Knee injuries are among the most common and debilitating injuries in athletes and active individuals. Two of the most serious issues that can occur simultaneously are an anterior cruciate ligament (ACL) tear and cartilage damage. While each injury on its own can significantly affect knee stability and function, the combination of the two presents unique challenges. Fortunately, advances in orthopedic surgery now allow for combined surgical solutions that address both injuries in a single, comprehensive approach, helping patients regain stability, reduce pain, and return to an active lifestyle.

Understanding ACL Tears and Cartilage Damage

The ACL is one of the major ligaments in the knee, responsible for maintaining stability during rotational movements and preventing the tibia from sliding forward relative to the femur. ACL tears commonly occur due to sudden pivoting, twisting, or high-impact sports activities. Symptoms often include a popping sensation at the time of injury, swelling, instability, and difficulty with sudden changes in direction.

Cartilage damage, particularly to the articular cartilage, is another common consequence of knee trauma. Cartilage acts as a smooth, shock-absorbing surface in the joint. When damaged, it can lead to pain, swelling, catching sensations, and, over time, early-onset osteoarthritis. Cartilage injuries often accompany ACL tears, especially in high-impact or twisting injuries.

Challenges of Combined Injuries

Treating an ACL tear is complex, and cartilage injuries add another layer of difficulty:

• Timing of Surgery: If only the ACL is reconstructed without addressing cartilage damage, the knee may remain painful and unstable, slowing rehabilitation.
• Joint Health: Cartilage damage, if left untreated, can worsen over time, leading to degenerative changes even after ACL reconstruction.
• Recovery Complexity: Combining procedures requires careful planning to ensure proper healing of both ligament and cartilage tissues while minimizing the risk of stiffness or re-injury.

Combined Surgical Solutions

Orthopedic surgeons have developed strategies to address both ACL tears and cartilage damage simultaneously. The primary goals of combined surgery are restoring knee stability, repairing or regenerating cartilage, and preserving long-term joint health. Common combined surgical approaches include:

1. ACL Reconstruction + Microfracture

   Microfracture is a procedure used to repair small cartilage defects. During surgery, tiny holes are created in the bone beneath the damaged cartilage, stimulating the growth of new fibrocartilage. When performed alongside ACL reconstruction:

   • The ACL provides stability for the knee.
   • The microfracture encourages cartilage repair in a controlled environment.
   • Early controlled motion is initiated to promote healing.

   This approach is generally recommended for smaller cartilage defects (less than 2 cm²) and younger patients with good healing potential.

2. ACL Reconstruction + Autologous Chondrocyte Implantation (ACI)

   ACI is a more advanced technique for larger cartilage defects. It involves:

   • Harvesting a small sample of the patient’s healthy cartilage.
   • Culturing chondrocytes in a lab to multiply them.
   • Re-implanting these cells into the damaged area under a protective membrane.

   Combining ACI with ACL reconstruction provides both ligament stability and cartilage regeneration, especially for larger or more complex lesions. This procedure is particularly beneficial for active individuals who want to return to high-demand sports.

3. ACL Reconstruction + Osteochondral Autograft or Allograft Transplantation

   In cases where cartilage damage is severe and involves the underlying bone, surgeons may use osteochondral grafts:

   • Autograft: Cartilage and bone are taken from a non-weight-bearing part of the patient’s knee.
   • Allograft: Donor tissue is used for larger defects.

   The graft restores the natural structure of the joint, while ACL reconstruction stabilizes the knee, allowing a more predictable recovery and improved long-term joint health.

Benefits of Combined Surgery

Combining ACL reconstruction with cartilage repair provides several advantages:

• Single Recovery Period: Patients undergo anesthesia and rehabilitation only once, reducing overall downtime
• Improved Knee Function: Addressing both injuries simultaneously improves stability, reduces pain, and restores knee mechanics.
• Joint Preservation: Early cartilage repair helps prevent degenerative changes, delaying or even preventing osteoarthritis.
• Higher Return-to-Activity Rates: Athletes and active individuals have a better chance of returning to sports when both injuries are treated at the same time.

Post-Surgery Rehabilitation

Rehabilitation after combined surgery is carefully structured to protect both the reconstructed ACL and repaired cartilage:

• Phase 1 (0–6 weeks): Focus on reducing swelling, regaining gentle range of motion, and protecting the surgical repair. Partial weight-bearing with crutches is often recommended.
• Phase 2 (6–12 weeks): Gradual increase in weight-bearing, continued range-of-motion exercises, and early strengthening of the quadriceps, hamstrings, and hip muscles.
• Phase 3 (12–20 weeks): Advanced strengthening, proprioception, and balance exercises. Controlled sports-specific drills may begin depending on the patient’s progress.
• Phase 4 (5–9 months): Return-to-sport activities, with emphasis on agility, power, and endurance. Full return to high-impact sports is usually allowed only after 9–12 months, depending on healing and surgeon recommendations.

Compliance with rehabilitation is crucial. Overloading the knee too early can compromise cartilage healing, while underuse can lead to stiffness and muscle weakness.

Factors Influencing Outcomes

Several factors affect the success of combined ACL and cartilage surgery:

• Age and Overall Health: Younger patients generally have better healing potential.
• Size and Location of Cartilage Damage: Larger or weight-bearing defects may require more advanced procedures.
• Surgical Technique: Skilled surgeons using modern arthroscopic techniques improve outcomes.
• Patient Compliance: Adhering to rehabilitation protocols, avoiding premature return to activity, and maintaining a healthy lifestyle are critical for optimal results.

Conclusion

An ACL tear combined with cartilage damage is a complex injury that requires a comprehensive treatment approach. Advances in orthopedic surgery now allow these injuries to be treated simultaneously, providing better knee stability, pain relief, and long-term joint preservation. Whether through microfracture, autologous chondrocyte implantation, or osteochondral grafts, combined surgical solutions offer patients a realistic pathway to returning to their active lifestyle. Coupled with a carefully monitored rehabilitation program, these procedures can restore knee function, reduce the risk of future degeneration, and help individuals regain confidence in their movement.