Houston Chronicle Interviews Dr. Mandelbaum about why Microfracture Surgery has Good Success if the Right Criteria is Met


Texans linebacker Jadeveon Clowney is believed to be a good candidate for the microfracture surgery.

Athletes are trendsetters, even when it comes to complicated medical procedures. Since performing microfracture surgery on the now most famous right knee in Texans' history - belonging to top overall draft pick Jadeveon Clowney - Dr. Walt Lowe has received more than 100 MRIs from people desperate to find relief from chronic knee pain.

Unfortunately, Lowe could only offer the same answer to most of them.

"No, no, no, no," he said. "A lot of microfractures are done for the wrong reasons, on people with problems it has no chance of fixing. There are certain indicators you look for, and if you don't hold to them rigidly, it won't work. That's why there's so much (negative) stuff out there about the procedure."

Microfracture involves the drilling of tiny - less than a millimeter in diameter - holes in the knee bone, permitting marrow and stem cells to leak through to the surface and rebuild articular cartilage where it has been gouged out by a sports injury or accident. The problem with the procedure's early incarnations was that the new "fibrocartilage" was essentially just scar tissue that grew in to unpredictable thicknesses and didn't hold up to the rigors of high-level athletic competition, jumping and sharp cutting in particular.

The current version, however, involves first setting a cartilage "matrix" from a donor (i.e., a cadaver) into the lesion, providing a structure not unlike rebar in concrete. This promotes the growth of new cartilage that far more closely approximates the natural material, called hyaline cartilage. There are several products now on the market that, Lowe said, "allow us to dictate the (cartilage's) thickness from the very beginning." Finally, a sticky, gluelike, man-made protein is applied to seal it.

Lowe admits, nonetheless, there's plenty of progress yet to be made, and even the strongest proponents of microfracture, such as Dr. Bert Mandelbaum, an orthopedic surgeon and co-chair of medical affairs at the Institute for Sports Sciences in Los Angeles, concedes that one in three procedures fail.

When the right criteria are met, however, "the success rate is really pretty high, 75 to 85 percent. The most important thing to understand is there's no one microfracture that's like any other. Every single one is different. That's why you can't take the procedure as a whole and attach an outcome to it (before the fact)."

Clowney was hurt in his first regular-season NFL game, against Washington Sept. 7, having landed awkwardly trying to avoid stepping on a fallen J.J. Watt. He suffered a torn meniscus cartilage and, apparently, damaged his articular cartilage. Because the latter doesn't always present symptoms such as pain or swelling, arthroscopic surgery to fix the meniscus frequently suffices. In Clowney's case, it didn't.

Because of patient privacy laws, Lowe can't discuss details of Clowney's case without his permission, and the Texans have made it clear they don't want that. (Lowe has been the team's official orthopedic surgeon since the franchise's inception.)

Since Lowe does about 10 microfractures a month, he was happy to explain how it works and to dispel the notion that it's a controversial, last-gasp option.

There are a number of indicators that make someone a better patient and at 21, Clowney's youth likely puts him in that category.

First, age 40 is the threshold when microfracture becomes less viable because the body's production of stem cells, essential to the procedure, has slowed. However, with the advances being made, this is becoming less of an issue.

Also, it's unlikely he's developed arthritis, and his meniscus had to still have been mostly intact. Other issues that would prevent a person from being a good candidate include having diabetes, an autoimmune disease or being a smoker.

"I don't care what you smoke," Lowe said, "it's going to prevent microfracture from working. This is a big issue, something that definitely prevents the formation of new cartilage. It's an oxygenation-blood flow issue. In the orthopedic world, smoking affects everything negatively - ACL repairs, rotator-cuff surgery, you name it."

The final component of successful microfracture is strict adherence to a rehab regimen. For the first five days, the knee has to be completely immobilized, then crutches are required for seven or eight more weeks before the leg becomes weight-bearing again. While professional athletes like Clowney have only to worry about recovering, the routine becomes problematic, Lowe conceded, "for those of us living in the normal world.

"Being on crutches for that long is hard, and you're going to lose a lot of strength, so then it takes a long time gain it back," he said. "You have to be committed totally to the whole process. But often we give up because we just don't have the time to put into it."

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