Managing Chondral Lesions: A Literature Review and Evidence-Based Clinical Guidelines

Abstract

Background

Articular cartilage lesions are becoming increasingly common. Optimum diagnosis and management of chondral defects cause a lot of dilemma. A number of surgical methods have been reported in the literature for treating focal cartilage defects. There is a lack of consensus on the most effective management strategy, with newer surgical and cell-based treatments being advocated regularly.

Study Design and Methods

A clinical review is constructed by appraising the published literature about clinical evaluation and diagnostic modalities for articular cartilage defects and subsequent surgical procedures, management strategies employed for such lesions. Prominent available databases (PUBMED, EMBASE, Cochrane) were also searched for trials comparing functional outcomes following cartilage procedures. Synthesis of a practical management guideline is then attempted based on the evidence assessed.

Results

Systematic examination and optimal use of diagnostic imaging are an important facet of cartilage defect management. Patient and lesion factors greatly influence the outcome of cartilage procedures and must be considered while planning management. Smaller lesions < 2 cm2 respond well to all treatment modalities. Autologous osteochondral transplants (OATs) are effective in high activity individuals with intermediate lesions. For larger lesions > 4 cm2, newer generation autologous chondrocyte implantation (ACI) has shown promising and durable results. Stem cells with scaffolds may provide an alternate option. Orthobiologics are a useful adjunct to the surgical procedures, but need further evaluation.

Conclusions

Most treatment modalities have their role in appropriate cases and management needs to be individualized for patients. The search for the perfect cartilage restoration procedure continues.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. 1.

    O’Driscoll, S. W. (1998). Current concepts review-the healing and regeneration of articular cartilage. The Journal of Bone and Joint Surgery, 80(12), 1795–1812.

    PubMed  Article  PubMed Central  Google Scholar 

  2. 2.

    Bartlett, W., Skinner, J. A., Gooding, C. R., Carrington, R. W. J., Flanagan, A. M., Briggs, T. W. R., & Bentley, G. (2005). Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee. A prospective, randomised study. The Journal of Bone and Joint Surgery, British Volume, 87(5), 640–645.

    CAS  Article  Google Scholar 

  3. 3.

    Farr, J., Cole, B., Dhawan, A., Kercher, J., & Sherman, S. (2011). Clinical cartilage restoration: evolution and overview. Clinical Orthopaedics and Related Research, 469(10), 2696–2705.

    PubMed  PubMed Central  Article  Google Scholar 

  4. 4.

    Widuchowski, W., Lukasik, P., Kwiatkowski, G., et al. (2008). Isolated full thickness chondral injuries. Prevalence and outcome of treatment. A retrospective study of 5233 knee arthroscopies. Acta Chir Orthop Traumatol Cech, 75(5), 382–386.

    CAS  PubMed  Google Scholar 

  5. 5.

    Gowd, A. K., Cvetanovich, G. L., Liu, J. N., Christian, D. R., Cabarcas, B. C., Redondo, M. L., et al. (2019). Management of chondral lesions of the knee: analysis of trends and short-term complications using the national surgical quality improvement program database. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 35(1), 138–146.

    PubMed  Article  PubMed Central  Google Scholar 

  6. 6.

    Gomoll, A. H., Farr, J., Gillogly, S. D., Kercher, J., & Minas, T. (2010). Surgical management of articular cartilage defects of the knee. The Journal of Bone and Joint Surgery, 92(14), 2470–2490.

    CAS  PubMed  Google Scholar 

  7. 7.

    Steadman, J. R., Rodkey, W. G., & Briggs, K. K. (2001). Microfracture to treat full-thickness chondral defects: surgical technique, rehabilitation, and outcomes. The Journal of Knee Surgery, 15(3), 170–176.

    Google Scholar 

  8. 8.

