Knee Surg Sports Traumatol Arthrosc (2011) 19:1154–1157
DOI 10.1007/s00167-011-1404-5
KNEE
Repair of horizontal meniscal cleavage tears with exogenous
fibrin clots
Tamiko Kamimura • Masashi Kimura
Received: 11 August 2010 / Accepted: 13 January 2011 / Published online: 3 February 2011
Ó Springer-Verlag 2011
Abstract
Purpose A novel indication and technique using exogenous fibrin clots to repair horizontal cleavage tears of the
meniscus is presented.
Methods Vertical sutures were placed on the meniscus
using FasT-Fix (Smith & Nephew Endoscopy, Andover,
MA, USA), and exogenous fibrin clots were inserted within
the cleft to promote healing and to preserve function.
Results Repeat arthroscopy showed healing and closure
of the cleft of the meniscus without affecting the articular
cartilage. Three medial and six lateral menisci were treated, and all of the patients showed improvements in their
functional scores and their quality of life.
Conclusions It appears that the exogenous fibrin clots act
as a scaffold to promote the healing process and that
growth factors in the fibrin clots had a beneficial effect on
meniscal healing. This procedure should be considered to
treat degenerative menisci for which repair options have
been limited until now.
Level of evidence IV.
Keywords Meniscus Meniscal repair Horizontal
cleavage tear Fibrin clot FasT-Fix
Introduction
A horizontal cleavage tear of the meniscus has been considered an indication for partial or subtotal meniscectomy
because the tear is located within an avascular area.
T. Kamimura (&) M. Kimura
Gunma Sports Medicine Research Center, Zenshukai Hospital,
Maebashi, Japan
e-mail: arthrotammy@aol.com
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Therefore, the pathological changes associated with
degeneration in most patients are difficult to treat. However, it would be better if the meniscus could be repaired
and meniscectomy could be avoided in these patients
because of the future risk of osteoarthritis [4, 15, 16]. We
have used exogenous fibrin clots for meniscal repair of
horizontal cleavage tears with meniscal degeneration. This
report summarizes the technique and the outcomes at
12 months after the procedure.
Technical note
Diagnostic arthroscopy was performed to observe the pathological condition of the meniscus before preparing the
exogenous fibrin clot. Blood samples (25–30 mL) were
collected from the patients into a glass syringe and stirred for
10 min with a stainless steel swizzle stick (Fig. 1a). Elastic
fibrin clots precipitated on the stick (Fig. 1b) and were cut
into lengths of 5–7 mm. The meniscus was abraded with a
basket punch and shaver to expose its tear margins (Fig. 2a).
Vertical sutures were placed using FasT-Fix (Smith &
Nephew Endoscopy, Andover, MA) to close the cleft of the
tear. The arthroscope was inserted via the ipsilateral portal of
the meniscal lesion, and the FasT-Fix was inserted via the
contralateral portal. For lateral meniscal lesions, the
arthroscope was inserted via the lateral portal and FasT-Fix
was inserted via the medial portal. For medial meniscal
lesions, the arthroscope was inserted via the medial portal
and the FasT-Fix was inserted via the lateral portal to avoid
injuring the popliteal nerves and arteries.
The FasT-Fix needle was inserted from the superior
(femoral) surface with the first anchor, and the second
anchor was placed across the horizontal cleavage tear into
the inferior (tibial) surface. The area within the cleft was
Knee Surg Sports Traumatol Arthrosc (2011) 19:1154–1157
Fig. 1 a Blood (25–30 mL) was collected from the patients and
stirred for 10 min with a swizzle stick in a glass syringe. b Preparation
of the fibrin clot
filled with exogenous fibrin clots before tightening the
suture (Fig. 2b), and the repair was completed in a sandwich fashion (Figs. 2c, 3).
After surgery, an extension brace or a cast was applied
and the patients were restricted to limited flexion and nonweight-bearing movements for 4 weeks postoperatively.
The patients were then permitted to do weight-bearing
movement, as tolerated, and physical therapy.
Repeat arthroscopy performed 12 months after surgery
revealed that the cleft had closed and had healed with a
layer of vascular synovial tissue extending over the proximal surface of the lateral meniscus. The knots of the FasTFix were covered with synovial scar tissue on the surfaces
and did not seem to disturb the articular cartilage (Fig. 4).
Discussion
The most important finding of the present study was that
the technique described restored the form of the meniscus
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as closely as possible to its natural anatomical shape and
thus preserved its function.
