Microfracture surgery

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Microfracture surgery
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Left knee-joint from behind, showing interior ligaments. (Lateral meniscus and medial meniscus are cartilage.)
Specialty orthopedic

Microfracture surgery is an articular cartilage repair surgical technique that works by creating tiny fractures in the underlying bone. This causes new cartilage to develop from a so-called super-clot.

Contents

The surgery is quick (typically lasting between 30 and 90 minutes), minimally invasive, and can have a significantly shorter recovery time than an arthroplasty (knee replacement).

Chronic articular cartilage defects do not heal spontaneously. [1] However, acute traumatic osteochondral lesions or surgically created lesions extending into subchondral bone, e.g. by Pridie drilling, [2] spongialization [3] abrasion [4] or microfracture causing the release of multipotent mesenchymal stem cells from the bone marrow, may heal with repair tissue consisting of fibrous tissue, fibrocartilage or hyaline-like cartilage. [5] The quality of the repair tissue after these "bone marrow stimulating techniques" depends on various factors including the species and age of the individual, the size and localization of the articular cartilage defect, the surgical technique, e.g., how the subchondral bone plate is treated, and the postoperative rehabilitation protocol. [6]

According to a 2017 article in the Journal of Orthopaedics, "Studies have shown that microfracture techniques do not fill in the chondral defect fully, and it forms fibro cartilage rather than hyaline cartilage. The microfracture techniques became controversial due to a lack of favourable reports on the long-term effects." [7]

History

The surgery was developed in the late 1980s and early 1990s by Dr. Richard Steadman of the Steadman-Hawkins clinic in Vail, Colorado. Steadman slowly refined the procedure through research (including tests on horses). [8] The surgery was called "controversial" by many sportswriters, due to a lack of studies on the long-term effects and the fact that an unsuccessful surgery could end an athlete's career. [9] Steadman has also adapted the surgery into a treatment to help reattach torn ligaments (a technique he calls the "healing response").[ citation needed ]

Procedure

The surgery is performed by arthroscopy, after the joint is cleaned of calcified cartilage. Through use of an awl, the surgeon creates tiny fractures in the subchondral bone plate. [10] Blood and bone marrow (which contains stem cells) seep out of the fractures, creating a blood clot that releases cartilage-building cells. The microfractures are treated as an injury by the body, which is why the surgery results in new, replacement cartilage. [11] The procedure is less effective in treating older patients, overweight patients, or a cartilage lesion larger than 2.5 cm. [11] Further on, chances are high that after only 1 or 2 years of the surgery symptoms start to return as the fibrocartilage wears away, forcing the patient to reengage in articular cartilage repair.

The effectiveness of cartilage growth after microfracture surgery is thought to be dependent on the patient's bone marrow stem cell population and some think increasing the number of stem cells increases the chances of success. A couple of physicians are promoting an alternative treatment implanting autologous mesenchymal stem cells directly into the cartilage defect, without having to penetrate the subchondral bone. [12] [13]

Microfracture reports

Studies have shown that microfracture techniques do not fill in the chondral defect fully, forming fibrocartilage rather than hyaline cartilage. Fibrocartilage is not as mechanically sound as hyaline cartilage; it is much denser and unable to withstand the demands of everyday activities as well as the original cartilage and is thus at higher risk of breaking down. [14] The blood clot is very delicate after surgery and needs to be protected. In terms of time, the clot takes about 8 to 15 weeks for conversion to fibrous tissue and is usually fibrocartilage by about four months post surgery, holding implications for the rehabilitation. [14]

Chondrocyte implantation procedures (CCI), a cell-based articular cartilage repair procedure that aims to provide complete hyaline repair tissues for articular cartilage repair, have been posed by some as an alternative to microfracture surgery. In February 2008, Saris et al. published a large-scale study claiming that CCI results in better structural repair for symptomatic cartilage defects of the knee than microfracture surgery. According to the study, one year after treatment, the regenerated tissue associated with CCI is of better quality than that of microfracture surgery. [15]