    Marcacci, M., Kon, E., Delcogliano, M., Filardo, G., Busacca, M., & Zaffagnini, S. (2007). Arthroscopic autologous osteochondral grafting for cartilage defects of the knee prospective study results at a minimum 7-year follow-up. The American Journal of Sports Medicine, 35(12), 2014–2021.

    PubMed  Article  Google Scholar 

  9. 9.

    Hangody, L., Vásárhelyi, G., Hangody, L. R., Sükösd, Z., Tibay, G., Bartha, L., & Bodó, G. (2008). Autologous osteochondral grafting—technique and long-term results. Injury, 39(1), 32–39.

    Article  Google Scholar 

  10. 10.

    LaPrade, R. F., & Botker, J. C. (2004). Donor-site morbidity after osteochondral autograft transfer procedures. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 20(7), e69–e73.

    PubMed  Article  PubMed Central  Google Scholar 

  11. 11.

    Peterson, L., Brittberg, M., Kiviranta, I., Åkerlund, E. L., & Lindahl, A. (2002). Autologous chondrocyte transplantation biomechanics and long-term durability. The American Journal of Sports Medicine, 30(1), 2–12.

    PubMed  Article  PubMed Central  Google Scholar 

  12. 12.

    Moseley, J. B., Jr., Anderson, A. F., Browne, J. E., Mandelbaum, B. R., Micheli, L. J., Fu, F., & Erggelet, C. (2010). Long-term durability of autologous chondrocyte implantation: a multicenter, observational study in US patients. The American Journal of Sports Medicine, 38, 238–246.

    PubMed  Article  PubMed Central  Google Scholar 

  13. 13.

    Saris, D. B., Vanlauwe, J., Victor, J., Haspl, M., Bohnsack, M., Fortems, Y., et al. (2008). Characterized chondrocyte implantation results in better structural repair when treating symptomatic cartilage defects of the knee in a randomized controlled trial versus microfracture. The American Journal of Sports Medicine, 36(2), 235–246.

    PubMed  Article  PubMed Central  Google Scholar 

  14. 14.

    Southworth, T. M., Naveen, N. B., Nwachukwu, B. U., Cole, B. J., & Frank, R. M. (2019). Orthobiologics for focal articular cartilage defects. Clinics in Sports Medicine, 38(1), 109–122.

    PubMed  Article  PubMed Central  Google Scholar 

  15. 15.

    Kraeutler, M. J., Chahla, J., LaPrade, R. F., & Pascual-Garrido, C. (2017). Biologic options for articular cartilage wear (platelet-rich plasma, stem cells, bone marrow aspirate concentrate). Clinics in Sports Medicine, 36(3), 457–468.

    PubMed  Article  PubMed Central  Google Scholar 

  16. 16.

    Bekkers, J. E., Creemers, L. B., Dhert, W. J., & Saris, D. B. (2010). Diagnostic modalities for diseased articular cartilage-from defect to degeneration: a review. Cartilage, 1(3), 157–164.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  17. 17.

    Gross, C. E., Chalmers, P. N., Chahal, J., et al. (2012). Operative treatment of chondral defects in the glenohumeral joint. Arthroscopy, 28(12), 1889–1901.

    PubMed  Article  PubMed Central  Google Scholar 

  18. 18.

    Richter, D. L., Schenck, R. C., Jr., Wascher, D. C., & Treme, G. (2016). Knee articular cartilage repair and restoration techniques: a review of the literature. Sports Health, 8(2), 153–160.

    PubMed  Article  PubMed Central  Google Scholar 

  19. 19.

    Merkely, G., Ackermann, J., & Lattermann, C. (2018). Articular cartilage defects: incidence, diagnosis, and natural history. Operative Techniques in Sports Medicine, 26(3), 156–161.

    Article  Google Scholar 

  20. 20.

    Group, M. K., Spindler, K. P., Huston, L. J., et al. (2018). Ten-year outcomes and risk factors after anterior cruciate ligament reconstruction: a MOON longitudinal prospective cohort study. The American Journal of Sports Medicine, 46(4), 815–825.

