Treatment of osteochondritis dissecans of the talus: use of the mosaicplasty technique--a preliminary report

A one-stage autogenous osteochondral grafting technique for the treatment of talar dome osteochondritis dissecans is described. Eleven patients with osteochondritis dissecans lesions, 10 mm or greater in diameter, were operated on using the mosaicplasty autogenous osteochondral transplantation technique. Osteochondral cylindrical grafts from the ipsilateral knee were delivered into the talar defect using specially designed tube chisels. These procedures were done by arthrotomy. With follow-up of 12 to 28 months (mean, 16 months), the patients returned to full activities and the results, using the Hannover scoring system, have been excellent.     

A possible role for saliva as a diagnostic fluid in patients with chronic pain

Magnetic resonance (MR) imaging of the joints with routine pulse sequences can show the three main categories of osteochondral and chondral injuries: osteochondral fractures, osteochondritis dissecans, and chondral fractures. Detecting acute osteochondral fractures, which frequently accompany ligament tears, may modify patient treatment and ultimately may prove important in long-term prognostication. Staging osteochondritis dissecans lesions is possible with MR imaging and can be used to guide therapy, both surgical and nonsurgical. Specific treatment for chondral fractures is evolving; preoperative diagnosis using MR imaging is advantageous because these lesions often are not initially suspected, they are radiographically occult, and they clinically mimic other internal derangements, for which therapy differs. The MR imaging finding that these traumatic lesions share is the frequent presence of an abnormality in the subchondral bone. Fat-suppressed images are the key to detecting subtle areas of subchondral edema, which in turn may draw attention to a defect in the overlying articular surface.     

Osteochondritis dissecans of the femoral condyle in the growth stage

The site of lesion, spontaneous healing, onset mechanism, and magnetic resonance imaging findings of 51 knees in 38 patients with osteochondritis dissecans involving the femoral condyle in the growth stage were investigated. tercondylar site, and the remaining 1/4 were in other sites. Compared with those in the other sites, the lesions in a medial intercondylar site had a lower healing rate and required a longer time to heal. T2 weighted images of the lesions showed a progression from low signal areas to the appearance of a high signal line at the fragment to parent to bone interface, to a high signal double line at the interface and parent-bone surface, or to disappearance of the line. Magnetic resonance imaging often revealed discoid menisci or meniscal tears in patients with lesions in the lateral condyle, suggesting that endogenous forces play an important role in the onset of osteochondritis dissecans.     

Lens and retinal changes in the WBN/Kob rat (spontaneously diabetic strain). Electron-microscopic study

Osteochondritis dissecans is a separation of an articular cartilage subchondral bone segment from the remaining articular surface. This is a different entity from osteonecrosis, with which osteochondritis dissecans is commonly confused. In osteochondritis dissecans, the fragment separates from a vascular normal bony bed, while in osteonecrosis, the fragment typically is more peripheral and separates from an avascular bony bed. Osteochondritis dissecans is more common in adolescents and young adults, with the knee, elbow, and ankle being the most common sites. Injury to an area of fairly tenuous blood supply is the most likely cause. Treatment is typically nonoperative for stable lesions and operative for unstable lesions. Most patients do well with no long-term sequelae, but this depends on a variety of factors including the location and size of the lesion, patient age, and treatment.     

Osteochondritis dissecans of elbow, ankle and hip: a comparison survey

In 36 patients treated for osteochondritis dissecans (OCD) of the elbow, ankle and hip during a period of 20 years in the same hospital, trauma seems to have been the main etiologic factor in about half of the patients. The first symptoms of the lesions occurred when the patients were between 15 and 20 years of age. Osteochondritis dissecans of the elbow was seen in 19 men. Osteochondritis dissecans in the ankle occurred in 6 men and 5 women. Osteochondritis dissecans in the hip appeared in 5 men and one woman. The first symptoms were pain and restriction of joint movement. Conservative treatment was satisfactory for about one-half of the patients. When operative treatment was indicated, extirpation of loose bodies or loosening fragments was the treatment of choice in OCD of the elbow and ankle. Fixation of the fragment gave satistfactory results in some cases of OCD of the hip. Late results were excellent in only about one-half of the patients. Osteoarthritic changes appeared in the hip, elbow, ankle, in order of decreasing frequency.     

The conservative treatment of complete tears of the anterior cruciate ligament in skeletally immature patients

We describe the results of conservative treatment for complete midsubstance tears of the anterior cruciate ligament (ACL) in 18 skeletally immature patients, followed for a minimum of 36 months. Six patients had an ACL reconstruction during the follow-up period and were assessed immediately before their operation. The average time from initial injury to evaluation was 51 months. All patients had symptoms when reviewed. The modified Lysholm knee score showed one excellent result, one good, eight fair, and eight poor with a mean score of 64.3. Only one patient had returned to her preinjury level of athletics. Secondary meniscal tears were confirmed in six patients, and three more had the clinical signs of a tear at follow-up. Radiological evidence of degenerative changes was found in 11 of the 18 patients. We conclude that the results of non-operative treatment for ACL injuries in this age group are poor and not acceptable.     

