Microfracture Treatment Research Articles

Autologous Matrix-Induced Chondrogenesis vs Microfracture with PRP for Chondral Lesions of the Knee in a Rabbit Model

Currently, microfracturing is the most commonly used cartilage repair procedure in cartilage defects. Our aim was to study the mechanism of in vivo cartilage repair in case of full-thickness articular cartilage damage of the knee using a three-dimensional matrix implanted without any preseeded cells in the defect. We also investigated whether platelet-rich plasma application after microfracture procedure of the knee is associated with improved outcome compared with traditional microfracture treatment alone in a rabbit model. Histological examination of the chondral defects, revealed the largest amount of new tissue with hyaline-like cartilage features in Hyalofast group. At 12 weeks from implantation of the Hyalofast scaffold demonstrated complete filling of the defect with hyaline cartilage in admixture with the scaffold and bone metaplasia in the deepest areas. In the PRP group, complete filling of the defect with an admixture of fibrous and hyaline-like cartilage tissue appeared with a discreet tendency of endochondral ossification. We confirmed the superiority of the autologous matrix-induced chondrogenesis compared to microfracture and PRP or microfracture alone in case of full-thickness articular cartilage damage of the knee.

Matrix-Applied Characterized Autologous Cultured Chondrocytes Versus Microfracture: Five-Year Follow-up of a Prospective Randomized Trial

Background: Matrix-based cell therapy improves surgical handling, increases patient comfort, and allows for expanded indications with better reliability within the knee joint. Five-year efficacy and safety of autologous cultured chondrocytes on porcine collagen membrane (MACI) versus microfracture for treating cartilage defects have not yet been reported from any randomized controlled clinical trial. Purpose: To examine the clinical efficacy and safety results at 5 years after treatment with MACI and compare these with the efficacy and safety of microfracture treatment for symptomatic cartilage defects of the knee. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: This article describes the 5-year follow-up of the SUMMIT (Superiority of MACI Implant Versus Microfracture Treatment) clinical trial conducted at 14 study sites in Europe. All 144 patients who participated in SUMMIT were eligible to enroll; analyses of the 5-year data were performed with data from patients who signed informed consent and continued in the Extension study. Results: Of the 144 patients randomized in the SUMMIT trial, 128 signed informed consent and continued observation in the Extension study: 65 MACI (90.3%) and 63 microfracture (87.5%). The improvements in Knee injury and Osteoarthritis Outcome Score (KOOS) Pain and Function domains previously described were maintained over the 5-year follow-up. Five years after treatment, the improvement in MACI over microfracture in the co-primary endpoint of KOOS pain and function was maintained and was clinically and statistically significant (P = .022). Improvements in activities of daily living remained statistically significantly better (P = .007) in MACI patients, with quality of life and other symptoms remaining numerically higher in MACI patients but losing statistical significance relative to the results of the SUMMIT 2-year analysis. Magnetic resonance imaging (MRI) evaluation of structural repair was performed in 120 patients at year 5. As in the 2-year SUMMIT (MACI00206) results, the MRI evaluation showed improvement in defect filling for both treatments; however, no statistically significant differences were noted between treatment groups. Conclusion: Symptomatic cartilage knee defects 3 cm2 or larger treated with MACI were clinically and statistically significantly improved at 5 years compared with microfracture treatment. No remarkable adverse events or safety issues were noted in this heterogeneous patient population.

Engineering Stem and Stromal Cell Therapies for Musculoskeletal Tissue Repair.

Stem cells and tissue-derived stromal cells stimulate the repair of degenerated and injured tissues, motivating a growing number of cell-based interventions in the musculoskeletal field. Recent investigations have indicated that these cells are critical for their trophic and immunomodulatory role in controlling endogenous cells. This Review presents recent clinical advances where stem cells and stromal cells have been used to stimulate musculoskeletal tissue repair, including delivery strategies to improve cell viability and retention. Emerging bioengineering strategies are highlighted, particularly toward the development of biomaterials for capturing aspects of the native tissue environment, altering the healing niche, and recruiting endogenous cells.

