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Repairing Knee Damage: The Microfracture Option (part 1 of 2)

November 9, 2004 12:01 PM

By Jim Brown, Ph.D., Executive Editor, Sports Performance Journal (athletesperformance.com), and Author, Tennis: Steps to Success, 3rd Edition

Tennis players and other athletes who sustain certain types of knee injuries may be candidates for a procedure called microfracture. Microfracture is a surgical technique to treat full-thickness tears — that is, when the damage involves loss of articular cartilage all the way down to the bone.

Microfracture is an arthroscopic procedure that has been developed by Richard Steadman, M.D., an internationally recognized orthopaedic surgeon at the Steadman-Hawkins Clinic in Vail, Colorado. Although the vast majority of the patients who undergo microfracture experience significant pain relief (including elite athletes who return to participation at the highest level), it is a procedure that is still not practiced universally. It is not clear why, but Arun Ramappa, M.D., an orthopaedic surgeon at Harvard Medical School, speculates that the profitability of total knee replacement makes it a more attractive alternative to the medical community than a procedure that allows for tissue regeneration on the surface of the knee. It should be noted that of those who choose the mircofracture option, 15 percent notice no change and five percent continue to have joint deterioration.

Are You a Candidate?
The symptoms of an articular cartilage injury that may be treated with the microfracture technique include:
• intermittent swelling caused by loose fragments floating in the knee
• pain with prolonged walking or climbing stairs
• giving way when the knee occasionally buckles or gives way
• locking or catching caused by loose, floating pieces of cartilage that catch in the joint as it bends
• Noise (crepitus) during motion, especially if the cartilage on the back of the kneecap is damaged

Who Is Not a Candidate?
Microfracture is not recommended when:
• the knee is poorly aligned.
• the defect is not all the way through the full thickness of the cartilage.
• the patient is not willing to follow a strict and rigorous rehabilitation protocol.
• the patient is older (generally over 65) and might have difficulty with crutch use and the rehabilitation process.
• the patient has disease-induced arthritis, cartilage disease, or any disease affecting the immune system (for example, rheumatoid arthritis)

The Microfracture Procedure
The microfracture procedure is done arthroscopically. The surgeon assesses the defect and performs the procedure using instruments that are inserted through three small incisions on the knee. Any unstable cartilage is removed from the exposed bone. The surrounding rim of remaining articular cartilage is checked for loose cartilage. This cartilage is also removed so that there is a stable edge of cartilage surrounding the defect.

Multiple holes, or microfractures, are then made in the exposed bone about 3 to 4mm apart. Bone marrow cells and blood from the holes combine to form a "super clot" that completely covers the damaged area. This clot is the basis for the new tissue formation. The microfracture technique produces a rough bone surface that the clot adheres to more easily. This clot eventually matures into firm repair tissue that becomes smooth and durable. Since this maturing process is gradual, it usually takes two to six months after the procedure for the patient to experience improvement in the pain and function of the knee. Improvement is likely to continue for two to three years.

In the next Sports Science column, possible complications, the rehabilitation process, and limitations of the microfracture procedure will be discussed.

© 2004 HMS Publishing, Inc.
Jim Brown will be contributing new content to this site on a monthly basis. If you have a question for Dr. Brown please feel free to email him at
sportsmed@mindspring.com.

 

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