Cartilage Transplantation in Turkey

Articular cartilage is the smooth white tissue that covers the ends of the bones inside a joint and lets them glide against each other with very little friction. When part of it is damaged, the joint surface can lose its smoothness and movement becomes painful. Because this cartilage has no adequate blood supply and does not heal well on its own, a defect can remain a source of pain for years and may progress over time to osteoarthritis.

People who search for "cartilage transplantation in Turkey" are usually looking for treatment of a focal cartilage defect in the knee. But the phrase does not describe a single operation. It covers several techniques that work in different ways: some stimulate the bone to form repair tissue, some implant cartilage cells grown in a laboratory, and some transfer a piece of cartilage and bone from a healthy area or from a donor.

These procedures are usually considered for younger patients and younger adults with a single focal defect. Older patients, or those with several defects in the same joint, are less likely to benefit. A cartilage lesion seen on an MRI scan does not, by itself, mean that surgery is needed. This guide explains the techniques and how they differ, what the studies show and where their limits lie, the risks and recovery, how the cost is estimated in Turkey, and what to ask before you travel. We focus on the knee, with short sections on the ankle and hip, where the evidence is weaker.

Do not confuse it with the meniscus. Articular cartilage transplantation is different from treatment of a meniscal tear. The menisci are two C-shaped cushions between the thigh bone and the shin bone, whereas articular cartilage is the layer that covers the surface of the bone itself. If your diagnosis is a meniscal tear, read Treatment of Meniscal Tear in Turkey. The two problems can occur in the same knee, and the surgeon treats any associated injuries during the same operation.

What does cartilage transplantation in Turkey mean?

Doctors distinguish three categories:

• Repair: stimulating the body to form substitute tissue, as in microfracture. The tissue that results is fibrocartilage, which is less durable than the original glass-like (hyaline) cartilage.
• Restoration: placing living cartilage tissue into the defect, either by transferring a bone-and-cartilage graft (OATS from the patient's own knee, or OCA from a donor), or by implanting cultured cartilage cells (ACI and MACI).
• Cartilage cell implantation: cartilage cells (chondrocytes) are taken from the patient's own cartilage, grown in the laboratory, and then implanted into the defect. These are cartilage cells, not stem cells, so the two terms should not be used interchangeably.

These surgical procedures are different from non-surgical treatments such as physical therapy. Stem cells and tissue engineering remain, for the most part, under investigation and at an experimental stage, and they are not a substitute for the procedures above. None of the current techniques fully rebuilds the original hyaline cartilage with its complete structure, so the practical goals are to relieve pain, improve function and slow deterioration as far as possible.

Causes and symptoms of cartilage damage

Cartilage can be damaged by injury or by wear over time. Most of the research on cartilage repair concerns focal defects caused by sports injuries and trauma in active people. The damage may extend into the bone beneath the cartilage (an osteochondral lesion). One factor linked to failure of repair is malalignment of the leg, which a systematic review found in about half of isolated cartilage defects.

The symptom most closely linked to cartilage damage is pain when the joint moves. This symptom is not specific: it can come from other knee problems, and cartilage damage is often accompanied by other injuries such as a torn meniscus or ligament. For that reason the decision is not based on symptoms alone but on the surgeon's assessment.

Cartilage defect versus osteoarthritis

A focal defect is a limited area of damage, whereas osteoarthritis is a wider wearing of the joint. Damaged cartilage can lead to joint arthritis over time. Repair and restoration procedures usually suit younger patients with a single defect, and older patients or those with multiple defects are less likely to benefit. If the arthritis is advanced, the decision rests with the surgeon, and options may include total knee replacement or partial knee replacement.

How is cartilage damage diagnosed?

• Clinical examination: the surgeon assesses pain, knee movement and stability, and the alignment of the leg.
• X-rays: hyaline cartilage contains no calcium, so it does not appear on an X-ray. X-rays do show the bones and are used to assess radiographic osteoarthritis.
• Magnetic resonance imaging (MRI): performed to evaluate the cartilage and its surroundings. It may reveal changes in the bone beneath a defect, which influences the choice of technique.
• Arthroscopy: cartilage defects are often found during knee arthroscopy, and several restorative procedures can be performed arthroscopically. For more detail: Arthroscopy in Turkey.

Damage is graded with the ICRS scale from grade 0 (normal cartilage) to grade 4. Grade 1 is superficial damage, grade 2 is damage to less than half the depth of the cartilage, grade 3 is damage deeper than half the thickness without breaching the bone, and grade 4 is damage that penetrates the bone beneath the cartilage.

