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The basics - Knee pain

20 March 2009

Knee pain is a common presentation that usually can be easily categorised, as Dr Louise Warburton explains.

There are three main categories of knee problems that a GP is likely to see.

In the young athletic population and the middle-aged athlete, knee injuries related to sports and exercise will be the most common reason for presentation.

In young to middle-aged females, anterior knee pain will be common.

From middle age to the elderly, osteoarthritis (OA) will be a common reason to consult.

Knee injuries fall into two categories: meniscal injuries and ligament tears.

Meniscal injuries The knee contains the medial and lateral menisci (cartilages), which act to lubricate and facilitate rotation of the femoral condyles upon the tibia. They also act as shock absorbers.

It is relatively easy to tear a meniscus if the knee is subjected to a shearing force while the foot is anchored on the ground, for example when football studs are worn.

The patient will be aware of pain within the knee, but may carry on playing. Once the game is finished, the knee may swell and cause pain.

Sometimes the knee will lock. This is classically due to a piece of cartilage breaking off and sticking between the articular surfaces. An acutely locked knee that will not straighten is an orthopaedic emergency.

More commonly, the patient will be able to play again after a few days, but the knee will swell and be painful after activity.

When the patient presents, take a good history as the nature of the injury will often give the diagnosis.

On examination, there may be a small effusion. Look carefully for quadriceps wasting, which can happen very soon after the injury.

Ask the patient to squat; this will be painful with a torn meniscus. Squatting on one leg may be even more difficult.

Walking on the haunches with knees bent (duck waddling) is painful with posterior meniscal tears.

The Thessaly test is done standing barefoot, first on the normal, healthy leg. The patient holds the examiner's hands for balance. The patient bends the knee of the standing leg five degrees and rotates the knee and body in and out three times.

The test is repeated with the knee flexed 20 degrees. Then the test is done on the involved or injured leg.

Patients with a meniscal tear feel pain or discomfort along the joint line on the side of the tear. They may have a feeling of locking or catching.

The classical McMurray test is also a test for meniscal tears. For this, the patient is supine and the affected knee is flexed and extended with the foot in medially and laterally rotated positions. This aims to catch the meniscus between the femoral condyles and tibia and will elicit pain.

It is very important to watch the patient's face carefully, as apprehension should be noted. The test must be performed very carefully after this point is reached. Diagnosis is confirmed by MRI.

Simple tears are usually treated with physiotherapy, as they tend to heal. Large tears or bucket-handle tears - where a circular circumferential tear in the meniscus happens, and the flap flicks over and can lock between the articular surfaces -often have to be treated with arthroscopy.

Ligament tears The cruciate ligaments are torn by significant force applied to the tibia, usually pushing it sideways and away from the femur, as in a heavy football tackle. The player will often feel a 'pop' within the joint. The knee will swell immediately and further play is impossible.

Lesser tears may be sustained by falls or slipping.

Laxity of the tibia on the femur, with the patient supine, is the typical finding. The anterior and posterior drawer tests involve 'drawing' the tibia anterior and posterior on the femur. Lachmann's test is similar, but with the knee partly flexed.

Diagnosis is again by MRI scanning. Repair is only undertaken in footballers and professional athletes.

Osteoarthritis Knee OA can affect up to 15 per cent of the older population and presents with pain and stiffness. Risk factors are occupational (common in farmers), previous injury (ligament tears and meniscal removals all predispose to OA) and genetic causes.

Diagnosis is on history and examination. Nocturnal pain suggests severe OA. Examination findings include quadriceps wasting and osteophyte formation along the joint line, which can be palpated.

Larger osteophytes cause remodelling of the joint surfaces, so that the size of the knee increases and bony projections can be easily palpated. Sometimes there will be an effusion.

A warm joint should raise suspicions of an inflammatory arthritis or gout. X-ray will confirm the findings.

Functional impairment can be assessed using the Oxford knee questionnaire. 1

Management includes weight loss and exercise such as swimming. Core stability exercises such as yoga and pilates are particularly useful.

Patients should not be referred for arthroscopic lavage and debridement unless there is a clear history of mechanical locking - not gelling, 'giving way' or X-ray evidence of loose bodies.

Paracetamol should be considered for pain relief in addition to core treatment.

Paracetamol and/or topical NSAIDs should be considered ahead of use of oral NSAIDs, COX-2 inhibitors or opioids.

Referral for joint replacement surgery should be considered in patients with OA with joint symptoms that have a substantial impact on their quality of life and are refractory to non-surgical treatment.

Corticosteroids and local anaesthetic injection into the joint can be effective treatment for pain relief.

Patellofemoral pain Patellofemoral pain (anterior knee pain) is common in young females; there is a continuum into OA of the patellofemoral joint (PFJ). Patellofemoral pain is also common in OA knee.

