Clinical Relevance of Chondral Lesions in the Treatment of the ACL-Deficient Knee: Microfracture Technique

  • Mark R. Geyer
  • William G. Rodkey
  • J. Richard Steadman
Chapter

Abstract

Anterior cruciate ligament (ACL) injuries and chondral defects are commonly associated. These chondral injuries can occur simultaneously with the ACL injury or remotely as a secondary injury from instability in the ACL-deficient knee. The literature does not provide clear direction in the management of this combination of injuries. If a chondral injury is encountered at the time of ACL treatment, we recommend that it be treated either concurrently or separately in a staged procedure. Despite a number of procedures described in the literature for chondral defects, our procedure of choice is microfracture. Microfracture is an economical, straightforward technique with a proven track record. The steps of the procedure and the associated rehabilitation process are critically related to one another, and all steps must be followed as described. The goal is to provide the optimal environment for the body’s own progenitor cells to make the reparative tissue in the defect. Over a course of 30 years, our experience with microfracture has developed and evolved through both basic science and clinical research. We have shown excellent results in treating patients with microfracture when the technique and rehabilitation are followed rigorously.

Keywords

Drilling Osteoarthritis Perforation 

References

  1. 1.
    Bekkers JE, Inklaar M, Saris DB. Treatment selection in articular cartilage lesions of the knee: a systematic review. Am J Sports Med. 2009;37 Suppl 1:148S–55.PubMedCrossRefGoogle Scholar
  2. 2.
    Blevins FT, Steadman JR, Rodrigo JJ, et al. Treatment of articular cartilage defects in athletes: an analysis of functional outcome and lesion appearance. Orthopedics. 1998;21:761–8.PubMedGoogle Scholar
  3. 3.
    Brophy RH, Zeltser D, Wright RW, et al. Anterior cruciate ligament reconstruction and concomitant articular cartilage injury: incidence and treatment. Arthroscopy. 2010;26:112–20.PubMedCrossRefGoogle Scholar
  4. 4.
    Frisbie DD, Trotter GW, Powers BE, et al. Arthroscopic subchondral bone plate microfracture technique augments healing of large chondral defects in the radial carpal bone and medial femoral condyle of horses. Vet Surg. 1999;28:242–55.PubMedCrossRefGoogle Scholar
  5. 5.
    Frisbie DD, Oxford JT, Southwood L, et al. Early events in cartilage repair after subchondral bone microfracture. Clin Orthop Relat Res. 2003;407:215–27.PubMedCrossRefGoogle Scholar
  6. 6.
    Frisbie DD, Morisset S, Ho CP, et al. Effects of calcified cartilage on healing of chondral defects treated with microfracture in horses. Am J Sports Med. 2006;34:1824–31.PubMedCrossRefGoogle Scholar
  7. 7.
    Gomoll AH, Filardo G, de Girolamo L, et al. Surgical treatment for early osteoarthritis. Part I: cartilage repair procedures. Knee Surg Sports Traumatol Arthrosc. 2012;20(3):450–66. doi: 10.1007/s00167-011-1780-x. Epub 2011 Nov 24.PubMedCrossRefGoogle Scholar
  8. 8.
    Harris JD, Brophy RH, Siston RA, et al. Treatment of chondral defects in the athlete’s knee. Arthroscopy. 2010;26:841–52.PubMedCrossRefGoogle Scholar
  9. 9.
    Hurst JM, Steadman JR, O’Brien L, et al. Rehabilitation following microfracture for chondral injury in the knee. Clin Sports Med. 2010;29:257–65.PubMedCrossRefGoogle Scholar
  10. 10.
    Joseph C, Pathak SS, Aravinda M, et al. Is ACL reconstruction only for athletes? A study of the incidence of meniscal and cartilage injuries in an ACL-deficient athlete and non-athlete population: an Indian experience. Int Orthop. 2008;32:57–61.PubMedCrossRefGoogle Scholar
  11. 11.
    Lewis PB, Nho SJ, Colton AE, et al. Overview and first-line treatment. In: Cole BJ, Busam ML, editors. Surgical management of articular cartilage defects in the knee. Chicago: AAOS; 2009.Google Scholar
  12. 12.
    Maffulli N, Binfield PM, King JB. Articular cartilage lesions in the symptomatic anterior cruciate ligament-deficient knee. Arthroscopy. 2003;19:685–90.PubMedCrossRefGoogle Scholar
  13. 13.
