Enhanced microfracture techniques in cartilage knee surgery: Fact or fiction?

Abstract

The limited intrinsic healing potential of human articular cartilage is a well-known problem in orthopedic surgery. Thus a variety of surgical techniques have been developed to reduce joint pain, improve joint function and delay the onset of osteoarthritis. Microfractures as a bone marrow stimulation technique present the most common applied articular cartilage repair procedure today. Unfortunately the deficiencies of fibrocartilaginous repair tissue inevitably lead to breakdown under normal joint loading and clinical results deteriorate with time. To overcome the shortcomings of microfracture, an enhanced microfracture technique was developed with an additional collagen I/III membrane (Autologous, Matrix-Induced Chondrogenesis, AMIC(®)). This article reviews the pre-clinical rationale of microfractures and AMIC(®), presents clinical studies and shows the advantages and disadvantages of these widely used techniques. PubMed and the Cochrane database were searched to identify relevant studies. We used a comprehensive search strategy with no date or language restrictions to locate studies that examined the AMIC(®) technique and microfracture. Search keywords included cartilage, microfracture, AMIC(®), knee, Chondro-Gide(®). Besides this, we included our own experiences and study authors were contacted if more and non published data were needed. Both cartilage repair techniques represent an effective and safe method of treating full-thickness chondral defects of the knee in selected cases. While results after microfracture deteriorate with time, mid-term results after AMIC(®) seem to be enduring. Randomized studies with long-term follow-up are needed whether the grafted area will maintain functional improvement and structural integrity over time.

Keywords: Autologous, Matrix-Induced Chondrogenesis; Cartilage; Chondro-Gide®; Knee; Microfracture.

Figure 1

Twenty years old female with a chondral defect on the lateral condyl after trauma. The AMIC^® technique was done arthroscopic assisted: after debridement of the chondral defect (A), numerous perforations of the subchondral lamina were performed (B, C). The implantation of the matrix was performed under dry, arthroscopic conditions, as published before (D)[27].

Figure 2

Significant improvements of the mean Lysholm and visual analogue scale score after 1 year and further increased values up to 2 years postoperatively in patients with cartilage knee defects treated with AMIC^®[32]. VAS: Visual analogue scale.

Figure 3

The same patient showing enhanced defect filling demonstrated by follow-up magnetic resonance imaging before surgery (A) and 3 (B), 6 (C), 12 (D) and 24 mo (E) after the index procedure.