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Osteochondritis Dissecans of the Trochlea: Case Reportଝ

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Osteochondritis Dissecans of the Trochlea: Case Reportଝ r e v b r a s o r t o p . 2 0 1 8;5 3(4):499–502 SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA www.rbo.org.br Case Report Osteochondritis dissecans of the trochlea: case reportଝ a,b,∗ a,b Guilherme Conforto Gracitelli , Fernando Cury Rezende , b,c a Ana Luiza Cabrera Martimbianco , Carlos Eduardo da Silveira Franciozi , a Marcus Vinicius Malheiros Luzo a Departamento de Ortopedia e Traumatologia, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil b Ortocity, Grupo do Joelho, São Paulo, SP, Brazil c Cochrane Brazil, São Paulo, SP, Brazil a r t i c l e i n f o a b s t r a c t Article history: The authors report a rare case of osteochondritis dissecans of the trochlea. The treatment Received 30 January 2017 of these lesions, in which the osteochondral fragment is not viable, is difficult and often Accepted 14 February 2017 limited in Brazil. A clinical case is presented with functional and radiological outcomes after Available online 8 June 2018 treatment with microfracture technique, bone graft, and collagen membrane coverage. © 2018 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Keywords: Ltda. This is an open access article under the CC BY-NC-ND license (http:// Knee joint creativecommons.org/licenses/by-nc-nd/4.0/). Cartilage, articular Osteochondritis dissecans Osteocondrite dissecante da tróclea: relato de caso r e s u m o Palavras-chave: Os autores relatam um caso raro de osteocondrite dissecante de tróclea. O tratamento dessas Articulac¸ão do joelho lesões com inviabilidade do fragmento osteocondral é difícil e muitas vezes limitado no Cartilagem articular nosso meio. Os autores apresentam resultados clínicos e radiológicos após o tratamento Osteocondrite dissecante com a técnica de microfratura, enxertia óssea e cobertura com membrana de colágeno. © 2018 Sociedade Brasileira de Ortopedia e Traumatologia. Publicado por Elsevier Editora Ltda. Este e´ um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http:// creativecommons.org/licenses/by-nc-nd/4.0/). ଝ Study conducted at Universidade Federal de São Paulo (Unifesp), Escola Paulista de Medicina, Departamento de Ortopedia e Trauma- tologia, Grupo do Joelho, São Paulo, SP, Brazil. ∗ Corresponding author. E-mail: [email protected] (G.C. Gracitelli). https://doi.org/10.1016/j.rboe.2018.05.003 2255-4971/© 2018 Sociedade Brasileira de Ortopedia e Traumatologia. Published by Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 500 r e v b r a s o r t o p . 2 0 1 8;5 3(4):499–502 bone edema at the base of the lesion, and partial bone marrow Introduction discontinuity of this fragment with horizontal orientation. In the intraoperative period, the osteochondral lesion Osteochondritis dissecans (OD) of the knee is an idiopathic, was unstable but not displaced (ICRS osteochondri- acquired, and focal lesion of the subchondral bone, which tis classification: Grade 3). The fragment measured may involve the adjacent articular cartilage. It occurs mainly 2.5 cm × 2.6 cm × 0.7 cm, with rounded edges, yellowish in active children and adolescents, affecting the femoral color, signs of bone resorption of the subchondral region, condyles of the knee. The patella (5–10%) and the trochlea and deep osteochondral cleft (typical signs of non-viability) (0.6–1%) are among the least-affected areas. The scientific (Fig. 2). literature on OD of the trochlea is scarce, and there is no con- The authors chose to resect the lesion and use de 1 sensus on the best treatment options. microfracture technique for treatment, using collagen mem- Treatment of juvenile OD is based on preservation of the ® brane (AMIC ) associated with bone grafting for coverage. A prominent osteochondral fragment, and efforts are made to lateral parapatellar incision was made; the retinaculum and 2 reinsert these fragments using metallic or absorbable screws. joint capsule were opened, and the osteochondral fragment In adult OD, the viability of the osteochondral fragment was identified and resected. The wound bed was debrided must be taken into account. If the fragment is viable, it with a curette. The edges of the lesion were cut vertically and is treated as the juvenile OD; if not, treatment follows the microfractures were made with a small joint icepick. 