Intraarticular anatomic variants associated with discoid meniscus in Koreans

From July 1990 through June 1994, 106 knees (102 patients) were treated for discoid meniscus. Fifteen knees (15 patients) were associated with other intraarticular anatomic variants. There were eight knees (8 patients) with anomalous insertion of the anterior horn of the medial meniscus into the anterior cruciate ligament, and seven knees (7 patients) with anterior expansion of the anterior portion of the anterior cruciate ligament below the anterior tibial margin. Among the latter, one patient also had anterior transposition of the anterior insertion of the medial meniscus, while obliteration of the popliteal hiatus was seen in another patient. The discoid menisci were reshaped in 13 knees (13 patients), totally resected in one knee, and in one patient the discoid meniscus was treated with repair of a peripheral tear and reshaping. Followup ranged from 24 to 54 months (average, 37 months) after surgery. The results were excellent in eight knees, good in five knees, and fair in two knees as graded using the Ikeuchi scale. These anatomic variants, other than the discoid meniscus, did not seem to be related to the patient's symptoms.     

Small wire external fixation of high energy tibial plateau fractures

Open plate osteosynthesis for high energy tibial plateau fractures with dissociation between the metaphysis and diaphysis has been plagued with frequent soft tissue complications. The Harbor-University of California at Los Angeles Medical Center's experience with small wire external fixation supplemented by limited internal fixation is examined. This alternative method of adequate stable fixation offers the advantage of minimal soft tissue compromise. Twenty-four patients with Schatzker Type VI tibial fractures were treated with small wire external fixation. Supplementary limited internal fixation was used with percutaneous screws in 10 patients and with open reduction in one patient. Sixteen patients had isolated fractures, and eight others suffered multiple injuries. Minimum followup was 12 months. All fractures healed. Complications included one septic knee, two infections at screw sites, and one 10 degrees knee flexion contracture. One knee had Grade 3 radiographic arthrosis, five had Grade 2, 10 had Grade 1, and eight showed no arthrosis. The outcomes (Knee Society clinical rating system) of this study compare favorably with outcomes described in reports published previously for this type of fracture, despite inclusion of eight multiply injured patients. This technique preserves the goals of early range of motion and stable fixation for these devastating injuries, while decreasing the observed major wound complications and nonunion rates. However, longer followup may reveal higher arthrosis rates, specifically in those fractures that were not anatomically reduced.     

Cast brace treatment of plateau and bicondylar fractures of the proximal tibia

Twenty-nine patients with 30 intraarticular proximal tibial fractures were treated with early application of a cast brace. All fractures united, knee motion was excellent or good in all but one patient. The fracture fragments did not lose position after cast brace application. Varus or valgus deformities could be corrected and maintained. Ninety per cent had no pain at follow-up. Hospital stay was as short as two days and generally under two weeks.     

Arthroscopic therapy of osteochondrosis dissecans of the talus--follow-up with a new "Ankle Score"

INTRODUCTION: Since the advent of operative ankle arthroscopy specific treatment of osteochondritis dissecans of the talus underwent rapid progress. Besides optimizing well-known methods as drilling, spongeous plastic, curettage or refixation of dissecates new trends go to transplantation of cultivated cartilage and osteochondral allografts. Previous follow-up examinations suffer on the one hand from partially small numbers of cases, on the other hand comparisons are difficult because so far no rating system of the function of the upper ankle does exist. MATERIAL AND METHODS: Within three years 34 patients underwent arthroscopic treatment of osteochondritis dissecans of the talus, 16 with percutaneous drilling, 12 spongeous plastics, three refixations and three curettages. The average age of the 22 men and 12 women was 25 years (11-48 years). A newly developed score system and a follow up MRI was used in a follow-up of 29 of the patients. Up to 100 points are given in the categories pain, stability/insecurity, efficiency/painfree walking distance, gait, differences in circumference, motility and power. RESULTS: 27 of the 34 patients had a trauma history. 20 lesions were localized at the lateral talus, they all had a trauma history. In 7 of the 14 lesions at the medial part of the talus there was no evidence of trauma. The 29 patients in the follow-up achieved an average of 87 points, the 16 patients after K-wire drilling 85 points and the 12 patients after spongeous plastic 90 points. Deductions were noted likewise in the subjective and objective parameters. 100 points were reached by 4 patients. DISCUSSION: Cultured chondrozytes and osteochondral grafts are new trends in treatment of osteochondritis dissecans while arthroscopically controlled spongeous plastic after curettage and K-wire drilling represent the main component of early stages with intact or partially fractured cartilage surface. Results of K-wire drilling are negligible worse than those of spongeous plastic, which is attributed to a generous perforation of the sclerosis. This is contributed to an improved preoperative diagnosis with MRI.     

