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Knee

Knee Cartilage Defects Treatment Options

Articular cartilage is the smooth, white, glistening tissue that covers the ends of the bones inside your knee joint. It allows the knee to bend and glide with very low friction, acting like a Teflon®-like surface. When this cartilage is damaged in a specific spot—called a focal articular cartilage defect—the underlying bone can become exposed. This can lead to pain, swelling, catching, or a sense that the knee is not moving smoothly.

Unlike a general “wear and tear” pattern seen in advanced osteoarthritis, cartilage defects are often localized injuries, frequently affecting younger or active patients. They may result from trauma (such as a twisting injury or impact), prior knee surgery, instability, malalignment, or conditions like osteochondritis dissecans. Left untreated, these defects can enlarge over time and may contribute to the development of early arthritis.

Diagnosis usually involves a careful history and physical examination, followed by imaging. Standard X-rays can help evaluate bone alignment and rule out arthritis, while MRI provides detailed information about the size, depth, and location of the cartilage defect. In some cases, the final assessment is made arthroscopically—using a small camera inside the knee.

Not every cartilage defect needs immediate surgery. For small lesions or patients with mild symptoms, nonsurgical treatment can be very helpful.

A structured physical therapy program targets the muscles that support and stabilize the knee—particularly the quadriceps, hamstrings, and hip muscles. Strong, well-coordinated muscles help decrease the load on the damaged area and improve the way the knee tracks during motion. Activity modification (such as reducing impact activities like running or jumping), weight management, and bracing can also ease symptoms.

Medications, including oral anti-inflammatory drugs and, in some cases, joint injections (such as corticosteroids, hyaluronic acid, or platelet-rich plasma), may reduce pain and inflammation. These treatments do not grow new cartilage, but they can significantly reduce symptoms and improve quality of life, especially when combined with exercise-based rehabilitation.

For some patients, the main problem is a rough, unstable cartilage flap that causes catching, locking, or sharp pain. In these cases, a minimally invasive procedure called arthroscopic debridement or chondroplasty may be recommended.

During this procedure, a small camera and instruments are introduced into the knee through tiny incisions. Loose or frayed cartilage is smoothed and unstable fragments are removed. This can reduce mechanical irritation and improve joint motion.

While chondroplasty does not restore normal cartilage, it can provide meaningful short- to mid-term relief and is often used in smaller lesions or in patients who are not candidates for more complex cartilage restoration procedures.

Microfracture is a commonly used technique for small to medium-sized full-thickness cartilage defects. After unstable cartilage is cleaned away, tiny holes are created in the underlying bone. This allows bone marrow cells to enter the defect and form a “repair tissue” called fibrocartilage.

Fibrocartilage is not as durable or smooth as native articular cartilage, but it can fill the defect and reduce pain, especially in patients with small, well-contained lesions. Microfracture is typically followed by a structured rehabilitation program that may include limited weight-bearing and early motion to optimize healing.

Unfortunately, the fibrocartilage that develops as a result of microfracture tends to wear out within only a few years, and the symptomatic improvement that patients’ get following surgery starts to decline after about two years. Because of this, microfracture is rarely the treatment of choice for a symptomatic focal articular cartilage defect.

For larger or more complex defects, osteochondral grafting techniques are often considered. These procedures replace the damaged area with a plug or patch of healthy cartilage and underlying bone.

Osteochondral Autograft Transfer (OATS/Mosaicplasty)

In this procedure, small cylindrical plugs of cartilage and bone are taken from a non–weightbearing area of the patient’s own knee and transferred into the defect. This allows immediate restoration of a true hyaline cartilage surface in the damaged area. It is typically used for focal lesions of limited size.

Osteochondral Allograft Transplantation (OCA)

For larger defects that are too big for autograft transfer, fresh donor (allograft) cartilage and bone can be used. The allograft is shaped to fit the defect and press-fit into place. OCA is particularly useful for large, deep lesions, revisions after failed prior cartilage surgery, or defects associated with bone loss.

Both autograft and allograft techniques can provide excellent pain relief and functional improvement when matched appropriately to lesion size, patient age, and activity level.

Autologous chondrocyte implantation (ACI) and its newer generation, matrix-assisted chondrocyte implantation (MACI), are cell-based treatments designed to regenerate cartilage in larger focal defects.

In ACI/MACI, cartilage cells (chondrocytes) are harvested from a small biopsy in the patient’s knee, expanded in a lab, and then re-implanted into the defect at a later surgery. In MACI, these cells are seeded onto a membrane or scaffold that is shaped to fit the defect and secured with fibrin glue. Over time, the implanted cells can produce cartilage-like tissue that fills the defect and restores a smoother joint surface.

These procedures are typically reserved for younger, active patients with symptomatic, well-defined lesions and minimal generalized arthritis. They often require a detailed rehabilitation program and a longer recovery period but can offer excellent long-term results in properly selected cases.

