Alternatives to knee microfracture surgery and cartilage implant surgery

Ross A. Hauser, MD. Caring Medical Florida
Danielle R. Steilen-Matias, MMS, PA-C. Caring Medical Florida

Alternatives to knee microfracture surgery and cartilage implant surgery

In this article we will present the non-surgical alternative to various surgical techniques that are designed to repair or regrow the articular cartilage of the knee.

Many people do very well with Microfracture knee surgery or Arthroscopic abrasion arthroplasty procedures. If you have been recommended to one of these procedures you probably do not need a detailed explanation as to what these procedures do, there is a drilling or scrapping into the bone beneath or behind the cartilage. The hope is that healing elements from the blood that is released from the bone drilling will help stimulate the repair of cartilage.

The people who do well with these procedures are usually not the people we see in our clinics. We see the people who have had the procedure fail on them, sometimes not once, but two or three times. Some of these people’s stories go something like this:

I’ve had multiple microfracture failures. I was then recommended to an ACI (autologous chondrocyte implant. In this procedure a small sample of good cartilage is taken from one part of the knee and used to patch a hole in another part of the knee), this surgery also failed. I am now being told to consider total knee replacement as soon as I get a little older. For now I have been told to stop my favorite activities, do as little weight bearing activity as possible and to live on pain pills.

If you are reading this article it is likely that you too have had multiple procedures that have either failed or “worn out.” ACI or autologous chondrocyte implant are designed to delay the need for knee replacement, not substitute for it.

Knee articular cartilage surgery: “the limited repairing capacity and the potential pitfalls of these techniques cannot be ignored.”

A September 2019 study in the journal Therapeutic advances in musculoskeletal disease (1) comes from Chinese and Australian researchers who gave this assessment of some of the surgical procedures they employ:

“Surgical intervention to repair cartilage may prevent progressive joint degeneration. A series of surgical techniques, including biological augmentation, microfracture and bone marrow stimulation, autologous chondrocyte implantation (ACI), and allogenic and autogenic chondral/osteochondral transplantation, have been used for various indications. However, the limited repairing capacity and the potential pitfalls of these techniques cannot be ignored.”

In researching such surgical options as:

We often find one of the successes of the surgery outcome in these procedures is that the patient did not need multiple surgeries and that these procedures put off eventual need for knee replacement.

In this image we can see the hole created by missing cartilage. In this particular image the impact of cortisone or steroid injections can be illustrated. A patient like this may be recommended to knee microfracture surgery and cartilage implant surgery.

In this image we can see the hole created by missing cartilage. In this particular image the impact of cortisone or steroid injections can be illustrated. A patient like this may be recommended to knee microfracture surgery and cartilage implant surgery.

Microfracture surgery for articular cartilage repair


“Currently, there is no effective non-surgical treatment for articular cartilage injury. . . functional recovery is not satisfactory”

In November 2017 doctors from the Institute of Orthopaedics in China wrote in the medical journal Trials, (2) “Spontaneous recovery from articular cartilage injury is difficult, and the ongoing progression of disease can eventually lead to osteoarthritis. Currently, there is no effective non-surgical treatment for articular cartilage injury. Arthroscopic debridement and microfracture surgery are performed for fibrocartilage repair. But fibrocartilage is different from normal articular cartilage, and functional recovery is not satisfactory.”

This research was not as enthusiastic as earlier 2017 studies where surgical researchers were happy to announce that cartilage repair or regeneration procedures (e.g., microfracture, Autologous Chondrocyte Implantation – ACI) typically result in a satisfactory outcome in selected patients.

This was detailed by doctors at the University of New Mexico who published research in which they suggest success in selective patients undergoing knee procedures including: chondroplasty, debridement, drilling, microfracture autologous chondrocyte implantation, osteochondral autograft, and osteochondral allograft, and that while these techniques may improve patient outcomes, NONE can reproduce normal hyaline cartilage.(3)

When microfracture is most successful and when it is not

In February 2020, surgeons at the University Hospital, LMU Munich published these findings in the journal Knee surgery, sports traumatology, arthroscopy: (4)

“Third-generation autologous chondrocyte implantation (ACI) is an established and frequently used method and successful method for the treatment of full-thickness cartilage defects in the knee. There are also an increasing number of patients with autologous chondrocyte implantation as a second-line therapy that is used after failed bone marrow stimulation in the patient’s history. . . In this study, the clinical results after the matrix-based autologous chondrocyte implantation in the knee in a follow-up over 3 years postoperatively were analysed. This study showed that third-generation autologous chondrocyte implantation is a suitable method for the treatment of full-thickness cartilage defects. However . . .autologous chondrocyte implantation after failed bone marrow stimulation leads to worse clinical results.”