Horizontal cleavage tears of the meniscus are accompanied by degenerative changes in the meniscal tissue,
particularly osteoarthritic changes [15]. Until now, the
preferred treatment for meniscal injury has been partial
meniscectomy or subtotal meniscectomy. The objective of
careful partial meniscectomy of the horizontal cleavage
tear is to preserve meniscal function [8, 12, 13]. The extent
of meniscal resection is inversely proportional to the
preservation of long-term knee function [7]. For degenerative tears, partial meniscectomy is preferred over subtotal
meniscectomy [5]. However, there are many reports of
radiographic changes and degeneration following partial
meniscectomy, and these outcomes should not be ignored
[14]. Partial loss of the meniscus increases the stress within
the knee, and it is better to retain rather than resect the
meniscus [3]. For individuals aged in their 30–40 s who
wish to continue sports or other activities, the initially
satisfactory results of partial meniscectomy tend to worsen,
and selecting partial meniscectomy as the treatment of
choice is questionable [19]. To prevent osteoarthritis, surgeons should limit the extent of resection and increase the
contact area of the meniscus, even the surface showing
degeneration. However, the horizontal cleavage tear often
reaches the peripheral edge of the meniscus and it is difficult to relieve the symptoms by minimal partial meniscectomy [8]. Furthermore, biological factors might be more
important than the surgical procedures in meniscus healing.
Because healing is influenced by the peripheral vasculature
of the meniscus, tears located in a vascular area can be
repaired with a higher rate of success. Accordingly, a
horizontal cleavage tear associated with early meniscal
degeneration is generally regarded as an indication for
meniscal repair.
The application of the exogenous fibrin clots is one
method to augment repair and promote meniscal healing
[9, 10]. Similar methods, such as the creation of vascular
access channels with trephination [20] and microfracture of
the intercondylar notch [6], have been reported to be
effective in enhancing meniscal healing in avascular areas.
The exogenous fibrin clots contain growth factors that
promote cellular infiltration and healing, as shown in animal models and human studies [1, 9, 10, 18].
Because exogenous fibrin clots have been widely used to
enhance meniscal repair, whether they could supply growth
factors and act as a scaffold to promote healing of degenerative meniscal tears was tested in this study. Accordingly, this report indicates that exogenous fibrin clots can
be used to heal difficult-to-treat injuries, including horizontal tears in the degenerative meniscus.
All-inside suture materials, such as FasT-Fix, are now
widely available. They provide high-strength sutures and a
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Knee Surg Sports Traumatol Arthrosc (2011) 19:1154–1157
Fig. 2 The patient was a
41-year-old woman who had
injured her right knee in a fall
from a balance beam when she
was 18 years old; her Lysholm
score was 57. a The extensive
horizontal cleavage tear with
degeneration reached the
peripheral edge of the meniscus
after the fibrillation had been
abraded. b Vertical sutures were
placed from the superior surface
to the inferior surface of the
lateral meniscus using FasT-Fix.
The fibrin clots filled the area
within the cleft. c The
completed repair
Fig. 3 Schematic diagram of the technique. The exogenous fibrin
clot was inserted via the same portal as the FasT-Fix using a hand
instrument designed as a rongeur or a grasper before tightening the
suture
shorter operating time than inside-out approaches. These
suture materials also provide optimal mechanical strength
through their self-locking mechanism [2, 17].
At our institution, we often use this self-locking mechanism to hold the fibrin clots within the cleft of the horizontal
cleavage tear. At the repeat arthroscopy 12 months after
surgery, the suture knots were covered with scar tissue and
there were no changes in the appearance of the surrounding
weight-bearing articular cartilage. Furthermore, the repeat
arthroscopy showed a vascular layer on the healed meniscus.
One limitation of this study is that the pathological
condition of the repaired horizontal cleavage tears was
unknown at the time of writing this report. However, it
seems likely that the exogenous fibrin clot acted as a
scaffold during meniscal healing, similar to that described
by Arnoczy et al. [1] and Webber et al. [18] in traumatic
vertical tears and in degenerative horizontal tears.
With ongoing developments in biotechnology, plateletrich plasma (PRP) may offer an alternative option to treat
meniscal tears. PRP is essentially similar to a fibrin clot but
contains more abundant growth factors [11]. Although
fibrin clots are more easily produced than PRP for practical
use, surgeons should also consider the use of PRP in
meniscal repair.
Conclusions
Fig. 4 A repeat arthroscopy at 12 months shows the closed cleft
and the healed area with regeneration of the pannus over the
femoral surface of the lateral meniscus. The patient’s Lysholm score
was 95
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The meniscal repair procedure described here offers an
alternative approach to treat a degenerative meniscus with
a horizontal cleavage tear, the repair of which has been
limited until now.
Knee Surg Sports Traumatol Arthrosc (2011) 19:1154–1157
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