    Mithoefer K, Steadman RJ. Microfracture in football (soccer) players: a case series of professional athletes and systematic review. Cartilage. 2012;3:18S–24.CrossRefGoogle Scholar
  14. 14.
    O’Connor DP, Laughlin MS, Woods GW. Factors related to additional knee injuries after anterior cruciate ligament injury. Arthroscopy. 2005;21:431–8.PubMedCrossRefGoogle Scholar
  15. 15.
    Osti L, Papalia R, Del Buono A, et al. Good results five years after surgical management of anterior cruciate ligament tears, and meniscal and cartilage injuries. Knee Surg Sports Traumatol Arthrosc. 2010;18:1385–90.PubMedCrossRefGoogle Scholar
  16. 16.
    Potter HG, Jain SK, Ma Y, et al. Cartilage injury after acute, isolated anterior cruciate ligament tear: immediate and longitudinal effect with clinical/MRI follow-up. Am J Sports Med. 2012;40(2):276–85. doi: 10.1177/0363546511423380. Epub 2011 Sep 27.PubMedCrossRefGoogle Scholar
  17. 17.
    Rodrigo JJ, Steadman JR, Silliman JF, et al. Impro­vement of full-thickness chondral defect healing in the human knee after debridement and microfracture using continuous passive motion. Am J Knee Surg. 1994;7:109–16.Google Scholar
  18. 18.
    Røtterud JH, Risberg MA, Engebretsen L, et al. Patients with focal full-thickness cartilage lesions benefit less from ACL reconstruction at 2–5 years follow-up. Knee Surg Sports Traumatol Arthrosc. 2011. doi: 10.1007/s00167-011-1739-y [Epub ahead of print].
  19. 19.
    Shelbourne KD, Jari S, Gray T. Outcome of untreated traumatic articular cartilage defects of the knee: a natural history study. J Bone Joint Surg Am. 2003;85-A Suppl 2:8–16.PubMedGoogle Scholar
  20. 20.
    Slauterbeck JR, Kousa P, Clifton BC, et al. Geographic mapping of meniscus and cartilage lesions associated with anterior cruciate ligament injuries. J Bone Joint Surg Am. 2009;91:2094–103.PubMedCrossRefGoogle Scholar
  21. 21.
    Steadman JR, Rodkey WG, Rodrigo JJ. Microf­racture: surgical technique and rehabilitation to treat chondral defects. Clin Orthop Relat Res. 2001;391(Suppl):S362–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Steadman JR, Rodkey WG, Briggs KK. Microfracture to treat full-thickness chondral defects: surgical technique, rehabilitation, and outcomes. J Knee Surg. 2002;15:170–6.PubMedGoogle Scholar
  23. 23.
    Steadman JR, Rodkey WG, Briggs KK. Microfracture chondroplasty: indications, techniques, and outcomes. Sports Med Arthrosc. 2003;11:236–44.CrossRefGoogle Scholar
  24. 24.
    Steadman JR, Miller BS, Karas SG, et al. The microfracture technique in the treatment of full-thickness chondral lesions of the knee in National Football League players. J Knee Surg. 2003;16:83–6.PubMedGoogle Scholar
  25. 25.
    Steadman JR, Briggs KK, Rodrigo JJ, et al. Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. Arthroscopy. 2003;19:477–84.PubMedCrossRefGoogle Scholar
  26. 26.
    Steadman JR, Rodkey WG, Briggs KK. Microfracture: its history and experience of the developing surgeon. Cartilage. 2010;1:78–86.CrossRefGoogle Scholar
  27. 27.
    Tandogan RN, Taşer O, Kayaalp A, et al. Analysis of meniscal and chondral lesions accompanying anterior cruciate ligament tears: relationship with age, time from injury, and level of sport. Knee Surg Sports Traumatol Arthrosc. 2004;12:262–70.PubMedCrossRefGoogle Scholar
  28. 28.
    Widuchowski W, Widuchowski J, Koczy B, et al. Untreated asymptomatic deep cartilage lesions associated with anterior cruciate ligament injury: results at 10- and 15-year follow-up. Am J Sports Med. 2009;37:688–92.PubMedCrossRefGoogle Scholar
  29. 29.
    Yüksel HY, Erkan S, Uzun M. The evaluation of intraarticular lesions accompanying ACL ruptures in military personnel who elected not to restrict their daily activities: the effect of age and time from injury. Knee Surg Sports Traumatol Arthrosc. 2006;14:1139–47.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  • Mark R. Geyer
    • 1
  • William G. Rodkey
    • 2
  • J. Richard Steadman
    • 1
  1. 1.The Steadman Clinic, Orthopaedic Sports MedicineVailUSA
  2. 2.Steadman Philippon Research InstituteVailUSA

Personalised recommendations