    Article  Google Scholar 

  21. 21.

    Sonin, A. H., Pensy, R. A., Mulligan, M. E., & Hatem, S. (2002). Grading articular cartilage of the knee using fast spin-echo proton density-weighted MR imaging without fat suppression. American Journal of Roentgenology, 179, 1159–1166.

    PubMed  Article  PubMed Central  Google Scholar 

  22. 22.

    Novakofski, K. D., Pownder, S. L., Koff, M. F., Williams, R. M., Potter, H. G., & Fortier, L. A. (2016). High-resolution methods for diagnosing cartilage damage in vivo. Cartilage, 7(1), 39–51.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  23. 23.

    Outerbridge, R. E. (1961). The etiology of chondromalacia patellae. The Journal of Bone and Joint Surgery. British Volume, 43(4), 752–757.

    PubMed  Article  PubMed Central  Google Scholar 

  24. 24.

    Fortun, C. M., Streit, J., Patel, S. H., & Salata, M. J. (2012). Cartilage defects in the hip. Operative Techniques Sports in Medicine, 20, 287–294.

    Article  Google Scholar 

  25. 25.

    Knutsen, G., Drogset, J. O., Engebretsen, L., et al. (2007). A randomized trial comparing autologous chondrocyte implantation with microfracture: findings at five years. The Journal of Bone and Joint Surgery. American Volume, 89, 2105–2112.

    PubMed  Article  PubMed Central  Google Scholar 

  26. 26.

    Goyal, D., Keyhani, S., Lee, E. H., & Hui, J. H. (2013). Evidence-based status of microfracture technique: a systematic review of level I and II studies. Arthroscopy, 29, 1579–1588.

    PubMed  Article  PubMed Central  Google Scholar 

  27. 27.

    Frank, R. M., Cotter, E. J., Strauss, E. J., Gomoll, A. H., & Cole, B. J. (2018). The utility of biologics, osteotomy, and cartilage restoration in the knee. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 26(1), e11-25.

    Article  Google Scholar 

  28. 28.

    Mithoefer, K., McAdams, T., Williams, R. J., Kreuz, P. C., & Mandelbaum, B. R. (2009). Clinical efficacy of the microfracture technique for articular cartilage repair in the knee an evidence-based systematic analysis. The American Journal of Sports Medicine, 37(10), 2053–2063.

    PubMed  Article  PubMed Central  Google Scholar 

  29. 29.

    Salzmann, G. M., Sah, B., Sudkamp, N. P., & Niemeyer, P. (2013). Clinical outcome following the first-line, single lesion microfracture at the knee joint. Archives of Orthopaedic and Trauma Surgery, 133(3), 303–310.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  30. 30.

    Na, Y., Shi, Y., Liu, W., Jia, Y., Kong, L., Zhang, T., et al. (2019). Is implantation of autologous chondrocytes superior to microfracture for articular-cartilage defects of the knee? A systematic review of 5-year follow-up data. International Journal of Surgery, 68(1), 56–62.

    PubMed  Article  Google Scholar 

  31. 31.

    Volz, M., Schaumburger, J., Frick, H., et al. (2017). A randomized controlled trial demonstrating sustained benefit of autologous matrix-induced chondrogenesis over microfracture at five years. International Orthopaedics, 41, 797–804.

    PubMed  Article  Google Scholar 

  32. 32.

    Mancini, D., & Fontana, A. (2014). Five-year results of arthroscopic techniques for the treatment of acetabular chondral lesions in femoroacetabular impingement. International Orthopaedics, 38, 2057–2064.

    PubMed  Article  Google Scholar 

  33. 33.

    Gudas, R., Kalesinskas, R. J., Kimtys, V., Stankevic̆ius, E., Tolius̆is, V., Bernotavic̆ius, G., & Smailys, A. (2005). A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 21(9), 1066–1075.