The pain is due to lateral displacement of patella during walking or running and imbalance of medial to lateral quadriceps strength.

It is more common with increased femoral anteversion, knee valgus (increased Q angle), increased tibial rotation, subtalar pronation and inadequate flexibility. Patella position is also important, as is degree of patellar movement.

Treatment of patellofemoral pain involves immediate reduction of pain. Reduce load on the PFJ with better training shoes, insoles, and a more sympathetic running surface. Quads training is also beneficial.

Taping of the patella improves the recruitment and contraction of fibres in vastus medialis oblique with relation to vastus lateralis, in the quadriceps muscle. Once the taping is discontinued, improved recruitment continues.

• Dr Warburton is a GPSI in rheumatology in Ironbridge, Shropshire References

1. Dawson J, et al. Questionnaire on the perceptions of patients about total knee replacement. J Bone Joint Surg Br 1998; 80(1): 63-9. www.orthopaedicscore.com/scorepages/oxford_knee_score.html

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• v.55(2); 2021 Apr

Managing Chondral Lesions: A Literature Review and Evidence-Based Clinical Guidelines

Sumit banerjee.

1 Department of Orthopedics, All India Institute of Medical Sciences, Jodhpur, Rajasthan 342001 India

K. Santosh Sahanand

2 Ortho-One Orthopedic Speciality Centre, Coimbatore, Tamil Nadu 641005 India

Articular cartilage lesions are becoming increasingly common. Optimum diagnosis and management of chondral defects cause a lot of dilemma. A number of surgical methods have been reported in the literature for treating focal cartilage defects. There is a lack of consensus on the most effective management strategy, with newer surgical and cell-based treatments being advocated regularly.

Study Design and Methods

A clinical review is constructed by appraising the published literature about clinical evaluation and diagnostic modalities for articular cartilage defects and subsequent surgical procedures, management strategies employed for such lesions. Prominent available databases (PUBMED, EMBASE, Cochrane) were also searched for trials comparing functional outcomes following cartilage procedures. Synthesis of a practical management guideline is then attempted based on the evidence assessed.

Systematic examination and optimal use of diagnostic imaging are an important facet of cartilage defect management. Patient and lesion factors greatly influence the outcome of cartilage procedures and must be considered while planning management. Smaller lesions < 2 cm 2 respond well to all treatment modalities. Autologous osteochondral transplants (OATs) are effective in high activity individuals with intermediate lesions. For larger lesions > 4 cm 2 , newer generation autologous chondrocyte implantation (ACI) has shown promising and durable results. Stem cells with scaffolds may provide an alternate option. Orthobiologics are a useful adjunct to the surgical procedures, but need further evaluation.

Conclusions

Most treatment modalities have their role in appropriate cases and management needs to be individualized for patients. The search for the perfect cartilage restoration procedure continues.

Articular cartilage is devoid of blood vessels which limit its capacity to heal and regenerate, particularly in full-thickness defects [ 1 ]. These defects affect the functioning of the knee and can progress to degenerative osteoarthritic changes [ 2 ]. While the exact incidence of articular cartilage defects is unknown, reports indicate that nearly 900,000 patients are affected by it annually in the US and leads to nearly 200,000 invasive interventions [ 3 ].

Another study reports that 57.3% of knees examined arthroscopically show indications of cartilage lesions [ 4 ].

The major disease load is concentrated in active adults, and thus, any debilitation leads to a significant drop in the functioning of individuals, a recent study analyzing the trends found the mean age of patients undergoing cartilage procedures to be 44 years in 2016 and a 206.4% increase in the number of procedures overall [ 5 ]. This has led to the development of various procedures, demonstrating the role of surgery in treating these defects [ 6 ]. Surgical procedures for managing cartilage defects can be categorized into three groups. Marrow stimulation technique best exemplified by microfracture is one of the most common technique used [ 5 ]; however, the repair tissue wears quickly and results are not durable [ 7 ]. Autologous osteochondral transplant (OATS) provides hyaline cartilage replacement for chondral defects. While it is reported to be effective in treating smaller lesions (< 2–4 cm 2 ) [ 8 ], it is limited by donor side morbidity [ 9 ] and fibrocartilage hypertrophy/uneven surface between plugs [ 10 ].

Autologous chondrocyte implantation (ACI) is based on the principle of restoration of hyaline cartilage and thus providing durable improvements [ 11 ]. Even though it has been reported to have improved clinical outcome over long follow-up [ 12 ]; it has its own drawbacks and is constantly being evolved to provide better delivery and less invasive methods of chondrocyte implantation [ 2 ].

Currently, there is no standardized protocol for treatment of cartilage defects and considerable ambiguity persists regarding surgical management providing optimum and durable results. In theory, ACI should have an advantage with better histological quality [ 13 ]; however, the results have been mixed. A number of publications have been based on trials that have low power and inadequate follow-up [ 3 ]. Another compounding factor is the modifications in ACI techniques (periosteal flap, collagen layer, and matrix induced).