This is the problem, the cartilage repair is not as durable as the native cartilage. It is not a long-term solution.

In March 2017, Rush University Medical Center researchers suggested in the journal Sports medicine and arthroscopy review:

And in January 2017 research from Rush and Duke Universities about youth athletes:

Good candidates for surgery, bad candidates for surgery

In February 2018 published in the Orthopaedic journal of sports medicine,(8) doctors at Keck School of Medicine, University of Southern California and the Department of Orthopedic Surgery, Rush University Medical Center offered these findings on which patients Microfracture would offer the most benefit stating that “Microfracture has become a common treatment option for relatively small, symptomatic cartilage defects in the knee.”

Patients who did not have a more desired response to surgery and were less than good candidates.

The researchers also noted that the surgery worked best when the cartilage tear was small and was the only tear. A wound in isolation. They note that this type of patient while ideal is rarer than the true to life patient who has many concomitant challenges such as meniscus damage, loose bodies in the knee, synovial inflammation of the knee requiring as Synovectomy or cleaning out of the inflamed synovial tissue. Additionally, some of the study subjects had the procedure done at the time of Anterior cruciate ligament reconstruction or Medial patellofemoral ligament reconstruction.

At our clinics, we rarely see a patient that has a small cartilage tear in isolation. When we do we find very high success rates with our regenerative medicine injections. Patients who have a more advanced knee injury or advanced levels of degeneration would obviously require a more comprehensive approach to healing.

“osteochondral allograft in the knee remains an inapplicable option in the treatment of post-traumatic end-stage arthritis of the young patient”

Doctors at Italy’s Bologna University looked at osteochondral allografts (cartilage transplantation from a donor) for their treatment of end-stage arthritis in younger post-traumatic arthritis patients. Here are their troubling findings:

The need for success options are obvious. Doctors at the University of Alberta and the University of Calgary in Canada (10) found that young athletes with post-traumatic knee arthritis had significant and rapid physical declines between the time of injury and the onset of arthritis.

In this study the Canadian researchers looked at:

The study’s authors reiterated in their conclusion: “This study provides preliminary evidence that youth/young adults following sport-related knee injury report more symptoms and poorer function, and are at greater risk of being overweight/obese 3-10 years post-injury compared to matched uninjured controls.”

Curious and troubling findings in patients who previously had Microfracture surgery and then went on to total knee replacement

Researchers writing in the medical journal Orthopedics found curious and troubling findings in patients who previous Microfracture surgery and then went on to total knee replacement. In comparing total knee replacement patients who had the Microfracture surgery and those who did not prior getting a knee replacement, the doctors found that

Surgery creates more bone damage

Doctors at Saarland University Medical Center in Homburg, Germany publishing in the journal Scientific reports (12) tested the hypothesis that early osteochondral repair following microfracture surgery is enhanced if bone marrow stem cell aspirate is added as an adjunct to the microfracture procedure.

The problem they were trying to solve was that the surgery creates more bone damage.

Interestingly, debridement down to the subchondral bone similarly led to a reduction of the bone volume both in the subchondral bone plate and subarticular spongiosa.

Surgeons adding bone marrow-derived stem cells to surgery and post-surgical care

Surgeons now consider adding bone marrow-derived stem cells to surgery.

Here in our opinion is another example of over complicating a simple procedure, the introduction of reparative stem cells into the knee.

So here is the understanding of it all:
1. Arthroscopic drilling
2. hyaluronic acid injections
3, stem cells therapy
and more injections six months later.

The study focused on the surgery and what made the surgery work better, and it wasn’t hyaluronic acid. It was the stem cells.

Why not try the repair with bone marrow aspirate stem cells without the surgery first?

