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    Chondral Shear Injury in a Teenage Basketball Player

    A 13-year-old male basketball player presents after injuring his left knee while running during a game. He’s diagnosed with a chondral shear injury. Which treatment option will help him get him back in the game?

    Authors

    Robert A. Jack II, MD, and Christopher D. Dodson, MD

    Introduction

    Chondral lesions of the knee are common, with a prevalence of more than 60% in patients undergoing knee arthroscopy.[1] Cartilaginous injuries occur frequently in athletes and may significantly limit performance if left unaddressed. [2,3] These are often acute injuries as a consequence of patellar instability, forced hyperextension, or direct blow to the knee, and they may lead to the creation of an osteochondral fragment. [4-7]

    In pediatric patients, the same mechanism may result in isolated cartilage shear injuries without bony involvement. [8,9] The treatment of these injuries remains challenging and somewhat controversial due to potentially decreased healing potential. [10,11]

    Treatment options for chondral injuries include:

    • Non-operative management with physical therapy
    • Cartilage repair
    • Bone marrow stimulation
    • Mosaicplasty/osteochondral autograft transfer system
    • Autologous chondrocyte implantation (ACI)
    • Osteochondral allograft (OCA) transplantation

    Treatment should be tailored to the patient’s age and the characteristics of the pathology, including size, multifocal involvement, location, subchondral bone involvement, and presence of bony malalignment.

    There is a paucity of data involving isolated chondral shear injuries, with no long-term data outlining rehabilitation, return to sport, or future development of degenerative joint disease in this patient population. As such, treatment and counseling of patients and their families remain challenging.

    One option for acute cartilage repair is the use of biocompression screws. The following case report demonstrates this treatment in a teenage athlete.

    Case Report

    A 13-year-old male basketball player presents with left knee pain 2 weeks after an injury sustained while running during a basketball game. He experienced a hyperextension injury to his knee and felt a pop, with immediate swelling and pain. He denies feeling any instability in the knee.

    Physical Exam

    • Height: 5 feet, 5 inches; weight: 112 pounds
    • Large effusion
    • Tenderness to palpation over the lateral joint line
    • Palpable and mobile fragment in the superolateral patellar pouch
    • Knee stable to varus/valgus stress

    Imaging

    • MRI demonstrates a large effusion, a chondral loose body (3.6cm x 2.0cm x 0.4cm) in the suprapatellar pouch and a full-thickness chondral injury to the lateral femoral condyle (Figures 1-2).

    Figure 1Sagittal T2weighted MRI revealing lateral femoral condyle chondral injury.

    Figure 2. Axial T2-weighted MRI demonstrating a large chondral loose body.

    Diagnosis

    • Chondral shear injury of the lateral femoral condyle

    Technique

    We discussed the diagnosis with the patient and his parents and recommended acute repair of the chondral shear injury with bioabsorbable screws. After carefully considering the possible complications, they agreed and surgery was scheduled.

    • The patient was placed in the supine position with appropriate padding of all bony prominences. A well-padded high-thigh tourniquet was applied to the operative extremity, and a leg positioner was used to ease extremity positioning during exposure and closure.
    • Diagnostic arthroscopy was performed first to identify other concomitant injuries. In this case, the medial meniscus, lateral meniscus, and medial compartment were found to be without injury. The loose fragment was encountered in the superolateral patellar pouch and was removed arthroscopically and placed into an antibiotic solution (Figure 3).
    • The donor lesion on the lateral femoral condyle was evaluated (Figure 4). It was determined that the donor fragment was in appropriate condition for repair and the remainder of the joint was found to be free of injury or loose bodies.
    • The knee was evacuated of fluid and the open portion of the procedure was started by extending the lateral portal incision inferiorly to the level of the meniscus and superiorly to the inferior pole of the patella.
    • Deep dissection was carried through to the joint as a standard lateral parapatellar arthrotomy. The defect was exposed by way of minimal fat pad debridement and army-navy retractors (Figure 5).
    • A curette was utilized to remove non-viable tissue within the defect until bleeding bone was encountered. To ensure adequacy of bleeding bone, a K-wire was used to make numerous holes in the base of the defect (Figure 6).
    • The defect and the loose fragment were sized. The fragment was found to be slightly larger than the defect due to swelling. The peripheral margins were debrided with a 15-blade to ensure anatomic fit (Figure 7).
    • The loose fragment was placed into the defect and held in place by 5 K-wires (Figures 8-9).
    • Seven 3-mm biocompression screws were placed into the fragment. Six screws were 20 mm in length and 1 was 18 mm (Figures 10-11).
    • Visual and tactile inspection confirmed anatomic repair of the fragment. The knee was then cycled to ensure stability of the fragment.
    • The wound was irrigated copiously with antibiotic solution and the parapatellar arthrotomy was then closed in the standard fashion.