Assisted Arthrscopic Microfracture Treatment of Osteochondral Lesions of the Knee

Background: chondral injuries in the knee are a common source of pain and morbidity. Treatment of symptomatic chondral defects is challenging due to the limited healing capacity of articular cartilage. Microfracture is the most common surgical technique used to treat chondral defects in the knee and utilizes marrow stimulation to generate a fibrocartilage repair. Microfracture has demonstrated good short-term postoperative outcomes. Long-term outcomes following microfracture are variable, with loss of improvement attributed to the poor mechanical qualities of the fibrous repair tissue. Aim of the work: this prospective study with a 12 months follow-up was conducted to determine the efficacy of microfracture in the postoperative follow-up. We prospectively followed up these patients preoperatively and postopertively, clinically and radiologically. The final diagnosis was confirmed during arthroscopy. Patients and Methods: thirty symptomatic patients with articular cartilage defects of the knee were treated with the microfracture technique. Prospective evaluation of patient outcome was performed for a minimum follow-up of twelve months with a combination of validated outcome scores, subjective clinical rating and cartilage-sensitive magnetic resonance imaging. Results: at the time of the latest follow-up, knee function was rated good to excellent for twenty patients (60%), fair for four patients (13%) and poor for eight (26%). A lower body-mass index correlated with higher scores for the activities of daily living, with the worst results for patients with a body-mass index of >30 kg/m2. Significant improvement in the activities of daily living score was more frequent with a preoperative duration of symptoms of less than twelve months (p < 0.05). Magnetic resonance imaging in 15 knees demonstrated good healing in tissue fill of eight patients (54%), moderate fill in four (29%) and poor fill in three patients (17%). The fill grade was correlated with the knee function scores. All knees with good fill demonstrated improved knee function, whereas poor fill grade was associated with limited improvement and decreasing functional scores after twelve months. Conclusions: microfracture healing of articular cartilage lesions in the knee results in significant functional improvement at a minimum follow-up of one year. The best short-term results were observed with good fill grade, low body-mass index and a short duration of preoperative symptoms. A high body-mass index adversely affects short-term outcome, and a poor fill grade was associated with limited short-term durability.

Arthroscopic debridement combined with microfracture for chronic enthesiopathy of achilles tendon

Objective To evaluate the efficacy of arthroscopic debridement combined with microfracture on management of chronic enthesiopathy of Achilles tendon. Methods Fifteen cases of chronic enthesiopathy of Achilles tendon were enrolled in this study from January 2013 to January 2016. There were 11 males and 4 females, with an average age of 55.5±8.9 years. Five were in left side, and 10 in right side. All the patients failed to recover after conservative treatments for 18 months to 10 years. Pathological tissue was eliminated by blade. Then microfracture was made. Arthroscopic awls (1.5 or 2 mm in diameter) were used for making multiple holes at the footprint of achilles tendon. These holes were made far enough (3-4 mm) apart so they do not break into each other. Fat droplets and bleeding from the marrow cavity were seen when the appropriate depth (approximately 5 to 10 mm) has been reached. The patients were evaluated preoperatively and postoperatively using American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores and visual analogue scale (VAS) scores. Results Average operation time and length of stay were 30.6±15.4 min and 6.2±2.8 d, respectively. Postoperative incisions were I stage healing for all patients. There were no perioperative and postoperative complications related to the procedure, such as rupture of achilles tendon, blood vessel and nerve injury. No infection and recurrence was found in all cases. All patients were followed up for an average time of 13.5 months. No rupture of achilles tendon or relapsing symptom was found. Average VAS scores before surgery, 6 month after surgery and at the lattest follow-up were 7.3±1.6, 2.4±1.3, and 2.3±1.3, respectively. Average AOFAS Ankle-Hindfoot scores were 38.5±7.8, 92.9±6.9, and 91.6±7.1, respectively. Average postoperative VAS scores and AOFAS Ankle-Hindfoot scores were significantly improved compared with those before surgery. There was no statistically significant difference among all check point after operation in VAS scores and AOFAS Ankle-Hindfoot scores. At the latest follow-up, all patients were satisfied with the degree of painful relief. According to AOFAS Ankle-Hindfoot scores, overall excellent and good rate was 93.3% (excellent in 10 cases, good in 4 cases, and fair in 1 case). Conclusion Clinical results of arthroscopic debridement combined with microfracture for treatment of chronic enthesiopathy of Achilles tendon are good. This technique is easy and safe to perform. Key words: Arthroscopy; Arthroplasty, subchondral; Achilles tendon; Heel pain

Patient compliance with touchdown weight bearing after microfracture treatment of talar osteochondral lesions

