The treatment of articular cartilage defects using the microfracture technique

Chondral defects of the articular surface pose a challenging problem to the orthopedic surgeon. The goal of surgery is to alleviate pain, maximize function, and prevent degenerative changes in the future. A number of techniques have been described to treat these lesions. When considering the treatment options for chondral defects, the surgeon must consider the size, depth, location, and chronicity of the lesion. In addition, the overall alignment of the joint must be evaluated. Prior to treating chondral defects, it is important to understand the indications and contraindications for the microfracture technique. When indicated, the microfracture technique has many advantages over other surgical options. This technique is relatively easy to perform, cost effective, and has low patient morbidity. In addition, the microfracture technique does not burn any long-term bridges, enabling the surgeon to choose a different procedure to revise the chondral defect if the microfracture fails. It is important to understand the mechanism of healing by microfracture, including the effects of the local environment. The postoperative protocol used after the procedure may be as important as the surgery itself. Understanding the science behind the microfracture procedure will lead to better surgical technique and improved outcomes.     

The microfracture technique to treat full thickness articular cartilage defects of the knee

Full thickness defects of the articular cartilage rarely heal spontaneously. While some patients do not develop clinically significant problems from chondral defects, most eventually develop degenerative changes associated with the cartilage damage over time. Techniques to treat chondral defects include abrasion, drilling, tissue autografts, allografts, and cell transplantation. The senior author has developed a procedure referred to as the "microfracture." This technique enhances chondral resurfacing by providing a suitable environment for tissue regeneration and by taking advantage of the body's own healing potential. This technique has now been used in more than 1400 patients. Specially designed awls are used to make multiple perforations, or "microfractures", into the subchondral bone plate. The perforations are made as close together as necessary, but not so close that one breaks into another. Consequently, the microfracture holes are approximately three to four millimeters apart (or 3 to 4 holes per square centimeter). Importantly, the integrity of the subchondral bone plate is maintained. The released marrow elements form a "super clot" which provides an enriched environment for tissue regeneration. Follow up with long term results of more than 8 years have been positive and very encouraging.     

Microfracture technique for the treatment of articular cartilage lesions of the talus

The microfracture technique is an established method for treating articular cartilage lesions of the talus. Symptomatic chondral or osteochondral lesions of grade II or higher with softening or fraying of the chondral surface or an unstable rim are indications for débridement of the lesion and use of the microfracture technique. In advanced degenerative lesions, the indication must be determined critically. In a prospective study, significant (p<0.001) improvement was observed at a mean follow-up of 5.2 years (range 3.8-6.6 years) in 23 ankles. According to the Hannover scoring system, 87% of the patients were rated as excellent or good. Results for patients older than 50 years were not inferior to those for younger patients. Results for overweight patients were significantly (p=0.03) worse compared with patients of normal weight. Magnetic resonance imaging findings revealed that filling of the defect is accomplished in the majority of cases with an inhomogeneous structure of the cartilage repair tissue and a high incidence of subchondral alterations. The microfracture technique appears to be a reliable method for treating chondral and osteochondral lesions of the talus, with good outcomes in a mid-term follow-up.     

Treatment of articular cartilage lesions of the knee

Treatment of articular cartilage lesions in the knee remains a challenge for the practising orthopaedic surgeon. A wide range of options are currently practised, ranging from conservative measures through various types of operations and, recently, use of growth factors and emerging gene therapy techniques. The end result of these methods is usually a fibrous repair tissue (fibrocartilage), which lacks the biomechanical characteristics of hyaline cartilage that are necessary to withstand the compressive forces distributed across the knee. The fibrocartilage generally deteriorates over time, resulting in a return of the original symptoms and occasionally reported progression to osteoarthritis. Our purpose in this study was to review the aetiology, pathogenesis and treatment options for articular cartilage lesions of the knee. At present, autologous cell therapies, growth factor techniques and biomaterials offer more promising avenues of research to find clinical answers.     

The microfracture technique in the treatment of full-thickness chondral lesions of the knee in National Football League players

Between 1986 and 1997, 25 active National Football League (NFL) players underwent microfracture to treat full-thickness chondral lesions. Average follow-up was 4.5 years (range: 2-13 years). Preoperative and postoperative data were rated according to symptoms (4 = severe, 1 = none), function (5 = unable to perform, 1 = no limitations), and activity level (10 = full activity, 1 = unable to perform). Nineteen (76%) players returned to football the season following microfracture. Six players retired for various reasons. At follow-up, pain, swelling, running, cutting, and squatting improved. Activities of daily living, strenuous work, and strenuous sport levels also improved. Those who returned to play averaged 4.6 seasons of participation (range: 1-13 seasons) and 56 games (range: 2-183 games) after microfracture. Nine (36%) players continue active participation in the NFL. Results of microfracture to resurface full-thickness chondral lesions in high-demand NFL players are encouraging. Microfracture is safe, effective, and appears to improve symptoms, function, and activity levels in NFL players.     

