Microfracture surgery - AbsoluteAstronomy.com

Microfracture surgery is one of the articular cartilage repair

Articular cartilage repair

The aim of an articular cartilage repair treatment is to restore the surface of an articular joint's hyaline cartilage. Over the last decades, surgeons and researchers have been working hard to elaborate surgical cartilage repair interventions...

surgical techniques

Surgery

Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

that works by creating tiny fractures

Bone fracture

A bone fracture is a medical condition in which there is a break in the continuity of the bone...

in the underlying bone

Bone

Bones are rigid organs that constitute part of the endoskeleton of vertebrates. They support, and protect the various organs of the body, produce red and white blood cells and store minerals. Bone tissue is a type of dense connective tissue...

. This causes new cartilage to develop from a so-called super-clot. Microfracture surgery has gained a profile in the sports world in recent years; numerous professional athletes including members of the NBA (most notably Anfernee Hardaway, Jason Kidd

Jason Kidd

Jason Frederick Kidd is an American professional basketball point guard who plays for the Dallas Mavericks of the National Basketball Association. Raised in Oakland, California, Kidd played college basketball at the University of California, Berkeley and was drafted second overall by the Dallas...

, Greg Oden

Greg Oden

Gregory Wayne Oden, Jr. is an American basketball player at the center position. Oden is a member of the Portland Trail Blazers of the NBA....

, Allan Houston

Allan Houston

Allan Wade Houston is a retired American professional basketball player for the NBA, and currently the Assistant General Manager for the New York Knicks. He was one of the top 3-point shooters in the NBA until a knee injury forced him to retire...

, Kenyon Martin

Kenyon Martin

Kenyon Lee Martin is an American professional basketball player. Nicknamed "K-Mart", he plays for the Xinjiang Flying Tigers in China. He was selected first overall in the 2000 NBA Draft, and has played in the NBA for the New Jersey Nets and Denver Nuggets...

, Tracy McGrady

Tracy McGrady

Tracy Lamar McGrady, Jr., is an American professional basketball player who last played for the Detroit Pistons.Entering the league after graduating from high school, McGrady eventually became a seven-time All-Star. He led the league in scoring in 2003 and 2004. He has also played for the Toronto...

, Chris Webber

Chris Webber

Mayce Edward Christopher "Chris" Webber, III , nicknamed C-Webb, is a retired American professional basketball player. He is a five-time NBA All-Star, a former All-NBA First Teamer, a former NBA Rookie of the Year, and a former #1 overall NBA Draftee...

, and Amar'e Stoudemire), MLB, NFL and NHL have undergone the procedure.

The surgery is quick (taking as short as 30 minutes but sometimes lasting as long as 90 minutes), is minimally invasive, and can have a significantly shorter recovery time than an arthroplasty

Arthroplasty

Arthroplasty is an operative procedure of orthopedic surgery performed, in which the arthritic or dysfunctional joint surface is replaced with something better or by remodeling or realigning the joint by osteotomy or some other procedure.-Background:Previously, a popular form of arthroplasty was...

(knee replacement

Knee replacement

Knee replacement, or knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve the pain and disability of osteoarthritis. It may be performed for other knee diseases such as rheumatoid arthritis and psoriatic arthritis...

Background

Chronic articular cartilage defects do not heal spontaneously. However, acute traumatic osteochondral lesions or surgically created lesions extending into subchondral bone, e.g. by Pridie

Kenneth Pridie

Kenneth Hampden Pridie was an English athlete who competed in the 1930 British Empire Games and in the 1934 British Empire Games....

drilling, spongialization abrasion or microfracture causing the release of pluripotent mesenchymal stem cells from the bone marrow, may heal with repair tissue consisting of fibrous tissue, fibrocartilage or hyaline-like cartilage. The quality of the repair tissue after these "bone marrow stimulating techniques" depends on various factors including the species and age of the individual, the size and localization of the articular cartilage defect, the surgical technique, e.g., how the subchondral bone plate is treated, and the postoperative rehabilitation protocol.

