Treatment options for concomitant cartilage damage in the anterior cruciate ligament (ACL)-injured athlete

Introduction

Acute anterior cruciate ligament (ACL) injuries are common in the athletic population due to their high functional demands (1). Cartilage injuries have been noted to be more common in athletes than in the general population, potentially due to high-energy mechanisms that increase the likelihood of cartilage injury (2). ACL injuries can affect athletes in both isolated and concomitant instances. In a cross-sectional study of 600 patients with ACL injuries, 28% of patients had chondral lesions (3). Farinelli et al. retrospectively observed that professional soccer players and alpine skiers were more likely to sustain ACL injuries accompanied by both chondral and meniscal injuries than isolated ACL injuries, indicating a higher burden of combined injury patterns in elite athletes (4). Cartilage injuries associated with ACL injuries have been well described in prior epidemiologic studies. Chondral lesions occur in approximately 20–40% of ACL injuries and most frequently involve the femoral condyles; the lateral femoral condyle is typically affected in the acute pivot-shift mechanisms while the medial femoral condyle is more commonly involved in chronic instability situations (4). Patellofemoral lesions are also reported, though less frequently. Lesion size varies, but defects between 1–4 cm² are most often described in the ACL-injured population (2). The presence, location, and size of these lesions influence both treatment choice and anticipated recovery.

The objective of this study is to review, evaluate, and compare current treatment strategies for concomitant chondral lesions in ACL-injured athletes, with a particular focus on return-to-sport timelines, functional outcomes, and long-term durability across nonoperative management, marrow stimulation techniques, osteochondral transplantation, and cell-based cartilage restoration procedures.

Key considerations in the management of these injuries include the decision between operative and nonoperative treatment, selection of the appropriate surgical technique, and whether to perform the intervention as a single event or a staged procedure. Throughout this review, studies that evaluate isolated cartilage injuries are distinguished from those that specifically assess chondral lesions occurring with ACL injuries. Treatment strategies may differ when chondral injury is accompanied by ACL deficiency because instability, graft choice, and postoperative rehabilitation sequencing can influence outcomes.

ACL reconstruction (ACLR) allows athletes to engage in high-level cutting and pivoting activities associated with knee stability, and therefore, operative management in the athlete is generally indicated. However, the athlete with concomitant cartilage damage presents a unique challenge, balancing return to play expectations, performance, and overall knee health with long term outcomes. Options for treatment of cartilaginous injuries include debridement, fixation or excision of osteochondral fragments, and reparative strategies such as microfracture with or without scaffold augmentation, osteochondral autograft transplantation (OAT), autologous regenerative procedures such as autologous chondrocyte implantation (ACI) and matrix-induced ACI (MACI), or osteochondral allograft transplantation (OCA). The use of biologics such as platelet-rich plasma (PRP) and bone marrow aspirate concentrate (BMAC) is an area that requires further study. Osteotomies have demonstrated effective unloading of articular cartilage damage and can contribute to long-term healing but may impact the athletes’ return-to-play (5). Finally, graft choice and associated harvest site morbidity can impact rehabilitation guidelines during ACL recovery and represent additional factors that may influence treatment selection and return-to-play time (6).

Overall, the treatment of cartilaginous lesions in the athlete undergoing ACLR is a complex problem with multiple patient factors and lesion-specific factors. Patient characteristics such as age, activity demands, body mass index (BMI), and rehabilitation capacity help determine whether restoration procedures or symptom-directed treatments are appropriate. Lesion characteristics, including size, depth, location, and bony involvement, as well as the presence of rotatory instability or meniscal deficiency, further guide the choice between debridement, reparative techniques such as microfracture, restorative osteochondral procedures, cell-based therapies, or alignment-correcting osteotomy.

