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A 2-staged method for treatment of deep osteochondral lesions of the knee joint
Case Report
A 2-Staged Method for Treatment of Deep Osteochondral Lesions of the Knee Joint Ozgur Cetik, M.D., F. Erkal Bilen, M.D., Yunus V. Sozen, M.D., and Gokhan Hepgur, M.D.
Abstract: We performed a 2-staged arthroscopic-assisted surgical procedure to treat a patient with a large osteochondral lesion of the knee joint. The osteochondral lesion was too comminuted to reattach; in addition, the underlying bony defect was too deep. In the first stage, autogenous cortical bone was used for grafting the bony defect along with screw fixation. The second stage consisted of screw removal and transplantation of autogenous osteochondral graft overlying the chondral defect. The osteochondral grafts were taken from the non–weight bearing areas of the same knee. Key Words: Osteochondritis dissecans—Mosaicplasty—Osteochondral defect.
O
steochondritis dissecans (OCD) is one of the most frequent causes of intra-articular loose bodies, especially in the knee joint. Approximately 85% of OCD is located in the lateral part of the medial femoral condyle.1,2 Two types of OCD have been described, the adolescent type and the adult type. OCD is most frequently seen between the ages of 13 and 21 years and it occurs twice as often in males than in females. The most common symptoms are general pain and locking of the knee joint. Repetitive trauma, focal vascular disturbances, disturbances in ossification of the femoral epiphyses, and genetic factors are thought to promote OCD formation, but the etiology of OCD remains uncertain. Its treatment is still evolving even though it was first described about 150 years ago.
CASE REPORT A 19-year-old man presented with complaints of swelling, pain, and occasional locking of his left knee. Physical examination showed a mild effusion covering the parapatellar grooves at the knee joint. There were no signs of infection. The range of motion of the knee joint was 0° to 130°, and pain was maximal above 90° of flexion. Radiographs revealed an intraarticular loose body and a defect of the lateral femoral
condyle (Figs 1 and 2). Computed tomographic scans showed the cystic nature and the depth of the bony defect (Figs 3 and 4). Magnetic resonance imaging showed a defect on the weight-bearing surface of the lateral femoral condyle 20 ⫻ 25 mm and 8 mm deep, including cystic areas (Fig 5). Arthroscopy showed osteochondral fragments distinct from the original lesion (Fig 6).
SURGICAL TECHNIQUE In the first stage, all loose bodies were removed. The defect was debrided using curettage and drilling with a Kirschner wire. A rongeur was used to shape the graft. A parapatellar mini-incision was used to pass the graft into the joint. The graft was stabilized with a cortical screw countersunk into the cartilage (Fig 7). After the graft had united with the defect, the second stage was performed. Between the first and the
Address correspondence and reprint requests to Ozgur Cetik, M.D., Sahrayi cedit mah tepe sok saray, Apt. No: 19/16, Kadikoy 81080, Istanbul, Turkey. E-mail: [email protected] © 2001 by the Arthroscopy Association of North America 1526-3231/01/1709-2908$35.00/0 doi:10.1053/jars.2001.26860
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: E35
1
2
FIGURE 1.
O. CETIK ET AL.
Preoperative plain-film anteroposterior radiograph.
FIGURE 2. Preoperative plain-film lateral radiograph showing the defect of the lateral femoral condyle and the loose body.
second stages full range of motion was allowed without weight bearing. Three months later, radiographs showed union of the graft (Fig 8) and this was confirmed arthroscopically when the screw was removed. Fibrous cartilage had formed over the graft (Figs 9 and 10), which required debridement. The chondral defect was restored using the Mosaicplasty system (Smith & Nephew, Andover, MA) in which autogenous hyaline osteochondral grafts were taken from the non–weight bearing surfaces of the lateral condyle and transplanted to the defective weight-bearing area (Fig 11). DISCUSSION OCD is characterized by the separation of osteochondral fragments from the joint surface and it often has a poor prognosis.3 The treatment of OCD should attempt to achieve a congruent joint surface with hyaline cartilage. The exact etiology of OCD is undetermined, but trauma, ischemia, genetics, and primary ossification defects of epiphyses are thought to be
FIGURE 3. Preoperative axial computed tomography scan showing the bony defect and the underlying cysts.
