ABSTRACT

Background

The most crucial function of the meniscus is its protective role, including shock
absorption and force transmission across the knee joint, by increasing the contact
area, which avoids contact stress on the articular cartilage(1). Knee kinematics
and loading are altered by meniscal injuries and loss, which ultimately results in
poor functional outcomes and a higher chance of developing osteoarthritis(2).
Following meniscal repair, clinical studies have documented better results and a
lower risk of osteoarthritis, while biomechanical studies have demonstrated
restored knee function(3). Meniscal repair surgeries are becoming more common,
indicating that orthopedic surgeons are trying to save the meniscus by repairing it
whenever possible.

Purpose

To report on the outcomes of 17 meniscus tears that were treated by

arthroscopic outside-in repair technique with fibrin clots augmentation. The
results demonstrated excellent clinical outcomes and good meniscal healing.

Methods

From 2021 to 2023, 17 patients undergoing arthroscopic suture repair of a

meniscus tear with fibrin clot augmentation were collected from a prospective
database. Follow-up included outcome scores evaluated by the Lynsholm score,
KOOS score, and Tegner score.

Results
There were 13 males and 4 females, with a mean age of 36 ±15. The medial
meniscus was repaired in 6 knees and the lateral in 6 knees while both of the
meniscus were repaired in 5 knees. Evaluation at 6 months post-operative
showwing Lysholm scores improved from 67,6 ± 10,2 to 96,8 ± 3,9, KOOS scores
improved in all categories while Tegner scores remained the same 6 months post-
operative.

Conclusion

This study demonstrates effective meniscal repairs with fibrin clot augmentation.
This surgical procedure appears to be a reliable and safe treatment method for
meniscus tears.

INTRODUCTION

It has previously been demonstrated that meniscal lesions, especially those larger
in size and situated in the white-white region of the meniscus, heal poorly(4).
Biologic agents have garnered more attention in recent years as a means of
promoting and accelerating the healing process in tissue that is typically more
avascular. Bone marrow aspirate concentrate and platelet-rich plasma are two
examples of biologic therapeutic agents with promising initial results(5, 6). These
alternatives are more time-consuming, expensive, resource-intensive, and subject
to more regulations than some more traditional agents, like fibrin clots. Fibrin
clots are widely accessible, simple to use, reasonably priced, and minimally
invasive. Additionally, fibrin clots give surgeons the ability to localize the
biological factors they want at the repair site. Initially explained by Arnoczky et al.
(4), Fibrin clots have been explored as a possible way to improve meniscus repair
in the avascular areas of the meniscus(7).
The purpose of this study was to determine the clinical outcome of arthroscopic
meniscal repair with fibirin clot augmentation in Hue University of Medicine and
Pharmacy, Vietnam, between 2021 and 2023.
METHODS AND MATERIALS
From 2021 to 2023, 17 consecutive patients with complete radial tears of the
meniscus underwent arthroscopic outside-in repair with fibrin clots. 17 patients
were male. 6 tears involved the lateral meniscus, 6 the medial meniscus, and 5
tears involved both of the meniscus.
Surgical procedure
All surgeries were performed by one experienced surgeon. Through the
anteromedial, anterolateral, and superolateral portals, an arthroscopic
examination was conducted. The meniscus tear was discovered after assessing
any concurrent cartilage damage and ligament injuries. Unstable meniscus
fragments were debrided using a motorized razor, rasp, and basket forceps. The
torn margin of the meniscus and adjacent synovium were abraded with a rasp
and shaver to improve the vascular supply to the lesion. The meniscus repair was
performed using the outside-in technique. To begin the outside-in repair, a spinal
needle is introduced by piercing the overlying capsule, advancing it under the
anterior edge of the medial or lateral meniscus (depending on the case), and
through the body of the anterior horn, thus traversing the area of the The inner
cannula of the needle is removed, and a 2-0 PDS suture (Ethicon, Inc., Johnson
&Johnson, Somerville, NJ, USA) is placed through the needle and into the joint.
Similarly, a second needle is passed through the capsule. The inner cannula is
again removed, and a second 2-0 PDS suture retriever is passed through the
second needle and into the joint. The 2 free ends of the 2 PDS sutures are then
pulled through the anteromedial portal using a grasper and tied together,
creating a knot outside the knee. The knot is then pulled back into the joint,
creating either a horizontal or vertical mattress suture, depending on the position
of the 2 spinal needles.
To prepare the fibrin clot, we drew 40–60 ml of peripheral blood from the patient
and placed it in a sterile glass beaker. Then, the blood was stirred gently with a
sintered glass stick until a fibrin clot precipitated on the surface of the stick after
3–5 min. The clot was placed on wet sterile gauze and trimmed to match the
lesion. A 2-0 vicryl suture was passed through the fibrin clot in order to facilitate
the delivery of the clot. Using the same outside-in technique, two 2-0 PDS sutures
are introduced into the joint. Their 2 free ends are pulled out through the
anteromedial portal and then tied to the 2 free ends of the 2-0 vicryl suture from
the clot. By pulling two 2-0 PDS sutures, the prepared fibrin clot is delivered into
the joint, exactly at the side of the meniscal tear.
After the delivery of the fibrin clot is complete, all the sutures are tied to the
anteromedial/lateral capsule with the knee flexed to 90°.
For 1-2 weeks after surgery, the knee was immobilized in a cast with full knee
extension passive motion exercises were advised to be used starting three days
following surgery. Six weeks after surgery, toe-touch partial weight-bearing was
permitted. At three months after surgery, light running was permitted.
Additionally, we gave special instructions to avoid doing so as much as possible,
but squatting was permitted simultaneously to start light running.
Evaluation methods
The patients were measured for the range of motion and evaluated knee function
using the Lysholm score, KOOS score, and Tegner score, both before and after
surgery.
Statistical analysis
Patients with incomplete data were excluded. Descriptive statistics were used to
report the sample characteristics. Because the outcomes were repeatedly
measured, we used the mixed-effects regression to model the response in the
data with high unexplained variability. The analysis was performed using R
4.3.1/RStudio 2023.