In another study doctors writing in the medical journal Arthroscopy (14) found that in 55 knees that underwent High Tibial Osteotomy (bone resurfacing or reshaping) and microfracture, those who received stem cells with hyaluronic acid had significantly better results than those who just received hyaluronic acid.

Other research including Caring Medical published findings

Here is a recent study that can suggest that trying the stem cell injections first may be a more realistic option for patients especially those concerned with microfracture knee surgery recovery time and rehab.

Abrasion Arthroplasty is a procedure that sounds exactly what is is – abrasions are created on the cartilage to create an injury with the hope that the body will repair not only the new injury but the deterioration of the joint as well. This is a surgical procedure. Studies have pointed out that this procedure may help alleviate symptoms of knee pain but it is not curative.(17)

Not only non-curative – may not work at all.

Doctors at RWTH Aachen University in Germany had a problem with Arthroscopic abrasion arthroplasty. They are not sure it worked at all. To test the theory that the surgery was helpful – they examined the effusion, the swelling fluids in the knee following the surgery.

What they found was the surgery indeed starting a healing process by stimulating STEM CELLS to repair the cartilage.

Now here is the amazing part. The doctors found that during the surgery, the doctors used constant suction to drain the surgical area. The researchers now “recommend not to use suction drainage as by this procedure a considerable amount of the regenerative potential of postoperative joint effusions might be extracted.”(18)

Treatment for articular cartilage is challenging because knee cartilage shows limited reparative and regeneration abilities following injury. Traditional non-operative (RICE therapy), various injection therapies and traditional arthroscopic techniques cannot restore the normal anatomy and function of cartilage in osteoarthritis.

Stem cell therapy for cartilage repair need not be a complicated procedure. In many instances bone marrow stem cells are drawn from a patient and injected into the patient’s knee with the hope of repairing cartilage and bone damage typical of a knee with severe osteoarthritis or damage from injury. The procedure is simple in concept: inject stem cells, heal knee. Please watch the video below.

Caring Medical Research

Please see our discussions in the medical journal Clinical Medicine Insights. Arthritis and musculoskeletal disorders where our team presented three difficult knee pain case histories treated with Bone Marrow Stem Cell AspirateIn this article we will present clinical research and case studies to support the use of Bone Marrow Aspirate for Knee Pain. Bone Marrow Aspirate therapy is often called bone marrow stem cell therapy or simply stem cell therapy.

Prolotherapy

We do not offer stem cell therapy or bone marrow aspirate therapy to ever patient. If the patient is a good candidate, we may suggest simpler dextrose Prolotherapy treatments.

In this video, Danielle R. Steilen-Matias, MMS, PA-C, of Caring Medical demonstrates how we treat a patient with a primary complaint of knee osteoarthritis.

PRP and Prolotherapy

In this video, you will notice that PRP as we perform it, is NOT a single injection. It is a comprehensive treatment that addresses problems, weakness, and instability of the whole knee capsule.

Do you have a question about Knee articular cartilage surgery or becoming a patient? Get help and information from our Caring Medical staff

