PATHOLOGY
Multiple chondral defects
TREATMENT
Autologous chondrocyte implantation of the trochlea and medial and lateral femoral condyles
SUBMITTED BY
Jack Farr, MD, Cartilage Restoration Center of Indiana, Ortholndy, Indi- anapolis, Indiana, USA
CHIEF COMPLAINT AND
HISTORY OF PRESENT ILLNESS
This patient is a 43-year-old man with a 10-year history of lateral- greater than medial-sided knee pain as well as anterior knee pain. He complains of catching and effusions in his right knee. At the time of evaluation, he provided a history of having undergone arthroscopic treat- ment previously that provided minimal relief of his symptoms. The patient works as a full-time firefighter and complained of difficulty per- forming all his duties because of activity- related pain. His desire is to return to higher levels of activity that he previously enjoyed, including jogging and racquetball. At the time of initial presentation, he limited his activities to golf and biking and had gained 401b during the previous 2 years.
Review of the operative record indicates that 6 years previously he underwent chondroplasty and drilling of his femoral condyle. A repeat chondroplasty and drilling was performed 1 year before presentation. Despite these treat- ments, his symptoms recurred.
with a slightly antalgic gait on the right. He has a trace effusion. He has no gross atrophy. His range of motion is 0 to 130 degrees on the right compared to 0 to 135 degrees on the left. His ligament exam is unremarkable. He has marked tenderness on the lateral joint line and, to a lesser degree, at the medial joint line and patellofemoral joint. There are no mechanical signs, and patellar tracking is normal.
RADIOGRAPHIC EVALUATION
Weight-bearing anteroposterior and lateral radiographs show slight medial joint space nar- rowing and ossification changes in the lateral femoral condyle (due to prior drilling) (Figure C26.1).The Merchant view shows the patella to be centrally located. His long-leg alignment views show only 2 degrees of varus compared to the contralateral side. His magnetic reso- nance image (MRI) is consistent with a chronic osteochondritis dissecans of the lateral femoral condyle and chondrosis of the medial and patellofemoral compartments.
PHYSICAL EXAMINATION SURGICAL INTERVENTION
Height, 5 ft, 9 in.; weight, 2281b. The patient stands in slight varus alignment compared to neutral on the contralateral hmb. He ambulates
At the time of staging arthroscopy and biopsy for autologous chondrocyte implantation (ACI), grade IV chondrosis was noted at the
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trochlea (2.0cm by 3.0cm), medial (1.5cm by 2.0 cm), and lateral (1.2 cm by 1.1cm) femoral condyles (Figure C26.2). These lesions were contained. The opposing articular cartilage was intact. At the time of definitive treatment, ACI was performed for all three lesions (Figure C26.3). No realignment was performed.
FIGURE C26.2. At index arthroscopy, lesions of the (A) medial femoral condyle, (B) trochlea, and (C) lateral femoral condyle are visualized.
FIGURE C26.1. Anteroposterior (A) and lateral (B) radiographs demonstrate maintenance of joint spaces.
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A DRB
FIGURE
C26.3. Autologous chondrocyte implanta- tion (ACI) periosteal patches in place: (A) medial and lateral femoral condyles and (B) trochlea.
Postoperatively, the patient was made pro- tected weight bearing with crutches for 6 weeks and utilized continuous passive motion for 3 weeks initially with restricted motion. The patient slowly advanced to full, unrestricted activities by 18 months.
FOLLOW-UP
The patient had returned to high-level activities including full-time firefiighting. Second-look arthroscopy 3 years following the implantation revealed excellent fill and marginal integration of all defects (Figure C26.4).
FIGURE