Development

The surgery was developed in the late 1980s and early 1990s by Dr. Richard Steadman

Richard Steadman

J. Richard Steadman, M.D. is a specialist knee surgeon, practising in Vail, Colorado and a Clinical Professor at the University of Texas Southwestern Medical Center in Dallas, Texas. He is best known medically for his work in the area of microfracture surgery, and publicly for treating injured...

of the Steadman-Hawkins clinic

Clinic

A clinic is a health care facility that is primarily devoted to the care of outpatients...

in Vail, Colorado

Vail, Colorado

The Town of Vail is a Home Rule Municipality in Eagle County, Colorado, United States. The population of the town was 4,589 in 2005. The town was established and built as the base village to Vail Ski Resort, with which it was originally conceived...

. Steadman slowly refined the procedure through research (including tests on horse

Horse

The horse is one of two extant subspecies of Equus ferus, or the wild horse. It is a single-hooved mammal belonging to the taxonomic family Equidae. The horse has evolved over the past 45 to 55 million years from a small multi-toed creature into the large, single-toed animal of today...

s). The surgery was soon called "controversial" by many sportswriters, due to a lack of studies on the long-term effects and the fact that an unsuccessful surgery could end an athlete's career. Dr. Steadman has also adapted the surgery into a treatment to help reattach torn ligaments (a technique he calls the "healing response")

Procedure

The surgery is performed by arthroscopy

Arthroscopy

Arthroscopy is a minimally invasive surgical procedure in which an examination and sometimes treatment of damage of the interior of a joint is performed using an arthroscope, a type of endoscope that is inserted into the joint through a small incision...

, after the joint is cleaned of calcified cartilage. Through use of an awl, the surgeon creates tiny fractures in the subchondral bone plate. Blood

Blood

Blood is a specialized bodily fluid in animals that delivers necessary substances such as nutrients and oxygen to the cells and transports metabolic waste products away from those same cells....

and bone marrow

Bone marrow

Bone marrow is the flexible tissue found in the interior of bones. In humans, bone marrow in large bones produces new blood cells. On average, bone marrow constitutes 4% of the total body mass of humans; in adults weighing 65 kg , bone marrow accounts for approximately 2.6 kg...

(which contains stem cell

Stem cell

This article is about the cell type. For the medical therapy, see Stem Cell TreatmentsStem cells are biological cells found in all multicellular organisms, that can divide and differentiate into diverse specialized cell types and can self-renew to produce more stem cells...

s) seep out of the fractures, creating a blood clot that releases cartilage-building cell

Cell (biology)

The cell is the basic structural and functional unit of all known living organisms. It is the smallest unit of life that is classified as a living thing, and is often called the building block of life. The Alberts text discusses how the "cellular building blocks" move to shape developing embryos....

s. The microfractures are treated as an injury by the body, which is why the surgery results in new, replacement cartilage. The procedure is less effective in treating older patients, overweight patients, or a cartilage lesion larger than 2.5 cm. Further on, chances are high that after only 1 or 2 years of the surgery symptoms start to return as the fibrocartilage wears away, forcing the patient to reengage in articular cartilage repair.

The effectiveness of cartilage growth after microfracture surgery is thought to be dependent on the patient's bone marrow stem cell population and some think increasing the number of stem cells increases the chances of success. A couple of physicians are promoting an alternative treatment implanting autologous mesenchymal stem cells directly into the cartilage defect, without having to penetrate the subchondral bone.

Microfracture Reports

Studies have shown that microfracture techniques do not fill in the chondral defect fully, forming fibrocartilage rather than hyaline cartilage. Fibrocartilage is not as mechanically sound as hyaline cartilage; it is much denser and unable to withstand the demands of everyday activities as well as the original cartilage and is thus at higher risk of breaking down. The blood clot is very delicate after surgery and needs to be protected. In terms of time, the clot takes about 8 weeks to 15 weeks convert to fibrous tissue and is usually fibrocartilage by about four months post surgery, holding implications for the rehabilitation.