    PubMed  Article  Google Scholar 

  34. 34.

    Epstein, D. M., Choung, E., Ashraf, I., et al. (2012). Comparison of mini-open versus arthroscopic harvesting of osteochondral autografts in the knee: a cadaveric study. Arthroscopy, 28, 1867–1872.

    PubMed  Article  Google Scholar 

  35. 35.

    Stuhlman, C. R., Krych, A. J., Levy, B. A., & Kelly, B. T. (2015). Cartilage restoration of the hip. Operative Techniques Sports in Medicine, 23, 175–183.

    Article  Google Scholar 

  36. 36.

    Dallich, A. A., Rath, E., Atzmon, R., Radparvar, J. R., Fontana, A., Sharfman, Z., & Amar, E. (2019). Chondral lesions in the hip: a review of relevant anatomy, imaging and treatment modalities. Journal of Hip Preservation Surgery, 6(1), 3–15.

    PubMed  PubMed Central  Article  Google Scholar 

  37. 37.

    Willers, C., Wood, D. J., & Zheng, M. H. (2003). A current review on the biology and treatment of articular cartilage defects (part I & part II). Journal of Musculoskeletal Research, 7(03n04), 157–181.

    Article  Google Scholar 

  38. 38.

    Steinwachs, M., & Kreuz, P. C. (2007). Autologous chondrocyte implantation in chondral defects of the knee with a type I/III collagen membrane: a prospective study with a 3-year follow-up. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 23(4), 381–387.

    PubMed  Article  Google Scholar 

  39. 39.

    Harris, J. D., Siston, R. A., Pan, X., & Flanigan, D. C. (2010). Autologous chondrocyte implantation: a systematic review. The Journal of Bone and Joint Surgery, 92(12), 2220–2233.

    PubMed  Article  Google Scholar 

  40. 40.

    Pestka, J. M., Bode, G., Salzmann, G., Sudkamp, N. P., & Niemeyer, P. (2012). Clinical outcome of autologous chondrocyte implantation for failed microfracture treatment of full-thickness cartilage defects of the knee joint. The American Journal of Sports Medicine, 40, 325–331.

    PubMed  Article  PubMed Central  Google Scholar 

  41. 41.

    Jungmann, P. M., Salzmann, G., Schmal, H., et al. (2012). Autologous chondrocyte implantation for treatment of cartilage defects of the knee: what predicts the need for reintervention? The American Journal of Sports Medicine, 40, 58–67.

    PubMed  Article  PubMed Central  Google Scholar 

  42. 42.

    Cotter, E. J., Wang, K. C., Yanke, A. B., et al. (2018). Bone marrow aspirate concentrate for cartilage defects of the knee: from bench to bedside evidence. Cartilage, 9(2), 161–170.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  43. 43.

    Gobbi, A., Chaurasia, S., Karnatzikos, G., & Nakamura, N. (2015). Matrix-induced autologous chondrocyte implantation versus multipotent stem cells for the treatment of large patellofemoral chondral lesions: a nonrandomized prospective trial. Cartilage, 6(2), 82–97.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  44. 44.

    Xu, Z., Yin, W., Zhang, Y., Qi, X., Chen, Y., Xie, X., & Zhang, C. (2017). Comparative evaluation of leukocyte-and platelet-rich plasma and pure platelet-rich plasma for cartilage regeneration. Scientific Reports, 7, 4330.

    Article  CAS  Google Scholar 

  45. 45.

    Wang, K. C., Frank, R. M., Cotter, E. J., et al. (2017). Arthroscopic management of isolated tibial plateau defect with microfracture and micronized allogeneic cartilage–plateletrich plasma adjunct. Arthroscopy Techniques, 6(5), e1613–e1618.

    PubMed  PubMed Central  Article  Google Scholar 

  46. 46.

