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Editorial Commentary: Platelet-Rich Plasma and Knee Meniscal Repair—The Use of Biologics Has Not Progressed Substantially Since 1983

      Abstract

      When it comes to meniscal repair, optimizing the local biological environment at the repair site by performing trephination to create bleeding from the extracapsular capillary network, by rasping to abrade the local synovial tissue, or by creating bleeding from the intercondylar notch is recommended. The addition of platelet-rich plasma probably also helps, especially absent the bleeding when meniscal repair is performed concomitantly with anterior cruciate ligament reconstruction. However, pending future research, there is not enough data to recommend platelet-rich plasma augmentation for meniscal repair in all cases.
      Have we made significant progress in biological meniscal augmentation since 1983? I think the answer is no. If we take a journey back in time to the elegant work of Arnoczky and Warren
      • Arnoczky S.P.
      • Warren R.F.
      The microvasculature of the meniscus and its response to injury. An experimental study in the dog.
      defining the blood supply of the meniscus, as well as the benefit of creating vascular access channels, we can see the potential for meniscal healing if the local biological environment is optimized. Still to this day, the article with the most compelling evidence for biological augmentation is the article of Cannon and Vittori
      • Cannon Jr., W.D.
      • Vittori J.M.
      The incidence of healing in arthroscopic meniscal repairs in anterior cruciate ligament-reconstructed knees versus stable knees.
      from 1992 showing a marked improvement in meniscal healing rates if a concomitant anterior cruciate ligament reconstruction was performed. Their results were substantiated by the recent article of Everhart et al.
      • Everhart J.S.
      • Cavendish P.A.
      • Eikenberry A.
      • Magnussen R.A.
      • Kaeding C.C.
      • Flanigan D.C.
      Platelet-rich plasma reduces failure risk for isolated meniscal repairs but provides no benefit for meniscal repairs with anterior cruciate ligament reconstruction.
      showing that it was beneficial to add leukocyte-rich platelet-rich plasma (PRP) augmentation to meniscal repair, but the results were no better than those obtained by just performing an anterior cruciate ligament reconstruction at the same time.
      So, what do these PRP data mean? Is there enough evidence to recommend PRP augmentation for all of our meniscal repairs? No. I think the article by Haunschild, Huddleston, Chahla, Gilat, Cole, and Yanke
      • Haunschild E.D.
      • Huddleston H.P.
      • Chahla J.
      • Gilat R.
      • Cole B.J.
      • Yanke A.B.
      Platelet-rich plasma augmentation in meniscus repair surgery: A systematic review of comparative studies.
      entitled “Platelet-Rich Plasma Augmentation in Meniscus Repair Surgery: A Systematic Review of Comparative Studies” is spot-on. Not enough high-quality data exist to even perform a meta-analysis; moreover, the existing data are riddled with confounders, such as differences in PRP preparation (e.g., leukocyte rich vs poor) and volume of PRP administration, as well as the collection of variable outcome measures.
      The question that we should be asking is, Should we be optimizing the local biological environment at the repair site in every case? I think the answer is yes. Whether this is accomplished by augmenting blood flow to the repair site by trephination to create bleeding from the extracapsular capillary network,
      • Fox J.M.
      • Rintz K.G.
      • Ferkel R.D.
      Trephination of incomplete meniscal tears.
      by rasping to abrade the local synovial tissue,
      • Uchio Y.
      • Ochi M.
      • Adachi N.
      • Kawasaki K.
      • Iwasa J.
      Results of rasping of meniscal tears with and without anterior cruciate ligament injury as evaluated by second-look arthroscopy.
      or by creating bleeding from the intercondylar notch,
      • Dean C.S.
      • Chahla J.
      • Matheny L.M.
      • Mitchell J.J.
      • LaPrade R.F.
      Outcomes after biologically augmented isolated meniscal repair with marrow venting are comparable with those after meniscal repair with concomitant anterior cruciate ligament reconstruction.
      reasonable data exist.
      Is using PRP better than not performing biological augmentation at all? The answer is probably yes. A randomized controlled trial by Kaminski et al.
      • Kaminski R.
      • Kulinski K.
      • Kozar-Kaminska K.
      • et al.
      A prospective, randomized, double-blind, parallel-group, placebo-controlled study evaluating meniscal healing, clinical outcomes, and safety in patients undergoing meniscal repair of unstable, complete vertical meniscal tears (bucket handle) augmented with platelet-rich plasma.
      provides the best proof because it included a cohort of patients who underwent second-look arthroscopy; the PRP group showed a higher healing rate than the control group. The question remains whether it is worth the expense and time to prepare PRP versus just locally augmenting the blood supply (trephination, rasping, and so on). In addition, what PRP preparation is best (leukocyte rich vs poor)? The existing data do not answer this question. For now, I would argue that optimizing the local biological environment at the repair site using any technique that has peer-reviewed evidence constitutes current best practice.

      Supplementary Data

      References

        • Arnoczky S.P.
        • Warren R.F.
        The microvasculature of the meniscus and its response to injury. An experimental study in the dog.
        Am J Sports Med. 1983; 11: 131-141
        • Cannon Jr., W.D.
        • Vittori J.M.
        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
        • Everhart J.S.
        • Cavendish P.A.
        • Eikenberry A.
        • Magnussen R.A.
        • Kaeding C.C.
        • Flanigan D.C.
        Platelet-rich plasma reduces failure risk for isolated meniscal repairs but provides no benefit for meniscal repairs with anterior cruciate ligament reconstruction.
        Am J Sports Med. 2019; 47: 1789-1796
        • Haunschild E.D.
        • Huddleston H.P.
        • Chahla J.
        • Gilat R.
        • Cole B.J.
        • Yanke A.B.
        Platelet-rich plasma augmentation in meniscus repair surgery: A systematic review of comparative studies.
        Arthroscopy. 2020; 36: 1765-1774
        • Fox J.M.
        • Rintz K.G.
        • Ferkel R.D.
        Trephination of incomplete meniscal tears.
        Arthroscopy. 1993; 9: 451-455
        • Uchio Y.
        • Ochi M.
        • Adachi N.
        • Kawasaki K.
        • Iwasa J.
        Results of rasping of meniscal tears with and without anterior cruciate ligament injury as evaluated by second-look arthroscopy.
        Arthroscopy. 2003; 19: 463-469
        • Dean C.S.
        • Chahla J.
        • Matheny L.M.
        • Mitchell J.J.
        • LaPrade R.F.
        Outcomes after biologically augmented isolated meniscal repair with marrow venting are comparable with those after meniscal repair with concomitant anterior cruciate ligament reconstruction.
        Am J Sports Med. 2017; 45: 1341-1348
        • Kaminski R.
        • Kulinski K.
        • Kozar-Kaminska K.
        • et al.
        A prospective, randomized, double-blind, parallel-group, placebo-controlled study evaluating meniscal healing, clinical outcomes, and safety in patients undergoing meniscal repair of unstable, complete vertical meniscal tears (bucket handle) augmented with platelet-rich plasma.
        Biomed Res Int. 2018; 2018: 9315815

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