What’s up with Microfracture?

When a surgical procedure is relatively easy, inexpensive, and performed arthroscopically- that, combined with some premature good press- no wonder insurance companies- because they have have your best interests at heart- call it a “standard”.

Ever notice that this never happens when a different procedure is difficult and expensive?

So it was with microfracture, a technique for “stimulating” the bone marrow by making small holes and causing a blood clot to form at the site of the cartilage loss. I perform microfracture frequently, and believe it has a place- albeit a small one- in the methods that I currently use for cartilage repair. I also have seen lots of failures of microfracture. Some of these failures were no doubt due to poor post-op management. There are good examples of microfracture failing by growing bone instead of cartilage. This is rather impressive when it occurs, and yes, it causes increased pain.

So when to use it? I refer the reader to work by  Mithoefer and others

J Bone Joint Surg Am. 2005 Sep;87(9):1911-20.
The microfracture technique for the treatment of articular cartilage lesions in the knee. A prospective cohort study.
Mithoefer K, Williams RJ 3rd, Warren RF, Potter HG, Spock CR, Jones EC, Wickiewicz TL, Marx RG.

that surveys a large group of patients who collectively had a high failure rate based upon MRI criteria. Over 40, overweight, long standing symptoms, and cartilage defects greater than 1 sq. cm are all negative predictors. So I don’t think microfracture is any sort of standard for cartilage repair, because in my view a standard of any sort would have a much higher overall success rate. Lets keep insurance companies away from that kind of nonsense; it can take a decade to re-educate medical directors who would deny care based upon such false assumptions, using the premise that no cartilage repair should be paid for unless microfracture has been tried.

And the next time anyone uses the word ‘standard’ in orthopaedics, lets make sure it is a really good and reliable¬† treatment, or abandon that word altogether.