Bioabsorbable rods and pins for fixation of metacarpophalangeal arthrodesis of the thumb

We report results on the use of bioabsorbable pins and intramedullary rods made of high-molecular-weight polylactic acid in both experimental and clinical conditions. In the experimental study, bioabsorbable rods were implanted in rabbit femora. Histologic assessment on nondecalcified bone showed that resorption of the material began at 4 months after implantation and gradually fragmented over a period of 3 years. In 12 patients 13 metacarpophalangeal joints of the thumb were arthrodesed by using one bioabsorbable intramedullary rod with one or two oblique pins. All joints fused within 6 to 8 weeks. During that period there was no sign of inflammation, and there were no nonunions. Postoperative magnetic resonance imaging assessment was done in all rabbits and eight patients. This modality is a useful tool in postoperative evaluation of the position and shape of the rod but is not sufficiently sensitive to assess the presence of local inflammation and the rate of resorption of the rods.     

Diagnosis of ostechondritis dissecans of the femoral condyles: the value of the lateral x-ray view

The lateral X-ray view of the knee is more likely to yield the diagnosis of osteochondritis dissecans of the femoral condyles if the examiner is aware that most cases are located in the subarticular bone of the medial femoral condyle between two lines: The first extended anteriorly from the density of the roof of the intercondylar notch, and the second, extended distally from the posterior cortex of the distal femoral diaphysis.     

Fresh osteochondral allografts for treatment of articular defects in osteochondritis dissecans of the lateral femoral condyle in adults

Fresh osteochondral allografts were used to patch defects in the lateral femoral condyle in 17 patients with osteochondritis dissecans. The patients included 12 males and five females, ages 16 to 46 years. All had previously undergone other procedures including pinning (4), primary removal of osteochondral fragments (16), and abrasion arthroplasty (14). Defects up to 3 cm in diameter were treated with isotopic grafts and fixed with Herbert screws. Larger defects were treated with crescent-shaped grafts fixed with multiple Herbert screws. Follow-up time ranged from two to nine years. Pain, stiffness, swelling, buckling, and locking were ablated in 16 of the 17 patients. No graft collapse has been noted in these individuals. Verification of graft viability was achieved at periods from six weeks to six years, typically at the time of hardware removal. The only failure occurred in an individual with a 3- x 4.5-cm defect who suffered gross fragmentation which left a large crater. Osteochondritis dissecans of the lateral femoral condyle provides an ideal opportunity for evaluating osteochondral grafts. Sixteen of 17 grafts were a success at two to nine years after surgery.     

Influence of magnetic resonance imaging on indications for arthroscopy of the knee

In a prospective study, magnetic resonance imaging was performed before arthroscopy for all patients (n = 121) with a meniscal tear (n = 125). Criteria of the study were stable cruciate and collateral ligaments, absence of pathologic radiographic findings, and absence of prior surgical interventions of the involved knee joint. In 43 knees (34%), the clinical diagnosis of a meniscal tear was discarded because of the results of the magnetic resonance imaging examination. Synovitis was diagnosed in 16 patients (13%), articular cartilage damage in 10 patients (8%), bone bruise injuries in 10 patients (8%), osteochondritis dissecans in 3 patients (2%), disruption of the inner layer of the medial collateral ligament in 3 patients (2%), and osteonecrosis in 1 patient. The use of magnetic resonance imaging in establishing diagnosis of disorders of the knee joint altered treatment in a significant proportion of patients. Magnetic resonance imaging should be done before arthroscopy of the knee in all cases in which the clinical diagnosis has been reduced to a suspected meniscus injury.     

Computerized tomography of osteochondral diseases of the talus dome

The definition "osteochondritis dissecans" of the talus improperly includes a variety of diseases involving the chondral surface of the talus dome and the relative subchondral bone. To investigate the CT diagnostic potentials in the study of these conditions, 35 patients complaining of a "painful ankle" were examined with plain radiography and axial and direct paracoronal CT over a 2-year period. Twelve patients were then examined with double contrast CT arthrography with air and iodated contrast agents. CT diagnostic accuracy was assessed evaluating the following parameters: the presence and extent of the subchondral bone fragment, the presence of residual bone fragment attachment at the lesion base or its intraarticular dislocation, the presence of subchondral bone cysts, of chondral surface lesions and, finally, of capsular and ligamentous damage. All the patients with CT findings of osteochondral conditions of the talus dome were submitted to arthroscopic examination/treatment and/or surgical arthrotomy. Baseline CT exams accurately depicted all the lesions, except for early (grade I) lesions. Moreover, the administration of intraarticular contrast agent (CT arthrography) increased the diagnostic accuracy in articular cartilage studies. Therefore, the authors believe baseline CT on the orthogonal planes to represent an effective tool for the staging of osteochondral talar lesions and for accurate treatment planning.     

