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Cartilage Restoration Surgery in India

Advanced surgical techniques to repair and regenerate damaged articular cartilage in knee joints, restoring function and preventing arthritis.

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Overview

Cartilage Restoration Surgery represents cutting-edge treatment for articular cartilage damage in the knee joint. Unlike osteoarthritis that affects the entire joint, focal cartilage defects result from sports injuries, trauma, or osteochondritis dissecans, causing pain and mechanical symptoms in otherwise healthy knees. Left untreated, these defects can progress to widespread arthritis, but timely cartilage restoration can preserve the joint and prevent degeneration. At Arthroscenter, Dr. Gurudeo Kumar offers comprehensive cartilage restoration techniques including MACI (Matrix-Induced Autologous Chondrocyte Implantation), ACI (Autologous Chondrocyte Implantation), osteochondral autograft transfer (OATS/mosaicplasty), and osteochondral allograft transplantation. The choice of technique depends on defect size, location, depth, patient age, activity level, and associated injuries. Dr. Kumar has successfully performed over 300 cartilage restoration procedures with 92% good-to-excellent outcomes at 5-year follow-up. These advanced procedures involve either transplanting the patient's own cartilage cells that have been cultured in a laboratory (ACI/MACI) or transferring healthy cartilage plugs from non-weight-bearing areas to the defect site (OATS). For large defects where autograft is insufficient, donor tissue (allograft) can be used. The goal is biological resurfacing that integrates with native cartilage, providing durable, pain-free function. In Bihar's active agricultural and sports population, cartilage restoration enables young patients to return to demanding physical activities while avoiding or delaying total knee replacement for decades.

Symptoms & Indications

This surgery may be recommended if you experience:

Deep, aching knee pain that worsens with activity and improves with rest

Intermittent knee swelling, especially after prolonged standing or walking

Catching, locking, or giving-way sensations in the knee joint

Clicking or grinding noises (crepitus) during knee movement

Pain localized to a specific area of the knee rather than diffuse

Difficulty with impact activities like running, jumping, or climbing stairs

Inability to fully straighten or bend the knee due to mechanical obstruction

Knee stiffness after periods of inactivity (gelling phenomenon)

Pain that persists despite conservative treatments like physical therapy or injections

History of significant knee trauma, sports injury, or previous surgery

Procedure Details

Duration

2-4 hours depending on defect size, technique used, and concurrent procedures

Anesthesia

Spinal or general anesthesia with optional nerve block for post-operative pain control

Preparation for Surgery

Comprehensive pre-operative assessment includes detailed MRI to map cartilage defect size, location, and depth, X-rays to evaluate bone quality and alignment, and sometimes CT or specialized cartilage imaging. Blood tests and medical optimization are performed. For ACI/MACI procedures, an initial arthroscopy is done 4-6 weeks before the definitive surgery to harvest healthy cartilage cells from a non-weight-bearing area of the knee; these cells are then sent to a specialized laboratory where they are cultured and expanded over several weeks. Patients are counseled extensively about the demanding rehabilitation protocol and need for strict compliance. Physical therapy is started pre-operatively to optimize range of motion and muscle strength. The procedure is performed under spinal or general anesthesia.

Surgical Steps

Arthroscopic examination: The knee is thoroughly inspected arthroscopically to assess cartilage defect characteristics, stability of surrounding cartilage, and any associated pathology like meniscal tears or ligament injuries that need concurrent treatment.

Defect preparation: The damaged cartilage and any unstable edges are carefully debrided back to stable, healthy cartilage margins. The underlying bone (subchondral plate) is evaluated—if intact, cartilage-only procedures can be done; if damaged, bone grafting may be needed.

For OATS/Mosaicplasty: Cylindrical osteochondral plugs (cartilage + underlying bone) are harvested from non-weight-bearing areas of the knee using specialized instruments. These donor plugs typically come from the edges of the femoral condyles or intercondylar notch.

Recipient site preparation: Matching cylindrical holes are created in the cartilage defect area using calibrated instruments. The depth and diameter are precisely matched to the harvested plugs to ensure flush fit with surrounding cartilage.

Plug insertion: The harvested osteochondral plugs are carefully press-fit into the prepared recipient holes in a mosaic pattern to cover the defect. Multiple plugs may be used for larger defects. The plugs are positioned to be flush with the surrounding cartilage surface.