Cartilage restoration techniques have been further augmented using orthobiologics.

Orthobiologics are a very heterogenous mix of compounds and consist of but not limited to platelet-rich plasma (PRP), hyaluronic acid, mesenchymal stem cells (MSCs), adipose-derived stem cells, bone marrow aspirate concentrate (BMAC), growth factors, and cytokine modulators [ 14 , 15 ]. Their role in treating cartilage defect is currently the topic of intense scrutiny in the research community.

Multiple treatment modalities and their interplay augur well for breakthroughs and improved understanding of the cartilage defects; it, however, causes considerable confabulation in the minds of the clinician looking for evidence-based answers and possibly an algorithm on managing cartilage defects in his settings. A further caveat especially in developing countries like ours is the economics and non-availability of the newer treatment options.

This review is an attempt to search the available literature on the various diagnostic tools utilized, treatment modalities, and reported outcomes, appraise it and endeavor to synthesize practical and evidence-based recommendations for management of articular cartilage defects.

A precise and early diagnosis is cornerstone to optimum management of cartilage defects and ensuring good prognosis [ 16 ].

Diagnosis of articular cartilage lesions involves following three approaches:

Cartilage lesions of the knee, hip, or ankle often present as pain during activities, while lesions of shoulder joint can be relatively asymptomatic and are diagnosed incidentally [ 17 ].

The signs and symptoms, none of which are specific to the lesions, include activity-related pain, often associated with swelling and progressive in nature, a decrease in the functional range of motion of the joint and mechanical symptoms like popping, locking, or catching [ 18 , 19 ].

A thorough physical examination is essential as it will elucidate tell-tale signs of joint health. Examination of the ROM of the joint is essential as lack of terminal extension in knee joint is a pointer toward OA [ 19 ] as is the loss of terminal abduction and rotations in hip and shoulder joint. The stability and alignment of the joint plays a crucial role not just in the pathogenesis but also the outcome of subsequent surgical procedures; hence, the joint must be carefully assessed for ligamentous stability, mechanical alignment, and the condition of menisci, capsule, and labrum [ 19 , 20 ].

Conventional radiology does not delineate cartilage lesions properly, but is essential to look for signs of OA and mechanical alignment. The imaging modality of choice is MRI, and while conventional MRI provides moderate-to-good clarity, newer image modes and programs have been developed to enhance image quality [ 16 ].

Proton density-weighted (PD) and fast spin echo (FSE) images help better appreciate hyaline cartilage, and differentiate it from synovial fluid and underlying bone [ 21 ], as depicted in Fig.  1 . They also help in quantifying the severity of lesions, as depicted in Fig.  2 .

Normal articular cartilage and cartilage defects on MRI

Spectrum of cartilage lesions on MRI imaging

Another development in MRI has been the use of contrasts to study glycosaminoglycan degradation products using delayed gadolinium enhanced magnetic resonance imaging of cartilage (dGEMRIC) protocols and sodium MRIs to evaluate the level of sodium in glycosaminoglycan in the cartilage tissues [ 22 ].

Arthroscopy allows for direct visualization of the cartilage lesions and remains, the first point of diagnosis for many lesions. However, it suffers from two disadvantages, one being the subjective nature of observations, and to counter this, a number of objective grading systems have been developed. The most widely known amongst these are Outerbridge scale [ 23 ] and the ICRS grading, as presented in Table ​ Table1 1 .

Classification and grading of chondral lesions

Modified from Dallich et al. [ 36 ]

Second, only macroscopic damage can be visualized, which means that while it can be a good tool to grade and plan treatment for moderate-to-severe lesions, it is not recommended in identifying early lesions [ 16 ].

Management of Cartilage Defects

The mainstay of treatment is surgical as the literature does not provide sufficient evidence about conservative management. Conservative treatments include but are not limited to NSAIDS, physiotherapy, visco-supplementation, and steroids; these may be used prior to surgical intervention.

The surgical treatment of cartilage defects can be broadly categorized into three groups.

• Debridement/chondroplasty.
• Microfracture
• Microfracture + augmentation with orthobiologics.
• OATS/mosaicplasty
• Autologous chondrocyte implantation
• BMAC/MSC + scaffolds.

Debridement and chondroplasty: involve smoothening of partial thickness defects and shaving off loose flaps to create stable edged lesions [ 24 ].

These procedures reduce the chances of formation of loose bodies and consequential mechanical blocks. They do not alter the natural progression of disease and are reserved for patients with advanced arthritis.