BackgroundThe aim of this study was to prospectively evaluate the compliance of our patients with a touchdown weight bearing (without supporting any weight on the affected side by only touching the plantar aspect of the foot to the ground to maintain balance to protect the affected side from mechanical loading) postoperative rehabilitation protocol after treatment of talar osteochondral lesion (TOL).MethodsFourteen patients, who had been treated with arthroscopic debridement and microfracture, were followed prospectively. The patients were evaluated for weight bearing compliance with using a stationary gait analysis and feedback system at the postoperative first day, first week, third week, and sixth week.ResultsThe mean visual analog scale (VAS) scores of the patients at the preoperative, postoperative first day, first week, third week, and sixth weeks were 5.5, 5.9, 3.6, 0.9, and 0.4, respectively. The decrease in VAS scores were statistically significant (p < 0.0001). First postoperative day revealed a mean value of transmitted weight of 4.08% ±0.8 (one non-compliant patient). The mean value was 4.34% ±0.8 at the first postoperative week (two non-compliant patients), 6.95% ±2.3 at the third postoperative week (eight non-compliant patients), and 10.8% ±4.8 at the sixth postoperative week (11 non-compliant patients). In the analysis of data, we found a negative correlation between VAS scores and transmitted weight (Kendall’s tau b = −0.445 and p = 0.0228).ConclusionsAlthough patients were able to learn and adjust to the touchdown weight bearing gait protocol during the early postoperative period, most patients became non-compliant when their pain was relieved. To prevent this situation of non-compliance, patients should be warned to obey the weight bearing restrictions, and patients should be called for a follow-up at the third postoperative week.

Comparison of distraction arthroplasty alone versus combined with arthroscopic microfracture in treatment of post-traumatic ankle arthritis

BackgroundThis study aims to compare clinical outcomes of distraction arthroplasty alone versus combined with arthroscopic microfracture in treating post-traumatic ankle arthritis.MethodsThe study cohort consisted of 96 patients (96 ankles) who underwent distraction arthroplasty alone or combined with arthroscopic microfracture between May 2005 and April 2012. Patients were divided into the distraction group (n = 46) and the combined group (n = 50). The American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analog scale (VAS), and ankle activity score (AAS) were used to compare the clinical outcomes between groups. Arthritis severity was assessed on the radiograph.ResultsAt the mean follow-up period of 30.8 ± 3.1 and 31.4 ± 3.6 months, respectively, no severe complications occurred and no further surgical interventions for symptomatic arthritis were required in both groups. The AOFAS scores improved significantly in the combined group than in the distraction group (59.0 ± 4.7 and 58.0 ± 4.9 preoperatively versus 85.0 ± 4.9 and 88.9 ± 5.4 at final visit, P < 0.001). The AAS scores were also significantly higher in the combined group (3.6 ± 1.1 and 3.3 ± 1.0 preoperatively versus 6.5 ± 1.1 and 7.1 ± 1.3 at final visit, P = 0.009). Pain was significantly alleviated in the combined group by the VAS scores (6.4 ± 0.9 and 6.7 ± 0.9 preoperatively versus 2.3 ± 0.8 and 2.0 ± 0.7 at final visit, P = 0.040). The combined group achieved better radiographic arthritis severity decrease than the distraction group (P = 0.012).ConclusionsCompared to distraction arthroplasty alone, distraction arthroplasty combined with arthroscopic microfracture can offer better functional recovery, pain relief, and ankle arthritis resolution for treating post-traumatic ankle arthritis.

Arthroscopic Hip Surgery in the Elite Athlete: Comparison of Female and Male Elite Athletes

