Microfracture for chondral defects of the kneeMicrofracture for chondral defects of the knee

Mr S. Kaleel, MRCS;Mr S. Kaleel, MRCS; Mr Z.Ahmad, MRCS; Mr S. Daivajna, MRCS; Mr C. Servant, FRCSMr Z.Ahmad, MRCS; Mr S. Daivajna, MRCS; Mr C. Servant, FRCSDepartment of Orthopaedics, Ipswich Hospital, Ipswich, Suffolk, United Kingdom.Department of Orthopaedics, Ipswich Hospital, Ipswich, Suffolk, United Kingdom.

Ipswich NHS Trust IntroductionIntroduction

Chondral regeneration can occur when provided an Chondral regeneration can occur when provided an appropriate environment for tissue regeneration.appropriate environment for tissue regeneration.

Microfracture of the bone releases pluripotent Microfracture of the bone releases pluripotent mesenchymal stem cells from the subchondral bone mesenchymal stem cells from the subchondral bone marrow leading to fibrocartilage formation (Steadman)marrow leading to fibrocartilage formation (Steadman)

Indications for microfracture treatment(Knutsen)Indications for microfracture treatment(Knutsen)– Full thickness loss of articular cartilageFull thickness loss of articular cartilage– Unstable cartilage overlying sub-chondral boneUnstable cartilage overlying sub-chondral bone– Degenerative joint disease with normal alignmentDegenerative joint disease with normal alignment

Contraindications (Knutsen):Contraindications (Knutsen):– Malalignment/InstabilityMalalignment/Instability– Partial thickness lossPartial thickness loss– Reciprocal lesionsReciprocal lesions– Patient unable or unwilling to comply with rehabilitationPatient unable or unwilling to comply with rehabilitation– Systemic Inflammatory ArthritisSystemic Inflammatory Arthritis– Clotting disorderClotting disorder

Study AimStudy Aim● ● To evaluate the outcome of microfracture treatment for To evaluate the outcome of microfracture treatment for

chondral defects.chondral defects.

Patients and MethodsPatients and MethodsThe patients were prospectively collected are those who The patients were prospectively collected are those who were diagnosed with chondral defects between 2005-2009 were diagnosed with chondral defects between 2005-2009

Single surgeon series: A total of 41 patients (27 Male: 14 Single surgeon series: A total of 41 patients (27 Male: 14 females) with age range of 16-73 had microfracture females) with age range of 16-73 had microfracture performed on their knees.performed on their knees.

– We collected the mechanism of injury, We collected the mechanism of injury, compartment involved, BMI, time since injury, compartment involved, BMI, time since injury, compartment, size of injury, and compartment, size of injury, and Tegner/Lysholm Scores.Tegner/Lysholm Scores.

Method:Method:1.1. Make curretage of area to remove unstable cartilage. Make curretage of area to remove unstable cartilage.

2.2. Clear subchondral bone(Fig. 1)Clear subchondral bone(Fig. 1)

3.3. Bone is perforated with tapered tool 3mm in diameter Bone is perforated with tapered tool 3mm in diameter and in depth. (Fig. 2)and in depth. (Fig. 2)

4.4. Resulting clot will result in fibrocartilagenous repair.(Fig. Resulting clot will result in fibrocartilagenous repair.(Fig. 3)3)

ResultsResults

Age-Tegner Score

43

73

5863

0

20

40

60

80

100

Age < 40 (N=14) Age > 40 (N=27)

Lysholm Pre op

Lysholm Post op

Age-Lysholm Score

Traumatic group: 23 patients 15 femoral compartment8 patella compartment Age Range: 16 to 58

Degenerative Group: 18 patients 8 femoral compartment10 patella compartment Age Range: 20-73

Conclusion:Microfracture :•Tegner Score stays the same in under 40 year age group.•Lysholm improves by 30pts to 73 in younger age group.•Lysholm improves in pts with less than BMI 30 in both tibiofemoral group and patello femoral group.•Gives symptom relief for chondral defects•Is more effective in younger patients and for traumatic lesions

•References:•Steadman 2003 Arthroscopy:

•Outcomes of Microfracture for Traumatic Chondral Defects of the Knee in under 45 year old patients

•Knutsen RCT JBJS 2004,2007•ACI vs Microfracture 2yr & 5 yr results

•Mithoefer: Prospective Cohort; JBJS 2005•The Microfracture Technique for the Treatment of Articular Cartilage Lesions in the Knee. A prospective cohort study.

5. Recovery Protocol:5. Recovery Protocol:

PFJ Protocol:PFJ Protocol:

Cyclical exerciseCyclical exercise

Brace - locked to allow 0 - 30°Brace - locked to allow 0 - 30°

FWB within braceFWB within brace

Strength training within range set by braceStrength training within range set by brace

After 8 wks, wean out of braceAfter 8 wks, wean out of brace

Closed chain exercisesClosed chain exercises

Return to full activity at 4 months Return to full activity at 4 months

Tibiofemoral protocol:Tibiofemoral protocol:• Cyclical exerciseCyclical exercise• Toe-touch weight-bearing for 6-8 wksToe-touch weight-bearing for 6-8 wks• Cycling – from 1 to 2 weeksCycling – from 1 to 2 weeks• Deep Water Exercise – from 1 to 2 weeksDeep Water Exercise – from 1 to 2 weeks• After 8 wks, FWB and active ROMAfter 8 wks, FWB and active ROM• No cutting, turning or jumping for 3-4 No cutting, turning or jumping for 3-4

months months

Distribution of defect:Distribution of defect:

Compartment Treated:Compartment Treated:

Distribution of BMI:Distribution of BMI:

Figure 1 Figure 2 Figure 3