Microfracture Technique Research Articles

Outcome of ACL Reconstruction and Concomitant Articular Injury Treatment.

Articular cartilage injuries are a common clinical problem at the time of ACL reconstruction with an incidence rate of 16-46%. Good results of ACL reconstruction combined with the treatment of chondral lesions have been published in some studies. After statistical analysis 30 patients were selected and divided in 2 groups. The first group consisted of 15 patients with isolated ACL tear without any other concomitant injuries and the second group consisted of 15 patients with ACL tear and concomitant high grade (grade 3 or 4 of outerbridge classification) contained articular cartilage injuries during arthroscopy. Group 1 underwent ACL reconstruction and group 2 underwent ACL reconstruction combined with chondroplasty via the drilling or microfracture technique. For each patient the Lysholm knee score questionnaire was completed before surgery, 6 months and 1 year after surgery. The mean Lysholm knee score in both groups improves: 9.6 points after 6 months and 16.06 points after 1 year in group 1, 23.26 points after 6 months, 30.66 after 1 year in group 2, which was statistically significant (Pvalue<0.05). Improvement in the Lysholm knee score in both groups shows that ACL reconstruction with concomitant chondroplasty in high grade chondral injuries has good results with patient satisfaction and improvement in their quality of life.

Knee cartilage defect: marrow stimulating techniques.

Painful chondral defects of the knee are very difficult problems. The incidence of these lesions in the general population is not known since there is likely a high rate of asymptomatic lesions. The rate of lesions found during arthroscopic exam is highly variable, with reports ranging from 11 to 72% Aroen (Aroen Am J Sports Med 32: 211-5, 2004); Curl(Arthroscopy13: 456-60, 1997); Figueroa(Arthroscopy 23(3):312-5, 2007;); Hjelle(Arthroscopy 18: 730-4, 2002). Examples of current attempts at cartilage restoration include marrow stimulating techniques, ostochondral autografts, osteochondral allografts, and autologous chondrocyte transplantation. Current research in marrow stimulating techniques has been focused on enhancing and guiding the biology of microfracture and other traditional techniques. Modern advances in stem cell biology and biotechnology have provided many avenues for exploration. The purpose of this work is to review current techniques in marrow stimulating techniques as it relates to chondral damage of the knee.

Microsphere-based gradient implants for osteochondral regeneration: a long-term study in sheep.

The microfracture technique for cartilage repair has limited ability to regenerate hyaline cartilage. The current study made a direct comparison between microfracture and an osteochondral approach with microsphere-based gradient plugs. The PLGA-based scaffolds had opposing gradients of chondroitin sulfate and β-tricalcium phosphate. A 1-year repair study in sheep was conducted. The repair tissues in the microfracture were mostly fibrous and had scattered fissures with degenerative changes. Cartilage regenerated with the gradient plugs had equal or superior mechanical properties; had lacunated cells and stable matrix as in hyaline cartilage. This first report of gradient scaffolds in a long-term, large animal, osteochondral defect demonstrated potential for equal or better cartilage repair than microfracture.

COMPUTATIONAL ANALYSIS OF THE REGENERATED KNEE STRUCTURE AFTER BONE MARROW STIMULATION TECHNIQUES

Bone marrow stimulation techniques, such as abrasion arthroplasty or microfracture, have been widely used for repairing cartilage; however, the mechanical stress analysis of these surgical techniques has not been fully investigated. In this study, finite element analysis was used to investigate stresses produced in complex structures (e.g., cartilage, subchondral bone and trabecular bone) using 2D knee structural models. Abrasion arthroplasty creates global damages only in subchondral bone, but, microfracture technique creates local damages in both trabecular and subchondral regions. Although stresses do not significantly change in trabecular bones as 50% recovery occurs in both abrasion and microfacture samples, significant changes are observed in both subchondral bone and cartilage layer depending on the procedure. The maximum stress levels in the microfractured bone represent approximately a 10.48% increase in cartilage and a 38.25% increase in subchondral bones compared to normal conditions. After 150% recovery, however, all three layers increase their stress levels in microfractured samples. Therefore, the 2D computational analysis results suggest that the microfracture technique should be cautiously used.