Workup and evaluation

A comprehensive workup is essential for determining appropriate management of cartilage injuries associated with ACL tears. Physical examination should assess knee effusion, joint line tenderness, mechanical symptoms, range of motion, and ligamentous stability. Standard radiographs, including weight-bearing anteroposterior, lateral, and patellofemoral views, assist with identifying malalignment, joint space narrowing, and associated bony pathology. Magnetic resonance imaging is the preferred modality to evaluate lesion chronicity, size, depth, subchondral bone involvement, and the presence of loose bodies. Magnetic resonance imaging (MRI) also helps identify concomitant pathology such as meniscal injury, rotatory instability patterns, or increased posterior tibial slope. These factors guide decision-making regarding debridement, reparative or restorative procedures, and whether combined correction (such as osteotomy) is required.

Treatment options

Before selecting a treatment strategy, both the location and size of the chondral lesion should be considered because lesions of the weight-bearing femoral condyles, patellofemoral joint, or tibial plateau may differ in prognosis and technical demands. Treatment options for chondral lesions in the setting of ACL injury can be varied based on patient characteristics such as age, BMI, pre-injury activity level, rehabilitation potential; lesion characteristics such as size, depth, bony involvement and location are important as well (7). When reviewing cited studies, we specify whether the reported outcomes reflect isolated cartilage injuries or chondral lesions associated with ACL injuries, as these scenarios may differ. In the combined setting, persistent instability, concomitant meniscal pathology, and graft harvest considerations can influence both the choice of cartilage procedure and expectations for return to play. Concomitant pathologies such as rotatory instability, including anterolateral or posteromedial patterns, excessive tibial slope and meniscal injury, will impact treatment options for cartilage injuries as well (8-10).

Nonoperative treatment

In athletes specifically, nonoperative management—consisting of targeted physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and activity modification—may be appropriate only for isolated, small, stable, and minimally symptomatic lesions or when short-term symptom control is needed to complete a season. However, athletes treated with conservative management who participate in high-demand activity may be more susceptible to tibiofemoral articular cartilage damage and long-term osteoarthritis, especially with concomitant ACL or meniscus injuries (10). Historically, surgical management is preferred for these injuries in an athlete’s knee with the goal of stimulating mesenchymal stem cell metaplasia to form fibrocartilage via debridement or microfracture, or replacing cartilage defects via OAT, OCA, or ACI (11).

Debridement

Arthroscopic intervention with simple debridement of the lesion has been a long-used surgical procedure for treatment of chondral lesions, with studies by Jackson et al. showing reports of significant rates of early-term improvement (88%) and moderate rates of prolonged improvement (68%) (12,13). Arthroscopic debridement has been noted as a potentially ideal procedure for in-season athletes, athletes who are against extensive rehabilitation, or athletes who are considering a cartilage restoration procedure later (14).

Microfracture

Microfracture has also been described to provide a fibrocartilage resurfacing of the chondral lesion (12,15,16). Studies referenced in this section differ in whether they address isolated chondral defects or defects associated with ACL injuries, and this distinction is identified to clarify applicability. Ulstein et al. published a cohort study comparing 5-year patient-related outcomes in patients who underwent ACLR with concomitant chondral injury; patients underwent either no treatment (n=23), debridement alone (n=4), or microfracture of the chondral lesion (n=3) (15). Results of the study showed that debridement and microfracture had no difference in patient-reported outcomes (PROMs) compared to the untreated group of patients (15). There are limitations in this study; 43% of patients were lost to follow-up and in this group, there was a higher percentage of patients with International Cartilage Repair Society (ICRS) grade 4 lesions and younger age.

Return to sport is a particular consideration for athletes undergoing procedures such as debridement and microfracture. A case series of 52 National Football League (NFL) athletes treated solely by debridement procedures had a return-to-sport rate of 67%. However, players who underwent concomitant microfracture were 4.4 times less likely to return to the NFL than were those who did not undergo this procedure (17). Among operative management of chondral lesions, microfracture has been reported to have long-term function and durability, which was inferior to other procedures such as ACI and OCA (14). A review article by Kambhampati et al. discussed a shorter mean time to failure and lower survival rates in patients treated with microfracture compared to those treated with osteochondral grafts (18). Additionally, microfracture has been associated with the lowest return-to-sport rates among surgical treatments for chondral lesions, with reported rates ranging from 58% to 75% in recent studies (19-21).