Originally described by Steadman [ 7 ], microfracture involves curetting the lesion down to subchondral bone and then making perforations into the bed of the lesions to release blood clots, as shown in Fig.  3 . The blood clot induces cartilage formation in the lesion; however, the cartilage produced has been shown to be fibrocartilage in nature, and hence, this procedure is classed as a reparative procedure [ 25 ].

Microfracture for treatment of focal chondral defects

Microfracture remains the most commonly performed procedure for cartilage defects worldwide. Gowd et al. [ 5 ] reported that microfracture accounts for nearly 1/3 of all cartilage procedures performed. This can ascribed to the fact that it is inexpensive, technically easy and minimally invasive [ 7 ].

Multiple studies have assessed outcome of microfractures in treating cartilage defects [ 18 , 26 , 27 ].

While the outcomes reported vary greatly, it provides significantly improved outcome in short-to-mid-term, but the benefits are not durable (i.e., beyond 5 years) [ 28 ].

Reported results have been better in patients < 40 years of age [ 29 ] and in lesions < 2.5 cm 2 and definitely inferior outcomes in lesions > 4 cm 2 [ 30 ].

Another pertinent point is inferior outcome in patients with damage to the subchondral bone and also inferior outcomes of revision cartilage restorative surgeries [ 5 ].

Researchers have proposed the idea of concentrating and augmenting the growth factors/cells within the lesion leading to the development of autologous matrix induce chondrogenesis, often described as microfracture deluxe edition, and involves covering the microfracture site with collagen membrane. This is postulated to allow better outcome and durability of the results in medium lesions > 2.5 cm 2 [ 31 ].

Investigators have reported equivalent results to ACI in small lesions 2–4 cm 2 [ 32 ].

There is not sufficient evidence yet to recommend it above ACI or other restorative procedures, but it may be preferable to MF alone specially in moderate-sized lesions.

This involves debridement of defect bed and transfer of osteochondral plug from donor site to recipient bed [ 9 ].

It has shown reproducible results in small lesions < 2–4 cm 2 [ 8 ] and is also recommended in athletes and high-demand individuals as it allows early return to activity [ 33 ]. The harvested plugs have matured native hyaline cartilage, which once incorporated can start functioning fairly quickly [ 18 ].

The harvested plugs have both hyaline cartilage and subchondral bone making it ideal for treatment of osteochondritis dissecans lesions [ 9 ].

Hangody et al. [ 9 ] reported good-to-excellent outcome at long-term follow-up (10 years) following OATS for knee lesions.

However, it is technically demanding and clinical outcomes depend greatly on perpendicular and flush seating of the harvested grafts within the recipient bed [ 34 ].

The procedure is limited by the size of lesion, and another option described for larger lesions and for revision procedures is the use of osteochondral allografts (OCA), which mitigates the donor side morbidity and provides hyaline cartilage at the defect side [ 35 ]. Success of the procedure hinges upon the viability of the chondrocytes in the allograft and freshly harvested allograft < 28 days prior to transplant have the best viability. The availability and matching of graft along with the chances of disease transmission, and failure of graft incorporation are issues which currently limit the use of this technique [ 36 ].

This entails, in the first surgery, a biopsy of healthy articular cartilage. Chondrocytes are extracted from the sample and cultured in-vitro to massively multiply the number of chondrocytes [ 11 ]. In second procedure, the defect bed is debrided, and the cultured chondrocytes are injected in and sealed with periosteal flap/collagen membranes [ 6 ].

This is hypothesized to produce hyaline cartilage and leads to a better functional outcome and is expected to have more durability [ 11 ]. It can be used to cover relatively large defects. While the principle has remained intact, research has concentrated on ensuring effective delivery of cultured chondrocytes.

In the first generation/conventional ACI (ACI-P), periosteal flap was sutured to cover the lesion. The shortcomings were large incision to harvest flap, technical difficulty in sealing the flap to prevent leakage and graft hypertrophy [ 37 ].

Second generation/(ACI-C) involves the use of type I/III collagen membrane to cover the defect, and sealed using fibrin glue. Steinwachs and Kreuz [ 38 ] reported significantly improved outcomes and no graft hypertrophy.

Matrix-induced autologous chondrocyte implantation (MACI) involves seeding of chondrocytes onto a collagen bilayer/scaffold (type I/III). The advantages of MACI are reported to be less invasive, possible arthroscopic procedure, and good stability of construct, and it has been shown to provide good outcomes [ 2 ].

More recently systematic reviews have analyzed outcomes following ACI and suggest it as the preferable method of treating larger defects (> 4 cm 2 ) [ 39 ]. It is also purportedly preferable in fresh lesions and in younger patients [ 12 ].

One distinct characteristic evident is the higher rate of failure with ACI following microfractures as against ACI as the first procedure [ 40 ]. This has been attributed to the fact that marrow stimulation can lead to degeneration of osteochondral unit [ 41 ].

