Positive predictors of hip mosaicplasty outcomes: a systematic review and meta-analysis with knee comparison

Introduction

Osteochondral defects of the hip present unique challenges for orthopedic surgeons due to their complexity and potential impact on quality of life. Although these defects are rare, they can result in mechanical dysfunction, substantial pain, and disability (1). Osteochondral lesions of the hip account for only 2% of such lesions. However, magnetic resonance imaging (MRI) reveals that up to 76% of patients presenting with mechanical hip dysfunction exhibit chondral lesions (2,3). The etiology of these defects is multifactorial and includes conditions such as avascular necrosis (AVN), trauma, femoroacetabular impingement (FAI), osteonecrosis, dysplasia, and cancer.

Several surgical interventions are available for treating osteochondral defects, including debridement, microfracture, autologous chondrocyte implantation (ACI) and osteochondral autograft transplantation (OAT), also known as mosaicplasty. Initially introduced by Hangody et al. in 1999 for knee cartilage defects, this procedure involves harvesting healthy cartilage from non-weight-bearing portions of the hip or knee for transplantation to the site of the cartilage defect (4). Despite the increasing adoption of OAT in clinical practice, its application in the hip remains underexplored, with most studies limited to small cohorts and case series.

Given the goal of restoring hip function and reducing pain, evaluating patient-reported outcomes like the Harris Hip Score (HHS) is essential in assessing the success of interventions, such as OAT. The HHS is a validated tool that evaluates pain, function, absence of deformity, and range of motion (5). A higher score is indicative of better hip function, with a total possible score of 100, signifying no dysfunction. Scores are categorized as poor (<70), fair [70–79], good [80–89], and excellent [90–100] (6). The purpose of this study is to explore the positive predictor factors for significant increases in the HHS score in post-operative patients undergoing hip OAT. By identifying these predictors, the study aims to provide insight into the characteristics and interventions associated with better outcomes, ultimately contributing to further research and clinical practice in the treatment of hip osteochondral defects. We present this article in accordance with the PRISMA reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-10/rc).

Methods

This systematic review and meta-analysis were performed by searching multiple databases, including PubMed, CINAHL, SCOPUS, Embase, and the Cochrane Central Register of Controlled Trials in December 2024 for articles related to mosaicplasty of the hip. The terms “hip” AND (“osteochondral autograft transfer” OR “mosaicplasty”), were searched from the database inception to December 2024. Screening was completed by team members. Studies were screened independently by two authors for relevance, ensuring a primary focus on OAT in the hip for human subjects. Eligible studies were then assessed for inclusion based on the following criteria: articles must be available as free full-texts or accessible via institutional subscriptions, studies must utilize the HHS pre- and post-operatively to evaluate patient functionality, and systematic review or meta-analysis articles were excluded. The study selection process followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, and a flow diagram illustrating the evaluation and selection process is shown in Figure 1. All included studies reported complete pre- and post- operative HHS data, with no missing values.

Figure 1 PRISMA flow diagram. HHS, Harris Hip Scores.

Due to the rarity of hip OAT procedures, non-randomized studies were included to capture a broader range of clinical experiences, recognizing that these studies may introduce heterogeneity. No randomized controlled trial (RCT) met the inclusion criteria, which reflects the limited high-level evidence currently available on hip OAT. As a result, the findings of this meta-analysis are based solely on observational studies, which are inherently more susceptible to bias and confounding. The quality of the methodologies of this study was evaluated using the Modified Coleman Methodology Scores (MCMS). The MCMS is a scaled 15-question tool used to quantify the methodology quality. Scores can range from 0–100 (0–54 is poor, 55–69 is fair, 70–84 is good, and 85–100 is excellent).

The risk of bias for the non-randomized studies was assessed using the Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool, which evaluates biases at seven domains, including confounding bias, selection bias, bias in classification of interventions, bias due to deviations from intended interventions, bias due to missing data, bias in measurement of outcomes and bias in selection of reported results. This tool was used for all included studies to establish transparency in reporting and account for the potential impact of biases on the results.