CartiHeal (Agili-C Aragonite Biphasic Scaffold)

CartiHeal (Agili-C) is an innovative implant designed to help repair articular cartilage and the underlying bone using a biphasic aragonite-based scaffold. The implant mimics the structure of both cartilage and subchondral bone, providing a porous framework into which the patient’s own cells can grow. Unlike cell-based procedures that require a cartilage biopsy and laboratory expansion (MACI), CartiHeal is a single-stage procedure that does not require harvesting cells or tissue from another location in the knee.

The aragonite scaffold is implanted press-fit into the defect after unstable cartilage is removed, allowing bone marrow elements to infiltrate the porous structure and begin forming new tissue. Over time, the scaffold is gradually resorbed and replaced by new cartilage-like tissue and underlying bone.

CartiHeal may be especially useful for patients with focal cartilage defects involving both cartilage and subchondral bone, including those with mild to moderate osteoarthritis who are not ideal candidates for MACI or osteochondral allograft transplantation. It is well-suited for individuals seeking a joint-preserving, single-stage treatment option to improve pain, restore smoother joint mechanics, and potentially delay the need for knee replacement. Athletes and active adults who want a biologic solution without the complexity of cell-based surgery may particularly benefit from this technology.

Focalplasty / Metallic Knee Resurfacing (OvertureTi)

Focal metallic resurfacing, often referred to as Focalplasty, uses small, contoured metal implants to resurface isolated cartilage defects in the knee. One of the newest technologies in this category is OvertureTi, a 3D-printed titanium implant designed to precisely match the shape and curvature of the patient’s native articular surface. These implants are engineered to replace only the damaged area of cartilage and bone, creating a smooth, durable surface while preserving the surrounding healthy tissue.

During surgery, the damaged cartilage and underlying bone are prepared, and the implant is press-fit or anchored into place so it sits flush with the surrounding cartilage. Because titanium is biocompatible and highly resistant to wear, these implants provide immediate structural support and allow patients to return to activity more quickly than with biologic cartilage regeneration procedures, which require months for tissue healing and maturation.

Focalplasty with OvertureTi may be best suited for older active adults or patients with moderate cartilage damage who are not ideal candidates for biologic procedures, particularly when the defect is focal and surrounded by reasonably healthy cartilage. It can also be an excellent option for individuals who have failed previous biologic cartilage procedures or have focal arthritic lesions that are too advanced for microfracture or MACI but not severe enough to warrant partial or total knee replacement. For the right patient, metallic resurfacing can provide durable pain relief, maintain native knee biomechanics, and postpone or avoid larger reconstructive surgeries.

Cartilage surgery is most successful when the underlying mechanics of the knee are optimized. If a patient has significant malalignment (varus or valgus), a meniscus deficiency, or ligament instability (such as ACL deficiency), these issues may need to be addressed at the same time as cartilage restoration—often with osteotomy, meniscus transplantation, or ligament reconstruction.

Ignoring malalignment or instability can overload the repaired area and lead to early failure of even the best cartilage procedure. For this reason, a comprehensive evaluation of alignment, stability, and meniscus status is essential in planning surgery.

Articular cartilage defects in the knee can be a major source of pain and limitation, particularly in active individuals and younger patients. Fortunately, there is a wide spectrum of treatment options—from nonsurgical management and simple arthroscopic smoothing to advanced cartilage restoration procedures including osteochondral transplants and cell-based therapies like MACI. The best approach depends on the size, location, and depth of the defect; your age and activity level; and the overall condition and alignment of your knee.

If you are experiencing persistent knee pain, swelling, or mechanical symptoms such as catching or locking, please contact Dr. José Vega’s office in Cleveland to schedule a consultation. Together, we can review your imaging, discuss your goals, and design a personalized treatment plan to restore your knee function and help you return to the activities you enjoy.

References

  1. Altschuler N, Zaslav KR, Di Matteo B, et al. Aragonite-Based Scaffold Versus Microfracture and Debridement for the Treatment of Knee Chondral and Osteochondral Lesions: Results of a Multicenter Randomized Controlled Trial. Am J Sports Med. 2023;51(4):957-967.
  2. de Caro F, Vuylsteke K, Van Genechten W, Verdonk P. Acellular Aragonite-Based Scaffold for the Treatment of Joint Surface Lesions of the Knee: A Minimum 5-Year Follow-Up Study. Cartilage. 2024;15(4):399-406.
  3. Ebert JR, Zheng M, Fallon M, Wood DJ, Janes GC. 10-Year Prospective Clinical and Radiological Evaluation After Matrix-Induced Autologous Chondrocyte Implantation and Comparison of Tibiofemoral and Patellofemoral Graft Outcomes. Am J Sports Med. 2024;52(4):977-986.
  4. Ghisa C, Zaslav KR. Novel Treatment Options for Knee Cartilage Defects in 2023. Sports Med Arthrosc Rev. 2024;32(2):113-118.
  5. Hinckel BB, Thomas D, Vellios EE, et al. Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures. Cartilage. 2021;13(1_suppl):473S-495S.
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Dr. Jose Vega

  • Board-certified orthopedic surgeon
  • Fellowship-trained sports medicine specialist
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