In vivo animal study and clinical outcomes of autologous atelocollagen-induced chondrogenesis for osteochondral lesion treatment

BackgroundCollagen acts as a scaffold for healing damaged cartilage. This study evaluated the results of an in vivo animal study and provides short-term clinical results on a mixture of atelocollagen and fibrin glue-enhanced microfracture techniques in patients with osteochondral lesions (OCL) of the talus.MethodsThis paper contains animal in vivo data and clinical outcomes on the effectiveness of atelocollagen. An in vivo animal study was conducted with full-thickness cartilage defects created in the femoral condyle of 12 rabbits equally divided into 4 groups evaluated at 2, 4, 8, and 12 weeks. Four chondral lesions were created according to one procedure on each rabbit with each lesion treated as follows: (1) microfracture, (2) microfracture and the lesion covered with atelocollagen, (3) microfracture and the lesion covered with mixture of atelocollagen and fibrin glue, and (4) microfracture and the lesion covered with fibrin glue. In the clinical evaluation, 17 patients were treated with a combination of microfracture and atelocollagen injection for symptomatic full-thickness OCL of the talus. They were evaluated by the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS), Hannover Ankle Score System (HSS), visual analog scale (VAS), and magnetic resonance imaging (MRI) at baseline and at 12-months follow-up. Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score of the post-op status was compared with the MOCART score and a modified Anderson’s score of the pre-op status.ResultsIn the animal study, subchondral bone and cartilage were generated completely in groups 2 and 3 microscopically. Hyaline-like cartilage was found in the repair tissue. In the clinical evaluation, mean AOFAS improved from 62 to 88, mean HSS improved from 62 to 87, and mean VAS score improved from 64 to 18, respectively (p <0.001). Fifteen patients (89 %) reported good or excellent satisfaction. We defined the improvement of most of the subchondral bone edema and bone cyst as well as a chondral lesion by radiologic evaluation.ConclusionsRapid regeneration of cartilage was demonstrated in the in vivo animal study, and patients showed significant clinical improvement. Atelocollagen-enhanced microfracture enabled a reasonable treatment of cartilage defects.

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.

Clinical Effects of Platelet-Rich Plasma and Hyaluronic Acid as an Additional Therapy for Talar Osteochondral Lesions Treated with Microfracture Surgery: A Prospective Randomized Clinical Trial.

Osteochondral ankle injuries commonly affect the dome of the talus, and these injuries are a common cause of athletic disability. Various treatment options are available for these injuries including intra-articular hyaluronic acid (HA) and platelet-rich plasma (PRP) injections. The purpose of this study was to compare the effects of HA and PRP as adjunct therapies after arthroscopic microfracture in osteochondral lesions (OCLs) of the talus. In this prospective, randomized blinded study, 40 patients with talar OCLs in their ankle joints were treated with arthroscopic debridement and a microfracture technique. Thirteen randomly selected patients received PRP, 14 patients received HA, and the remaining 13 patients received saline as a control group. The participants were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog pain scale (VAS) scores after a 15.3-month (range, 11-25 months) follow-up. Postoperatively, all the groups exhibited significantly increased AOFAS scores and decreased VAS scores compared with their preoperative results (P < .005). The AOFAS scores were significantly increased in the PRP group versus the HA and control groups (P < .005), although the increased AOFAS scores in the HA group versus the control group were also significant (P < .005). Similar to the AOFAS scores, the decrease in the VAS scores was significantly lower in the PRP group versus the HA and control groups (P < .005). In addition, the HA group had significantly lower VAS scores than the control group (P < .005). Both PRP and HA injections improved the clinical outcomes of patients who underwent operation for talar OCLs in the midterm period and can be used as adjunct therapies for these patients. Because a single dose of PRP provided better results, we recommend PRP as the primary adjunct treatment option in the talar OCL postoperative period. Level I, prospective randomized study.

