Strategies for Optimizing Outcomes in Cartilage Restoration

When a younger (e.g., less than 50 years old), active patient presents with a symptomatic focal cartilage defect, orthopaedists are posed with a difficult treatment dilemma. When defect-associated pain significantly limits a formerly active lifestyle, secondary medical and psychological problems may occur. Joint replacement may not be a viable option due to the patient’s age and or preference for a high-demand lifestyle. For these cases, many may consider from a host of potential cartilage restoration options, ranging from microfracture to osteochondral allograft. The success of these procedures varies significantly depending on a multitude of factors.

Cartilage defects are often caused by biomechanical problems like joint instability, meniscal insufficiency, and or malalignment. According to Robert A. Gallo, M.D., assistant professor at Penn State Hershey Bone and Joint Institute, “In any patient with a cartilage defect, it’s advisable to first obtain long-length standing X-rays, to examine the weight bearing axis and conduct a thorough exam of ligamentous stability. If one addresses biomechanical problems prior to cartilage restoration procedures, the likelihood of significant benefit is greatly increased.” Often, osteotomies and ligamentous reconstructions are performed concomitantly with cartilage restoration procedures to improve the biomechanical milieu of the affected joint.

Close up images of four-step graft process

Figure A: Patellar lesion. Figure B: Following preparation of a lesion. Figure C: After placement of DeNovo graft. Figure D: After fibrin glue has been allowed to cure.
[click image for larger version]

The decision on the cartilage restoration technique to pursue rests largely on the size and location of the defect. For lesions smaller than 1 cm², microfracture is often the first-line modality due to the ease of the procedure and its proven outcomes. However, microfracture has important limitations.

“Microfracture is almost doomed to fail in patients with larger cartilage defects, those who have ‘kissing’ lesions, and patients with underlying disease or obesity,” explains Gallo. “Because microfractured regions heal with fibrocartilage, the durability of the repair has been questioned. Therefore, many surgeons are looking for other surgical options.”

Patients with larger cartilage defects or those for whom microfracture has failed may choose to undergo other restoration procedures. “At the Bone and Joint Institute, for patients with defects involving the femoral condyles, we tend to use osteoarticular grafts, autografts for smaller lesions and allografts for larger lesions,” Gallo states. “For lesions involving areas of complex topography, such as patella or trochlea, we prefer cartilage-only solutions, such as autologous chondrocyte implantation (Carticel) or, more recently, allograft minced juvenile cartilage (DeNovo).” While these procedures can provide long-lasting pain relief and restoration of function, Gallo cautions against over-zealous use of these procedures, especially newer,unproven technologies, “Over the past few years, there has been a proliferation of new products to the market. Unfortunately, many of the procedures do not have published long- or even mid-term results. ”

Emerging techniques in cartilage restoration have potential to allow individuals suffering from cartilage defect to maintain active lifestyles. However, patient selection, identification of associated biomechanical abnormalities, and choosing the optimal procedure are important in achieving a successful result.

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headshot photo of Robert Gallo, M.D.

Robert Gallo, M.D.

Robert A. Gallo, M.D.

  • Assistant professor, sports medicine
  • Orthopaedic surgeon, sports medicine
  • Phone: 717-531-4837
  • Fellowship: Sports medicine and shoulder surgery, Hospital for Special Surgery, New York, NY
  • Residency: Orthopaedic surgery, Allegheny General Hospital, Pittsburgh, PA
  • Medical School: Penn State College of Medicine, Hershey, PA

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