For ACI/MACI: The cultured chondrocytes (for ACI) or chondrocyte-seeded membrane (for MACI) are implanted into the prepared defect. For ACI, a periosteal or collagen membrane is sutured over the defect to contain the cells. For MACI, the cell-seeded matrix is shaped to fit and glued into place.

Concurrent procedures: Any associated injuries are addressed—meniscal repairs, ligament reconstructions, or realignment osteotomies if limb malalignment is present. Addressing all pathology is crucial for cartilage restoration success.

Closure and dressing: After confirming stable graft fixation and smooth articular surface, instruments are removed, portals closed with sutures, and sterile dressing applied. A knee brace is typically applied to protect the graft during early healing.

Recovery Timeline

What to expect during your recovery journey

Week 0-2

Strict Non-Weight-Bearing

Complete non-weight-bearing on operated leg using crutches. Knee brace locked in extension. Gentle passive range of motion exercises and quad sets begin immediately. Ice and elevation to control swelling. Pain management with prescribed medications. Focus is on protecting the cartilage graft while preventing stiffness and muscle atrophy.

Week 2-6

Partial Weight-Bearing

Gradual progression to partial weight-bearing (25-50% body weight) with crutches as tolerated. Active assisted range of motion exercises introduced. Stationary bike without resistance for gentle motion. Continued emphasis on quadriceps activation and patellar mobilization. Swelling management remains important. Brace may be unlocked for controlled motion but locked during ambulation.

Week 6-12

Progressive Weight-Bearing

Transition to full weight-bearing as graft matures. Wean off crutches gradually over 2-4 weeks. Advance to active range of motion exercises and progressive strengthening program. Low-impact exercises like swimming and cycling encouraged. Focus on neuromuscular control and proprioception training. Most patients achieve near-normal gait by week 10-12.

Week 12-24

Strength and Conditioning

Intensive strengthening of quadriceps, hamstrings, and hip muscles. Progress resistance exercises and functional training. May begin light jogging on soft surfaces if strength and graft maturity adequate. Sport-specific drills for athletes. Continued emphasis on proper biomechanics and movement patterns to protect the cartilage repair.

Week 24-36

Return to Impact Activities

Gradual return to higher impact activities and sports based on graft maturity, strength testing, and functional assessment. Running program advanced from jogging to sprinting. Agility drills and sport-specific training intensified. Most recreational athletes return to sports by 6-9 months. Professional athletes may require 9-12 months.

Month 12+

Maintenance and Long-term Care

Unrestricted activity levels for most patients. Continued strength maintenance and cardiovascular fitness. Regular follow-up with MRI or specialized cartilage imaging to assess graft incorporation and maturation. Lifelong attention to weight management, activity modification to avoid excessive impact, and maintenance exercises to preserve joint health and prevent future degeneration.

Tips for Faster Recovery

Strictly adhere to weight-bearing restrictions—premature loading can cause graft failure and procedure failure

Perform prescribed exercises 4-5 times daily even when difficult; consistency is crucial for optimal healing

Use ice therapy 20 minutes every 2-3 hours during the first 2 weeks to minimize swelling and pain

Take pain medications as prescribed to enable participation in physical therapy exercises

Sleep with leg elevated on pillows for first 2 weeks to reduce swelling and promote healing

Attend all physical therapy sessions and communicate openly with your therapist about pain and progress

Maintain optimal nutrition with adequate protein (1.5-2g/kg body weight) to support tissue healing

For ACI/MACI patients, understand that cartilage maturation takes 12-18 months; be patient with gradual progression

Avoid squatting, kneeling, and high-impact activities until cleared by Dr. Kumar, typically not before 9-12 months

Commit to lifelong weight management and regular low-impact exercise to protect your cartilage restoration investment

Frequently Asked Questions

Common questions about this procedure

Q1.What is the difference between cartilage restoration and microfracture surgery?

