Treatment options for concomitant cartilage damage in the anterior cruciate ligament (ACL)-injured athlete

Acute anterior cruciate ligament (ACL) tears are common in athletes and frequently occur with concomitant cartilage injuries, which can significantly impact knee function and return-to-sport outcomes. Professional athletes have a higher prevalence of ACL injuries with associated chondral lesions, compared with nonprofessional athletes. Management of ACL injuries with concurrent cartilage damage requires careful consideration of operative versus nonoperative treatment, timing, surgical technique, and the extent of cartilage involvement. The objective of this study is to review and compare treatment strategies for concomitant chondral lesions in ACL-injured athletes, with emphasis on return-to-sport outcomes, functional results, and long-term durability. Nonoperative measures include nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and activity modification. Surgical management strategies are tailored to high-demand athletes and have demonstrated improved outcomes with return-to-sport rates consistent with positive functional recovery. Arthroscopic debridement offers short-term symptom relief, while microfracture provides fibrocartilage repair but demonstrates lower long-term durability and return-to-sport rates. Osteochondral autograft transplantation (OAT) and osteochondral allograft transplantation (OCA) techniques restore hyaline cartilage and show superior functional outcomes and higher return-to-sport rates, particularly for larger defects. Cell-based therapies, including autologous chondrocyte implantation (ACI) and matrix-induced ACI (MACI), combined with ACL reconstruction (ACLR), have been associated with improved clinical results for symptomatic chondral lesions, with comparable outcomes to isolated procedures. Cell-based therapies limit damage to the subchondral bone plate but do require maturation of the repair tissue to be effective. Procedures such as high tibial or distal femoral osteotomy (DFO) correct malalignment and can improve graft and cartilage durability. Biologic augmentation with platelet-rich plasma (PRP) or bone marrow aspirate concentrate (BMAC) represents an emerging strategy to enhance cartilage healing and patient-reported outcomes (PROMs). Of these treatment modalities, OAT and OCA procedures demonstrated the fastest return-to-sport rates when compared with other surgical options, including debridement and microfracture. Long-term durability was highest in patients treated with OAT and ACI. Overall, treatment of chondral lesions in ACL-injured athletes requires individualized strategies that balance functional recovery, durability of repair, and timing of return to play, with evolving techniques that demonstrate trends toward improved long-term outcomes and joint preservation.