Arthroscopic Knee Cartilage Repair With Covered Microfracture and Bone Marrow Concentrate

Abstract

In recent years several single-stage cartilage repair approaches have been devised to treat focal cartilage lesions. These usually associate microfracture (MFX) and a coverage scaffold. We describe a novel arthroscopic technique that combines MFX, autologous bone marrow concentrate (BMC), and a protective scaffold. Bone marrow aspirate from the iliac crest is centrifuged to obtain BMC. The cartilage defect is debrided, MFX holes are created, and the final defect is measured by use of a bent K-wire. The scaffold is then shaped to match the defect, immersed in BMC, introduced into the joint with a grasper, and fixed in place with a mixture of fibrin glue and BMC. This technique aims to augment the original single-stage procedure with a number of mesenchymal stem cells and growth factors contained in the BMC, to increase the defect filling and the rate of hyaline-like cartilage regeneration. The procedure combining MFX, BMC, and a protective scaffold is inexpensive and reproducible and has already shown the ability to regenerate hyaline-like cartilage. Its use as an alternative to autologous chondrocyte implantation requires further investigation.

Chondrogenic Differentiation Processes in Human Bone Marrow Aspirates upon rAAV-Mediated Gene Transfer and Overexpression of the Insulin-Like Growth Factor I

“…Application of marrow concentrates as a practical, singlestep approach to treat articular cartilage lesions is clinical reality to provide options that are less complex and invasive than those based on the implantation of isolated progenitor cells, 10,11,43 but the quality of the repair tissue generated with such treatments still remains inferior to that of the original hyaline cartilage. This issue might be addressed by genetically modifying the concentrates to improve their chondroregenerative capabilities.…”

“…Several therapeutic options are available to treat articular cartilage defects, including autologous chondrocyte implantation and marrow-stimulating techniques, 2-5 but these procedures generally lead to the production of a fibrocartilaginous repair tissue (type-I collagen) of lesser quality than the natural hyaline cartilage (type-II collagen, proteoglycans) that does not integrate well with the surrounding unaffected cartilage, and cannot withstand mechanical stress. [5][6][7] Such issues have been addressed, at least in part, by elaborating progenitor cell-based therapies for cartilage repair by the administration of isolated chondroregenerative cells like bone marrow-derived mesenchymal stem cells (MSCs) 5,8,9 or of marrow concentrates containing MSCs among various cell subpopulations (hematopoietic cells, fibroblasts) as a single-step, convenient therapeutic procedure [10][11][12] due to the extensive, specific ability of MSCs to undergo competent chondrogenic differentiation in this environment. [13][14][15] Nevertheless, even though the clinical outcomes of such trials have been encouraging, complete reconstruction of an original cartilaginous surface in treated patients has not been reported to date, demonstrating the clear need for improved protocols.…”

The state of cartilage regeneration: current and future technologies

“…Reports on clinical outcomes are limited and have not included level I or II data. Gigante et al reported the use of BM-MSCs in conjunction with a fibrin carrier to arthroscopically treat cartilage lesions as a microfracture adjunct in a single patient [38]. Nejadnik et al reviewed a cohort undergoing either firstgeneration ACI or cultured BM-MSCs [39•].…”

Processing Volumes and Therapeutic Cellular Doses of Point of Care Bone Marrow Concentrates

“…In this regard, inversely to the developmental pathway of traditional drugs where high quality clinical studies are performed before its accessibility, BMC have fast moved from basic research to clinical practice even at the expense of not truly understanding intimate mechanisms associated to this therapy. On the contrary, based on case reports and short clinical trials, BMC-derived therapies have spread increasingly in the traumatology arena supported basically by observational results reporting safe and successful functional outcomes [3][4][5][6] . As a consequence, substantial concepts such as the definition of BMC´s active substance, its mode of action and the dose to be applied for a particular diagnostic remain questions yet to be answered.…”