Microdrilling Surgery Augmented With Intra-articular

Bone Marrow Aspirate Concentrate, Platelet-Rich

Plasma, and Hyaluronic Acid: A Technique for
Cartilage Repair in the Knee
Joseph E. Broyles, M.D., M. Adaire OBrien, M.P.H., and M. Patrick Stagg, M.D.

Abstract: The ideal treatment of large full-thickness chondral lesions in the knee, especially kissing lesions and oste-
oarthritis, has not been determined. Microdrilling surgery augmented with injections of peripheral blood stem cells and
hyaluronic acid has been used to treat patients with a wide range of articular cartilage disease including patients with
bipolar lesions and joint space narrowing. Excellent results in this difcult patient population have been reported, and
second-look biopsy has shown repair tissue very similar to native hyaline cartilage. Because of Food and Drug Admin-
istration regulations, this technique is not currently allowed in the United States. We describe a Food and Drug
Administrationecompliant modication of this technique using microdrilling augmented with intra-articular bone
marrow aspirate concentrate, platelet-rich plasma, and hyaluronic acid.

T he ideal treatment of large full-thickness chondral

lesions in the knee, especially kissing lesions, has
not been determined. Most surgeons believe that con-
ventional treatment such as microfracture is relatively
contraindicated for bipolar cartilage damage and for
lesions greater than 4 cm2. The repair tissue formed by
microfracture is primarily brocartilage, which is
known to be inferior to hyaline cartilage.1 Saw et al.2,3
have reported on a technique that combines
arthroscopic microdrilling with injections of peripheral
blood stem cells (PBSCs) and hyaluronic acid (HA).
Second-look biopsy has shown tissue with histology
very similar to native hyaline cartilage as well as
excellent clinical scores in a difcult patient population
including patients with bipolar and diffuse cartilage
damage.2,3 Food and Drug Administration (FDA)
regulations do not currently allow use of PBSCs in the
From the Bone and Joint Clinic of Baton Rouge (J.E.B., M.A.O.); and
Medical Oncology Our Lady of the Lake Physician Group (M.P.S.), Baton
Rouge, Louisiana, U.S.A.
The authors report that they have no conicts of interest in the authorship
and publication of this article.
Received July 29, 2016; accepted September 10, 2016.
Address correspondence to Joseph E. Broyles, M.D., Bone and Joint Clinic of
Baton Rouge, 7301 Hennessy Blvd, Ste 200, Baton Rouge, LA 70808, U.S.A.
E-mail: jbroyles@bjcbr.com
2016 by the Arthroscopy Association of North America
2212-6287/16735/$36.00
http://dx.doi.org/10.1016/j.eats.2016.09.024
knee.4 We describe an FDA-compliant technique that
combines arthroscopic microdrilling with postoperative
injections of bone marrow aspirate concentrate
(BMAC), platelet-rich plasma (PRP), and HA to treat
full-thickness chondral damage including large bipolar
lesions.
Technique
BMAC and PRP Preparation
After appropriate general anesthesia, patients are
turned into the lateral decubitus position. The poste-
rior pelvic region is prepared and draped. A tiny (1- to
2-mm) stab incision is created over the posterior su-
perior iliac spine ipsilateral to the operative knee. A
15-gauge Illinois bone marrow needle (CareFusion,
McGaw Park, IL) with the lower sleeve removed is
positioned on the central posterior superior iliac spine
and tapped approximately 1 cm deep with a mallet
(Fig 1A). The needle stylus is then removed. A 20-mL
catheter-tip syringe prelled with 100 U of heparin
(100 U/mL) is attached to the back of the needle, and
negative pressure is applied to aspirate 15 to 20 mL of
bone marrow. The syringe is then detached, capped
with an 18-gauge needle, and inverted several times to
ensure adequate mixing.
The mixture is injected through a coupler
(GD896894; Fenwal, Lake Zurich, IL) into a 150-mL
polyvinyl chloride transfer bag (140902; Charter

Arthroscopy Techniques, Vol 6, No 1 (February), 2017: pp e201-e206 e201

e202 J. E. BROYLES ET AL.