Statistical analyses

Statistical analyses were performed using Stata 15.1 Software. A random-effects meta-analysis model evaluated HHS improvements, allowing for the variability observed across the included studies. Subgroup analyses were performed to explore differences in outcomes based on gender, follow-up duration, age, defect size, etiologies, donor site, surgical approach, and the presence of complications. Given the small sample sizes and heterogeneity of the studies, random-effects models ensured stronger and more generalizable estimates of effect size. Additionally, meta-regression analyses were conducted to determine the influence of specific variables, with significance set at P<0.2 due to the limited number of studies. Sensitivity analyses were not conducted due to the limited number of studies; however, the stability was reviewed by assessing heterogeneity.

Results

After querying the databases and registers, 1,233 articles were identified, of which only 11 free full-text articles met the inclusion criteria. These studies included a total of 70 patients, with sample sizes ranging from 1 to 22 participants per study. The MCMS scores for methodological quality ranged from 31 to 80, with a mean of 44.32, categorizing the overall quality as poor. Table 1 summarizes the study characteristics, including demographic data, design features, and reported outcomes. The risk of bias, assessed using the ROBINS-I tool, revealed that all eleven studies were classified as having moderate risk (Table 2). The reported post-operative HHS improvements across studies ranged from 25.80 to 53.00 points, reflecting significant subjective surgical success (Figure 2). Low heterogeneity was observed among the studies, as indicated by an I² statistic of 10.1%, suggesting consistency in the reported outcomes. This low heterogeneity is likely due to consistent surgical interventions.

Figure 2 Clinical outcomes HHS. CI, confidence interval; d.f., degrees of freedom; ES, effect size; HHS, Harris Hip Score; I-V, inverse-variance.

Subgroup analysis

Gender based analyses categorized patients into male, female, and mixed-gender cohorts. HHS improvements ranged from 31.00 to 53.00 points (I²=6.3%, P=0.37) for males, 40.00 points in female-only cohorts, and 26.70 to 45.85 points (I²=3.2%, P=0.39) for mixed-gender studies. Although all gender groups showed significant improvements (P<0.001), no statistically significant differences were found between groups (heterogeneity between groups: P=0.26; meta regression: P=0.21).

Follow-up durations were grouped into 0–2, 3–5, and >5 years. Improvements ranged from 26.70 to 53.0 points for the 0–3 years cohort (I²=3.0%, P=0.40), 25.80 to 45.85 points for the 3–5 years cohort (I²=45.0%, P=0.16), and 41.00 points for the >5 years cohort. Despite observed differences, no statistically significant variation in outcomes was noted between follow-up periods (heterogeneity between groups: P=0.52; meta-regression: P=0.71).

Patients were categorized into three age groups: <20, 20–30, and >30 years. Subgroup analysis revealed the following: <20 years cohort showed improvements of 26.70 points, the 20–29 years cohort improved from 25.80 to 53 points (I²=10.0%, P=0.35), and the >30 years cohort showed an improvement of 29.40 to 45.85 points (I²=56.1%, P=0.13). No statistically significant differences were found between the age groups (heterogeneity between groups: P=0.54; meta-regression: P=0.38).

Defects were categorized into <1 cm, 1–2 cm, and >2 cm. HHS improvements ranged from 29.40 to 41.00 points for defects <1 cm (I²=0.0%, P=0.52), 31.00 to 45.85 points for defects 1–2 cm (I²=0.0%, P=0.60), and 25.80 to 53.00 points for defects >2 cm (I²=64.9%, P=0.058). Despite these ranges, no statistically significant differences were observed between defect size groups (heterogeneity between groups: P=0.52; meta-regression: P=0.43).

The studies included osteochondral defects arising from trauma, AVN, FAI, dysplasia, oncologic disease, and Perthes disease. Analysis of HHS changes based on the etiology revealed no significant differences in scores, as indicated by tests for heterogeneity (P=0.30).

Donor cartilage harvested from the ipsilateral knee demonstrated greater HHS improvements (29.40 to 53.00 points; I²=0.0%, P=0.45), compared to the ipsilateral femoral head (25.80 to 32.10 points; I²=0.0%, P=0.73). Grafts from the ipsilateral knee showed superior outcomes (heterogeneity between groups: P=0.06); meta-regression P=0.09).

The surgical approach was categorized as open or arthroscopic. HHS improvements ranged from 29.40 to 34.00 points for arthroscopic procedures (I²=0.0%, P=0.61) and 25.80 to 53.00 points for open procedures (I²=25.9%, P=0.21). No statistically significant difference in outcomes was observed between the two techniques (heterogeneity between groups: P=0.79; meta-regression: P=0.80).