Use in professional sports

Many notable professional athletes have undergone the procedure. Partially because of the high level of stress placed on the knees by these athletes, the surgery is not a panacea and results have been mixed. Many players' careers effectively end despite the surgery. However, some players such as Jason Kidd, Steve Yzerman, John Stockton, Kenyon Martin and Zach Randolph [16] have been able to return at or near their pre-surgery form while players Ron Harper, Brian Grant, Chris Webber, Allan Houston, Penny Hardaway, and the late Derek Smith never regained their old form. [10] Others such as Jamal Mashburn and Terrell Brandon never recovered and retired. [ citation needed ]

Portland Trail Blazers rookie Greg Oden underwent the procedure on his right knee in early September 2007 and missed the entire 2007–2008 NBA season. At only 19 at the time of the surgery, doctors were confident that he would return to at or near his full strength by the 2008–2009 season; he had a second microfracture surgery, this time on his left knee, in November 2010. Subsequently, Oden did not play in the NBA for over four years, missing the entirety of the 2011–2012 and 2012–2013 NBA seasons. [17] The former San Antonio Spurs and Houston Rockets player, Tracy McGrady also underwent microfracture surgery; doctors were confident that the two-time scoring champion would return to full strength. As of 2012 he has not had the same speed and jumping ability he formerly did. McGrady retired in 2013, never regaining his previous form after the surgery.

In October 2005, young star Amar'e Stoudemire of the NBA's Phoenix Suns underwent one of the highest-profile microfracture surgeries to date. He returned to the court in March 2006 and initially appeared to have made a full recovery, but subsequently started feeling stiffness in both knees (his right knee had been overcompensating for the injured left knee). He and the team doctor decided he needed more time to rehab and he did not return until the 2006–2007 NBA season. [18] During the 2006–2007 season, Stoudemire returned to form, averaging 20.4 points and 9.6 rebounds per game while playing in all 82 regular-season games and the 2007 NBA All-Star Game. His success brought positive publicity to the procedure, further distancing it from a previous reputation as a possible "career death sentence" in the sports world, though he was one of the youngest of the aforementioned players to undergo the surgery. [19]

In June 2010, Grady Sizemore of the Cleveland Indians underwent microfracture surgery after injuring his left knee while diving back to first base earlier in the season. Sizemore was re-activated as the Indians center fielder in April 2011, ending an 11-month stretch of being disabled due to his injury. In his first game back on April 17, 2011, Sizemore showed no signs of slowing down as he had two hits in four AB which included a double and home run. Currently, Sizemore is the only player in MLB history to come back from knee microfracture surgery and play center field. [20]

Terrell Davis is one of the only notable football players that have the procedure done as well.

Recovery

One study has shown a success rate of 75 to 80 percent among patients 45 years of age or younger. [21] [22]

It is an outpatient procedure and causes only small discomfort. The harder part is the restrictions that are placed on the patient during the post-operative recovery period. This can be a major challenge for many patients. For optimal re-growth of joint surface, the patients need to be very patient and also extremely cooperative. They usually need to be on crutches for four to six weeks (sometimes longer). Sometimes a brace is needed. This all depends on the size and/or location of the joint surface defect that is being repaired or regenerated. The patients are encouraged to spend approximately 6–8 hours a day on a CPM (continuous passive motion) machine that helps with optimal re-growth of joint surface. The procedure can be painless for some patients to the extent that the patients avoid these critically important steps and expose the knee to physical activity before the joint fully heals. However, with other patients the procedure can be very painful for weeks even months. Pain medication may be required to manage pain levels in those patients.[ citation needed ]

Steadman cites the significance of a patient's natural joint alignment in addition to disciplined rehabilitation in recovery from the procedure. [10]

Related Research Articles

<span class="mw-page-title-main">Cartilage</span> Resilient and smooth elastic tissue present in animals

Cartilage is a resilient and smooth type of connective tissue. It is a semi-transparent and non-porous type of tissue. It is usually covered by a tough and fibrous membrane called perichondrium. In tetrapods, it covers and protects the ends of long bones at the joints as articular cartilage, and is a structural component of many body parts including the rib cage, the neck and the bronchial tubes, and the intervertebral discs. In other taxa, such as chondrichthyans and cyclostomes, it constitutes a much greater proportion of the skeleton. It is not as hard and rigid as bone, but it is much stiffer and much less flexible than muscle. The matrix of cartilage is made up of glycosaminoglycans, proteoglycans, collagen fibers and, sometimes, elastin. It usually grows quicker than bone.