DEEP OSTEOCHONDRAL LESIONS OF THE KNEE
FIGURE 4. Preoperative sagittal computed tomography scan showing the depth of the bony defect.
FIGURE 6. dyle.
3
Arthroscopic view of the defect in the femoral con-
factors playing a role in OCD formation. No isolated factors have been shown to cause OCD.2-5 OCD can occur on any joint surface, including the talus, patella, capitellum, femoral head, wrist, and pilon tibia, but the femoral condyles are the most common location for the formation of OCD.3 Several classifications exist for OCD. According to the most popular classification by Clanton and DeLee, our case is a type 4 OCD.3 In this type, the treatment
FIGURE 5. Preoperative coronal section magnetic resonance imaging showing the defect at the lateral femoral condyle and the underlying cystic changes.
FIGURE 7. Early postoperative plain-film radiographs showing the position of the cortical graft.
4
O. CETIK ET AL.
FIGURE 10.
FIGURE 8. Three-month postoperative lateral radiograph showing the union of the graft.
FIGURE 9.
Arthroscopic view of the union of the graft to the bone.
The femoral condyle before Mosaicplasty.
of choice has been to debride the defective surface and to stabilize the osteochondral fragment using a Kirschner wire,4,6 bioabsorbable materials,7 or bony pegs.8 If the original osteochondral fragment is amenable to stabilization, autogenous osteochondral grafts are used for reconstruction.3 Coverny et al.9 used allografts to fix large osteochondral defects, but they observed early osteolysis and collapse of the allografts. Additionally, they found in their second-look arthroscopies that the cartilage of the allografts had became much thinner. We recommend a 2-staged approach for deep OCD. The first stage is to adequately prepare the OCD bed for the second stage, which uses autogenous cortical bone graft for the defect. In the second stage, after the graft has united to the host bone, osteochondral grafts
FIGURE 11.
The cortical grafts after Mosaicplasty.
DEEP OSTEOCHONDRAL LESIONS OF THE KNEE are used for reconstruction of the joint surface (Mosaicplasty).
REFERENCES 1. Mitsuoka T, Shino K, Hamada M, Horibe S. Osteochondritis dissecans of the lateral condyle of the knee joint. Arthroscopy 1999;15:20-26. 2. Schenck RC, Goodnight JM. Current concepts review osteochondritis dissecans. J Bone Joint Surg Am 1996;78:439-452. 3. Berlet CG, Mascia A, Miniaci A. Treatment of unstable osteochondritis dissecans of the knee using autogenous osteochondral grafts (Mosaicplasty). Arthroscopy 1999;15:312-316. 4. Cugat R, et al. Osteochondritis dissecans: A historical review
5. 6. 7. 8. 9.
5
and its treatment with cannulated screws. Arthroscopy 1993;9: 675-684. Federico DJ, Lynch KJ, Joki P. Osteochondritis dissecans of the knee: A historical review of etiology and treatment. Arthroscopy 1990;6:190-197. Johnson L, et al. Osteochondritis dissecans of the knee: Arthroscopic compression screw fixation. Arthroscopy 1990;6:179189. Matava M, Brown C. Osteochondritis dissecans of the patella: Arthroscopic fixation with bioabsorbable pins. Arthroscopy 1997;13:124-128. Victorof BN, Randal EM, Deutsch A. Arthroscopic bone peg fixation in the treatment of osteochondritis dissecans in the knee. Arthroscopy 1996;12:506-509. Convery RF, et al. Long-term survival of chondrocytes in an osteochondral articular cartilage allograft. J Bone Joint Surg Am 1996;78:1082-1088.