Results of microfracture in the treatment of articular cartilage defects of the talus

BACKGROUND: The microfracture technique has been used successfully for the treatment of cartilage defects in the knee. The purpose of this study was to evaluate the microfracture technique in the treatment of osteochondral and degenerative chondral defects of the talus. METHODS: In a prospective study, 30 ankles in 30 consecutive patients (17 men and 13 women; average age, 41 years; range 20 to 74 years were treated with arthroscopic microfracture. Twenty patients had osteochondral defects and 10 had degenerative chondral defects. Patients were evaluated with clinical examination and MRI preoperatively and at 3, 6, 12, and 24 months postoperatively. RESULTS: At a mean followup of 2 years (range 22 to 27 months), 29 patients were available for follow-up. The results for all ankles according to the Hannover Scoring System were 45% excellent, 38% good, and 17% satisfactory. Results in patients older than 50 years were not inferior to those in younger patients. Visual Analog Score revealed an average of 8 +/- 2 for pain (preoperatively 3 +/- 2; p < or = 0.001), 8 +/- 2 for function (preoperatively 3 +/- 2; p < or = 0.001) and 8 +/- 2 for satisfaction (preoperatively 2 +/- 2; p < or = 0.001). MRI and arthroscopic assessment suggested the presence of cartilage in the microfractured area. CONCLUSIONS: At short-term followup, the microfracture technique appeared to repair severe cartilage damage with a good functional outcome. Age was not shown to be a limiting factor.     

Surgical technique for articular cartilage transplantation to full-thickness cartilage defects in the knee joint

Focal arthritic defects in the knee lead to pain, swelling, and dysfunction. Treatment of the defects has includeddrilling, abrasion, and grafting. This report describes our surgical technique of autogenous articular cartilage grafting of arthritic and traumatic articular cartilage lesions. Articular cartilage grafting can be performed as a single arthroscopic outpatient procedure. The mixture of articular cartilage and cancellous bone appears to provide a supportive matrix for cartilage formation. Pain relief is excellent if careful surgical technique and a defined rehabilitation program is followed. Further collagen typing data and additional biopsies will reveal more about the durability of the newly formed cartilage.     

Arthroscopic debridement for focal articular cartilage lesions of the knee: A systematic review

Background and purpose of the studyArthroscopic debridement, the most commonly applied surgical technique for focal cartilage lesions in the knee, is not included in most treatment algorithms because of discouraging results in the management of osteoarthritis of the knee. The present systematic review evaluates the outcome of arthroscopic cartilage debridement as the primary treatment of focal knee chondral lesions in adults, and defines its indications and role as the primary treatment of focal knee chondral lesions.MethodsTwo independent investigators searched PubMed, Cochrane CENTRAL, and Virtual Health Library databases using the terms “knee”, “cartilage”, “chondral”, “lesions”, “injury”, “damage”, “debridement”, “chondroplasty”, “chondrectomy”, alone and in combination. Clinical studies evaluating the effect of mechanical cartilage debridement in adults with symptomatic focal cartilage lesions in the knee joint regardless of the defect size and depth were included. We excluded studies if patients had a concomitant ligament or meniscus injury, and/or had additional debridement with monopolar radiofrequency energy.Main findingsAvailable studies suggest good to excellent short and medium-term functional outcomes (KOOS, LKSS, Tegner scale) for focal cartilage lesions treated with debridement regardless of the defect size and depth. Data are lacking comparing cartilage debridement versus other cartilage repair techniques.ConclusionsArthroscopic debridement of focal articular cartilage lesions of the knee is associated with good to excellent short and medium-term postoperative outcomes, especially in terms of functional improvement. Arthroscopic debridement may be considered in the primary treatment of focal cartilage injuries regardless of the defect size and depth. However, available studies are limited and the level of evidence is low.     

