You Were Told Your Joint Is Too Damaged for Anything Short of Replacement? There May Be Another Option.
Cartilage does not heal on its own. When the smooth, low-friction surface that lines your joints is damaged — from injury, from repetitive stress, from a single traumatic event, or from years of wear — the body cannot regenerate it. Scar tissue fills the defect instead. That scar tissue is not cartilage. It is a structurally inferior substitute that breaks down under load, produces pain and swelling, and progresses toward arthritis.
For decades, the surgical options for significant cartilage damage were limited: microfracture, which produces scar tissue rather than real cartilage; cartilage transfer from another part of the patient's own joint, which robs Peter to pay Paul; or joint replacement, which trades a biological joint for a metal and plastic one. For young, active patients — those for whom joint replacement is premature and the stakes of getting the treatment wrong are highest — none of these options was truly satisfying.
Fresh osteochondral allograft transplantation changed that equation. By transplanting living donor cartilage and bone — precisely matched to the defect in size, curvature, and tissue type — it became possible to restore a damaged joint surface with real hyaline cartilage rather than a substitute. The cartilage is alive. It integrates with the patient's own bone. It behaves like native cartilage because it is native cartilage — just from a different source. Traditionally, only one area of damage could be restored by transplantation, but Dr Mirzayan has pushed the envelope in many patients by doing multiple transplantation grafts in mulitple parts of the joint.
Dr. Raffy Mirzayan has performed more than 350 cartilage transplantation procedures across the knee, shoulder, and elbow over 25 years — more than any surgeon in Los Angeles. He has invented procedures, published foundational science, and treated patients who were told their only option was a metal and plastic joint replacement. His outcomes have included marathon runners, professional baseball players, Division I collegiate athletes, and active adults who simply wanted their lives back. He is also the Editor of a textbook entitled Cartilage Injury in the Athlete. He is a member of MOCA (Metrics on Osteochondral Allografts), an international group of allograft surgeons, and has published expert opinions on osteochondral allograft in the knee and patellofemoral joint.
If you have been told your cartilage damage is too severe for anything short of replacement — call (310) 746-5918. That may not be the whole story.
What Makes Cartilage Surgery Different — and Why Experience Is Everything
Cartilage transplantation is not a procedure that most orthopedic surgeons perform at meaningful volume. The technical demands are high — precise sizing, careful preparation of the recipient site, and secure fixation of a graft that must integrate with living bone — and the consequences of errors in technique or judgment compound over time in ways that are not always immediately visible.
The surgeon who has performed ten cartilage transplantation procedures and the surgeon who has performed 350 are not the same surgeon. Volume produces a level of technical refinement, anatomical familiarity, and clinical judgment that cannot be replicated by reading a textbook or attending a course. Knowing which patients are candidates, which graft sizes to select, how to prepare the recipient site, how to prepare and fix the graft, and how to manage the rehabilitation to protect healing tissue — these are skills that develop over hundreds of cases.
Dr. Mirzayan has performed cartilage transplantation procedures across three joints — the knee, the shoulder, and the elbow — at a volume that places him among the most experienced cartilage surgeons in the United States. His cross-joint expertise is genuinely unusual: most cartilage surgeons specialize in one joint. Dr. Mirzayan has applied the same biological principles and refined technique to the most anatomically complex cartilage restoration challenges in each joint — including procedures that no other surgeon had previously attempted.
Cartilage Restoration Across Three Joints
The Knee — Femoral Condyle and Tibial Plateau
The femoral condyle — the rounded end of the thigh bone that contacts the tibia — is the most common site for significant cartilage defects in the knee. These defects occur from direct trauma, from repetitive loading in athletes, or from osteochondritis dissecans — a condition in which a segment of bone and cartilage separates from the joint surface. When the defect is large enough that microfracture or smaller cartilage procedures are insufficient, fresh osteochondral allograft transplantation to the femoral condyle is the most reliable way to restore a durable, functional cartilage surface.
Dr. Mirzayan performs femoral condyle osteochondral allograft transplantation as the majority of his knee cartilage work — and has developed his technique to a level of precision and reproducibility that reflects hundreds of cases across 25 years. He demonstrated his femoral condyle allograft technique in a surgical video produced by Arthrex — the world's leading orthopedic surgical device company and a platform used by surgeons globally for continuing education: Femoral Condyle Allograft OATS Technique — Arthrex Surgical Video
BioPFJ™ — Biologic Patellofemoral Joint Reconstruction
For patients with cartilage damage to the kneecap and its groove — the patellofemoral joint — Dr. Mirzayan invented BioPFJ™: a complete biological reconstruction of the entire patellofemoral joint surface using fresh donor tissue from a single matched donor. By using the same donor for both the patella and trochlea grafts, the articular surfaces are perfectly congruent — matching in geometry, curvature, and cartilage thickness in a way that mismatched grafts from different donors cannot achieve.