OAT

Osteochondral autografts used for OAT have shown beneficial long-term results for chondral injury, replacing damaged cartilage with articular cartilage rather than fibrocartilage (12). Previous studies have reported OAT to be a superior procedure for cartilage restoration in comparison to OCA, ACI, MACI, and microfracture, with return-to-sport rates ranging from 84.4–93% in recent literature (19-22). Imade et al. reported that 1-year PROMs were similar in patients with ACL injury and concomitant cartilage injury undergoing OAT versus microfracture (23). However, longer-term studies have shown improved results with OAT. In a prospective study of 102 patients comparing PROMs in patients with ACL injury and concomitant articular cartilage injury that underwent microfracture, debridement, or OAT, Gudas et al. reported improved 3-year outcome scores with OAT compared to microfracture and debridement (16). Additionally, Klinger et al. reported that combining ACLR with osteochondral autologous grafting in a single-stage procedure is an effective and efficient approach for treating symptomatic full-thickness cartilage defects in the setting of ACL instability (24).

Krych et al. (19) evaluated 44 studies including 2,549 patients undergoing cartilage restoration procedures with return to sport as an outcome. Overall, 76% of athletes who underwent surgical treatment for cartilage repair returned to sport at a mean of 9 months postoperatively. Procedure-specific return-to-sport rates were highest after OAT (93%), followed by OCA (88%), ACI (82%), and lowest after microfracture (58%). OAT also demonstrated the fastest return to sport (mean 5.2 months), compared with 9.1 months for microfracture, 9.6 months for OCA, and 11.8 months for ACI. Importantly, meta-regression revealed that age, lesion size, and preoperative activity level were not significant determinants of return-to-sport rate, underscoring the influence of procedure type itself. Long-term data suggest durability of outcomes is highest with OAT and ACI, whereas return-to-sport rates after microfracture decline over time. Procedure choice directly impacts the likelihood and timing of return to play, with OAT offering the most favorable profile for high-demand athletes. However, these findings are derived from isolated cartilage procedures and may not be generalizable to patients undergoing combined surgeries, where concomitant ligament reconstruction, osteotomy, or other interventions typically prolong rehabilitation and may reduce return-to-sport rates.

While OAT is a viable option for cartilage restoration with typically good outcomes, donor site morbidity should be considered preoperatively. Donor site morbidity is a known problem with limited supporting literature, requiring further research to identify safe donor sites and develop techniques with fewer risks and complications (25). Nakagawa et al. further discussed the limited reports available regarding donor site morbidity and noted 15% of the patients in their case series to have symptoms such as occasional knee pain and radiographic changes after osteochondral graft harvest in healthy knees (26). Furthermore, Andrade et al. noted other donor site morbidity complaints in the knee, such as patellofemoral disturbances, crepitus, instability and stiffness (27). Lesion size represents an important limitation for OAT transfer. Hangody et al. reported that the ideal defect size is between 1–4 cm², as donor-site availability, morbidity and technical feasibility largely dictate this threshold (28). While mosaicplasty can occasionally be extended to larger lesions up to 8–9 cm², such cases are associated with a higher risk of donor-site morbidity, making this approach less desirable in high-demand athletes.

OCA

Like OAT procedures, OCA provides a mature articular cartilage solution to treat lesions, but is preferred for medium-to large-sized defects (>20 mm diameter). Like OAT this procedure can be performed in one surgical procedure without the risk of donor site morbidity (29). However, many experts in the field treating these lesions recommend a diagnostic arthroscopy prior to obtaining these expensive grafts to enssure necessity and efficacy, avoiding unexpected intra-articular pathology that can impact results. In a case series involving 15 professional athletes representing a variety of sports, eleven athletes returned (66.7%); of those who returned, 10/11 (90.9%) reached same/higher level compared to their preoperative status (30). Recent literature comparing OCA transplantation to OAT procedures demonstrates favorable PROMs with similar graft survival at mid-term follow-up. In an analysis of 1,631 patients who underwent OCA transplantation (34.5±12.1 years old; 51.6% female) and 967 patients who underwent OAT procedures (32.1±12.9 years old; 51.0% female), Kaplan-Meier survival curves comparing operation-free survival at 5 years indicated no significant difference between the groups (OCA, 88.0% vs. OAT, 89.5%; P=0.23) (31). Wang et al. found that OCA transplantation in the setting of prior or concomitant ACLR had noninferior outcomes and failure rates in comparison to staged procedures (32). These evidence-based findings help reduce the number of operations and potential complications in these patients with large cartilage defects and concurrent ACL injury.

