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Microfracture: Cartilage Repair Procedure Explained

Microfracture is a minimally invasive surgical technique used to treat cartilage defects in joints. Small holes are drilled into the bone to stimulate the natural regeneration of cartilage tissue.

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Things worth knowing about "Microfracture"

Microfracture is a minimally invasive surgical technique used to treat cartilage defects in joints. Small holes are drilled into the bone to stimulate the natural regeneration of cartilage tissue.

What is Microfracture?

Microfracture is a minimally invasive orthopaedic surgical procedure used to treat localised cartilage defects in joints. The goal of the procedure is to harness the body's natural healing capacity to regenerate damaged cartilage tissue. The technique was largely developed and popularised in the 1990s by American orthopaedic surgeon J. Richard Steadman.

Cartilage is a specialised tissue that covers joint surfaces and acts as a cushion between bones. Unlike most other body tissues, cartilage has a very limited capacity for self-repair because it lacks a direct blood supply. The microfracture technique attempts to overcome this limitation by deliberately inducing bleeding from the underlying bone.

Indications – When is Microfracture Used?

Microfracture is primarily indicated for localised, full-thickness cartilage defects (Grade III–IV according to the ICRS classification). Common applications include:

Cartilage damage in the knee joint (most frequent indication)
Cartilage defects of the ankle joint
Cartilage damage in the shoulder joint
Injury-related cartilage defects in younger, physically active patients

The technique is particularly well-suited for defects with an area of up to 2–4 cm². For larger defects or advanced osteoarthritis, alternative procedures are often preferred.

How the Procedure Works

Microfracture is typically performed arthroscopically (keyhole surgery) using small skin incisions and a camera. The procedure involves the following steps:

Preparation of the defect: Damaged cartilage and unstable cartilage fragments are carefully removed until a stable cartilage rim remains. The calcified cartilage layer (tidemark) is gently debrided.
Creating microfractures: Using a specialised sharp instrument (an awl or pick), small holes approximately 3–4 mm apart and about 1–2 mm deep are made in the subchondral bone.
Blood clot formation: Through the perforations, blood and bone marrow cells (including mesenchymal stem cells) are released and form a blood clot (coagulum) within the defect.
Fibrocartilage formation: Over weeks and months, the clot differentiates into fibrocartilage, which fills the defect. Although fibrocartilage differs in composition from the original hyaline articular cartilage, it can significantly improve joint function.

Aftercare and Rehabilitation

Post-operative rehabilitation is a critical determinant of treatment success and typically includes:

Offloading the joint for 6–8 weeks (crutches for knee procedures)
Early passive range-of-motion exercises (e.g. with a continuous passive motion, or CPM, machine) to promote cartilage maturation
Gradual return to weight-bearing under physiotherapy supervision
Return to sports and strenuous activities usually after 6–12 months

During rehabilitation, it is essential to allow the newly formed fibrocartilage tissue sufficient time to consolidate and adapt to mechanical loading.

Outcomes and Prognosis

Microfracture demonstrates good to very good short-term outcomes, particularly in younger patients (under 40 years of age) with small, well-defined defects. Long-term results can be variable, as the resulting fibrocartilage is mechanically less durable than the original hyaline cartilage. In some cases, deterioration may occur after several years.

Factors associated with better outcomes include:

Younger patient age
Small defect size
Short duration of symptoms prior to surgery
Consistent post-operative rehabilitation
Normal body weight

Alternatives to Microfracture

Depending on the size and location of the cartilage defect and the age of the patient, the following alternatives are available:

Autologous Chondrocyte Implantation (ACI): The patient's own cartilage cells are harvested, expanded in a laboratory, and then implanted into the defect.
Osteochondral Autograft Transfer (OATS / Mosaicplasty): Cartilage-bone cylinders are harvested from less load-bearing areas of the joint and transplanted into the defect.
Matrix-Associated Autologous Chondrocyte Implantation (MACI): An advanced version of ACI using scaffold matrices to support cell delivery.
Conservative management: Physiotherapy, weight reduction, and pharmacological treatment for less severe defects.

References

Steadman JR, Briggs KK, Rodrigo JJ, Kocher MS, Gill TJ, Rodkey WG: Outcomes of microfracture for traumatic chondral defects of the knee: average 11-year follow-up. In: Arthroscopy, 2003; 19(5): 477–484.
Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR: Clinical efficacy of the microfracture technique for articular cartilage repair in the knee. In: The American Journal of Sports Medicine, 2009; 37(10): 2053–2063.
Hunziker EB: Articular cartilage repair: basic science and clinical progress. A review of the current status and prospects. In: Osteoarthritis and Cartilage, 2002; 10(6): 432–463.

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