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Microfracture of the Knee

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

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

2

Interprets basic imaging studies

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

3

Prescribes and manages non-operative treatment

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

4

Makes informed decision to proceed with operative treatment

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

5

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
B

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies

  • MRI

2

Provides complex nonoperative treatment

  • concomitant injuries
  • ligament
  • fractures

3

Modifies and adjusts post-operative treatment plan as needed

  • knee arthrofibrosis
  • continued pain
C

Preoperative H & P

1

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.

2

Order basic imaging studies

  • order triplanar standing radiographs of the knee

3

Perform operative consent

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

Operative Techniques

E

Preoperative Plan

1

Determine pathology using MRI

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

2

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
F

Room Preparation

1

Surgical Instrumentation

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

2

Room setup and Equipment

  • standard OR table with leg holder

3

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
G

Scope Insertion

1

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

2

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

3

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
H

Diagnostic Arthroscopy

1

Visualize

  • 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)

2

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

3

Visualize

  • 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
I

Initial Preparation

1

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

2

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

3

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
J

Microfracture

1

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

2

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

3

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

4

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
K

Wound Closure

1

Use 3-0 and 4-0 biosyn for closure

  • Apply steristrips

2

Cover with tegaderm and occlusive dressings

Postoperative Patient Care

O

Perioperative Inpatient Management

1

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
R

Complex Patient Care

1

Treat complex complications

 

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