.
The fibrin clot is placed into the meniscal tear with
FIGURE 3.
The separated edges of the meniscal tear.
scopic surgeons. Some potential reasons for not using a clot include the additional time it takes to prepare a clot, unfamiliarity with the technique, operating department staff with unfamiliarity with the technique, and the cumbersome handling of the clot. In addition, the preparation of the fibrin clot extravascularly raises the possibility of introducing an infectious organism when the clot is introduced into the joint. We describe a simple, intra-articular technique for delivery of blood clot “local growth factors” that do not depend on exogenous preparation. TECHNIQUE The arthroscopic procedure is performed with the knee flexed 90° in a dependent position. Arthroscopic portals are established in the anterior medial and lateral aspects of the knee. Additional portal sites are made as required to perform the meniscal repair. The joint is distended with fluid and positioned to allow clear visualization and access to the meniscal tear. The tear site is prepared for approximation, including debridement of loose tissue and rasping of the torn meniscal surfaces. If the repair is one in which fixation is planned by suture, the sutures are placed in the appropriate locations and left untied. The meniscal tear edges are left separated 3 to 5 mm (Fig 3). If repair is planned with meniscal anchor devices, the sides of the meniscal tear are separated about 3 to 5 mm using an intra-articular probe. After site preparation, the synovium directly above the tear site is abraded with a shaver, rasp, or small intra-articular banana blade. The water inflow cannula is then closed and the outflow cannula is opened to vacuum suction, allowing collapse of the distended
MENISCAL REPAIR WITH AN IN SITU FIBRIN CLOT joint. Under these circumstances, negative intra-articular pressure is produced in the knee joint. This condition is maintained for 1 to 2 minutes and induces bleeding from the abraded synovial site. The dependent position causes the blood to run down the synovial wall and into the meniscal cleft, pooling there and forming a clot adherent to the edges of the separated meniscal tear. The negative pressure is then released, and the knee is allowed to equilibrate with the ambient atmospheric conditions. This allows slight distention of the knee. The bleeding and subsequent clot formation can be seen under direct visualization through the air that is now in the joint (Fig 4). After a total elapsed time of 5 to 6 minutes, allowing adequate clot formation via the induced clotting arcade, irrigating fluid is again allowed to distend the knee if needed. Often this is not necessary because adequate visualization is possible through the air that has entered the knee joint during the preparation. A fresh clot will be seen adhering to the edges of the meniscal tear, filling the cleft between them. The planned meniscal repair is then completed by tying the previously placed sutures or by reapproximating the tear with meniscal anchors. The blood clot is left trapped between the approximated tissues (Fig 5). This procedure has also been found to be a simple and minimally invasive mechanism for clot placement. The exposed collagen of the meniscal tear provides an ideal surface for a relatively tenacious clot attachment. It provides the healing factors that are reported to induce successful meniscal healing.
FIGURE 4. The abraded edges of the synovium, under negative intra-articular pressure, bleed into the tear.
3
FIGURE 5. The tear, repaired with Meniscus Arrow (Bionx, Blue Bell, PA).
CONCLUSIONS The use of a fibrin clot is a well-described procedure. It has been shown to provide clinical success with low morbidity. The use of biologic adjuncts in meniscal repair may be a glimpse into the future of tissue repair, because the field of growth factors continues to explode. We describe a modification of Arnoczsky and Warren’s9 technique. This technique, which has a parallel to the improved results seen with meniscal repair ion anterior cruciate ligament (ACL) reconstruction,10 provides the local delivery of growth factors to the repaired meniscus in an effort to improve the healing rate. It is our experience that use of the in situ clot increases the rate of successful repairs, at least from a clinical standpoint, because we do not routinely perform second-look arthroscopy in asymptomatic patients. We believe that the local delivery of blood to the clot in a controlled fashion is as effective as spinning down a fibrin clot. One concern is that the clot may be irrigated away. It is our experience that the in situ clot stays at the side of the meniscal tear. We have decompressed the knee and then entered arthroscopically again to check for dissolution of the clot, and it is routinely present (similar to the clot that routinely forms in the intercondylar notch during ACL reconstruction). We believe that this is a safe and easy technique that takes advantage of the biologic enhancement of healing. It does not require the assistance of a skilled operating room assistant or the assistance of the circulating operating room staff, nor does it add a significant amount of time to the meniscal repair, irre-
4
P. M. SETHI ET AL.
spective of repair technique. We routinely practice it with our repairs and find it to be a useful adjunct for meniscal repair.
