Académique Documents
Professionnel Documents
Culture Documents
Abstract: The ideal treatment of large full-thickness chondral lesions in the knee, especially kissing lesions and oste-
oarthritis, has not been determined. Microdrilling surgery augmented with injections of peripheral blood stem cells and
hyaluronic acid has been used to treat patients with a wide range of articular cartilage disease including patients with
bipolar lesions and joint space narrowing. Excellent results in this difcult patient population have been reported, and
second-look biopsy has shown repair tissue very similar to native hyaline cartilage. Because of Food and Drug Admin-
istration regulations, this technique is not currently allowed in the United States. We describe a Food and Drug
Administrationecompliant modication of this technique using microdrilling augmented with intra-articular bone
marrow aspirate concentrate, platelet-rich plasma, and hyaluronic acid.
Fig 1. Bone marrow aspiration and ltration. (A) With the patient positioned lateral, a 15-gauge Illinois bone marrow needle
with the lower sleeve removed is inserted into the central posterior superior iliac spine. Fifteen to twenty milliliters of bone
marrow is drawn into a 20-mL syringe prelled with 100 U of heparin. (B) The syringe is capped with an 18-gauge needle, and
the bone marroweheparin mixture is injected through a coupler into a 150-mL polyvinyl chloride transfer bag. (C) The contents
are run through a 210-mm lter to remove any bony particulates. (D) The ltered bone marrow is divided between two 10-mL
red-top serum tubes.
Medical, Winston-Salem, NC) (Fig 1B). The contents divided between two 10-mL serum tubes (BD Vacu-
are then run through a 210-mm lter (11141-48; Hos- tainer [366441]; Becton Dickinson, Franklin Lakes, NJ)
pira, Lake Forest, IL) in a sterile closed system to (Fig 1D). The tubes are centrifuged for 10 minutes at
remove any clots and bony particulates (Fig 1C) and 1,300g (VanGuard V6500; Hamilton Bell, Montvale,
BIOLOGIC AUGMENTED MICRODRILLING IN KNEE e203
Fig 2. Bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) preparation. (A) The red-top tubes containing
the ltered bone marrow are centrifuged for 10 minutes at 1,300g. (B) After centrifugation, the tubes are carefully uncapped, and
a spinal needle is used to aspirate the buffy coat and some plasma from both tubes, yielding 3 to 5 mL of BMAC. (C) The Biomet
GPS III system is used to obtain 7 mL of PRP from 55 mL of whole blood. (D) The 3 biologic components, ready to be combined
for a knee injection: 25 mg of hyaluronic acid (HA), PRP, and BMAC.
NJ) (Fig 2A). The tubes are carefully uncapped, and a Usually 3 to 5 mL of BMAC is obtained in this manner.
10-mL Luer-Lok syringe (Becton Dickinson) with an This mixture is then passed onto the sterile eld.
18-gauge 3.5-inch spinal needle is used to aspirate the The patient is positioned supine while the BMAC is
buffy coat and some plasma from both tubes (Fig 2B). prepared. While the patient is being positioned,
e204 J. E. BROYLES ET AL.
Microdrilling Procedure
The foot of the operating room bed is dropped down
90 . The contralateral leg is fully abducted on an arm
board attached to the end of the bed (Fig 3A). A tour-
niquet is placed on the operative leg, but it usually is
not required. After preparation and draping, standard
medial and lateral arthroscopy portals are established.
Many of these patients have undergone multiple pre-
vious knee operations, so debridement of scar tissue is
usually needed for appropriate visualization. Clinically
signicant meniscal pathology is addressed rst.
Attention is then turned to the chondral lesions. A ring
curette is used to remove any remaining damaged
cartilage in the full-thickness defect or defects. A No. 11
scalpel blade is often used as well to develop well-
dened margins. The calcied cartilage layer is also
removed using the ring curette.
Microdrilling of each lesion is then performed. Dril-
ling is performed with a 2.9-mm mini burr (3530;
Fig 3. Surgical preparation. (A) Patient positioning for Smith & Nephew, London, England). The 2.9 mm
microdrilling surgery. The foot of the operating room bed is represents the diameter of the protective sleeve. The
dropped down 90 . The contralateral leg is fully abducted on burr itself measures 2 mm. Seven millimeters of the
an arm board attached to the end of the bed. (B) A Smith & protective sleeve is removed with a wire cutter to allow
Nephew 2.9-mm mini burr is modied for drilling holes 2 mm use of the burr for drilling (Fig 3B). The crimped end of
in diameter and 7 mm deep. Seven millimeters of the pro- the cut sleeve is then opened back up using an obtu-
tective sleeve is removed with a wire cutter to allow the burr rator from a 3-mm outow cannula (720491; Smith &
to drill to the appropriate depth. Nephew). Holes are drilled to a depth of 7 mm (when
the remaining sleeve contacts the bone) and are placed
anesthesia personnel obtain blood through venipunc- 2 to 3 mm apart (Fig 4A). Drilling is performed slowly
ture to prepare PRP using the Biomet GPS III platelet so that thermal damage of the bone does not occur
concentration system (Biomet Biologics, Warsaw, IN) (Table 1).
