The Utility of Biologics, Osteotomy, and Cartilage Restoration in the Knee

Rachel M. Frank, MD; Eric J. Cotter, BS; Eric J. Strauss, MD; Andreas H. Gomoll, MD; Brian J. Cole, MD, MBA


J Am Acad Orthop Surg. 2018;26(1):e11-e25. 

In This Article

Abstract and Introduction


The management of complex cartilage and meniscal pathology in young, athletic patients is extremely challenging. Joint preservation surgery is most difficult in patients with concomitant knee pathologies, including cartilage defects, meniscal deficiency, malalignment, and/or ligamentous insufficiency. Clinical decision making for these patients is further complicated by articular cartilage lesions, which often are incidental findings; therefore, treatment decisions must be based on the confirmed contribution of articular cartilage lesions to symptomatology. Surgical management of any of the aforementioned knee pathologies that is performed in isolation typically results in acceptable patient outcomes; however, concomitant procedures for the management of concomitant knee pathologies often are essential to the success of any single procedure. The use of biologic therapy as an alternative to or to augment more conventional surgical management has increased in popularity in the past decade, and indications for biologic therapy continue to evolve. Orthopaedic surgeons should understand knee joint preservation techniques, including biologic and reconstructive approaches in young, high-demand patients.


The management of complex knee pathology in young, athletic patients is challenging. Various joint preservation strategies have been introduced in the past several decades, with biologic therapy recently being incorporated into the treatment algorithm for complex knee pathology. Although successful outcomes can be achieved in patients with complex knee pathology who undergo nonsurgical treatment, most patients require surgical treatment to preserve and/or restore joint biomechanics and function. The ability to perform complex and concomitant knee joint preservation procedures in these patients is increasing given recent advances in surgical techniques, instrumentation, and imaging modalities, as well as the availability of off-the-shelf implants and biologic agents.

One of the main challenges in the treatment of patients with multiple knee pathologies is determining which pathology is symptomatic, which pathology must be managed (even if asymptomatic), and which pathology can remain unmanaged. Although every effort should be made for joint preservation in these patients, disadvantages, including inherent surgical risks and unique rehabilitation protocols, are associated with each joint preservation technique; therefore, care must be taken to avoid overmanagement of asymptomatic lesions. Surgical decision making is challenging in patients with tibiofemoral malalignment, ligamentous instability, and chondral/meniscal damage; therefore, all joint preservation options must be considered.[1] Historically, corrective procedures for the management of any of the aforementioned knee pathologies that are performed in isolation result in adequate patient outcomes; however, concomitant procedures for the management of concomitant knee pathologies often are essential to the success of any single procedure. Some patients may have limited access to timely care, especially with respect to allograft availability, and orthopaedic surgeons must account for potential disparities in healthcare access with regard to surgical decision making.

The last option for patients with debilitating and advanced joint line pain is joint arthroplasty, such as unicompartmental knee arthroplasty or total knee arthroplasty (TKA), both of which result in consistent pain relief and restoration of function in appropriately selected patients. Although knee arthroplasty is effective, such procedures are not ideal for younger and/or active patients, especially those with moderate- to high-demand activity levels.[1] Younger age has been reported to be a negative prognostic factor for clinical outcomes and revision surgery in patients who undergo knee arthroplasty,[2–4] which highlights the importance of knee joint preservation rather than knee replacement in these patients. Orthopaedic surgeons must determine the chronologic and physiologic age of patients in whom joint preservation procedures are considered. For example, older patients who historically may have been considered candidates for joint arthroplasty only may be excellent candidates for joint preservation surgery, depending on their weight, overall health, activity level, and surrounding joint anatomy. Conversely, younger patients who historically would never be considered candidates for joint arthroplasty because they are too young may not be good candidates for joint preservation based on their weight, overall health, postoperative expectations, and overall joint health. An understanding of the potential activity restrictions after joint preservation procedures is particularly important for younger patients, who are more likely than older patients to place higher demands on their joints postoperatively.