• Drilling angle different than microfracture
  
• Access different areas with pics
  
• No thermal effect
  
• Long term follow up shows continued improvement up to 3 years if good at 3 years then good at 9 years
  
• Age < 35 more acute lesions
  
• 2X2 cm lesion OK to microfracture
  
  

Periosteal graft +/- chondrocytes - Erickson

Periosteal graft (cambium layer down) glued over drilled subchondral bone - ESKA Journal -same results as with chondrocytes - but it was not hyaline cartilage

O'Driscoll - cambium layer up - reported good results

Peterson - chondrocytes - not an operation for osteoarthritis - isolated large (2X2) lesions on femoral condyle - 80% good results

There is currently a double blinded prospective randomized study of cells vs no cells - sponsored by Genzyme

Also another study of microfracture vs abrasion vs genzyme - blinded going into the procedure.

OATS - Bobic reported on 80 subjects in mostly ACL deficient knees at the AAOS

Many were 1 -2 cm lesions

Jurgen uses a small plug for OCD to fix the loose fragment and to fill the crater with larger plugs in other cases

Branch - Isolated chondral fractures - - single dowel 1cm look good. Mosacicplasty does not look as good, it is hard to reproduce the curvature

Tom Carter - 18 cases - favorable results

Roland Jacob is a believer in the OATS

The gap between the dowels doesn't heal normally, only with fibrocartilage. Does the donor site lead to OA?

Some cases had fibrocartilage grow out of the donor site.

One long tern study showed OA in the region of the dowel transplant.

Stone showed his microfracture and packing the base with blood clot and cartilage from the notch. Showed 1 year follow up with biopsies.




Natural History of Acute, Isolated Non-operated Treated Posterior Cruciate Ligament Injuries - Don Shelbourne

This study reported on 133 patients

All patients had original exam, but only half had exam in follow up (others were examined by questionnaire)

There was no correlation between quads strength and PCL grade

10/67 had x-ray changes in the involved knee, and no correlation with grade

There was no correlation with the pain and stability and the grade

54% reported no instability and did not correlate with objective laxity

The mean score of subjective results did not deteriorate over time.

The PCL is different than the ACL. The ACL doesn't heal.

The PCL heals but with abnormal laxity, does not change over time

What about the meniscal chondral injury in 20%? Only scope if symptomatic.

Only 4 patients had late arthroscopy for meniscal tear.

Important examination point. If in internal rotation, the posterior displacement is eliminated, then this is an isolated injury.




Long Term Results of Full Thickness Chondral Defects Treated with Microfracture - Richard Steadman

1200 cases of acute lesions over 15 years

Technique points

Not for degenerative joint disease

Cut the edges sharp with curette

Use pics at the edge and do not connect the dots - 2 mm

Rehab partial weight bearing and CPM for 8 weeks

For patellofemoral joint, brace in extension for 8 weeks


Results

235 pts > 2 yrs

no complications related to microfracture

75% improved

71% back to same sport at same level

result does not fall off over time

95% no further surgery at 4 years

92% at 7 years no further surgery

no difference in site for the < 35 yrs

no real difference in size of lesions

horse study - better looking fibrocartilage over time

Failures should be treated with genzyme




Advanced MRI of Articular Cartilage - Charles Ho

MRI arthrography - injection of fluid to outline the articular cartilage

Routine MRI with T1 and T2 and spin echo will demonstrate the cartilage

Must do 2 views - sagital/coronal + axial and T1 and T2

Blind spots must be examined for. Especially the trochlea




Articular Cartilage Injury - ACL Injury to Cartilage Grading - Paul Marks

Ctyokinins increase in the injured knee

88 patients had chondral surface injury grading

These patients were 6 months from injury, maybe they had re-injury

The 'ACL risk equation'

Message: This study demonstrated that the longer out from the ACL injury, the higher the grade of chondral injury.




High Tibial Osteotomy for the Treatment of OCD - Daniel Slawski

HTO should be done for a patient with OCD with varus angulation.

7 patients reported on

All had medial pain and positive bone scan

OCD knees had 0* of alignment pre and were corrected to 9* post-op

All patients had pain improved and returned to low level sports

The patients with crater defects, the outcome was not as good. These may need chondrocyte transplantation




Articular Cartilage Defects Associated with ACL Injuries - Dereck Bickerstaff

In this series of chronic ACL deficient patients, 20% had chondral defects, mostly medial side. 50% of these would be amenable to chondral grafting

There is no relationship with the meniscal tear and chondral injury

These chondral injuries are unexplained

Summary 1 in 10 chronic ACL deficient knees need some chondral surgery

No natural history known of these chondral injuries; so, do they need treatment?




Allograft Meniscal Reconstruction - T.P. Vail

Canine study to remove the meniscus, transplant it, and look for osteoarthritis

The transplant did not prevent osteoarthritis in the canine model.




Surgical Technique for Cartilage Transplantation - Kevin Stone

This is an interim procedure, after micro fracture and before the genzyme.

89 patients, chronic, 43 years old

large lesions 268 mm

Procedure

debride the crater

microfracture

take articular cartilage from the notch

pack graft into the base - punch it in. packing in with dowel

NWB for 6-8 weeks

re-scope and biopsy

Biopsy - fibrous tissue, type 1 and type 2 collagen (hyaline like cartilage)

He also grafts the trochlea

Results

Pain improved