Microfracture for cartilage repair in the knee: a systematic review of the contemporary literature

  • Patrick Orth
  • Liang Gao
  • Henning MadryEmail author



To systematically review and evaluate novel clinical data following microfracture treatment of knee articular cartilage defects.


A systematic review was performed by searching PubMed, ScienceDirect, and Cochrane Library databases for clinical trials on microfracture treatment, published between 2013 and 2018. Titles, abstracts, and articles were reviewed, and data concerning patient demographics, study design, pre-, intra-, and postoperative findings were extracted. PRISMA guidelines were applied. The methodological quality of the included studies was analyzed by the modified Coleman Methodology Score (CMS), and aggregate data were generated.


Eighteen studies including 1830 defects (1759 patients) were included. Of them, 8 (59% of patients) were cohort studies without a comparison group. Overall study quality was moderate (mean total CMS: 64 points), mainly due to low patient numbers, short follow-up periods, lack of control groups and structural repair tissue evaluation, and inhomogeneity in outcome parameters. Microfracture treatment of full-thickness articular cartilage defects (3.4 ± 2.1 cm2) was performed at 43.4 ± 68.0 months of symptom duration. Postoperative assessment at 79.5 ± 27.2 months revealed failure rates of 11–27% within 5 years and 6–32% at 10 years. Imaging analysis was conducted in 10 studies, second-look arthroscopies were reported twice (n = 205 patients) and revealed well integrated fibrocartilaginous repair tissue.


Microfracture provides good function and pain relief at the mid-term and clinically largely satisfying results thereafter. Standardized, high-quality future study designs will better refine optimal indications for microfracture in the context of cartilage repair strategies.

Level of evidence

This systematic review is based on studies with levels of evidence ranging between I and IV (see results section and Table). Therefore, and according to this journals Instructions for Authors (SYSTEMATIC REVIEWS AND META-ANALYSES are assigned a level of evidence equivalent to the lowest level of evidence used from the manuscripts analysed), level of evidence is IV.


Marrow stimulation Microfracture Articular cartilage Subchondral bone 



Funding information not available (no funding was received).

Compliance with ethical standards

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

Ethical approval statement not applicable.

Human and animal rights

This article does not contain any studies with human participants or animals performed by any of the authors.

Supplementary material

167_2019_5359_MOESM1_ESM.doc (6.3 mb)
Supplementary material 1 (DOC 6477 KB)
167_2019_5359_MOESM2_ESM.tif (8.5 mb)
Supplementary material 2 (TIF 8697 KB)