2 precepts of that for adult osteochondral lesions. Because An opening was made in the lateral cortical of the femur these are extensive lesions with subchondral bone involve- and the cancellous bone graft was removed with a curette. The ment, subchondral bone and cartilage repair techniques are bone graft was impacted at the bottom of the osteochondral used. The techniques include autologous osteochondral trans- lesion up to one millimeter above the level of the adjacent plantation (mosaicplasty), fresh homologous osteochondral subchondral bone. The defect was measured, and the porcine 2–4 transplantation, and bone grafting with collagen mem- ® ® collagen membrane (Chondro-Gide/Geistlich ) was cut to fit, brane/autologous matrix-induced chondrogenesis (AMIC ) and sutured with monochryl 5.0. Fibrin glue was placed at the 5–7 treatment, recently made available in Brazil. edges of the membrane as an additional sealing and fixation method (Fig. 3). In the immediate postoperative period, full weight-bearing Clinical case description in full extension (knee brace) was authorized as tolerated. Physical therapy with passive assisted ROM was authorized on the second postoperative week. After four weeks, a conven- Male patient, 19 years of age, with history of pain and knee tional physical therapy protocol was initiated, with emphasis effusion two years after sports practice. He had practiced on analgesia, muscle strengthening, stretching, and sensory- recreational football for four years. He denied instability and motor training. current or previous trauma. At physical examination, he pre- sented hypotrophy of the left quadriceps, symmetrical range After 12 months, the patient reported improvement in pain; ◦ ◦ of motion (ROM; 5 recurvatum and 140 of flexion), joint effu- complete ROM and moderate quadriceps hypotrophy were sion +2/+4, and patellar pain at compression (positive Rabot). observed. The magnetic resonance imaging evidenced repair The preoperative magnetic resonance image (Fig. 1) showed tissue that filled the surface of the lesion with satisfactory joint effusion and osteochondral lesion of the lateral trochlear bone integration and adequate leveling. No unstable frag- ◦ ◦ region (2.2 × 1.7 × 0.6 cm) with penetration of synovial fluid ments were detected (Fig. 4). The IKDC score improved from in to the bed of the lesion, signs that are characteristic of osteo- 62.7 to 74.7. The KOOS-pain improved from 83.3 to 94.4; KOOS- chondral fragment instability. The imaging exam also showed symptoms, from 60.7 to 85.7; KOOS-quality of life, from 56.2 to signs of chronic lesion, with the presence of subcortical cysts, 81.2; finally, the KOOS-daily life activity was 100 points in the Fig. 1 – Preoperative magnetic resonance imaging. A and B, axial sections indicating unstable osteochondral lesion with subchondral bone cysts; C, sagittal section showing partial reabsorption and fragmentation of the subchondral bone of the osteochondral fragment. r e v b r a s o r t o p . 2 0 1 8;5 3(4):499–502 501 Fig. 2 – A and B, unstable and fragmented lesion with partial resorption of the subchondral bone. Fig. 3 – A, debridement of the edges of the lesion and microfracture; B, removal of the spongy bone graft from the lateral femoral metaphysis; C, impaction of the bone graft; D, final appearance after coverage and suturing with collagen membrane. Fig. 4 – Post-operative magnetic resonance imaging showing bone graft integration, subchondral bone recovery, and early repair tissue formation at the joint surface. pre- and postoperative periods. The KOOS-sports/recreation compromise the entire trochlea. The literature demonstrates score worsened, from 95 to 85 points. that fresh homologous osteochondral transplantation is an excellent treatment option in cases of extensive osteochon- 2,6 dral lesions, but the patient did not agree in participating Discussion in this institution’s osteochondral transplantation program. Therefore, the authors decided on the microfracture tech- The present case reported an osteochondral lesion with seque- nique, bone grafting, and collagen membrane coverage. lae from a rare OD of the trochlea. Among the treatment A randomized clinical trial compared the results of the ® options, mosaicplasty was considered to be inadequate due AMIC technique with those of simple microfracture for the to the need to remove osteochondral cylinders from the treatment of small to medium chondral lesions in the knee 2 medial trochlea, which could create additional lesion and (mean of 3.6 cm ). A satisfactory improvement in clinical and 502 r e v b r a s o r t o p . 2 0 1 8;5 3(4):499–502 radiological outcomes was observed with both treatments up 2. Sadr KN, Pulido PA, McCauley JC, Bugbee WD. Osteochondral to two years of follow-up, and no differences were observed allograft transplantation in patients with osteochondritis 8 dissecans of the knee. Am J Sports Med. 2016;44(11):2870–5. between groups. 3. Gracitelli GC, Meric G, Briggs DT, Pulido PA, McCauley JC, Recently, a five-year follow-up study demonstrated deterio- Belloti JC, et al. Fresh osteochondral allografts in the knee: ration of clinical outcomes in patients who underwent isolated comparison of primary transplantation versus microfracture after two years of follow-up; those clinical out- transplantation after failure of previous subchondral marrow ® 6 comes remained stable in patients undergoing AMIC . The stimulation. Am J Sports Med. 2015;43(4):885–91. quality of the regenerated tissue was assessed by magnetic 4.
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