    Kasir, R., Vernekar, V. N., & Laurencin, C. T. (2015). Regenerative engineering of cartilage using adipose-derived stem cells. Regenerative Engineering and Translational Medicine, 1(4), 42–49.

    PubMed  PubMed Central  Article  Google Scholar 

  47. 47.

    Knutsen, G., Drogset, J. O., Engebretsen, L., Grøntvedt, T., Ludvigsen, T. C., Løken, S., et al. (2016). A randomized multicenter trial comparing autologous chondrocyte implantation with microfracture: long-term follow-up at 14 to 15 years. JBJS, 98(16), 1332–1339.

    Article  Google Scholar 

  48. 48.

    Vanlauwe, J., Saris, D. B., Victor, J., Almqvist, K. F., Bellemans, J., Luyten, F. P., & TIG/ACT/01/2000&EXT Study Group. (2011). Five-year outcome of characterized chondrocyte implantation versus microfracture for symptomatic cartilage defects of the knee: early treatment matters. The American Journal of Sports Medicine, 39(12), 2566–2574.

    PubMed  Article  PubMed Central  Google Scholar 

  49. 49.

    Gobbi, A., Kon, E., Berruto, M., Filardo, G., Delcogliano, M., Boldrini, L., et al. (2009). Patellofemoral full-thickness chondral defects treated with second-generation autologous chondrocyte implantation: results at 5 years’ follow-up. The American Journal of Sports Medicine, 37(6), 1083–1092.

    PubMed  Article  PubMed Central  Google Scholar 

  50. 50.

    Brittberg, M., Recker, D., Ilgenfritz, J., Saris, D. B., & SUMMIT Extension Study Group. (2018). Matrix-applied characterized autologous cultured chondrocytes versus microfracture: five-year follow-up of a prospective randomized trial. The American Journal of Sports Medicine, 46(6), 1343–1351.

    PubMed  Article  PubMed Central  Google Scholar 

  51. 51.

    Horas, U., Pelinkovic, D., Herr, G., Aigner, T., & Schnettler, R. (2003). Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. The Journal of Bone and Joint Surgery, 85(2), 185–192.

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  52. 52.

    Bentley, G., Biant, L. C., Vijayan, S., Macmull, S., Skinner, J. A., & Carrington, R. W. J. (2012). Minimum ten-year results of a prospective randomised study of autologous chondrocyte implantation versus mosaicplasty for symptomatic articular cartilage lesions of the knee. The Journal of Bone and Joint Surgery, British Volume, 94(4), 504–509.

    CAS  Article  Google Scholar 

  53. 53.

    Teo, A. Q., Wong, K. L., Shen, L., Lim, J. Y., Toh, W. S., Lee, E. H., & Hui, J. H. (2019). Equivalent 10-year outcomes after implantation of autologous bone marrow-derived mesenchymal stem cells versus autologous chondrocyte implantation for chondral defects of the knee. The American Journal of Sports Medicine, 47(12), 2881–2887.

    PubMed  Article  PubMed Central  Google Scholar 

Download references

Acknowledgements

The authors would like to acknowledge the help of Dr. Suvinay Saxena and Dr. Pawan Garg both from the Department of Diagnostic and Interventional Radiology, AIIMS Jodhpur for their valuable help with imaging figures in the article.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Sumit Banerjee.

Ethics declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest. No financial aid of any nature was obtained from any source for this article.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study, informed consent is not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Banerjee, S., Sahanand, K.S. Managing Chondral Lesions: A Literature Review and Evidence-Based Clinical Guidelines. JOIO (2021). https://doi.org/10.1007/s43465-021-00355-z

Download citation

Keywords

  • Articular cartilage
  • Cartilage lesions
  • Arthroscopy
  • Microfracture
  • Autologous chondrocyte implantation
  • Mosaicplasty
  • Bone marrow aspirate
  • Orthobiologics
  • Stem cells
  • Functional outcome