Full-thickness cartilage defects are repaired via a microfracture technique and intraarticular injection of the small-molecule compound kartogenin.

IntroductionMicrofracture does not properly repair full-thickness cartilage defects. The purpose of this study was to evaluate the effect of intraarticular injection of the small-molecule compound kartogenin (KGN) on the restoration of a full-thickness cartilage defect treated with microfracture in a rabbit model.MethodsFull-thickness cartilage defects (3.5 mm in diameter and 3 mm in depth) were created in the patellar groove of the right femurs of 24 female New Zealand White rabbits. The rabbits were divided into two groups (12 in each group) based on postsurgery treatment differences, as follows: microfracture plus weekly intraarticular injection of KGN (group 1) and microfracture plus dimethyl sulfoxide (group 2). Six rabbits from each group were illed at 4 and 12 weeks after surgery, and their knees were harvested. The outcome was assessed both macroscopically, by using the International Cartilage Repair Society (ICRS) macroscopic evaluation system, and histologically, by using the modified O’Driscoll histologic scoring system. Immunohistochemistry for type II and I collagen was also conducted.ResultsAt 4 weeks, group 1 showed better defect filling and a greater number of chondrocyte-like cells compared with group 2. At 12 weeks, group 1 showed statistically significantly higher ICRS scores and modified O’Driscoll scores compared with group 2. More hyaline cartilage-like tissue was found in the defects of group 1 at 12 weeks.ConclusionsIntraarticular injection of KGN enhances the quality of full-thickness cartilage defects repair after microfracture, with better defect filling and increased hyaline-like cartilage formation.

The Use of Human Amniotic Allograft on Osteochondritis Dissecans of the Talar Dome: A Comparison with and without Allografts in Arthroscopically Treated Ankles

Arthroscopy of the ankle with micro-fracture technique is one way to initially treat symptomatic talar dome lesions. Human amniotic allograft has been used in similar bone, soft tissue and cartilage defects to aid in healing of tissue using graft cells that have not differentiated into a particular cell line. Patients were taken from the primary surgeon’s practice to include those who had undergone arthroscopy with micro-fracture technique for treatment of a talar dome lesion less than 2 cm2. 101 patient surgeries were completed arthroscopically without additional major procedures. 54 surgeries were completed with human amniotic allograft; 47 were completed without (control group). Modified ACFAS ankle scores were taken pre-operatively, 3, 12 and 24 months post-operatively. Visual analog pain scores were taken pre-operatively and 24 months post-operatively. Results comparing pre-operative modified ACFAS scores between the control and graft groups were not significantly different (p = 0.14). There was a significant improvement in both groups’ scores following ankle arthroscopy with micro-fracture as expected. However, the amniotic tissue group did significantly better when comparing the post-operative scores between the control and graft group. Pain scores comparing control and amniotic patient groups were significant (p 2, significantly improves the patients’ pain and ACFAS scores.

Microfracture for chondral defects: assessment of the variability of surgical technique in cadavers

The purpose of this study was to assess the variability of the microfracture technique when performed by experienced knee arthroscopy surgeons. Four surgeons were each asked to perform microfracture on six preformed cartilage defects in fresh human cadaveric knees. Surgeons were instructed on penetration depth, inter-hole distance, and to place the holes perpendicular to the subchondral surface. Micro-computed tomography was used to calculate depth error, inter-hole distance error, and deviation of penetration angles from the perpendicular. All surgeons misjudged depth and inter-hole distance, tending to make microfracture holes too deep (depth error 1.1mm±1.9) and too close together (inter-hole distance error: -0.8mm±0.4). Fifty-one per cent of holes were angled more than 10° from the perpendicular (range 2.6°-19.8°). Both depth and distance errors were significantly lower in the trochlear groove than on the femoral condyle (p<0.05). Surface shearing was associated with both penetration depth >4mm and angles >20°. Inter-hole infraction occurred in holes closer than 2.5mm to each other. Even experienced knee arthroscopy surgeons demonstrate inconsistency in surgical technique when performing microfracture. While further research will be required to demonstrate that these variations in surgical technique are associated with poorer clinical outcomes after microfracture, surgeons should attempt to minimizing such variations in order to prevent surface shearing and inter-hole infraction.