Athlete-specific outcomes following OCA transplantation have also been encouraging. Crawford et al. systematically reviewed 13 studies with 722 total patients, noting that 75–82% of patients returned to sport following OCA transplantation (33). In this review, 10 studies provided reoperation data on 695 total patients, with six studies reporting reoperation rates ranging from 34–53%. These repeat surgeries included minimal procedures such as loose body removal or debridement. Despite these reoperation rates, this review of studies observed improvements in PROMs; specifically, the Cincinnati Knee and Knee Injury and Osteoarthritis Outcome (KOOS) sport scores reached a minimally clinically important difference. Similarly, in a cohort of 149 knees (mean age 31 years, 45% highly competitive athletes), Nielsen et al. found that at a mean follow-up of 6 years, 75% of patients returned to sport or recreational activity, with 79% able to participate in moderate-to-strenuous activities and 91% reporting satisfaction with their outcome (34). Graft survivorship was excellent, with 91% survival at 5 years and 89% at 10 years. Patients who did not return to sport often cited lifestyle changes and persistent knee symptoms rather than graft failure as the primary reasons. Factors associated with a lower likelihood of returning to sport included female sex, non-sport-related injury mechanisms, larger graft size, and patellar lesion involvement. These findings reinforce OCA as a durable treatment option for athletes, restoring high levels of function and activity. However, return to the same preinjury competitive level was less consistent, occurring in 5.3% of patients (P=0.176) when preoperative International Knee Documentation Committee (IKDC) assessments were compared to postoperative evaluations.

ACI and MACI

More recently, cell-based methods, either through ACI or MACI, have been studied in the setting of ACL injury. Dhinsa et al. published a prospective study to investigate the effects of the timing of ACI with respect to the time of ACLR (35). Results showed similar outcomes in patients treated with combined ACI-ACLR as compared to those patients treated with staged ACLR followed by ACI; interestingly, worse functional scores were noted in the group undergoing ACI without ACLR (36). Mehl et al. found that ACI combined with concurrent ACLRs resulted in good clinical short-term outcomes with results similar to patients treated with isolated ACI procedures (37).

In comparison to other ACI techniques, MACI membrane implantation is suture-free and therefore less time-consuming (38). In a prospective case series, Amin et al. reported shorter anesthetic and tourniquet time associated with ACLR combined with MACI procedures specifically, compared with earlier periosteum-based ACI methods; this reduction in time required for the procedure was attributed to the simplified, suture-free membrane implantation, making this an advantageous and potentially more cost-effective procedure (39). Large chondral defects and revision ACLRs are factors that may pose a challenge in the setting of concomitant cartilage and ACL injuries; however, patients ultimately have long-term outcomes at 10-year minimum follow-up with improved pain and function (18). Overall, MACI/ACI with ACLR is a feasible method to treat concurrent cartilage and ACL injuries (40).

The use of ACI/MACI in the treatment of athletes has yielded promising results in previous literature. Campbell et al. observed a return-to-sport rate of 84% in athletes treated with ACI (n=259) in their systematic review (21). Furthermore, an 83% return-to-sport rate was observed in competitive soccer players after ACI by Mithoefer et al., with 87–100% of players maintaining their ability to play sports 5 years post-operatively. (41) Factors affecting return to play after ACI included age <25 years, competitive athletes, preoperative interval duration <12 months, simultaneous surgery, and minimally invasive procedures. In professional athletes who participate in high-impact sports, such as soccer, ACI/MACI has led to improved clinical and functional scores in the knee and ankle. MACI specifically has been reported to reduce two-stage procedure design to one-stage, while simultaneously accelerating return-to-play time and reducing patient morbidity (42). Beyzadeoglu et al. describe MACI used to treat a professional football player who has continued to play professionally with outcomes and second-look arthroscopy that were very encouraging at two-year follow-up (43). In a systematic review analyzing return-to-sport rates in athletes undergoing articular cartilage restoration procedures, MACI demonstrated the highest odds ratio (2.15, CI=95%) for return to the same or higher level of play (44). Lesion location included femoral condyles (n=264), trochlea (n=32), and patella (n=47) with a mean lesion size of 3.99 cm².

