Mosaicplasty may be performed entirely arthroscopically, as a combined arthroscopic and mini-arthrotomy procedure, or as an open technique. Tourniquet control is recommended. For knee lesions, the patient is put in supine position for arthroscopy. A standard lateral portal is made for scope insertion and diagnostic arthroscopy is undertaken to evaluate all cartilage damage as well as concomitant knee or other joint pathology.

Once identified the edges of the defect are sharply debrided with curettes, and an arthroscopic resection is used to abrade the lesion down to a viable subchondral bone. It is important to prepare the shoulder of the lesion such that sharply defined vertical walls of intact, normal, hyaline cartilage surround the defect.

Lesion size is estimated using sizers on prepared subchondral bone. At this point planning of the number and size of grafts is completed to give optimal lesion filling with available donor sites.

Donor sites are chosen from areas that have the least contact pressure in the joint like superior lateral aspect of the lateral femoral condyle followed by the superior medial aspect of the intercondylar notch. When performing core harvest, it is essential that the tube harvester be oriented perpendicular to the donor articular cartilage.

The principle of recipient bed preparation is to create a socket in the subchondral bone that enables a secure press-fit osteochondral graft to be placed. No additional fixation is used, thus graft size and socket size are created to achieve a secure press-fit fixation upon seating of each core.

Larger diameter grafts are more stable than smaller ones and that reinsertion after pullout significantly reduced primary fixation strength.  When multiple grafts are to be transplanted it is vital that each one is completed before the creation of additional recipient sockets to avoid fracture of the recipient tunnel walls.

The donor harvester tubes are 1 mm larger than the recipient harvester tubes, allowing for press-fit insertion of grafts.

Graft transfers are continued until the defect is filled adequately and congruency is achieved with the surrounding articular surface.

After the closure of the wound, drains are routinely placed and left for 24 hours or until the output is minimal. Cold therapy is used in all patients for up to 7 to 10 days for control of swelling and pain relief.

Immediate continuous passive motion is started in the hospital and continued upon discharge.

The technique of mosaicplasty outside the knee is identical to that already described, although the approach to the lesion is joint specific. The ipsilateral knee is used for donor grafts.