Microfracture technique forfull-thickness chondral defects: Technique and clinical results
Abstract
Articular cartilage defects rarely heal spontaneously. The changes are progressive and they become irreversible if no intervention is applied. Many techniques have been used in the past to include abrasion, drilling, tissue autografts, allografts, and cell transplantation. Physicians have taken a greater interest in treating chondral defects recently in part because of our better understanding of cartilage biology and pathology, and because of advances in imaging and arthroscopy. The senior author has developed a procedure referred to as the “microfracture” technique to enhance chondral resurfacing by providing a suitable environment for tissue regeneration. This technique has now been used in more than 1,200 patients. An arthroscopic awl is used to make multiple holes, or “microfractures,” in the subchondral bone plate of full-thickness chondral defects. The holes are made as close together as necessary, but not so close that one breaks into another, thus damaging the subchondral plate between them. This technique usually results in microfracture holes that are approximately 3 to 4 millimeters apart (or 3 to 4 holes per square centimeter). The arthroscopic awls produce much less thermal necrosis of the bone than would a hand-driven or motorized drill. The released marrow elements form a “super clot” which provides an enriched environment for tissue regeneration. Long-term results, with follow-up covering more than 8 years, have been and continue to be very positive.
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Cited by (433)
Osteochondral lesions of the talar dome
2023, Orthopaedics and Traumatology: Surgery and ResearchAnkle pain and/or instability is a frequent, non-specific reason for consultation, and may reveal an osteochondral lesion of the talar dome (OLTD).
There are 2 types of OLTD: (1) posteromedial, usually idiopathic, wide and deep, featuring isolated pain with severe functional impact; (2) anterolateral, often implicating trauma and associated in 30% of cases with lateral ligament involvement, in a clinical presentation associating pain and instability.
The aim of the present study was to review the issue of OLTD, with 5 questions:
There are no specific clinical signs. A diagnosis of OLTD should be considered in all cases of painful and/or unstable ankle and especially in case of history of sprain. The clinical work-up screens systematically for laxity or associated hindfoot malalignment. CT-arthrography is the gold-standard, enabling morphologic analysis of OLTD.
CT-arthrography determines length, depth and any cartilage dissection, classifying OLTD in 3 grades. Grade 1 is a lesion < 10 mm in length and <5 mm in depth. Grade 2 is > 10 mm in length and/or > 5 mm in depth with intact cartilage around the lesion. Grade 3 is the same as grade 2 but with overlying cartilage dissection.
After failure of 6 months’ well-conducted medical treatment (sports rest, analgesics, physiotherapy), surgical options in France today comprise microfracture in grade 1 OLTD, raising the fragment, freshening the floor of the lesion and fixing the fragment (known as “lift, drill, fill, fix” (LDFF)) in grade 2, and mosaicplasty in grade 3.
Treatments are progressing and improving. Ideal treatment should restore hyaline cartilage to prevent secondary osteoarthritis. Matrix and cell culture techniques need to be validated.
Management according to grade secures AOFAS scores ≥ 80/100 in 80% of cases, whatever the grade. Return to sport is feasible in 80% of case, at a mean 6 months. Progression is satisfactory after treatment adapted to the lesion.
V, expert opinion.
Augmented Marrow Stimulation: Drilling Techniques and Scaffold Options: “Next Generation Cartilage Repair and the Pre-Arthroplasty Patient” Operative Techniques in Sports Medicine
2022, Operative Techniques in Sports MedicineMarrow stimulation is a commonly used surgical adjunct in the treatment of knee cartilage injuries. While initial studies on traditional microfracture demonstrated favorable short-term results, survivorship and clinical outcomes at medium- and long-term follow-up were subsequently shown to be inferior as compared to cell- and graft-based treatment options. As a result, numerous technical modifications and biologic augmentation approaches have been developed with the goal of improving the efficacy and the durability of marrow stimulation procedures. This chapter presents an overview of the basic and clinical science of marrow stimulation, its evolution over the past 25 years, and preliminary outcomes of treatment augmentation with biologic, scaffold, and cartilage-based approaches.
Osteochondral lesions of the talar dome
2022, Revue de Chirurgie Orthopedique et TraumatologiqueDes douleurs et/ou une instabilité de la cheville sont un motif de consultation fréquent, non spécifique, qui peut révéler une lésion ostéo-chondrale du dôme talien (LODT). Deux types de LODT ont été identifiés : lésions postéro-médiales : le plus souvent idiopathiques, larges et profondes, dont la symptomatologie prédominante est une douleur isolée, avec un fort retentissement fonctionnel ; lésions antéro-latérales : souvent rencontrées dans un contexte traumatique et associées dans 30 % des cas à une atteinte ligamentaire latérale ; le tableau clinique associe douleur et instabilité. L‘objectif de cette étude est de faire le point sur les LODT en 5 questions.
Il n’existe aucun signe clinique spécifique. Le diagnostic de LODT doit être évoqué devant toute cheville douloureuse et/ou instable, surtout en cas d’antécédent d’entorse de cheville. Le bilan clinique recherchera toujours une laxité ou un défaut d’axe de l’arrière- pied associé. L’arthro-TDM est l’examen de référence, permettant une analyse morphologique de la LODT.