Objectives:1) To compare ability to return to prior competitive sports activity after arthroscopic hip surgery by gender, with an emphasis on the rate of return to the same level of competition. 2) To compare gender differences in type of sports activities, diagnosis and treatment in athletes requiring hip arthroscopy.Methods:Prospectively obtained data on all high-level elite athletes (professional, NCAA collegiate and/or Olympic) treated between 2007 and 2014 were retrospectively reviewed. The clinical and surgical records of 547 hips in 484 consecutive patients who underwent primary hip arthroscopy by the senior author for non-arthritic hip pain during the study period were included. Elite athletes who had a Hip Sports Activity Score (HSAS) of over 6 were identified. Patients completed a pre-operative questionnaire that included medical and sports activity history and level of competition, hip-specific outcome scores (Modified Harris Hip Score [MHHS] and International Hip Outcome Tool-33 [iHOT-33]) at baseline and most recent follow-up. Surgical findings and time to return to competitive sports activity were documented.Results:A total of 98 elite athletes with a mean follow up period of 18.8 months (±12.7) were identified. There were 49 females and 49 males. 27 athletes had bilateral hip arthroscopy, 5 of which had 1 operation elsewhere. All patients were available for follow up. Of the 80 patients desiring to return to their original competitive activity, 38 were female (42 hips) (Female Athlete group [FA]) and 42 were male (54 hips) (Male Athlete group [MA]) their mean ages were 21.5(±3.9) and 20.5(±1.9), duration of pain prior to surgery was 12.1 (±10.3) months and 15.1 (±1.9) months, respectively. 84.2% of FA and 83.3% of MA were able to return to the same level of competition at a mean of 8.3 (±3) and 8.8 (±2.9) months, respectively. Statistically significant improvements between pre- and post-operative mean MHHS and iHOT-33 scores were seen in both groups (p <.0001; p <.0001). FA had significantly higher proportions of hips that were diagnosed with Pincer type FAI (p =.0004), and Instability (p <.0001). Conversely, the MA had significantly higher proportions of hips that were diagnosed with Combined type FAI (p <.0001), had more extensive acetabular cartilage rim damage (p =.0002), and in particularly had more hips that required microfracture treatment (p =.001). When comparing cam lesions (includes Cam and Combined type FAI) the alpha angle was statistically greater in MA (mean 74°±6.7) compared to FA (mean 65.4°±6.8) (p <.0001). The category of sports the FA participated in were more flexibility (11%) and endurance (24%) type sports. MA participated more in cutting (33%), contact (14%) and asymmetric (31%) type sports. Patients who were able to return to same level of competitive activity had a significantly shorter duration of pre-operation symptoms compared to those who could not (p < 0.05). Microfracture treatment did not affect the ability to return to sports.Conclusion:A similar high percentage of both female and male elite athletes were able to return to competitive sports activity after arthroscopic treatment of FAI and/or hip instability. Distinct differences in diagnosis, treatment and participating type of sports activities were seen when comparing female and male athletes. Duration of symptoms negatively correlated with outcomes. Extensive cartilage damage and Microfracture did not affect outcome / return to sports.

Autologous Collagen-Induced Chondrogenesis Technique for Knee Chondral Lesions

Objectives:The purpose of the study was to evaluate a series of patients with osteochondral lesions who underwent a microfractures treatment and autologous collagen-induced chondrogenesis technique (ACIC).Methods:Microfracture treatment and ACIC was performed in eight patients with grade IV cartilage lesion of more than 3 cm2 long. Two patients were discarded due to short follow-up. Four women and two men were evaluated with 50 year-old mean age. The average follow-up was 12.5 months. An associated valgus osteotomy was performed in two patients. Patients were evaluated using the Lysholm score and IKDC. Radiographs were evaluated and a Magnetic Resonance (MRI) was performed in 3 patients.Results:Six patients were evaluated with a 1 B, 2 C and 3 D arthrosis grade according to IKDC classification. Atelocollagen was placed in the medial femoral condyle in four patients (2 associated to tibial valgus osteotomy), in the trochlea in one patient and in both in one patient. Pre and post operative average score IKDC was 38/58 and Lysholm 34/89. One case of postoperative artrofibrosis was registered which was mobilized under anesthesia with satisfactory results. The MRI showed signal with coverage of the chondral defect in more than 70%. There were no cases of infection or reactive synovitis.Conclusion:Atelocollagen combined with microfractures improved the clinical conditions in patients with articular cartilage lesions of the knee. It is necessary more patients and longer follow-up to verify this data.

Ankle arthroscopy for ankle impingement syndrome through anterior and posterior passage

To analyze clinical efficiency and intraoperative considerations of ankle arthroscopy for ankle impingement syndrome through anterior and posterior passage. From April 2011 to April 2015, the clinical data of 17 patients diagnosed as ankle impingement syndrome were performed arthroscopy, including 12 males and 5 females, with an average age of 32.4 years (ranging from 22 to 47). Ankle arthroscopy cleaning were carried out according to clinical symptoms and radiological imaging, crashed part were cleaned too. Non steroidal anti-inflammatory drugs and intra-articular injection of sodium hyaluronate were used as conventional postoperatively treatment. AOFAS score and Ogilvie-Harris score were used to assess preoperative situation and postoperative situation. Intra-operative conditions showed 8 cases with anterior lateral impingement syndromes, 2 cases with anterior medial impingement syndromes, 2 cases with posterior impingement syndromes and 3 cases combined with anterior and posterior impingement syndromes. Distal bundle of anterior tibiofibular ligament, anterior talusfibular ligament and synovial tissue and scar tissue were cleared up during operation. Four patients were combined with concomitant articular cartilage injury, and damage area were about 1 mm×3 mm to 1.5 mm×4 mm. Microfracture treatment were performed by 1.2 mm diameter Kirschner wire. All patients were followed up from 8 to 24 months with an average of 14.3 months. AOFAS score increased from 62.3±5.20 preoperatively to 87.6±5.40 postoperatively, Ogilvie-Harris ankle score increased from 6.70±0.98 preoperatively to 12.80±1.21 postoperatively. No neurovascular damage, wound infection or wound healing problem occurred. Ankle swelling were appeared with different degrees, but disappeared at 4 to 8 weeks postoperatively. For ankle impingement syndrome patients, ankle arthroscopy through anterior with posterior passage could effectively clear up bone and soft tissue impingement. Postoperatively non-steroidal anti-inflammatory drugs and intra-articular injection of sodium hyaluronate could effectively relieve ankle pain and swollen and achieve good therapeutic effect.