6. 7.
REFERENCES 8. 1. Rodeo S. Arthroscopic meniscal repair with use of the outside-in technique. J Bone Joint Surg Am 2000;82:127-141. 2. Rubman MH, Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears that extend into the avascular zone: A review of 198 single and complex tears. Am J Sports Med 1998;26:87-95. 3. Annandale T. An operation for displaced semilunar cartilage. Br J Med 1885;1:779. 4. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br 1948;30:664-670. 5. Johnson MJ, Lucas G, Dusek J, et al. Isolated arthroscopic
9. 10.
11.
meniscal repair: A long term outcome study. Am J Sports Med 1999;27:44-49. Appel H. Late results after meniscectomy in the knee joint: A clinical and radiological follow-up investigation. Acta Ortho Scand Suppl 1970;133. DeHaven K, Black KP, Griffiths H. Open meniscus repair: Technique and two to nine year results. Am J Sports Med 1989;17:788-795. DeHaven K. Meniscus repair. Am J Sports Med 1999;27:242251. Arnoczky S, Warren R, Spivak J. Meniscal Repair using an exogenous fibrin clot: An experimental study in dogs. J Bone Joint Surg Am 1988;70:1209-1217. Cannon WD, Vittori J. The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament reconstructed knees versus stable knees. Am J Sports Med 1992;20: 176-181. Henning CE, Lynch MD, Yearout KM, et al. Arthroscopic meniscal repair using an exogenous fibrin clot. Clin Orthop 1990;252:64-72.
Technical Tips in Orthopaedics: Meniscal Repair With Use of an In Situ Fibrin Clot Paul M. Sethi, M.D., Andrew Cooper, B.S., and Peter Jokl, M.D.
Abstract: The importance of meniscal preservation has become increasingly clear, and many authors advocate repair of the meniscus whenever possible, forgoing patient age and tear location. In accordance with the common goal of preserving meniscal tissue, we describe a simple technique to augment meniscal repairs with the use of an in situ fibrin clot. The site is prepared accordingly: the synovium directly above the tear site is abraded with a shaver, rasp, or small intra-articular banana blade. Next, the water inflow cannula is closed, and the outflow cannula is opened to vacuum suctioning, allowing collapse of the distended joint. Under these circumstances, negative intraarticular pressure is produced in the knee joint. This condition is maintained for a period of 1 to 2 minutes and induces bleeding from the abraded synovial site. The knee in a dependent position causes the blood to run down the synovial wall and into the meniscal cleft, pooling there and forming a clot adherent to the edges of the separated meniscal tear. This procedure has been found to be a simple and minimally invasive mechanism for clot placement. The exposed collagen of the meniscal tear provides an ideal surface for a relatively tenacious clot attachment. It provides the healing factors reported to induce successful meniscal healing. Key Words: Meniscus—Arthroscopy—Fibrin clot.