Patients without complications showed HHS improvements ranging from 29.40 to 53.00 points (I²=0.0%, P=0.44), whereas those with complications exhibited a smaller range of improvement from 25.80 to 32.10 points (I²=0.0%, P=0.73). The meta-regression analysis indicated a statistically significant difference between these groups (heterogeneity between groups: P=0.06; meta-regression: P=0.09).

Discussion

OAT has been extensively studied in the knee, and emerging data on its application in the hip show promising potential for significant functional improvements. In this review, we analyzed 11 studies that used the HHS to assess functional outcomes of OAT for hip defects. The meta-analysis revealed significant mean post-operative increases in HHS across all studies included. The lowest reported post-operative score was 79.5, which is on the border between fair (14). All other scores were reported within the good to excellent range. These findings suggest that OAT can significantly improves patient reported outcomes compared to their pre-operative status.

All gender groups demonstrated significant increases in HHS, however, with no notable differences in improvements between groups. This aligns with the observation that most included studies examined both male and female participants without specifically reporting gender-based scores. Interestingly, studies of knee OAT have reported conflicting results regarding the gender influence. For instance, Ollat et al. suggested that male patients experience better outcomes compared to females, while Bentley et al. reported no significant difference (18,19). The role of gender in OAT outcomes for both the hip and knee remains unclear, requiring further investigation.

Consistent improvements in HHS scores across follow-up durations suggest that the functional benefits from OAT are maintained over time. However, the limited follow-up durations in most studies, with few extending beyond 5 years, limit the ability to evaluate long-term outcomes. Among the studies with >5 years of follow-up, patients continued to demonstrate improved HHS scores, suggesting sustained functional gains. Nonetheless, isolated case series have described instances of graft wear, partial resorption, or progressive joint degeneration over time, particularly in patients with higher initial defect burden or underlying osteoarthritis (20). These findings emphasize the need for extended longitudinal studies to characterize the durability and failure rates of hip mosaicplasty more accurately beyond the mid-term follow-up period. Recent work by Beck et al. (2025) supports this, demonstrating long-term functional improvements but also variability in outcomes tied to lesion size and pre-existing joint pathology (21).

Although this review includes a small number of studies with follow-up periods extending beyond 5 years, long-term outcome data on hip mosaicplasty remain sparse. The few available studies report continued improvement in functional scores; however, these are limited by small sample sizes and a lack of standardized reporting. Without robust longitudinal data, it is difficult to draw definitive conclusions regarding the durability and longevity of graft integration or the potential for degeneration over time. Future research should prioritize long-term follow-up studies with consistent outcome measures to better evaluate sustained efficacy and inform patient expectations regarding hip OAT.

Postoperative HHS improvements were observed across all age groups, with no significant differences between them. This finding contrasts with studies on knee OAT, where age has been reported as both a positive and a negative predictive factor. For example, Frank et al. found that older patients reported higher Knee Injury and Osteoarthritis Outcome Score (KOOS) scores than younger patients, possibly due to differing recovery expectations (22). Meanwhile, Emre et al. identified an inverse relationship between age and functional knee scores, while Chow et al. found no significant differences between age groups (23,24). The conflicting evidence highlights the need for further research to better understand the role of age in OAT outcomes.

The influence of defect size on outcomes remains uncertain. While smaller cartilage defects are often associated with better results in both hip and knee OAT, this review did not find significant differences in HHS improvements based on defect size. Previous literature, such as Viamont-Guerra et al., reported that lesions >2 cm² have smaller improvements in clinical scores, while Anthonissen et al. identified larger defect sizes as a negative predictive factor (9,25). Comparatively, in knee OAT, Hangody et al. determined that lesions between 1–4 cm² is the ideal size for OAT, a finding solidified by Emre et al., who observed worse functional outcomes in patients with lesions >4 cm² (23,26). Future research with larger cohorts and standardized reporting on defect size is necessary to clarify its impact on hip OAT outcomes.