Fig 1. Bone marrow aspiration and ltration. (A) With the patient positioned lateral, a 15-gauge Illinois bone marrow needle
with the lower sleeve removed is inserted into the central posterior superior iliac spine. Fifteen to twenty milliliters of bone
marrow is drawn into a 20-mL syringe prelled with 100 U of heparin. (B) The syringe is capped with an 18-gauge needle, and
the bone marroweheparin mixture is injected through a coupler into a 150-mL polyvinyl chloride transfer bag. (C) The contents
are run through a 210-mm lter to remove any bony particulates. (D) The ltered bone marrow is divided between two 10-mL
red-top serum tubes.

Medical, Winston-Salem, NC) (Fig 1B). The contents divided between two 10-mL serum tubes (BD Vacu-
are then run through a 210-mm lter (11141-48; Hos- tainer [366441]; Becton Dickinson, Franklin Lakes, NJ)
pira, Lake Forest, IL) in a sterile closed system to (Fig 1D). The tubes are centrifuged for 10 minutes at
remove any clots and bony particulates (Fig 1C) and 1,300g (VanGuard V6500; Hamilton Bell, Montvale,
 BIOLOGIC AUGMENTED MICRODRILLING IN KNEE e203

Fig 2. Bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) preparation. (A) The red-top tubes containing
the ltered bone marrow are centrifuged for 10 minutes at 1,300g. (B) After centrifugation, the tubes are carefully uncapped, and
a spinal needle is used to aspirate the buffy coat and some plasma from both tubes, yielding 3 to 5 mL of BMAC. (C) The Biomet
GPS III system is used to obtain 7 mL of PRP from 55 mL of whole blood. (D) The 3 biologic components, ready to be combined
for a knee injection: 25 mg of hyaluronic acid (HA), PRP, and BMAC.

NJ) (Fig 2A). The tubes are carefully uncapped, and a Usually 3 to 5 mL of BMAC is obtained in this manner.
10-mL Luer-Lok syringe (Becton Dickinson) with an This mixture is then passed onto the sterile eld.
18-gauge 3.5-inch spinal needle is used to aspirate the The patient is positioned supine while the BMAC is
buffy coat and some plasma from both tubes (Fig 2B). prepared. While the patient is being positioned,
e204 J. E. BROYLES ET AL.
Fig 3. Surgical preparation. (A) Patient positioning for
microdrilling surgery. The foot of the operating room bed is
dropped down 90
. The contralateral leg is fully abducted on
an arm board attached to the end of the bed. (B) A Smith &
Nephew 2.9-mm mini burr is modied for drilling holes 2 mm
in diameter and 7 mm deep. Seven millimeters of the pro-
tective sleeve is removed with a wire cutter to allow the burr
to drill to the appropriate depth.
anesthesia personnel obtain blood through venipunc-
ture to prepare PRP using the Biomet GPS III platelet
concentration system (Biomet Biologics, Warsaw, IN)
(Fig 2C). Per instructions in this system, 52 mL of blood
is combined with 8 mL of anticoagulant citrate dextrose
and used to generate approximately 7 mL of PRP. This
is also passed onto the sterile eld. The BMAC, PRP,
and 25 mg of HA (Supartz; Bioventus, Durham, NC) are
combined in a single 20-mL syringe for use at the
conclusion of the procedure (Fig 2D).
Microdrilling Procedure
The foot of the operating room bed is dropped down
90
. The contralateral leg is fully abducted on an arm
board attached to the end of the bed (Fig 3A). A tour-
niquet is placed on the operative leg, but it usually is
not required. After preparation and draping, standard
medial and lateral arthroscopy portals are established.
Many of these patients have undergone multiple pre-
vious knee operations, so debridement of scar tissue is
usually needed for appropriate visualization. Clinically
signicant meniscal pathology is addressed rst.
Attention is then turned to the chondral lesions. A ring
curette is used to remove any remaining damaged
cartilage in the full-thickness defect or defects. A No. 11
scalpel blade is often used as well to develop well-
dened margins. The calcied cartilage layer is also
removed using the ring curette.
Microdrilling of each lesion is then performed. Dril-
ling is performed with a 2.9-mm mini burr (3530;
Smith & Nephew, London, England). The 2.9 mm
represents the diameter of the protective sleeve. The
burr itself measures 2 mm. Seven millimeters of the
protective sleeve is removed with a wire cutter to allow
use of the burr for drilling (Fig 3B). The crimped end of
the cut sleeve is then opened back up using an obtu-
rator from a 3-mm outow cannula (720491; Smith &
Nephew). Holes are drilled to a depth of 7 mm (when
the remaining sleeve contacts the bone) and are placed
2 to 3 mm apart (Fig 4A). Drilling is performed slowly
so that thermal damage of the bone does not occur
(Table 1).
Drilling of lesions on the femoral condyles and
trochlea is usually fairly straightforward, with small
accessory portals required to ensure perpendicular
drilling. A spinal needle is always placed rst to deter-
mine the proper placement of these portals. Lesions of
the patella and tibial plateau are more difcult to access.
For the patella, especially in a tight knee, a lateral
Fig 4. Trochlea lesion in a
right knee, with arthro-
scopic views from the ante-
rolateral portal. (A) Lesion
after debridement and dril-
ling. The holes are 7 mm
deep and placed 2 to 3 mm
apart. (B) The same lesion is
injected with bone marrow
aspirate concentrate,
platelet-rich plasma, and
hyaluronic acid with an 18-
gauge 3.5-inch spinal nee-
dle under arthroscopic
guidance.
 BIOLOGIC AUGMENTED MICRODRILLING IN KNEE e205

