Osteochondritis dissecans in bilateral lateral femoral condyle in knees

r e v b r a s o r t o p . 2013;48(6):578–580

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Case

Report

Osteochondritis

dissecans

in

bilateral

lateral

femoral

condyle

in

knees

夽

Ari

Zekcer

_,

_Ricardo

_Soares

_da

_Silva

,

Renato

Akira

Iwashita

,

Mario

Carneiro

Filho

a_{KneeSurgerySector,TatuapéOrthopedicsClinic,Taubaté,SP,Brazil}

b_{DepartmentofOrthopedicsandTraumatology,EscolaPaulistadeMedicina,UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil}

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Articlehistory:

Received30September2012 Accepted15January2013

Keywords:

Osteochondritisdissecans Knee

Cartilagearticular

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Theosteochondritisdissecans(OCD)isadiseaseofunknowncausethatclassicallyaffects thekneelateralborderofthemedialfemoralcondyle.WepresentararecaseofOCDin bilaterallateralfemoralcondyle.

©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Osteocondrite

dissecante

em

côndilo

femural

lateral

bilateral

nos

joelhos

Palavras-chave:

Osteocondritedissecante Joelho

Cartilagemarticular

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e

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Aosteocondritedissecante(OCD)éumapatologiadecausadesconhecida,que classica-menteacometenojoelhoabordalateraldocôndilofemuralmedial.Apresentamosumraro casodeOCDnocôndilofemurallateralbilateral.

©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

Case

report

Thepatientwasa28-year-oldwhitefemalenurseof seden-tary habits who presented a complaint of sudden pain in her left knee around 20 days earlier, without any history oftrauma.Theconditionimprovedwithnon-steroidal anti-inflammatorydrugsandworsenedafterphysicalexertion.She alsoreportedthatshehadhadasimilarconditioninherright

夽

WorkperformedattheTatuapéOrthopedicsClinic,Taubaté,SP,Brazil. ∗ _{Correspondingauthor.}

E-mail:ricardoortop@hotmail.com(R.S.daSilva).

kneethreeyearsearlier,buttherightkneewasasymptomatic atthistime.

On physical examination, she presented bilateral genu valgum with crepitation on flexion–extension and pain on anterolateral palpation in both knees.The pain was more intenseintheleftknee,whichalsopresentedeffusion(+/4+). RadiographsinAP,lateraland tunnelviewswere produced onthepatient,andalsobilateralmagneticresonance imag-ing (MRI). This revealed unstable osteochondral fragments

rev bras ortop.2013;48(6):578–580

579

Figure1–PreoperativeMRIontheleftknee.

measuring30mm×20mminthelateralfemoralcondylein

theleftkneeand30mm×28mmintherightknee.

Accord-ingtotheInsallclassificationforMRIonosteochondritis,1_the

lesionswereclassifiedasstageVontheleftsideandstageIV ontherightside(Figs.1and2).

Weimplemented surgicaltreatment initiallyon the left knee.Thepatientunderwentarthroscopywithjoint inspec-tion, in which we observed a chondral lesion of around 30mm×20mminthelateralfemoralcondyleoftheleftknee,

withaloosechondralfragmentinthejoint.Thisfragmentdid notpresentvitalityandwasofivoryappearance,andinsitu fixationwascontraindicated.Wethenperformedarthrotomy, withexposureofthelateralcondyleofthefemur.Wedecided toperformmosaicplasty,usinganautologousosteochondral graft. This was obtained by removing three osteochondral plugsfromthelateralfaceofthetrochleaofthelateralfemoral condyle(donorzone),usingtrephineswithan8mmArtrex® guide(Fig.3),inordertofilltheinjuredarea(recipientzone). Thepatientwasdischargedfromhospitalonedayafterthe

Figure2–PreoperativeMRIontherightknee.

Figure3–PostoperativeMRIontheleftknee.

surgery, without immobilization, but shecontinued to use crutchesfor45days,withoutweight-bearing,andwithpassive range-of-motionexercises.Herconditionevolved satisfacto-rily,withoutpainorlimitations.

Oneyear afterthe surgeryon theleft knee, the patient startedtocomplainofpainandjointlockingintherightknee. She then underwent surgical treatment with arthroscopy, which showed the lesion in the lateral femoral condyle and the presence of a free intra-articular body measuring around 30mm×30mm. We performed lateral arthrotomy,

withremovaloftheloosefragment,andmosaicplastyonthe lateralfemoralcondyle,inwhichthreeosteochondralplugs wereremovedfromthedonorzoneonthelateralfaceofthe trochlea,inthesamewayasdoneintheprocedureontheleft knee.However,thistime,theplugswereofdiameter10mm andweusedtrephineswithaJohnson&Johnson®_guide.We thenusedthesamepostoperativeprotocol,withsatisfactory evolution(Fig.4).

Oneyearandsixmonthshasnowpassedsincethe opera-tionontheleftknee,andsixmonthssincetheoperationon therightknee,andthepatientdoesnothaveanycomplaints orlimitations.

Discussion

Osteochondritisdissecans(OCD)isapathologicalcondition ofunknowncausethatoccursinthesubchondralbone.2,3_It

presentsinajuvenileform,whenthegrowthplateisopen, orinanadultform,whenitispresentinthemature skele-ton.Thelattergenerallyrequiressurgicaltreatmentandhas worseprognosis.Clinically,itpresentsseveralformsof mani-festation.

Itclassicallyaffectsthelateralborderofthemedialfemoral condyle.2_{Bilateraloccurrenceandcasesinthelateralfemoral}

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Figure4–PostoperativeMRIontherightknee.

Itisclassifiedinaccordancewiththeanatomicallocation, stabilityofthefragmentandalterationsseenonMRI, scintig-raphyandradiographs.2 _{Alterationsseen inimagingaid in}

choosingthetherapyand,whenthisisthecase,inthe evolu-tionofconservativetreatment.3

Thesurgical treatmentcomprises several techniques,4–8

such as resection of the fragment, arthroscopic drilling, mosaicplasty,insitufixationofthefragmentand microfrac-turing,amongothers,accordingtothelocationandviabilityof thefragment.9_{However,initialarthroscopyhasbeenshown}

to beimportant forevaluating the type and extent ofthe lesionandthemobilityoftheosteochondralfragment.Ithas adirectimplicationinthechoiceofappropriatetherapyand inperformingitarthroscopicallywhenpossible.Arthrotomy canalsobechosen,whennecessary.10_{In thepresent case,}

afterperformingarthroscopyandassessingthevitalityofthe fragmentanditssize,wedecidedtousemosaicplasty.

In this manner, we have reported a rare bilateral case ofosteochondritis dissecansofthe lateralfemoralcondyle, whichwastreatedbymeansofthemosaicplastytechnique withgoodclinicalresults.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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