Adding microfracture to an SVF-based arthroscopic pathway was associated with greater 24-month improvements in pain,...

To determine whether adding arthroscopic microfracture provides incremental clinical and magnetic resonance imaging (MRI)-based structural benefit within a standardized stromal vascular fraction (SVF)-based arthroscopic treatment pathway for moderate knee osteoarthritis.

In this prospective, single-centre randomized controlled trial, patients with Kellgren-Lawrence grade II-III knee osteoarthritis and a contained, full-thickness chondral lesion confirmed at arthroscopy were randomized to (1) arthroscopic debridement plus intra-articular SVF (SVF-only) or (2) the same debridement protocol augmented with microfracture followed by SVF (microfracture + SVF). SVF was harvested from subcutaneous abdominal adipose tissue and processed intraoperatively; the injectate volume was standardized to 5 mL. Total nucleated cell count (TNCC) was quantified for quality control. Outcomes included Visual Analogue Scale (VAS) pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Lysholm scores. MRI structural outcomes were assessed at baseline, 12 and 24 months using the Whole-Organ Magnetic Resonance Imaging Score (WORMS) cartilage morphology domain by blinded musculoskeletal radiologists.

Fifty patients completed 24-month follow-up. Mean TNCC in the 5-mL injectate was 7.32 × 10⁷ ± 2.47 × 10⁷ cells and did not differ between groups (p = 0.42). At 24 months, the microfracture + SVF group demonstrated greater improvement in pain and osteoarthritis-specific function (VAS and WOMAC) than SVF-only. MRI outcomes also favoured microfracture + SVF, with a greater improvement in WORMS cartilage morphology over time. Lysholm scores improved in both groups but did not distinguish between groups at mid- or long-term follow-up.

In patients with moderate knee osteoarthritis treated within a standardized SVF-based arthroscopic pathway, adding microfracture was associated with superior 24-month pain and WOMAC improvement and more favourable MRI-based cartilage morphology compared with SVF without microfracture. Longer-term and component-isolating studies are needed to confirm durability and clarify the contribution of each treatment element.

Level I, randomized controlled trial.