de Leeuw, P.A.J.

van Bergen, C.J.A.

van Dijk, C.N.

English

Debridement and bone marrow stimulation of the subchondral bone is currently considered to be the primary surgical treatment of most osteochondral lesions of the talus. Different methods of bone marrow stimulation are used, including drilling, abrasion, and microfracturing. The latter has gained recent popularity. In this technical note we describe a potential pitfall in the microfracturing technique. The microfracture awl can easily create small bony particles on retrieval of the probe that may stay behind in the joint. It is emphasized that the joint should be carefully inspected and flushed at the end of each procedure, in order to prevent leaving behind any loose bony particle

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UvA-DARE is a service provided by the library of the University of Amsterdam (https://dare.uva.nl)UvA-DARE (Digital Academic Repository)Potential pitfall in the microfracturing technique during the arthroscopictreatment of an osteochondral lesionvan Bergen, C.J.A.; de Leeuw, P.A.J.; van Dijk, C.N.DOI10.1007/s00167-008-0594-yPublication date2009Document VersionFinal published versionPublished inKnee Surgery Sports Traumatology ArthroscopyLink to publicationCitation for published version (APA):van Bergen, C. J. A., de Leeuw, P. A. J., & van Dijk, C. N. (2009). Potential pitfall in themicrofracturing technique during the arthroscopic treatment of an osteochondral lesion. KneeSurgery Sports Traumatology Arthroscopy, 17(2), 184-187. https://doi.org/10.1007/s00167-008-0594-yGeneral rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s)and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an opencontent license (like Creative Commons).Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, pleaselet the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the materialinaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letterto: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. Youwill be contacted as soon as possible.Download date:09 Mar 2023ANKLEPotential pitfall in the microfracturing technique duringthe arthroscopic treatment of an osteochondral lesionChristiaan J. A. van Bergen Æ Peter A. J. de Leeuw ÆC. Niek van DijkReceived: 1 July 2008 / Accepted: 3 July 2008 / Published online: 23 September 2008 The Author(s) 2008. This article is published with open access at Springerlink.comAbstract Debridement and bone marrow stimulation ofthe subchondral bone is currently considered to be theprimary surgical treatment of most osteochondral lesions ofthe talus. Different methods of bone marrow stimulationare used, including drilling, abrasion, and microfracturing.The latter has gained recent popularity. In this technicalnote we describe a potential pitfall in the microfracturingtechnique. The microfracture awl can easily create smallbony particles on retrieval of the probe that may staybehind in the joint. It is emphasized that the joint should becarefully inspected and flushed at the end of each proce-dure, in order to prevent leaving behind any loose bonyparticles.Keywords Osteochondral lesion  Osteochondral defect Ankle arthroscopy  Microfracturing  Loose bodyIntroductionOsteochondral defects (ODs) of the talus are often pre-ceded by a trauma [2]. The lesions typically cause deepankle pain on weight bearing, and may have a major impacton the patient’s daily life and (sporting) activities. Thediagnosis is frequently delayed, since the complaints maybe attributed to the previous trauma [2]. Both conventionalradiographs and additional diagnostics, such as computedtomography (CT) or magnetic resonance imaging (MRI),may reveal the lesion [4].Various treatment options exist, including nonoperativetreatment, debridement with or without bone marrowstimulation, autologous chondrocyte implantation, allografttransplantation, and osteochondral autograft transplantationor mosaicplasty [4, 12]. Despite advancements in some ofthese options, arthroscopic debridement combined withbone marrow stimulation is still the best currently availabletreatment [11]. It is considered the treatment of choice forprimary lesions not exceeding 15 mm in diameter [1, 6].Different methods are used to approach the lesion duringarthroscopy, e.g. full plantar flexion, distraction, and trans-malleolar or retrograde drilling [5, 7, 8, 10]. Depending onthe location of the defect, the arthroscopic approach can beperformed from either anterior or posterior [4]. Furthermore,different tools for bone marrow stimulation can be used, i.e. aK-wire, drill or microfracture awl. Bone marrow stimulationby means of the microfracture technique has recently gainedpopularity [9]. One of the advantages of this approach in theankle joint is its accessibility due to the curved end of the awl.In this report we describe a potentially important