Clinical efficacy of treating knee osteoarthritis by microfracture under arthroscopy

Objective To explore the clinical efficacy of microfracture technique in treating knee osteoarthritis under arthroscopy.Methods 80 patients with knee osteoarthritis undergoing arthroscopy were equally divided into microfracture group and debridement group.In the debridement group,the osteoarthritis degeneration,such as the floating cartilage,the exofoliative cartilage,osteophyte,was debrided under the arthoscopy.the lateral ligament was released and the synovial hyperplasia was planed in the platellofemoral hypertension or patella mal-track case.What' s more,microfractue was performed in the chondral defect area in the microfracture group.Hospital for special surgery knee score (HSS knee score system) and Tegner activity score system were implied to evaluate the knee function.Results All the patieuts had got a (13.1 ±0.5) months follow-up.In the debridement group,9 cases was excellent,22 cases was good,the effective rate was 77.5％.In the microfracture group,22 cases was excellent,15 cases was good,the effective rate was 92.5％.There was a significant difference in efficacy between the two groups.Conclusion The microfracture technique under the arthroscopy is a much more effective than the simple debridement.It is characterized by simplicity and efficacy. Key words: Arthroscopy; Joint debridement; Osteoarthritis of the knee; Effect

Do we Need Ankle Arthoscopy After Malleolar Fractures at the Time of Implant Removal?

Objectives:The purpose of this study was to evaluate the status of ankle joint arthroscopically, in patients with an appropriately treated ankle fracture.Methods:Arthroscopic examination was performed at the time of implant removal after an average of 12.8 months (range 8 to 16 months) in a series of 40 consecutive patients. There were 24 women and 16 men with an average age of 55.4 years (range 17 to 67 years old). The Danis-Weber classification system was used for these fractures. All the patients were evaluated by the AOFAS Clinical Rating System before and after implant removal.Results:In all the patients the fractures were healed without need of a second operation. Synovitis was present in all the patients and was located antero-laterally in 29 patients. Articular cartilage damage was noted in 19 patients, among whom 16 were treated by shaving and 3 were treated with the microfracture technique. In 13 patients we removed loose bodies. The lesions tended to be worse in patients over 60 years of age. The frequency and severity of the lesions also increased in type-B and type-C fractures.Conclusion:There is clear evidence that despite anatomic and appropriate reduction postoperative results of ankle fractures are not free of complications. Synovitis is a common finding after ankle fractures, and chondral lesions are commonly found associated especially with the more severe ankle fracture pattern. Our findings show that arthroscopy at the time of implant removal is useful in identifying and in treating intra-articular ankle lesions.

Arthroscopic Acetabular Microfracture With the Use of Flexible Drills: A Technique Guide

Chondral injuries of the hip joint are often symptomatic and affect patient activity level. Several procedures are available for addressing chondral injuries, including microfracture. Microfracture is a marrow-stimulating procedure, which creates subchondral perforation in the bone, allowing pluripotent mesenchymal stem cells to migrate from the marrow into the chondral defect and form fibrocartilaginous tissue. In the knee, microfracture has been shown to relieve pain symptoms. In the hip, microfracture has been studied to a lesser extent, but published studies have shown promising clinical outcomes. The depth, joint congruity, and geometry of the hip joint make microfracture technically challenging. The most common technique uses hip-specific microfracture awls, but the trajectory of impaction is not perpendicular to the subchondral plate. Consequently, the parallel direction of impaction creates poorly defined channels. We describe an arthroscopic microfracture technique for the hip using a flexible microfracture drill. The drill and angled guides simplify access to the chondral defect. The microfracture drill creates clear osseous channels, avoiding compaction of the surrounding bone and obstruction of the channels. Furthermore, this technique allows for better control of the angle and depth of the drill holes, which enhances reproducibility and may yield improved clinical outcomes.

