Are outcomes of articular cartilage lesions in athletes better after microfracture or ACI?

September 23, 2022

4 min read


Brittberg M, et al. Am J Sports Med. 2018;doi:10.1177/0363546518756976.

Bugbee reports being a consultant for JRF Ortho and Arthrex. Mallett and Sarris report no relevant financial disclosures.

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Click here to read the cover story, “New techniques emerge amid the evolution of cartilage repair.”

Better function, improvement with cartilage restoration

Articular cartilage injuries in athletes require careful consideration when establishing a treatment plan, as an athlete’s high activity level and training schedule require optimization of the surgical treatment and intervention timing.

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A variety of surgical procedures exist to address these injuries, including restoration of articular cartilage injuries with autologous chondrocyte implantation (ACI), osteochondral allograft transplantation (OCA) and reparative marrow-stimulation techniques, such as microfracture.

Daniel B. Sarris
Daniel B. Sarris
Katherine E. Mallett
Katherine E. Mallett

ACI has proven to be a durable option for cartilage restoration in athletes who are able to schedule adequate recovery time. Five-year data from a randomized controlled trial comparing ACI to microfracture revealed patients who underwent ACI reported significantly better improvements in pain, function and activities of daily living compared with patients who underwent microfracture. Twenty-year outcomes have demonstrated excellent long-term durability following cartilage restoration with ACI. These results suggest ACI provides superior results to microfracture at 5 years with durable long-term benefits. One potential downside of ACI is the two-stage surgery and longer recovery time. While average ACI rehabilitation timelines have decreased to 11 months, this recovery period may not be appropriate for late-career athletes or those with contracts up for renewal. Return to sport is also significantly better when cartilage repair is performed within 1 year of injury, a narrow timeline which may limit ACI feasibility in some.

In athletes whose schedule is not amenable to ACI, OCA cartilage restoration has also shown excellent results, with 88% returning to sport and 79% fully returning to pre-injury level. Like ACI, return to sport outcomes are better in patients who undergo OCA within 1 year of injury. Patients who underwent osteochondral autograft transfer (OATs) procedures also had higher activity levels than patients who underwent microfracture. Compared with ACI, athletes return to sport at an average of 9.6 months following OCA; therefore, OCA may be preferable to ACI in athletes with tighter recovery timelines.

In-season athletes or those unable to take 9 to 11 months off for a cartilage restoration procedure may benefit from a simple arthroscopic debridement with consideration of a restorative procedure later. While microfracture has been promoted as a single-stage treatment with limited down-time, long-term results suggest athletes have better function and more durable improvements with cartilage restoration procedures such as ACI and OCA. Overall, both ACI and OCA have superior durability and return to sport rates in athletes. Therefore we recommend selecting one of these two options for cartilage restoration, tailoring timing to each athlete’s unique career timeline and goals.

Daniel B. Sarris, MD, PhD, an orthopedic surgeon, professor of orthopedics and professor of regenerative medicine, and Katherine E. Mallett, MD, an orthopedic surgery resident, are at the Mayo Clinic in Rochester, Minnesota.

Multiple factors in decision-making

The question of which cartilage repair techniques provide the best outcome in athletes is difficult to answer. Evolving techniques, the myriad of clinical situations, such as associated pathology (other tissue damage, including meniscus or ligament pathology), and the “type” of athlete (recreational, school age, collegiate, professional, senior) all play a role in decision. -making, clinical outcome and return to sport. Athletes are a unique group of patients. They are highly motivated and expect not only a successful result, but rapid recovery, timely return to sport and long-term durability from a cartilage repair procedure.

William Bugbee
William Bugbee

Furthermore, the practice of cartilage repair has progressed rapidly in the last decade, with many established techniques, such as microfracture, ACI, OATs and OCA, evolving into new iterations, and many newer devices and procedures introduced into clinical practice.

I have used fresh OCA as my treatment of choice for cartilage repair for more than 25 years, including in athletes. I do not treat many professionals. More commonly, I treat high school, college and recreational athletes, which is probably typical of the practice of most cartilage surgeons. For me, OCAs are well suited to the desire for significant relief of pain, functional improvement, rapid recovery, return to sport and long-term durability. Our results with OCA in the athletic population have demonstrated 75% to 80% return to sport, 90% 10-year survivorship and 90% patient satisfaction. Similar results have been described by others, as well. Thus, I have been reluctant to explore other techniques. However, it is evident from published studies of cartilage repair in athletes that other techniques, such as OATs and ACI, can achieve similar outcomes to OCA. Several well-done systematic reviews and meta-analyses have been performed comparing return to sport rates following cartilage repair procedures. These studies generally slightly favor osteochondral procedures, such as OATs and OCA, over ACI and microfracture, although it may be too soon to tell if newer versions of ACI (MACI) and “augmented microfracture” will demonstrate better results.

The question of which technique provides the best outcome in athletes probably depends on who you ask. Ultimately, it is probably less about the technique and more about the characteristics of the athlete being treated.

William Bugbee, MD, is a clinical professor in the department of orthopedic surgery, the fellowship director of joint reconstruction and replacement, chief of the Cartilage Restoration Service and Lower Extremity Joint Reconstruction and clinical director of the Shiley Center for Orthopedic Research and Education at Scripps Clinic in La Jolla, California.

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