Dr. Mirzayan has performed BioPFJ™ in approximately 75 patients — more than any other surgeon in the world — with 100% graft integration, no revisions, no conversions to joint replacement, and dramatic improvements across every functional outcome measure. Patients have returned to marathon running, collegiate athletics, cycling, tennis, and competitive sport. His outcomes study was published in the peer-reviewed journal Cartilage. Learn more about BioPFJ™
OCD of the Capitellum — The Elbow
In 2006, Dr. Mirzayan became the first surgeon in the world to use fresh osteochondral allograft transplantation to treat osteochondritis dissecans of the capitellum — a cartilage condition seen in young baseball pitchers and gymnasts. He has since published the largest single-surgeon series on this condition in the medical literature, reporting in the American Journal of Sports Medicine in 2024 on 35 patients with a mean follow-up of nearly 8 years: 100% graft incorporation, 100% return to overhead sport at the same level or higher, KJOC scores improving from 40.8 to 90.6, and pain scores dropping from 7.5 to 0.3 out of 10. Two patients went on to pitch professionally. Learn more about OCD of the Capitellum
Shoulder Cartilage Restoration
Cartilage injuries in the shoulder are far less common than in the knee — and far less well understood. Dr. Mirzayan has been performing fresh osteochondral allograft transplantation in the shoulder since 2011, applying techniques developed in the knee and elbow to glenoid and humeral head defects in patients with recurrent instability, failed prior surgery, and early shoulder arthritis. He has contributed to the peer-reviewed literature on shoulder cartilage restoration through book chapters in the ISAKOS textbook and Springer surgical reference series, and his shoulder OCA series spans more than 14 years with outstanding functional outcomes and zero re-operations in patients with available follow-up. He has authored two book chapters on this topic entitled Fresh Osteochondral Allograft Transplantation in the Shoulder and Grafting for Humeral Bone Loss.
The Biological Advantage: Why Fresh Allograft Outperforms Every Alternative
Not all cartilage procedures are equal — and understanding the difference matters enormously for patients making treatment decisions.
Microfracture stimulates bleeding from the bone to fill a cartilage defect with fibrocartilage — a scar tissue substitute. Fibrocartilage is not hyaline cartilage. It does not have the same mechanical properties, does not withstand the same loads, and degrades under the compressive and shear forces of an active joint. Most sports medicine surgeons have abandoned microfracture for significant cartilage defects in the knee because the literature consistently shows deterioration of outcomes over time. Dr. Mirzayan does not perform microfracture for significant cartilage defects.
Autograft transfer — harvesting cartilage plugs from a less-loaded area of the patient's own joint — restores hyaline cartilage but creates a donor site defect. For small defects in precisely the right location, it can be appropriate. For larger defects, or in joints where donor site options are limited, it is inadequate.
MACI (Matrix-Associated Chondrocyte Implantation) is a two-stage biological cartilage procedure in which cartilage cells are harvested from the patient's knee at a first surgery, sent to a laboratory where they are cultured and expanded on a collagen scaffold over several weeks, and then implanted into the cartilage defect at a second surgery. MACI produces hyaline-like cartilage — tissue that is closer to native cartilage than fibrocartilage but is not true hyaline articular cartilage. It requires two separate surgical procedures, a waiting period of several weeks between them, and a recovery that is among the longest of any cartilage procedure — typically 12 to 18 months before return to high-demand activity. For appropriately selected patients with contained defects, MACI produces meaningful results. But it is a two-stage commitment with a prolonged recovery and a cartilage product that, while superior to microfracture, does not match the biological quality of what fresh osteochondral allograft transplantation delivers.
Fresh osteochondral allograft restores the defect with living hyaline cartilage and the underlying bone that supports it — from a donor matched in size and joint geometry. The cartilage is alive at the time of transplantation, integrates with the patient's own bone over weeks to months, and provides a durable, biologically appropriate joint surface that no other technique can match for significant defects. In Dr. Mirzayan's hands across three joints and more than 350 cases, the results have been consistently excellent.
Who Is a Candidate?
Fresh osteochondral allograft transplantation is appropriate for a specific group of patients — and Dr. Mirzayan evaluates each one individually.
The ideal candidate is a patient with a significant focal (localized) cartilage defect and who is too young or too active for joint replacement. The defect may result from trauma, osteochondritis dissecans, avascular necrosis, or progressive wear. The remainder of the joint should be in acceptable condition. If there is arthritis affecting the entire joint surface, then the pateint may not be a candidate.