Full-thickness cartilage defects repair with microfracture technique and intra-articular injection of a small molecule compound kartogenin

Full-thickness cartilage defects repair with microfracture technique and intra-articular injection of a small molecule compound kartogenin

T2-mapping at 3 T after microfracture in the treatment of osteochondral defects of the talus at an average follow-up of 8 years

To compare repaired cartilage with native cartilage, and inter-observer reliability, using T2 mapping at 3T for assessing cartilage repair in osteochondral defects of the talus after the microfracture technique. We enrolled eight females and seven males undergoing arthroscopic microfracture for osteochondral defects of the talus at an average follow-up of 7.9±2.2years (range 5-13years). Cartilage tissue was assessed using a 3-T magnetic resonance imaging unit with an 8-channel phased array foot and ankle coil (gradient strength, 50mT/m; slew rate, 200T/m/s). T2 maps were then calculated. Three independent boarded specialists evaluated the images, and magnetic resonance observation of cartilage repair tissue scores was used to assess the cartilage and joint status. Clinical results were assessed using the Hannover Scoring System (HSS) for the ankle and the American Orthopaedic Foot and Ankle Society (AOFAS) hind-foot score. No significant mean differences were found between the T2 properties of the repair tissue and those of the native reference cartilage (T2=38.6±5.3ms, range 30.2-55.8ms vs. 40.3±8.5ms, range 31.4-59.8ms, respectively; intra-class correlation coefficient=0.94; confidence interval 0.84-0.99, P≤0.001). Despite ≥50% defect filling in all patients, subchondral bone changes were considerable. The HSS at the follow-up revealed a mean score of 87±12 (range 51-97), and the AOFAS-Score was 90±13 (range 59-100). 3T T2 maps were similar in repaired and native cartilage with good inter-observer reliability. IV.

Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up

PurposeTo compare long-term functional and radiological outcome following microfracture technique (MF) versus osteochondral autologous transplantation (OAT) mosaicplasty for treating focal chondral lesions of the knee. MethodsTwenty-five patients (mean age 32.3 years, SD 7.7) with a full-thickness (International Cartilage Repair Society grade 3 or 4) chondral lesion of the articulating surface of the femur were randomized to either MF (n = 11) or OAT mosaicplasty (n = 14). At a median follow-up of 9.8 years (range 4.9–11.4), the patients were evaluated using Lysholm score (n = 25), Knee Injury and Osteoarthritis Outcome Score (KOOS, n = 25), isokinetic quadriceps measurement and hamstring strength measurement (n = 22) and standing radiographs (n = 23).ResultsThere were no significant differences in Lysholm score, KOOS, isokinetic muscle strength or radiographic osteoarthritis between MF-treated patients and OAT mosaicplasty-treated patients at follow-up. Mean Lysholm score at follow-up was 69.7 [95 % confidence interval (CI), 55.1–84.4] for the MF group and 62.6 (95 % CI, 52.6–72.6) for the OAT mosaicplasty group.ConclusionAt long-term follow-up, there were no significant differences between patients treated with MF and patients treated with OAT mosaicplasty in patient-reported outcomes, muscle strength or radiological outcome.Level of evidenceTherapeutic study, Level II.

Enhanced microfracture techniques in cartilage knee surgery: Fact or fiction?

The limited intrinsic healing potential of human articular cartilage is a well-known problem in orthopedic surgery. Thus a variety of surgical techniques have been developed to reduce joint pain, improve joint function and delay the onset of osteoarthritis. Microfractures as a bone marrow stimulation technique present the most common applied articular cartilage repair procedure today. Unfortunately the deficiencies of fibrocartilaginous repair tissue inevitably lead to breakdown under normal joint loading and clinical results deteriorate with time. To overcome the shortcomings of microfracture, an enhanced microfracture technique was developed with an additional collagen I/III membrane (Autologous, Matrix-Induced Chondrogenesis, AMIC(®)). This article reviews the pre-clinical rationale of microfractures and AMIC(®), presents clinical studies and shows the advantages and disadvantages of these widely used techniques. PubMed and the Cochrane database were searched to identify relevant studies. We used a comprehensive search strategy with no date or language restrictions to locate studies that examined the AMIC(®) technique and microfracture. Search keywords included cartilage, microfracture, AMIC(®), knee, Chondro-Gide(®). Besides this, we included our own experiences and study authors were contacted if more and non published data were needed. Both cartilage repair techniques represent an effective and safe method of treating full-thickness chondral defects of the knee in selected cases. While results after microfracture deteriorate with time, mid-term results after AMIC(®) seem to be enduring. Randomized studies with long-term follow-up are needed whether the grafted area will maintain functional improvement and structural integrity over time.

