Knee Cartilage Defect - I was given 5 different surgery options. (Story)

I was only 22 years old when I tore my meniscus playing football and I needed to have a part of it removed surgically. The surgery was (probably) a success and after a 6-month recovery process, I was back to playing sports again. I was more cautious this time around, and I took physiotherapy very seriously. But unfortunately, 2 and a half years later, I was struck by another knee injury. This time, it was a cartilage defect right above where the meniscus was removed. It looked something like this:

I knew that this was a more serious injury. If I had not done everything I could to heal it, I might never have been able to play sports again. I started doing my research immediately, and I went to see 8 different surgeons in the UK, Switzerland, and Germany to get their opinions on what the best treatment options were. To my surprise, I was given 6 different options to treat my cartilage defect:

1. Microfractures: involves drilling small holes in the bone beneath the cartilage to promote the growth of new cartilage-like tissue.

2. Debridement: Cleaning up the cartilage defect and removing damaged tissue.

3. Osteochondral Autograft Transplantation (OATS): The surgeon takes cartilage and bone from a different area of the knee and transplants it into the defect.

4. Autologous Chondrocyte Implantation (ACI and MACI): Involves taking cartilage cells from the knee, growing them in a laboratory, and then transplanting them back into the knee.

5. Minced Cartilage Technique: This procedure involves harvesting cartilage fragments from the defect, mincing and mixing them with PRP into a glue-like gel, and pasting that gel into the defect.

6. Do no surgery and do physiotherapy.

The opinions of the 8 doctors were something like the following bar chart. The y-axis denotes the number of surgeons which recommended a particular surgical procedure.

I was overwhelmed by the options and the different opinions of the surgeons.

How is one supposed to decide which surgery to choose based on this? How should one know which doctor to trust? I wanted to make the best decision.

After spending a lot of time reading the scientific literature and talking to the doctors, I came to the following conclusions about the surgery types:

1. Microfractures: the major disadvantage is that the new cartilage-like tissue is not as strong as the original and can therefore break down eventually. There are studies which show that the microfractures procedure often has worse results than e.g. OATS (https://pubmed.ncbi.nlm.nih.gov/34304280/).

2. Debridement: This procedure does not really solve the underlying problem which is a hole in the cartilage.

3. OATs: This procedure is performed often and with good results. It may cause some problems at the donor site (the place from where they harvest the transplanted cartilage) but apparently this is rare and the donor site is non-weight bearing.

4. Autologous Chondrocyte Implantation (ACI): The major downside is that ACI and MACI are mostly done as a two-stage procedure which makes the rehabilitation process complicated. I heard that a one-stage version may exist, but this is not standard (https://medisearch.io/are-there-versions-of-maci-with-only-one-surgical-procedure). Also, many surgeons told me that they don't do ACI/MACI anymore because the procedure does not make financial sense for the healthcare provider, even though it has good results.

5. Minced Cartilage Technique: This is a relatively new technique with good results (https://pubmed.ncbi.nlm.nih.gov/32715735/). Most doctors had very positive opinions about it. A potential risk with MCT is the relatively little clinical data, even though the data is good.

6. No surgery: Some surgeons have the opinion that every surgery increases the chances of osteoarthritis. One doctor told me that I already had such a high chance of getting osteoarthritis (after one meniscectomy and another cartilage injury) that I should definitely not get any more surgery because not only will I not be able to play sport, but I may even struggle to walk in a couple of years. I think (and hope) he was wrong. All the other surgeons told me that my chances are good, and that it was a very bad idea to not have surgery in my case.

In total, I spent about ~300 hours reading papers and talking to doctors to decide on which surgery to have. In the end, it was either OATS or MCT. I chose MCT because I managed to get hold of Dr. Salzmann who is very experienced with MCT (he is the first author on the paper above https://pubmed.ncbi.nlm.nih.gov/32715735/) and the surgeons which suggested OATS had a bit less experience with it.

The surgery went well, I had nearly no pain after the surgery (much less than after the meniscectomy 3 years ago), and I am very satisfied with the results. The knee isn't 100% yet, but I think it will be in a couple of months.

One information that I still don't have, is the underlying cause for my injuries. Most doctors told me that I was simply unlucky. I was a bit surprised by how little attention they gave in trying to help me figure out the underlying cause, but maybe that's how the whole system is set up... I also think that I could improve in my physiotherapy as it is a bit random. If anyone knows of some physio or online resources which could help me find out the underlying cause of my injuries, or simply with my rehabilitation, I would be very grateful! Also, feel free to ask me any questions if there's anything that I can do to help you.