    Figure 3. Arthroscopic view of the loose chondral fragment.

    Figure 4. Arthroscopic view of the defect demonstrating an almost fullthickness cartilage shear injury of the lateral femoral condyle.

    Figure 5. Lateral femoral condyle defect with a thin layer of articular cartilage remaining.

    Figure 6. Lateral femoral condyle defect after cartilage debridement and K-wire penetration.

    Figure 7. Evaluation of the chondral fragment size compared with the defect size.

    Figures 8- 9. Chondral fragment fixation into the defect with 5 K-wires.

    Figures 1011. Final appearance of chondral shear repair with 7 biocompression screws.

    Postoperative Care

    0 to 6 Weeks Postoperatively

    • The patient was kept non-weight-bearing in a hinged knee brace locked in extension.
    • He used a continuous passive motion machine early postoperatively.
    • The patient also began isometric strengthening of the quadriceps and hamstring muscles.

    6 to 8 Weeks Postoperatively

    • Partial weight-bearing was allowed, and the hinged knee brace was progressively unlocked during ambulation.
    • Quadriceps and hamstring muscle strengthening were continued.

    8 to 12 Weeks Postoperatively

    • The patient progressed to full weight-bearing.

    3 to 9 Months Postoperatively

    • Full weight-bearing and rehabilitation for strengthening were continued.

    6 to 9 Months Postoperatively

    • An MRI at 6 months after surgery revealed an intact repair and complete restoration of the articular contour (Figures 12-14).
    • The patient was allowed to begin jogging and sport-specific rehabilitation.

    9 Months Postoperatively

    • Return-to-play testing was done at 9 months postoperatively. The patient was allowed full return to sport once he completed and passed this testing.

     

    Figures 12-14T1- and T2-weighted sagittal and T2-weighted axial MRI images, respectively, demonstrating an intact repair and complete restoration of the articular contour at 6 months postoperatively.

    Discussion

    In young patients who sustain osteochondral injuries to the knee, acute fixation is recommended due to the inherent healing capabilities associated with bone-to-bone healing. [4,5] It was previously thought that cartilage-to-cartilage healing was not ideal or even possible due to the lack of blood supply; however, limited in vivo data exist. [10-12] With advancement of technology related to implant options, more data have emerged revealing favorable outcomes after acute fixation of these injuries. [8,9]

    Alternative treatment options have been suggested for chondral injuries in the young patient, including: [13-18]

    • Fragment excision
    • Microfracture
    • Osteoarticular autograft transfer
    • Autologous chondrocyte implantation
    • Osteochondral allograft transfer

    One study reported rapid progression of osteoarthritis after fragment excision alone for osteochondritis dissecans in a young cohort. [19] The long-term outcomes of the remainder of these treatment options, including the development of degenerative osteoarthritis, is largely unstudied in this patient population. The best evidence for these techniques is primarily reported in the adult literature, which is a group that will experience fewer decades of an active lifestyle. This emphasizes the importance of restoring “normal” articular cartilage in adolescent athletes.

    Jeuken et al [9] reported on 3 pediatric patients who underwent fixation of chondral-only shear injuries to the femoral condyle. The method of fixation in these patients consisted of a combination of fibrin glue and suture. Short-term outcomes (12 months) for these patients revealed 100% return to sport, full range of motion, and no signs of fragment loosening or complications. [9]

    A recent multicenter study reviewed outcomes of 15 pediatric patients treated for chondral-only shear injuries. [8] The median age was 12.7 years, with median follow-up of 12 months. The patella was most commonly involved (n=6), followed by the trochlea (n=5), and the lateral femoral condyle (n=4). Fixation with bioabsorbable implants was performed in all 15 cases at a mean of 1.6 weeks from the injury. MRI was performed in 9 patients, with 5 patients (56%) showing restoration of the cartilage contour and the resolution of subchondral edema. Two patients showed thinning but intact cartilage; 1 had cartilage thickening; and 1 had subchondral edema, fissuring, and cystic changes. All patients returned to sport at a median of 6.5 months. [8]

    Acute repair of a chondral shear injury is a useful tool for joint preservation. The acuity of the injury and, more importantly, the quality of the chondral fragment should be considered when determining the appropriate treatment. Time will delineate the long-term outcomes and development of degenerative joint disease in these patients. Limited data on acute repair of a chondral shear injury with bioabsorbable screws yields favorable short-term outcomes and high rates of return to sport.

    Author Information

    Robert A. Jack II, MD, and Christopher D. Dodson, MD, are from The Rothman Institute, Philadelphia, Pennsylvania.

    Disclosures: The authors have no disclosures relevant to this article.

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