L’analyse arthro-scannographique précise la longueur, la profondeur et l’éventuelle dissection cartilagineuse. Il permettra de classer les LODT en 3 stades. Stade 1 : défini par une lésion de moins de 10 mm dans son plus grand axe et de moins de 5 mm de profondeur. Stade 2 : défini par une lésion de plus de 10 mm dans son plus grand axe et/ou de plus de 5 mm de profondeur avec un cartilage respecté en regard de la lésion. Stade 3 : défini de la même manière mais le cartilage sus jacent à la lésion est disséqué.
Après échec du traitement médical (repos sportif, antalgiques, kinésithérapie) bien conduit pendant 6 mois, les traitements chirurgicaux disponibles en France à ce jour sont : pour les lésions de stade 1, les microfractures, celles de stade 2 un relèvement du fragment, un avivement du fond de la lésion et une refixation du fragment (technique « lift drill fill fix, (LDFF)) et celles de stade 3 une mosaïcoplastie.
Les traitements évoluent et se perfectionnent. Le traitement idéal devra permettre de reconstituer un cartilage hyalin pour limiter l’apparition d’une arthrose secondaire. La validation de l’utilisation de matrices et de techniques de culture cellulaire est nécessaire.
La prise en charge des LODT en fonction de leur stade permet d’obtenir un score AOFAS supérieur ou égal à 80/100 dans 80 % des cas quel que soit le stade de la lésion. Le retour au sport est possible dans 80 % des cas, en moyenne au 6e mois postopératoire. L’évolution est satisfaisante avec un traitement adapté à la lésion.
V, avis d’expert.
Expedited gene delivery for osteochondral defect repair in a rabbit knee model: A one-year investigation
2022, Osteoarthritis and Cartilage OpenTo evaluate a single-step, gene-based procedure for repairing osteochondral lesions.
Osteochondral lesions were created in the patellar groove of skeletally mature rabbits. Autologous bone marrow aspirates were mixed with adenovirus vectors carrying cDNA encoding green fluorescent protein (Ad.GFP) or transforming growth factor-β1 (Ad.TGF-β1) and allowed to clot. The clotted marrow was press-fit into the defects. Animals receiving Ad.GFP were euthanized at 2 weeks and intra-articular expression of GFP examined by fluorescence microscopy. Animals receiving Ad.TGF-β1 were euthanized at 3 months and 12 months; repair was compared to empty defects using histology and immunohistochemistry. Complementary in vitro experiments assessed transgene expression and chondrogenesis in marrow clots and fibrin gels. In a subsequent pilot study, repair at 3 months using a fibrin gel to encapsulate Ad.TGF-β1 was evaluated.
At 2 weeks, GFP expression was seen at variable levels within the cartilaginous lesion. At 3 months, there was no statistically significant improvement (p > 0.05) in healing of lesions receiving Ad.TGF-β1 and variability was high. At 12 months, there were still no significant difference (p > 0.05) between the empty defects and those receiving Ad.TGF-β1 in the overall, cartilage, and bone scores. Variability was still high. In vitro experiments suggested that variability reflected variable transduction efficiency and chondrogenic activity of the marrow clots; using fibrin gels instead of marrow may address this issue but more research is needed.
This approach to improving the repair of osteochondral lesions needs further refinement to reduce variability and provide a more robust outcome.
Marrow stimulation in football (soccer) players: a narrative review
2022, Journal of Cartilage and Joint PreservationThe prevalence of focal cartilage defects in elite athletes is estimated to be as high as 36%, and treatment in professional football players poses a complex clinical challenge. Marrow stimulation is a common treatment option for athletes with symptomatic, contained, full-thickness chondral injuries.
To report the current indications for and efficacy of marrow stimulation in football players.
PubMed, Scopus, and Embase were searched. All levels of evidence (I-IV) pertaining to marrow stimulation in football players were analyzed and presented in a narrative review.
Reported return to sport rates following microfracture range from 52% to 95%, with up to 67% of athletes returning to preinjury level of performance. Clinical outcomes improve shortly after microfracture but may decline by 2 years postoperatively. Augmented marrow stimulation techniques have since been developed in an effort to improve repair quality and clinical outcomes, though supporting data is limited.
In professional football players, marrow stimulation is a viable treatment for the repair of small (<2 cm2), isolated cartilage injuries, though deterioration of mid- to long-term outcomes may hamper its widespread use. Multiple augmentation techniques have demonstrated the potential to generate a mechanically and biologically superior repair; however, more robust, high-level studies are needed to adequately assess efficacy.
Review of K.H. Pridie (1959) on “A method of resurfacing osteoarthritic knee joints”
2022, Journal of ISAKOSThis classic discusses the original publication “A method of resurfacing osteoarthritic knee joints” by Dr K.H. Pridie (1959), where this pioneer surgeon described a newly developed method for the treatment of osteoarthritic joint surfaces of the knee, which he named subchondral drilling. This short and concise 11-line publication appeared in the Proceedings of the Congress of the British Orthopaedic Association. It has generated 464 citations since 1959, becoming part of the hundred most-cited publications in knee research. Pridie introduced in clinical experimentation the entity of Marrow Stimulation Techniques to liberate mesenchymal stem cells from cancellous bone. He was aware that the results induced, in terms of quality of the regrown tissue, was limited and “only” fibrocartilage. His idea might have been raised from the work of numerous animal researchers who confirmed repeatedly since 1905 that cartilage needed an osseous perforation to heal. Although the past 60 years brought modifications from the technique described in the original article, the concept of marrow stimulation introduced by Pridie remains the most frequently used in cartilage repair surgery today.