Comprehensive Patellofemoral Cartilage Restoration: Trochlear OCA, Patellar MACI, and TTO.

Background: Bipolar patellofemoral chondral defects in young, active patients present a challenging clinical problem due to persistent pain, functional limitation, and complex biomechanical contributors. While cartilage restoration procedures such as matrix-induced autologous chondrocyte implantation (MACI), osteochondral allograft (OCA) transplantation, and tibial tubercle osteotomy (TTO) have demonstrated favorable outcomes individually, combined restoration strategies addressing both focal cartilage loss and patellofemoral mechanics are less well described. We performed a single-stage, triple-modality comprehensive patellofemoral cartilage restoration, including a trochlear OCA, a patellar MACI, and TTO to offload and realign the patellofemoral joint. Indications: The described combined procedure was indicated in a healthy, active 37-year-old female with bilateral symptomatic full-thickness bipolar patellofemoral chondral defects refractory to extensive nonoperative treatment. Imaging demonstrated bipolar patellofemoral cartilage lesions consisting of a full-thickness trochlear osteochondral defect and a full-thickness patellar chondral defect with associated lateral patellar subluxation but without instability, abnormal patellar height, or elevated tibial tubercle-trochlear groove distance. Technique Description: The patellar defect was prepared with stable vertical walls for MACI implantation while preserving the subchondral bone. The trochlear lesion was sized, reamed, and reconstructed using a size-matched fresh OCA prepared to achieve flush articular congruity. A TTO with approximately 1 cm medialization and anteriorization was performed to reduce patellofemoral contact pressures and protect the cartilage restoration constructs. The MACI graft was then trimmed to match the patellar defect and secured with fibrin glue. Standard layered closure and structured rehabilitation with protected weightbearing and early motion were utilized postoperatively. Results: At 5-month follow-up, the patient demonstrated improved pain, full patellar mobility, and range of motion from 0° to 135°, with return to baseline activities. Radiographs demonstrated healed tibial tubercle osteotomies and well-incorporated OCAs bilaterally. These findings are consistent with the existing literature, which demonstrates significant improvements in patient-reported outcomes after combined cartilage restoration and patellofemoral unloading procedures, including high satisfaction and return-to-sport rates after MACI, OCA, and TTO procedures. Discussion/Conclusion: This case demonstrates a comprehensive approach to bipolar patellofemoral cartilage disease that simultaneously addresses focal cartilage pathology and the underlying biomechanical environment. The literature supports the use of MACI for isolated chondral defects, OCA for osteochondral lesions with subchondral involvement, and TTO to improve graft protection and patellofemoral mechanics. Hybrid restoration strategies combining these techniques may provide favorable functional outcomes and joint preservation in appropriately selected patients. Further prospective studies are needed to clarify long-term survivorship, optimal graft selection, and return-to-sport outcomes after combined OCA/MACI reconstruction procedures. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.