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A man with ipsilateral genu valgum, meniscus deficiency and osteochondral lesion
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A 21-year-old man presented with a 3-year history of intermittent 8/10 lateral right knee pain. He failed two prior surgical procedures done at outside hospitals. The patient initially sustained a jumping injury while playing basketball and recalled feeling a pop at the time. At presentation, his knee pain was associated with a catching sensation and swelling. He tried viscosupplementation injections and physical therapy without resolution of symptoms. Two years ago, he underwent arthroscopic partial lateral meniscectomy and chondroplasty at an outside hospital without improvement in symptoms. One year ago, he underwent arthroscopy and microfracture at a different outside hospital. His symptoms persisted and continued to be aggravated by playing basketball and other impact activities.
On examination, the patient could ambulate normally. Right knee flexion was 0° to 130° and was symmetric to his contralateral knee. Knee stability testing was normal. There was a small effusion. There was point tenderness that localized to the distal aspect of the lateral femoral condyle with the knee flexed 90°. Strength, sensation and reflex exams were normal and symmetric to the contralateral knee.
Radiographs of the right knee were grossly normal (Figure 1). A recent MRI demonstrated minimal chondromalacia patellae and a focal articular cartilage defect of the lateral femoral condyle which measured 2.4 cm anterior to posterior and 1.8 cm medial to lateral. A severe lateral meniscus deficiency was also apparent (Figures 2 and 3).
Source: Atul F. Kamath, MD, and Matthew L. Webb, MD
What is your diagnosis and treatment plan?
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Right lateral femoral condyle focal articular cartilage defect and lateral meniscus deficiency
A plan was made for right knee chondroplasty, partial lateral meniscectomy and articular cartilage biopsy. Biopsied cartilage would be used to produce an autologous chondrocyte implant for a subsequent lateral meniscus allograft and autologous chondrocyte implantation (ACI). The patient was counseled that any anterior knee pain may paradoxically worsen for the first 6 weeks following arthroscopy due to quadriceps weakness. In the meantime, he was advised to apply ice to the knee daily and continue weight-bearing as tolerated. Ultimately, the plan would be to undergo lateral meniscus allograft transplantation with ACI. He understood this plan.
The patient underwent arthroscopy of the right knee. The medial meniscus, ACL and PCL all appeared normal. There were diffuse grade I and II chondral changes of the medial and lateral tibial plateaus, and a small region of grade III chondral changes about the median ridge of the patella. In the setting of prior lateral meniscectomy, the lateral meniscus was noted to be markedly diminutive with about 90% of the meniscus removed.
On the lateral femoral condyle, a grade IV full-thickness focal articular cartilage lesion was found which measured 3.3 cm anterior to posterior and 2.4 cm medial to lateral. There were a few chondral loose bodies adjacent to this focal defect which were removed, the largest of which was 12 mm. Smaller additional loose bodies were also identified and removed from the medial and lateral gutters and throughout the knee. The unstable chondral fragments associated with the focal defect were resected and the surfaces of the defect were smoothed with a motorized shaver. In light of the size and location of this cartilage defect, ACI was considered to be the lead treatment option. Therefore, a biopsy of healthy articular cartilage was harvested from the far lateral aspect of the trochlea and sent to the proper destination using a biopsy transfer kit.
What additional information should be obtained prior to surgery, meniscus transplant and ACI?
Scanogram of lower extremities
A standing scanogram of the bilateral lower extremities was obtained which showed significant right knee valgus deformity (Figure 4).
It was believed that this valgus deformity should be corrected prior to ACI surgery to protect the integrity of the meniscus transplant and osteochondral autograft and to prevent treatment failure and recurrence of symptoms. These surgical procedures each involve several weeks of postoperative weight-bearing and activity restriction to protect implanted tissues from load and shear forces and to allow time for bony healing of osteotomy. To minimize the patient’s time in convalescence and rehabilitation, distal femoral osteotomy was offered as a simultaneous procedure along with lateral meniscus transplantation and ACI. The patient was counseled regarding extensive postoperative rehabilitation protocol and rationale for simultaneous procedures and he was aggregable with this.