Comparison of Juvenile Allogenous Articular Cartilage and Bone Marrow Aspirate Concentrate versus Microfracture in Arthroscopic Treatment of Talar Osteochondral Lesions

Category: Ankle Introduction/Purpose: There are few prior investigations that report the clinical and radiographic outcomes of juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate in the ankle. Reports that do exist have offered conflicting results and suggest that this relatively new technique has no significant advantage over current repair techniques. The purpose of this study was to compare the functional and radiographic outcomes of patients who received juvenile allogenic chondrocyte implantation with autologous bone marrow aspirate for treatment of talar osteochondral lesions with those of patients who underwent microfracture. Methods: After approval was obtained from our institutional review board, the institution’s foot and ankle registry was searched using relevant Current Procedural Terminology codes for all patients who underwent either microfracture or juvenile allogenic chondrocyte implantation with bone marrow aspirate concentrate for an osteochondral lesion of the talus between 2006 and 2014. Ninety-six patients fit the inclusion criteria and composed the study cohort. Of these 96 patients, 50 had undergone microfracture treatment and 46 had received DeNovo NT for juvenile allogenic chondrocyte implantation with bone marrow aspirate concentrate treatment, composing the microfracture (MF) and JACI-BMAC groups, respectively. Retrospective chart review was performed and functional outcomes were assessed pre- and postoperatively using the Foot and Ankle Outcome Score (FAOS) and Short Form-12 (SF-12) general health questionnaire. Postoperative magnetic resonance (MR) images were reviewed and evaluated using a modified Magnetic Resonance Observation of Cartilage Tissue (MOCART) score. Results: The average followup was 40.0 (range 5.0 to 113.6) months with the MF group having an average followup of 40.3 months (range 5 to 133.6) and the JACI-BMAC group averaging a 18.6 month followup (range 9.1 to 39.6). Both the JACI-BMAC and MF groups had significant pre-to-postoperative improvements in Pain, Daily Activities, Sports, Quality of Life, and overall FAOS Scores; however, there were no significant differences in any patient reported outcomes between the groups. SF-12 scores were improved in both JACI-BMAC and MF groups, however the MF change from pre- to-postoperative did not reach significance (p = 0.214). Radiographically, both the JACI-BMAC and MF groups produced reparative tissue that exhibited a fibrocartilage composition. The JACI-BMAC group tended to have more patients with hypertrophy exhibited on MR imaging than the MF group (p = 0.030). Conclusion: Juvenile allogenic chondrocyte implantation and microfracture resulted in improved functional outcomes. However, none of the differences in FAOS scores between groups achieved the minimal clinically important difference, suggesting there may not be enough of a difference between these treatments to distinguish them in terms of patient outcomes in the short term. Both techniques produced reparative tissue that exhibited fibrocartilage composition radiographically. Based on our results, juvenile allogenous cartilage has not demonstrated a significant advantage over the microfracture technique in the treatment of talar osteochondral lesions. Longer term studies will be needed to see if these findings are maintained over time.

Clinical Outcomes Following Arthroscopic Micro Fracture of the Hip

Objectives:Objective and clinical results of microfracture for treatment of chondral defects of the knee is well documented, yet outcomes for microfracture of the hip have not been extensively studied. Recently, several studies demonstrated clinical improvements in patients treated with microfracture of the hip. The purpose of this study is to examine clinical outcomes and survivorship in patients who underwent microfracture during arthroscopic hip surgery.Methods:A retrospective analysis of a prospectively collected database was performed. Thirty-eight patients with a mean age of 41 (range, 17-64) who underwent microfracture during arthroscopic hip surgery by a single surgeon (senior author) were identified. Demographic data, diagnosis, and details regarding operative procedures were collected. All patients were indicated for hip arthroscopy based on standard pre-operative examination as well as routine and advanced imaging. Baseline pre-operative modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS) were compared to mHHS and NAHS at two-year follow-up. Additionally, survivorship data was assessed to determine failure, defined as any subsequent revision arthroscopic surgery and/or hip arthroplasty of the same hip.Results:Thirty-four of the 38 (89.5%) patients were available for two-year clinical follow-up. Baseline mean mHHHS and NAHS for all patients improved from 50.6 (+/- 12.7) and 46.9 (+/-12.8) to 84.7 (+/- 12.5) and 85.6 (+/- 11.2) respectively. Both improvements were statistically significant (p < 0.05). Eight patients (23.5%) met failure criteria and underwent additional surgery at an average of 23.9 months. Two patients (5.8%) underwent revision arthroscopic surgery, and six patients (17.7%) underwent hip arthroplasty.Conclusion:Significant improvements in clinical outcomes are seen at two-year follow-up after microfracture treatment of chondral lesions of the hip. Despite overall success, failure rates are relatively high. As with microfracture of the knee, results favor short-term clinical improvements, but results may decline at two years. Larger studies are needed to fully assess the efficacy of microfracture in arthroscopic hip surgery.

