Augmented Marrow Stimulation for Cartilage Repair

  • Christoph ErggeletEmail author


Representing the most popular marrow stimulation technique, microfracture has been established as a gold standard for the treatment of articular cartilage defects.

In order to maintain the idea of using autologous cells for cartilage repair and to further develop the idea of an autologous one-step procedure to repair cartilage lesions, the use of resorbable scaffolds was developed with an increase of primary stability due to an initial protection of the blood clot.

Augmented marrow stimulation techniques for the treatment of cartilage defects promise the potential for:
  • Faster rehabilitation due to increased initial stability of the regenerating tissue

  • Better tissue quality since early compression and shear stress promotes chondrogenesis

  • The benefits of a single-stage procedure compared to a chondrocyte transplantation

  • Multiple future options to increase outcome quality, e.g., with growth factor augmentation or drug release

A variety of different techniques and materials are available for arthroscopic and open surgery.

The evidence for the effectiveness of the microfracture procedure alone or the scaffold augmented variation is largely derived from case series and few randomized trials – both with obvious limitations.

Maybe a new approach to clinical evidence might be necessary. International registries should be able to create comprehensive datasets at significant lower costs and administrative hurdles and therefore promote the safe and quick implementation of new developments in the field of cartilage repair.


Cartilage repair Augmented marrow stimulation Microfracture Scaffolds 


  1. 1.
    Rodrigo JJ, Steadman JR, Silliman J, Fulstone HA. Improvement of full thickness chondral defect healing in the human knee after debridement and microfracture using continuous passive motion. Am J Knee Surg. 1994;7:109–16.Google Scholar
  2. 2.
    Krüger JP, Endres M, Neumann K, Häupl T, Erggelet C, Kaps C. Chondrogenic differentiation of human subchondral progenitor cells is impaired by rheumatoid arthritis synovial fluid. J Orthop Res. 2010;28(6):819–27. Scholar
  3. 3.
    Shapiro F, Koide S, Glimcher MJ. Cell origin and differentiation in the repair of full-thickness defects of articular cartilage. J Bone Joint Surg Am. 1993;75:532–53.CrossRefPubMedGoogle Scholar
  4. 4.
    Johnson LL. Arthroscopic abrasion arthroplasty historical and pathologic perspective: present status. Arthroscopy. 1986;2:54–69.CrossRefPubMedGoogle Scholar
  5. 5.
    Pridie KH. A method of resurfacing osteoarthritic knee joints. J Bone Joint Surg Am. 1959;41-B:618–9.Google Scholar
  6. 6.
    Ficat RP, Ficat C, Gedeon P, Toussaint JB. Spongialization: a new treatment for diseased patellae. Clin Orthop Relat Res. 1979; (144):74–83.Google Scholar
  7. 7.
    Steadman JR, Miller BS, Karas SG, Schlegel TF, Briggs KK, Hawkins RJ. The microfracture technique in the treatment of full-thickness chondral lesions of the knee in National Football League players. J Knee Surg. 2003;16:83–6.PubMedGoogle Scholar
  8. 8.
    Jung Y, Kim SH, Kim YH, Kim SH. The effects of dynamic and three-dimensional environments on chondrogenic differentiation of bone marrow stromal cells. Biomed Mater. 2009;4(5):055009. Epub 2009 Sep 25.CrossRefPubMedGoogle Scholar
  9. 9.
    Schätti O, Grad S, Goldhahn J, Salzmann G, Li Z, Alini M, Stoddart MJ. A combination of shear and dynamic compression leads to mechanically induced chondrogenesis of human mesenchymal stem cells. Eur Cell Mater. 2011;22:214–25.CrossRefPubMedGoogle Scholar
  10. 10.
    Erggelet C, Neumann K, Endres M, Haberstroh K, Sittinger M, Kaps C. Regeneration of ovine articular cartilage defects by cell-free polymer-based implants. Biomaterials. 2007;28:5570–80.CrossRefPubMedGoogle Scholar
  11. 11.
    Frisbie DD, Trotter GW, Powers BE, Rodkey WG, Steadman JR, Howard RD, Park RD, McIlwraith CW. Arthroscopic subchondral bone plate microfracture technique augments healing of large chondral defects in the radial carpal bone and medial femoral condyle of horses. Vet Surg. 1999;28:242–55.CrossRefPubMedGoogle Scholar
  12. 12.
    Steadman JR, Rodkey WG, Briggs KK. Microfracture to treat full-thickness chondral defects: surgical technique, rehabilitation, and outcomes. J Knee Surg. 2002;15:170–6.PubMedGoogle Scholar
  13. 13.
    Chen H, Sun J, Hoemann CD, Lascau-Coman V, Ouyang W, McKee MD, Shive MS, Buschmann MD. Drilling and microfracture lead to different bone structure and necrosis during bone-marrow stimulation for cartilage repair. J Orthop Res. 2009;27(11):1432–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Erggelet C, Sittinger M, Lahm A. The arthroscopic implantation of autologous chondrocytes for the treatment of full-thickness cartilage defects of the knee joint. Arthroscopy. 2003;19(1):108–10.CrossRefPubMedGoogle Scholar
