Treatment of Osteochondral Lesions of the Medial Femoral Condyle

Initial Assessment and Patient Selection

The American Academy of Orthopaedic Surgeons recommends that patients with osteochondral lesions of the medial femoral condyle should meet specific criteria for joint-preserving surgery, including age between skeletal maturity and 50 years, minimal or no osteoarthritis, and no inflammatory arthritis 1, 2
Patients should have full-thickness defects, but no bipolar lesions, and should be able to perform rigorous postoperative physical therapy 1, 2
All patients must complete and document at least 6 weeks of supervised physical therapy with objective documentation of compliance and failure to achieve adequate symptom relief before surgical intervention 2

For small lesions (<2 cm²), the first-line treatment is microfracture, which creates small holes in subchondral bone to release marrow cells and growth factors, resulting in a 93% fill rate with good-quality cartilage macroscopically at second-look arthroscopy 1
For medium lesions (2-6 cm²), the first-line treatment is osteochondral allograft transplantation, which has graft survival rates of 94% at 5 years and 84% at 10 years, and return to sport rates as high as 88% with an average time of 9.6 months 1, 2
For large lesions (6-8 cm²), osteochondral allograft transplantation is preferred over autograft due to donor site limitations with autograft 1, 2
For very large lesions (>8 cm²), total knee arthroplasty may be considered, particularly for patients approaching the upper age limit or those with early osteoarthritic changes 1

For stable lesions predicted to fail nonsurgical treatment, anterograde versus retrograde drilling may be considered, although the optimal approach is unclear 3, 4, 5
For unstable lesions, fixation options include minifragment screws, variable pitch screws, or bioabsorbable pins, although the optimal fixation method is unclear 3, 4, 5
For non-salvageable OCD lesions, fresh osteochondral allograft or autologous chondrocyte implantation may be considered 2, 3, 4, 5

Following osteochondral allograft transplantation, immediate passive range of motion, heel-touch weight-bearing at 6 weeks, and return to sport-specific activity after 8 months may be recommended 2

Osteochondral allograft should not be proceeded with if bipolar lesions are present, and meniscal status must be addressed before or concurrent with osteochondral allograft 2
Stem cell therapy is not currently recommended due to heterogeneity and lack of standardization 1