(Fig 2C). Per instructions in this system, 52 mL of blood Drilling of lesions on the femoral condyles and
is combined with 8 mL of anticoagulant citrate dextrose trochlea is usually fairly straightforward, with small
and used to generate approximately 7 mL of PRP. This accessory portals required to ensure perpendicular
is also passed onto the sterile eld. The BMAC, PRP, drilling. A spinal needle is always placed rst to deter-
and 25 mg of HA (Supartz; Bioventus, Durham, NC) are mine the proper placement of these portals. Lesions of
combined in a single 20-mL syringe for use at the the patella and tibial plateau are more difcult to access.
conclusion of the procedure (Fig 2D). For the patella, especially in a tight knee, a lateral
Table 1. Pearls and Pitfalls release of the medial collateral ligament in the method
Do not use an arthroscopic leg holder because deep knee exion is described by Fakioglu et al.5 The improved access al-
more difcult. lows medial tibial lesions to be more easily drilled
Use a padded Mayo stand to rest the foot on while drilling the patella. (Video 1). Posterior tibial plateau lesions are accessed
Drill slowly with the burr and back out several times to clear bone
debris and prevent thermal necrosis.
from a midcoronal portal, whereas anterior plateau
Check under the meniscus for cartilage defects. Retract the meniscus lesions are accessed from an anterior portal.
with a probe while drilling there. After all lesions are drilled, water is suctioned from
Create additional mini portals as necessary to maintain perpendicular the knee. An 18-gauge spinal needle is inserted
drilling. percutaneously into the primary chondral lesion. All
Perform a percutaneous medial collateral ligament release when
necessary to drill the tibia. (Do not resort to a microfracture awl.)
portals are closed with nylon suture. The 20-mL syringe
Bear in mind that performing a lateral release greatly improves access containing the BMAC, PRP, and HA is afxed to the
for patella drilling. spinal needle, and the mixture is then injected into the
Use a tenaculum clamp on the patella for easier patella positioning knee (Fig 4B). A standard sterile dressing is applied.
and stability while drilling.
When injecting buffered lidocaine for bone marrow aspiration, Postoperative Rehabilitation
inltrate the periosteum in an area approximately 2 cm in diameter
to minimize discomfort.
Continuous passive motion for 2 hours per day is
Begin early isometric loading of the patellofemoral joint after started on postoperative day 2 and continued for
patellofemoral joint drilling. 4 weeks. Patients with tibiofemoral lesions are kept
Advise patients that they should not expect improvement from partially weight bearing for 6 weeks, whereas patients
baseline until 3-6 months postoperatively. with patellofemoral lesions may only bear weight as
tolerated with the knee extended. Early on in physical
release is often necessary to be able to tilt the patella therapy, there is a focus on isometric exercises in varying
enough to drill the central ridge. A tenaculum clamp degrees of exion to load all drilled areas. Early dynamic
placed on the patella through tiny stab incisions greatly loading is not recommended to avoid shear injury to
facilitates positioning of the patella by an assistant repair tissue. This protocol was established in accordance
(Fig 5). The placement of the accessory portals for pa- with previously published recommendations.2 Cycling is
tella drilling must be posterior enough to allow drilling allowed at 1 month, jogging at 9 months, and return to
as perpendicular as possible. Drilling of the central ridge sport at 1 year postoperatively (Table 2).
usually requires drilling from both the medial and
lateral aspects of the knee, because any drilling of the Postoperative Injections
medial side of the ridge from the lateral side, for Beginning 1 week postoperatively, intra-articular knee
example, will tend to skive. For drilling of the medial injections of BMAC, PRP, and HA are administered once
tibial plateau, we now usually perform a percutaneous per week for 5 weeks. The aspiration-injection procedure
Fig 5. Microdrilling surgical technique for a medial patella facet lesion in a right knee. All arthroscopic views are from the
superomedial portal with a 30 arthroscope. (A) A ring curette is used to debride the lesion and to remove the calcied cartilage
layer. The curette enters the knee posteromedial to the patella. (B) Drilling of debrided lesion. Tilting the patella with a te-
naculum clamp facilitates perpendicular drilling of the patella. (C) A mini shaver is used to smooth the edges of the lesion after
drilling.
e206 J. E. BROYLES ET AL.