References for this article

1 Gao Y, Gao J, Li H, Du D, Jin D, Zheng M, Zhang C. Autologous costal chondral transplantation and costa-derived chondrocyte implantation: emerging surgical techniques. Therapeutic Advances in Musculoskeletal Disease. 2019 Sep;11:1759720X19877131. [Google Scholar]
2 Ma N, Wang H, Xu X, Wan Y, Liu Y, Wang M, Yu W, Dai Y, Peng J, Guo Q, Yu C. Autologous-cell-derived, tissue-engineered cartilage for repairing articular cartilage lesions in the knee: study protocol for a randomized controlled trial. Trials. 2017 Dec;18(1):519.  [Google Scholar]
3 Richter DL, Schenck RC Jr, Wascher DC, Treme G. Knee Articular Cartilage Repair and Restoration Techniques: A Review of the Literature. Sports Health. 2015 Oct 12. pii: 1941738115611350 [Google Scholar]
4 Müller PE, Gallik D, Hammerschmid F, Baur-Melnyk A, Pietschmann MF, Zhang A, Niethammer TR. Third-generation autologous chondrocyte implantation after failed bone marrow stimulation leads to inferior clinical results. Knee Surgery, Sports Traumatology, Arthroscopy. 2020 Feb 1;28(2):470-7. [Google Scholar]
5 Scotti C, Gobbi A, Karnatzikos G Martin I, Shimomura K, Lane JG, Peretti GM, Nakamura N. Cartilage repair in the inflamed joint: considerations for biological augmentation towards tissue regeneration. Tissue Eng Part B Rev. 2015 Oct 15. [Google Scholar]
6. Frank RM, Cotter EJ, Nassar I, Cole B. Failure of Bone Marrow Stimulation Techniques. Sports Medicine and Arthroscopy Review. 2017 Mar 1;25(1):2-9. [Google Scholar]
7. Cvetanovich GL, Riboh JC, Tilton AK, Cole BJ. Autologous chondrocyte implantation improves knee-specific functional outcomes and health-related quality of life in adolescent patients. The American journal of sports medicine. 2017 Jan;45(1):70-6. [Google Scholar]
8 Weber AE, Locker PH, Mayer EN, Cvetanovich GL, Tilton AK, Erickson BJ, Yanke AB, Cole BJ. Clinical outcomes after microfracture of the knee: midterm follow-up. Orthopaedic journal of sports medicine. 2018 Feb 6;6(2):2325967117753572.
9 Giannini S, Buda R, Ruffilli A, Pagliazzi G, Ensini A, Grigolo B, Desando G, Vannini F.  Failures in bipolar fresh osteochondral allograft for the treatment of end-stage knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2015 Jul;23(7):2081-9. doi: 10.1007/s00167-014-2961-1. [Google Scholar]
10 Whittaker JL, Woodhouse LJ, Nettel-Aguirre A, Emery CA. Outcomes associated with early post-traumatic osteoarthritis and other negative health consequences 3-10 years following knee joint injury in youth sport. Osteoarthritis Cartilage. 2015 Jul;23(7):1122-9. doi: 10.1016/j.joca.2015.02.021. Epub 2015 Feb 26.  [Google Scholar]
11 Ansari MH, Pareek A, Johnson NR, Abdel MP, Stuart MJ, Krych AJ. Clinical Outcome of Total Knee Arthroplasty After Prior Microfracture: A Matched Cohort Study. Orthopedics. 2017 May 1;40(3):e473-e478. [Google Scholar]
12 Gao L, Orth P, Müller-Brandt K, Goebel LKH, Cucchiarini M, Madry H. Early loss of subchondral bone following microfracture is counteracted by bone marrow aspirate in a translational model of osteochondral repair. Scientific Reports. 2017;7:45189. [Google Scholar]
13 Saw KY, Anz A, Siew-Yoke Jee C, Merican S, Ching-Soong Ng R, Ahmad RS, Ragavanaidu K. Articular Cartilage Regeneration With Autologous Peripheral Blood Stem Cells Versus Hyaluronic Acid: A Randomized Controlled Trial. Arthroscopy. 2013 Feb 4. [Google Scholar]
14 Wong KL, Lee KB, Tai BC, Law P, Lee EH, Hui JH. Injectable Cultured Bone Marrow-Derived Mesenchymal Stem Cells in Varus Knees With Cartilage Defects Undergoing High Tibial Osteotomy: A Prospective, Randomized Controlled Clinical Trial With 2 Years’ Follow-up. Arthroscopy. 2013 Dec;29(12):2020-8. [Google Scholar]
15 Gobbi A, Karnatzikos G, Scotti C, Mahajan V, Mazzucco L, Grigolo B. One-step cartilage repair with bone marrow aspirate concentrated cells and collagen matrix in full-thickness knee cartilage lesions: results at 2-year follow-up. Cartilage. 2011 Jul;2(3):286-99. [Google Scholar]
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18 Beckmann R, Lippross S, Hartz C, Tohidnezhad M, Ferreira MS, Neuss-Stein S, Seekamp A, Nebelung S, Kweider N, Rath B, Jahr H. Abrasion arthroplasty increases mesenchymal stem cell content of postoperative joint effusions. BMC Musculoskeletal Disorders. 2015;16. [Google Scholar]

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