Although small cartilage injuries are commonly found in knee arthroscopy procedures,
significant chondral and osteochondral injuries are relatively infrequent. Incidence
of cartilage injury rises when considering traumatic origin, especially when approaching
significant ligamentous or meniscal pathology. Options for restoration span the gamut
from benign neglect to open procedures that restore both cartilage and subchondral
bone. The best choice of procedure largely depends on lesion size, depth, and location.
Smaller lesions isolated to cartilage <2 cm2 can be treated with marrow stimulation techniques such as microfracture with or without
biologic options (bone marrow aspirate concentrate or platelet-rich plasma with or
without cartilage precursors or scaffolds). Microfracture alone in larger lesions
has been reported to be less durable and it is therefore not recommended for larger
lesions. Smaller lesions <2 cm2 that include a subchondral injury can be treated with osteochondral autograft implantation,
in which a core of cartilage and bone is transferred from a relative non-weightbearing
surface to the lesion.
Larger osteochondral lesions >2 cm2 are better treated with osteochondral allograft transplantation, where osteochondral
cores from a size-matched, fresh cadaver are matched to the patient's lesion. This
option may require multiple cores to be placed in a “snowman” pattern; however, recent
literature demonstrated that a single plug might produce better outcomes. Alternatively,
for large chondral-only lesions, a resurfacing procedure may be chosen that may include
biologic options. Autologous chondrocyte implantation (ACI), currently in its third
iteration (matrix ACI [MACI]), is an excellent choice with good long-term durability.
In addition, MACI may be used for chondral lesions in the patellofemoral joint where
matching the native joint topology may be more difficult. If the patient has an underlying
bone marrow lesion but an intact cartilage cap that appears healthy on arthroscopic
examination, one may consider a core decompression and injection with biologics such
as BMAC and bony scaffold with fibrin glue (also known as bioplasty).
It is also critical that the surgeon address any concomitant knee pathology that would
compromise cartilage restoration. This includes addressing malalignment with distal
femoral, proximal tibial, or tibial tubercle osteotomy, significant meniscal deficiency
with meniscal transplant, and any instability from lack of cruciate or collateral
ligaments with ligament reconstruction.