Osteotomy

Osteotomy can also serve as a valuable adjunct to ACLR and cartilage repair, particularly in the presence of coronal malalignment or excessive posterior tibial slope that may compromise graft stability and cartilage durability. High tibial osteotomy (HTO) is most indicated for varus-aligned knees with medial compartment chondral damage, while DFO is used for valgus malalignment with lateral compartment disease. Malalignment greater than 3–5° in the coronal plane is often considered clinically significant, and posterior tibial slope reduction is recommended in select patients, particularly in revision ACL cases or when the slope exceeds 10–12°, to decrease anterior tibial translation and protect the graft (45). Preoperative planning with long-leg standing radiographs and sagittal alignment assessment is critical to guide correction strategy. Newer technologies, including CT-based planning with custom, patient-specific cutting guides (PSCG) may assist in the feasibility of osteotomies for low-volume surgeons by allowing them to save time and fluoroscopy exposure without compromising outcomes (46).

Favorable PROMs have been reported following combined osteotomy, ACLR, and cartilage procedures in appropriately selected patients. In a series of opening-wedge HTO with concomitant OCA for varus knees with medial femoral condyle defects, 79% of patients returned to at least one sport at an average of 11 months, though only 42% achieved their preinjury level of play (47). At 10-year follow-up of simultaneous ACLR and opening-wedge HTO for varus knees with early medial osteoarthritis, 80% of patients returned to sport, with approximately one-third returning at the same competitive level; stability was restored in most cases, though radiographic osteoarthritic progression was observed in a subset (48). Similarly, medial closed-wedge DFO combined with ACLR for valgus knees has been shown to restore knee stability, achieve bony union at a mean of just over 3 months, and produce significant improvements in IKDC and KOOS scores at 1 year (49). In the revision setting, systematic review data support the use of HTO in combination with ACL revision to address excessive posterior tibial slope and/or coronal malalignment, demonstrating improvements in stability, functional scores, and low complication rates, with no reported graft failures (45,50).

Although combined osteotomy, ACLR, and cartilage procedures often yield favorable outcomes, especially in controlling malalignment, athletes must be counseled about realistic risks. HTO has a relatively low nonunion rate, reported between 0% and 4.4%, with most patients returning to sport or work by 1 year when appropriately selected and technically executed (51). In athletic populations, studies of HTO have shown that more than 80% of patients resume sport or occupational activities by 1 year, with roughly two-thirds returning at the same or higher level; however, return is more common in recreational or low-impact sports, while high-demand pivoting and contact sports demonstrate lower rates of full return (51). When performed simultaneously with ACLR, functional outcomes similarly improve, but the likelihood of regaining preinjury performance levels is less predictable, and ACL graft re-ruptures have been reported to occur during sport participation (52). Combined HTO and ACLR carries variable complication rates, ranging from 0% to 23.5%, including HTO reoperations (~6.5%) and ACL graft failure (~17.5%) (52). Additionally, cases of residual laxity or progression of osteoarthritis have been observed despite good early functional outcomes (53). These findings underscore that while osteotomy can support restoration of stability and protect reconstructed structures, clinicians and athletes should remain mindful of potential complications and long-term joint effects. For athletes, single-stage alignment correction combined with ACLR and cartilage restoration offers the advantage of addressing all mechanical and biologic risk factors in one setting, potentially reducing total rehabilitation time compared to staged procedures. Nevertheless, combined procedures require more extensive bony and soft tissue work, which often prolongs rehabilitation. This extended recovery can delay sport-specific training and likely contributes to the lower and less predictable rates of return to preinjury performance reported in the literature (52). However, these combined surgeries often require a longer period of protected weight-bearing and may delay return to sport relative to isolated ACLR. When performed with careful tunnel and plate positioning to avoid hardware conflict, complication rates are like isolated osteotomy. In these instances, PSCG can minimize tunnel interference and maintain appropriate tunnel position while reducing operative and fluoroscopy exposure time without compromising correction accuracy. Most patients can expect meaningful improvements in stability and function and a high likelihood of returning to recreational sports; athletes should be counseled that return to elite or preinjury level competition is less predictable, even with technically successful procedures (45).

