AOSSM/AANA Specialty Day 2020-Chondral Defects_ My Decision-Making Has Evolved Over Time

Chondral Defects_ My Decision-Making Has Evolved Over Time

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This presentation by Dr. Bert R. Mandelbaum outlines the evolution of decision-making in managing chondral (cartilage) defects in the knee from 2000 to 2020. Key shifts in practice include viewing the knee as an organ—considering alignment, meniscal and ligament integrity—and advances in ACL injury understanding, prevention, and treatment.<br /><br />ACL injuries often cause cartilage damage through mechanisms like bone bruising, shear, and compression forces. Prevention strategies developed since 1999 focus on avoidance, flexibility, strengthening, plyometrics, and agility drills, aiming to reduce the high incidence of ACL tears and related cartilage injuries.<br /><br />The role of orthobiologics has expanded considerably. Treatments now include corticosteroids, hyaluronic acid, platelet-rich plasma (PRP), cytokine modulators, and various stem cell therapies (including adipose-derived, bone marrow aspirate concentrate (BMAC), and allogeneic cells). These aim to protect and facilitate cartilage repair and potentially modify osteoarthritis progression.<br /><br />For cartilage defect repair, microfracture has been common with moderate success, but its durability is limited. Mosaicplasty shows better long-term outcomes in some cases. Advanced techniques like matrix-induced autologous chondrocyte implantation (MACI) have proven superior to microfracture in large randomized trials, showing improved pain and function over 2-to-5 years. BMAC and autologous chondrocyte implantation (ACI) have comparable results.<br /><br />Osteochondral allografts (OCA) and autograft transplantation (OAT/OATS) are used for larger or osteochondral lesions, with return-to-sport rates generally higher after these procedures compared to microfracture. No single cartilage repair technique is universally superior, although microfracture is statistically inferior in some measures.<br /><br />Treatment algorithms now incorporate lesion size, depth, bone involvement, and patient-specific factors (e.g., malalignment, instability). Techniques include core decompression with BMAC (interosseous bioplasty), osteochondral transplantation (OATS, OCA), ACI/MACI, and combined approaches ("sandwich techniques"). Biologic adjuncts and consideration of comorbidities (meniscal pathology, malalignment) are integral.<br /><br />Overall, advances in biologics, surgical techniques, and a holistic joint-focused perspective guide improved cartilage defect management and long-term knee health.

Keywords

chondral defects

knee cartilage

ACL injury

orthobiologics

microfracture

mosaicplasty

autologous chondrocyte implantation

osteochondral allografts

treatment algorithms

cartilage repair techniques