While the reported advantages have been more pronounced with the newer generation of ACI; high cost, need for second surgery, and longer recovery time means that the search for an ideal procedure continues.

Numerous biological options have been studied to assess their roles in managing cartilage defects in the last decade. Notable amongst them are bone marrow aspirate concentrate (BMAC), platelet-rich plasma (PRP), mesenchymal stem cells (MSCs), and adipose-derived stem cells (ASCs).

BMAC: This involves harvesting and concentrating bone marrow to increase the number of MSCs in the specimen. Not only does it provide stem cells it is also a veritable kitchen sink of growth factors and cytokines notably transforming growth factor beta, VEGF, bone morphogenic protein (BMP)-2 and 7, and other chondropoietic factors [ 42 ].

Initially, BMAC was used as an adjunct, but it is being increasingly utilized with scaffolds as an alternative to ACI. Gobbi et al. [ 43 ] found significantly improved functional outcomes with BMAC supplemented collagen scaffolds in focal cartilage lesions.

A key advantage of using BMAC with scaffolds is that it is a one step process, reducing cost and treatment time and with no reported adverse effects. It makes BMAC an attractive alternative to ACI with good efficacy and safety profile [ 14 ].

PRP: Although it is beneficial for cartilage wear in OA patients, its role in cartilage lesions is mainly as an adjunct. Lack of standardized protocol makes it very difficult to compare outcomes following its application. Leukocyte poor PRP reportedly provides a favorable climate for stem cell expansion and improved cartilage growth [ 44 ]. PRP is utilized with micronized allogenic articular cartilage to augment microfractures [ 45 ].

However, currently, there is insufficient evidence to recommend its usage for cartilage defects outside of research settings.

Adipose-derived mesenchymal stem cells (ASCs): They provide an easily accessible route to harvesting stem cells; and are reported to have a higher concentration of stem cells than BMAC [ 46 ].

ASC still remains an experimental option [ 14 ] with lot of research interest.

Outcome Comparisons

We searched published literature for clinical trials comparing ACI to other cartilage repair and restoration techniques. Greater emphasis was laid on identifying studies that were comparative trials or cohorts, had a longer follow-up and larger sample size. Preference was given to recently published trials. We searched PUBMED, EMBASE and Cochrane database for clinical studies that reported functional outcomes/PROM following cartilage procedures. Table ​ Table2 2 outlines the characteristics, outcome measures and results of the studies utilized for outcome comparison between cartilage procedures.

Knutsen et al. [ 47 ] compared first-generation ACI to microfracture in 80 participants and followed them over 14–15 years. They found that both group of patients improved significantly following intervention. There was no significant difference in Lysholm scores, VAS, or SF-36 reported outcomes amongst the two groups. At the last follow-up (14–15 years), there were 17 failures in the ACI group and 13 in MF group, which was not statistically significant.

Similarly, Vanlauwe et al. [ 48 ] reported no significant difference in the outcome between ACI and MF at 5 year follow-up, measured using KOOS ( p  = 0.116).

Kon et al. [ 49 ] studied second-generation ACI compared to MF in 80 patients and at 5 year follow-up reported significantly better IKDC scores and return to sports in ACI group. They also reported deterioration of results with MF over time.

Recently, Brittberg et al. [ 50 ] compared MACI with MF after 5 year follow-up, and they too reported significantly better objective functional outcomes in the MACI group (KOOS, p  = 0.02).

Thus, the reported literature shows equivalent results with first gen-ACI and MF, but better and more durable outcomes with newer generation ACI interventions.

Horas et al. [ 51 ] evaluated 40 patients treated with OATS and ACI, and found no significant difference between PROMs at 2 years.

In a larger study, Bentley and associates [ 52 ] followed up patients undergoing ACI/OATs for 10 years and found that significantly better maintained results in the ACI group. The Cincinnati rating scores were also significantly higher in the ACI cohort.

These studies point toward improved outcome with ACI and OAT, but improvements were sustained better over long term with ACI.

Gobbi and colleagues [ 43 ] compared BMAC against MACI, found no adverse events in either arm, and showed improvements in both arms with significantly improved subjective IKDC scores in BMAC group.

In a study with minimum 10 year follow-up, Teo et al. [ 53 ] analyzed outcomes comparing BMSCs with conventional ACI and found comparable PROM scores at final follow-up.

BMAC appears to be potential candidate for primary cartilage procedure along with newer generation ACI, but needs further evaluation in larger cohorts.

Studies comparing outcomes following ACI and other cartilage procedures

Factors Affecting Outcome and Management Guidelines

As evident from the preceding paragraphs, there is no one size fits all procedure for cartilage defects. An attempt is now made to focus on features, which have the potential to influence treatment protocols and subsequent outcome of the cartilage reparative/restorative procedure.

The patient characteristics that influence outcomes following cartilage procedures and consequently the choice of procedure are detailed in Table ​ Table3 3 .