Patients who have failed prior cartilage procedures — including microfracture, autograft transfer, or other techniques — may still be candidates for osteochondral allograft transplantation, depending on the condition of the remaining joint surface and the size of the salvageable area.
Dr. Mirzayan will review your imaging (x-ray and MRI) and prior pictures from arthroscopy if the patient has had one — and give you an honest assessment of whether cartilage restoration is appropriate for your specific situation, which technique is most suitable, and what a realistic outcome looks like for your joint and your goals.
What to Expect: Surgery and Recovery
Fresh osteochondral allograft transplantation is performed as an outpatient procedure under general anesthesia. The specific approach — arthroscopic, open, or combined — depends on the joint and the location of the defect. The recipient site is prepared by removing the damaged cartilage and underlying bone down to a stable margin. The donor graft is sized, shaped, and press-fit into the defect. Screws or anchors are typically not needed.
Recovery follows a staged protocol designed to protect the healing graft while progressively restoring motion and strength. Weight-bearing restrictions, range of motion protocols, and return-to-sport timelines vary by joint and by the specific procedure performed. Full unrestricted range of motion is initiated imediately after surgery. Weight bearing is protected for a couple of short weeks. Full return to high-demand athletic activity typically occurs by 6 months. Dr. Mirzayan will give you a personalized recovery timeline based on your specific anatomy, the joint involved, the procedure performed, and your activity goals.
Coming from Las Vegas, Phoenix, or Out of State?
Fresh osteochondral allograft transplantation at the volume and complexity Dr. Mirzayan performs it is available at very few centers in the United States. The combination of knee, shoulder, and elbow cartilage expertise — with published outcomes in all three joints — does not exist at most orthopedic practices. For patients who have been told their cartilage damage is too severe for anything short of replacement, or who want access to a surgeon with the volume and the published evidence to perform this procedure at the highest level, traveling to Los Angeles is worth serious consideration.
Dr. Mirzayan regularly treats patients from Las Vegas, Henderson, Phoenix, Scottsdale, and across the country. If you carry a commercial insurance plan — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, or a self-funded employer plan — you likely have out-of-network benefits that cover a substantial portion of the cost of surgery. His office will verify your coverage before you commit to anything. Many patients find the out-of-pocket cost of traveling to Los Angeles for the right surgeon is comparable to — or less than — what they would pay locally for in-network care.
Virtual consultations are available. You can submit your MRI in advance, meet Dr. Mirzayan on video, and determine whether cartilage restoration is the right next step — before committing to travel or time away from activity.
Call (310) 746-5918 or contact us online to schedule your consultation.
Frequently Asked Questions
What is fresh osteochondral allograft transplantation?
Fresh osteochondral allograft transplantation is a surgical procedure in which living donor cartilage, and the underlying bone that supports it, are transplanted to a damaged area of a joint. The graft is matched in size and curvature to the recipient site and press-fit into the prepared defect without screws or pins. Over weeks to months, the donor bone integrates with the patient's own bone, and the donor cartilage — which is alive at the time of transplantation — provides a durable, biologically appropriate joint surface. It is the most reliable technique for restoring significant cartilage defects with real hyaline cartilage that we are born with.
Why is fresh allograft better than microfracture?
Microfracture produces fibrocartilage — a scar tissue substitute that is structurally inferior to the hyaline cartilage that normally lines joints. Fibrocartilage does not withstand the same mechanical loads, degrades under compressive and shear forces, and consistently shows deterioration in outcomes over time in the published literature. Fresh osteochondral allograft restores the defect with living hyaline cartilage — the same type of cartilage that was lost — producing more durable results for significant defects. Most experienced sports medicine surgeons have abandoned microfracture for large cartilage defects in favor of allograft transplantation.
Is there a risk of rejection with donor cartilage?
No. Cartilage is immunologically privileged tissue — the chondrocytes within the cartilage matrix are protected from immune recognition. Across Dr. Mirzayan's entire series of more than 350 cartilage transplantation procedures spanning the knee, shoulder, and elbow, there have been no graft rejections and no graft failures attributable to immune response. Dr Mirzayan uses grafts procured by a tissue bank Joint Restoration Foundation with decades of great trach record in this space.
Am I too young for this procedure?
This procedure is specifically designed for patients who are too young and too active for joint replacement. The age of the patient is not necessarily a cut off for this procedure but the overall health of the joint is what differentiates whether a pateint is a candidate or not. The younger the patient, the more important it is to restore the joint with a biological solution that can last decades.
Am I too old for this procedure?