Results
1. Patient characteristics
Characteristics Result Characteristics Result
Age 36.2±15.5 Causes of Sports injury 10 (58.8%)
Age range 16-65 injury Traffic 7 (41.2%)
accident
Gender Female 4 (23.5%) Side of knee Left 7 (41.2%)
Male 13 (76.5%) Right 10 (58.8%)
Time from <3 months 5 (29.4%) Signs of Knee joint 6 (35.3%)
injury to discoid palpation 7 (41.2%)
surgery 3-6 months 4 (23.5%) meniscus McMurray 9 (52.9%)
(Medial vs. 11 (64.7%)
Lateral)
6-12 months 5 (29.4%) Apley 8 (47.1%)
7 (41.2%)
>12 months 3 (17.7%) MRI Both 5 (29.4%)
diagnosis Medial only 6 (35.3%)
Lateral only 6 (35.3%)
Note: Results are reported as mean±sd, min-max, or number(percent).

Comment: The study sample had a mean age of 36.2±15.5 years (normally
distributed), ranging from 16 to 65. The male was the predominant gender
(76.5%). Two causes of injury were sports injuries (58.8%) and traffic accidents
(41.2%). The right knee had a higher proportion than the left knee (58.8%
compared to 41.2%). The delay time from injury to surgery was evenly distributed
at less than 3 months, 3-6 months, 6-12 months, and more than 12 months. The
Knee joint palpation and McMurray signs were seen more in the lateral discoid
meniscus, whilst the Apley sign predominated in its medial counterpart. There
were the same number of 6 patients who had been injured only one
medial/lateral discoid meniscus (35.3%), and 5 patients (29.4%) had both
wounded discoid menisci.

2. Treatment outcomes
Hospital stay

Comment: The median length of hospital stay was one week (interquartile range:
5-7 days). No patients had to stay longer than 2 weeks. We did not find any factor
which had a statistically significant affect on the hospital stay.

Range of motion outcomes (compared to the normal knee)

Movement Preoperative 1 months 3 months 6 months

Flexion (°) 31±23 49±11*** 5±4*** 2±3***
Extension (°) 4±2 5±2*** 1±1*** 0±1***
Note: *** Data were statistically significant at level 0.001 compared to
preoperative time.

Comment: Regarding both types of movement, after one month, the range of
motion had not been improved yet. However, after 3 months onwards, the
differences between the injured knee and the normal knee gradually decreased.
There were statistically significant differences between each follow-up period and
the preoperative time (p<0.001).

KOOS and Lysholm score

Comment: One month after the operation, the decrease in knee function was
seen in all dimensions, including symptoms & stiffness, pain, daily living, sports &
recreational activities, quality of life, and the Lysholm score. However, it was
improving significantly later onwards and became nearly 100 points after 6
months.