pitfall thatis related to this procedure.Case reportA 30-year-old female presented to our clinic with anosteochondral defect in the central talar dome of the rightankle. The medical history revealed a bimalleolar anklefracture which was surgically treated one year earlier. Atthe time of her visit, the fracture had healed, but the patienthad developed deep ankle pain on weight bearing. Onexamination there was no swelling. The range of motionElectronic supplementary material The online version of thisarticle (doi:10.1007/s00167-008-0594-y) contains supplementarymaterial, which is available to authorized users.C. J. A. van Bergen (&)  P. A. J. de Leeuw  C. N. van DijkDepartment of Orthopaedic Surgery, Amsterdam MedicalCenter, Location G4-262, University of Amsterdam,P.O. Box 22660, 1100 DD Amsterdam, The Netherlandse-mail: c.j.vanbergen@amc.nl123Knee Surg Sports Traumatol Arthrosc (2009) 17:184–187DOI 10.1007/s00167-008-0594-ywas slightly diminished, with a dorsiflexion–plantar flexionof 10-0-40, compared to 15-0-45 on the healthy side. Onpalpation there was no recognizable tenderness.Anteroposterior and lateral weight-bearing radiographsrevealed an OD located in the central talar dome (Fig. 1). ACT-scan of the ankle confirmed this finding, and showedthe exact location and extent of the lesion. Treatment bymeans of arthroscopic debridement and microfracturingthrough an anterior approach was scheduled.Surgical techniqueDuring the procedure the patient was placed in a supineposition, with slight elevation of the ipsilateral buttock, andthe hip supported. A tourniquet was applied around theinvolved upper leg and was inflated up to 300 mmHg. Forirrigation normal saline was used with gravity flow. Theprocedure was performed under spinal anaesthesia. Theanterior ankle arthroscopic approach was performed bymeans of routine anteromedial and anterolateral portalplacement [4].With the arthroscope in the anterolateral portal, theankle was fully plantarflexed until the OD came into view(Fig. 2a). The contours of the defect were defined with aprobe, and the edges were sharpened with a curette. Then ashaver system (Bone Cutter Dyonics, Smith & Nephew,Andover, Massachusetts) was used to debride the osteo-chondral defect and underlying necrotic talar bone (Video).Next, a microfracture awl, angled 45, was introducedthrough the anteromedial portal and the subchondral platewas punctured several times at intervals of approximately3 mm (Fig. 2b) [9]. On inspection it was noted that mul-tiple loose bony fragments were created during retrieval ofthe awl (Fig. 3a). The fragments were carefully identified,Fig. 1 Preoperative anteroposterior (left) and lateral (right) weight-bearing radiographs of the right ankle of a 30-year-old female withpersistent deep ankle pain after a successfully treated bimalleolarankle fracture. The X-rays reveal an osteochondral lesion located inthe central talar dome (:). The osteosynthesis material is also seenFig. 2 a Intra-operative view of the untreated lesion ( ) of the samepatient as in Fig. 1. The arthroscope is located in the anterolateralportal. b After debridement of the defect, the subchondral bone ispierced with the microfracture awlFig. 3 a Arthroscopic view of the same lesion as in Figs. 1 and 2,after microfracturing. Multiple loose fragments (*) are seen. b Allfragments are removed with a grasper, the lesion is again debrided,and the ankle joint is flushedKnee Surg Sports Traumatol Arthrosc (2009) 17:184–187 185123and were removed with a grasper (Fig. 3b). At the end ofthe procedure the joint was extensively flushed to wash outall possible remaining bony particles. After removal of theinstruments the incisions were sutured with 3.0 Ethilonsutures.Postoperative coursePostoperatively the patient was prescribed partial weightbearing for 6 weeks. She had an uneventful recovery.DiscussionArthroscopic debridement and bone marrow stimulation isthe primary treatment for most osteochondral lesions of thetalus, with 87% good or excellent results [11]. The objec-tive of the technique is firstly to remove all unstablecartilage, including the underlying necrotic bone, andsecondly to stimulate healing of the defect by opening thesubchondral bone. The latter is achieved by creating sev-eral defects into the calcified zone that usually covers thedefect. Irrespective of the technique used, the aim of theprocedure is to stimulate the formation of a fibrin clot intothe defect. Pluripotential stem cells are recruited from thebone marrow, and the formation of fibrocartilaginous tissueis initiated [9]. This can be accomplished by using a 2 mmdrill, a 1.4–2.0 mm K-wire, or a microfracture awl.The different instruments which can be used to open thesubchondral bone each have specific advantages and dis-advantages. Small diameter drills and K-wires have beensuccessfully used in routine