Osteotomy should be considered in ACL-deficient athletes with underlying coronal plane malalignment or excessive posterior tibial slope; these deformities can place the reconstructed graft or articular cartilage at elevated risk for failure or accelerated degeneration. Biomechanical and radiologic data support that increased posterior tibial slope significantly increases anterior tibial translation under load, thereby increasing strain on the ACL or graft (54,55). Clinical series of a young, athletic population combining slope correction or alignment osteotomy with ACLR in patients with malalignment or steep slope have shown improved knee stability and may help protect the graft and joint over time. In this series, 63% of patients had marked cartilage damage in the medial compartment. At a follow-up (mean 4.5 years), 66% of patients returned to sports without symptoms (56). Although combined procedures may prolong rehabilitation and render return to high-demand sport less predictable, for appropriately selected patients, the benefits of mechanical realignment and slope correction justify consideration of osteotomy to optimize long-term graft and cartilage longevity.

Biologics

The role of biologics in the treatment of chondral lesions in the setting of ACL injuries has also been studied. Platelet-rich plasma (PRP) injections have been used to treat an array of musculoskeletal injuries. Schneider et al. reviewed the current state of PRP injections as an effective method to improve quality of life and maintain long-term efficacy with fewer side effects compared to other treatments for various conditions, including ACL and chondral knee injuries (57). A prospective randomized trial by Danieli et al. reported that patients with ACLR and concomitant grade III chondral lesions treated by chondroplasty who received intraoperative PRP injections (treated group) achieved faster improvements in pain and function, with significantly higher Lysholm and IKDC scores at 3 and 6 months, compared to patients with ACLR and concomitant grade III chondral lesions who did not receive PRP injections (control group). The clinical benefits of PRP injections are further supported by superior IKDC, KOOS, and Tegner scores at medium-term follow-up (2 years) (58). Furthermore, a systematic review and meta-analysis by Robinson et al. revealed a 100% return-to-sport rate in patients (n=22) treated with PRP and peripheral blood stem cells as adjuncts for operative management (microfracture, MACI, ACI, OCA, OAT) of knee chondral defects, with outcomes assessed at a mean mid-term follow-up of 5.2 years (20). BMAC is another biologic that has been used to treat a variety of musculoskeletal pathologies. BMAC augmentation has been reported to lead to increased metabolic activity and remodeling, as well as potential accelerated ligamentization in patients undergoing ACLR (59). In a 5-year follow-up, cartilage injuries yielded better clinical outcomes and more durable repair when treated with a hyaluronic acid-based scaffold with activated BMAC when compared to these same injuries treated via microfracture (60). The hyaluronic acid-based scaffold (Hyalofast; Anika Therapeutics Inc.) was used to cover the BMAC-filled cartilage defect and secured to surrounding cartilage with a polydioxanone suture (PDS II 6-0; Ethicon, Johnson and Johnson Inc.) and/or fibrin glue (Tisseal; Baxter Inc.). In a prospective study of patients with concomitant ACL injuries, Gobbi et al. proposed that BMAC combined with a collagen I/III matrix may serve as a viable treatment option for grade IV chondral lesions of the knee (61). Supporting this, a double-blinded randomized controlled trial by Berlinberg et al. demonstrated that patients undergoing ACLR with BMAC augmentation—particularly in the setting of concurrent meniscal or cartilage injuries—achieved superior PROMs compared to those who did not receive BMAC (62).

