PATHOLOGY
Lateral femoral condyle osteochondritis dissecans
TREATMENT
Fresh osteochondral allograft transplantation
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 male college student whose chief complaint is that of activity-related lateral-sided left knee pain, with associated swelling, stiffness, locking, and a sense of giving-way. His symptom onset began suddenly 2 years previously while playing soccer. His symptoms are made worse with weight bearing, running, impact activities, and prolonged standing. He desires to participate in collegiate-level sports.
He was initially treated 1 year previously with arthroscopy and removal of a necrotic 2.5 cm by 2.5 cm osteochondral fragment consistent with chronic osteochondritis dissecans of the lateral femoral condyle (Figure C14.1). He failed to improve following loose body removal and was referred for definitive treatment.
PHYSICAL EXAMINATION
Height, 6 ft, 2 in.; weight, 185 lb. He has a normal gait. Alignment reveals slight symmetric physi- ologic varus of approximately 2 degrees. He has a mild effusion with tenderness along the lateral femoral condyle. His range of motion is from 0 to 130 degrees. There is no evidence of any meniscal findings. He has shght patellofemoral and lateral compartment crepitus with range of motion. He has no evidence of quadriceps
atrophy. He has a normal patellofemoral joint and a normal ligament examination.
RADIOGRAPHIC EVALUATION
Forty-five-degree posteroanterior flexion weight-bearing and lateral radiographs demon- strate osteochondritis dissecans of the lateral femoral condyle of the left knee with a large cavitary defect involving more than 5 to 8 mm of subchondral bone at the base of the defect (Figure C14.2).
SURGICAL INTERVENTION
Because of the size, location, and depth of the lesion, the patient was indicated for fresh osteochondral allograft transplantation (Figure C14.3). Postoperatively, he was made non- weight bearing for approximately 8 weeks and used continuous passive motion for 6 weeks for 6 to 8h/day. At 6 months, he was permitted to engage in high-impact activities.
FOLLOW-UP
Two years following his allograft transplant, he complains of no pain, swelling, or catching. He has returned to all activities. He has radi- ographic evidence of graft incorporation and preservation of joint space (Figure C14.4).
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Case 14
43FIGURE
C14.1. Arthroscopic photograph of the defect obtained at the time of fragment removal demon- strates exposed subchondral bone with normal meniscus and normal lateral tibial plateau.
FIGURE
C14.2. Forty-five-degree flexion posteroan- terior weight-bearing (A) and lateral (B) radi- ographs demonstrate osteochondritis dissecans of
the lateral femoral condyle of the left knee with a
large cavitary defect.
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Case 14
B
FIGURE C14.3. Twelve months following fragment
removal, intraoperative photographs demonstrate fibrocartilage covering the subchondral bone (A).
(B) Fresh osteochondral allograft, measuring 25 mm by 25 mm, is press-fit within the lateral femoral condyle.
B
FIGURE C14.4. Two-year postoperative 45-degree
flexion posteroanterior weight-bearing (A) and non- weight-bearing (B) flexion lateral radiographs
demonstrate excellent incorporation of the lateral
femoral condyle osteochondral allograft.
Case 14
DECISION-MAKING FACTORS
1. A young high-demand patient with osteo- chondritis dissecans of the weight-bearing zone of the lateral femoral condyle.
2. Failure of previous treatment involving frag- ment removal with persistent symptoms.
3. A large (6.25 cm^) and deep lesion (greater than 6 to 8 mm of subchondral bone involve-
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