Patient characteristics influencing outcome of cartilage procedures

IE insufficient evidence to recommend any specific modality over the other

Lesion characteristics play a pivotal role in the outcome of cartilage reparative/restorative procedures. The subsequent table delineates the recommendations for cartilage procedures based on lesion characteristics (Table ​ (Table4 4 ).

Lesion characteristics influencing outcome of cartilage procedure

While appraising all the evidence, it has to be borne in mind that the reported studies have a lot of heterogeneity in terms of outcome scores, defining success and treatment failure, and follow-up periods, and hence, it is difficult to pool the data to synthesize a consolidated recommendation. This in a way mirrors the actual clinical scenario wherein patient characteristics and expectations, surgeon preferences, and availability and economics of the procedure play a big part in the management decision. Nevertheless, an attempt has been made to create an evidence-based algorithm/guidance tool for managing cartilage lesions, and is presented in Fig.  4 .

Algorithm for management of full-thickness cartilage defects

In general, cartilage procedures discussed have been reported to be efficacious in varying degrees across the spectrum of cartilage defects managed and management strategy needs to be customized for each patient. Newer generation ACI has shown improved mid- to long-term outcomes in properly selected patients. Stem cells with scaffolds have also shown promising early results, and further research and longer prospective trials are needed to assess their comparative efficacy. The search for the ideal cartilage restorative therapy continues, with further refinements being developed and assessed. The ever-increasing use and research into biologics and chondrogenic factors are another potential area from which newer methods of managing chondral defects may emerge.

Acknowledgements

The authors would like to acknowledge the help of Dr. Suvinay Saxena and Dr. Pawan Garg both from the Department of Diagnostic and Interventional Radiology, AIIMS Jodhpur for their valuable help with imaging figures in the article.

Compliance with Ethical Standards

On behalf of all authors, the corresponding author states that there is no conflict of interest. No financial aid of any nature was obtained from any source for this article.

This article does not contain any studies with human or animal subjects performed by the any of the authors.

For this type of study, informed consent is not required.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Sumit Banerjee, Email: moc.liamg@eejrenabtimusrd .

K. Santosh Sahanand, Email: moc.liamg@dnanahas .

What is cloud computing?

With cloud computing, organizations essentially buy a range of services offered by cloud service providers (CSPs). The CSP’s servers host all the client’s applications. Organizations can enhance their computing power more quickly and cheaply via the cloud than by purchasing, installing, and maintaining their own servers.

The cloud-computing model is helping organizations to scale new digital solutions with greater speed and agility—and to create value more quickly. Developers use cloud services to build and run custom applications and to maintain infrastructure and networks for companies of virtually all sizes—especially large global ones. CSPs offer services, such as analytics, to handle and manipulate vast amounts of data. Time to market accelerates, speeding innovation to deliver better products and services across the world.

What are examples of cloud computing’s uses?

Get to know and directly engage with senior mckinsey experts on cloud computing.

Brant Carson is a senior partner in McKinsey’s Vancouver office; Chandra Gnanasambandam and Anand Swaminathan are senior partners in the Bay Area office; William Forrest is a senior partner in the Chicago office; Leandro Santos is a senior partner in the Atlanta office; Kate Smaje is a senior partner in the London office.

Cloud computing came on the scene well before the global pandemic hit, in 2020, but the ensuing digital dash  helped demonstrate its power and utility. Here are some examples of how businesses and other organizations employ the cloud:

• A fast-casual restaurant chain’s online orders multiplied exponentially during the 2020 pandemic lockdowns, climbing to 400,000 a day, from 50,000. One pleasant surprise? The company’s online-ordering system could handle the volume—because it had already migrated to the cloud . Thanks to this success, the organization’s leadership decided to accelerate its five-year migration plan to less than one year.
• A biotech company harnessed cloud computing to deliver the first clinical batch of a COVID-19 vaccine candidate for Phase I trials in just 42 days—thanks in part to breakthrough innovations using scalable cloud data storage and computing  to facilitate processes ensuring the drug’s safety and efficacy.
• Banks use the cloud for several aspects of customer-service management. They automate transaction calls using voice recognition algorithms and cognitive agents (AI-based online self-service assistants directing customers to helpful information or to a human representative when necessary). In fraud and debt analytics, cloud solutions enhance the predictive power of traditional early-warning systems. To reduce churn, they encourage customer loyalty through holistic retention programs managed entirely in the cloud.
• Automakers are also along for the cloud ride . One company uses a common cloud platform that serves 124 plants, 500 warehouses, and 1,500 suppliers to consolidate real-time data from machines and systems and to track logistics and offer insights on shop floor processes. Use of the cloud could shave 30 percent off factory costs by 2025—and spark innovation at the same time.

