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The comprehensive arthroscopic management (CAM) procedure for the treatment of glenohumeral osteoarthritis in young patients
Published in Andreas B. Imhoff, Jonathan B. Ticker, Augustus D. Mazzocca, Andreas Voss, Atlas of Advanced Shoulder Arthroscopy, 2017
Justin J. Mitchell, J. Christoph Katthagen, Salvatore J. Frangiamore, Sandeep Mannava, Peter J. Millett
If focal high grade Outerbridge grade IV chondral defects with stable walls are present, they are frequently treated with microfracture (Figure 45.4).23,24 Our preferred technique for microfracture includes stabilizing the walls of the lesion so that it remains fully contained, debriding the calcified cartilage layer with a combination of mechanical shavers and curettes, and finally perforation of the underlying subchondral bone with microfracture picks to a depth of 2–4 mm under arthroscopic visualization. The bone perforations should be no more than 3–4 mm apart and evenly spaced throughout the cartilage defect. After completing the microfracture procedure, inflow of arthroscopic fluid is temporarily stopped and a gentle suction is applied to the region of the microfracture. A completed and thorough microfracture procedure should yield egress of fat droplets, blood, and marrow out of each of the previously placed subchondral holes.
Articular Cartilage Pathology and Therapies
Published in Kyriacos A. Athanasiou, Eric M. Darling, Grayson D. DuRaine, Jerry C. Hu, A. Hari Reddi, Articular Cartilage, 2017
Kyriacos A. Athanasiou, Eric M. Darling, Grayson D. DuRaine, Jerry C. Hu, A. Hari Reddi
Microfracture is the simplest, quickest, and least expensive treatment option, with arthroscopic operating time being as little as 30–90 minutes. This technique has been widely employed for isolated chondral defects of the knee (Bae et al. 2006; Mithoefer et al. 2006), shoulder (Siebold et al. 2003), and ankle (Becher and Thermann 2005). Microfracture involves having the surgeon cause small fractures into the bone of a full-thickness defect connecting into the underlying bone marrow to allow bleeding and clot formation in the defect (Mithoefer et al. 2006). This also allows for stem cells and other factors in the bone marrow to migrate into the defect. The damaged cartilage is first removed down to the calcified zone to expose healthy adjacent tissue. The calcified cartilage is then removed, and an arthroscopic awl perforates the subchondral plate to a depth of approximately 4 mm, with holes spaced 3–4 mm apart. Blood fills the defect, resulting in a fibrin clot that initiates a healing response. This clot, over a period of 8–12 weeks, will be replaced with fibrocartilage, which, although filling the defect and providing improved outcomes, is less mechanically robust than hyaline cartilage. Thus, fibrocartilage only serves as a temporary treatment.
Mesenchymal Stem Cell Treatment of Cartilage Lesions in the Hip
Published in K. Mohan Iyer, Hip Joint in Adults: Advances and Developments, 2018
George Hourston, Stephen McDonnell, Wasim Khan
Related to microfracture, another therapeutic strategy that employs material from the affected joint is autologous chondrocyte implantation (ACI). ACI is a two-part procedure involving the isolation and expansion of chondrocytes from an intact non-weightbearing region of the joint and then transplantation of these cells into the osteochondral defect in the weight-bearing part of the joint, which are then covered with a periosteal flap [23,24]. ACI has been shown to produce more hyaline cartilage, containing type II collagen fibres, which are critical for the macromolecular structure of the extracellular matrix, which gives articular cartilage its unique biomechanical properties [24]. Alternatively, the implanted chondrocytes can be seeded onto a scaffold, a biodegradable type I/III collagen membrane, and this technique is commonly referred to as matrix-induced autologous chondrocyte implantation (MACI) [25,26]. MACI is thought to offer improved surgical application and clinical outcomes when compared with ACI [26,27]. These procedures involving chondrocyte implantation do offer an improvement over microfracture in reconstituting articular cartilage, but there are several problems. The chondrocytes used have a limited expansion capacity, and furthermore, ACI/MACI requires two surgeries: an initial arthroscopy to gather the chondrocytes and a cell implantation step, often an open surgery, exposing the patient to a risk of infection and prolonging his or her recovery [28]. It is also expensive owing to the laboratory costs of in vivo culturing of the cells as well as the extra theatre time [28]. These disadvantages have caused scarce adoption of ACI among hip surgeons, despite frequent use in the knee [28].
