Saturday, April 26, 2014

Microfractures Revisited

This post that I wrote comparing whether to get a microfracture or ACI (autologous chondrocyte implantation) got a lot of reads. Perhaps surprisingly, I came down on the side of the traditional microfracture procedure. I partly based that on this study, which said that functional outcomes between microfracture and ACI patients were found to be about the same

I also happened to mention that, in support of microfracture, it’s the less extensive surgery that the NBA pros -- who could afford any kind of procedure -- choose. 

So recently, along comes this article featuring the NBA’s Greg Oden, a superstar talent felled at a young age by a pair of bad knees, that claims that doctors are moving away from microfracture to fix cartilage defects in NBA players. Among the alternatives, besides ACI: OATS (osteochondral autograft transfer, for small tears), platelet-rich plasma therapy and the Orthokine procedures that Kobe Bryant popularized that are similar to platelet-rich plasma therapy.

It’s certainly true that one or even all of these treatments may be superior to the old-fashioned microfracture, but a few points:

* The knees of NBA players take an epic amount of abuse. It’s important to appreciate that from the outset. It’s not just the jumping and running, but also the diving for loose balls, colliding with opponents in the normal course of play, making quick shifts in direction, etc.

* With that in mind, when someone writes, “the history of microfracture, especially among NBA players, has been dotted with success stories ... and failures,” I wouldn’t take that as necessarily an indictment. I’d be surprised if any knee operation ever had a 100 percent success rate, or even close to it, for such a subject population: too-tall men who bang their knees really hard every two or three days.

* The article tells us the problem is that the microfracture process (in which holes are drilled in bone, which creates bleeding that results in a new layer of cartilage) leads to rubbery fibrocartilage, not the good sort of hyaline articular cartilage. True, but interestingly enough, that fibrocartilage after a while can begin to take on characteristics of normal cartilage. In a study published in Arthroscopy in April 2006, researchers who took biopsies to inspect the cartilage that was formed after a microfracture observed that "this healed tissue is a combination, or hybrid, of fibrocartilage and hyaline-like cartilage."

So is fibrocartilage more of an intermediary state on the way to some form of cartilage that, if not normal, is at least much more normal in function and characteristics? Or what does fibrous cartilage created by a microfracture look like after 20 years, in a well-cared-for knee?

I don’t know. But I suspect that the answer may surprise some people who are critical of the procedure.


  1. Here is my story(regarding Orthokine - Kobe Bryant treatment):

    My name is Goran. I'm 42 years old. I live in Croatia, Europe.
    I apologize in advance for my bad English.
    For some time I have problems with my knees that do not allow me to live a normal life.
    Diagnosis chondromalacia patella .

    I did treatments of physical therapy ( ozone , magnet , ultrasound , exercise ), but with no particular improvement of the knees.
    In the meantime, I spent a lot of money best orthopedists and physiatrists in Croatia . Some say it will pass, some it won’t. Some recommend hyaluronic acid , another MBST ( treatment of cartilage by magnetic resonance - MBST® - Nuclear Magnetic Resonance Therapy, also started for the first time in Germany ) and Orthokin therapy (Globally known as a “Kobe Bryant treatment”), some of them to carry on with quadriceps exercises.
    But they all agree that the operation does not help a lot if the patella is tracking correctly (in the middle), which is my case.
    I finally came across one of the best orthopedist in Croatia who himself suffer from 4th degree chondromalacia patella, and he also recommended Orthokin therapy(which he also tried after the arthroscopy for micro fractures in subchondral bone and he sad that therapy did help him) and MBST therapy.
    Since he’s fighting chondromalacia for whole life he says that it comes and goes in waves of year or two. He generally had more pain in winter, less in summer when swimming in see etc.
    I also found on the internet very few cases of complete healing or regeneration of cartilage. In the meanwhile, I take diet supplements all the time. Fish oil and tablets or powders with glucosamine ... but it does not help ...

    As described conventional methods of treatment have not produced results , I decided to apply Orthokin therapy for both knees.
    The day after the first injection constant pain in my right knee ( scratching , tension ) has begun to weaken. At the time of writing this post ( three days after the second injection ) pain in the right knee is lower by about 70 % , and I could finally start doing the most normal things like watching television, reading newspapers etc. ..
    My impression is that nothing can regenerate damaged cartilage. Impression of pain is individual and subjective and does not depend or partially depend on the degree of cartilage damage.
    Summary is that Orthokin definitely works because it will significantly reduce the pain with chondromalacia patella . Injection does not hurt nor does it have side effects except for a tiny sting that heals in a few days . Whether this will rebuild cartilage , we'll see . I think there are are poor chances for that. But, less pain means more movement, and more movement means faster healing.
    My plan is also to try MBST treatments and with that, all the possibilities, of so called "modern" medicine, which does not seem to make progress towards complete cartilage restoration method are exhausted.

    REFRESH: 6 days after the third injection in both right knee is still 10 % better , even with the left I feel a lot less pain when lifting from a chair and walk down the stairs.

    REFRESH 2: After 5th and last injection I still feel the pain but knees are much better now.

    1. Goran from Croatia here. After 8 months from orthokine treatment the knees feels the same. Orthokine treatment did well(70% less pain) and results lasts long.(supposedly 1-3 years) On a pain scale: Before treatment 5-8, after treatment 1-6.

    2. Very interesting. Thanks for the first comment and the update, Goran.