A 2-Staged Method for Treatment of Deep Osteochondral Lesions of the Knee Joint Ozgur Cetik, M.D., F. Erkal Bilen, M.D., Yunus V. Sozen, M.D., and Gokhan Hepgur, M.D.
Abstract: We performed a 2-staged arthroscopic-assisted surgical procedure to treat a patient with a large osteochondral lesion of the knee joint. The osteochondral lesion was too comminuted to reattach; in addition, the underlying bony defect was too deep. In the first stage, autogenous cortical bone was used for grafting the bony defect along with screw fixation. The second stage consisted of screw removal and transplantation of autogenous osteochondral graft overlying the chondral defect. The osteochondral grafts were taken from the non–weight bearing areas of the same knee. Key Words: Osteochondritis dissecans—Mosaicplasty—Osteochondral defect.
O
steochondritis dissecans (OCD) is one of the most frequent causes of intra-articular loose bodies, especially in the knee joint. Approximately 85% of OCD is located in the lateral part of the medial femoral condyle.1,2 Two types of OCD have been described, the adolescent type and the adult type. OCD is most frequently seen between the ages of 13 and 21 years and it occurs twice as often in males than in females. The most common symptoms are general pain and locking of the knee joint. Repetitive trauma, focal vascular disturbances, disturbances in ossification of the femoral epiphyses, and genetic factors are thought to promote OCD formation, but the etiology of OCD remains uncertain. Its treatment is still evolving even though it was first described about 150 years ago.
CASE REPORT A 19-year-old man presented with complaints of swelling, pain, and occasional locking of his left knee. Physical examination showed a mild effusion covering the parapatellar grooves at the knee joint. There were no signs of infection. The range of motion of the knee joint was 0° to 130°, and pain was maximal above 90° of flexion. Radiographs revealed an intraarticular loose body and a defect of the lateral femoral
condyle (Figs 1 and 2). Computed tomographic scans showed the cystic nature and the depth of the bony defect (Figs 3 and 4). Magnetic resonance imaging showed a defect on the weight-bearing surface of the lateral femoral condyle 20 ⫻ 25 mm and 8 mm deep, including cystic areas (Fig 5). Arthroscopy showed osteochondral fragments distinct from the original lesion (Fig 6).
SURGICAL TECHNIQUE In the first stage, all loose bodies were removed. The defect was debrided using curettage and drilling with a Kirschner wire. A rongeur was used to shape the graft. A parapatellar mini-incision was used to pass the graft into the joint. The graft was stabilized with a cortical screw countersunk into the cartilage (Fig 7). After the graft had united with the defect, the second stage was performed. Between the first and the
Address correspondence and reprint requests to Ozgur Cetik, M.D., Sahrayi cedit mah tepe sok saray, Apt. No: 19/16, Kadikoy 81080, Istanbul, Turkey. E-mail: [email protected] © 2001 by the Arthroscopy Association of North America 1526-3231/01/1709-2908$35.00/0 doi:10.1053/jars.2001.26860
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 9 (November-December), 2001: E35
1
2
FIGURE 1.
O. CETIK ET AL.
Preoperative plain-film anteroposterior radiograph.
FIGURE 2. Preoperative plain-film lateral radiograph showing the defect of the lateral femoral condyle and the loose body.
second stages full range of motion was allowed without weight bearing. Three months later, radiographs showed union of the graft (Fig 8) and this was confirmed arthroscopically when the screw was removed. Fibrous cartilage had formed over the graft (Figs 9 and 10), which required debridement. The chondral defect was restored using the Mosaicplasty system (Smith & Nephew, Andover, MA) in which autogenous hyaline osteochondral grafts were taken from the non–weight bearing surfaces of the lateral condyle and transplanted to the defective weight-bearing area (Fig 11). DISCUSSION OCD is characterized by the separation of osteochondral fragments from the joint surface and it often has a poor prognosis.3 The treatment of OCD should attempt to achieve a congruent joint surface with hyaline cartilage. The exact etiology of OCD is undetermined, but trauma, ischemia, genetics, and primary ossification defects of epiphyses are thought to be
FIGURE 3. Preoperative axial computed tomography scan showing the bony defect and the underlying cysts.
