Arthroscopy: The Journal of Arthroscopic and Related Surgery 7(2):177-181 Published by

Raven Press, Ltd. 0 1591ArthroscopyAssociationof North

Arthroscopic

America

Meniscal Repair with Fibrin Glue

Masao Ishimura,

Susumu Tamai, and Yosiyuki Fujisawa

Summary: Since 1984 we have arthroscopically repaired 40 meniscal tears in 32 patients using fibrin glue in our operative technique. This technique was reported initially in 1985 (Ishimura M, Samma M, Habata T, Fujisawa Y. The use of fibrin glue for fresh knee injury. Cent Jpn Orthop Traumat 1985; 28:1404-8), with a more detailed study published in 1987 [Ishimura M, Samma M, Fujisawa Y, et al. Arthroscopic repair of the meniscus tears with fibrin glue. Arthroscopy (Jpn) 1987;12:3M]. During the follow-up period, which ranged from 10 months to 6 years and 7 months (mean: 3 years and 8 months), only two patients complained of meniscal symptoms and underwent arthroscopic partial meniscectomy. Twenty patients with 25 repairs underwent repeat arthroscopy at an average of 5.7 months (range: 2 months-l year and 2 months) after the initial repair. Twenty repairs were rated as good, four as fair, and one as poor by arthroscopic evaluation criteria. At present, the most appropriate use of this arthroscopic meniscal gluing technique is in tears in the posterior segment, which are difficult to suture without arthrotomy. Even a long tear with a stable reduced position can be expected to show good healing. When reduction of the tear is not stable, additional sutures should be used. Key Words: Meniscus-Meniscal repair-Meniscal adhesion-Fibrin glue-Repeat arthroscopy.

The first report

of meniscal

healing

enlarged the indications for arthroscopic gluing of meniscal tears. The first use of fibrinogen for tissue adhesion was reported in 1940 by Young and Medawar (6), who attempted the repair of rabbit peripheral nerves. These trials were unsuccessful because of insufftcient adhesive power and the effect of fibrinolysis. However, since the early 1970s a highly concentrated human fibrinogen has been available, and its use with aprotinin has been successful.

was published

by King in 1936 (1). Scapinelli in 1963 (2) and Arnoczky and Warren in 1982 (3) demonstrated that, in human cadavers, the outer lO-20% of the meniscus has a blood supply and that tears within that portion have the ability to heal. Based on these reports, the suturing of peripheral meniscal tears recently has become more popular (4,5), but it is difficult to suture meniscal tears of the posterior segment without arthrotomy because of the risk of injuring the popliteal neurovascular bundle. Therefore, we have repaired such tears arthroscopically using fibrin glue. Initially, only tears in the posterior segment were treated this way; we have gradually

MATERIALS AND METHODS Arthroscopic meniscal repair using fibrin glue was performed in 32 patients (24 women and 8 men) between the ages of 12 and 45 years (mean: 18 years). Seventeen patients had meniscal tears affecting the right knee and 15 had left-sided lesions. Although 6 knees had isolated meniscal tears (isolated group), 26 knees had anterior cruciate ligament lesions in addition to the meniscal tear (combined group).

From the Department of Orthopaedic Surgery, Nara Medical University (MI., S.T.) and Nara Sinohmiya Seikeigeka (Y.F.), Nara, Japan. Address correspondence and reprint requests to Dr. M. Ishimura at Department of Orthopaedic Surgery, Nara Medical University, Esta-Takanohara 5-305, Kabutodai, 2-chome, Kizucho, Soraku-gun, Kyoto prefecture 619-02, Japan.

177

M. ISHIMURA

178

I

Factor~Cactivated)

lFibrinogen ~Fibrin

&Fibrin nIonoIner

IFibrin

POlYlTl‘ZCsoluble

Polymer insoluble

FIG. 1. Fibrin formation.

The duration of meniscal symptoms ranged from 1 day to 2 years and 2 months (mean: 21 weeks). Eighteen of the 40 tears were treated within 3 weeks of occurrence, and the others were old injuries. There were 20 medial meniscal tears and 20 lateral meniscal tears. Four were bucket-handle tears, and the others were longitudinal tears. One tear extended from the anterior to the posterior segment, 5 extended from the middle to the posterior segment, and 34 were located entirely within the posterior segment. The fibrin adhesive system used consisted of fibrinogen, thrombin, aprotinin, CaCl,, and factor XIII. When fibrinogen is transformed into fibrin and polymerized, it has tissue adhesion qualities (Fig. l), and has been shown to facilitate tissue healing (7). Fibrin glue has been used for the fixation of osteochondral fragments (8,9), the repair of nerve and vessel tears (lo), and in skin grafting (I 1).