  15. 15.
    Erggelet C, Mandelbaum BR. Operative treatment of articular cartilage defects. In: Principles of cartilage repair. Steinkopff; Darmstadt 2008. p. 39–72.Google Scholar
  16. 16.
    Driesang IM, Hunziker EB. Delamination rates of tissue flaps used in articular cartilage repair. J Orthop Res. 2000;18(6):909–11.CrossRefPubMedGoogle Scholar
  17. 17.
    Hunziker EB, Stähli A. Surgical suturing of articular cartilage induces osteoarthritis-like changes. Osteoarthr Cartil. 2008;16(9):1067–73. Epub 2008 Mar 4.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Drobnic M, Radosavljevic D, Ravnik D, Pavlovcic V, Hribernik M. Comparison of four techniques for the fixation of a collagen scaffold in the human cadaveric knee. Osteoarthr Cartil. 2006;14(4):337–44. Epub 2006 Jan 6.CrossRefPubMedGoogle Scholar
  19. 19.
    Knecht S, Erggelet C, Endres M, Sittinger M, Kaps C, Stüssi E. Mechanical testing of fixation techniques for scaffold-based tissue-engineered grafts. J Biomed Mater Res B Appl Biomater. 2007;83((1):50–7.CrossRefGoogle Scholar
  20. 20.
    Zelle S, Zantop T, Schanz S, Petersen W. Arthroscopic techniques for the fixation of a three-dimensional scaffold for autologous chondrocyte transplantation: structural properties in an in vitro model. Arthroscopy. 2007;23(10):1073–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Shive MS, Stanish WD, McCormack R, Forriol F, Mohtadi N, Pelet S, Desnoyers J, Méthot S, Vehik K, Restrepo A. BST-CarGel® treatment maintains cartilage repair superiority over microfracture at 5 years in a multicenter randomized controlled trial. Cartilage. 2015;6(2):62–72.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Stanish WD, McCormack R, Forriol F, Mohtadi N, Pelet S, Desnoyers J, Restrepo A, Shive MS. Novel scaffold-based BST-CarGel treatment results in superior cartilage repair compared with microfracture in a randomized controlled trial. J Bone Joint Surg Am. 2013;95(18):1640–50.CrossRefPubMedGoogle Scholar
  23. 23.
    Gobbi A, Scotti C, Karnatzikos G, Mudhigere A, Castro M, Peretti GM. One-step surgery with multipotent stem cells and Hyaluronan-based scaffold for the treatment of full-thickness chondral defects of the knee in patients older than 45 years. Knee Surg Sports Traumatol Arthrosc. 2017;25(8):2494–501.CrossRefPubMedGoogle Scholar
  24. 24.
    Farr J, Yao JQ. Chondral defect repair with particulated juvenile cartilage allograft. Cartilage. 2011;2(4):346–53.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Patrascu JM, Freymann U, Kaps C, Poenaru DV. Repair of a post-traumatic cartilage defect with a cell-free polymer-based cartilage implant: a follow-up at two years by MRI and histological review. J Bone Joint Surg Br. 2010;92(8):1160–3.CrossRefPubMedGoogle Scholar
  26. 26.
    Siclari A, Mascaro G, Gentili C, Kaps C, Cancedda R, Boux E. Cartilage repair in the knee with subchondral drilling augmented with a platelet-rich plasma-immersed polymer-based implant. Knee Surg Sports Traumatol Arthrosc. 2013;22:1225–34.CrossRefPubMedGoogle Scholar
  27. 27.
    Cole BJ, Fortier LA, Cook JL, Cross J, Chapman H-S, Roller B. The use of micronized allograft articular cartilage (biocartilage) and platelet rich plasma to augment marrow stimulation in an equine model of articular cartilage defects. Orthop J Sports Med. 2015; 44(9):2366–74.Google Scholar
  28. 28.
    Sharma B, Fermanian S, Gibson M, Unterman S, Herzka DA, Cascio B, Coburn J, Hui AY, Marcus N, Gold GE, Elisseeff JH. Human cartilage repair with a photoreactive adhesive-hydrogel composite. Sci Transl Med. 2013;5(167):167.CrossRefGoogle Scholar
  29. 29.
    Anders S, Volz M, Frick H, Gellissen J. A randomized, controlled trial comparing autologous matrix-induced chondrogenesis (AMIC®) to microfracture: analysis of 1- and 2-year follow-up data of 2 centers. Open Orthop J. 2013;7:133–43.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Gille J, Behrens P, Volpi P, de Girolamo L, Reiss E, Zoch W, Anders S. Outcome of Autologous Matrix Induced Chondrogenesis (AMIC) in cartilage knee surgery: data of the AMIC Registry. Arch Orthop Trauma Surg. 2013;133(1):87–93.CrossRefPubMedGoogle Scholar
  31. 31.
    Mithoefer K, Williams R Jr, Warren RF, Potter HG, Spock CR, Jones EC, Wickiewicz TL, Marx RG. The microfracture technique for the treatment of articular cartilage lesions in the knee. A prospective cohort study. J Bone Joint Surg Am. 2005;87:1911–20.CrossRefPubMedGoogle Scholar
  32. 32.
    Kreuz PC, Erggelet C, Steinwachs MR, Krause SJ, Lahm A, Niemeyer P, Ghanem N, Uhl M, Sudkamp N. Is microfracture of chondral defects in the knee associated with different results in patients aged 40 years or younger? Arthroscopy. 2006;22:1180–6.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.University Medical CenterFreiburgGermany
  2. 2.Alphaclinic ZurichZurichSwitzerland

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