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Microfracture Technique for Knee Injuries

Microfracture is a form of cartilage repair that was popularised in the 1980s by Richard Steadman in Colorado, USA. It is not overly technically demanding and has shown good functional outcomes for small (<2cm2) lesions. Original data from the 1980s suggested its use for larger lesions (up to 4cm2). More recent evidence such as NICE guidance and alternative treatments, such as autologous chondrocyte implantation (ACI), have narrowed the indications of microfracture based on size.

It is a straightforward procedure to undertake in one sitting and worthwhile for appropriate sized lesions. However it must be appreciated that microfracture creates repair-type fibrocartilage rather than hyaline cartilage, which is inferior in terms of biomechanics and longevity.

Modern cartilage regeneration techniques are also available and garnering good evidence, especially for larger lesions. Autologous cartilage implantation (ACI) for example is a much more costly, 2-stage procedure. The size of the lesion therefore is critical in the decision making process as the results of ACI can be impaired by previous failed regenerative procedures including microfracture.

OrthOracle readers will also find the following instructional techniques of interest:

Diagnostic knee arthroscopy

Stem cell harvest and transplant for knee osteochondral defect (Synergy Medical technologies)

Femoral trochlea chondral lesion: Chondrogide membrane(Geistlich pharma) for chondral regeneration.

Arthroscopic medial menisectomy and chondroplasy of knee

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- Discussion: - see management of osteochondral injuries and cartilage menu
- microfracture is a knee surgery that involves the creation of multiple perforations (microfractures in the subchondral bone) in areas that are cartilage deficient.
- theory behind this type of technique is that simple abrasion arthroplasty may not allow a sustained reparative response (no more than 2 weeks of healing) where as the micro-fracture technique (which penetrates the subchondral bone) allows a better and more sustained healing process.
- microfracture is often chosen as the benchmark for which to compare to other cartilage repair procedures.
- much of the healing will be manifested as fibrocartilage;
- ref: Cartilage repair approach and treatment characteristics across the knee joint: a European survey

- Surgical Technique:
        - an arthroscopic awl is used to make multiple perforations (microfractures) in the subchondral bone;
- theory behind this type of technique is that simple abrasion arthroplasty may not allow a sustained reparative response (no more than 2 weeks of healing) where as the micro-fracture technique (which penetrates the subchondral bone) allows a better and more sustained healing process;
        - removal of the calcified cartilage layer:
                 - curet is then used to remove the calcified cartilage layer from the base of the lesion; (see articular cartilage)
calcified cartilage layer: (see articular cartilage defects)
- thin layer between the deep zone of the cartilage and the subchondral bone
- can increase in thickness with age
- removal of the calcified cartilage may improve the bonding of the repair tissue to the subchondral bone after microfracture;
- references:
- Arthroscopic subchondral bone plate microfracture technique augments healing of large chondral defects in the radial carpal bone and medial femoral condyle of horses.
                                     - Effects of calcified cartilage on healing of chondral defects treated with microfracture in horses.
- bone perforations:
                 - bone is perforated every 4-5 mm to a depth of 3-4 mm (some evidence for 6 mm depth)
- classic teaching is to use an awl, but recent evidence supports deep drilling;
- references:
- Drilling and microfracture lead to different bone structure and necrosis during bone-marrow stimulation for cartilage repair.
- Complete vs. Central Hole Placement to Improve Percentage Fill after Microfracture.
- Depth of subchondral perforation influences the outcome of bone marrow stimulation cartilage repair
- Characterization of Subchondral Bone Repair for Marrow-Stimulated Chondral Defects and Its Relationship to Articular Cartilage Resurfacing

Chondral regenerative techniques have been used for many years, but due to the problems in funding for autologous chondrocyte implantation techniques, the non-cell-based techniques using membranes are gaining popularity for the treatment of focal articular defects. In distinction to focal resurfacing there is a slower recovery and some post-operative restrictions are required, but the potential of biological reconstruction without removing any native joint is appealing in the younger population. These biological reconstruction techniques usually require a period of reduced weightbearing up to 2 months and often a restricted range of movement range using a brace. The chondral membrane techniques may be used as isolated chondral surface regenerates or they may be combined with stimulation techniques which breach the subchondral bone. Similarly the chondral membrane techniques may be combined with bone grafting (autologous or allograft which is my preference) or for some surgeons synthetic bone graft substitute to reconstruct a bone void beneath a chondral lesion.

