Hello, and thank you so much for having me at this talk. My name is Scott Fawcett. I work for the Centers for Advanced Orthopedics in Washington DC. I'm going to discuss with you today the smaller lesion debate, microfracture versus autograft transfer. Here are my disclosures. Ulcerative cartilage is a troublesome problem and once destroyed, it never repairs. That was a famous quote by William Hunter all the way back in 1743 and I think we're still trying to find the best way to manage these problems. Today, I'm going to talk to you about microfracture versus autograft transfer for small lesions. We'll discuss lesion characteristics, their size and location, microfracture techniques, as well as cartilage transfer techniques and then I'll close with a summary. First off, it's important to get a good clinical evaluation of these problems. We want to look at the symptoms. Are they having joint line pain or locking? What's their injury history? Have they had any previous treatment history? Risk and preference activity? The risk preference for further surgery, as well as what activity they're trying to get back to. On exam, we want to assess, is this joint really super inflamed? Is there an infusion? Is this a recent injury? What's their range of motion? Is there an unstable fragment causing locking? Then also their meniscal examination. Is there a concomitant injury that we need to be worried about? Then their body mass index. On a case-by-case basis, we also need to roll out subtle infections. This is a patient of mine who had intraarticular chlamydia and a college student, a basketball player, basically removed all the cartilages needed because he continued to play with his knee infusion. Biopsy results showed chlamydia infection, but he's going to have lifelong problems with his knee, as well as rheumatological conditions. Secondly, we need to review patient goals. What types of activities are they able to get back to and what's their risk aversion for further surgeries? Lastly, review your planned rehabilitation with these patients. This is not a clean-up procedure. This is going to have a significant impact in their lives. On radiographic evaluation, we want to make sure we get AP. Also, make sure you get that Rosenberg notch view. It's really critical to get that postural lateral wear, particularly of the OCD. It's also helpful to get a magnification ball for templating and sizing, as well as I like to get a standing alignment on any operative knee patient to understand what the mechanics of our knee and what are the chances for failure for a soft tissue procedure, such as ligament, cartilage, or meniscus surgery. The MRI is very helpful to identify the size and location of the lesion. You want to look at both the T1 and T2 sequences. Bony edema can tell you how much of the subchondral bone may be involved. You also don't forget to look at the adjacent meniscus and identify any tears that may need to be addressed. Do these patients already have arthritis? Has osteophytes already settled in and been created? And then again, look for that subchondral bone. Fragmentation of the piece is critical. Diagnostic arthroscopy can be very helpful in these cases. In-office arthroscopy has some advantages. It's quick, it's real-time, can discuss with the patient the results right away and make some decisions. Doesn't require any anesthesia other than local anesthesia. The disadvantages is only what you can see. There are very little treatment options. And in some cases, it can be difficult to get a probe to evaluate the tissue itself. A surgical diagnostic arthroscopy can be helpful because you can perform chondroplasty at a time. You can do a biopsy, particularly for your membrane-associated cartilage implantation. You can also probe the tissue a lot easier. The disadvantages is it requires anesthesia, scheduling, takes longer time, it's more expensive. But you can get very good information from the in-office arthroscopy. You can see here, this area, this cartilage flap right here, showing good cartilage. However, when we bend the patient's knee, you can begin to see the cartilage defect becoming more clear and that weight-bearing area. And so this is very helpful, particularly to look for contained lesions or versus uncontained and may affect your treatment plan. So that goes to our first step in understanding how to treat microfracture versus autograft transfer. First is the lesion characteristics. We all talk about two centimeters squared, but what is two centimeters squared when you're doing this arthroscopic? You need to have a reference. And if you look at a probe, that's about four millimeters in my award. So you're looking for a circular-shaped defect that's 16 millimeters in diameter or four probes across or a square area of 14 millimeters by 14 millimeters. And I would propose under a scope, that is a huge lesion. You're gonna be intimidated by the size of them as opposed to maybe seeing something like that in an open setting. The second is, where is this occurring? Are you able to access this arthroscopically? Maybe only arthroscopically? Obviously then, microfracture may be your choice. But if you can get to this through a small arthrotomy or even arthroscopically with knee and minimal flexion, you might be able to consider doing a autograft transfer. Is this in the weight-bearing area? So that we're gonna get good compression of this plug. That's better versus weight-bearing area where you're gonna get expression of that fiber clot. That's not good. Also, are you able to match the topography very well? If you're having a very difficult topography of the cartilage, such as in the trochlea or at the time mark area, you may wanna consider using the microfracture technique because that will allow you to have a more versatile, flexible topography. Whereas taking an autograft transfer may be very difficult to match from the lateral trochlea, specifically into the area of the medial femoral condyle or those other difficult areas. My cartilage treatment options are, again, using that two centimeter cutoff, looking at the concept of this engaging lesion. Smaller lesions, most patients can get away with. It may need no treatment whatsoever. So be mindful of those incidental cartilage lesions. Don't go microfracturing those. You should have a plan to address the cartilage lesion you identified