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Review
. 2021 Dec;13(1_suppl):473S-495S.
doi: 10.1177/1947603521993219. Epub 2021 Mar 20.

Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures

Betina B Hinckel  1 , Dimitri Thomas  2 , Evan E Vellios  3 , Kyle John Hancock  4 , Jacob G Calcei  5 , Seth L Sherman  6 , Claire D Eliasberg  7 , Tiago L Fernandes  8 , Jack Farr  9 , Christian Lattermann  10 , Andreas H Gomoll  7
Affiliations
Review

Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures

Betina B Hinckel et al. Cartilage. 2021 Dec.

Abstract

Objective: To create a treatment algorithm for focal grade 3 or 4 cartilage defects of the knee using both classic and novel cartilage restoration techniques.

Design: A comprehensive review of the literature was performed highlighting classic as well as novel cartilage restoration techniques supported by clinical and/or basic science research and currently being employed by orthopedic surgeons.

Results: There is a high level of evidence to support the treatment of small to medium size lesions (<2-4 cm2) without subchondral bone involvement with traditional techniques such as marrow stimulation, osteochondral autograft transplant (OAT), or osteochondral allograft transplant (OCA). Newer techniques such as autologous matrix-induced chondrogenesis and bone marrow aspirate concentrate implantation have also been shown to be effective in select studies. If subchondral bone loss is present OAT or OCA should be performed. For large lesions (>4 cm2), OCA or matrix autologous chondrocyte implantation (MACI) may be performed. OCA is preferred over MACI in the setting of subchondral bone involvement while cell-based modalities such as MACI or particulated juvenile allograft cartilage are preferred in the patellofemoral joint.

Conclusions: Numerous techniques exist for the orthopedic surgeon treating focal cartilage defects of the knee. Treatment strategies should be based on lesion size, lesion location, subchondral bone involvement, and the level of evidence supporting each technique in the literature.

Keywords: articular cartilage; cartilage repair; cartilage transplantation.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Autologous matrix-induced chondrogenesis (AMIC). (A) Chondral lesion in the lateral femoral condyle. (B) After debridement, microfracture is performed. (C) Lesion is covered with a collagen membrane and fixed with sutures or fibrin glue.
Figure 2.
Figure 2.
Particulated juvenile allograft cartilage (DeNovo NT) applied directly to a patellar lesion. The pieces are arranged in one layer and close together (touching or almost touching). Fibrin glue is added. The whole implant is recessed below the margins of the defect (1 mm).
Figure 3.
Figure 3.
Cryopreserved viable osteochondral allograft (CVOCA; Cartiform). (A) Cartilage defect in the trochlea after debridement. (B) Cartiform implant. (C) The implant is fixed with small suture anchors on the edges of the defect.
Figure 4.
Figure 4.
Aragonite biphasic osteochondral scaffolds (Agili-C). (A) Chondral defect in the medial and lateral trochlear facets. (B) Implants inserted into the recipient site in a press-fit manner making sure that the top of the implant is recessed in relation to the cartilaginous surface.
Figure 5.
Figure 5.
Cartilage restoration algorithm: traditional and new technologies. MST = bone-marrow stimulation; OAT = osteochondral autograft transfer; AMIC = autologous matrix-induced chondrogenesis, BMAC = bone marrow aspirate concentrate implantation; PJAC = particulated juvenile allograft cartilage; PACI = particulated autologous cartilage implantation; CVOCA = cryopreserved viable osteochondral allograft.
Figure 6.
Figure 6.
Osteochondral allograft transplantation (OCA). (A) Osteochondral lesion in the lateral femoral condyle. (B) Osteochondral allograft transplanted in the defect.
See this image and copyright information in PMC

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