Surgical management of osteochondritis dissecans of the capitellum

Ten cases of osteochondritis dissecans of the humeral capitellum which were treated surgically are reviewed. All 10 cases were males and involved the dominant side. The ages at surgery ranged from 13 to 17 years. Follow-up ranged from 1 to 7 years. All of the youths had competed in organized athletics, either baseball or football. By position there were three pitchers, two catchers, two infielders, and one outfielder; in addition there were one quarterback and one linebacker. Only one patient presented with locking of the elbow, whereas the others presented with pain and limitation of extension. The locked elbow was explored immediately and the others were explored after immobilization failed to relieve their symptoms. In seven of the joints a loose fragment of the capitellum was found lying either in the joint or in a defect in the capitellum. The fragment had multiple small holes. In three cases there was no loose fragment. In this situation a corticol window was cut above the capitellum. The capitellum was then drilled and bone was grafted from above. Over all, there were one excellent, six good, one fair, and two poor results. There seemed to be little difference between curretting alone or curetting and drilling. The cases with the cartilage intact and bone grafted from above did worse, with one fair and one poor result of three cases. The two poor results required further surgery, which consisted of partial excision of the capitellum. All cases lacked elbow extension before and after surgery, but nine of 10 gained some motion after surgery. Pre- and postoperative x-rays are shown in this report and a brief review of the literature concerning osteochondritis dissecans is presented.     

To the incidence of nucleoli in circulating myeloblasts of patients suffering from acute myeloblastic, promyelocytic and myelomonocytic leukemias

This retrospective clinical study describes three years of experience with cryoprotected-cryopreserved allograft transplantation. During this period 33 knee joints were operated on for different reasons including osteoarthritis, osteochondritis dissecans and post-traumatic surface irregularity. The mean follow-up was nearly two years and the mean age of the patients was 48 years. The grafts were harvested and processed at the West Hungarian Tissue Bank according to the criteria promulgated by the European Association of Tissue Banks. All the operations were performed in the same way. Three types of grafts were used: cylindrical or mushroom-shaped for the femoral condyle and patellar and shell allografts for resurfacing the tibial plateau. Bone matrix gelatine (BMG) and fibrin sealant (Tissucol) were used locally to enhance the revascularisation and to improve the decreased osteoinductivity of the frozen cancellous bone. According to the modified Bentley score, the success rate of the short term follow-up was similar to that of other reported series. An analysis of four biopsies showed that the BMG and fibrin sealant did not appear to affect the viability of the articular cartilage. We conclude that application of these materials is not contra-indicated in allograft surgery.     

Arthroscopic reduction and internal fixation of a displaced intraarticular lateral femoral condyle fracture of the knee

Anatomic reduction, typically obtained by direct visualization through an arthrotomy and internal fixation (open reduction and internal fixation), is the traditional treatment method for displaced intraarticular condylar fractures of the distal femur. We present a case report describing an alternative treatment method, namely, arthroscopic reduction and internal fixation, of a displaced, malrotated intraarticular lateral femoral condyle fracture of the knee. The potential benefits of decreased blood loss, shortened operative time, excellent intraarticular visualization, decreased soft tissue dissection, and shortened postoperative recovery are outlined.     

Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty

We reviewed the results an average of fifty months (range, twenty-four to 120 months) after the use of thirty-five allografts in thirty patients during primary or revision total knee replacement. Twenty-nine femoral-head allografts, five distal femoral allografts, and one proximal tibial allograft were used in conjunction with a long-stemmed implant to reconstruct large osseous defects. The patients were evaluated clinically, radiographically, and subjectively (with use of a questionnaire). Twenty-six (87 per cent) of the thirty patients had a good or excellent clinical result, and no revisions were necessary. As none of the patients had collapse of the graft, subsidence of the implant, or revision, we believe that the outcome of treatment with a femoral-head allograft, particularly in association with a component inserted with cement, is excellent. Four non-porous-coated components were placed without cement on structural allografts. Radiographically, three of those components subsided, but none of the three needed revision and two were associated with a good clinical result. Our current practice is to cement components in all arthroplasties involving grafting. Our findings suggest that the use of a stemmed component reduces the stress on the allograft, host bone, and fixation interface. In addition, such a component contributes to the longevity of a total knee replacement associated with a bone graft. Additional studies with long-term follow-up are necessary to confirm this outcome.