Three months later, the patient underwent these procedures simultaneously. Right knee arthroscopy was performed in the normal manner and findings of severely diminutive lateral meniscus and focal defect of the lateral femoral condyle were redemonstrated. The lateral meniscal allograft was prepared by removing the meniscus from the allograft bone specimen with a scalpel. A running locking #2 suture was placed within the posterior horn near the posterior root. A similar running locking suture was placed within the anterior horn near the anterior root. A traction suture was placed in the junction of the body and posterior horn using a vertical-mattress, inside-out configuration with #0 absorbable suture (Figure 5). The residual meniscus was arthroscopically trimmed to a 1-mm rim for the remaining peripheral fragment. This remnant served to enhance fixation strength (Figure 6).
Meniscal allograft implantation
The posterior horn attachment sites on the tibial plateau were identified. A curette and burr were used to debride the overlying articular cartilage and superficial bone until bleeding bone was observed. Subsequently, the targeting guide for establishing the tibial tunnel for ACL reconstruction was used to drill a 2.4-mm transtibial tunnel from the anteromedial tibia to the posterior horn attachment site. A suture-passing wire was placed through this passage into the joint. A wire loop was then introduced into the joint and subsequently retrieved through the medial portal. The medial portal was enlarged, so that it was approximately 2.5-cm in length. Dissection was continued, overlying the capsule to allow the suture passing wire to be used to shuttle the suture about the junction of the body and posterior horn through the capsule about 1-cm apart. The meniscus allograft was then passed into the joint by pulling traction sutures attached to the posterior horn and the passing sutures. The graft was fixed at the posterior horn by tying the suture passed through the transtibial tunnel over a metallic button on the anteromedial tibial cortex. One all-inside meniscal repair device was used to repair the posterior horn. The traction sutures that were passed through the capsule were then sewn over the capsule to reinforce this repair.
The medial arthrotomy was then established immediately medial to the patella and patellar tendon. Care was taken to avoid injury to the articular cartilage and menisci. The anterior horn was secured with a suture anchor device. Three additional #0 absorbable sutures were placed in an outside-in manner through the anterior horn and anterior aspect of the body of the meniscus and were tied over the capsule, securing the meniscal allograft transplant. The meniscus allograft was circumferentially probed following repair to ensure that it was entirely secure. The meniscus was well visualized through the arthrotomy directly, as well as by using the arthroscopic camera, and found to have normal morphology.
ACI surgery with collagen membrane
The patella was gently subluxated laterally to provide adequate exposure of the lateral femoral condyle (Figures 7). The focal articular cartilage defect of the lateral femoral condyle was prepared for ACI by excising all unhealthy cartilage from the perimeter of the defect using a scalpel, sharp elevator and curettes. There was some central bony sclerosis and fibrous tissue, which was removed with the burr and curettes, respectively. Any bleeding of the subchondral bone was minimized by applying a sponge soaked in thrombin. A piece of foil was placed over the cartilage defect and traced with a fine-marking pen (Figure 8). This template was cut out and placed adjacent to the autologous cultured chondrocytes on porcine collagen membrane (matrix autologous chondrocyte implant - MACI). The MACI was then cut to the size of the template using scissors. The MACI was carefully oriented properly with respect to both rotation and version. The MACI was fixed to the articular margin of the cartilage defect with 6-0 absorbable suture using a simple technique in five places to ensure the membrane was secure (Figure 9). Fibrin glue was applied under the MACI. Gentle digital pressure was applied for 3 minutes. Additional fibrin glue was applied to the perimeter of the MACI to further secure the ACI.
All particulate debris was removed. The knee was carefully rinsed and then drained in the regions away from the recent ACI. The medial retinaculum and arthrotomy were repaired with a #1 braided absorbable suture using a figure-of-eight technique. Patellar tracking was evaluated and found to be central throughout the range of motion. The deep fascia immediately adjacent to the tibial tubercle was repaired with #0 braided absorbable suture. The deep dermal layer was closed with buried 2-0 braided absorbable suture.
Femoral osteotomy
Attention was then turned to the femoral osteotomy. The distal femur and shaft were approached through a standard subvastus exposure. Care was taken to identify and coagulate any perforating vessels in the surgical plane. Retractors were placed about the bone to prevent injury to neurovascular structures posteriorly and medially. The ideal location for eventual placement of the plate was identified using multiple fluoroscopic views of the distal femur.
A guide pin was placed parallel to the joint line. Next, using the alignment guide, two parallel pins were placed in the plane of the eventual osteotomy, leaving a sufficient bridge to the medial cortex (Figure 10). This was kept proximal to the patellofemoral articulation. The lateral cortex was opened with a thin kerf saw under saline cooling. Specialized osteotomes were then used parallel to the guide pins to finish the osteotomy. Appropriate plane and trajectory were confirmed in multiple planes. Next, opening wedge osteotomy was performed. Confirmation of appropriate correction in accordance with preoperative templating was made in the coronal and sagittal planes, and verified using a long-limb rigid rod technique. Appropriate weight-bearing coronal alignment was achieved.
