Surgical treatment of isolated cartilage lesions during anterior cruciate ligament reconstruction was associated with greater lesion stability but similar 2‐year clinical outcomes: A registry‐based matched‐pair second‐look study

Abstract Purpose The management of cartilage lesions encountered during anterior cruciate ligament reconstruction (ACLR) remains debated, with limited evidence on whether surgical treatment affects lesion progression or outcomes. This study aimed to compare structural progression and clinical outcomes of isolated cartilage lesions treated or left untreated during primary ACLR, using data from the Swedish Knee Ligament Registry (SKLR). Methods Patients who underwent both primary and revision ACLR between 2005 and 2024 were identified in the SKLR. Inclusion required an isolated cartilage lesion documented arthroscopically at primary ACLR. Multi‐compartment lesions and multi‐ligament procedures were excluded. A 1:1 matched analysis compared patients who underwent surgical cartilage treatment (debridement or microfracture) with untreated patients. Structural evolution was assessed by comparing arthroscopic findings at primary and revision ACLR and classified as stable, progressed or regressed based on International Cartilage Repair Society (ICRS) grade and lesion size. Secondary analyses included 2‐year revision‐free survival and patient‐reported outcomes (Knee injury and Osteoarthritis Outcome Score, EuroQol 5‐Dimension questionnaire, EuroQol Visual Analogue Scale) in patients without revision within 2 years. Results A matched cohort of 156 patients (78 treated and 78 untreated) was included. Baseline characteristics were comparable, except for operated side ( p = 0.007). At revision ACLR, treated patients showed higher lesion stability than untreated patients (21.8% vs. 5.1%; p = 0.005). This effect was significant in low‐grade lesions (ICRS I–II), with higher stability (27.1% vs. 5.1%; p = 0.002) and lower progression (15.3% vs. 32.2%; p = 0.050), while no differences were observed in high‐grade lesions. Two‐year revision‐free survival was comparable (log‐rank p = 0.53). Among patients without revision ( n = 88), both groups improved in patient‐reported outcome measures with no between‐group differences. Conclusions Surgical treatment of isolated cartilage lesions during primary ACLR was associated with greater structural stability at revision surgery, particularly in low‐grade lesions, without superior short‐term clinical outcomes. These findings suggest structural benefits may not translate into early improvement. Level of Evidence Level II, prospective comparative study.