Can chondral healing be improved following microfracture? The effect of adipocyte tissue derived stem cell therapy

BackgroundWe aimed to investigate the effect of adipose tissue-derived mesenchymal stem cells (ADSCs) on chondral healing using the microfracture (MF) technique. MethodsThirty male rabbits were randomly divided into three groups. Standard cylindrical osteochondral defects (OCDs) were created in the weight-bearing areas of the medial condyles of all the right knees; the defects were four millimeters in diameter and two millimeters in depth. The control group (group A) was restricted to spontaneous healing. For group B, we performed MF with a 1.5-mm drill. For group C, we applied MF using the same method and then applied 3×106 ADSCs to the defect area. At eight weeks post-operation, the subjects were sacrificed, and the distal femoral joint surfaces were evaluated histopathologically for chondral healing. The samples were scored according to the International Cartilage Repair Society (ICRS) scale. ResultsThe results for group C were significantly better than those for group A in terms of the surface properties (p=0.003). The matrix evaluation was better for group A than for group C (p=0.01). The cell distribution, cell viability and subchondral bone parameters were similar between the groups (p=0.198, p=0.387 and p=0.699). The cartilage mineralization parameter was better for group C than for group A (p=0.001). The signs of healing were better for group C than for group B, but the differences were not significant (p=0.185). ConclusionsImprovements with additional ADSC treatments were not statistically significant in cases in which ADSC treatment was compared with isolated MF treatment. Clinical RelevanceAdditional ADSCs treatment may have positive effect on chondral healing but it doesn’t seem significant.

Effect on Patient-Reported Outcomes of Debridement or Microfracture of Concomitant Full-Thickness Cartilage Lesions in Anterior Cruciate Ligament–Reconstructed Knees

Background: The treatment of concomitant cartilage lesions in anterior cruciate ligament (ACL)–injured knees is debatable. Purpose: To evaluate the effect of debridement or microfracture (MF) compared with no treatment of concomitant full-thickness (International Cartilage Repair Society [ICRS] grades 3-4) cartilage lesions on patient-reported outcomes after ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Six hundred forty-four patients who underwent primary unilateral ACL reconstruction and had a concomitant full-thickness cartilage lesion treated simultaneously by debridement (n = 129) or MF (n = 164), or underwent no treatment (n = 351) of the cartilage lesion, registered in the Norwegian and Swedish National Knee Ligament Registries from 2005 to 2008 were included. The Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to measure patient-reported outcomes. At a mean follow-up of 2.1 ± 0.2 years after surgery, 357 (55%) patients completed the KOOS. Linear regression analyses were used to evaluate the effect of debridement or MF on the KOOS. Results: No significant effects of debridement were detected in the unadjusted or adjusted regression analyses on any of the KOOS subscales at 2-year follow-up. The MF treatment of the cartilage lesions had significant negative effects at 2-year follow-up on the KOOS Sport and Recreation (Sport/Rec) (regression coefficient [β] = −8.9; 95% confidence interval [CI], −15.1 to −1.5) and Knee-Related Quality of Life (QoL) (β = −8.1; 95% CI, −14.1 to −2.1) subscales in the unadjusted analyses. When adjusting for confounders, MF had significant negative effects on the same KOOS subscales of Sport/Rec (β = −8.6; 95% CI, −16.4 to −0.7) and QoL (β = −7.2; 95% CI, −13.6 to −0.8). For the remaining KOOS subscales of Pain, Symptoms, and Activities of Daily Living, there were no significant unadjusted or adjusted effects of MF. Conclusion: MF of concomitant full-thickness cartilage lesions showed adverse effects on patient-reported outcomes at 2-year follow-up after ACL reconstruction. Debridement of concomitant full-thickness cartilage lesions showed neither positive nor negative effects on patient-reported outcomes at 2-year follow-up after ACL reconstruction.