Age alone is not a disqualifying factor. What matters is the overall condition of the joint — whether the cartilage damage is focal enough to be addressed by transplantation, and whether the surrounding cartilage and bone are in sufficient condition to support a durable result. Dr. Mirzayan evaluates each patient individually and will give you an honest assessment of whether cartilage restoration is appropriate for your specific situation.
How long does recovery take?
Recovery varies by joint and by the specific procedure performed. Full return to high-demand athletic activity typically occurs typically by 6 months. Weight-bearing restrictions and rehabilitation protocols are tailored to the individual procedure and the patient's goals. Dr. Mirzayan will give you a personalized recovery timeline at your consultation.
Can cartilage transplantation be combined with other procedures?
Yes — and it frequently is. In the knee, cartilage transplantation is often combined with ligament reconstruction, meniscus repair, or realignment osteotomy when multiple problems are present simultaneously. In the shoulder, it is combined with instability reconstruction. In the elbow, it is combined with arthroscopic loose body removal and joint preparation. Addressing all contributing problems in a single surgical setting produces the best outcomes and avoids staged procedures.
Do you offer virtual consultations for out-of-state patients?
Yes. Dr. Mirzayan offers virtual consultations for patients traveling from out of state. Please submit your x-ray, MRI, and prior arthroscopy pictures in advance, so the defect size, location, and surrounding joint condition can be fully assessed before your visit. Call (310) 746-5918 to schedule.
Does being out-of-network mean I will pay full price out of pocket?
No. Many patients with commercial insurance — especially PPO plans and self-funded employer plans — have strong out-of-network benefits. Dr. Mirzayan's office will verify your coverage before your consultation so you have a clear picture of what to expect before making any decisions.
Who is the best cartilage surgeon in Los Angeles?
Dr. Raffy Mirzayan is the most experienced cartilage transplantation surgeon in Los Angeles — with more than 350 fresh osteochondral allograft procedures performed across the knee, shoulder, and elbow over 25 years. He invented BioPFJ™ — the world's first complete biological patellofemoral joint reconstruction — was the first surgeon in the world to use fresh osteochondral allograft transplantation for OCD of the capitellum in the elbow, and has been performing shoulder cartilage restoration since 2011. His published outcomes span multiple peer-reviewed journals including the American Journal of Sports Medicine and Cartilage, and his surgical techniques are featured on the Arthrex global education platform. No surgeon in Los Angeles has more experience with cartilage transplantation across more joints. Virtual consultations are available for patients traveling from out of state — call (310) 746-5918.
About Dr. Raffy Mirzayan, MD — Cartilage Restoration Specialist in Los Angeles
Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon and the most experienced cartilage transplantation surgeon in Los Angeles — with more than 350 fresh osteochondral allograft procedures performed across the knee, shoulder, and elbow over a 25-year career. He is the inventor of BioPFJ™ — the world's only complete biological patellofemoral joint reconstruction using fresh matched donor tissue — and the first surgeon in the world to use fresh osteochondral allograft transplantation for osteochondritis dissecans of the capitellum in the elbow, beginning in 2006. His published outcomes in the elbow include the largest single-surgeon series on OCD of the capitellum in the medical literature, reported in the American Journal of Sports Medicine with 100% graft incorporation and 100% return to overhead sport. His BioPFJ™ outcomes — published in the peer-reviewed journal Cartilage — demonstrate 100% graft integration across approximately 75 cases with no revisions and no conversions to joint replacement. His shoulder cartilage series spans more than 14 years with outstanding results in patients with instability-related cartilage loss, failed prior surgery, and early arthritis.
What makes Dr. Mirzayan's cartilage practice genuinely unique is not any single procedure — it is the breadth of joints he treats at high volume, the published evidence base he has built across all three, and his fundamental commitment to biological solutions that preserve the native joint rather than replace it. He does not perform microfracture for significant cartilage defects. He does not recommend joint replacement for patients who are too young and too active to accept its limitations. He offers the full spectrum of cartilage restoration techniques — from isolated condyle transplantation to complete patellofemoral joint reconstruction — and selects the right procedure for each patient based on the joint involved, the size and location of the defect, and the patient's individual anatomy and goals.
As a Clinical Professor of Orthopaedic Surgery at USC, an Arthrex consultant and educator whose techniques are featured on the Arthrex global education platform, Co-Founder of Shoulder360™, and author of 88 peer-reviewed publications, Dr. Mirzayan brings academic depth and surgical volume to every cartilage case he treats. He practices at DOCS Health in Los Angeles and welcomes patients from across the United States — including Las Vegas, Phoenix, and Scottsdale — for virtual consultations and in-person care.
DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com