<span class="mw-page-title-main">Knee</span> Leg joint in primates

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

<span class="mw-page-title-main">Osteochondritis dissecans</span> Ischemic bone disease

Osteochondritis dissecans is a joint disorder primarily of the subchondral bone in which cracks form in the articular cartilage and the underlying subchondral bone. OCD usually causes pain during and after sports. In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. Physical examination in the early stages does only show pain as symptom, in later stages there could be an effusion, tenderness, and a crackling sound with joint movement.

A meniscus transplant or meniscal transplant is a transplant of the meniscus of the knee, which separates the thigh bone (femur) from the lower leg bone (tibia). The worn or damaged meniscus is removed and is replaced with a new one from a donor. The meniscus to be transplanted is taken from a cadaver, and, as such, is known as an allograft. Meniscal transplantation is technically difficult, as it must be sized accurately for each person, positioned properly and secured to the tibial plateau. Its success also depends on donor compatibility, stability of the transplant, and long-term health of the underlying articular cartilage.

<span class="mw-page-title-main">Chondrogenesis</span>

Chondrogenesis is the biological process through which cartilage tissue is formed and developed. This intricate and tightly regulated cellular differentiation pathway plays a crucial role in skeletal development, as cartilage serves as a fundamental component of the embryonic skeleton. The term "chondrogenesis" is derived from the Greek words "chondros," meaning cartilage, and "genesis," meaning origin or formation.

Articular cartilage, most notably that which is found in the knee joint, is generally characterized by very low friction, high wear resistance, and poor regenerative qualities. It is responsible for much of the compressive resistance and load bearing qualities of the knee joint and, without it, walking is painful to impossible. Osteoarthritis is a common condition of cartilage failure that can lead to limited range of motion, bone damage and invariably, pain. Due to a combination of acute stress and chronic fatigue, osteoarthritis directly manifests itself in a wearing away of the articular surface and, in extreme cases, bone can be exposed in the joint. Some additional examples of cartilage failure mechanisms include cellular matrix linkage rupture, chondrocyte protein synthesis inhibition, and chondrocyte apoptosis. There are several different repair options available for cartilage damage or failure.

<span class="mw-page-title-main">Meniscus tear</span> Rupturing of the fibrocartilage strips in the knee called menisci

A tear of a meniscus is a rupturing of one or more of the fibrocartilage strips in the knee called menisci. When doctors and patients refer to "torn cartilage" in the knee, they actually may be referring to an injury to a meniscus at the top of one of the tibiae. Menisci can be torn during innocuous activities such as walking or squatting. They can also be torn by traumatic force encountered in sports or other forms of physical exertion. The traumatic action is most often a twisting movement at the knee while the leg is bent. In older adults, the meniscus can be damaged following prolonged 'wear and tear'. Especially acute injuries can lead to displaced tears which can cause mechanical symptoms such as clicking, catching, or locking during motion of the joint. The joint will be in pain when in use, but when there is no load, the pain goes away.

Articular cartilage repair treatment involves the repair of the surface of the articular joint's hyaline cartilage, though these solutions do not perfectly restore the articular cartilage. These treatments have been shown to have positive results for patients who have articular cartilage damage. They can provide some measure of pain relief, while slowing down the accumulation of damage, or delaying the need for joint replacement surgery.

