Staging and Practical Issues in Complex Cases

Abstract

The management of articular cartilage defects poses a complex challenge to the orthopedic surgeon. Developing an appropriate treatment plan requires a patient-centered approach with a thorough evaluation of a patient’s clinical history, physical exam, and imaging results. Many factors impact the appropriate treatment such as demographics, patient lifestyle, defect characteristics, and any concomitant pathology such as meniscal deficiency, malalignment, or instability. Once all factors are considered and surgical management is indicated, the chondral defect can be successfully treated with a variety of modalities including debridement, microfracture, autologous chondrocyte implantation, osteochondral autograft transplant, or osteochondral allograft, among others. Concomitant pathology can be managed with either staged or combined procedures, but failure to address these additional pathologies predisposes the patient to treatment failure and symptomatic recurrence. There are several complicated scenarios that occur relatively common: concomitant meniscal deficiency and chondral defect; concomitant malalignment and chondral defect; concomitant ligamentous injury and chondral defect; concomitant malalignment, meniscal deficiency, and chondral defect; and chondral defect with history of failed cartilage surgery. When appropriately applied, cartilage repair and restoration surgery provide reliably successful outcomes in patients with symptomatic articular cartilage defects, even in the most complex cases.