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Grand Rounds from HSS Management of Complex Cases

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Grand Rounds from HSS Management of Complex Cases WINTER 2011 VOLUME 2 ISSUE 1 Grand Rounds from HSS MANAGEMENT OF COMPLEX caSES Authors FROM THE EDITOR Federico P. Girardi, MD The discussion of complex cases in Grand Rounds from Hospital for Associate Attending Orthopaedic Surgeon Special Surgery focuses on the application of sound principles in Hospital for Special Surgery orthopaedic care. The principles emerging in the promising advances Associate Professor of Orthopaedic Surgery in knee joint restoration and preservation are evident in the first case: Weill Cornell Medical College Scott Rodeo uses osteotomy and allograft transplants to restore Amar S. Ranawat, MD alignment, the knee articular surface and meniscus in a young female Associate Attending Orthopaedic Surgeon athlete. The next case involves the knee of a patient with rheumatoid Hospital for Special Surgery arthritis that is beyond preservation, with cyst formation and significant Associate Professor of Orthopaedic Surgery bone loss, successfully replaced by Amar Ranawat using a custom Weill Cornell Medical College total knee implant. Severe traumatic segmental tibial bone loss in a seventeen-year-old male represents a Scott A. Rodeo, MD great challenge in limb salvage and tibial reconstruction. Roger Widmann is able to not only Attending Orthopaedic Surgeon save the limb but successfully restore structural integrity with meticulously staged bifocal Hospital for Special Surgery tibial transport. And in the final case, Federico Girardi demonstrates a novel approach to Professor of Orthopaedic Surgery treat a condition that continues to pose a challenging problem for spine surgeons: high Weill Cornell Medical College grade spondylolisthesis and spondylosis. Roger F. Widmann, MD You may view this publication on www.hss.edu, where you will find additional images and Associate Attending Orthopaedic Surgeon references as well as links to related articles on topics such as joint preservation and the Hospital for Special Surgery musculoskeletal specialists at HSS. We hope you find these cases to be of interest and the Associate Professor of Orthopaedic Surgery principles presented informative. Comments are always welcome at [email protected]. Weill Cornell Medical College Co-authors Arkady Blyakher, MD Pediatric Orthopaedics Surgical Assistant — Edward C. Jones, MD, MA, Assistant Attending Orthopaedic Surgeon Hospital for Special Surgery Vladimir Goldman, MD in this issue Orthopaedic Surgery Fellow, Limb Lengthening Hospital for Special Surgery Osteotomy and Allograft Transplants to Restore Stephanie Ihnow, BA Knee Articular Surface and Meniscus 1 Weill Cornell Medical College Morteza Meftah, MD Adult Reconstruction Research Fellow Complex Primary Total Knee Replacement Hospital for Special Surgery with Large Cystic Lesions 2 Fred Mo, MD Orthopaedic Surgery Fellow, Spine/Scoliosis Hospital for Special Surgery Severe Traumatic Tibial Bone Loss and Clifford Voigt, MD Orthopaedic Surgery Research Fellow Bifocal Tibial Transport 3 Hospital for Special Surgery Each author certifies that Hospital for Special Surgery has Management of High Grade approved the reporting of this case and that all investigations were conducted in conformity with ethical principles of Spondylolisthesis research. 4 1 Osteotomy and Allograft Transplants to Restore Knee Articular Surface and Meniscus Case presented by Scott A. Rodeo, MD, and Clifford Voigt, MD CASE CASE REPORT: A 25-year-old female basketball DISCUSSION: Approximately 1.5 million player presented to Hospital for Special Surgery arthroscopic knee procedures are carried (HSS) with pain localized largely to the lateral out each year, with over 50 percent involving side of her right knee, made worse with stair meniscal surgery. Meniscal preservation in the climbing. The patient had undergone subtotal form of meniscal repair is favored over partial lateral meniscectomy 11 years prior, followed or total meniscectomy. Commonly, patients who later by lateral meniscus transplantation as well as have undergone meniscectomy have articular placement of two osteochondral autografts in the cartilage defects likely due to excessive articular lateral femoral condyle. This procedure ultimately cartilage contact stresses. Appreciation of the Figure 1: MRI of the right knee demonstrating failed and she presented to HSS with complaints role of the meniscus in load transmission in incongruity of the lateral femoral condyle at of persistent pain and swelling in the right knee. the knee has led to an emphasis on meniscal the site of the prior osteochondral autograft preservation as well as possible meniscus with loss of articular cartilage. Attenuated Physical examination demonstrated valgus allograft transplantation. lateral