Clinical and Magnetic Resonance Imaging Outcomes After Microfracture Treatment With and Without Augmentation for Focal Chondral Lesions in the Knee: A Systematic Review and Meta-analysis

Abstract

Background: Focal cartilage lesions represent a common source of knee pain and disability, with the potential for the development and progression of osteoarthritis. Currently, microfracture (MFx) represents the most utilized first–line surgical treatment for small, focal chondral lesions. Recent investigations have examined methods of overcoming the limitations of MFx utilizing various augmentation techniques. Purpose: To perform a systematic review and meta–analysis evaluating clinical and radiographic outcomes in patients undergoing isolated MFx versus MFx augmented with orthobiologics or scaffolds for focal chondral defects of the knee. Study Design: Systematic review and meta-analysis; Level of evidence, 4. Methods: A systematic review was performed to identify studies evaluating outcomes and adverse events in patients undergoing isolated MFx versus augmented MFx for focal chondral defects in the knee from 1945 to June 1, 2021. Data were extracted from each article that met the inclusion/exclusion criteria. Meta-analyses were performed for all outcomes reported in a minimum of 3 studies. Results: A total of 14 studies were identified, utilizing 7 different types of injectable augmentation regimens and 5 different scaffolding regimens. Across the 14 studies, a total of 744 patients were included. The mean patient age was 46.8 years (range, 34-58 years), and 58.3% (n = 434/744) of patients were women. The mean final follow–up time was 26.7 months (range, 12-60 months). The mean chondral defect size ranged from 1.3 to 4.8 cm2. A post hoc analysis comparing mean improvement in postoperative outcomes scores compared with preoperative values found no significant differences in the improvement in the visual analog scale (VAS), International Knee Documentation Committee (IKDC), or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between patients undergoing isolated MFx and those undergoing MFx + augmentation. Patients undergoing MFx + augmentation reported significantly greater improvements in the Lysholm score and postoperative MOCART (magnetic resonance observation of cartilage repair tissue) scores compared with the isolated MFx group. Conclusion: Patients undergoing combined MFx + augmentation reported significant improvements in mean Lysholm and MOCART scores, without significant improvements in VAS, IKDC, or WOMAC scores when compared with patients undergoing isolated MFx.

Tissue Regrowth and Its Vascularization Through Bone Marrow Stimulation: Microfracture at the Acetabular Rim for Irreparable Labral Tear in a Porcine Model

“…Fibrocartilage-like tissue did regrow at the defect area in various studies. 5,6 Similarly, our result of HE staining showed that fibrochondrocytes were concentrated at the part close to the acetabulum while the periphery formed a matrix of fibroblast cells and fibrochondrocytes within the regrown tissue at 6 weeks. The technique of bone marrow stimulation did have the capacity to re-create fibrocartilage-like tissue at the labral defect area through differentiation of the mesenchymal stem cells induced by the surrounding environment.…”

What’s New in Sports Medicine

“…Microfracture with augmentation resulted in greater improvement by a clinically important margin in Lysholm and MOCART (magnetic resonance observation of cartilage repair tissue) scores; however, there were no differences in the mean improvement in the visual analog scale (VAS) pain, IKDC, or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. A subgroup analysis in which cases with concomitant high tibial osteotomy were excluded demonstrated the same clinical findings 13 .…”

“…A focal chondral defect within the knee remains a challenging problem with many surgical treatment options. Fortier et al 13 completed a systematic review and meta-analysis comparing microfracture treatment with and without augmentation for focal chondral defects in the knee, including 14 studies of 744 patients with a mean age of 46.8 years, a mean follow-up of 26.7 months, and a mean chondral lesion size ranging from 1.3 to 4.8 cm 2 . Microfracture augmentation with orthobiologics (platelet-rich plasma, hyaluronic acid, mesenchymal stem cells) was used in 57% of studies and scaffolds (biomembranes, fibrin-based) were used in 43% of studies.…”

Particulated Costal Allocartilage With Microfracture Versus Microfracture Alone for Knee Cartilage Defects: A Multicenter, Prospective, Randomized, Participant- and Rater-Blinded Study

“…However, a subjective synthesis performed with 4 randomized controlled trials noted that 2 trials showed significantly greater improvements in the KOOS or IKDC score after combined microfracture and augmentation at the 2-year follow-up; conversely, the other 2 studies showed no differences when compared with microfracture alone. Recently, Fortier et al 11 performed a systematic review and meta-analysis of 744 patients within 14 studies comparing augmented microfracture using various types of adjuvants and isolated microfracture. They reported a significant improvement in the Lysholm score for patients who underwent augmented microfracture, but similar improvement in VAS, IKDC, or Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores compared with patients who underwent only microfracture.…”

“…A recent meta-analysis of randomized controlled trials comparing the outcomes after microfracture treatment with and without augmentation reported significant improvements in the postoperative MOCART score after microfracture with augmentation (mean, 64.3) as compared with that after isolated microfracture (mean, 46.1). 11 However, this meta-analysis included only 3 studies owing to a lack of high-quality randomized controlled comparison studies, of which 2 used porcine-derived collagen as an augment. Our study adds further evidence that augmentation with microfracture could improve the quality of the repaired cartilage, as compared with isolated microfracture.…”