  1. 1.
    Bae DK, Song SJ, Yoon KH, Heo DB, Kim TJ (2013) Survival analysis of microfracture in the osteoarthritic knee-minimum 10-year follow-up. Arthroscopy 29:244–250CrossRefGoogle Scholar
  2. 2.
    Behery O, Siston RA, Harris JD, Flanigan DC (2014) Treatment of cartilage defects of the knee: expanding on the existing algorithm. Clin J Sport Med 24:21–30CrossRefGoogle Scholar
  3. 3.
    Brittberg M, Recker D, Ilgenfritz J, Saris DBF (2018) Matrix-applied characterized autologous cultured chondrocytes versus microfracture: five-year follow-up of a prospective randomized trial. Am J Sports Med 46:1343–1351CrossRefGoogle Scholar
  4. 4.
    Campbell AB, Pineda M, Harris JD, Flanigan DC (2017) Return to sport after articular cartilage repair in athletes’ knees: a systematic review. Arthroscopy 32:651–668CrossRefGoogle Scholar
  5. 5.
    Chalmers PN, Vigneswaran H, Harris JD, Cole BJ (2013) Activity-related outcomes of articular cartilage surgery: a systematic review. Cartilage 4:193–203CrossRefGoogle Scholar
  6. 6.
    Coleman BD, Khan KM, Maffulli N, Cook JL, Wark JD (2000) Studies of surgical outcome after patellar tendinopathy: clinical significance of methodological deficiencies and guidelines for future studies. Victorian Institute of Sport Tendon Study Group. Scand J Med Sci Sports 10:2–11CrossRefGoogle Scholar
  7. 7.
    Dasar U, Gursoy S, Akkaya M, Algin O, Isik C, Bozkurt M (2016) Microfracture technique versus carbon fibre rod implantation for treatment of knee articular cartilage lesions. J Orthop Surg (Hong Kong) 24:188–193CrossRefGoogle Scholar
  8. 8.
    Devitt BM, Bell SW, Webster KE, Feller JA, Whitehead TS (2017) Surgical treatments of cartilage defects of the knee: Systematic review of randomised controlled trials. Knee 24:508–517CrossRefGoogle Scholar
  9. 9.
    Eldracher M, Orth P, Cucchiarini M, Pape D, Madry H (2014) Small subchondral drill holes improve marrow stimulation of articular cartilage defects. Am J Sports Med 42:2741–2750CrossRefGoogle Scholar
  10. 10.
    Flanigan DC, Harris JD, Trinh TQ, Siston RA, Brophy RH (2010) Prevalence of chondral defects in athletes’ knees: a systematic review. Med Sci Sports Exerc 42:1795–1801CrossRefGoogle Scholar
  11. 11.
    Gao L, Orth P, Cucchiarini M, Madry H (2017) Autologous matrix-induced chondrogenesis: a systematic review of the clinical evidence. Am J Sports Med 2017. (Epub ahead of print)Google Scholar
  12. 12.
    Gobbi A, Karnatzikos G, Kumar A (2014) Long-term results after microfracture treatment for full-thickness knee chondral lesions in athletes. Knee Surg Sports Traumatol Arthrosc 22:1986–1996CrossRefGoogle Scholar
  13. 13.
    Goyal D, Keyhani S, Lee EH, Hui JH (2013) Evidence-based status of microfracture technique: a systematic review of level I and II studies. Arthroscopy 29:1579–1588CrossRefGoogle Scholar
  14. 14.
    Gracitelli GC, Moraes VY, Franciozi CE, Luzo MV, Belloti JC (2016) Surgical interventions (microfracture, drilling, mosaicplasty, and allograft transplantation) for treating isolated cartilage defects of the knee in adults. Cochrane Database Syst Rev 9:CD010675Google Scholar
  15. 15.
    Knutsen G, Drogset JO, Engebretsen L, Grontvedt T, Isaksen V, Ludvigsen TC, Roberts S, Solheim E, Strand T, Johansen O (2007) A randomized trial comparing autologous chondrocyte implantation with microfracture. Findings at five years. J Bone Jt Surg Am 89:2105–2112Google Scholar
  16. 16.
    Knutsen G, Drogset JO, Engebretsen L, Grontvedt T, Ludvigsen TC, Loken S, Solheim E, Strand T, Johansen O (2016) A randomized multicenter trial comparing autologous chondrocyte implantation with microfracture: long-term follow-up at 14 to 15 years. J Bone Joint Surg Am 98:1332–1339CrossRefGoogle Scholar
  17. 17.
    Kon E, Gobbi A, Filardo G, Delcogliano M, Zaffagnini S, Marcacci M (2009) Arthroscopic second-generation autologous chondrocyte implantation compared with microfracture for chondral lesions of the knee: prospective nonrandomized study at 5 years. Am J Sports Med 37:33–41CrossRefGoogle Scholar
  18. 18.
    Kowalczuk M, Musahl V, Fu FH (2018) Cochrane in CORR(R): surgical interventions (Microfracture, Drilling, Mosaicplasty, and Allograft Transplantation) for treating isolated cartilage defects of the knee in adults. Clin Orthop Relat Res 476:16–18CrossRefGoogle Scholar
  19. 19.
    Kreuz PC, Steinwachs MR, Erggelet C, Krause SJ, Konrad G, Uhl M, Sudkamp N (2006) Results after microfracture of full-thickness chondral defects in different compartments in the knee. Osteoarthritis Cartilage 14:1119–1125CrossRefGoogle Scholar