That’s not to mention experiences we all take for granted: using apps on a smartphone, streaming shows and movies, participating in videoconferences. All of these things can happen in the cloud.

Learn more about our Cloud by McKinsey , Digital McKinsey , and Technology, Media, & Telecommunications  practices.

How has cloud computing evolved?

Going back a few years, legacy infrastructure dominated IT-hosting budgets. Enterprises planned to move a mere 45 percent of their IT-hosting expenditures to the cloud by 2021. Enter COVID-19, and 65 percent of the decision makers surveyed by McKinsey increased their cloud budgets . An additional 55 percent ended up moving more workloads than initially planned. Having witnessed the cloud’s benefits firsthand, 40 percent of companies expect to pick up the pace of implementation.

The cloud revolution has actually been going on for years—more than 20, if you think the takeoff point was the founding of Salesforce, widely seen as the first software as a service (SaaS) company. Today, the next generation of cloud, including capabilities such as serverless computing, makes it easier for software developers to tweak software functions independently, accelerating the pace of release, and to do so more efficiently. Businesses can therefore serve customers and launch products in a more agile fashion. And the cloud continues to evolve.

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Cost savings are commonly seen as the primary reason for moving to the cloud but managing those costs requires a different and more dynamic approach focused on OpEx rather than CapEx. Financial-operations (or FinOps) capabilities  can indeed enable the continuous management and optimization of cloud costs . But CSPs have developed their offerings so that the cloud’s greatest value opportunity is primarily through business innovation and optimization. In 2020, the top-three CSPs reached $100 billion  in combined revenues—a minor share of the global $2.4 trillion market for enterprise IT services—leaving huge value to be captured. To go beyond merely realizing cost savings, companies must activate three symbiotic rings of cloud value creation : strategy and management, business domain adoption, and foundational capabilities.

What’s the main reason to move to the cloud?

The pandemic demonstrated that the digital transformation can no longer be delayed—and can happen much more quickly than previously imagined. Nothing is more critical to a corporate digital transformation than becoming a cloud-first business. The benefits are faster time to market, simplified innovation and scalability, and reduced risk when effectively managed. The cloud lets companies provide customers with novel digital experiences—in days, not months—and delivers analytics absent on legacy platforms. But to transition to a cloud-first operating model, organizations must make a collective effort that starts at the top. Here are three actions CEOs can take to increase the value their companies get from cloud computing :

• Establish a sustainable funding model.
• Develop a new business technology operating model.
• Set up policies to attract and retain the right engineering talent.

How much value will the cloud create?

Fortune 500 companies adopting the cloud could realize more than $1 trillion in value  by 2030, and not from IT cost reductions alone, according to McKinsey’s analysis of 700 use cases.

For example, the cloud speeds up design, build, and ramp-up, shortening time to market when companies have strong DevOps (the combination of development and operations) processes in place; groups of software developers customize and deploy software for operations that support the business. The cloud’s global infrastructure lets companies scale products almost instantly to reach new customers, geographies, and channels. Finally, digital-first companies use the cloud to adopt emerging technologies and innovate aggressively, using digital capabilities as a competitive differentiator to launch and build businesses .

If companies pursue the cloud’s vast potential in the right ways, they will realize huge value. Companies across diverse industries have implemented the public cloud and seen promising results. The successful ones defined a value-oriented strategy across IT and the business, acquired hands-on experience operating in the cloud, adopted a technology-first approach, and developed a cloud-literate workforce.

Learn more about our Cloud by McKinsey and Digital McKinsey practices.

What is the cloud cost/procurement model?

Some cloud services, such as server space, are leased. Leasing requires much less capital up front than buying, offers greater flexibility to switch and expand the use of services, cuts the basic cost of buying hardware and software upfront, and reduces the difficulties of upkeep and ownership. Organizations pay only for the infrastructure and computing services that meet their evolving needs. But an outsourcing model  is more apt than other analogies: the computing business issues of cloud customers are addressed by third-party providers that deliver innovative computing services on demand to a wide variety of customers, adapt those services to fit specific needs, and work to constantly improve the offering.

What are cloud risks?

The cloud offers huge cost savings and potential for innovation. However, when companies migrate to the cloud, the simple lift-and-shift approach doesn’t reduce costs, so companies must remediate their existing applications to take advantage of cloud services.

For instance, a major financial-services organization  wanted to move more than 50 percent of its applications to the public cloud within five years. Its goals were to improve resiliency, time to market, and productivity. But not all its business units needed to transition at the same pace. The IT leadership therefore defined varying adoption archetypes to meet each unit’s technical, risk, and operating-model needs.

Legacy cybersecurity architectures and operating models can also pose problems when companies shift to the cloud. The resulting problems, however, involve misconfigurations rather than inherent cloud security vulnerabilities. One powerful solution? Securing cloud workloads for speed and agility : automated security architectures and processes enable workloads to be processed at a much faster tempo.