Epidemiology of pediatric cartilage restoration procedures in the United States: insurance and geography play a role
Published in The Physician and Sportsmedicine, 2023
Tyler B. Hall, Max J. Hyman, Neeraj M. Patel
In their recent systematic review, Valtanen et al found that OAT, OCA, and ACI all produced postoperative improvements in at least one patient-reported outcome score that surpassed the minimal clinically important difference (MCID) threshold. However, the authors also noted that inconsistent use of validated outcome measures makes it difficult to assess the relative efficacies of cartilage restoration procedures [15]. Beyond inconsistent reporting, there is a lack of high-quality evidence comparing the various cartilage restoration techniques in children and adolescents. To date, only one randomized clinical trial has studied cartilage restoration procedures in children. In this study, Gudas et al compared OAT to microfracture and reported failure rates of 0% and 41% for OAT and microfracture, respectively, at an average of 4.2 years follow-up. Furthermore, microfracture showed significant deterioration in clinical improvement over the study’s duration [8]. While these are promising results relative to microfracture, an operation that produces fibrocartilage, the long-term efficacy of OAT compared to other hyaline cartilage restoration procedures remains unclear in the pediatric population.
Poor outcome after a surgically treated chondral injury on the medial femoral condyle: early evaluation with dGEMRIC and 17-year radiographic and clinical follow-up in 16 knees
Published in Acta Orthopaedica, 2018
Jon Tjörnstrand, Paul Neuman, Björn Lundin, Jonas Svensson, Leif E Dahlberg, Carl Johan Tiderius
Cartilage injuries, with or without complicating ligamentous/meniscal injury, often occur after a twisting/compression trauma during sports activities. Cartilage has a limited healing potential with a complex structure with low chondrocyte density and avascularity. The best treatment for chondral defects remains controversial, despite decades of efforts (Hunziker et al. 2015). Microfracture (MFX) and autologous chondrocyte implantation (ACI) are the most commonly used techniques. In MFX, mesenchymal stem cells are recruited from the bone marrow by drilling or punching multiple holes in the subchondral bone plate of the cartilage lesion. First described in 1959 and having subsequently evolved, this is presently the most used technique (Pridie 1959, Steadman et al. 2001). ACI is a more technically demanding procedure, introduced in 1994 (Brittberg et al. 1994). This first-generation ACI includes two surgical procedures with arthroscopic harvesting of cartilage at the first operation for in vitro cultivation of chondrocytes. At the second operation, 3 weeks later, the expanded chondrocytes are injected under a periosteum flap that is sutured over the cartilage defect.
Arthroscopic triple arthrodesis for the patient with rheumatoid arthritis; a case report
Published in Modern Rheumatology Case Reports, 2021
Tomoyuki Nakasa, Yasunari Ikuta, Munekazu Kanemitsu, Nobuo Adachi
Subtalar joint: To access the subtalar joint, 2 portals were applied at the sinus tarsi (Figure 2(A,B)). A 2.7-mm 30° oblique arthroscope (Smith&Nephew, Memphis, TN) was used. Articular cartilage had broadly disappeared and exposed subchondral bone was partially covered with scar tissue (Figure 3(A)). Scar tissue and residual articular cartilage was curetted with a chisel, and the anterior, middle and the posterior facet were fully decorticated using a 3.5 mm cylindrical bone burr, taking care not to advance it in a medial direction, so as to avoid damage to the flexor hallucis tendon, tibial nerve and posterior tibial artery (Figure 3(B)). After that, microfracture was performed to promote subchondral bleeding (Figure 3(C)).