# Is Microfracture Alone Enough?
## 3 Microfracture Plus Scaffolds and Stem Cells  
Over the last few years, mesenchymal stem cell-based treatments for the regeneration of cartilage defects have received significant recognition for various reasons. The capacity of MSCs to turn into connective tissue, such as hyaline cartilage, and the ease of obtaining them from diverse tissues (bone marrow, adipose tissue, trabecular bone, etc.) make them easy targets regarding the harvesting of cells. Among them, ADSCs are easy to obtain for clinical use, with increased isolation yields, and are not altered by the patient's sex, age group, or physiological status. The available studies performed on animals suggest that intra-articular injection of human ADSCs can facilitate regeneration of articular cartilage [4; 17; 18]. The process includes isolating ADSCs one day before the MFX. The stromal vascular fraction and MSCs are isolated from adipose fragments obtained from the patient. Cells are cultured in T-25 flasks at a final concentration, in order to assess the quantity of mesenchymal-like progenitors in the stromal vascular fraction [19]. After the arthroscopic bone marrow stimulation procedure of MFX described above, a fibrin scaffold is introduced in two separate syringes. One syringe contains lyophilized human plasma fibrinogen in 1 mL of aprotinin solution and the other has thrombin in a calcium chloride solution. The glue is intended to immediately form a gel when the two solutions are combined. The cell suspension (stromal vascular fraction containing MSCs) is loaded into the thrombin solution in a 1:1 ratio. Then, the cell-thrombin suspension is added to the fibrinogen solution (1:1) using a syringe support system, and they are implanted together into each source on the cartilage lesion surface. The most suitable option for implantation of this cell-thrombin-fibrinogen suspension is through arthroscopic guidance after the arthroscopic liquid is drawn [17]. The available data are in favor of MFX + ADSC therapy. A systematic review conducted by [PERSON] et al. in 2017 includes 18 articles that compare various MFX + techniques with MFX alone. Out of the 18, two studies dealt with ADSCs as an injectable augmentation to MFX. The outcomes showed statistically significant improvement on the postoperative International Knee Documentation Committee Subjective Knee Form (IKDC) and Knee injury and Osteoarthritis Outcome Score (KOOS) two years after the procedure. After that, only two important studies have been published on this topic. [PERSON] et al. divided the subjects into three categories: treatment with arthroscopic MFX and intra-articular injection of normal saline (M group), MFX + HA (MS group), and MFX + HA + ADSCs (MSR group). Patients in the MS and MSR groups showed a meaningful response to therapy, based on clinical evaluation of Western Ontario and McMaster Universities Arthritis Index (WOMAC) and 36-Item Short Form Survey (SF-36) scores. Regarding the quantitative evaluation of defect size and cartilage volume by MRI and arthroscopy, the two groups also showed significant improvements. During the first 9 months after treatment, the discrepancies between groups were non-significant. However, after 12 months, clinical improvements were significantly greater in the MSR group than the M and MS groups, on most scales. The M group managed to maintain clinical improvement for 9 months; after that, the benefits of microfracture were progressively lost. This finding is in agreement with published studies that also claim that after 1 year the clinical benefits of MFX alone begin to diminish. In the MS and MSR groups, clinical benefits also appeared to diminish after 1 year, but the patient outcomes were still slightly improved at 24-month follow-up compared to baseline. However, these findings are hardly sufficient to recommend ADSCs as an augmentation to MFX, due to the need for an additional surgery [3; 20]. Another noteworthy study, conducted by [PERSON] et al., compared MFX alone (\(n=4\)) with MFX + ADSCs (\(n=7\)).