Scaffold-associated procedures are superior to microfracture in managing focal cartilage defects in the knee: A systematic review & meta-analysis

Background: Debate continues as to whether surgical treatment with chondral-regeneration devices is superior to microfracture for focal articular cartilage defects in the knee.Purpose: To evaluate the superiority of scaffold-associated chondral-regeneration proce-dures over microfracture by assessing: (1) Patient-reported outcomes; (2) Intervention fail-ure; (3) Histological quality of cartilage repair.Study Design: A three-concept keyword search strategy was designed, in accordance with PRISMA guidelines: (i) knee (ii) microfracture (iii) scaffold. Four databases (Ovid Medline, Embase, CINAHL and Scopus) were searched for comparative clinical trials (Level I-III evi-dence). Critical appraisal used two Cochrane tools: the Risk of Bias tool (RoB2) for random-ized control trials and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I). Study heterogeneity permitted qualitative analysis with the exception of three patient-reported scores, for which a meta-analysis was performed.Results: Twenty-one studies were identified (1699 patients, age range 18-66 years): ten ran-domized control trials and eleven non-randomized study interventions. Meta-analyses of the International Knee Documentation Committee (IKDC), Knee Injury And Osteoarthritis Outcome Score (KOOS) for pain and activities of daily living, and Lysholm score demon-strated statistically significant improvement in outcomes for scaffold procedures compared to microfracture at two years. No statistical difference was seen at five years.Conclusion: Despite the limitations of study heterogeneity, scaffold-associated procedures appear to be superior to MF in terms of patient-reported outcomes at two years though sim-ilar at five years. Future evaluation would benefit from studies using validated clinical scor-ing systems, reporting failure, adverse events and long-term clinical follow up to determine technique safety and superiority.Crown Copyright (c) 2023 Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).