Clinical Outcomes of Cartilage Procedures Performed in Conjunction With Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review

Background: Cartilage lesions are frequently encountered during anterior cruciate ligament reconstruction (ACLR) and may influence long-term outcomes. Surgical options include debridement, microfracture, osteochondral autograft transfer (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI), yet the optimal approach remains controversial. Purpose: To systematically review clinical outcomes of cartilage procedures performed during ACLR and compare them with cases where cartilage lesions were left untreated. Study Design: Systematic review; Level of evidence, 4. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, Ovid MEDLINE, and Scopus were searched through July 15, 2025. Inclusion criteria comprised studies reporting outcomes of primary ACLR with concomitant cartilage lesions treated with debridement, microfracture, OAT, OCA, ACI, or no treatment. Outcomes assessed included patient-reported outcome measures, return to sport, osteoarthritis (OA) progression, and reoperation rates. Methodological quality was evaluated using the Modified Coleman Methodology Score, and the certainty of evidence for each outcome was further assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. Results: A total of 14 studies (1003 patients; mean age range, 28-39 years; mean follow-up range, 2.1-95 months) met the inclusion criteria. Microfracture and debridement resulted in significant postoperative improvement but did not consistently outperform no treatment, with some studies reporting worse Knee injury and Osteoarthritis Outcome Score (KOOS) Sport and Recreation and Quality of Life subscale scores after microfracture. OAT, OCA, and ACI produced greater improvements in patient-reported outcomes, with OAT showing higher return-to-sport rates (63.6% vs 38.5% for microfracture) and ACI demonstrating substantial pain reduction and functional gains. OA progression was highest after microfracture (up to 48%) and lowest with OAT and ACI. OCA improved KOOS domains but had the highest reoperation rate (32%). The overall certainty of evidence was very low due to heterogeneity, small sample sizes, and methodological limitations. Conclusion: Microfracture and debridement performed during primary ACLR did not consistently improve outcomes compared with no treatment. In contrast, OAT, OCA, and ACI demonstrated greater functional improvements. Limited evidence from a single study suggested a higher return-to-sport rate with OAT than with microfracture, though further research is required to confirm this finding. OA progression appeared more frequent after microfracture, whereas ACI and OAT were associated with lower rates of progression and reoperation. Substantial limitations in available data and study design prevent definitive conclusions related to the effect of articular cartilage treatment at the time of primary ACLR. Registration: CRD420251137854 (PROSPERO identifier).