Meniscal Repair With Fibrin Clot Augmentation

Abstract

Meniscal injuries and meniscal loss are associated with changes in knee kinematics and loading, ultimately leading to poor functional outcomes and increased risk of progression to osteoarthritis. Biomechanical studies have shown restored knee function, and clinical studies have reported improved outcomes and decreased risk of osteoarthritis after meniscal repair. This has led orthopaedic surgeons to try and save the meniscus by repair whenever possible, as shown by increasing incidence of meniscal repair surgeries. Historically, meniscal lesions, particularly those greater in size and located in the white-white region of the meniscus, have been shown to have poor healing. In recent years, there has been an increasing interest in the use of biologic agents to help stimulate and expedite healing in traditionally more avascular tissue. Preliminary results for biologic therapeutic agents, such as platelet rich plasma and bone marrow aspirate concentrate, have been encouraging. However, these options are more demanding in regard to time, financial burden, resources, and regulations than some more classic agents such as fibrin clots. Fibrin clot is readily available, easy to use, affordable, and minimally invasive. This Technical Note describes a step-by-step and reproducible technique for harvesting, preparation, and using a fibrin clot to augment healing of meniscal repairs.

Fig 1

Patient positioning. The operative (left) leg is sterilized in the standard fashion. Coband is wrapped around the calf and extended distally around the patient's left foot. The surgeon should ensure that sufficient work space is exposed around the patient's knee.

Fig 2

Peripheral blood draw being performed to prepare a fibrin clot. A 60 cc syringe is used to draw up blood from a peripheral vein on the dorsal aspect of the patient's right hand. Approximately 60 cc of patient blood should be drawn to prepare the fibrin clot.

Fig 3

Sixty cubic centimeters of blood is collected from the patient and then placed in a basin on the surgical field.

Fig 4

After placing approximately 60 cc of blood into the basin, a surgical assistant then stirs the blood with a glass syringe for approximately 15 minutes to assure adequate clot formation around the glass syringe.

Fig 5

Clot preparation steps. (A) After approximately 15 minutes of stirring, the fibrin clot is carefully removed from the glass syringe onto a sterile surgical pad. (B) A baster is used to add 2 to 3 drops of water to enhance clot formation, which allows for improved clot visualization during arthroscopy. (C) A scalpel and pickups can then be used to shape the clot to best fit the meniscal lesion. (D) Final fibrin clot product, ready to arthroscopic implantation into the surgical site.

Fig 6

Intraoperative image showing the insertion of the fibrin clot with a curved Kocher forceps (on the left) and arthroscopic picture (as viewed from the anteromedial portal) of the clot entering the joint on a right knee (image on the right).

Fig 7

Arthroscopic view (anterolateral portal) demonstrating the sutures and the fibrin clot underneath the meniscus. After the clot is stabilized by the sutures, the knee was flexed to 90° of flexion and the sutures were fastened down and then tied over the posteromedial capsule.