  20. 20.
    Madry H, Gao L, Eichler H, Orth P, Cucchiarini M (2017) Bone marrow aspirate concentrate-enhanced marrow stimulation of chondral defects. Stem Cells Int 2017:1609685CrossRefGoogle Scholar
  21. 21.
    Madry H, Kon E, Condello V, Peretti GM, Steinwachs M, Seil R, Berruto M, Engebretsen L, Filardo G, Angele P (2016) Early osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc 18:419–433CrossRefGoogle Scholar
  22. 22.
    Madry H, van Dijk CN, Mueller-Gerbl M (2010) The basic science of the subchondral bone. Knee Surg Sports Traumatol Arthrosc 18:419–433CrossRefGoogle Scholar
  23. 23.
    McCormick F, Harris JD, Abrams GD, Frank R, Gupta A, Hussey K, Wilson H, Bach B Jr, Cole B (2014) Trends in the surgical treatment of articular cartilage lesions in the United States: an analysis of a large private-payer database over a period of 8 years. Arthroscopy 30:222–226CrossRefGoogle Scholar
  24. 24.
    Mithoefer K, Acuna M (2013) Clinical outcomes assessment for articular cartilage restoration. J Knee Surg 26:31–40CrossRefGoogle Scholar
  25. 25.
    Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR (2009) Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med 37:2053–2063CrossRefGoogle Scholar
  26. 26.
    Mithoefer K, Venugopal V, Manaqibwala M (2016) Incidence, degree, and clinical effect of subchondral bone overgrowth after microfracture in the knee. Am J Sports Med 44:2057–2063CrossRefGoogle Scholar
  27. 27.
    Montgomery SR, Foster BD, Ngo SS, Terrell RD, Wang JC, Petrigliano FA, McAllister DR (2014) Trends in the surgical treatment of articular cartilage defects of the knee in the United States. Knee Surg Sports Traumatol Arthrosc 22:2070–2075CrossRefGoogle Scholar
  28. 28.
    Moran CJ, Pascual-Garrido C, Chubinskaya S, Potter HG, Warren RF, Cole BJ, Rodeo SA (2014) Restoration of articular cartilage. J Bone Jt Surg Am 96:336–344CrossRefGoogle Scholar
  29. 29.
    Mundi R, Bedi A, Chow L, Crouch S, Simunovic N, Sibilsky Enselman E, Ayeni OR (2016) Cartilage restoration of the knee: a systematic review and meta-analysis of level 1 studies. Am J Sports Med 44:1888–1895CrossRefGoogle Scholar
  30. 30.
    Niemeyer P, Albrecht D, Andereya S, Angele P, Ateschrang A, Aurich M, Baumann M, Bosch U, Erggelet C, Fickert S, Gebhard H, Gelse K, Gunther D, Hoburg A, Kasten P, Kolombe T, Madry H, Marlovits S, Meenen NM, Muller PE, Noth U, Petersen JP, Pietschmann M, Richter W, Rolauffs B, Rhunau K, Schewe B, Steinert A, Steinwachs MR, Welsch GH, Zinser W, Fritz J (2016) Autologous chondrocyte implantation (ACI) for cartilage defects of the knee: a guideline by the working group “Clinical Tissue Regeneration” of the German Society of Orthopaedics and Trauma (DGOU). Knee 23:426–435CrossRefGoogle Scholar
  31. 31.
    Orth P, Cucchiarini M, Kohn D, Madry H (2013) Alterations of the subchondral bone in osteochondral repair–translational data and clinical evidence. Eur Cell Mater 25:299–316CrossRefGoogle Scholar
  32. 32.
    Orth P, Duffner J, Zurakowski D, Cucchiarini M, Madry H (2016) Small-diameter awls improve articular cartilage repair after microfracture treatment in a translational animal model. Am J Sports Med 44:209–219CrossRefGoogle Scholar
  33. 33.
    Orth P, Madry H (2015) Advancement of the subchondral bone plate in translational models of osteochondral repair—implications for tissue engineering approaches. Tissue Eng Part B Rev 21:504–520CrossRefGoogle Scholar
  34. 34.
    Petri M, Broese M, Simon A, Liodakis E, Ettinger M, Guenther D, Zeichen J, Krettek C, Jagodzinski M, Haasper C (2013) CaReS (MACT) versus microfracture in treating symptomatic patellofemoral cartilage defects: a retrospective matched-pair analysis. J Orthop Sci 18:38–44CrossRefGoogle Scholar
  35. 35.
    Rotterud JH, Sivertsen EA, Forssblad M, Engebretsen L, Aroen A (2013) Effect of meniscal and focal cartilage lesions on patient-reported outcome after anterior cruciate ligament reconstruction: a nationwide cohort study from Norway and Sweden of 8476 patients with 2-year follow-up. Am J Sports Med 41:535–543CrossRefGoogle Scholar
  36. 36.
    Salzmann GM, Sah B, Sudkamp NP, Niemeyer P (2013) Clinical outcome following the first-line, single lesion microfracture at the knee joint. Arch Orthop Trauma Surg 133:303–310CrossRefGoogle Scholar
  37. 37.
