Marrow stimulation

Written by Dr Sheila Strover on March 14, 2025

Marrow stimulation involves different techniques that allow bone marrow cells to enter a joint cartilage defect to enhance healing there.

Photograph of the articular surface of the femur after a microfracture procedure, showing the small pick holes in the joint surface
Here the normal white joint cartilage has deteriorated, exposing the yellowish bone underneath. The surgeon has used a microfracture pick to create holes in this area through the subchondral bone to allow bleeding.
Illustration of the joint surface of the femure, showing microfracture being performed with a small pick.
Illustration to show the microfracture pick, which is a long thin instrument that is passed through the arthroscopy keyholes, and tapped with a mallet from outside the joint.

Marrow stimulation techniques

The issue is that joint cartilage has no blood supply of its own and when damaged it has little ability to heal itself. Surgeons discovered that penetrating the bone plate below the cartilage layer allowed blood to enter the area, causing a local clot and creating the environment for progenitor cells and growth factors to cover the damaged area with fibrocartilage.

An early technique evolved of drilling tiny holes from within the knee joint through the cartilage base plate (Pridie drilling) , but this apparently could cause heat damage and the technique was superceded by microfracture, where a small 'pick' was used to create the holes. Microfracture is now giving way to nanofracture, which is more of a needling technique, and this is now often done in combination with deliberate enhancement of the healing environment with other regenerative methods.

Painful chondral defects of the knee are very difficult problems.

M Zain Murza et al

Shortcomings of marrow stimulation techniques include the following: limited production of hyaline repair tissue, unpredictable repair cartilage volume, deterioration of results over time, and potential negative impacts on later cellular transplantation, if required

M Zain Murza et al

Recent studies show some promise when combining microfracture with other adjuncts such as PRP or other progenitor cell stimulants, or scaffolding.

M Zain Murza et al

Regenerative surgery, Abrasion arthroplasty, Microfracture, Nanofracture, AMIC, NAMIC