What is the initial treatment for an osteochondral lesion?

Initial Treatment for Osteochondral Lesions

For osteochondral lesions, initial treatment depends critically on lesion size: lesions <2 cm should be treated with microfracture as first-line therapy, while lesions 2-6 cm require osteochondral allograft transplantation. 1

Treatment Algorithm Based on Lesion Size

Small Lesions (<2 cm)

• Microfracture is the first-line surgical treatment for small osteochondral defects in appropriately selected patients 1
• Mosaicplasty (autologous osteochondral graft) serves as an effective second-line option when microfracture fails or is not suitable 1
• Autograft transplantation provides immediate hyaline cartilage restoration in a single procedure with superior mechanical properties compared to fibrocartilage 2
• The main limitation is donor site morbidity, which can be minimized by careful harvest technique from the lateral trochlea 1, 3

Medium Lesions (2-6 cm)

• Osteochondral allograft transplantation is the first-line treatment for medium-sized defects 1
• This approach eliminates donor site morbidity while providing immediate mechanical joint surface restoration 1
• Fresh allografts should be used within 28 days to maintain chondrocyte viability 2
• Microfracture can be considered as second-line treatment for lesions closer to 2 cm 1

Large Lesions (6-8 cm)

• Osteochondral allograft remains first-line treatment due to donor site limitations with autograft 1
• Osteochondral transplantation serves as second-line option 1

Very Large Lesions (>8 cm)

• Total hip arthroplasty should be considered when lesions exceed 8 cm 1

Patient Selection Criteria

These treatment algorithms apply only to carefully selected patients who meet ALL of the following criteria: 1

• Age from skeletal maturity to 50 years
• Minimal or no osteoarthritis (Tönnis grade ≤1) on radiography
• No inflammatory arthritis present
• One or more full-thickness defects without bipolar lesions (both surfaces involved)
• Well-contained lesion architecture
• Ability to perform rigorous postoperative physical therapy regimen

Conservative Management Considerations

• Conservative treatment with rest, immobilization, and NSAIDs is only successful in pediatric patients with isolated chondral injuries 4
• In adults, conservative measures should only be considered as adjuvant to surgical treatment, not as primary therapy 4
• Spontaneous healing is possible with bone bruise in subchondral bone across all age groups, but isolated chondral injuries in adults do not heal conservatively 4
• More than one-third of cases fail conservative treatment, necessitating surgical intervention 5

Location-Specific Modifications

Acetabular Lesions

• For acetabular defects <2 cm: microfracture is recommended 1
• For acetabular defects 2-6 cm: microfracture remains first-line, with suture repair for delaminated chondral flaps with viable cartilage 1
• For acetabular defects >6 cm: consider conversion to total hip arthroplasty 1

Critical Pitfalls to Avoid

• Do not use arthroscopic surgery for degenerative subchondral lesions, as it provides no benefit over conservative management 3
• Avoid delayed recognition of osteochondral injuries, as unrecognized lesions lead to progressive demarcation and joint degeneration 4, 6
• Do not attempt allograft transplantation in patients with bipolar lesions, as this is a contraindication 7
• Ensure adequate meniscal tissue is present or plan concurrent meniscal allograft if deficient 7

Mandatory Prerequisites Before Surgery

• Complete at least 6 weeks of supervised, in-person physical therapy with documented compliance and failure 7
• Obtain definitive imaging (MRI or CT) to confirm the opposing articular surface is free of significant disease 7, 4
• Verify knee stability with negative Lachman, anterior/posterior drawer, and pivot shift tests 7