What kind of cloud talent is needed?

The talent demands of the cloud differ from those of legacy IT. While cloud computing can improve the productivity of your technology, it requires specialized and sometimes hard-to-find talent—including full-stack developers, data engineers, cloud-security engineers, identity- and access-management specialists, and cloud engineers. The cloud talent model  should thus be revisited as you move forward.

Six practical actions can help your organization build the cloud talent you need :

• Find engineering talent with broad experience and skills.
• Balance talent maturity levels and the composition of teams.
• Build an extensive and mandatory upskilling program focused on need.
• Build an engineering culture that optimizes the developer experience.
• Consider using partners to accelerate development and assign your best cloud leaders as owners.
• Retain top talent by focusing on what motivates them.

How do different industries use the cloud?

Different industries are expected to see dramatically different benefits from the cloud. High-tech, retail, and healthcare organizations occupy the top end of the value capture continuum. Electronics and semiconductors, consumer-packaged-goods, and media companies make up the middle. Materials, chemicals, and infrastructure organizations cluster at the lower end.

Nevertheless, myriad use cases provide opportunities to unlock value across industries , as the following examples show:

• a retailer enhancing omnichannel  fulfillment, using AI to optimize inventory across channels and to provide a seamless customer experience
• a healthcare organization implementing remote heath monitoring to conduct virtual trials and improve adherence
• a high-tech company using chatbots to provide premier-level support combining phone, email, and chat
• an oil and gas company employing automated forecasting to automate supply-and-demand modeling and reduce the need for manual analysis
• a financial-services organization implementing customer call optimization using real-time voice recognition algorithms to direct customers in distress to experienced representatives for retention offers
• a financial-services provider moving applications in customer-facing business domains to the public cloud to penetrate promising markets more quickly and at minimal cost
• a health insurance carrier accelerating the capture of billions of dollars in new revenues by moving systems to the cloud to interact with providers through easier onboarding

The cloud is evolving  to meet the industry-specific needs of companies. From 2021 to 2024, public-cloud spending on vertical applications (such as warehouse management in retailing and enterprise risk management in banking) is expected to grow by more than 40 percent annually. Spending on horizontal workloads (such as customer relationship management) is expected to grow by 25 percent. Healthcare and manufacturing organizations, for instance, plan to spend around twice as much on vertical applications as on horizontal ones.

Learn more about our Cloud by McKinsey , Digital McKinsey , Financial Services , Healthcare Systems & Services , Retail , and Technology, Media, & Telecommunications  practices.

What are the biggest cloud myths?

Views on cloud computing can be clouded by misconceptions. Here are seven common myths about the cloud —all of which can be debunked:

• The cloud’s value lies primarily in reducing costs.
• Cloud computing costs more than in-house computing.
• On-premises data centers are more secure than the cloud.
• Applications run more slowly in the cloud.
• The cloud eliminates the need for infrastructure.
• The best way to move to the cloud is to focus on applications or data centers.
• You must lift and shift applications as-is or totally refactor them.

How large must my organization be to benefit from the cloud?

Here’s one more huge misconception: the cloud is just for big multinational companies. In fact, cloud can help make small local companies become multinational. A company’s benefits from implementing the cloud are not constrained by its size. In fact, the cloud shifts barrier to entry skill rather than scale, making it possible for a company of any size to compete if it has people with the right skills. With cloud, highly skilled small companies can take on established competitors. To realize the cloud’s immense potential value fully, organizations must take a thoughtful approach, with IT and the businesses working together.

For more in-depth exploration of these topics, see McKinsey’s Cloud Insights collection. Learn more about Cloud by McKinsey —and check out cloud-related job opportunities if you’re interested in working at McKinsey.

Articles referenced include:

• “ Six practical actions for building the cloud talent you need ,” January 19, 2022, Brant Carson , Dorian Gärtner , Keerthi Iyengar, Anand Swaminathan , and Wayne Vest
• “ Cloud-migration opportunity: Business value grows, but missteps abound ,” October 12, 2021, Tara Balakrishnan, Chandra Gnanasambandam , Leandro Santos , and Bhargs Srivathsan
• “ Cloud’s trillion-dollar prize is up for grabs ,” February 26, 2021, Will Forrest , Mark Gu, James Kaplan , Michael Liebow, Raghav Sharma, Kate Smaje , and Steve Van Kuiken
• “ Unlocking value: Four lessons in cloud sourcing and consumption ,” November 2, 2020, Abhi Bhatnagar , Will Forrest , Naufal Khan , and Abdallah Salami
• “ Three actions CEOs can take to get value from cloud computing ,” July 21, 2020, Chhavi Arora , Tanguy Catlin , Will Forrest , James Kaplan , and Lars Vinter

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