T
he importance of meniscal preservation has become increasingly clear, and many authors advocate repair of the meniscus whenever possible, forgoing patient age and tear location.1,2 In accordance with the common goal of preserving meniscal tissue, we describe a simple technique for augmenting meniscal repairs with the use of an in situ fibrin clot. The first meniscus repair was reported in 1885 by Annandal3; however, the utility of repair was not fully recognized until Fairbank’s landmark paper in 1948,4 in which he noted radiographic arthritic changes in 69% of patients who underwent meniscectomy. In
From the Yale University School of Medicine, New Haven, Connecticut, U.S.A. Address correspondence and reprint requests to Peter Jokl, M.D., Director of Sports Medicine, Yale University School of Medicine, 800 Howard Ave, Yale Physicians Building, New Haven, CT 06511, U.S.A. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 1526-3231/03/1905-3367$30.00/0 doi:10.1053/jars.2003.50164
efforts to reduce the negative consequences of total meniscectomy, procedures have progressed to subtotal meniscectomy, partial meniscectomy, and subsequently to arthroscopic debridement. Each of these techniques show with improved outcomes, but all are associated with long-term arthritic changes nonetheless.5,6 In 1981, DeHaven et al.7 and DeHaven,8 aware of the benefits of sparing the meniscus, described the technique of open meniscal repair. The 9-year follow-up showed a 79% success rate. Since the initial report, many specific repair techniques have been described, and these descriptions continue to evolve. These techniques essentially fall into 3 categories: inside out, outside in, and all arthroscopic techniques. All the methods include excision of loose tags or fragments, rasping of the torn meniscus, and rasping of the parameniscal synovium. The use of sutures, both vertical and horizontal mattress, as well as use of biodegradable fixation devices, has been described with great success.1
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 5 (May-June), 2003: E44
1
2
P. M. SETHI ET AL.
FIGURE 1. A standard extracorporeal fibrin clot with absorbable sutures before implantation.
In addition to fixation techniques and devices, several biologic adjunctive methods to enhance meniscal healing have been described. These include vascular access channels, synovial flaps, adding Hyaluron, and making a fibrin clot (Figs 1 and 2). The latter technique is the most studied. Arnocyky and Warren9 have showed the experimental efficacy of a clot, and this was confirmed by Cannon10 and later by Henning et al.,11 who reported a reduction in failures from 61% to 8% with the addition of a fibrin clot. The mechanism by which the clot works has not yet been fully elucidated, but it is presumed that the local delivery of growth factors enhances the ability of the tissues to repair themselves. There are few downsides to adding a fibrin clot. However, despite the low morbidity associated with use of a clot in meniscal repair, this technique is not uniformly used by arthro-
FIGURE 2. sutures.
The fibrin clot is placed into the meniscal tear with
FIGURE 3.
The separated edges of the meniscal tear.
scopic surgeons. Some potential reasons for not using a clot include the additional time it takes to prepare a clot, unfamiliarity with the technique, operating department staff with unfamiliarity with the technique, and the cumbersome handling of the clot. In addition, the preparation of the fibrin clot extravascularly raises the possibility of introducing an infectious organism when the clot is introduced into the joint. We describe a simple, intra-articular technique for delivery of blood clot “local growth factors” that do not depend on exogenous preparation. TECHNIQUE The arthroscopic procedure is performed with the knee flexed 90° in a dependent position. Arthroscopic portals are established in the anterior medial and lateral aspects of the knee. Additional portal sites are made as required to perform the meniscal repair. The joint is distended with fluid and positioned to allow clear visualization and access to the meniscal tear. The tear site is prepared for approximation, including debridement of loose tissue and rasping of the torn meniscal surfaces. If the repair is one in which fixation is planned by suture, the sutures are placed in the appropriate locations and left untied. The meniscal tear edges are left separated 3 to 5 mm (Fig 3). If repair is planned with meniscal anchor devices, the sides of the meniscal tear are separated about 3 to 5 mm using an intra-articular probe. After site preparation, the synovium directly above the tear site is abraded with a shaver, rasp, or small intra-articular banana blade. The water inflow cannula is then closed and the outflow cannula is opened to vacuum suction, allowing collapse of the distended
MENISCAL REPAIR WITH AN IN SITU FIBRIN CLOT joint. Under these circumstances, negative intra-articular pressure is produced in the knee joint. This condition is maintained for 1 to 2 minutes and induces bleeding from the abraded synovial site. The dependent position causes the blood to run down the synovial wall and into the meniscal cleft, pooling there and forming a clot adherent to the edges of the separated meniscal tear. The negative pressure is then released, and the knee is allowed to equilibrate with the ambient atmospheric conditions. This allows slight distention of the knee. The bleeding and subsequent clot formation can be seen under direct visualization through the air that is now in the joint (Fig 4). After a total elapsed time of 5 to 6 minutes, allowing adequate clot formation via the induced clotting arcade, irrigating fluid is again allowed to distend the knee if needed. Often this is not necessary because adequate visualization is possible through the air that has entered the knee joint during the preparation. A fresh clot will be seen adhering to the edges of the meniscal tear, filling the cleft between them. The planned meniscal repair is then completed by tying the previously placed sutures or by reapproximating the tear with meniscal anchors. The blood clot is left trapped between the approximated tissues (Fig 5). This procedure has also been found to be a simple and minimally invasive mechanism for clot placement. The exposed collagen of the meniscal tear provides an ideal surface for a relatively tenacious clot attachment. It provides the healing factors that are reported to induce successful meniscal healing.