Seeing cartilage damage on an image does not automatically mean the patient needs a transplant. Cartilage defects were found in 61% of knees undergoing arthroscopy in one older series cited by a recent review, and not all of them cause symptoms. The decision rests on symptoms, age, activity level, the size and location of the defect, and the condition of the joint as a whole.

Techniques for cartilage transplantation and restoration

Microfracture

The surgeon makes small holes in the bone beneath the damaged area, which can be done arthroscopically, so that blood and cells reach the joint surface and form new tissue. The resulting tissue is fibrocartilage, which is less durable than hyaline cartilage but may help in smaller defects. The technique is generally favoured for patients with lower activity demands who have a single smaller defect and healthy bone beneath the cartilage, whereas large defects in more active patients may need other procedures. In the Turkish surgeon survey it was the most commonly used technique for defects smaller than 2.5 cm².

Previous microfracture may weaken the result of a later restorative procedure, which is why it is generally reserved for small defects in people with lower activity demands. It is worth discussing this with your surgeon before choosing it.

A systematic review published in 2024 pooled nine studies with follow-up of 10 years or more and defects of 2.3 to 4 cm². Patients improved compared with their condition before surgery, but scores declined over time in several studies. Radiographic progression of arthritis occurred in 40% to 48% in the studies that measured it. Return to the previous level of sport was between 17.2% and 20% in two long-term studies, and the rate of reoperation or failure ranged from 2.9% to 41% because the definition of failure differed between studies. In a randomised trial in athletes that compared microfracture with autologous graft transfer after about 10 years, failure was 38% versus 14%, and 5 of 29 returned to their previous sporting level versus 10 of 29.

Limits of this review: its studies are level IV evidence, its defects were at the larger end of what the technique usually treats, so its results do not apply to very small defects, and some of its authors disclosed financial relationships with companies in the field. It does not say the technique is without value; it says its durability is limited in medium and large defects.

Autologous chondrocyte implantation (ACI and MACI)

In the first operation, performed arthroscopically, a small sample of the patient's cartilage is taken from a non-weight-bearing area and sent to a laboratory. The cells are grown on a collagen membrane for about a month, then implanted in the defect in a second, open operation, where they are fixed with a biological glue. MACI is generally favoured for younger patients with a single relatively large defect, and it takes several weeks and requires a surgical incision. ACI is classed in generations: the first covers the cells with a membrane taken from the periosteum, the second uses a collagen membrane, and the third (MACI) loads the cells onto a membrane. A systematic review noted that the number of third-generation patients was too small to compare it with the others.

What the studies show:

• The SUMMIT randomised trial (MACI versus microfracture): 144 patients were treated and 137 (95%) completed the two-year assessment. The mean age was 33.8 years and the mean defect 4.8 cm², and the trial included grade III or IV defects of 3 cm² or more in the femoral condyles or trochlea. Pain (from 37.0 to 82.5 versus 35.5 to 70.9 on the KOOS scale) and function (from 14.9 to 60.9 versus 12.6 to 48.7) improved more in the MACI group, and the proportion of non-responders was 12.5% versus 31.9%. But MRI and microscopic examination showed no difference between the groups in the quality of the repair tissue. In an extension to five years that included 128 of the original patients, the clinical improvement in the MACI group persisted, with no significant difference in MRI and no notable adverse events. Some of the trial's authors are employees of the manufacturer.
• The 2010 JBJS review: a defect larger than 4 cm² was the only factor that predicted the superiority of ACI over other procedures, and complications were higher with the old open technique that used a periosteal cover.
• Long-term follow-up (14 to 15 years): a Norwegian randomised trial in 80 patients compared ACI with microfracture and found no significant clinical difference. There were 17 failures in the ACI group versus 13, 6 patients converted to knee replacement versus 3, and radiographic arthritis was present in 57% versus 48% of survivors. This result concerns the ACI technique that was used many years ago and should not be generalised to MACI, but it shows that long-term superiority has not been settled.

Availability in Turkey: in a survey of 147 Turkish surgeons (2015 data), MACI was the most favoured procedure for defects above 4 cm² (67%). However, the researchers noted that second-generation ACI is not widely performed in Turkey and that reimbursement for it is limited, that regulations severely restrict the use of MACI, and that reimbursement is possible in selected hospitals after prior approval from the Ministry of Health. This survey is not enough to establish current availability, and we have no recent source that settles it, so the availability of MACI is subject to direct confirmation from the hospital and surgeon after your case is assessed.