The etiology of osteochondral lesions did not significantly influence post-operative HHS outcomes. However, donor cartilage harvested from the ipsilateral knee resulted in significantly greater HHS improvement compared to grafts from the ipsilateral femoral head. This finding highlights the potential advantages of biomechanical compatibility, as knee cartilage may better align with the functional and mechanical demands of the recipient site (27). Biomechanically, articular cartilage from the knee, particularly from the femoral condyles, exhibits structural properties that may favor its use in hip OAT (26). Studies have shown that the compressive stiffness and aggregate modulus of cartilage in the femoral condyles are comparable to those in the femoral head, suggesting similar load-bearing capabilities and resistance to shear forces (28,29). Furthermore, cartilage thickness in these regions is similar between the hip and knee, which may enhance congruity and graft integration at the recipient site. These properties may explain the improved outcomes observed in patients receiving knee-derived grafts, as they potentially support superior structural compatibility and long-term durability of the repair. Nonetheless, harvesting from the knee introduces concerns about surgical morbidity and patient satisfaction. Controlled studies are needed to validate these findings and evaluate the long-term impact of donor site selection.

When considering treatment options for hip cartilage defects, mosaicplasty is one of several surgical strategies available. Microfracture remains a widely used technique for small lesions due to its simplicity and cost-effectiveness, but studies have shown that it may lead to fibrocartilage formation with inferior mechanical properties and diminished long-term durability (30). Augmented microfracture using scaffolds or biologics has been developed to address some of these limitations, yet evidence in the hip remains limited. ACI, though more established in the knee, has been applied to the hip with promising results for larger defects; however, it requires two stages and specialized infrastructure (29). Osteochondral allograft transplantation is another viable option for larger or previously treated lesions, particularly when autograft availability is limited, but it presents challenges such as graft viability, immune response, and limited availability (31). Recent reviewers have emphasized that despite the range of available techniques, an ideal standard for hip cartilage repair remains transient due to the variability in lesion presentation and surgical expertise (32). Compared to these techniques, mosaicplasty offers the advantage of hyaline cartilage transplantation in a single-stage procedure, with favorable short- to mid-term outcomes particularly in younger patients with focal lesions.

The type of surgical approach, whether open or arthroscopic, did not significantly affect post-operative HHS outcomes. Heterogeneity analyses confirmed consistency across techniques. While these results suggest similar functional benefits, future research could explore differences in recovery trajectories and the impact of surgical techniques on short-term outcomes.

Patients without complications exhibited significantly greater HHS improvements compared to those with complications. Pain, whether anticipated or unexpected, is a key factor influencing mobility and functional recovery. Complications can hinder these improvements, emphasizing the importance of minimizing intraoperative and postoperative risks through careful surgical planning, adequate technique, and thorough follow-up care.

Despite its contributions, this study has several limitations. Recognizing these limitations is essential for appropriately contextualizing our findings and guiding future clinical application and research. No RCTs met our inclusion criteria, and all included studies were observational, primarily small non-randomized case series. This limits the overall strength of the evidence and increases the potential for bias and confounding. The low mean methodological quality score was 44.32, indicating poor quality across included studies. Most of the studies were non-randomized case series with small sample sizes and lacked control groups, limiting the internal validity and increasing susceptibility to bias. The total number of patients across all studies was only 70, which further restricts the generalizability of our findings and may not capture the full spectrum of presentation. ROBINS-I assessment identified eleven studies with a moderate risk, highlighting the need for cautious interpretation of our findings. The small sample sizes and variation in follow-up durations limit the generalizability of these results and weaken confidence in the pooled outcomes. To strengthen the evidence base, future research should focus on conducting larger, high-quality RCTs with a more diverse. Long-term follow-up studies are essential to assess the durability of HHS improvements and their impact on quality of life. Finally, incorporating alternative outcome measures such as imaging data could offer a more comprehensive assessment of hip OAT’s efficacy.

Conclusions

OAT shows promising potential for improving functional outcomes in patients with hip cartilage defects, as evidenced by the postoperative increases in HHS across diverse patient groups. This study aimed to evaluate positive predictors for significant increases in HHS scores in postoperative patients, revealing that donor cartilage harvested from the ipsilateral knee and the absence of complications were associated with superior outcomes. While the procedure appears effective regardless of age, gender, defect size, or surgical approach, further high-quality RCTs with long-term follow-up are essential. The current literature we have is an introduction to the potential this procedure holds for patients, emphasizing the need to refine patient selection criteria, optimize donor site usage, and assess the durability of outcomes to fully establish OAT’s role in hip cartilage repair.

Acknowledgments

This research was previously presented and published as an abstract at the Tower Health Research Day in April 2024 (https://scholarcommons.towerhealth.org/th_researchday/2023-2024/online_posters/75/).

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-10/rc

Peer Review File: Available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-10/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-25-10/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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