DEEP OSTEOCHONDRAL LESIONS OF THE KNEE
FIGURE 4. Preoperative sagittal computed tomography scan showing the depth of the bony defect.
FIGURE 6. dyle.
3
Arthroscopic view of the defect in the femoral con-
factors playing a role in OCD formation. No isolated factors have been shown to cause OCD.2-5 OCD can occur on any joint surface, including the talus, patella, capitellum, femoral head, wrist, and pilon tibia, but the femoral condyles are the most common location for the formation of OCD.3 Several classifications exist for OCD. According to the most popular classification by Clanton and DeLee, our case is a type 4 OCD.3 In this type, the treatment
FIGURE 5. Preoperative coronal section magnetic resonance imaging showing the defect at the lateral femoral condyle and the underlying cystic changes.
FIGURE 7. Early postoperative plain-film radiographs showing the position of the cortical graft.
4
O. CETIK ET AL.
FIGURE 10.
FIGURE 8. Three-month postoperative lateral radiograph showing the union of the graft.
FIGURE 9.
Arthroscopic view of the union of the graft to the bone.
The femoral condyle before Mosaicplasty.
of choice has been to debride the defective surface and to stabilize the osteochondral fragment using a Kirschner wire,4,6 bioabsorbable materials,7 or bony pegs.8 If the original osteochondral fragment is amenable to stabilization, autogenous osteochondral grafts are used for reconstruction.3 Coverny et al.9 used allografts to fix large osteochondral defects, but they observed early osteolysis and collapse of the allografts. Additionally, they found in their second-look arthroscopies that the cartilage of the allografts had became much thinner. We recommend a 2-staged approach for deep OCD. The first stage is to adequately prepare the OCD bed for the second stage, which uses autogenous cortical bone graft for the defect. In the second stage, after the graft has united to the host bone, osteochondral grafts
FIGURE 11.
The cortical grafts after Mosaicplasty.
DEEP OSTEOCHONDRAL LESIONS OF THE KNEE are used for reconstruction of the joint surface (Mosaicplasty).
REFERENCES 1. Mitsuoka T, Shino K, Hamada M, Horibe S. Osteochondritis dissecans of the lateral condyle of the knee joint. Arthroscopy 1999;15:20-26. 2. Schenck RC, Goodnight JM. Current concepts review osteochondritis dissecans. J Bone Joint Surg Am 1996;78:439-452. 3. Berlet CG, Mascia A, Miniaci A. Treatment of unstable osteochondritis dissecans of the knee using autogenous osteochondral grafts (Mosaicplasty). Arthroscopy 1999;15:312-316. 4. Cugat R, et al. Osteochondritis dissecans: A historical review
5. 6. 7. 8. 9.
5
and its treatment with cannulated screws. Arthroscopy 1993;9: 675-684. Federico DJ, Lynch KJ, Joki P. Osteochondritis dissecans of the knee: A historical review of etiology and treatment. Arthroscopy 1990;6:190-197. Johnson L, et al. Osteochondritis dissecans of the knee: Arthroscopic compression screw fixation. Arthroscopy 1990;6:179189. Matava M, Brown C. Osteochondritis dissecans of the patella: Arthroscopic fixation with bioabsorbable pins. Arthroscopy 1997;13:124-128. Victorof BN, Randal EM, Deutsch A. Arthroscopic bone peg fixation in the treatment of osteochondritis dissecans in the knee. Arthroscopy 1996;12:506-509. Convery RF, et al. Long-term survival of chondrocytes in an osteochondral articular cartilage allograft. J Bone Joint Surg Am 1996;78:1082-1088.