Osteochondral autograft transfer (OATS)

One or more cylinders of bone and cartilage are moved from an area of the knee that bears little weight to the defect, either arthroscopically or through an open incision, so the defect receives hyaline cartilage. It is used for smaller defects because the donor area is limited, and it is useful when MRI shows changes in the bone beneath the defect. Symptoms at the donor site were described as under 5% in the studies cited by the Turkish survey. In the same survey, OATS (mosaicplasty) was the first choice of 69% of surgeons for defects of 2.5 to 4 cm² in more active patients.

A systematic review of 10 studies and 610 patients with a mean age of 27 years, a mean defect of 2.6 cm² and 10.2 years of follow-up found success in 72%, failure in 28% and reoperation in 19%, and failure was associated with older age, previous surgery and larger defects. It is level IV evidence and heterogeneous.

Osteochondral allograft from a donor (OCA)

A graft from a deceased donor is used when the defect is too large to be treated with the patient's own graft. The graft is sterilised in the laboratory and tested to exclude diseases that might be transmitted, and surgery is usually through an open incision. After a mean follow-up of 12.3 years in a systematic review, failure was 25% and reoperation 36%; 72% of failures were conversion to joint replacement, and reoperation was higher in the patellofemoral joint (83%) than elsewhere (34%). We do not assume that OCA is available in any Turkish hospital: its availability needs confirmation from the hospital and surgeon, because it depends on licensed tissue banks.

Membrane with marrow stimulation (AMIC) and scaffolds

AMIC combines microfracture with a collagen membrane covering the defect, and was introduced in 2003 as a single-stage procedure. A systematic review of 15 studies found short- and medium-term improvement in patient scores, but the techniques, membranes and rehabilitation protocols varied widely; results peaked at 24 months and then declined when the procedure was used alone, and the evidence is mixed on the effect of defect size and location. For microfracture supported by a scaffold, the Turkish survey reported that 90% of surgeons had not used it, and the researchers pointed to limited evidence. We did not find enough evidence in what we reviewed to support a general recommendation for either.

Realignment of the leg and associated procedures

The patient may need correction of leg deformity by cutting the bone (osteotomy), or treatment of a torn ligament or meniscus along with the cartilage procedure. A systematic review reported that malalignment is present in about half of isolated defects and was linked to failure of repair, and that combining osteotomy with cartilage restoration gives the best results in younger, non-obese patients with focal defects and inward-angled (varus) knees, without major involvement of the outer side or the kneecap. All of this is decided case by case and is not a fixed part of every operation. For associated ligament injuries see Treatment of Anterior Cruciate Ligament Tear in Turkey.

A scientific comparison of the techniques

Microfracture: stimulates the bone marrow to form fibrous tissue, in a single operation. It is generally favoured for small defects with healthy bone in people with lower activity demands. Its limits are declining results over time and progression of arthritis, and it may weaken the outcome of a later restorative procedure.

Cartilage cell implantation (ACI and MACI): cultured cells are implanted, and in MACI they are loaded onto a membrane; it requires two operations. It is favoured for a single larger defect, above 4 cm² in studies and in the Turkish survey. Its limits are few long-term studies and uncertain availability in Turkey.

Autograft transfer (OATS): bone-and-cartilage grafts from the patient's own knee, in a single operation. It suits smaller defects and defects accompanied by bone changes. Its limits are the limited donor area and failure that rises with age and defect size.

Donor graft (OCA): a bone-and-cartilage graft from a donor, in a single operation. It is used when the defect is too large to be treated with an autograft. Its limits are the need for a tissue bank and a reoperation rate of 36% after 12.3 years in one review.

Membrane with marrow stimulation (AMIC): microfracture with a membrane covering the defect, in a single operation. It is chosen for selected cases at the surgeon's discretion. Its limits are mixed evidence and a decline after 24 months when used alone.

This summary is educational and is not a treatment recommendation; the choice is made by the orthopaedic surgeon according to your case.

Who is a suitable candidate, and when is a transplant not suitable?

Factors in choosing a technique

There is no single rule; the surgeon weighs several factors together:

• Size and depth of the defect: the patient's age, activity level, body mass index and the size of the defect were rated among the most important determinants of technique in the Turkish survey.
• Condition of the bone beneath the cartilage: if the bone has changed, techniques that transfer bone together with cartilage are favoured.
• Age and activity level: most candidates are younger patients and younger adults with a single defect, while older patients or those with multiple defects are less likely to benefit. Older age, previous surgery and larger defects were linked to more failures after OATS. Half of the surgeons in the Turkish survey set 50 years as an upper limit for restoration, which is the opinion of practitioners and not a firm scientific criterion. In a meta-analysis of return to sport, neither patient age nor defect size was a decisive factor in the rate of return.
• The state of the whole joint: knee stability, healthy ligaments and meniscus, and leg alignment.
• Ability to commit to the rehabilitation programme and follow-up.