before surgery, rather than chasing some minor cartilage fragmentation at the time of surgery that may be smaller than needs to be treated. But for these larger lesions, which typically are around one centimeter squared to two centimeters squared, these are engaging lesions and can cause problems in the knee. And what I mean by engaging is that when the circumference of the rotation of the femur engages within that tibia and cause blocking and symptoms. Need to make sure to consider the subchondral bone equality, right? So things like edema, OCD, previous treatment, that's going to lead me more to autograft transfer rather than doing another microfracture because we need to treat that subchondral bone. As well as adjacent injuries, meniscus, I'm going to do a transfer versus microfracture because it's just more reliable. The microfracture, though, is still a very good technique. It is considered the gold standard worldwide technique for treating cartilage injury, originally described by Dr. Stedman and Rocky. It's a marrow stimulation technique. It's readily available. It's very inexpensive, just takes your all. It's very important, though, when you're doing this procedure to remove the calcified layer of bone. So you need to spend your time cleaning up the edges with a curette, sharp curette or radiofrequency covalent. You need to also go in there and scrape the edge of the bone with your curettes, your open curettes, get that calcified layer off. And then use your tool of choice to create some small, shallow, got to be six millimeters in depth. You get beyond that cortical bone into the mesenchymal bone, the spongy bone. You got to get that deep. You want to create multiple holes. You also want them to be about two to three millimeters apart. Sometimes there may be advantages to drilling or impact versus the standard chisel because sometimes that can damage the subchondral bone pretty much. From there, the superclaviform fill in those shoulder defects and then become scar cordage. Rehabilitation is important. You're looking at eight weeks, non-weight-bearing on crutches, six to eight months before return to sport. In regards to osteochondral transplant, we know we can do autografts, as we were talking about today. There's also allograft transplants. And there are some of those that are available in these smaller sizes that can be ready to go. Don't need the whole hemicondyle. You can get those shipped in for you to use, but they can be expensive. Key things when you're doing this are stability versus healing. The bigger the plug you do, the more difficult it is to heal. The more creeping substitution will have to occur, but it will be more stable. The shorter the plug, the less healing that has to occur. Six millimeters is the ideal plug. But if you're getting shorter than that, you risk destabilizing the plug and getting delamination and it falling off and becoming a loose body. So six millimeters is the ideal plug length. And you can do mosaoplasty or a snowman-type graft or a singular graft. And this is a technique for an arthroscopic allograft transfer, as described by Dr. Cole and Cecilia Pascual-Garrido. Here's the cartilage. We identify it, core it out, and then put the plug in. So we're going to address a few cases because those are always fun to review. So this is a 28-year-old male physical education teacher who's having pretty severe lateral-sided pain. Active volleyball player, he can't jump or squat. Fairly good size defect right here in the lateral femoral condom. Didn't realize how big that was going to look arthroscopically Complete delamination here, 12 by 15. So it's just right at that level of two centimeters squared. It's pretty big, but we did not have any cartilage transplant available. And I didn't feel like doing an autograft transfer for him because he's a volleyball player, active volleyball player, and felt that he really was going to need that trochlear cartilage. So we performed an augmented microfracture procedure using this oil here. And we unloaded him for a period of time, well, three months, this is six months. And he's able to get back to what he needs to do. Here's another case. Again, a lateral-sided lesion. It's a 26-year-old obese female with lateral knee pain. She's had a previous chondroplasty, which for me is still okay to perform microfracture, but she had a relatively larger size lesion and we're doing concomitant surgery. So I want to have a more reliable surgery than microfracture for me. So here we can see she's in valgus here. So obviously microfracture, probably not a good idea. And even in a plug, I'm going to want to make sure that we completely unload her. Here's her defect size, a little bit of subchondral edema. Here's her arthroscopic images, fairly large, irregular shape. Issues with the lesion being unshouldered here. So that's another reason to consider a plug. So in this case, we did a distal frontal osteotomy to neutralize her alignment. And then did, in this case, an allograft. But you can do a mosaoplasty autograft plug. Okay, when you get this big though, the allograft plugs tend to do better than more than a one to two plug treatment. So in summary, when evaluating a patient with cartilage injury, it requires a systematic approach with patient-specific counseling. Need to rule out and correct malalignment to improve the odds of success. Diagnose adjacent worrisome lesions with both MRI and diagnostic arthroscopy. Patients with appropriate cartilage treatment do well with 75 to 100% midterm survivorship. And for 10-year outcomes, small lesions have been shown to have equivalent outcome regardless of treatment, looking for microfracture versus autograft plug. But when you compare the two of these together, these are some of the concepts you should come away with. You want to use microfracture for the smaller lesions. Use them for the difficult topography, the trochlea, the transition joint. You also want to make sure you have fully shoulder lesions. And on the cartilage side, use these for damaged subchondral bone, larger lesions, lesions that are in the weight-bearing zone, as well as partially unshouldered lesions. Thank you very much and thank you to the OSA for the opportunity to talk to you all today. I wish you all the best.

Scott Fawcett

orthopedic specialist

microfracture

autograft transfer

cartilage lesions