Cartilage extra-cellular matrix biomembrane for the enhancement of microfractured defects

The purpose of the study was to evaluate whether the biomembrane made of cartilage extracellular matrix, designed to provide cartilage-like favourable environments as well as to prevent against washout of blood clot after microfracture, would enhance cartilage repair compared with the conventional microfracture technique. A prospective trial was designed to compare the biomembrane cover after microfracture with conventional microfracture among patients with grade III-IV symptomatic cartilage defect in the knee joint. Patients aged 18-60 years were assigned to either the microfracture/biomembrane (n = 45) or microfracture groups (n = 19). Among them, 24 knees in the microfracture/biomembrane and 12 knees in the microfracture were followed up for 2 years. Cartilage repair was assessed with magnetic resonance imagings taken 6 months, 1 year, and 2 years postoperatively, and the clinical outcomes were also recorded. Compared with conventional microfracture, microfracture/biomembrane resulted in greater degree of cartilage repair (p = 0.043). In the intra-group analysis, while microfracture showed moderate to good degree of cartilage repair in nearly 50 % of the patients (47 % at 6 months to 50% at 2 years; n.s.), microfracture/biomembrane maintained an equivalent degree of repair up to 2 years (88% at 6 months to 75% at 2 years; n.s.). The clinical outcome at 2 years also showed improved knee score and satisfaction and decreased pain in each group, but the difference between the two groups was not statistically significant. Compared with conventional microfracture, biomembrane cover after microfracture yielded superior outcome in terms of the degree of cartilage repair during 2 years of follow-up. This implies that initial protection of blood clot and immature repair tissue at the microfractured defect is important for the promotion of enhanced cartilage repair, which may be obtained by the application of a biomembrane. Prospective comparative study, Level II.

The treatment of chondral lesions of the knee with the microfracture technique and platelet-rich plasma.

to assess the efficacy of associating the microfracture technique with platelet-rich plasma (PRP) injections in the treatment of chondral lesions to promote acceleration and optimization of the healing process compared with the traditional microfracture approach. from September 2011 to August 2012, 20 patients (9 males and 11 females, aged 30-55 years) were treated. All presented with chondral lesions of the medial femoral condyle of the knee and a pain duration ranging from 8 to 12 months. The patients were randomized into two groups (A and B). Group A was treated with the microfracture technique and a total of three intra-articular injections of PRP. Group B was treated with microfractures alone. Clinical follow-up was performed at 3, 6 and 12 months after treatment. Clinical function was assessed on the basis of the International Knee Documentation Committee (IKDC) score. Pain was evaluated using a visual analogue scale (VAS). the patients in group A had a mean baseline IKDC score of 31.2, which rose to 84.2 at 12 months. The IKDC scores in group B were at 30.1 at baseline and 81 at 12 months. the results of our study suggest that functional recovery and resolution of pain are obtained more quickly in PRP-treated patients. We also observed a better functional outcome in the patients treated with the combination of PRP and microfractures, even at 12 months, although the difference was not statistically significant. level II, randomized clinical study.

Microfracture Technique vs Mosaic Plasty: No Difference in Knee Scores at 5-11 Years Follow-up in a Prospective Randomized Clinical Trial

Microfracture Technique vs Mosaic Plasty: No Difference in Knee Scores at 5-11 Years Follow-up in a Prospective Randomized Clinical Trial