Both treat cartilage defects but through different mechanisms and are suited for different situations. Microfracture is a marrow stimulation technique where small holes are made in the bone beneath the cartilage defect, causing bleeding and fibrocartilage (scar-like cartilage) formation—it is simpler, single-stage, and less expensive but produces inferior fibrocartilage rather than true hyaline cartilage. Cartilage restoration techniques (MACI/ACI/OATS) transplant actual hyaline cartilage or cells capable of producing it, resulting in more durable, biomechanically superior repair that better resembles native cartilage. Dr. Kumar typically reserves microfracture for small defects (<2cm²) in older or lower-demand patients, while cartilage restoration is preferred for larger defects (>2-4cm²), younger active patients, failed microfracture, or professional athletes requiring optimal long-term outcomes. Studies show cartilage restoration has superior durability—85-90% good results at 10 years versus 60-70% for microfracture. At Arthoscenter, the choice is individualized based on defect size, patient age, activity demands, previous treatments, and willingness to undergo the more demanding rehabilitation required for cartilage restoration.

Q2.Am I a good candidate for cartilage restoration surgery?

Ideal candidates are typically younger patients (15-50 years) with symptomatic focal cartilage defects from trauma or osteochondritis dissecans, rather than diffuse osteoarthritis. Best results occur with: isolated cartilage defects 2-10cm² in size on weight-bearing surfaces (femoral condyles or trochlea), intact surrounding cartilage, stable knee without significant ligament instability, normal or correctable limb alignment, healthy subchondral bone or defects amenable to bone grafting, BMI <35, non-smokers, and patients willing to commit to extensive rehabilitation (often 9-12 months). You are NOT a good candidate if you have widespread osteoarthritis affecting multiple compartments, uncorrected knee instability or malalignment (these must be addressed first), active infection, unrealistic expectations, or inability/unwillingness to comply with strict weight-bearing restrictions and rehabilitation. Age is relative—Dr. Kumar has successfully performed cartilage restoration in motivated 55-year-olds and conversely may decline unmotivated 30-year-olds. In Bihar's agricultural population, farmers who can modify their activities during recovery are often excellent candidates as cartilage restoration enables them to return to demanding physical work. The key is appropriate patient selection through thorough evaluation and honest discussion of commitment required.

Q3.How long does the cartilage restoration graft last?

When successful, cartilage restoration can last 15-20+ years and potentially a lifetime with proper maintenance and favorable conditions. Long-term studies of MACI show 85-90% graft survival at 10 years and 70-80% at 15 years. OATS procedures have similar durability. Success and longevity depend on multiple factors: proper patient selection (appropriate age, defect characteristics), surgical technique quality, graft integration and maturation, post-operative rehabilitation compliance, return to appropriate activity levels (avoiding excessive high-impact activities), maintaining optimal weight and muscle strength, and avoiding new trauma. Failed grafts typically occur due to: premature excessive loading before maturation, inadequate rehabilitation leading to muscle weakness and abnormal loading, return to very high-impact sports (competitive soccer, basketball, long-distance running), significant weight gain, or new trauma. At Arthoscenter, Dr. Kumar emphasizes that cartilage restoration is an investment requiring lifelong attention—patients who maintain ideal weight, perform regular strengthening exercises, modify high-impact activities, and attend periodic follow-ups enjoy excellent long-term outcomes. The goal is to provide 15-20 years of high-quality function, potentially eliminating or significantly delaying the need for total knee replacement. For a 30-year-old, successful cartilage restoration can mean avoiding knee replacement until age 50+, versus early arthritis progression without treatment.

Q4.What is the success rate of cartilage restoration surgery?

Success rates are generally high when appropriate patients are selected and comprehensive rehabilitation is completed. MACI (the most advanced technique) shows 85-95% good-to-excellent outcomes at 2 years, 80-90% at 5 years, and 70-85% at 10 years. OATS/mosaicplasty shows similar results for smaller defects (<2-4cm²). At Arthoscenter, Dr. Kumar's cartilage restoration outcomes match or exceed published literature—92% patient satisfaction at 5-year follow-up. Success is defined as significant pain reduction (typically 70-80% improvement), return to desired activity level, objective evidence of graft incorporation on MRI, and avoiding knee replacement. Factors associated with higher success include: younger age (better outcomes in patients <40 years), smaller defect size (best results for 2-4cm² defects), traumatic etiology rather than degenerative, normal BMI and limb alignment, concurrent correction of associated pathology (meniscus, ligaments, malalignment), meticulous surgical technique with healthy graft tissue, and excellent rehabilitation compliance. Failed cartilage restoration (5-15% of cases) usually results from inadequate graft integration, premature return to impact activities, non-compliance with rehabilitation, or unrecognized/uncorrected contributing factors like malalignment. Even when cartilage restoration doesn't achieve perfect results, it often provides significant symptom improvement and delays the need for knee replacement by many years.

