Editorial Commentary: Cartilage Restoration Typically Requires Joint Optimization as Well as Local Cartilage Resurfacing to Achieve Best Outcomes: The 30,000 Foot View

Successful resurfacing of the articular surface often requires surgical optimization of the joint environment, in addition to the cartilage restoration procedure. This is the 30,000-foot view theory, where surgical planning concentrates on changing the forces in the joint that may have led to the cartilage lesion by performing essential procedures, such as osteotomies; scar tissue releases and/or ligament lengthening; joint stabilization; or meniscus replacement. With this view, which cartilage procedure should I perform becomes a secondary question. This approach involves looking at the environment of the joint as a whole and can lead to improved outcomes. Recent research shows that treatment of bipolar cartilage lesions results in inferior outcomes compared with unipolar lesions. But experience shows that results may be improved when treating bipolar lesions by using a structural graft on one surface, such as an osteochondral allograft, and a cellular or particulate graft on the opposite surface rather than using two nonstructural grafts. Before the transplantation, the surgeon corrects the joint forces as a whole. Over the past 10 years, I have consistently seen the benefits of cartilage restoration procedures using techniques anywhere from autologous cellular grafts to large, structural osteochondral allografts. Finally, the 30,000 foot view also includes addressing modifiable patient factors, such as weight loss. For the most part, the results have been promising, achieving significantly improved patient response rates, defined as a minimal clinically important difference (or MCID).