Suture fixation of osteochondral fractures of the patella

The Joystick Method: A Mini Open Technique for Repairing Patellar Osteochondral Fractures With Concomitant Medial Patellofemoral Ligament Reconstruction

Fixation of osteochondral fractures after patellar dislocation is typically done using an open approach due to the location of the defect. This is traditionally performed through a medial parapatellar arthrotomy to allow adequate visualization. By using the joystick method, adequate visualization is achieved with a smaller arthrotomy. Careful placement of the joystick in the planned anchor site of the medial patellofemoral ligament reconstruction reduces the number of drill sites in the patella.

Medial patellofemoral ligament reconstruction with simultaneous osteochondral fracture fixation is an effective treatment for adolescent patellar dislocation with osteochondral fractures

BACKGROUND

Osteochondral fractures can occur during patellar dislocation and often require treatment. The purpose of this study is to determine the incidence of recurrent instability and second surgery following osteochondral fracture fixation with concomitant medial patellofemoral ligament reconstruction.

METHODS

A retrospective review of a cohort of 365 medial patellofemoral ligament reconstructions by a single surgeon from 2008 to 2019 was performed to identify patients who underwent simultaneous osteochondral fracture fixation with bioabsorbable nails. Demographic data, surgical details, clinical follow-up, and subsequent procedures were collected.

RESULTS

Forty medial patellofemoral ligament reconstructions with osteochondral fracture fixation were performed by a single surgeon from 2008 to 2019. The average age at surgery was 14.6 years (range 10.7-19.6 years). The average length of follow-up was 2.6 years (range 0.7-7.0 years). Eleven (28%) patients required a second surgery on the ipsilateral knee. One patient had recurrent instability and required revision medial patellofemoral ligament reconstruction and osteochondral allograft. The other 10 patients underwent a second surgery to address cartilage damage or debridement of nails. Of the four patients who required nail debridement, the average number of nails initially placed was 7 ± 1.7. This was significantly more than the patients who did not require second surgery related to nail debridement (4.1 ± 1.6, p < .05).

CONCLUSION

28% of patients required a second procedure, most of which involved debridement of unhealed portions of the osteochondral fracture. At 2.6-year follow-up, only 2% of patients had a failure of their osteochondral fracture fixation requiring a cartilage restoration procedure. Osteochondral fracture fixation in adolescents with patellofemoral instability can be effectively treated with fixation and simultaneous medial patellofemoral ligament reconstruction.

LEVEL OF EVIDENCE

level IV.

Osteochondral Fractures After Patellar Dislocation: Current Concepts

Osteochondral fractures of the knee occur frequently after acute patellar subluxation or dislocation. They can be challenging to manage because of the difficulty in diagnosing and treating these injuries in a timely fashion, in addition to choosing the optimum fixation method. This review presents the background, considerations for patient evaluation, and the best treatment options available for osteochondral fractures.

Management of Chondral Defects Associated with Patella Instability

Cartilage defects of the patellofemoral joint are commonly found in association with patellar instability owing to abnormal biomechanics. Strategies to address chondral defects of the patellofemoral joint secondary to instability should first address causes of recurrent instability. Most patellofemoral chondral defects associated with instability are less than 2 cm2 and do not generally require intervention beyond chondroplasty. Larger defects of the patella and/or the trochlea can be repaired with osteochondral or surface cartilage repair.

Osteochondral Fracture Fixation With Fragment Preserving Suture Technique

Osteochondral fractures are relatively uncommon injuries that typically present after an acute or subacute traumatic injury. Osteochondral fracture fixation is traditionally performed in the acute setting with internal fixation procedures using pins or compression screws through the fragment. Outcomes have generally been good, but cartilage thinning, subchondral remodeling, and tissue reactions can occur after internal fixation through the fragment. This article describes osteochondral fracture fragment fixation with a fragment-preserving technique that does not violate the articular cartilage of the fragment. This technique minimizes risk to articular cartilage that has already sustained injury and also provides superior fixation.

Clinical Results and MRI Evaluation of Patellar Osteochondral Fracture Fixation following Patellar Dislocation

Aim

The aim of the study was to analyze the clinical results and MRI scans after transpatellar osteochondral fracture fixation following patellar dislocation.

Methods

Our study group comprised 17 patients with patellar dislocation followed by osteochondral fracture of the articular surface of the patella. All patients underwent surgery where the fractured osteochondral fragments of the patella were attached using the transpatellar suture technique. The mean age at the time of surgery was 14.1 years, and the mean follow-up period was 7.5 years.

Results

The results of the patellar compression test and the apprehension test were negative in all patients. The mean Lysholm and Kujala scores were 89.2 and 89.6, respectively. The MRI scan revealed healing of the fixed fragment and restoration of the articular surface in all patients. In 16 cases, subchondral bone of the fixed fragment area was described as irregular: its articular cartilage was narrowed and not homogenous. Progressive degenerative changes were observed in the patellofemoral joint at follow-up in three patients.

