Microfracture is more cost-effective than autologous chondrocyte implantation: a review of level 1 and level 2 studies with 5 year follow-up.

PURPOSE: Focal cartilage defects in the knee may have devastating effect on the knee joint, where two of the main surgical treatment options are microfracture and autologous chondrocyte implantation. Comparative studies have failed to establish which method yields the best clinical results. A cost-effectiveness analysis of microfracture and autologous chondrocyte implantation would contribute to the clinical decision process. METHODS: A PubMed search identifying level I and level II studies with 5 year follow-up was performed. With the data from these studies, decision trees with associated service provision and costs connected to the two different techniques were designed. In addition to hospital costs, we included costs connected to physiotherapy following surgery. To paint a broader cost picture, we also included indirect costs to the society due to productivity loss caused by work absence. RESULTS: Four high-quality studies, with a follow-up of 5 years, met the inclusion criteria. A total of 319 patients were included, 170 undergoing microfracture and 149 autologous chondrocyte implantation. The re-operation rate was 23 (13.5%) following microfracture, and 18 (12.1%) for autologous chondrocyte implantation. Both groups achieved substantially better clinical scores at 5 years compared to baseline. Microfracture was more cost-effective when comparing all clinical scores. CONCLUSION: Microfracture is associated with both lower costs and lower cost per point increase in patient reported outcome measures. There is a need of well-designed, high-quality randomized controlled trials before reliable conclusions regarding cost-effectiveness in the long run is possible. LEVEL OF EVIDENCE: III.

Microfractures at the rotator cuff footprint: a randomised controlled study.

PURPOSE: Microfractures at the footprint may be a potential additional source of growth factor and enhance the tendon healing at the bone-tendon junction when repairing rotator cuff tears. METHODS: Fifty-seven patients who underwent shoulder arthroscopy for repair of complete rotator cuff tears were randomly divided into two groups, using a block randomisation procedure. Patients underwent microfracture at the footprint in the treatment group. The patients in the control group (n = 29) did not receive that treatment. All patients had the same post-operative rehabilitation protocol. RESULTS: The two groups were homogeneous. There was a significant improvement from baseline to the last minimum follow-up of two years. At three months from the index procedure, visual analogue scale (VAS), range of motion (ROM) and University of California at Los Angeles (UCLA) and Constant scores were significantly better in group 1 than in group 2 (P < .05). At the last follow-up (minimum two years), clinical and functional outcomes were further improved in both the groups but inter-group differences were not significant. No technique-related complications were recorded. CONCLUSIONS: Microfractures at the footprint are simple, safe, inexpensive and effective at producing less pain in the short term in patients who undergo rotator cuff repair, but at two years they do not result in significantly different outcomes, either clinically or at imaging, compared to traditional rotator cuff repair.

Implantation of orthobiologic, biodegradable scaffolds in osteochondral repair.

The treatment of articular cartilage lesions is complicated, but novel tissue engineering approaches seem to improve the outcome. A tissue engineering approach is less invasive and reduces surgical time, periosteal hypertrophy, and morbidity. Cell-based therapies using scaffolds have advantages compared with microfracture techniques, but the efficacy and cost-effectiveness need to be investigated. Second-generation cell-based therapies have lower morbidity and the ease of the technique is not significantly different from that of first-generation autologous chondrocyte implantation techniques. Third-generation cell-based therapies such as the use of tissue engineered scaffolds need to be studied in more detail.

[The microfracture technique in the treatment of full-thickness chondral lesions of the knee]. / Diz ekleminde tam kat kikirdak lezyonlarinin tedavisinde mikrokirik yöntemi.

OBJECTIVES: Chondral lesions of the knee joint present a difficult challenge because of their poor potential for spontaneous healing. In this study, we evaluated the results of the microfracture technique in the treatment of full-thickness chondral lesions. METHODS: The study included 20 patients (12 males, 8 females; mean age 44 years; range 18 to 60 years) who were treated with the microfracture technique for 22 lesions of osteoarthritis or traumatic chondral injuries. The patients were evaluated at the end of a mean follow-up period of 3.8 years with a visual analog scale and Lysholm II scores. Wilcoxon signed-rank test was used for statistical analysis. RESULTS: The size of the chondral lesions varied between 0.5 to 2.25 cm2. Most of the lesions were in the medial femoral condyle (n=11), followed by the medial femoral condyle and trochlear groove (n=4), the lower aspect of the patella (n=3), trochlear groove (n=3), and the lateral femoral condyle (n=1). The mean visual analog scale score was 69.5 (range 20 to 100) preoperatively and 11 (range 0 to 60) postoperatively (p<0.001). The mean Lysholm II score increased from a preoperative 73.7 (range 49 to 90) to a postoperative 86.1 (range 51 to 100) (p=0.017). CONCLUSION: The microfracture technique is a method that relieves the symptoms, and results in considerable improvement in the function and activity of the patients with full-thickness chondral lesions. The advantages of this arthroscopic treatment method are cost-effectiveness and low morbidity rate.