Both PRP and BMAC remain limited by substantial variability in preparation methods and the absence of standardized reporting, resulting in biologic products with inconsistent cellular and cytokine profiles (63). These inconsistencies—combined with heterogeneous indications, delivery techniques, and outcome measures—limit the comparability of existing studies (64). Overall, the clinical literature for ACL and cartilage applications in athletes is composed primarily of level III–IV evidence, with few high-quality randomized trials, small sample sizes, and short-term follow-up (65,66). Key gaps include insufficient standardization of biologic formulations, limited data on long-term structural or functional benefits (e.g., durable cartilage regeneration or graft incorporation), and a lack of adequately powered, sport-specific outcome studies (67). Consequently, despite growing interest in orthobiologic injections, the current evidence base remains inadequate to support definitive conclusions regarding their efficacy in athletic ACL or cartilage injuries.

The recent development of the arthroscopic-assisted MACI (MACI-Arthro, Vericel Inc.) technique may allow concomitant or staged ACLR to be performed more effectively by limiting patient morbidity while allowing less impact on standard rehabilitation protocols (68). The senior author has performed this technique in several athletes as a staged procedure after ACLR in primary and revision ACLRs. The lesions of the lateral or medial femoral condyle were noted at reconstruction and biopsy obtained. The second stage MACI-Arthro technique was performed after 4–6 weeks through a 2 cm incision along the corresponding region of the knee (Figure 1). Postoperatively, progression of range of motion was not limited with progression to full flexion and weight-bearing as tolerated by 4 weeks.

Figure 1 Intraoperative photos of the second stage MACI-Arthro procedure. (A) Revision quadriceps anterior cruciate ligament reconstruction 6 weeks after procedure; (B) medial femoral condyle lesion; (C,D) arthroscopic preparation of the lesion site; (E) arthroscopic implantation of MACI graft; (F) 2 cm medial based incision. MACI, matrix-induced autologous chondrocyte implantation.

Timing on return to play following ACL and concomitant cartilage injury typically follows the cartilage injury timeline with anticipated return to sports at the previously reported 9–12-month time point following ACI (69). Although 9–12 months are often cited as the standard timeline for return to sport following isolated ACLR, some research indicates that athletes who undergo the isolated OAT procedure typically return to play in approximately 6 months, compared to 9–11 months or longer for those treated with OCA, ACI, or MACI procedures (19,21,70). Studies of cartilage repair alone indicate return to sport can occur between 7 and 18 months postoperatively, with overall return-to-sport rates around 73% in athletic populations (71). For isolated ACLR, return to unrestricted sport is commonly advised at 9–12 months, depending on graft healing, functional recovery, and sport demands (72). However, published data on return to sport after combined ACLR with cartilage repair are sparse. Consequently, it remains unclear whether the addition of cartilage repair delays return to sport relative to standard ACLR. This uncertainty should be acknowledged in counseling patients and highlights the need for prospective studies. Table 1 summarizes and compares these different treatment options.

Conclusions

Cartilage injuries in the setting of ACL pathology can be challenging. Complex knee surgeries require evaluating and managing any related pathologies, either at the same time or in separate stages. Newer techniques are becoming available and may aid the clinician, allowing for a more nuanced approach to these lesions, creating a more durable repair, potentially avoiding later osteoarthritic development. OAT procedures demonstrate higher return-to-sport rates and favorable outcomes for small-to-medium defects, while ACI/MACI and OCA procedures are appropriate for larger defects or revision cases. Microfracture has consistently demonstrated worse long-term PROMs than the other procedures. This review highlights the need for future high-quality comparative trials to optimize care for athletes across the entire continuum of care—from initial injury through return to sport.

Acknowledgments

The authors would like to thank Graylin Jacobs, Senior Clinical Research Coordinator, and Joseph Laurent, Clinical Research Coordinator, for their administrative support of this research project.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Jeremy Burnham, Patrick Cook and Brian Godshaw) for the series “Evaluation and Treatment of ACL Injuries in High Level Athletes: The Continuum of Care” published in Annals of Joint. The article has undergone external peer review.

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-2025-1-75/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-2025-1-75/coif). The series “Evaluation and Treatment of ACL Injuries in High Level Athletes: The Continuum of Care” was commissioned by the editorial office without any funding or sponsorship. D.J. reports receiving consulting fees for contributions as a speaker for Vericel and serving as a member of the Vericel advisory board. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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