meniscus extruded into the lateral deformity of the right knee. There was a large gutter. Deformity of the lateral tibial plateau effusion with full range of motion and lateral joint This case illustrates the combination of factors with diminished articular cartilage. line tenderness. A Steinman test reproduced that must be considered in complex knee both pain and clicking. Ligament stability was reconstruction; the primary factors include the intact. MRI demonstrated incongruity of the status of: 1) articular cartilage; 2) meniscus; lateral femoral condyle at the site of the prior 3) axial alignment; and 4) ligament stability. osteochondral autograft (Figure 1). Articular Malalignment must be corrected in conjunction cartilage on the transplanted osteochondral plugs with or prior to any type of articular cartilage Figure 2: Standing had been largely denuded. The transplanted resurfacing or meniscus replacement. A varus- hip to ankle AP lateral meniscus was diminutive and extruded producing osteotomy was used here to correct x-ray showing into the lateral gutter. There was deformity of the excessive valgus alignment. valgus alignment the lateral tibial plateau from excessive lateral of the right knee. The indications for meniscus transplantation placement of the lateral meniscus transplant bone include symptoms of early arthrosis in the slot. Our assessment at this time was early lateral setting of only early arthrosis. The knee should compartment arthrosis in the setting of lateral be stable and have appropriate alignment (i.e., meniscus deficiency and valgus malalignment in a lateral meniscus should not be transplanted a young patient (Figure 2). into a knee with excessive valgus alignment). We reconstructed the lateral compartment by The primary indication at this time for meniscus performing a single stage varus producing distal transplantation is to treat symptoms (typically femoral osteotomy with osteochondral allograft pain and swelling); there is currently no evidence resurfacing of the lateral femoral condyle as well that meniscus transplantation can forestall or as implantation of an osteochondral hemi-tibial reverse progressive degenerative changes in plateau allograft with attached lateral meniscus. the involved compartment. It is recognized Post-operative radiographs have demonstrated that the transplanted meniscus may ultimately Figure 3: AP and lateral x-rays of the right complete allograft incorporation with no degenerate; thus, meniscus transplantation knee after varus producing distal femoral progressive lateral compartment arthrosis may be considered an interim step in joint osteotomy with osteochondral allograft re- surfacing of the lateral femoral condyle as (Figure 3). The screws affixing the lateral tibial preservation in young patients. well as implantation of an osteochondral hemi-plateau allograft were removed at 15 months Meniscus transplantation can be done with hemi-tibial plateau allograft with attached following the surgery, at which time arthroscopic or without bone attached to the anterior lateral meniscus. inspection demonstrated the lateral meniscus to and posterior horns. Biomechanical studies have normal size, position and morphology with demonstrate superior fixation using bone at the intact horn attachments (Figure 4). The articular horn attachments. This can be done using either cartilage on the osteochondral allograft in both small, individual bone plugs on each horn or one the lateral femoral condyle and the lateral tibial common bone slot connecting the anterior and plateau appeared intact. The junction between posterior horns. The bone slot technique requires the osteochondral plug in the lateral femoral that the recipient slot be made just adjacent to condyle and the surrounding native articular the anterior cruciate ligament (ACL) with care Figure 4: Arthroscopic views of the right cartilage could still be discerned. There were knee demonstrate the lateral meniscus to taken not to injure the ACL or to displace the slot have normal size, position, and morphology early degenerative changes in the medial and too far into the lateral compartment. In this case with intact horn attachments. The articular patellofemoral compartments. At her most recent it appeared that the bone slot used for the initial cartilage on the osteochondral allograft in follow-up two years after surgery, the patient had lateral meniscus transplantation was displaced both the lateral femoral condyle and the mild activity-related discomfort but is able to lateral tibial plateau appeared intact. into the lateral compartment, damaging the The junction between the osteochondral participate in light activities such as hiking. articular surface of the tibial plateau. plug in the lateral femoral condyle and the surrounding native articular cartilage Article and references
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