ET AL. der of the medial collateral ligament with the needle tip placed on the meniscal tear (Fig. 2). The normal saline solution in the knee is aspirated through the trocar or through the needle. The glue components are prepared, and OS-l.0 ml of each are injected simultaneously into the meniscal tear through a needle with a special adapter for this purpose. Solution A is fibrinogen, and solution B is thrombin, aprotinin, and CaCl,. After the injection, the torn meniscus is reduced again with the grasping forceps and held in position for l-2 min (Fig. 3A). When the tear is in the lateral meniscus, the needle for injecting the fibrin glue must be inserted from around the anterior border of the lateral collateral ligament. Otherwise, the procedure is the same as for the repair of the medial meniscus (Fig. 3B). When there is also an anterior cruciate ligament lesion, meniscal repair must be performed concomitantly with reconstruction of the ligament. Reduction of the tear was unstable in one meniscal tear in the combined group and two meniscal tears in the isolated group. These were supplemented with arthroscopic sutures. POSTOPERATIVE

MANAGEMENT

In the isolated group, the leg was immobilized in a plaster cast with the knee joint slightly flexed (- 15-20”) and in neutral rotation for 3-4 weeks and then followed by partial weight bearing for 2 weeks. In the combined group, postoperative management was the same as for a ligamentous operation.

OPERATIVE TECHNIQUE RESULTS For tears of the medial meniscus, a lateral infrapatellar approach is used for visibility. The tear is refreshed using a rosette knife or retrograde knife via the medial infrapatellar approach. The inner margin of the torn meniscus is held with grasping forceps, and the position at reduction is confirmed. The fibrin glue is administered through a 20-gauge 90-mm needle inserted from around the anterior bor-

The follow-up period ranged from 10 months to 6 years and 7 months (mean: 3 years and 8 months). Only two patients complained of meniscal symptoms. Twenty patients with 25 repairs had repeat arthroscopy at an average of 5.7 months after repair (range: 2 months-l year and 2 months) and were evaluated using the following arthroscopic criteria

FIG. 2. Twenty-gauge, 90-mm needle with special adapter for administering fibrin glue.

ARTHROSCOPIC

MENISCA .L REPAIR

WITH FIBRIN

GLUE

179

3A,B

fibrin

grasping

in glut

FIG. 3. Arthroscopic

meniscal repair with fibrin-adhesive

forceps

systems for medial meniscal tear (A) and lateral meniscal tear (B).

full length of the tear shows (Table 1): Good-The firm adhesion even under traction with grasping forceps (Fig. 4). Fair-Adhesion has been obtained, but the tear is filled with wide scar tissue and is unstable under traction (Fig. 5). Poor-An unadhered area remains within the tear (Fig. 6). In the isolated group all tears were rated as good, whereas in the combined group two repairs were fair and one was poor. Of the two patients who complained of meniscal symptoms, one had a repair evaluated as fair with symptoms developing 1 year and 3 months after surgery. The other repair was evaluated as poor and symptoms developed 7 months after surgery. On repeat arthroscopy, the menisci were found to be torn again, and both required partial meniscectomies. Although the results for the repairs of fresh tears were better, 73% of old tears also showed a good result. Thus, old tears also appear to be suitable for arthroscopic fibrin glue repair. Repair of lateral meniscal tears was less successful than repair of medial meniscal tears. In particular, tears near the popliteal hiatus tended to remain unhealed. There was no significant difference in the results of repair between longitudinal and bucket-handle tears. Even a long tear extending from the anterior to the posterior segment was treated successfully, and the length of the tear did not affect substantially the rate of healing. When the tears were in the avascular (white) portion of the meniscus where it has been considered

that healing can never be expected, good and two were fair.

one result was

DISCUSSION Suturing has recently become a common procedure for peripheral meniscal tears, but arthroscopic suture repair carries a significant risk of neurovascular injury when the tear is in the posterior segment. We initially used fibrin glue only to repair tears in the posterior segment, but we gradually have enlarged the indications for this type of arthroscopic surgery. In this prospective study, only 2 patients of the 32 TABLE 1. Arthroscopic

evaluation of meniscal repair Good

Fair

Poor

Combined group“ Isolated groupb

15 5

4 0

1 0

Fresh tear Old tear

9 11

1 3

0

Medial meniscus Lateral meniscus

10 10

0 4

0

Longitudinal tear Bucket-handle tear

18 2

4 0

0 1

Anterior-posterior segment Middle-posterior segment Posterior segment

: 10

0 3 1

0 1 0

Red White-red White

15 4 1

1

1

1 2

0 0

1 1

(1Knees that had both meniscal tears and anterior cruciate ligament lesions. b Knees that had isolated meniscal tears.

Arthroscopy,

Vol. 7, No. 2, 1991

M. ISHIMURA

ET AL.