    Salzmann GM, Sah B, Sudkamp NP, Niemeyer P (2013) Reoperative characteristics after microfracture of knee cartilage lesions in 454 patients. Knee Surg Sports Traumatol Arthrosc 21:365–371CrossRefGoogle Scholar
  38. 38.
    Sanders TL, Pareek A, Obey MR, Johnson NR, Carey JL, Stuart MJ, Krych AJ (2017) High rate of osteoarthritis after osteochondritis dissecans fragment excision compared with surgical restoration at a mean 16-year follow-up. Am J Sports Med 45:1799–1805CrossRefGoogle Scholar
  39. 39.
    Saris D, Price A, Widuchowski W, Bertrand-Marchand M, Caron J, Drogset JO, Emans P, Podskubka A, Tsuchida A, Kili S, Levine D, Brittberg M (2014) Matrix-applied characterized autologous cultured chondrocytes versus microfracture: two-year follow-up of a prospective randomized trial. Am J Sports Med 42:1384–1394CrossRefGoogle Scholar
  40. 40.
    Saris DB, Vanlauwe J, Victor J, Almqvist KF, Verdonk R, Bellemans J, Luyten FP (2009) Treatment of symptomatic cartilage defects of the knee: characterized chondrocyte implantation results in better clinical outcome at 36 months in a randomized trial compared to microfracture. Am J Sports Med 37(Suppl 1):10S–19SCrossRefGoogle Scholar
  41. 41.
    Shapiro F, Koide S, Glimcher MJ (1993) Cell origin and differentiation in the repair of full-thickness defects of articular cartilage. J Bone Jt Surg Am 75:532–553CrossRefGoogle Scholar
  42. 42.
    Shive MS, Restrepo A, Totterman S, Tamez-Pena J, Schreyer E, Steinwachs M, Stanish WD (2014) Quantitative 3D MRI reveals limited intra-lesional bony overgrowth at 1 year after microfracture-based cartilage repair. Osteoarthr Cartil 22:800–804CrossRefGoogle Scholar
  43. 43.
    Solheim E, Hegna J, Inderhaug E (2017) Long-term clinical follow-up of microfracture versus mosaicplasty in articular cartilage defects of medial femoral condyle. Knee 24:1402–1407CrossRefGoogle Scholar
  44. 44.
    Solheim E, Hegna J, Inderhaug E, Oyen J, Harlem T, Strand T (2016) Results at 10–14 years after microfracture treatment of articular cartilage defects in the knee. Knee Surg Sports Traumatol Arthrosc 24:1587–1593CrossRefGoogle Scholar
  45. 45.
    Solheim E, Hegna J, Strand T, Harlem T, Inderhaug E (2018) Randomized study of long-term (15–17 Years) outcome after microfracture versus mosaicplasty in knee articular cartilage Defects. Am J Sports Med 46:826–831CrossRefGoogle Scholar
  46. 46.
    Stanish WD, McCormack R, Forriol F, Mohtadi N, Pelet S, Desnoyers J, Restrepo A, Shive MS (2013) Novel scaffold-based BST-CarGel treatment results in superior cartilage repair compared with microfracture in a randomized controlled trial. J Bone Jt Surg Am 95:1640–1650CrossRefGoogle Scholar
  47. 47.
    Steadman JR, Briggs KK, Matheny LM, Guillet A, Hanson CM, Willimon SC (2015) Outcomes following microfracture of full-thickness articular cartilage lesions of the knee in adolescent patients. J Knee Surg 28:145–150Google Scholar
  48. 48.
    Steadman JR, Hanson CM, Briggs KK, Matheny LM, James EW, Guillet A (2014) Outcomes after knee microfracture of chondral defects in alpine ski racers. J Knee Surg 27:407–410CrossRefGoogle Scholar
  49. 49.
    Steadman JR, Rodkey WG, Rodrigo JJ (2001) Microfracture: surgical technique and rehabilitation to treat chondral defects. Clin Orthop Relat Res 391:S362–369CrossRefGoogle Scholar
  50. 50.
    Ulstein S, Aroen A, Rotterud JH, Loken S, Engebretsen L, Heir S (2014) Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up. Knee Surg Sports Traumatol Arthrosc 22:1207–1215CrossRefGoogle Scholar
  51. 51.
    Ulstein S, Bredland K, Aroen A, Engebretsen L, Rotterud JH (2017) No negative effect on patient-reported outcome of concomitant cartilage lesions 5–9 years after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 25:1482–1488CrossRefGoogle Scholar
  52. 52.
    Vanlauwe J, Saris DB, Victor J, Almqvist KF, Bellemans J, Luyten FP (2011) Five-year outcome of characterized chondrocyte implantation versus microfracture for symptomatic cartilage defects of the knee: early treatment matters. Am J Sports Med 39:2566–2574CrossRefGoogle Scholar
  53. 53.
    Von Keudell A, Atzwanger J, Forstner R, Resch H, Hoffelner T, Mayer M (2011) Radiological evaluation of cartilage after microfracture treatment: a long-term follow-up study. Eur J Radiol 81:1618–1624CrossRefGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2019

Authors and Affiliations

  1. 1.Center of Experimental OrthopaedicsSaarland UniversityHomburgGermany
  2. 2.Department of Orthopaedic SurgerySaarland University Medical CenterHomburgGermany

Personalised recommendations