¹Universitätsmedizin Mannheim, Klinik für Orthopädie und Unfallchirurgie, Mannheim, Deutschland
²Brigham and Women’s Hospital, Division of Sports Medicine, Boston, USA
³Medizinische Universität Wien, Abteilung für Orthopädie und Unfallchirurgie, Wien, Österreich

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Objectives and questions: Articular cartilage injuries of the knee can significantly impair function and quality of life, often leading to chronic pain and activity limitations. Despite advances in surgical techniques, outcomes vary widely. Emerging research suggests that psychological factors, including mental health status, pain catastrophizing, and resilience, may affect both subjective and objective measures of recovery following cartilage repair. However, their influence on key patient-reported outcomes remains insufficiently characterized. This systematic review and meta-analysis aimed to synthesize existing evidence on the impact of preoperative mental health on functional outcomes after knee cartilage restoration procedures.

Material and methods: A comprehensive search of EMBASE, PubMed, Web of Science, PsycINFO, and CINAHL was conducted from database inception in August 2024, following PRISMA guidelines. Eligible studies included patients with symptomatic, isolated or multiple knee cartilage defects (ICRS/Outerbridge grades 3–4), or osteochondritis dissecans (grade 3–4). Interventions involved autologous chondrocyte implantation (ACI), osteochondral autografts/allografts (OCA), autologous matrix-induced chondrogenesis (AMIC), minced cartilage, or bioceramic-based scaffolds, with a minimum one-year follow-up. Studies were excluded if patients had prior cartilage procedures or if prior procedures were not clearly stated. Included studies reported at least one psychosocial measure (SF-12/36 MCS) and one clinical or functional outcome (e.g., IKDC, KOOS). Meta-analysis of change scores (delta from pre- to postoperative) was performed using a random-effects model.

Results: Thirteen studies with a total of 527 patients met the inclusion criteria. Overall, mental health scores improved postoperatively (pooled mean MCS from 49.47±4.06 to 54.54±5.56). A significant negative association was found between higher preoperative MCS and improvements in key functional outcomes, including the IKDC (estimate = –1.40, p = 0.0033) and KOOS Pain (estimate = –1.46, p = 0.0236). Although clinical outcomes generally exceeded minimal clinically important difference thresholds, individuals reporting higher baseline mental health tended to exhibit smaller gains on certain measures.

Discussion and conclusion: Preoperative mental health status appears to influence self-reported improvements following knee cartilage restoration. Patients presenting with lower baseline MCS demonstrated relatively greater functional gains. These findings underscore the importance of considering mental screening and support when planning knee cartilage procedures, as optimizing mental health may enhance postoperative recovery trajectories.