Management of the patient with symptomatic full-thickness chondral or osteochondral defects of the knee presents a challenging problem for the orthopedic surgeon. The natural history of untreated lesions demonstrates progressive degenerative changes and deterioration in functional outcome scores. Medical management, osteotomies, lavage, and debridement procedures temporize symptoms and slow progression. Cartilage restoration procedures such as microfracture and cell-based therapies have shown promise, but there are concerns of the long-term durability of these procedures in the active population. Mosaicplasty allows for restoration of articular defects with hyaline cartilage, and has shown excellent durability. Articular defect should measure between 1 to 4 cm(2) in diameter and extend 10 mm into subchondral bone. Mosaicplasty can be challenging when attempted arthroscopically, and the threshold to convert to an open procedure should be low when adequate visualization is not achieved. Use of variable graft size maximizes defect fill with hyaline cartilage. Avoidance of graft prominence >1 mm and attention to the contour of the joint optimizes the recreation of articular surface. This is achieved by placing central grafts in a large defect slightly prouder to obtain a convex shape to the articular surface. With attention to the nuances of the surgical technique, mosaicplasty offers an excellent option for cartilage restoration in the young active patient.
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