Abstract
The use of microfracture in hip arthroscopy is increasing dramatically. However, recent reports raise concerns not only about the lack of evidence to support the clinical use of microfracture, but also about the potential harm caused by violation of the subchondral bone plate. The biology and pathology of the microfracture technique were described based on observations in translational models and the clinical evidence for hip microfracture was reviewed systematically. The clinical outcomes in patients undergoing microfracture were the same as those not undergoing microfracture. However, the overall clinical evidence quality is poor in hips. This review identified only one study with Level III evidence, while most studies were Level IV. There were no randomized trials available for review. Repair tissue is primarily of fibrocartilaginous nature. Reconstitution of the subchondral bone is often incomplete and associated with poor quality repair tissue and faster degeneration. Subchondral bone cyst formation is associated with microfracture, likely secondary to subchondral bone plate disruption and a combination of pressurized synovial fluid and inflammatory mediators moving from the joint into the bone. There is a lack of clinical efficacy evidence for patients undergoing microfracture. There is evidence of bone cyst formation following microfracture in animal studies, which may accelerate joint degeneration. Bone cyst formation following microfracture has not been studied adequately in humans.
Highlights
Hip arthroscopy is an area under constant development, with a 6-fold increase in incidence from 2006 to 2010 [1, 2]
The biology and pathology of the microfracture technique were described based on observations in translational models and the clinical evidence for hip microfracture was reviewed systematically
Popular for the treatment of knee articular cartilage defects as a first line intervention to produce stem cell-based regeneration by bone marrow stimulation, we question the evidence for sustained clinical improvement following microfracture and have concerns about the potential harm caused by violation of the subchondral bone plate, the increased incidence of subchondral bone cyst formation and other pathology and adverse outcomes of autologous chondrocyte implantation following microfracture [4, 5]
Summary
Hip arthroscopy is an area under constant development, with a 6-fold increase in incidence from 2006 to 2010 [1, 2]. Popular for the treatment of knee articular cartilage defects as a first line intervention to produce stem cell-based regeneration by bone marrow stimulation, we question the evidence for sustained clinical improvement following microfracture and have concerns about the potential harm caused by violation of the subchondral bone plate, the increased incidence of subchondral bone cyst formation and other pathology and adverse outcomes of autologous chondrocyte implantation following microfracture [4, 5]. Microfracture [8] and most recently the nanofracture technique [9, 10] are variations of an operation that breaches the subchondral bone plate to allow migration of stem cells and growth factors into a cartilage defect to form a ‘super clot’ and enhance repair. Microfracture is inexpensive and relatively performed arthroscopically, but more recent reports raise the concerns about the evidence to support the clinical technique traditionally in the knee and more recently in the hip [16, 17]
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