When is a transplant not suitable?

• Multiple defects or older age: the chance of benefit is lower. If arthritis is widespread in the joint, another route is usually more appropriate, to be decided by the surgeon.
• Uncorrected malalignment: it is linked to failure of repair.
• Other injuries that have not been treated: such as a torn meniscus or ligament, which are usually treated during the same operation.
• Previous microfracture: it may weaken the result of a later restorative procedure, and this should be discussed with the surgeon.
• Inability to follow the rehabilitation period, during which the joint is protected for weeks.

Not being suitable does not mean being denied treatment; it means a different route may be more appropriate.

How is the operation performed?

The surgeon decides the approach (arthroscopic or open) according to the technique and the location and size of the defect:

• Microfracture: can be performed arthroscopically, in a single operation.
• ACI and MACI: a first arthroscopic operation to take a cartilage sample, then cell culture for about a month, then a second, open operation to implant the cells. The place of culture and the arrangements for the patient's stay between the two stages must be confirmed by the hospital.
• OATS: arthroscopically or through an open incision.
• OCA: usually through an open incision.

The type of anaesthesia and the length of hospital stay are decided by the medical team according to the case.

Risks and complications

Like any operation, these procedures carry general risks that your surgeon will explain before you consent; they vary with your health and the technique. We do not quote figures here for general risks for which we found no specific source. What is established from specific studies:

• Microfracture: declining results over time and progression of arthritis, and breaching the plate of bone beneath the cartilage may increase the risk of cysts forming in the bone.
• ACI: in a systematic review, failure was 5.8% overall, 7.7% with the old periosteal technique versus 1.5% to 3.3% with newer techniques. Reoperation was 33% overall (including planned procedures), while unplanned reoperation was 27% with the periosteal technique versus about 5% with others. Graft hypertrophy and delamination were common with the periosteal technique, and joint stiffness (arthrofibrosis) with open surgery. The authors judged 90% of the studies to be of poor quality, and the number of MACI patients too small to analyse.
• OATS: symptoms at the donor site, and failure of 28% with reoperation of 19% after 10.2 years.
• OCA: failure of 25% and reoperation of 36% after 12.3 years, most failures being conversion to joint replacement.

If worrying symptoms appear after surgery, such as fever, increasing pain or swelling, shortness of breath or chest pain, contact the medical team or emergency services at once and do not wait.

Recovery after cartilage transplantation and physiotherapy

There is no single schedule for all cartilage operations. After surgery the joint surface must be protected while the cartilage heals, you may not be allowed to put weight on the leg for weeks, a continuous passive motion machine and physiotherapy may be prescribed, and it may be months before it is safe to return to sport. The programme varies with the technique, the size and location of the defect and any associated procedures, and the surgeon sets it for each patient.

• Microfracture: in the long-term studies covered by the review, patients were usually non-weight-bearing for 6 to 8 weeks, then progressed to full weight-bearing at about week 8, with a continuous passive motion machine for 6 to 8 hours a day, and a return to sport at 4 to 8 months. These are the protocols of those studies, and current practice may differ.
• MACI: a consensus of US experts (the lowest level of evidence) reported full weight-bearing at 7 to 9 weeks for defects in the thigh-bone and shin-bone joint, and immediate full weight-bearing in a brace for defects behind the kneecap depending on associated procedures, reaching 90 degrees of bending by week 4 and full movement at 7 to 9 weeks on average. More than 75% of the experts agreed on each domain, with time ranges for work and sport that depend on the patient and the defect.
• Across techniques: knee movement starts in the first week universally, but the timing of starting weight-bearing varies between centres.
• Return to sport: in a meta-analysis of 44 studies, the mean time ranged from about 5 months after OATS to 9 after microfracture, 9.6 after OCA and 11.8 after ACI. In the Turkish survey, surgeons' opinion was 6 months after microfracture, 9 after OATS and 12 after MACI, which are opinions and not evidence.

Results are usually assessed after two years or more; the SUMMIT trial measured at two and five years.