Articular cartilage damage in the knee may be found on its own but it will more often be found in conjunction with injuries to ligaments and menisci. People with previous surgical interventions face more chances of articular cartilage damage due to altered mechanics of the joint. Articular cartilage damage may also be found in the shoulder causing pain, discomfort and limited movement. Cartilage structures and functions can be damaged. Such damage can result from a variety of causes, such as a bad fall or traumatic sport-accident, previous knee injuries or wear and tear over time. Immobilization for long periods can also result in cartilage damage.

Autologous chondrocyte implantation is a biomedical treatment that repairs damages in articular cartilage. ACI provides pain relief while at the same time slowing down the progression or considerably delaying partial or total joint replacement surgery.

Mesenchymal stem cells (MSCs) are multipotent cells found in multiple human adult tissues, including bone marrow, synovial tissues, and adipose tissues. Since they are derived from the mesoderm, they have been shown to differentiate into bone, cartilage, muscle, and adipose tissue. MSCs from embryonic sources have shown promise scientifically while creating significant controversy. As a result, many researchers have focused on adult stem cells, or stem cells isolated from adult humans that can be transplanted into damaged tissue.

Kevin Robert Stone is an American physician, orthopedic surgeon, clinician, researcher, and company founder of The Stone Clinic and the Stone Research Foundation in San Francisco.

Autologous matrix-induced chondrogenesis (AMIC) is a treatment for articular cartilage damage. It combines microfracture surgery with the application of a bi-layer collagen I/III membrane. There is tentative short to medium term benefits as of 2017.

<span class="mw-page-title-main">Hip arthroscopy</span>

Hip arthroscopy refers to the viewing of the interior of the acetabulofemoral (hip) joint through an arthroscope and the treatment of hip pathology through a minimally invasive approach. This technique is sometimes used to help in the treatment of various joint disorders and has gained popularity because of the small incisions used and shorter recovery times when compared with conventional surgical techniques. Hip arthroscopy was not feasible until recently, new technology in both the tools used and the ability to distract the hip joint has led to a recent surge in the ability to do hip arthroscopy and the popularity of it.

Cartilage repair techniques are the current focus of large amounts of research. Many different strategies have been proposed as solutions for cartilage defects. Surgical techniques currently being studied include:

<span class="mw-page-title-main">Index of trauma and orthopaedics articles</span>

Orthopedic surgery is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal injuries, sports injuries, degenerative diseases, infections, bone tumours, and congenital limb deformities. Trauma surgery and traumatology is a sub-specialty dealing with the operative management of fractures, major trauma and the multiply-injured patient.

The treatment of equine lameness is a complex subject. Lameness in horses has a variety of causes, and treatment must be tailored to the type and degree of injury, as well as the financial capabilities of the owner. Treatment may be applied locally, systemically, or intralesionally, and the strategy for treatment may change as healing progresses. The end goal is to reduce the pain and inflammation associated with injury, to encourage the injured tissue to heal with normal structure and function, and to ultimately return the horse to the highest level of performance possible following recovery.

<span class="mw-page-title-main">Alberto Gobbi</span> Italian surgeon (born 1956)

Alberto Gobbi is an Italian surgeon and researcher in orthopedics, traumatology and sports medicine known for his contributions in the fields of arthroscopic surgery, cartilage repair and regenerative medicine.

Nasal chondrocytes (NC) are present in the hyaline cartilage of the nasal septum and in fact are the only cell type within the tissue. Similar to chondrocytes present in articular cartilage, NC express extracellular matrix proteins such as glycosaminoglycans and collagen.

Artificial cartilage is a synthetic material made of hydrogels or polymers that aims to mimic the functional properties of natural cartilage in the human body. Tissue engineering principles are used in order to create a non-degradable and biocompatible material that can replace cartilage. While creating a useful synthetic cartilage material, certain challenges need to be overcome. First, cartilage is an avascular structure in the body and therefore does not repair itself. This creates issues in regeneration of the tissue. Synthetic cartilage also needs to be stably attached to its underlying surface i.e. the bone. Lastly, in the case of creating synthetic cartilage to be used in joint spaces, high mechanical strength under compression needs to be an intrinsic property of the material.

References

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