Chondrocyte Implantation
Autologous chondrocyte implantation
Autologous chondrocyte implantation is a biomedical treatment that repairs damages in articular cartilage. ACI provides pain relief while at the same time slowing down the progression or considerably delaying partial or total joint replacement surgery...

procedures (CCI), a cell based articular cartilage repair

Articular cartilage repair

procedure that aims to provide complete hyaline repair tissues for articular cartilage repair, have been posed by some as an alternative to microfracture surgery. In February 2008, Saris et. al published a large-scale study claiming that CCI results in better structural repair for symptomatic cartilage defects of the knee than microfracture surgery. According to the study, one year after treatment, the tissue regenerate associated with CCI is of better quality than that of microfracture surgery.

Use in professional sports

There have been many notable professional athletes who have undergone the procedure. Partially because of the high level of stress placed on the knees by these athletes, the surgery is not a panacea

Panacea (medicine)

The panacea , named after the Greek goddess of healing, Panacea, also known as panchrest, was supposed to be a remedy that would cure all diseases and prolong life indefinitely...

and results have been mixed. Many players' careers effectively end despite the surgery. However, some players such as Jason Kidd

Jason Kidd

, Steve Yzerman

Steve Yzerman

Stephen Gregory "Steve" Yzerman is a retired Canadian professional ice hockey player and current general manager of the Tampa Bay Lightning of the National Hockey League...

, John Stockton

John Stockton

John Houston Stockton is a retired American professional basketball player who spent his entire career as a point guard for the Utah Jazz of the NBA from 1984 to 2003. Stockton is regarded as one of the best point guards of all time, holding the NBA records for most career assists and steals by...

, Kenyon Martin

Kenyon Martin

and Zach Randolph

Zach Randolph

Zachary Randolph , nicknamed Z-Bo, is an American professional basketball player currently with the Memphis Grizzlies of the NBA...

have been able to return at or near their pre-surgery form while players Ron Harper

Ron Harper

Ronald "Ron" Harper is a retired American professional basketball player whose career spanned from 1986 to 2001 with four teams in the NBA. At 6 ft 6 in , his position was shooting guard/point guard.- Collegiate career :...

, Brian Grant

Brian Grant

Brian Wade Grant is a retired American basketball player. He played the power forward and center positions for five teams during 12 seasons in the National Basketball Association. He was known for his tenacious rebounding and blue-collar defense...

, Chris Webber

Chris Webber

, Allan Houston

Allan Houston

, Penny Hardaway

Penny Hardaway

Anfernee Deon "Penny" Hardaway is a former American professional basketball player who played in the National Basketball Association , specializing as a small forward, shooting guard, and point guard. His most productive years came in his days as a member of the Orlando Magic as well as the early...

, and the late Derek Smith

Derek Smith (basketball)

Derek Ervin Smith was an American NBA player. He won a national championship with the Louisville Cardinals in 1980, and spent nine years in the NBA in a career shortened by a knee injury. He would later become an assistant coach for the Washington Bullets from 1994 until his death.-Career:Smith...

never regained their old form. Others such as Jamal Mashburn

Jamal Mashburn

Jamal Mashburn is a retired American professional basketball player. A small forward, Mashburn was a prolific scorer in his 12 seasons in the league, with a career scoring average of 19.1 points per game...

and Terrell Brandon

Terrell Brandon

Thomas Terrell Brandon is a retired American professional basketball player in the National Basketball Association . Terrell was known throughout his 10-year career for his passing ability and stealing skills.-Early life:...

never recovered and retired. Portland Trail Blazers rookie Greg Oden

Greg Oden

Gregory Wayne Oden, Jr. is an American basketball player at the center position. Oden is a member of the Portland Trail Blazers of the NBA....

underwent the procedure on his right knee in early September 2007 and missed the entire 2007-2008 NBA season. At only 19 at the time of the surgery, doctors were confident that he would return to at or near full strength by the 2008-2009 season; he had a second microfracture surgery, this time on his left knee, in November 2010. The Detroit Pistons player, Tracy McGrady

Tracy McGrady

also underwent microfracture surgery, doctors were confident that the 2 time scoring champion will return to full strength. As of 2010 he has not had the same speed and jumping ability as he formerly did.

