A 16-Year-Old Boy With Concerning, Recurrent Knee Problems

Zoran Rajković, MD; Dino Papeš, MD

Disclosures

February 05, 2019

The treatment of OCD of the knee depends on the age of the patient and the grade of the disease. The general rule is that the younger the patient, the better the prognosis; this is especially true in children with open physes, who are generally felt to do better than adolescent or adult patients in whom the physes are already closed. Nonetheless, it is possible for children with open physes to experience long-term problems from their lesions.[5]

In skeletally immature children with nondisplaced fragments, initial treatment includes limitation of activity with the use of crutches and restricted range of motion (eg, knee immobilizer, range-of-motion brace), cryotherapy, and oral analgesics.[5] Earlier surgical intervention should be considered for lesions in children who are approaching physeal closure and with a higher grade of OCD. A trial of nonsurgical treatment can be recommended for 3-6 months. If symptoms persist or failure to unite is observed on x-rays, patients should be treated surgically.

Adults may also be given a trial of conservative treatment for knee OCD; however, they are less likely to improve without surgical intervention. Therefore, in adults, the threshold for surgery should be lower.[5] Surgery can be arthroscopic or open. Several surgical options are available, including drilling of the fragment to stimulate healing, pin or screw fixation of the fragment, removal of loose bodies, osteochondral autograft or allograft transplantation, and autologous chondrocyte implantation.[5] The success rates of the above-mentioned procedures vary in different studies and depend on the patient's age and OCD grade.

A promising alternative to osteochondral cylinder transfer or conventional autologous chondrocyte implantation (ACI) for knee OCD may be concomitant reconstruction of deep osteochondral defects of the knee with monocortical cancellous cylinders and matrix-associated ACI.[27] Ochs et al reported their 2- to 5-year results in 26 patients with International Cartilage Repair Society grade III/IV OCD who underwent the novel, biologic, 1-step procedure. All clinical rating scores had significant improvement in these patients, and there was concomitant and timed tissue remodeling with clinical improvement.[27] In addition, good results were also observed on MRI.

In this case, the patient underwent arthroscopy, as MRI was unavailable. On arthroscopy, a large defect of the patella was found (3 × 1 cm), so conversion to mini arthrotomy was performed (Figure 2).

Figure 2.

The bone fragment was fixed with 2 screws and 2 resorptive pins. Control x-rays during follow-up showed normal healing of the fracture, and after physical therapy, the patient recovered full knee function.

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