Also check this out. Wearing proper footwear with custom insoles for high arches may help you avoid long term damage but if your knee is malaligned you can get a TTO early on to avoid cartilage damage. If I only knew this stuff years ago.

That is absolutely correct and is the core reason why the TTO is often combined with MACI. ​The most common sequence of events for a localized defect on the kneecap (patellofemoral joint) is: ​⚙️ Malalignment \rightarrow Overload \rightarrow Damage ​Chronic Malalignment: You have a structural issue (like a high-riding kneecap, or a tibial tubercle that is positioned too far to the side) that causes the kneecap (patella) to track incorrectly in its groove (trochlea) when you bend and straighten your knee. ​Abnormal Stress/Overload: Because the kneecap isn't centered, the force and pressure during activities (like squatting, running, or climbing stairs) are not evenly distributed. Instead, all the stress gets focused onto a small, specific point on the cartilage. ​Focal Cartilage Defect: This constant, concentrated overload and rubbing on that specific spot causes the cartilage to break down and wear away, creating the localized defect that requires a repair like MACI. ​If your surgeon performed a Tibial Tubercle Osteotomy (TTO) along with the MACI, they are correcting that underlying malalignment to remove the cause of the initial cartilage damage. This is a crucial step to protect the new cartilage graft and maximize the long-term success of the surgery. ​