Adhesive Hydrogels as Fixation and Regeneration Platforms in Cartilage Surgery: Rethinking Scaffold-Tissue Integration from a Clinical Perspective

Articular cartilage defects affect millions of patients annually and pose one of the most persistent challenges in orthopedic surgery, owing to the tissue's inherent avascular and alymphatic nature. Current surgical approaches, microfracture, autologous chondrocyte implantation (ACI/MACI), and osteochondral grafting, share a common failure mode: inadequate adhesion between repair constructs and surrounding native cartilage, contributing to deterioration rates of 15-75% at five-year follow-up across all techniques. This review repositions adhesion not as a supplementary material property but as the central determinant of clinical success in cartilage repair. We systematically evaluate the biomechanical demands imposed by the joint environment and define clinically relevant adhesion thresholds. Adhesive hydrogel strategies are categorized by surgical context: microfracture augmentation, ACI/MACI enhancement, osteochondral graft integration, and standalone repair platforms. Material platforms are analyzed across catechol/dopamine systems, NHS ester chemistry, photocrosslinkable hydrogels, supramolecular approaches, and multi-mechanism hybrids. Injectable formulations for arthroscopic delivery are critically examined alongside key translational barriers, including fatigue durability, biocompatibility-adhesion trade-offs, sterilization compatibility, batch variability, and regulatory classification ambiguity. Future directions encompass 4D bioprinting, AI-guided formulation optimization, and stimuli-responsive reversible adhesion systems. Adhesive hydrogels represent the missing link that current cartilage repair paradigms require.