PATHOLOGY
Medial femoral condyle focal chondral defect
TREATMENT
Osteochondral autograft transplant
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 42-year-old woman who had an acute twisting event and developed the onset of medial-sided right knee pain. She continued to complain of persistent right knee medial-sided weight-bearing pain and discomfort in addition to activity-related swelling. Her symptoms were not alleviated by a trial of antiinflammatory medication as well as a course of physical therapy.
PHYSICAL EXAMINATION
Height, 5 ft, 4 in.; weight, 1551b. She has an antalgic gait. Her right knee has a moderate effusion. Her range of motion is 0 to 130 degrees. She is tender to palpation over the medial joint line and femoral condyle. Meniscal findings are equivocal, with pain reported with a varus axial load and rotation, but no palp- able click. Her hgament examination is within normal limits.
RADIOGRAPHIC EVALUATION
Plain radiographs were unremarkable (Figure CI 1.1). A magnetic resonance image (MRI) was obtained and found to be within normal limits.
SURGICAL INTERVENTION
Initially, it was believed that she had a medial meniscus tear and was therefore indicated for arthroscopy. At arthroscopy, she was diagnosed as having an isolated grade III to IV chondral defect measuring 12 mm by 12 mm in the weight-bearing zone of the medial femoral condyle. As this was the only pathology identified, it was treated with an isolated microfracture technique (Figure CI 1.2). Post- operatively, the patient was made nonweight bearing for approximately 6 weeks and was placed on continuous passive motion for a similar period of time. She did well for approx- imately the first 8 months. As her activity level increased, however, she developed activity- related effusions and persistent medial-sided symptoms.
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FIGURE CI 1.1. Anteroposterior (A) and lateral (B) radiographs of patient with a symptomatic medial femoral condyle chondral lesion diagnosed at
B
arthroscopy, but with no evidence of defect demon- strated by plain radiographs or MRI.
Because of persistent symptoms, she was indicated for osteochondral autograft trans- plantation of the medial femoral condyle. At the time of surgery, there was significant fibro-
cartilage fill of the medial femoral condyle, which was replaced with a 10-mm osteochon- dral autograft harvested from the lateral aspect of the trochlea (Figure CI 1.3).
FIGURE CI 1.2. (A) Arthroscopic photograph of a grade III to grade IV lesion of the weight-bearing zone of the medial femoral condyle with delamination. (B) Microfracture technique used to treat this lesion.
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B
FIGURE CI 1.3. At second-look arthroscopy (A), there is significant fibrocartilage fill within the previ- ously microfractured defect. However, it is soft to
palpation and the patient remains symptomatic.
(B) Ten-millimeter osteochondral autograft plug impacted into place.
FOLLOW-UP
At 18 months postoperatively, the patient remains painfree and has resumed all her activities. Follow-up radiographs demonstrate
excellent incorporation of the osteochondral autograft with no joint space narrowing, cystic change, or joint incongruity (Figure C11.4).
FIGURE CI 1.4. Anteroposterior (A) and lateral (B) radiographs, at 1-year follow-up demonstrate excel- lent incorporation of the osteochondral autograft
without evidence of joint space narrowing, cystic change, or joint incongruity.
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