Factors affecting the Lysholm score improvement

Factors Value Std. error p-value

Time from injury to surgery 74.5 12.1 <0.001
Period Preoperative - - -
1 months -9.9 2.3 <0.001
 3 months 23.2 2.3 <0.001
6 months 31.5 2.3 <0.001
Age -0.03 0.28 0.903
Gender Female - - -
Male -10.9 6.2 0.107
Cause of Sport injuries - - -
injuries Traffic accident -4.9 7.7 0.538
Discoid Both - - -
meniscus Medial only 2.7 4.3 0.541
injured
Lateral only 5.7 4.5 0.231

Comment: Only the length of follow-up showed statistical significance in affecting

the Lysholm score. (p<0.001). Older age, male, traffic accident, and both discoid
menisci injuries seemed to decrease the Lymsholm score improvement. However,
there was no statistical evidence on this data.

Tegner score

Preoperative 6 months p-value

Tegner score 4 (3-6) 4 (3-5) 0.224
Comment: No statistically significant difference in Tegner score between 6 months
of follow-up and the preoperative time (p>0.05).

DISCUSSION
The meniscus of the knee plays essential roles in providing stability, lubricating
the joint, absorbing shock, and increasing joint congruence. The meniscus's
primary protective function involves absorbing shock and transmitting force
across the knee joint by expanding the contact area, thereby preventing contact
stress on the articular cartilage. The use of fibrin clots made from autologous
blood improves the healing of longitudinal tears in the middle or posterior region
of the meniscus and avoids osteoarthritis, the long-term effects of partial
meniscectomy. In reviewing the literature, numerous authors have reported good
to excellent results when using fibrin clots to repair a meniscus tear.
Histologically, a fibrin clot serves as a scaffold and promotes the growth of cells
and tissue. Tissue formation is facilitated by the hematoma rather than the direct
vascular supply, which is not possible in the meniscus's avascular zone following
traumatic rupture(8, 9). It seemed that the fibrin clot's fibroblasts contributed to
the meniscal tissue's continued healing(10).
Our technique shows simplicity and effectiveness with basic instruments, and the
whole process is carried out under direct vision. The fibrin clot inserted and
secured into the torn meniscus defect ensures an early healing response and
regeneration.
In our study, the effectiveness of arthroscopic meniscal repair assisted by fibrin
clot was demonstrated by the improvement of the LYSHOLM score as well as the
KOOS score before and after surgery: Knee function according to the Lysholm
score was recorded at the Average level before surgery (67.6 ± 10.2), after 6
months it reached the Very Good level (96.8 ± 3.9); at the same time, there was a
significant improvement in all categories of the KOOS score: including symptoms
and stiffness, pain, daily living, sports and recreational activities, quality of life.
Compared with studies from other authors around the world, our study shows
similarities with the improvement of the LYSHOLM score as well as the reduction
of pain symptoms, recorded in the study of author Myers P (2023): Lysholm
scores improved from 53.97 (SD 18.14) to 92.08 (SD 8.97), KOOS pain scores from
61.49 (SD 22.76) to 93.54 (SD 8.06)(11), as well as the work of indian author
Sachin Kale (2022): The mean Lysholm score improved significantly from 67.63 ±
6.55 points preoperatively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 3
years follow-up(12).
Regarding the Tegner score of the activity level of patients before and after
surgery, our study showed that there was no difference in the activity level of the
study subjects after 6 months of surgery, with the mean Tegner score before and
after surgery being 4. Tamiko (2014) studied with a sample size of 10 patients and
found that 60% of patients maintained their activity level with the Tegner score
returning to pre-operative levels after a mean follow-up period of 40.8 ± 5.4
months(13). Meanwhile, author Peter SE Davies (2024) showed a slight
improvement in the activity level of surgical patients, with Tegner scores recorded
from a median of 4.0 to 5.0, however, this increase was not statistically significant
with p = 0.1388(14).

Our study also examined the correlation of several factors with postoperative
knee function using the Lynsholm score. While factors such as meniscal tear
location, age, gender, or mechanism of injury did not affect the Lynsholm score, it
is noteworthy that the time from injury to surgery was inversely correlated with
the patient's Lynsholm score. This suggests that the longer the time from injury
onset to surgery, the lower the rate of knee recovery. Animal studies have
previously demonstrated that meniscal cell count and morphology remain
consistent to 12 weeks following meniscal bucket-handle tear but progressively
deteriorate thereafter(15). It has also been shown that the success rate of
meniscal repair decreases with increased chronicity(16). However, the work of
Peter SE Davies (2024) showed that failed cases were not identified to have
higher chronicity(14). This difference may be due to the fact that in our study, the
Lynsholm score was recorded at the follow-up time of 6 months, which is much
shorter than the Lynsholm score recorded in the above study (46 months). A
longer follow-up time is consistent with patients having more time to recover and
rehabilitate, so the Lynsholm score should theoretically be higher.

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