Q5.Can cartilage restoration be done arthroscopically or does it require open surgery?

The approach depends on the specific technique used. OATS/mosaicplasty for small to moderate defects can often be performed entirely arthroscopically or through mini-arthrotomy (small 4-6cm incision), providing the benefits of minimally invasive surgery—less pain, faster recovery, smaller scars. However, MACI/ACI procedures and larger OATS grafts typically require mini-arthrotomy for adequate visualization and precise graft placement, though the incision is much smaller than traditional open surgery. Dr. Kumar uses the least invasive approach that allows optimal execution of the chosen technique—the priority is technical excellence and graft quality rather than incision size. Even when mini-arthrotomy is needed, recovery is substantially faster than traditional open surgery. At Arthoscenter, diagnostic arthroscopy is performed first to fully assess the cartilage defect and associated pathology, then the appropriate restorative technique is executed through either arthroscopic or mini-open approach based on defect characteristics. The critical factors for success are proper graft preparation, precise fit and fixation, and addressing all associated injuries—these determine outcomes more than whether the final approach was fully arthroscopic or mini-open. Most patients are more concerned with functional results than incision size.

Q6.What are the risks and complications of cartilage restoration surgery?

While generally safe in experienced hands, cartilage restoration carries specific risks beyond standard arthroscopy: graft failure is the primary concern (5-15%), where the transplanted cartilage doesn't properly integrate or degenerates, requiring revision surgery or alternative treatment; donor site morbidity from OATS procedures can cause pain or defects at harvest sites (usually minimal and resolves, but 5-10% have persistent symptoms); infection risk is slightly higher than simple arthroscopy due to longer operative time and graft implantation (<2% with proper antibiotic prophylaxis); joint stiffness (arthrofibrosis) can occur if rehabilitation is inadequate (5-10%), sometimes requiring manipulation or arthroscopic release; blood clots (DVT/PE) are rare but possible (<1%) given the extended non-weight-bearing period; nerve or blood vessel injury is uncommon (<1%); persistent pain despite intact graft occurs in 10-15%, sometimes from inadequately treated concurrent pathology; and graft hypertrophy (overgrowth) can occur with ACI/MACI (5-10%), occasionally requiring arthroscopic trimming. Specific to ACI/MACI, there's a risk of periosteal patch failure, delamination, or immune rejection (very rare with autologous cells). Dr. Kumar minimizes complications through meticulous patient selection, addressing all concurrent pathology, using refined surgical techniques, comprehensive rehabilitation protocols, and close monitoring. Most complications can be successfully managed, but realistic expectations are important—not every cartilage restoration achieves perfect results, though significant improvement is typical.

Q7.How is cartilage restoration different from knee replacement?

These are fundamentally different procedures for different conditions. Cartilage restoration repairs focal defects in otherwise healthy knees, preserving your native joint by transplanting or regenerating cartilage in a specific damaged area—it's typically for younger patients with localized cartilage damage from injury. Total knee replacement removes the entire arthritic joint and replaces it with metal and plastic components—it's for older patients with widespread osteoarthritis affecting the whole knee. Cartilage restoration offers biological repair using your own tissue or cells, maintains normal knee anatomy and bone stock, allows return to higher-impact activities, and requires demanding rehabilitation but provides potentially 15-20+ years durability. Knee replacement provides artificial joint replacement, removes bone and changes anatomy, restricts high-impact activities lifelong, has more straightforward rehabilitation, but provides reliable 15-20 year implant longevity before revision may be needed. At Arthoscenter, Dr. Kumar views cartilage restoration as the preferred option for appropriate young patients as it preserves their native joint and delays or prevents eventual need for knee replacement. For a 30-year-old with a focal cartilage defect, successful restoration can provide excellent function for 15-20+ years, postponing knee replacement until age 50 or beyond when outcomes are better and durability expectations align with remaining lifespan. The goal is "the right operation at the right time"—cartilage restoration when young with focal defects, knee replacement when older with widespread arthritis.

Q8.Will I be able to return to sports after cartilage restoration?

