PATHOLOGY
Focal chondral defect lateral femoral condyle, prior lateral meniscectomy, and small focal chondral defect lateral tibial plateau
TREATMENT
Fresh osteochondral allograft transplant lateral femoral condyle, lateral meniscus transplant, and microfracture lateral tibial plateau
SUBMITTED BY
Brian J. Cole, MD, MBA, Rush Cartilage Restoration Center, Rush Univer- sity Medical Center, Chicago, Illinois, USA
CHIEF COMPLAINT AND
HISTORY OF PRESENT ILLNESS
This patient is a 19-year-old college student who was referred with a chief complaint of right knee weight-bearing lateral-sided knee pain, swelling, and inability to participate in high- level sports. Past surgical history is significant for a right knee lateral meniscectomy per- formed 5 years before his initial evaluation. The patient did well initially, for 2 years, and then underwent a repeat arthroscopy. At that time, he was documented to have grade III to grade IV changes of the lateral femoral condyle and some early tibial plateau changes. This debride- ment actually led to some symptom relief until his symptoms recurred, and he presented with progression of pain, swelling, and difficulty playing college-level baseball. At this time, he is unable to play baseball and is having some difficulty with other noncompetitive sports and high-level activities of daily living.
PHYSICAL EXAMINATION
Height, 6ft, 2 in.; weight, 1851b. He ambulates with a nonantalgic gait. He stands in symmetric and neutral alignment. His range of motion is 0
to 130 degrees. His right knee has a small effu- sion. He is tender to palpation over the lateral femoral condyle and lateral joint line.
Patellofemoral joint demonstrates good track- ing with no evidence of crepitus. Ligamentous testing is within normal limits.
RADIOGRAPHIC EVALUATION
Posteroanterior 45-degree flexion weight- bearing radiograph demonstrates signs of femoral condyle flattening, joint space narrow- ing along the lateral compartment, and early osteophyte formation along the tibial emi- nences of the right knee (Figure C32.1).
SURGICAL INTERVENTION
The patient was indicated for a diagnostic arthroscopy, at which time he was noted to have an absent lateral meniscus, a grade III to grade IV lesion of the lateral femoral condyle measur- ing approximately 30 mm by 30 mm, and an area of nearly grade IV cartilage loss in the central region of the tibial plateau measuring approxi- mately 10mm by 10mm (Figure C32.2). A formal microfracture of the lateral tibial plateau
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112 Case 32
FIGURE
C32.1. Forty-five-degree flexion posteroanterior radiograph demon- strates flattening of the right lateral femoral condyle, joint space narrowing, and early degenerative changes along the lateral tibial eminence.
was performed in an effort to prepare the knee for future lateral meniscus transplantation and fresh osteochondral allograft transplantation (Figure C32.3). The patient utilized continuous passive motion postoperatively and was non- weight bearing for approximately 6 weeks.
Six months following the microfracture, the patient still complained of lateral-sided pain, activity-related swelling, and difficulties with
activities of daily living and high-level sports. In consideration of the size of the lateral femoral condyle lesion and the early degenerative changes of the tibia, he was indicated for an osteochondral allograft transplant of the lateral femoral condyle and a simultaneously per- formed lateral meniscus allograft transplant.
Preoperative planning included radiographic sizing images (Figure C32.4). At the time of
FIGURE
C32.2. Index arthroscopy demonstrating diffuse grade IV changes of the lateral femoral condyle, absent lateral meniscus, and a localized area of articular cartilage loss on the lateral tibial plateau measuring approximately 10 mm by 10 mm.
FIGURE
C32.3. Focal cartilage defect of the lateral
tibial plateau treated with a microfracture technique.
Case 32 113
FIGURE C32.4. Anteroposterior (A) and lateral (B) radiographs with a 100-mm sizing marker in place being utilized for sizing of the allograft meniscus
transplant. Anteroposterior (C) and lateral (D) radi- ographs with magnification markers to calculate the required fresh osteochondral allograft size.
definitive treatment, the lateral tibial plateau was noted to have excellent fibrocartilage fill of the previously microfractured lesion (Figure C32.5). The patient underwent a fresh osteo-
chondral allograft transplant using a 30 mm by
30 mm fresh osteochondral allograft as well as
a concomitant lateral meniscus transplant
(Figure C32.6).
FIGURE
C32.5. Six-month second-look arthroscopy following isolated microfracture of the lateral tibial plateau demonstrates fibrocartilage fill of the central tibial plateau defect.
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FIGURE
C32.6. Intraoperative photograph at the time of arthrotomy of the focal cartilage defect of the lateral femoral condyle (A), with preparing the defect (B) for a 30 mm by 30 mm fresh osteochon-
dral allograft transplant (C). (D) Arthroscopic view
of lateral meniscus and osteochondral allograft in
place.
Case 32 115
FIGURE C32.7. Eighteen-month postoperative 45- degree flexion weight-bearing posteroanterior (A) and lateral (B) radiographs demonstrate allograft incorporation, preservation of joint space, incorpo-
B