The classic patient for biological reconstruction is in the 18-50 age range with a focal chondral lesion which is symptomatic and has failed traditional non-operative treatments such as offloader bracing and injection therapies such as visco-supplementation. Steroid injection is controversial for these patients as there may be some symptomatic relief, but likely damage to the good native chondral surface and therefore this is not part of my standard practice for young chondral damage patients.

Please remember to check alignment as osteotomy is an excellent proven treatment for the malaligned overloaded joint. Chondral regenerative techniques will not work in mechanically overloaded joints without osteotomy, which is a principle this applies in the tibiofemoral as well as the patella-femoral joints which are covered on OrthOracle at Patella stabilisation : Tibial tubercle osteotomy and Medial patellofemoral ligament reconstruction.

Chondrogide is a Porcine Collagen type I/III matrix produced by Giestlich. It has been used clinically for over 15 years with a metanalysis from 2019 demonstrating its clinical efficacy in the knee with benefit maintained for at least 5 years in a population of 20-50 year old patients.

Steinwachs MR, Gille J, Volz M, Anders S, Jakob R, De Girolamo L, Volpi P, Schiavone-Panni A, Scheffler S, Reiss E, Wittmann U. Systematic Review and Meta-Analysis of the Clinical Evidence on the Use of Autologous Matrix-Induced Chondrogenesis in the Knee. Cartilage. 2019 Sep 11:1947603519870846. doi: 10.1177/1947603519870846. Epub ahead of print. PMID: 31508990.

The Chondrogide membranes are available in 3 sizes and are sold with a sterile aluminium foil template for ease of measuring the chondral defect.

Readers will also find of interest the following OrthOracle techniques:

Medial Femoral Condyle Focal Resurfacing with HemiCAP(Arthrosurface)

Knee arthroscopy and microfracture of osteochondral defect

Stem cell harvest and transplant for knee osteochondral defect (Synergy Medical technologies)

HAMIC and Medial malleolar osteotomy for Osteochondral defect of talus, using Chondrotissue by Biofuse.

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        - adjunctive measures:
                 - Concentrated Bone Marrow Aspirate Improves Full-Thickness Cartilage Repair Compared with Microfracture in the Equine Model
        - post op care and rehab:
                 - patients are kept on CPM 8 hours per day and non wt bearing for 6-8 weeks, although this too has been questioned;
- Arthroscopic microfracture of chondral defects of the knee: a comparison of two postoperative treatments.
- Rehabilitation following microfracture for chondral injury in the knee.
   - references:
                          - The surgical treatment of knee injuries in skiers.
- Treatment of articular cartilage defects in athletes: An analysis of functional outcome and lesion appearance.
- Early events in cartilage repair after subchondral bone microfracture.
- Chondral Defect Repair After the Microfracture Procedure.  A Nonhuman Primate Model.
- The microfracture technique for the treatment of articular cartilage lesions in the knee. A prospective cohort study.
- A Randomized Trial Comparing Autologous Chondrocyte Implantation with Microfracture. Findings at Five Years
- Healing of canine articular cartilage defects treated with microfracture, a type-II collagen matrix, or cultured autologous chondrocytes.
                          - Results after microfracture of full-thickness chondral defects in different compartments in the knee

- Role Microfracture in Degenerative Arthritis in the Knee (see osteoarthritis and arthroscopy of the degenerative knee)
- references:
                  - The Treatment of Articular Cartilage. Defects Using the Microfracture Technique
- Orthopaedic Surgeon Performs Innovative Microfracture Procedure On Arthritic Knees Avoiding Knee Replacement Surgery
- Microfracture Surgery Recovery: Slow Down for Best Results
                  - Steadman Hawkins Research Foundation
- Microfracture Surgery for Cartilage Regeneration in Degenerative Arthritis of the Knee.
- Knee Microfracture Surgery: New York Times Health Guide
- Knee microfracture surgery
- What is New in the Treatment of Focal Chondral Injuries of the Knee?
- Microfracture success depends not only on the operation but rehabilitation as well
                  - Treatment of Osteoarthritis of the Knee with Microfracture and Rehabilitation
                  - Cartilage healing after microfracture in osteoarthritic knees.
- Patient satisfaction and outcome after microfracture of the degenerative knee.
- Articular cartilage regeneration with microfracture and hyaluronic acid.
- [Early results of medial opening wedge osteotomy in varus gonarthrosis]
- Benefit of microfracture, implant for cartilage defects seen in early studies

Enhanced Microfracture with Autologous Hamstring Resurfacing Arthroplasty

Articular cartilage regeneration with microfracture and hyaluronic acid

Microfracture techniques in the treatment of osteochondral injuries.

The Use of Continuous Passive Motion Following Knee Cartilage Defect Surgery: A Systematic Review