Small-Diameter Awls Improve Articular Cartilage Repair After Microfracture Treatment in a Translational Animal Model

Background: Microfracture is the most commonly applied arthroscopic marrow stimulation procedure. Hypothesis: Articular cartilage repair is improved when the subchondral bone is perforated by small-diameter microfracture awls compared with larger awls. Study Design: Controlled laboratory study. Methods: Standardized rectangular (4 × 8 mm) full-thickness chondral defects (N = 24) were created in the medial femoral condyle of 16 adult sheep and debrided down to the subchondral bone plate. Three treatment groups (n = 8 defects each) were tested: 6 microfracture perforations using small-diameter awls (1.0 mm; group 1), large-diameter awls (1.2 mm; group 2), or without perforations (debridement control; group 3). Osteochondral repair was assessed at 6 months in vivo using established macroscopic, histological, immunohistochemical, biochemical, and micro–computed tomography analyses. Results: Compared with control defects, histological cartilage repair was always improved after both microfracture techniques (P < .023). Application of 1.0-mm microfracture awls led to a significantly improved histological overall repair tissue quality (7.02 ± 0.70 vs 9.03 ± 0.69; P = .008) and surface grading (1.05 ± 0.28 vs 2.10 ± 0.19; P = .001) compared with larger awls. The small-diameter awl decreased relative bone volume of the subarticular spongiosa (bone volume/tissue volume ratio: 23.81% ± 3.37% vs 30.58% ± 2.46%; P = .011). Subchondral bone cysts and intralesional osteophytes were frequently observed after either microfracture treatment. Macroscopic grading, DNA, proteoglycan, and type I and type II collagen contents as well as degenerative changes within the adjacent cartilage remained unaffected by the awl diameter. Conclusion: Small-diameter microfracture awls improve articular cartilage repair in the translational sheep model more effectively than do larger awls. Clinical Relevance: These data support the use of small microfracture instruments for the surgical treatment of cartilage defects and warrant prolonged clinical investigations.

Trends of Concurrent Ankle Arthroscopy at the Time of Operative Treatment of Ankle Fracture: A National Database Review.

The purpose of this study was to report trends associated with concurrent ankle arthroscopy at the time of operative treatment of ankle fracture. The current procedural terminology (CPT) billing codes were used to search the PearlDiver Patient Record Database and identify all patients who were treated for acute ankle fracture in the United States. The Medicare Standard Analytic Files were searchable between 2005 and 2011 and the United Healthcare Orthopedic Dataset from 2007 to 2011. Annual trends were expressed only between 2007 and 2011, as it was the common time period among both databases. Demographic factors were identified for all procedures as well as the cost aspect using the Medicare data set. In total, 32 307 patients underwent open reduction internal fixation (ORIF) of an ankle fracture, of whom 313 (1.0%) had an ankle arthroscopy performed simultaneously. Of those 313 cases, 70 (22.4%) patients received microfracture treatment. Between 2005 and 2011, 85 203 patients were treated for an ankle fracture whether via ORIF or closed treatment. Of these, a total of 566 patients underwent arthroscopic treatment within 7 years. The prevalence of arthroscopy after ankle fracture decreased significantly by 45% from 2007 to 2011 (P< .0001). When ORIF and microfracture were performed concurrently, the total average charge for both procedures drops to $4253.00 and average reimbursement to $818.00 compared with approximately $4964.00 and $1069.00, respectively, when they were performed subsequently. Despite good evidence in favor of arthroscopy at the time of ankle fracture treatment, it appears that only a small proportion of surgeons in the United States perform these procedures concurrently. Therapeutic, Level IV: Retrospective.

Effect on Patient-Reported Outcome of Debridement or Microfracture of Concomitant Full-Thickness Cartilage Lesions in Anterior Cruciate Ligament-Reconstructed Knees

