# Is Microfracture Alone Enough?
## 2 Microfracture Alone  
The procedure starts with the creation of three portals around the knee; for the inflow cannula, the working instruments, and the arthroscope. First, an elaborate evaluation of the knee is carried out, including the suprapatellar pouch, patellofemoral joint, medial and lateral gutters, notch, and medial and lateral compartments. After visualization of the cartilage defect, the uncovered bone is debrided of any remaining cartilage tags by using a resector, and the intact cartilage around the defect is surgically prepared in order to form a pool where a clot can form. The calcified layer of cartilage that remains is delicately detached with a shaver. Caution must be taken not to harm the subchondral bone. Next, an arthroscopic awl is utilized to create a series of holes (microfractures) in the uncovered subchondral bone. The holes are about 3 to 4 mm apart and with a depth of 4 mm. This is  
\begin{table}
\begin{tabular}{c p{142.3 pt}} \hline \hline
**Adjuvant MFX** & **Brief Definition** \\ \hline Mesenchymal stem cells & Characterized by the capacity to go through self-renewal and multi-lineage differentiation and create fully differentiated cells [7] \\ \hline Platelet-rich plasma & Autologous concentration of human thrombocytes in a small quantity of plasma [8] \\ \hline Hyaluronic acid & Natively occurring glycosaminoglycan with elasticity and viscosity properties that acts as a lubricating and shock absorbing liquid in joints [9] \\ \hline Chitosan-based scaffolds & Chitosan, the main constituent, is obtained from de-acetylation of chitin, the structural component of crustacean shells; it has reduced toxicity and good biocompatibility, adhesivity, and biodegradability [10] \\ \hline Collagen-based scaffolds & Collagen, the main constituent, is the most abundant protein in the extracellular matrix of many hard and soft tissues in the human body; the most important is type I collagen, which provides structural support to resident cells in both types of tissue [11] \\ \hline \hline \end{tabular}
\end{table}
Table 1: The main adjuvant treatments with MFX.  
the optimal distance that avoids the possible confluence of one hole into another. Typically, the microfractures are started from the periphery, moving to the center of the cartilage defect. After that, blood and droplets of fat from the holes can be observed [5; 12; 13].  
The penetrated subchondral bone plate leads to the formation of a clot in the defect. This clot comprises pluripotent mesenchymal stem cells derived from the marrow, which will fabricate a fibrocartilage repair with varying quantities of type II collagen [14].  
Although this is an inexpensive, easy, and popular technique, various studies have reported a series of limitations. The most important are that the benefits are not persistent, and the long-term results are unsatisfactory. [PERSON] et al. conducted a systematic review of 15 studies, and the overall results showed that microfracture has good results at short-term follow-up, but beyond 5 years postoperatively, failure can be expected, regardless of the size of the lesion. [PERSON] et al. also performed a systematic review of bone marrow stimulation techniques, including MFX. They also found good early results, but noted that due to the abnormal new cartilage, unsatisfactory results can be expected in the long run, especially in larger defects [15; 16].