Table 1. Pearls and Pitfalls
Do not use an arthroscopic leg holder because deep knee exion is
more difcult.
Use a padded Mayo stand to rest the foot on while drilling the patella.
Drill slowly with the burr and back out several times to clear bone
debris and prevent thermal necrosis.
Check under the meniscus for cartilage defects. Retract the meniscus
with a probe while drilling there.
Create additional mini portals as necessary to maintain perpendicular
drilling.
Perform a percutaneous medial collateral ligament release when
necessary to drill the tibia. (Do not resort to a microfracture awl.)
Bear in mind that performing a lateral release greatly improves access
for patella drilling.
Use a tenaculum clamp on the patella for easier patella positioning
and stability while drilling.
When injecting buffered lidocaine for bone marrow aspiration,
inltrate the periosteum in an area approximately 2 cm in diameter
to minimize discomfort.
Begin early isometric loading of the patellofemoral joint after
patellofemoral joint drilling.
Advise patients that they should not expect improvement from
baseline until 3-6 months postoperatively.
release is often necessary to be able to tilt the patella
enough to drill the central ridge. A tenaculum clamp
placed on the patella through tiny stab incisions greatly
facilitates positioning of the patella by an assistant
(Fig 5). The placement of the accessory portals for pa-
tella drilling must be posterior enough to allow drilling
as perpendicular as possible. Drilling of the central ridge
usually requires drilling from both the medial and
lateral aspects of the knee, because any drilling of the
medial side of the ridge from the lateral side, for
example, will tend to skive. For drilling of the medial
tibial plateau, we now usually perform a percutaneous
release of the medial collateral ligament in the method
described by Fakioglu et al.5 The improved access al-
lows medial tibial lesions to be more easily drilled
(Video 1). Posterior tibial plateau lesions are accessed
from a midcoronal portal, whereas anterior plateau
lesions are accessed from an anterior portal.
After all lesions are drilled, water is suctioned from
the knee. An 18-gauge spinal needle is inserted
percutaneously into the primary chondral lesion. All
portals are closed with nylon suture. The 20-mL syringe
containing the BMAC, PRP, and HA is afxed to the
spinal needle, and the mixture is then injected into the
knee (Fig 4B). A standard sterile dressing is applied.
Postoperative Rehabilitation
Continuous passive motion for 2 hours per day is
started on postoperative day 2 and continued for
4 weeks. Patients with tibiofemoral lesions are kept
partially weight bearing for 6 weeks, whereas patients
with patellofemoral lesions may only bear weight as
tolerated with the knee extended. Early on in physical
therapy, there is a focus on isometric exercises in varying
degrees of exion to load all drilled areas. Early dynamic
loading is not recommended to avoid shear injury to
repair tissue. This protocol was established in accordance
with previously published recommendations.2 Cycling is
allowed at 1 month, jogging at 9 months, and return to
sport at 1 year postoperatively (Table 2).
Postoperative Injections
Beginning 1 week postoperatively, intra-articular knee
injections of BMAC, PRP, and HA are administered once
per week for 5 weeks. The aspiration-injection procedure

