Updated: 10/4/2016

Microfracture of the Knee

Preoperative Patient Care


Outpatient Evaluation and Management


Obtains focused history and performs focused exam

  • concomitant and associated orthopaedic injuries
  • evaluate for
  • knee pain
  • mechanical symptoms
  • pain or swelling with ADLs and sports
  • joint line tenderness
  • knee effusion
  • associated with decreased quadriceps strength


Interprets basic imaging studies

  • standing radiographs
  • 30 degree flexion lateral
  • AP weightbearing in extension
  • 45 degree PA flexion weightbearing views


Prescribes and manages non-operative treatment

  • Injects/aspirates knee
  • guides trial of medical managment
  • attempts trial of physical therapy
  • quad strength closed chain


Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention


Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • remove sutures
  • diagnose and management of early complications
  • continue touchdown weightbearing
  • stationary biking without resistance and deep water exercises are started 1 to 2 weeks postoperatively
  • postop: 4-6 week postoperative visit
  • check range of motion
  • after 8 weeks of touchdown weightbearing, touchdown weightbearing as tolerated
  • low impact exercises is emphasized during weeks 9 to 16
  • diagnosis and management of late complications
  • postop: 4 months year postoperative Visit
  • no return to sports that involve pivoting, cutting and jumping until at least 4 to 9 months after treatment

Advanced Evaluation and Management


Appropriately orders and interprets advanced imaging studies

  • MRI


Provides complex nonoperative treatment

  • concomitant injuries
  • ligament
  • fractures


Modifies and adjusts post-operative treatment plan as needed

  • knee arthrofibrosis
  • continued pain

Preoperative H & P


Obtain history and perform basic physical exam

  • history
  • Age
  • Gender
  • HPI
  • PMHx
  • identify medical co-morbidities that might impact surgical treatment
  • Social history
  • physical exam
  • ROM
  • joint effusion
  • joint tenderness
  • complete neurovascular exam of extremity.


Order basic imaging studies

  • order triplanar standing radiographs of the knee


Perform operative consent

  • describe complications of surgery including
  • pain
  • infection
  • gritty sensation of the joint
  • loss of motion
  • recurrent effusion

Operative Techniques


Preoperative Plan


Determine pathology using MRI

  • radial tear
  • horizontal cleavage tear
  • displaced bucket handle tear
  • meniscal root tear
  • discoid meniscus


Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical Instrumentation

  • standard arthroscopy pump
  • motorized meniscal shaver
  • toothed grasper
  • double loaded 2-0 or 0 nonabsorbable sutures with long flexible needles


Room setup and Equipment

  • standard OR table with leg holder


Patient Positioning

  • supine
  • leg holders
  • place leg holder 5 to 8 cm proximal to the superior pole of the patella to maximize control of the limb
  • contralateral leg is placed in a well leg holder
  • for the diagnostic portion of the procedure is placed at the foot of the bed
  • for the remainder of the procedure, the foot of the bed is dropped

Scope Insertion


Mark out the anatomy of the knee

  • draw out the patella, patellar tendon, medial and lateral joint lines and the posterior contours of the medial and lateral femoral condyles


Place anterolateral portal

  • use 22 gauge needle on syringe and bury the needle
  • make wheal at skin and then 11 blade in same direction as the needle
  • place scope in same direction as needle and blade
  • hug the patellar tendon


Place anteromedial portal

  • place knee in 30 degrees of flexion with valgus moment applied
  • use a spinal needle to assess direction and appropriate superior/inferior direction.
  • visualize with lateral portal

Diagnostic Arthroscopy



  • suprapatellar pouch
  • patellofemoral joint (take picture)
  • place bump under heel prn
  • lateral gutter
  • look for loose bodies and peripheral tears of LM
  • get MFC in view
  • bring knee into slight flexion and valgus as you go into medial compartment.
  • foot goes on to opposite hip and use standee to stabilize your foot
  • medial meniscus (take picture)
  • drop leg to flexion (bump should be under knee)


Establish far anteromedial portal

  • use 18-gauge needle to make sure that you clear the MFC and can get to the 2 o’clock (LEFT) or 10 o’clock (RIGHT) knee



  • medial compartment - probe medial meniscus, articular cartilage
  • intercondylar notch – ACL/PCL (take picture)
  • lateral compartment – probe lateral meniscus, articular cartilage (take picture)
  • assess the full thickness articular lesion

Initial Preparation


Debride all unstable cartilage

  • debride all of the exposed bone of all remaining unstable cartilage
  • use a hand held curved curette and a full thickness radius resector to debride the cartilage
  • it is critical to debride all loose or marginally attached tissue from the surrounding rim of the lesion


Remove the calcified cartilage layer

  • remove the calcified cartilage layer that remains as a cap to many lesions
  • this is preferabely done with a curette
  • thorough and complete removal of the calcified cartilage layer is extremely important


Maintain the integrity of the subchondral plate

  • do not debride to deeply
  • the prepared lesion with a stable perpendicular edge of healthy well attached viable cartilage surrounding the defect provides a pool that helps hold the marrow clot (super clot) as it forms



Make multiple holes

  • these are microfractures in the exposed subchondral bone plate
  • use an awl with an angle that permits the tip to be perpendicular to the bone as it is advanced
  • typically this is 30 or 45 degrees
  • use a 90 degree awl on the patella or other soft bone
  • this should only be advanced manually


Position the holes appropriately

  • make the holes close together but not so close that one breaks into another IE breaking the subchondral plate between them
  • this usually results in microfracture holes that are approximately 3 to 4 mm apart


Determine the appropriate depth of the holes

  • when fat droplets can be seen coming from the marrow cavity, the appropriate depth of 2-4 mm has been reached


Drill holes in the appropriate order

  • microfracture holes around the periphery of the defect should be made first
  • these holes should be made immediately adjacent to the healthy stable cartilage rim
  • complete the process by making the microfracture holes towards the center of the defect

Wound Closure


Use 3-0 and 4-0 biosyn for closure

  • Apply steristrips


Cover with tegaderm and occlusive dressings

Postoperative Patient Care


Perioperative Inpatient Management


Discharges patient appropriately

  • pain meds
  • schedule follow up in 2 weeks
  • outpatient physical therapy
  • cold therapy for 1 to 7 days
  • crutch assisted touch down weightbearing for 6 to 8 weeks
  • passive range of motion starting postop day one
  • begin therapy immediately after surgery with an emphasis on patellar mobility with instructions to perform medial to lateral and superior to inferior movement of the patella
  • medial and lateral movement of the quadriceps and patellar tendons
  • this is imperative to prevent patellar tendon adhesions
  • ROM exercises without limitations are initiated during the day of surgery

Complex Patient Care


Treat complex complications


Please rate topic.

Average 5.0 of 3 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Case ID Date Hospital Faculty CPT Codes
Topic COMMENTS (0)
Private Note