FIGURE 4. The abraded edges of the synovium, under negative intra-articular pressure, bleed into the tear.
3
FIGURE 5. The tear, repaired with Meniscus Arrow (Bionx, Blue Bell, PA).
CONCLUSIONS The use of a fibrin clot is a well-described procedure. It has been shown to provide clinical success with low morbidity. The use of biologic adjuncts in meniscal repair may be a glimpse into the future of tissue repair, because the field of growth factors continues to explode. We describe a modification of Arnoczsky and Warren’s9 technique. This technique, which has a parallel to the improved results seen with meniscal repair ion anterior cruciate ligament (ACL) reconstruction,10 provides the local delivery of growth factors to the repaired meniscus in an effort to improve the healing rate. It is our experience that use of the in situ clot increases the rate of successful repairs, at least from a clinical standpoint, because we do not routinely perform second-look arthroscopy in asymptomatic patients. We believe that the local delivery of blood to the clot in a controlled fashion is as effective as spinning down a fibrin clot. One concern is that the clot may be irrigated away. It is our experience that the in situ clot stays at the side of the meniscal tear. We have decompressed the knee and then entered arthroscopically again to check for dissolution of the clot, and it is routinely present (similar to the clot that routinely forms in the intercondylar notch during ACL reconstruction). We believe that this is a safe and easy technique that takes advantage of the biologic enhancement of healing. It does not require the assistance of a skilled operating room assistant or the assistance of the circulating operating room staff, nor does it add a significant amount of time to the meniscal repair, irre-
4
P. M. SETHI ET AL.
spective of repair technique. We routinely practice it with our repairs and find it to be a useful adjunct for meniscal repair.
6. 7.
REFERENCES 8. 1. Rodeo S. Arthroscopic meniscal repair with use of the outside-in technique. J Bone Joint Surg Am 2000;82:127-141. 2. Rubman MH, Noyes FR, Barber-Westin SD. Arthroscopic repair of meniscal tears that extend into the avascular zone: A review of 198 single and complex tears. Am J Sports Med 1998;26:87-95. 3. Annandale T. An operation for displaced semilunar cartilage. Br J Med 1885;1:779. 4. Fairbank TJ. Knee joint changes after meniscectomy. J Bone Joint Surg Br 1948;30:664-670. 5. Johnson MJ, Lucas G, Dusek J, et al. Isolated arthroscopic
9. 10.
11.
meniscal repair: A long term outcome study. Am J Sports Med 1999;27:44-49. Appel H. Late results after meniscectomy in the knee joint: A clinical and radiological follow-up investigation. Acta Ortho Scand Suppl 1970;133. DeHaven K, Black KP, Griffiths H. Open meniscus repair: Technique and two to nine year results. Am J Sports Med 1989;17:788-795. DeHaven K. Meniscus repair. Am J Sports Med 1999;27:242251. Arnoczky S, Warren R, Spivak J. Meniscal Repair using an exogenous fibrin clot: An experimental study in dogs. J Bone Joint Surg Am 1988;70:1209-1217. Cannon WD, Vittori J. The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament reconstructed knees versus stable knees. Am J Sports Med 1992;20: 176-181. Henning CE, Lynch MD, Yearout KM, et al. Arthroscopic meniscal repair using an exogenous fibrin clot. Clin Orthop 1990;252:64-72.