In October 2005, young star Amar'e Stoudemire of the NBA's Phoenix Suns

Phoenix Suns

The Phoenix Suns are a professional basketball team based in Phoenix, Arizona. They are members of the Pacific Division of the Western Conference in the National Basketball Association and the only team in their division not to be based in California. Their home arena since 1992 has been the US...

underwent one of the highest-profile microfracture surgeries to date. He returned to the court in March 2006 and initially appeared to have made a full recovery, but subsequently started feeling stiffness in both knees (his right knee had been overcompensating for the injured left knee). He and the team doctor decided he needed more time to rehab and he did not return until the 2006-2007 NBA season. During the 2006-2007 season, Stoudemire returned to form, averaging 20.4 points and 9.6 rebounds per game while playing in all 82 regular-season games and the 2007 NBA All-Star Game

2007 NBA All-Star Game

The 2007 NBA All-Star Game was played on Sunday, February 18, 2007 at the University of Nevada, Las Vegas's Thomas and Mack Center in Las Vegas, Nevada, United States. It was the 56th annual All-Star Game. It was the first time the All-Star Game was played in a city without an NBA franchise and...

. His recent success has brought positive publicity to the procedure, further distancing it from a previous reputation as a possible "career death sentence" in the sports world, though he was one of the youngest of the aforementioned players to undergo the surgery.

In June 2010, Grady Sizemore of the Cleveland Indians underwent microfracture surgery after injuring his left knee while diving back to first base earlier in the season. Sizemore was re-activated as the Indians center fielder in April 2011, ending an 11-month stretch of being disabled due to his injury. In his first game back on April 17, 2011 Sizemore showed no signs of slowing down as he had 2 hits in 4 AB which included a double and Home Run. Currently, Sizemore is the only player in MLB history to comeback from knee microfracture surgery and play centerfield.
Recovery=
One study has shown a success rate of 75 to 80 percent among patients 45 years of age or younger.

It is an outpatient procedure and causes only small discomfort. The harder part is the restrictions that are placed on the patient during the post-operative recovery period. This can be a major challenge for many patients. For optimal re-growth of joint surface, the patients need to be very patient and also extremely cooperative. They usually need to be on crutches for four to six weeks (sometimes longer). Sometimes a brace is needed. This all depends on the size and/or location of the joint surface defect that is being repaired or regenerated. The patients are encouraged to spend approximately 6–8 hours a day on a CPM (Continuous Passive Motion

Continuous passive motion

Continuous passive motion devices are used during the first phase of rehabilitation following a soft tissue surgical procedure or trauma. The goals of phase 1 rehabilitation are Control post-operative pain, Reduce inflammation, Provide passive motion in a specific plane of movement , and Protect...

) machine that helps with optimal re-growth of joint surface. Patients usually feel pretty good and think they can avoid these critically important steps, and even start running and jumping (or playing sports) before the internal aspects of the knee, and the joint surface, are ready.

Steadman cites the significance of a patient's natural joint alignment in addition to disciplined rehabilitation in recovery from the procedure.
External links

OsCell Team at the Oswestry Hospital under Professor James Richardson do Microfracture surgery
Articular Cartilage Repair of the Knee
MedlinePlus Medical Encyclopedia
Cartilage Health - Information on Articular Cartilage Injury Prevention, Repair and Rehabilitation

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