Fig 5. Microdrilling surgical technique for a medial patella facet lesion in a right knee. All arthroscopic views are from the
superomedial portal with a 30
arthroscope. (A) A ring curette is used to debride the lesion and to remove the calcied cartilage
layer. The curette enters the knee posteromedial to the patella. (B) Drilling of debrided lesion. Tilting the patella with a te-
naculum clamp facilitates perpendicular drilling of the patella. (C) A mini shaver is used to smooth the edges of the lesion after
drilling.
e206 J. E. BROYLES ET AL.
Table 2. Procedure and Rehabilitation Timeline
Time Event
Day 1 Surgery and rst injection of PRP, BMAC,
and HA
Day 3 Start CPM and PT, partial weight bearing
Weeks 2-6 Five more weekly injections of PRP, BMAC,
and HA
Week 4 Stop CPM
Week 6 Advance to weight bearing as tolerated
4 mo Three more weekly injections of PRP, BMAC,
and HA
9 mo Return to jogging
1 yr Three more weekly injections of PRP, BMAC,
and HA
Return to sport
BMAC, bone marrow aspirate concentrate; CPM, continuous pas-
sive motion; HA, hyaluronic acid; PRP, platelet-rich plasma; PT,
physical therapy.
is performed in the ofce with the patient under local
anesthesia. To minimize patient discomfort, lidocaine is
buffered with 8.4% sodium bicarbonate at a lidocaine-
bicarbonate ratio of 10:1. An effusion, if present,
should be aspirated rst. At 4 months and at 1 year
postoperatively, 3 more weekly injections are per-
formed, for a total of 12 injections including the rst in-
jection given at the time of surgery.
Discussion
Treatment of full-thickness chondral lesions of the
knee with microdrilling and injections of BMAC, PRP,
and HA is a technically feasible FDA-compliant modi-
cation of the technique described by Saw et al.2,3
Biologic-augmented microdrilling has the advantage of
an all-arthroscopic procedure amenable to a wide range
of chondral diseases. Although we recommend 12 total
bone marrow aspirationseknee injections over the
course of 1 year after microdrilling surgery, we have
optimized the in-ofce procedure to minimize surgeon
time and maximize patient comfort (Table 3). Like other
cartilage repair techniques, our technique is not indi-
cated for patients with signicant malalignment unless
Table 3. Advantages and Disadvantages
Advantages
The technique is applicable to a wide range of cartilage damage,
including bone-on-bone arthritis.
Bone marrow processing materials are inexpensive compared with
commercially available bone marrow concentration kits.
The technique is a single-surgery arthroscopic procedure.
Failure of previous cartilage restoration procedures does not seem
to be a negative prognostic factor.
Disadvantages
A large number of postoperative bone marrow aspirations and
knee injections are required.
Postoperative injections are not covered by insurance.
Standard insurance reimbursement for microfracture surgery is
low for the time involved in treating large or multiple lesions.
Table 4. Indications and Contraindications
Indications
Symptomatic International Cartilage Repair Society grade III or IV
chondral lesions of the knee in any compartment
Treatment area up to 18 cm2 for bipolar lesions or up to 9 cm2 for
unipolar lesions
Contraindications
Body mass index >35
Age >60 yr
Signicant varus or valgus*
Flexion contracture 10

* Mechanical axis of the knee passing more than halfway from the
midline of the tibia to the edge of the tibial condyle.
combined with an osteotomy. In addition, age over
60 years may be a relative contraindication (Table 4).
To date, this procedure has been performed in 40
knees, with treatment area ranging from 0.6 to
14.7 cm2. On the basis of the outcomes of patients 1 to
5 years postoperatively, an upper limit of treatment
area has not been determined. Although these results
need to be conrmed with more patients and long-term
follow-up, early outcomes are generally very good
regardless of treatment area, location, or number of
involved compartments. Similar to microdrilling with
PBSCs described by Saw et al.,2,3 the available data
suggest that the FDA-compliant biologic-augmented
microdrilling technique described in this article may be
applicable to a wide range of chondral diseases.
Acknowledgment
The authors acknowledge Kaitlin Hanken, M.P.H., for
compiling and editing the video and gure images.
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