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


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          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 references 72

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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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              Autologous chondrocyte implantation compared with microfracture in the knee. A randomized trial.

              New methods have been used, with promising results, to treat full-thickness cartilage defects. The objective of the present study was to compare autologous chondrocyte implantation with microfracture in a randomized trial. We are not aware of any previous randomized studies comparing these methods. Eighty patients without general osteoarthritis who had a single symptomatic cartilage defect on the femoral condyle in a stable knee were treated with autologous chondrocyte implantation or microfracture (forty in each group). We used the International Cartilage Repair Society, Lysholm, Short Form-36 (SF-36), and Tegner forms to collect data. An independent observer performed a follow-up examination at twelve and twenty-four months. Two years postoperatively, arthroscopy with biopsy for histological evaluation was carried out. The histological evaluation was done by a pathologist and a clinical scientist, both of whom were blinded to each patient's treatment. In general, there were small differences between the two treatment groups. At two years, both groups had significant clinical improvement. According to the SF-36 physical component score at two years postoperatively, the improvement in the microfracture group was significantly better than that in the autologous chondrocyte implantation group (p = 0.004). Younger and more active patients did better in both groups. There were two failures in the autologous chondrocyte implantation group and one in the microfracture group. No serious complications were reported. Biopsy specimens were obtained from 84% of the patients, and histological evaluation of repair tissues showed no significant differences between the two groups. We did not find any association between the histological quality of the tissue and the clinical outcome according to the scores on the Lysholm or SF-36 form or the visual analog scale. Both methods had acceptable short-term clinical results. There was no significant difference in macroscopic or histological results between the two treatment groups and no association between the histological findings and the clinical outcome at the two-year time-point. Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

                Author and article information

                +1-617-7329813 , +1-617-7329730 , agomoll@partners.org
                Knee Surg Sports Traumatol Arthrosc
                Knee Surgery, Sports Traumatology, Arthroscopy
                Springer-Verlag (Berlin/Heidelberg )
                4 February 2010
                4 February 2010
                April 2010
                : 18
                : 4
                : 434-447
                [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
                © The Author(s) 2010
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                © Springer-Verlag 2010


                microfracture, cartilage repair, subchondral bone, autologous chondrocyte implantation


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