Female athletes may have a greater challenge in returning to sport after contemporary cartilage procedures in the knee: A systematic review and meta-analysis.

Purpose: The goal of this systematic review is to assess the current literature for differences in return to sport (RTS) rates between male and female athletes after common cartilage procedures in the knee including autologous chondrocyte implantation (ACI), matrix-induced autologous chondrocyte implantation (MACI), osteochondral autograft transplantation (OAT), and osteochondral allograft transplantation (OCA).

Methods: Electronic databases were searched from inception to November 2024. Two independent reviewers screened 2,482 articles. The inclusion criteria were: studies from 2004 to present, level of evidence 1-4, reporting RTS data and sex specific outcomes after OAT, MACI, ACI, or OCA of the knee, with minimum follow-up of 12 months. The main outcome was difference in RTS rate among male and female athletes. RTS was defined as the percentage able to resume sport or military duty, and the percentage able to return to their pre-injury level (RPL) or full duty. A meta-analysis was conducted using the inverse variance method with a random-effects model to account for both within- and between-study variability to identify sex differences in RTS. Statistical analyses were conducted using R (Version 2024.09.0+375).

Results: Twenty-two primary studies encompassing 1,468 athletes after OAT, MACI, ACI, or OCA, reported sex specific outcomes. Fifteen of these reported no statistically significant difference in RTS in females vs. males. Five studies reported better RTS in males, and one reported better RTS in females. Only one study reported specific sex differences in RPL. Meta-analysis identified RTS rate of 75% for males and 56% for females.

Conclusion: There is a paucity of available data on RTS based on sex following contemporary cartilage procedures for chondral injuries of the knee. Meta-analysis of available data suggests females may have more difficulty with returning to sport than males.