Surgical alternatives for treatment of articular cartilage lesions

Articular cartilage injuries in the knee are common; fortunately, full-thickness articular cartilage defects constitute only a small portion of this group. These lesions may be incidentally encountered during ligament or meniscal surgery, having been silent or asymptomatic for an unknown period of time. However, when they are large and symptomatic, the surgeon may choose from a wide array of techniques available for treatment. The relatively small number of natural history studies regarding full-thickness articular surface lesions complicates the decision-making process. Accurate evaluation and classification of the anatomic defect aids in the development of a clinical algorithm for treatment. Surgical techniques are either reparative or restorative in nature. Reparative techniques fall short of complete reestablishment of the articular cartilage; however, the resultant repairs may remain quite functional for varying periods of time. Restorative techniques attempt to reestablish the native articular surface. To date, no peer-reviewed, prospective, randomized, controlled studies of operative versus nonoperative treatment for full-thickness articular cartilage lesions have been published. Even though the long-term results of surgical treatment for full-thickness articular surface lesions remain unknown, the early results are encouraging.     

Analysis of articular cartilage lesions in 5114 knee arthroscopies]

The cartilage lesions become the increasing social problem, which occurs often in young people. It influences the normal knee function and may predispose patients for osteoarthritis. The aim of this study was the epidemiologic and etiological analysis of the knee articular cartilage lesions diagnosed in arthroscopy. From 1997 to 2002, arthroscopy of the knee joint was performed in 5114 patients. Chondral lesions were found in 2931 cases--57.3. Non-isolated cartilage lesions accounted for 67.9%. Grade II according to ICRS classification evaluated in arthroscopy was the most frequent grade of the cartilage lesion (47.8%) and grade 4B the least frequent one (0.11%). The patellar articular surface (43.3%) and the medial femoral condyle (39.6%) were the most common locations of the lesions.     

Minimum ten-year results of a prospective randomised study of autologous chondrocyte implantation versus mosaicplasty for symptomatic articular cartilage lesions of the knee

Autologous chondrocyte implantation (ACI) and mosaicplasty are methods of treating symptomatic articular cartilage defects in the knee. This study represents the first long-term randomised comparison of the two techniques in 100 patients at a minimum follow-up of ten years. The mean age of the patients at the time of surgery was 31.3 years (16 to 49); the mean duration of symptoms pre-operatively was 7.2 years (9 months to 20 years). The lesions were large with the mean size for the ACI group being 440.9 mm(2) (100 to 1050) and the mosaicplasty group being 399.6 mm(2) (100 to 2000). Patients had a mean of 1.5 previous operations (0 to 4) to the articular cartilage defect. Patients were assessed using the modified Cincinnati knee score and the Stanmore-Bentley Functional Rating system. The number of patients whose repair had failed at ten years was ten of 58 (17%) in the ACI group and 23 of 42 (55%) in the mosaicplasty group (p < 0.001). The functional outcome of those patients with a surviving graft was significantly better in patients who underwent ACI compared with mosaicplasty (p = 0.02).     

微骨折术修复关节软骨缺损

[目的]探讨关节镜下微骨折术修复膝关节全层软骨缺损的疗效。[方法]对2001年3月~2008年5月收治的膝关节软骨全层缺损的35例患者进行回顾性分析;平均随访(25.3±6.5)个月(16~53个月)。其中,剥脱骨软骨炎12例,外伤性骨软骨骨折20例,自发性骨坏死1例,继发性骨坏死2例。采用公认的功能评分系统,软骨MR I扫描和主观评分作为疗效判定标准。[结果]微骨折技术修复膝关节软骨全层缺损的总有效率为85.7%,其中疗效优19个膝关节,占54.3%,良11个膝关节,占31.4%,差5个膝关节,占14.3%。33例接受MR I检查,其中19例显示缺损软骨修复充填好,占57.6%,充填中等11例,占33.3%,充填差3例,占9.1%,平均Tegner评分从1.5±1.1提高到5.1±1.2(P0.01);Lysholm平均评分由42.3±11.3提高到85.5±12.1(P0.01)。[结论]微骨折技术是一项可供选择的实用有效修复膝关节软骨缺损的完全在关节镜下操作的微创技术;软骨修复充填程度与关节功能恢复密切相关。     

The classification and treatment of acute articular cartilage lesions

Sixty-five articular cartilage knee lesions were diagnosed by arthroscopy over a 5-year period, and classified according to the age, the size, the depth, and the location of the lesion. The purpose of this study was to evaluate surgical outcome of a standardized treatment regimen consisting of complete vertical excision of diseased or injured articular cartilage followed by drilling of the subchondral bone plate. A standardized postoperative rehabilitation protocol was used, which included non-weight bearing for eight weeks. Overall clinical results at two years revealed 69% good, 3% fair, and 28% poor knees. Seventy-one percent of patients underwent follow-up arthroscopy at 1 year and 57% consented to biopsy. Retrospective analysis revealed that the group with the best prognosis consisted of small-to-medium acute partial thickness lesions on the weight bearing portion of the femoral condyles. Ninety-five percent of this group had good results.