Combined Trochlear,Patellar,Medial and Lateral Condyle Fresh Osteochondral Allograft Transplantation: A Case Report

Abstract

Background:

This is a case report of a 41-year-old man with torsional knee trauma in 2019 and chondral lesions. Previous microfracture had failed, and the patient presented with a dull pain and knee effusion. Imaging revealed multiple focal lesions including trochlea, patella, medial condyle, and lateral condyle. Fresh osteochondral allograft (OCA) transplantation is a versatile treatment for large defects as it is based on mature, living hyaline cartilage attached to a bone interface. A patient with multiple chondral lesions is rare, and this report presents a case with multiple symptomatic large focal lesions in the knee that underwent a fresh OCA in all 3 knee compartments.

Indications:

Osteochondral allograft is indicated for patients who present with activity-related pain and recurrent knee effusion. Contraindications are patient clinical conditions that may lead to complications, such as tobacco use, inflammatory arthritis, or septic arthritis.

Technique Description:

After the chondral defect is exposed, an appropriate allograft Mega-OATS sizer (15-30 mm) is chosen. Cartilage and the subchondral bone are drilled until the desired depth. The donor allograft is drilled in the desired diameter, and excess bone is removed according to the previous measurements of the recipient site. The graft is advanced with firm pressure into the created socket. Postoperative rehabilitation includes a limited range of motion and proprioceptive weightbearing in the first 2 weeks but expected total weightbearing and a full range of motion by the sixth week.

Results:

Range of motion was full by 6 weeks of surgery. The effusion lasted for 2 months after the surgery. Fresh OCA is a good surgical option for patients with multiple large chondral defects.

Discussion/Conclusion:

Patient satisfaction is high since the mature cartilage leads to a fast rehabilitation compared with the other surgical procedures for large chondral defects. This technique appears to be effective also for multiple focal lesions as presented in this article.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This is a video case presentation of combined trochlear, patellar, medial and lateral condyle fresh osteochondral allograft transplantation in the knee.

Our conflicts of interest can be seen here.

Large chondral defects can present with pain and knee effusion. The treatment can be challenging, especially for multiple focal lesions.^3,5 Fresh osteochondral allograft transplantation is a versatile treatment for large defects since it is based on mature, living, hyaline cartilage.^1,2,4,6

In this case, we present a 41-year-old man with torsional trauma on his left knee during a soccer match in 2019. He presented with dull pain and knee effusion. A magnetic resonance imaging (MRI) scan from November 2019 revealed a trochlear chondral lesion with an intralesional osteophyte with the size of 20 mm × 15 mm and a lateral femoral chondral condyle lesion with the size of 13 mm × 10 mm.

An arthroscopic microfracture was performed with another orthopaedic surgeon team. The postoperative management included 15 days partial weightbearing with crutches and CPM (continuous passive motion) was not included.

In the follow-up, in 2022, with our team, the patient complains of joint effusion and persistent pain during activities. The physical examination reveals bilateral varus alignment, crepitus over flexion-extension, and hypotrophy of the left thigh.

Full-limb radiographs reveal mild bilateral varus alignment. The MRI reveals a trochlear lesion of 25 mm × 30 mm and a patellar lesion of 13 mm × 11 mm with an intralesional osteophyte, a medial femoral condyle chondral lesion of 11 mm × 8 mm, and also a lateral femoral condyle chondral lesion with an intralesional osteophyte.

A 2-stage surgical treatment was indicated: a first stage with an arthroscopic inspection and a second stage with a fresh osteochondral allograft transplantation with trochlear, patellar, medial femoral condyle, and lateral femoral condyle allografts.

In the arthroscopic inspection, we see a medial condyle chondral lesion (the medial meniscus is intact) and a lateral condyle chondral lesion (with a previous microfracture and the lateral meniscus is also intact). There is also a large trochlear chondral lesion with a lateral flap and a patellar chondral lesion. Here is a review of the arthroscopic inspection of the knee.

The step-by-step procedure of the osteochondral allograft technique is shown in this slide. We start with a midline skin incision and medial parapatellar approach. We expose the chondral defect; here we can see the trochlear defect.

To start, we compare the donor and the recipient by placing a guide wire and comparing the proximal and distal depth. We confirm the depth in the donor and then drill the graft. It is important to mark the 12-o’clock position. And this is the final aspect.

We drill with a 30-mm drill, place the dilator, and check the depth of all 4 cardinal points. We remove the graft from the donor, checking the graft height, and remove the bone excess. Wash the graft to avoid osteochondral donor cells and then place the graft in the socket. Fix it gently, tapping with a hammer, and then flexion-extension to accommodate the graft. This is the final aspect.

In the patellar defect, we repeat the previous procedure, placing a guide wire, drilling the defect, and placing the dilator. In the donor, we mark the donor site and drill a deep osteochondral graft. After that, we check the height of the plug and remove the bone excess. Always, wash the graft before. While placing the graft, add Vicryl at the bottom of the defect. This will help you remove the graft in case needed. And this is the final aspect.

Moving on to the medial femoral condyle, we saw a longitudinal lesion and decided to use two 10-mm plugs. We mark the defect area, place the guide wire, and drill the defect. Extract the plug from the medial femoral donor condyle and place it gently into the recipient. We fix the first plug with a K-wire and then repeat the procedure for the second plug: extracting from the donor and placing it into the recipient. This is the final aspect.

Finally, we make a lateral approach to expose the lateral defect; we see the previous failed microfracture and repeat the previous steps. Place a guide pin perpendicular to the cartilage, drill the recipient, checking always the desired depth, and then drill the donor, again checking the desired depth, and remove the bone excess. The height should be equal to the depth in the recipient. Wash the graft before placing it into the recipient. This is the final aspect.

To conclude, this is the trochlear defect and after a 30-mm plug; the patellar defect and after a 15-mm plug; the medial condyle defect and after two 10-mm plugs; and the lateral condyle defect and after an 18-mm plug. This is a quick summary of the surgery and all plug sizes; also the depth of all 4 cardinal points is here. And the donor final aspect.

The postoperative rehabilitation protocol included an extension knee brace for 2 weeks, an immediate range of motion from 0° to 90° as tolerated. In the first 2 weeks, it also included proprioceptive weightbearing with 2 crutches and then partial weightbearing with 2 crutches and finally full weightbearing with just 1 crutch. CPM was used for 4 weeks, and the return to play is estimated between 8 and 12 months.

Those are the references used in this video.

We thank you all for your attention.