Bone Marrow Stimulating Techniques: Drilling, Abrasion Arthroplasty, and Microfracture

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Chapter 4A Bone Marrow Stimulating Techniques

Drilling, Abrasion Arthroplasty, and Microfracture

Wayne Gersoff

Introduction

The principle of bone marrow stimulating techniques involves the penetration of the subchondral bone plate to provide vascular access channels to the area of chondral defect. This allows for mesenchymal cells to fill the defect and provide a repair tissue fill of the articular cartilage defect. Three techniques are commonly used: abrasion arthroplasty,1 subchondral drilling,2 and microfracture.3

Steps Common to all Techniques

1. During knee arthroscopy, identify the area of articular cartilage injury (Fig. 4A-1).
2. Utilizing an arthroscopic shaver or curette, debride the borders of the defect back to stable, vertical walls (Figs. 4A-2 and 4A-3).
3. Remove calcified cartilage from subchondral bone using a shaver or curette. Leave no loose flaps or debris in the lesion site. The defect is now prepared (Fig. 4A-4).
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FIGURE 4A-1 Articular cartilage damage to femoral condyle.

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FIGURE 4A-2 and FIGURE 4A-3 Utilizing a shaver and curette to debride.

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FIGURE 4A-4 Debridement of calcified cartilage.

Abrasion Arthroplasty

1. Using an arthroscopic burr—either round or oval—abrade the exposed subchondral bone to produce a punctuate bleeding surface. If using a tourniquet, let it down to confirm the presence of punctuate bleeding bone (Figs. 4A-5 and 4A-6).
2. A smooth surface must be created, avoiding any divots. Any hypertrophic or sclerotic bone must be removed.
3. After completion of abrasion and confirmation of bleeding, avoid irrigating or disrupting coverage of the defect.
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FIGURE 4A-5 A burr abrading bone.

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FIGURE 4A-6 Punctuate bleeding.

Subchondral Drilling

1. Select an appropriate size drill bit or K-wire and attach to the drill.
2. Starting in the periphery and progressing centrally, place multiple drill holes into the defect, penetrating the subchondral bone plate (Fig. 4A-7).
3. The drill hole should be placed 3 to 4 mm apart, and convergence should be avoided (Fig. 4A-8).
4. Confirm the presence of bleeding from drill holes. If applicable, the tourniquet should be released and water flow stopped (Fig. 4A-9).
5. Drill holes that are not bleeding may need to be drilled deeper.
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FIGURE 4A-7 K-wire penetrating the subchondral bone plate of defect.

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FIGURE 4A-8 Multiple drill hole placement.

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FIGURE 4A-9 Bleeding from drill holes.

Microfracture

1. The microfracture awls come in various angles. Select the appropriate awl to facilitate access to the lesion (Fig. 4A-10).
2. Moving from the periphery to the center of the defect, use the awl to create holes penetrating the subchondral bone plate (Fig. 4A-11).
3. Holes should be placed 3 to 4 mm apart. Holes should be perpendicular to the bone surface and convergence avoided (Fig. 4A-12).
4. Remove any bony debris.
5. Deflate the tourniquet, if applicable. Drain the knee, and then turn water off. Confirm bleeding. Avoid disrupting the fibrin clot (Fig. 4A-13).
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FIGURE 4A-10 Awls.

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FIGURE 4A-11 Awl penetrating subchondral bone.

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FIGURE 4A-12 Multiple holes.

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FIGURE 4A-13 Formation of clot in defect.

References

1. Johnson L.L. Arthroscopic abrasion arthroplasty historical and pathologic perspective: present status. Arthroscopy. 1986;2:54-69.

2. Pridie K.H. A method of resurfacing osteoarthritic knee joints. J Bone Joint Surg BR. 1959;41:618-619.

3. Steadman J.R., Rodkey W.G., Singleton S.B., Briggs K.K. Microfracture technique for full thickness chondral defects: Technique and clinical results. Oper Tech Orthop. 1997;7:300-304.

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