Microfracture Surgery - Explained

Hello again! In my initial posting, I briefly mentioned the injury which provided my initial set back. Below I am actually going to explain what it is, attach some diagrams, some pictures, and maybe a video if I can get you tube working right.

By definition -
Microfracture surgery is an articular cartilage repair surgical technique that works by creating tiny fractures in the underlying bone. This causes new cartilage to develop from a so-called super-clot. Microfracture surgery has gained popularity in sports in recent years; numerous professional athletes elected to have the procedure done.

The surgery was developed in the late 1980s and early 1990s by Dr. Richard Steadman of the Steadman-Hawkins clinic in Vail, Colorado. Steadman slowly refined the procedure through research (including tests on horses). 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")

The surgery is performed by arthroscopy, after the joint is cleaned of calcified cartilage. Through use of an awl, the surgeon creates tiny fractures in the subchondral bone plate. Blood and bone marrow (which contains stem cells) seep out of the fractures, creating a blood clot that releases cartilage-building cells. 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

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 and results have been mixed. Many players' careers effectively end despite the surgery. However, some players such as Jason Kidd, Steve Yzerman, John Stockton, Kenyon Martin and Zach Randolph have been able to return at or near their pre-surgery form while players Ron Harper, Brian Grant, Chris Webber, Allan Houston, Penny Hardaway, and the late Derek Smith never regained their old form. Others such as Jamal Mashburn and Terrell Brandon never recovered and retired.

 Portland Trail Blazers rookie Greg Oden 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. Oden is once again expected to miss most of the 2011-2012 season after missing the previous season due to knee issues. The Atlanta Hawks player, Tracy McGrady also underwent microfracture surgery, doctors were confident that the 2 time scoring champion will return to full strength. As of 2012 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 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. 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 come back from knee microfracture surgery and play centerfield.

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) machine that helps with optimal re-growth of joint surface. The procedure is so painless that some patients avoid these critically important steps and expose the knee to physical activity before the joint fully heals.
Steadman cites the significance of a patient's natural joint alignment in addition to disciplined rehabilitation in recovery from the procedure.

Below is a photo detailing what actually was wrong, which caused me to have to undergo the procedure.

 

What you are looking at in the above photo is an image during the surgery of my Lateral Femoral Condyle . As you can see there, it basically looks like someone took a golf club to the cartilage in this particular area..  This is considered Grade 4 Osteo-Arthritis (where the bone is showing). 

The Left Image details the "hanging cartilage" which was causing all the pain and swelling in my knee in the events leading up to the surgery.

Above is a video detailing the actual process involved in performing the actual procedure. It is difficult to watch, especially when you are on an operating room table, seeing it live time.


Post Microfracture Surgery : Rehabilitation & Coping

Getting the actual procedure done was 1/10th of the battle, literally..... From Day 0 until 6 weeks out, I was on crutches with no ground contact. Your knee is strapped into a Continuous Passive Motion Machine (CPM) at least 8 hours a day... I elected to do this during my sleeping hours (it would annoy me from time to time), but otherwise I was ok... The actual CPM process was not elective, you had to get it done, otherwise the knee would lock up due to scar tissue.

0 hour - Post OP.. Put  my GRT patch on my knee to remind myself why I do what I do. 

36 Hours POST OP -  Couch Ridden, and knee in the actual CPM unit. Swelling and all.


Post Op recovery was probably the largest test of mental fortitude that I have displayed to date.. I can honestly say I wouldn't have made it as far as I did without some support from some unexpected people.

The First Week Post Op I layed on the couch, and occasionally drove places (with my opposing good leg acting as gas/brake), regretting the decision to have the procedure done.. I was absolutely miserable.   Below you will see a photo of my 800meter run time the day before surgery.

Yep 2 minutes and 50 seconds for a 1/2 mile, with an injured leg.

Days progressed into weeks, and weeks progressed into regrets.. I was hemorrhaging muscle mass & strength, barely able to perform upper body maintenance workouts.

It wasn't until graduation day (as my sports med doc called it), when I shed the crutches, I made tracks for the gym, slowly but I did, I think I spent 3 hours at the local ymca that night... pedaling a bike, 26 minutes for a mile, at Level 1 intensity...   The elderly man, with extensive arthritis was passing me by, but you know what.. It was a small victory.


In the weeks pursuant to getting rid of the crutches,  rehab continued, CPM use continued,  Daily Bicycling continued, and any possible rehab was done....     Rehab Rehab Rehab, if you are as unfortunate as I was in this procedure, please follow the rehab, its made the world of difference... You may not think it at the time, as trust me, I was as disgruntled as any, but it worked out in the end. Its mid January, and with my Bledsoe brace on, I am able to do just about everything up to a run... Squatting is pathetic right now for me, but the weight will come... I check my Ego at the door to the gym, and today I give thanks for what I have... Not what I've lost.   Thank you..



-T