Microfracture/Bone Marrow Stimulation
The simplest type of cartilage repair procedure is called microfracture or bone marrow stimulation. This outpatient surgery is performed with minimally invasive arthroscopy using small cameras and instruments.
After the damaged cartilage is removed from the talus, a small tool that resembles a pick or awl is used to make several holes into the bone at the base of the cartilage crater. Through these small holes, blood and cells will trickle up to fill the defect and form a blood clot. Over the next several months, this clot turns into a type of scar tissue cartilage called fibrocartilage.
In smaller osteochondral injuries, this type of repair can give excellent results in up to 85% of patients including return to sports and running.
In patients with larger osteochondral injuries or those that have already failed microfracture, more advanced surgical techniques are needed to repair the damaged cartilage. In these cases, cartilage that has been donated from human cadavers can be used to help supplement the repair. Older versions of cadaver cartilage graft were extremely expensive, limited in availability, and had a short shelf life. A newer commercially available graft, called BioCartilage, is highly processed into a powder form that contains collagen, proteins and growth factors. This is mixed with living stem cells harvested from the patient’s blood or bone marrow.
After minimally invasive arthroscopy is used to remove the damaged cartilage, a small incision is made to insert the BioCartilage into the defect. This outpatient surgery has a similar rehabilitation to microfracture and appears to offer successful results in most patients.
Another surgical option is to transplant a cylinder of bone and overlying cartilage – from the patient’s own knee or from a cadaver – into the ankle defect to restore a smooth surface. This is a more invasive surgery, especially if the graft is harvested from the patient’s knee, and often requires breaking a portion of the ankle bone to access the damaged area for insertion. This may be reserved for extremely large defects or in cases where all other techniques have failed.
Ongoing research is underway to compare these exciting surgical options to refine techniques and offer patients better information.
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