Return to sports is definitely possible but depends on sport type, competition level, and graft maturation. Low-impact sports (swimming, cycling, golf, walking) can typically resume by 6-9 months. Moderate-impact sports (recreational tennis, skiing, recreational basketball/soccer) can resume by 9-12 months if strength and graft integrity are confirmed. High-impact competitive sports require careful assessment—some athletes successfully return to competitive soccer, basketball, or running by 12-18 months, while others may need to modify their sport or competition level. The quality and integration of the cartilage restoration, age, position played, and ability to modify technique all factor into decisions. Professional athletes often return successfully but may require 12-18 months and accept higher long-term risks to graft durability. Dr. Kumar guides return-to-sport decisions through objective criteria: MRI evidence of graft incorporation and maturation, achievement of >85% strength symmetry compared to opposite leg, functional testing including single-leg hop and agility assessments, and sport-specific movement patterns without pain or mechanical symptoms. At Arthoscenter, over 80% of athletes return to their pre-injury sport level, though some choose to reduce intensity or impact frequency to protect their restoration long-term. Bihar's cricket players, for instance, often successfully return to competitive play by 10-12 months. The key is graduating return through progressive loading, avoiding premature high-impact activities that risk graft failure.

Q9.Why do some cartilage restorations fail and what can be done if mine fails?

Cartilage restoration failure (incomplete graft integration, degeneration, or persistent symptoms) occurs in 10-15% of cases due to various factors: inadequate patient selection (underlying arthritis or malalignment not recognized), technical factors (poor graft quality, inadequate fixation, incomplete defect coverage), biological factors (poor healing response, inadequate blood supply, immune issues), premature excessive loading before graft maturation, inadequate rehabilitation leading to muscle weakness and abnormal joint loading, unrecognized or inadequately treated concurrent pathology (meniscal tear, ligament instability, malalignment), new trauma or injury to the graft area, or patient factors like obesity, smoking, or poorly controlled diabetes. When failure occurs, treatment depends on the specific problem. If graft degeneration is early and partial, conservative management with activity modification, physical therapy, injections (PRP, hyaluronic acid), and weight optimization may suffice. If there's complete graft failure with significant symptoms, options include repeat cartilage restoration (success rates 70-80%, lower than primary procedures), conversion to alternative technique (e.g., allograft if autograft failed, MACI if OATS failed), realignment osteotomy if malalignment is contributing, or ultimate salvage with unicompartmental or total knee replacement. Dr. Kumar thoroughly evaluates failed cartilage restorations to identify correctable factors before recommending revision. At Arthoscenter, the revision approach addresses previous shortcomings—if malalignment was missed initially, corrective osteotomy is performed concurrently; if rehabilitation was inadequate, more intensive protocols are implemented. While failure is disappointing, most patients still achieve some benefit and often avoid knee replacement for additional years even when restoration doesn't fully succeed.

Q10.How much does cartilage restoration surgery cost and is it covered by insurance?

Cartilage restoration costs vary significantly based on technique used and are generally higher than simpler procedures due to complexity and advanced technology. At Arthoscenter in Patna, OATS/mosaicplasty typically costs ₹1,50,000-2,50,000 depending on defect size and number of plugs. MACI/ACI procedures are more expensive (₹3,00,000-5,00,000) due to laboratory costs for cell culture and specialized graft materials. These fees include surgeon charges, hospital stay (typically 1-3 days), anesthesia, implants/graft materials, and initial post-operative care. Additional costs include pre-operative imaging (MRI ₹8,000-12,000), post-operative physical therapy (₹30,000-60,000 over 6-9 months), and follow-up imaging to assess graft integration. Insurance coverage varies widely—government schemes (PMJAY, state health insurance) typically don't cover advanced cartilage restoration as it's considered specialized/elective. Some private insurance policies cover it under "medically necessary joint-preserving procedures," particularly for traumatic defects, but pre-authorization is required and coverage limits apply. Many patients find cartilage restoration more cost-effective long-term than repeated conservative treatments that ultimately fail, leading to early knee replacement. Dr. Kumar provides detailed cost estimates during consultation and works with patients to optimize timing and financing. For young patients, investing in cartilage restoration that preserves the native joint for 15-20 years is often worthwhile compared to knee replacement which has limited durability and may require revision surgery. Arthoscenter offers flexible payment options to make these life-changing procedures accessible to Bihar's population.

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