Results and the limits of the evidence

We do not use the phrase "cartilage transplant success rate", because success is measured by different criteria:

• Pain and function: MACI improved more than microfracture at two and five years in SUMMIT, but a long Norwegian trial found no difference between ACI and microfracture after 14 to 15 years.
• Return to sport: in a meta-analysis of 44 studies (18 of level I or II and 26 of level III or IV, with mean follow-up of about 4 years), the rates of return to sport at any level were 93% after OATS, 88% after OCA, 82% after ACI and 58% after microfracture. The analysis was itself classed as level IV, and some of its authors disclosed relationships with companies. These rates do not mean a return to the previous level. In the long term (10 years or more), return to the previous level after microfracture was 17.2% to 20%.
• Graft survival and avoiding joint replacement: after 10 to 12 years failure was 28% after OATS and 25% after OCA. Definitions of failure differ between studies.
• Arthritis: progressed on X-ray in 40% to 48% after microfracture, and in 57% of survivors after ACI versus 48% after microfracture in the Norwegian trial.
• Quality of tissue: MRI and microscopy in SUMMIT showed no difference between MACI and microfracture.

In short: the newer techniques may give better results in particular defects and particular patients, but there is no conclusive evidence that they prevent arthritis, or of a consistent superiority between techniques after a decade or more. Most studies are level IV evidence, and none of these procedures is presented as a guaranteed cure.

What about the ankle and the hip?

Knee results do not transfer automatically to these two joints.

Ankle: small defects are usually treated with microfracture. In a retrospective study of 120 ankles, clinical failure was 10.5% for defects under 150 mm² versus 80% for larger ones. A systematic review of 25 studies concluded that this technique is reserved for defects not exceeding about 107 mm² and about 10 mm in diameter, and warned that 88% of the studies were level III or IV and 96% were of poor quality. Another review agrees that the quality of the evidence on defect size is low. For larger defects, the options are discussed with a specialist foot and ankle surgeon.

Hip: the evidence is weaker than for the knee. A systematic review of 21 studies and 596 hips found that 85.7% were case series or case reports, that most defects were in the acetabulum (the socket), and that there were no robust comparative studies of the techniques. So we do not present any specific technique for the hip as a proven option. If arthritis advances, the option may be hip replacement, depending on the case.

Cost of cartilage transplantation in Turkey

O9 Medical's preliminary estimate for cartilage transplantation and restoration procedures in Turkey is between USD 8,000 and USD 18,000. This is a general range that runs from the average cost of cartilage restoration procedures to the more complex packages. It is a general estimate that requires an individual quotation from the hospital, not a fixed or guaranteed price for all procedures, and it does not mean every technique is included in it.

The final cost varies with:

• The affected joint and the location of the cartilage damage.
• The area and depth of the injury.
• The surgical procedure and the technique used.
• The number of stages of treatment: techniques based on cell culture require two operations.
• The need for associated procedures, such as realignment or treatment of a ligament or meniscus.
• The patient's condition, the hospital, and the services included in the package (accommodation, physiotherapy, follow-up).

We do not assume the estimate includes accommodation, flights, medication, physiotherapy or follow-up. Before accepting any offer, ask for what it covers in writing, whether it covers both stages if the technique has two stages, and what happens if you need an additional procedure. The final price is set after your medical reports and images have been reviewed.

Treatment, travel to Turkey and follow-up after you return

Before you travel: prepare your MRI and X-ray reports and any previous surgeries, and ask which technique is proposed and why, and whether it is actually available with the surgeon and hospital. See The Best Orthopedic and Joint Surgery Hospitals in Turkey.

If the technique has two stages: MACI takes several weeks to complete. Ask whether you stay in Turkey between the stages or return home and travel again, and where the cells are cultured and how they are transported and stored.

Air travel after surgery: we found no studies of air travel after cartilage surgery. The nearest evidence concerns hip and knee replacement: in a survey of British surgeons there was no consensus on a safe interval, and advice varied from 14 to 180 days. These figures cannot be applied directly to cartilage transplantation, so the surgeon decides the timing of travel and the measures to prevent blood clots according to your case, and it is wise to ask the airline and your insurer.

After you return: bring the operation report, the type of technique or graft used, the written rehabilitation protocol and the follow-up images. Identify a physiotherapist in your country who will read the protocol, and agree with the surgeon on a channel of communication and a date to assess the results. For a broader look at our services in this field: Orthopedic and Joint Surgery in Turkey.

Medical note: this information is for general education. It does not replace consultation with a specialist doctor and is not a diagnosis or a prescription.