4A-C

FIG. 4. Left knee of l&year-old woman had a bucket-handle tear that ranged from the middle to the posterior segment in the medial meniscus. A: Ten days after injury. The mobile fragment displaced in the intercondyle notch. B: The fragment was reduced by probe. C: Five months after the operation. The meniscal tear has firm adhesion and is evaluated as good.

had recurrence of meniscal symptoms. Arthroscopic evaluation showed that 20 of 25 repairs (80%) were good. In the combined group, four repairs were only fair and one was rated as poor. In all these cases, the reconstructed anterior cruciate ligament had failed to maintain sufficient tension, suggesting that in such knees meniscal repairs tend to fail. When the healing rates for medial and lateral meniscal lesions were compared, the latter were found to be lower. This was probably because the lateral meniscus is more mobile and because tears near the

popliteal hiatus do not have a sufficient blood supPlY. Our technique was used only for longitudinal or bucket-handle tears because maintaining reduction of radial, horizontal, or parrot-beak tears is difficult. Our current question is whether tears in the avascular part of the meniscus can heal or not. We have had good results in one case and fair results in two cases of tears in the white, avascular area, which until now has been thought to be impossible to repair because of the lack of a blood supply (12). Scott

FIG. 5. Right knee of ll-year-old man had a longitudinal tear in the posterior segment of the lateral meniscus, combined with an anterior cruciate ligament lesion. A: One year after injury. B: Six months after the operation. The meniscal tear has good adhesion but is tilled with wide scar tissue and is evaluated as fair.

Arthroscopy,

Vol. 7, No. 2, 1991

ARTHROSCOPIC

MENISCAL

REPAIR

WITH FIBRIN

GLUE

181

6A,B

FIG. 6. Right knee of 22-year-old man had a longitudinal tear that ranged from the middle to the posterior segment in the lateral meniscus. combined with an anterior cruciate ligament lesion. A: Four months after injury. B: Five months after the operation. Adhesion is not obtained and is evaluated as poor.

et al. reported in 1986 (13) that by abrading the perimeniscal synovial membrane, superior rates of healing could be obtained. Furthermore, Arnoczky et al. (14) reported that after filling with an exogenous fibrin clot, lesions in the avascular regions of dog menisci healed well. We believe that further studies in the avascular portion are needed. REFERENCES 1. King DX. The healing of semilunar cartilages. J Bone Joint Surg [Am] 1936;18:333-42.

2. Scapinelli RX. Studies on the vasculature of the human knee joint. Acta Anat (Base0 1963;70:305-31. 3. Amoczky SP. Warren RF. Microvasculature of the human meniscus. Am J Sports Med 1982;10:9&5. 4. DeHaven WG. Arthroscopic meniscal repair. Orthopedics 1983;6: 1125-9.

5. Hamberg P, Gillquist J, Lysholm J. Suture of new and old peripheral meniscus tears. J Bone Joint Surg [Am] 1983; 65: 193-7.

6. Young H, Medawar PB. Fibrin suture of peripheral nerves. La&r 1940;2: 126. 7. Staindl 0. Galvan G. Macher M. The influence of fibrin stabilization and fibrinolysis on the fibrin-adhesive systems. Arch Otorhinolaryngol

1981;223:105-16.

8. Ishimura M, Samma M, Habata T, Fujisawa Y. The use of fibrin glue for fresh knee injury. Cenf Jpn Orthop Truumat 1985;28: 1404-8.

9. Albrecht F, Roessner A, Zimmermann E. Closure of osteochondral lesions using chondral fragments and fibrin adhesive. Arch Orthop Trauma Surg 1983;101:213-7. IO. Brunner FX. Histoloaical findines in sutured and tibringlued microvascular anastomos;. Arch Otorhinolatygol 1984;240:3 11-8. 11. Staindl 0. Die Gewebe Kiebung mit hochkonozentriertem hummanen Fibrinogen am Beispiel der freinen, autologen Hauttransplantation. Arch Otorhinolaryngol 1977:217:219. 12. Ishimura M, Samma M, Fujisawa Y, et al. Arthroscopic repair of the meniscus tears with fibrin glue. Arthroscopy (Jpn) 1987;12:31-6.

13. Scott GA, Jolly BL. Henning CE. Combined posterior incision and arthroscopic intra-articular repair of the meniscus. J Bone Joint Surg [Am] 1986;68:847-61. 14. Arnoczky SP, Warren RF, Spivak JM. Meniscal repair using an exogenous fibrin clot. J Bone Joint Surg [Am] 1988; 70:120!-17.

Arthroscopy.

Vol. 7. No. 2, 1991

Arthroscopic meniscal repair with fibrin glue.

Since 1984 we have arthroscopically repaired 40 meniscal tears in 32 patients using fibrin glue in our operative technique. This technique was reporte...
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