The definitive plate was then placed. It was provisionally fixed, and a 6.5-mm cancellous screw was placed into the distal fragment. The long-limb alignment was preserved. Rotational alignment was again verified, as well as patellar tracking. The plate was then secured with multiple 4.5-mm cortex screws. Irrigation was then performed. Final fluoroscopy films in multiple planes demonstrated adequate osteotomy reduction, as well as appropriate placement of the fixation device. The limb was assessed and demonstrated appropriate length, alignment and rotation.
The wound was thoroughly irrigated. Hemostasis was confirmed. The fascia was closed using #0 absorbable suture to afford a water-tight closure. The knee was again taken through a range of motion and demonstrated excellent stability, patellar tracking and range of motion from full extension up to 90° flexion. Supplemental irrigation was then performed. The deep overlying tissues were closed with 2-0 absorbable suture. The skin was closed with 3-0 nylon suture. A sterile dressing was placed over the knee and an elastic wrap bandage was placed from the toes all the way up to the groin over a calf-high compressive stocking. A hinged-knee brace was applied in the OR under anesthesia and was locked in 0° extension.
The patient tolerated the above well. Intraoperative findings, rehabilitation plan and prognosis were discussed with the patient and family postoperatively. Continuous passive range of motion began 6 to 8 hours postoperatively starting at 0° to 30° of flexion and was advanced 5° to 10° per day up to 60°. During week 2, continuous passive motion was continued in 1-hour sessions for a maximum of 6 to 8 hours per day with maximum flexion of 90°. Otherwise the knee was kept braced at 0° flexion for the first 4 weeks. The patient was kept non-weight-bearing for the first 4 weeks postoperatively. At the 4-week postoperative visit, he was advanced to 25% weight-bearing as some evidence of healing was noted at the osteotomy site without hardware complication (Figure 11). At last follow-up, the patient was compliant with the postoperative rehabilitation protocol, tolerating it well and he was healing appropriately.
- References:
- DiBartola AC, et al. Knee. 2016;doi:10.1016/j.knee.2016.01.017.
- Flanigan DC, et al. J Bone Joint Surg Am. 2017;doi:10.2106/JBJS.16.01132.
- Frank RM, et al. J Am Acad Orthop Surg. 2018;doi:10.5435/JAAOS-D-17-00087.
- Harris JD, et al. Osteoarthritis Cartilage. 2011;doi:10.1016/j.joca.2011.02.010.
- Kamath AF et al. Clin Orthop Relat Res. 2010;doi:10.1007/s11999-010-1334-4.
- Magnussen RA, et al. Clin Orthop Relat Res. 2008;doi:10.1007/s11999-007-0097-z.
- Pareek A, et al. Cartilage. 2016;doi;10.1177/1947603516630786.
- Rosso F, et al. Am J Sports Med. 2015;doi:10.1177/0363546514536021.
- Sherman SL, et al. J Am Acad Orthop Surg. 2018;doi:10.5435/JAAOS-D-16-00179.
- For more information:
- James L. Carey, MD, MPH; and Matthew L. Webb, MD, can be reached at Hospital of the University of Pennsylvania, Department of Orthopaedic Surgery, 3400 Spruce St., Philadelphia, PA 19104. Carey’s email: james.carey @uphs.upenn.edu. Webb’s email: matthew.webb@uphs.upenn.edu.
- Atul F. Kamath, MD, can be reached at Center for Hip Preservation, Cleveland Clinic, Orthopaedic and Rheumatologic Institute, Cleveland, OH 44915; email: kamatha@ccf.org.
- Edited by Michael C. Ciccotti, MD, and Michael C. Fu, MD, MHS. Ciccotti is a chief resident in the department of orthopaedic surgery at Thomas Jefferson University and Rothman Orthopaedic Institute and will be a sports medicine fellow at the Steadman Phillipon Research Institute in Vail, Colorado following residency. Fu is a chief resident at Hospital for Special Surgery and will be a sports medicine and shoulder surgery fellow at Rush University Medical Center following residency. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
Disclosures: Carey reports he receives research support from AlloSource, Anika Therapeutics and Ossur and is a paid consultant for and receives research support from Vericel Corporation. Kamath and Webb report no relevant financial disclosures.