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      The subchondral bone in articular cartilage repair: current problems in the surgical management

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          Abstract

          As the understanding of interactions between articular cartilage and subchondral bone continues to evolve, increased attention is being directed at treatment options for the entire osteochondral unit, rather than focusing on the articular surface only. It is becoming apparent that without support from an intact subchondral bed, any treatment of the surface chondral lesion is likely to fail. This article reviews issues affecting the entire osteochondral unit, such as subchondral changes after marrow-stimulation techniques and meniscectomy or large osteochondral defects created by prosthetic resurfacing techniques. Also discussed are surgical techniques designed to address these issues, including the use of osteochondral allografts, autologous bone grafting, next generation cell-based implants, as well as strategies after failed subchondral repair and problems specific to the ankle joint. Lastly, since this area remains in constant evolution, the requirements for prospective studies needed to evaluate these emerging technologies will be reviewed.

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          Most cited references71

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          Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up.

          In this study, we measured functional outcomes of patients treated arthroscopically with microfracture for full-thickness traumatic defects of the knee. A case series of patients with 7 to 17 years' follow-up. Between 1981 and 1991, a total of 72 patients (75 knees) met the following inclusion criteria: (1) traumatic full-thickness chondral defect, (2) no meniscus or ligament injury, and (3) age 45 years and younger (range, 13 to 45 years). Seventy-one knees (95%) were available for final follow-up (range, 7 to 17 years). All patients completed self-administered questionnaires preoperatively and postoperatively. The following results were significant at the P <.05 level. Significant improvement was recorded for both Lysholm (scale 1 to 100; preoperative, 59; final follow-up, 89) and Tegner (1 to 10; preoperative, 3; final follow-up, 6) scores. At final follow-up, the SF-36 and WOMAC scores showed good to excellent results. At 7 years after surgery, 80% of the patients rated themselves as "improved." Multivariate analysis revealed that age was a predictor of functional improvement. Over the 7- to 17-year follow-up period (average, 11.3 years), patients 45 years and younger who underwent the microfracture procedure for full-thickness chondral defects, without associated meniscus or ligament pathology, showed statistically significant improvement in function and indicated that they had less pain.
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            Microfracture: surgical technique and rehabilitation to treat chondral defects.

            Full-thickness articular cartilage defects rarely heal spontaneously. Some patients may not have clinically significant problems from chondral defects, but most eventually have degenerative changes. Techniques to treat chondral defects include abrasion, drilling, autografts, allografts, and cell transplantation. The senior author (JRS) developed the microfracture technique to enhance chondral resurfacing by providing a suitable environment for new tissue formation and taking advantage of the body's own healing potential. Microfracture has been done in more than 1800 patients. Specially designed awls are used to make multiple perforations, or microfractures, into the subchondral bone plate. Perforations are made as close together as possible, but not so close that one breaks into another. They usually are approximately 3 to 4 mm apart. The integrity of the subchondral bone plate must be maintained. The released marrow elements (including mesenchymal stem cells, growth factors, and other healing proteins) form a surgically induced super clot that provides an enriched environment for new tissue formation. The rehabilitation program is crucial to optimize the results of the surgery. It promotes the ideal physical environment for the marrow mesenchymal stem cells to differentiate into articular cartilagelike cells, ultimately leading to development of a durable repair cartilage that fills the original defect.
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              Results after microfracture of full-thickness chondral defects in different compartments in the knee.

              To determine if the clinical results after microfracture of full-thickness cartilage lesions deteriorate over a period of 36 months. Between 1999 and 2002 85 patients (mean age 39.5 years) with full-thickness cartilage lesions underwent the microfracture procedure and were evaluated preoperatively and 6, 18 and 36 months after surgery. Exclusion criteria were meniscal pathologies, axial malpositioning and ligament instabilities. Baseline clinical scores were compared with follow-up data by paired Wilcoxon-tests for the modified Cincinnati knee and the International Cartilage Repair Society (ICRS)-score. The effects of the lesion localization and Magnetic resonance imaging (MRI) parameters were evaluated using the Pearson correlation and independent samples tests. Both scores revealed significant improvement 18 months after microfracture (P<0.0001). Within the second 18 months after surgery there was a significant deterioration in the ICRS-score (P<0.0001). The best results could be observed in chondral lesions of the femoral condyles. Defects in other areas of the knee deteriorated between 18 and 36 months after microfracture. MRI 36 months after surgery revealed best defect filling in lesions on the femoral condyles with significant difference in the other areas (P<0.02). The Pearson coefficient of correlation between defect filling and ICRS-score was 0.84 and significant at the 0.01 level. Microfracture is a minimal invasive method with good short-term results in the treatment of small cartilage defects. A deterioration of the results starts 18 months after surgery and is most evident in the ICRS-score. The best prognostic factors have young patients with defects on the femoral condyles.
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                Author and article information

                Contributors
                +1-617-7329813 , +1-617-7329730 , agomoll@partners.org
                Journal
                Knee Surg Sports Traumatol Arthrosc
                Knee Surgery, Sports Traumatology, Arthroscopy
                Springer-Verlag (Berlin/Heidelberg )
                0942-2056
                1433-7347
                4 February 2010
                4 February 2010
                April 2010
                : 18
                : 4
                : 434-447
                Affiliations
                [1 ]Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 850 Boylston St. Suite 112, Chestnut Hill, MA 02467 USA
                [2 ]Institute for Experimental Orthopaedics, Saarland University and Department of Orthopaedic Surgery, Saarland University Medical Center, Kirrberger Strasse, Building 37, 66421 Homburg, Germany
                [3 ]Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Room G4-219, PO Box 22700, 1100 Amsterdam, The Netherlands
                [4 ]Department of Orthopaedic Surgery, University of Tromsø, University Hospital North Norway, 9038 Tromsø, Norway
                [5 ]Service de Chirurgie Orthopédique, Centre de L’ Appareil Locomoteur de Médecine du Sport et de Prévention, Centre Hospitalier de Luxembourg-Clinique d’Eich 78, rue d’Eich, 1460 Luxembourg, Luxembourg
                [6 ]Department of Orthopaedics, Kungsbacka Hospital, Cartilage Research Unit, University of Gothenburg, 43480 Kungsbacka, Sweden
                [7 ]Laboratorio di Biomeccanica, Istituti Ortopedici Rizzoli, Via Di Barbiano, 1/10, 40136 Bologna, Italy
                Article
                1072
                10.1007/s00167-010-1072-x
                2839476
                20130833
                e10dcf0e-7bde-4d21-95ca-f1b710b71873
                © The Author(s) 2010
                History
                : 8 January 2010
                : 15 January 2010
                Categories
                Knee
                Custom metadata
                © Springer-Verlag 2010

                Surgery
                microfracture,cartilage repair,subchondral bone,autologous chondrocyte implantation
                Surgery
                microfracture, cartilage repair, subchondral bone, autologous chondrocyte implantation

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