Why Microfracture Has Fallen Out of Favor Amongst Cartilage Surgeons

Posted on: January 7th, 2025 by Our Team

Microfracture surgery was once a go-to procedure for cartilage surgeons, particularly in treating athletes with joint injuries. This technique, which involves creating small holes in the subchondral bone to stimulate a healing response, initially showed promising short-term results. However, its long-term efficacy has often fallen short, leading many specialists to move toward advanced alternatives. In this blog, we’ll explore why microfracture has lost its prominence and how modern cartilage restoration procedures have reshaped the approach to joint preservation.

Understanding the Basics of Microfracture

Articular cartilage is the smooth, low-friction surface that covers the ends of bones in our joints. Its dense matrix, sparse cells, and lack of blood supply make it uniquely durable but also notoriously challenging to heal after injury. When this cartilage is damaged—often due to sports injuries—the body’s natural healing response is limited.

Microfracture aims to stimulate repair by creating access to the bone marrow, allowing stem cells and blood to form a clot at the injury site. This clot is intended to mature into repair tissue that resembles cartilage. While the technique can offer temporary relief, the repair tissue often lacks the durability and mechanical properties of native articular cartilage. True cartilage surgeons know this repair tissue is not articular cartilage but rather “Fibro”-Cartilage as in fibrous or scar tissue.

In some cases, surgeons may use the terms abrasionplasty or abrasion arthroplasty to describe procedures similar to microfracture. These approaches also involve manipulating the subchondral bone to encourage a healing response, but they follow slightly different technical steps.

Some surgeons recommend augmentation of the microfracture bed with synthetic scaffolds. While these advanced microfracture procedures may have some promise, the variability on the procedure as well as the lack of long-term research make these experimental.

Why Microfracture Often Falls Short

1. Repair Tissue Quality
The tissue formed after microfracture is primarily fibrocartilage, not the original hyaline cartilage that lines healthy joints. Fibrocartilage is less resilient, more prone to wear, and unable to withstand the repetitive forces of daily activities and sports.
2. Progressive Deterioration
Multiple studies have shown that while microfracture can provide short-term improvement, the repair tissue frequently deteriorates within a few years. This often leads to recurring pain and the need for further intervention.
3. Mechanical Demands of the Joint
Everyday activities, such as walking (which involves 2–3 million steps per year), exert forces up to five times body weight on the joints. Pivoting and high-impact sports amplify these stresses. When the repair tissue from microfracture fails to hold up under such conditions, the underlying bone becomes exposed, exacerbating joint pain and dysfunction.
4. Limitations of Natural Healing
Microfracture relies on the body’s natural healing capabilities, which are often insufficient on their own to repair cartilage effectively. Without augmentation, the body struggles to keep up with the demands placed on a weight-bearing joint.

The Shift Toward Advanced Cartilage Restoration Techniques

Given these limitations, cartilage surgeons specializing in joint preservation now favor techniques that restore articular or hyaline cartilage. Procedures such as osteochondral allograft transplantation and autologous chondrocyte implantation (MACI) have emerged as more effective and durable solutions. The research has supported this in head to head studies against microfracture.

• Osteochondral Allograft Transplantation involves replacing damaged cartilage and underlying bone with healthy donor tissue, providing a robust and long-lasting repair.
• MACI (Matrix-Induced Autologous Chondrocyte Implantation) uses a patient’s cultured cartilage cells, implanted on a scaffold, to regenerate hyaline cartilage. This technique aims to provide a repair tissue closer to the joint’s original structure and function.

These advanced methods leverage cutting-edge biology and technology to achieve durable results, reducing the likelihood of recurring pain and further surgeries.

Looking Forward: The Future of Cartilage Repair

The field of cartilage restoration continues to evolve rapidly, driven by the need to address the shortcomings of traditional approaches like microfracture. Innovations in biologics, stem cell therapy, and synthetic cartilage replacements are opening new doors for durable and effective joint preservation. These advancements offer hope for patients, ensuring that cartilage injuries no longer spell a lifetime of pain and disability.

Final Thoughts

While microfracture was once celebrated for its simplicity and accessibility, its limitations have become increasingly evident over time. The transition toward advanced techniques highlights the importance of achieving durable, biologically sound repairs to protect joint health. For athletes and individuals with cartilage injuries, the future holds exciting possibilities—procedures that not only repair but truly restore the function of their joints.

If you’re exploring options for cartilage restoration, consult with Dr. Ronak M. Patel who focuses on joint preservation. The right approach can make all the difference in preserving mobility and maintaining an active lifestyle.