Conclusions

By fixing osteochondral fragments, the patellar articular surface can be restored. The MRI scans show that the cartilage in the reconstructed surface is narrowed after a mean 7.5-year follow-up.

Age-related histological changes in calcified cartilage and subchondral bone in femoral heads from healthy humans

OBJECTIVE

Age is the most important risk factor for osteoarthritis (OA). It is suggested that changes in subchondral bone and calcified cartilage may occur in early OA. Therefore, the aim was to investigate age-related changes in the femoral head composition. We hypothesise that the thickness of the subchondral bone plate decreases with age, while the thickness of the calcified cartilage increases with age as seen in early-stage OA.

METHODS

Femoral heads from 29 women (20-74 years) and 32 men (23-78 years), who had died suddenly and unexpectedly, were obtained at autopsy. Individuals with bone or joint diseases or macroscopic abnormal cartilage were excluded. Using design-based stereology, femoral head volume as well as thickness and volume of the calcified cartilage and subchondral bone plate were estimated and correlated to sex and age.

RESULTS

The thickness and volume of the subchondral bone plate were not correlated with age. Calcified cartilage thickness and volume correlated positively with age in women, while the femoral head volume was correlated positively with age in men.

CONCLUSION

In human femoral heads obtained from a cross-sectional population without macroscopic OA changes, the thickness of the subchondral bone plate did not change with age, which differs from the thinning seen in early OA. Surprisingly, the age-related changes of the volume and thickness of the calcified cartilage and of the volume of the femoral head were different for women and men. This indicate that cartilage and bone metabolism is sex-specific, which may influence ageing of the hip joint.

Two Years of Follow-up Magnetic Resonance Imaging for Osteochondral Injury of the Lateral Femoral Condyle in an Adolescent Basketball Player

Chondral and osteochondral injuries of the femoral condyle are rare, and relatively few cases have been reported. Therefore, the mechanism, treatment, and findings on follow-up of these injuries are not well described. Here, we report the case of an adolescent basketball player who sustained a sports-related traumatic osteochondral injury of the lateral femoral condyle. He was treated with open reduction and internal fixation with the pull-out suture technique. Two years later, he was able to resume sporting activities at his pre-injury level with no symptoms. Magnetic resonance imaging (MRI) confirmed survival of the fixed osteochondral fragment and restoration of the congruity of the articular cartilage with no sign of delamination. This report describes the clinical outcome of this osteochondral injury of the lateral femoral condyle as seen on MRI at the 2-year follow-up and discuss the mechanism and treatment of this injury. J. Med. Invest. 66 : 213-217, February, 2019.

Fixation versus Excision of Osteochondral Fractures after Patellar Dislocations in Adolescent Patients: A Retrospective Cohort Study

Background

Patellar dislocation is one of the most common knee injuries in the adolescent population. It is often combined with osteochondral fracture. The purpose of this study was to compare the outcomes between fixation and excision of osteochondral fractures not involving the bearing surface in adolescent patients with patellar dislocations.

Methods

Patients who underwent surgery for osteochondral fracture following patellar dislocation in our institution from 2007 to 2014 were retrospectively evaluated. Visual analog scale (VAS) of pain and the International Knee Documentation Committee (IKDC) form were used to assess knee pain and function at follow-up. Patient satisfaction was evaluated. Differences in the values of variables among groups were assessed using t-test if equal variance or Mann-Whitney U-test if not equal variance. The Pearson's Chi-square test was applied for dichotomous variables if expected frequency was >5 or Fisher's exact test was applied if not. A value of P < 0.05 was considered statistically significant.

Results

Forty-three patients were included, with the average age of 14.1 ± 2.3 (range, 9.0-17.0) years. Nineteen underwent fixation of osteochondral fractures and 24 did not. The average follow-up time was 28 ± 10 months. There was no significant difference in age, gender, follow-up time, causes of injury, times of dislocation, and location of osteochondral fracture between fixation and excision groups. The fixation group had a significantly longer surgery time (82 ± 14 min) and larger size of osteochondral fracture (2.30 ± 0.70 cm²) than the excision group (43 ± 10 min, 1.88 ± 0.62 cm², respectively, t = 10.77, P < 0.01 and t = 0.84, P < 0.05). At the last follow-up, the average IKDC score in the fixation group (82.52 ± 8.71) was significantly lower than that in the excision group (89.51 ± 7.19, t = 2.65, P < 0.01). There was no significant difference in VAS of pain and patients' satisfaction. There were 7 (16%) patients with recurrent dislocation.

Conclusion

Excision of osteochondral fractures has equivalent or better outcomes compared to fixation in adolescent patients with patellar dislocations when these fractures do not involve the bearing surface.

