Summer 2007

Osteochondral Defect: Case Study

The patient, JD, was a 23-year-old male college student who presented for evaluation of his right knee. JD came in for evaluation because he had experienced a significant twisting injury while playing basketball, which resulted in pain, swelling and a locked knee that didn't allow full extension. Most activities, including walking, produced pain.

Four years previously, JD had experienced another twisting injury to the knee, which caused intermittent swelling and discomfort. About two years after the injury, JD started to feel a vague catching sensation in that knee.

A local physician performed an MRI and referred him to UCSF orthopaedic surgeon Christina Allen, M.D.

Allen's examination of JD demonstrated a decreased range of motion on the right leg (a lack of 10 degrees of extension to 120) when compared with the left (0 to 140). JD could stand only with his right knee bent. He had 20 percent quadriceps atrophy on the right side. Patellofemoral examination demonstrated no tendon tenderness, zero patellar tilt, no medial or lateral facet tenderness, 2+ medial and lateral patellar glide, and negative Clarke's sign. He had no lateral joint line tenderness, but some deep anteromedial joint line tenderness just medial to the patella and over the most lateral aspect of the medial femoral condyle.

Radiographs showed a loose body in the intercondylar notch about 3 centimers in size, and a 2 centimeters by 2 centimeters bone defect on the lateral aspect of the medial femoral condyle. MRI revealed the same defect, showing that it was 12 millimeters deep. In addition, there was some osteonecrosis in the underlying bone.

Diagnosis

Right knee osteochondral defect with possible osteochondral loose body in the interchondylar notch.

Treatment

JD was presented with several treatment options, including an immediate grafting of the defect with fresh cadaver allograft vs. removing loose bodies, working on getting back JD's range of motion and staging the site for either a mosaicplasty or a large osteochondral allograft. An option for interim treatment was to remove loose bodies arthroscopically, bone-graft the defect and pin the torn cartilage and bone back into place. But because the patient was being seen eight weeks after injury, the chance of having viable cartilage to pin was low.

The patient chose to have an osteochondral allograft if the displaced cartilage and bone fragment could not be pinned into place. A 14-millimeter diameter, 15-millimeter deep bone and cartilage plug was obtained from a size-matched cadaver. An open surgery was performed to cut out the damaged area and place the donor plug in the femur.

JD was nonweight-bearing on the leg for eight weeks after surgery, but against advice played basketball within four months of surgery and reinjured the knee. Allen did an arthroscopic evaluation after the reinjury and found some scar tissue, which she cleaned up. The patient then properly rehabilitated from the second arthroscopy and now plays basketball without pain. He reports that some sports involving twisting motions, such as snowboarding and golf, still cause occasional discomfort.

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