ankle arthroscopy [3, 8].Eventual necrosis, due to heat caused by the drilling, can beminimized by using low speed and sufficient flushing,which also improves visualization. Compared to a drill, theK-wire has the advantage of flexibility and thus less risk ofbreakage. The use of either a drill or a K-wire also allows atransmalleolar or retrograde approach to the lesion [7, 10].A drawback of the transmalleolar approach is the iatro-genic damage of the opposing tibial articular cartilage.Moreover, it has been associated with persistent pain andoedema, and even a stress fracture may occur [7].The bone marrow stimulation technique with a micro-fracture awl is based on the theory that the use of an awlresults in microfractures of the trabeculae rather thandestruction of the bone, thereby inducing a healingresponse [9]. An advantage is that lesions can be treated‘‘around the corner’’, because the end of the awl is curved[12]. This makes constant distraction unnecessary, whichmay lead to fewer complications [4]. Furthermore, possibleheat necrosis in the case of drilling without cooling isavoided.We describe an important drawback of the procedure.With the microfracture technique loose bony particles arecreated, which easily become detached upon withdrawal ofthe awl. If the particles are not removed properly, they mayact as loose bodies. These might subsequently give rise tolocking and cartilage damage (Fig. 4).Until better alternatives have been sufficiently investi-gated, debridement and bone marrow stimulation remainsthe treatment of choice for primary ODs of the talus. Thetechnique is reliable and reproducible, and is associatedwith a high percentage of good or excellent outcome [11].However, when using the microfracture awl, one must bealert for the creation of intra-articular loose bodies, espe-cially when the microfracturing awl is retrieved. The jointshould be inspected carefully, any loose bodies should beremoved, and we recommend extensive flushing at the endof each procedure.Conflict of interest This research was not supported by outsidefunding or grants. None of the researchers or an affiliated institute hasreceived (or agreed to receive) from a commercial entity something ofvalue related in any way to this manuscript.Open Access This article is distributed under the terms of theCreative Commons Attribution Noncommercial License which per-mits any noncommercial use, distribution, and reproduction in anymedium, provided the original author(s) and source are credited.References1. Chuckpaiwong B, Berkson EM, Theodore GH (2008) Micro-fracture for osteochondral lesions of the ankle: outcome analysisand outcome predictors of 105 cases. Arthroscopy 24:106–1122. Van Dijk CN, Bossuyt PMM, Marti RK (1996) Medial ankle painafter lateral ligament rupture. J Bone Joint Surg Br 78:562–5673. Van Dijk CN, Scholte D (1997) Arthroscopy of the ankle joint.Arthroscopy 13:90–964. Van Dijk CN, Van Bergen CJA (2008) Advancements in anklearthroscopy. J Am Acad Orthop Surg (in press)Fig. 4 CT-scan of a right ankle that shows a loose body which issituated in the talar cartilage (:). Coronal (left) and sagittal (right)reconstructions are shown186 Knee Surg Sports Traumatol Arthrosc (2009) 17:184–1871235. Ferkel RD, Heath DD, Guhl JF (1996) Neurological complica-tions of ankle arthroscopy. Arthroscopy 12:200–2086. Giannini S, Vannini F (2004) Operative treatment of osteo-chondral lesions of the talar dome: Current concepts review. FootAnkle Int 25:168–1757. Robinson DE, Winson IG, Harries WJ, Kelly AJ (2003) Arthro-scopic treatment of osteochondral lesions of the talus. J BoneJoint Surg Br 85:989–9938. Schuman L, Struijs PAA, Van Dijk CN (2002) Arthroscopictreatment for osteochondral defects of the talus. Results at follow-up at 2 to 11 years. J Bone Joint Surg Br 84:364–3689. Steadman JR, Rodkey WG, Rodrigo JJ (2001) Microfracture:surgical technique and rehabilitation to treat chondral defects.Clin Orthop Relat Res 391(suppl):362–36910. Taranow WS, Bisignani GA, Towers JD, Conti SF (1999) Ret-rograde drilling of osteochondral lesions of the medial talardome. Foot Ankle Int 20:474–48011. Verhagen RAW, Struijs PAA, Bossuyt PMM, Van Dijk CN(2003) Systematic review of treatment strategies for osteochon-dral defects of the talar dome. Foot Ankle Clin 8:233–24212. Zengerink M, Szerb I, Hangody L, Dopirak RM, Ferkel RD, VanDijk CN (2006) Current concepts: treatment of osteochondralankle defects. Foot Ankle Clin 11:331–359Knee Surg Sports Traumatol Arthrosc (2009) 17:184–187 187123

Potential pitfall in the microfracturing technique during the arthroscopic treatment of an osteochondral lesion

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Potential pitfall in the microfracturing technique during the arthroscopic treatment of an osteochondral lesion

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