Objectives:To evaluate the effect of debridement or microfracture compared with no treatment of concomitant full-thickness (International Cartilage Repair Society [ICRS] grades 3-4) cartilage lesions on patient-reported outcome after ACL reconstruction in a large population-based cohort study.Methods:644 patients with a primary unilateral ACL reconstruction and a concomitant full-thickness cartilage lesion treated simultaneously by debridement (n=78) or microfracture (n=88), or receiving no treatment (n=191) of the cartilage lesion, registered in the Norwegian and the Swedish National Knee Ligament Registry during 2005-2008 were included. Knee Injury and Osteoarthritis Outcome Score (KOOS) was used to measure patient-reported outcome. At a mean follow-up of 2.1 years (SD, 0.2) after surgery, 357 (55%) patients completed the KOOS. Linear regression analyses were used to evaluate the effect of debridement or microfracture on KOOS. The multiple regression analyses were adjusted for gender, age, previous knee surgery, time from injury to surgery, concomitant ligament injury, concomitant meniscal lesion(s), type of ACL graft, area of cartilage lesion, ICRS grade of cartilage lesion, location of cartilage lesion and preoperative KOOS scores.Results:No significant effects of debridement were detected in the unadjusted or adjusted regression analyses on any of the KOOS subscales at 2-year follow-up. Microfracture treatment of the cartilage lesions had significant negative effects at 2 year follow-up on the KOOS subscales Sport/Recreation (regression coefficient [β] = -8.9; 95% CI, -15.1 to -1.5) and Knee-Related Quality of Life (QoL) (β = -8.1; 95% CI, -14.1 to -2.1) in the unadjusted analyses. When adjusting for confounders, microfracture had significant negative effects on the same KOOS subscales, Sport/Recreation (β = -9.1; 95% CI, -16.9 to -1.2), and QoL (β = -7.3; 95% CI, -13.7 to -0.9). For the remaining KOOS subscales Pain, Symptoms and Activity of Daily Living (ADL) there were no significant unadjusted or adjusted effects of microfracture.Conclusion:Microfracture of concomitant full-thickness cartilage lesions showed adverse effects on patient-reported outcome at 2-year follow-up after ACL reconstruction. Debridement of concomitant full-thickness cartilage lesions showed neither positive nor negative effects on patient-reported outcome at 2-year follow-up after ACL reconstruction.

Delivering rhFGF-18 via a bilayer collagen membrane to enhance microfracture treatment of chondral defects in a large animal model.

Augmented microfracture techniques use growth factors, cells, and/or scaffolds to enhance the healing of microfracture-treated cartilage defects. This study investigates the effect of delivering recombinant human fibroblastic growth factor 18 (rhFHF18, Sprifermin) via a collagen membrane on the healing of a chondral defect treated with microfracture in an ovine model. Eight millimeter diameter chondral defects were created in the medial femoral condyle of 40 sheep (n = 5/treatment group). Defects were treated with microfracture alone, microfracture + intra-articular rhFGF-18 or microfracture + rhFGF-18 delivered on a membrane. Outcome measures included mechanical testing, weight bearing, International Cartilage Repair Society repair score, modified O'Driscoll score, qualitative histology, and immunohistochemistry for types I and II collagen. In animals treated with 32 μg rhFGF-18 + membrane and intra-articularly, there was a statistically significant improvement in weight bearing at 2 and 4 weeks post surgery and in the modified O'Driscoll score compared to controls. In addition, repair tissue stained was more strongly stained for type II collagen than for type I collagen. rhFGF-18 delivered via a collagen membrane at the point of surgery potentiates the healing of a microfracture treated cartilage defect.

Osteochondral Autologous Transfer and Bulk Allograft for Biological Resurfacing of Large Osteochondral Lesions of the Talus

Osteochondral lesions of the talus that have previously undergone surgical management or involve the shoulder region of the talus require methods other than microfracture for treatment. For those lesions that have failed microfracture and do not involve the shoulder of the talus, osteochondral autologous transfer is our preferred treatment of choice. Perpendicular access to the lesion, often by osteotomy, is required for this technique. For those osteochondral lesions of the talus that involve the shoulder of the talus, structural allograft is indicated. This article describes our technique for osteochondral autologous transfer and structural allograft implantation. Level of Evidence: Diagnostic Level 5. See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Treatment of Hip Chondral Defects With Bone Marrow Stimulation and BST-CarGel

Microfracture, the current standard of care for the treatment of non-degenerative chondral lesions in the hip joint, is limited by the poor quality of the filling fibrocartilaginous tissue. BST-CarGel (Piramal Life Sciences, Laval, Quebec, Canada) is a chitosan-based biopolymer that, when mixed with fresh, autologous whole blood and placed over the previously microfractured area, stabilizes the blood clot and enhances marrow-triggered wound-healing repair processes. BST-CarGel has been previously applied in the knee, with statistically significant greater lesion filling and superior repair tissue quality compared with microfracture treatment alone. In this report we describe the application of BST-CarGel for the arthroscopic treatment of hip chondral lesions. Our preliminary data suggest that our BST-CarGel procedure provides high-quality repair tissue and therefore may be considered a safe, cost-efficient therapeutic choice for the treatment of hip chondral defects.