A successful technique to repair an osteochondral patellar fracture composed of largely primary articular cartilage

A 15-year-old girl presented with knee pain, inability to extend and weight bear after a twisting injury to the knee leading to dislocation and spontaneous reduction of the patella. An osteochondral defect was identified over the medial facet of patella with a loose osteochondral fragment with very little bone attached to the large cartilaginous part. This unusual fracture was fixed using four biocomposite suture anchors and a bioabsorbable pin. Three months after the surgery, she was mobilising fully, weight bearing and had a full range of motion with satisfactory outcome. MRI six months postop suggested complete healing of the fragment. Usually such fractures occur due to an impaction injury of the medial patellar facet over the lateral femoral condyle during the relocation phase of an injury. In this case, the patella was dislocated and then reduced spontaneously. There are very few case reports in the literature with successful repair of this type of patellar fracture and a good patient outcome.

Adolescent patellar osteochondral fracture following patellar dislocation

PURPOSE

Patellar dislocations in adolescents may cause osteochondral fractures of the patella. The aim of this study was to review the outcomes of adolescent patients who underwent surgical intervention for patellar osteochondral fracture following patellar dislocation.

METHODS

Nine patients who underwent surgery for osteochondral fracture of the patella following dislocation were identified retrospectively. Following arthroscopic examination, if the fragment was large enough to support fixation, headless screws or bioabsorbable pins were used. Otherwise, the loose body was excised, and the donor site was managed with a microfracture. Postoperatively, patients were assessed using the International Knee Documentation Committee (IKDC) and Knee injury and Osteoarthritis Outcome Score (KOOS) outcome measures.

RESULTS

The average age of the patients was 14.6 with average follow-up 30.2 months. Four of the nine patients underwent fixation, while five patients underwent removal of loose body with microfracture. The average defect size in the nonfixation group was 1.2 cm(2) compared with 3.2 cm(2) in the fixation group. The IKDC scores for fixation and nonfixation groups were 63.9 (SD = 18) and 76.1 (SD = 11.7), respectively. The KOOS subscale scores for symptoms, function in sports and recreation, and knee-related quality of life were higher for the nonfixation group when compared to the fixation group.

CONCLUSIONS

This is the first known series examining surgical outcomes of osteochondral fractures of the patella following patellar dislocations in the adolescent population. While patients without fixation were less symptomatic in this series, this may be attributable to more severe injuries in patients undergoing fracture fixation.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

[Fractures of the patella]

Fractures of the patella account for approximately 0.5% to 1.5% of all skeletal injuries. The diagnosis is made by means of the mechanism of injury, physical and radiological findings. The kind of treatment of patella fractures depends on the type of fracture, the size of the fragments, the integrity of the extensor mechanism and the congruity of the articular surface. Independent of the kind of treatment an early rehabilitation is recommended. Modified tension band wiring is the most commonly used surgical treatment for patella fractures and can be used for almost every type of fracture. Due the superior stability in biomechanical studies two parallel cannulated lag screws combined with a tension band wiring are the treatment of choice for horizontally displaced two-part fractures. In comminuted fractures a partial or total patellectomy may be necessary. However, since the loss of quadriceps muscle power and the poor outcome total patellectomy should be considered as a salvage procedure.

Late repair of an osteochondral fracture of the patella

Acute patellar dislocations are a common injury in young patients. Osteochondral fractures are commonly associated with this injury, frequently necessitating surgical treatment. This article presents a case of a 23-year-old woman who sustained a large osteochondral fracture of the medial facet of the patella during a first-time acute patellar dislocation. The patient was lost to follow-up; consequently, surgical treatment was not performed until 8 weeks after injury. Diagnostic arthroscopy demonstrated a large osteochondral fragment in the suprapatellar pouch and a defect on the medial facet of the patella with early fibrocartilage growth. Using an open approach, the osteochondral fracture was fixed with headless screws buried beneath the cartilage. After fracture fixation, continued lateral subluxation of the patella was present; therefore, to improve patellar tracking and protect our fracture fixation, a Fulkerson tibial tubercle osteotomy (including a lateral release) and a medial patellofemoral ligament repair were performed. At the conclusion of the surgery, we had achieved rigid fixation of the fracture and normalized patellofemoral tracking.At 1 year post-injury, the patient has achieved union of her patellar osteochondral fracture and tibial tubercle osteotomy. She has full range of motion and minimal anterior knee pain and has not experienced further episodes of patellar instability. Even in patients who present in a delayed fashion, consideration should be given to the repair of patellar osteochondral fractures and, if necessary, realignment of the extensor mechanism.

Suture bridge fixation of a femoral condyle traumatic osteochondral defect

Internal fixation of a traumatic osteochondral defect presents a challenge in terms of obtaining anatomic reduction, fixation, and adequate compression for healing. Fixation with countersunk intraarticular screws, Herbert screws, bioabsorbable screws and pins, mini-cancellous screws, and glue tissue adhesive have been reported with varying results. We present an alternative fixation method used in two patients for femoral condylar defects that achieved anatomic reduction with compression via a cruciate-shaped suture bridge construct tied down over a bony bridge. This fixation method allowed early passive range of motion and permitted high-quality MRI for followup of fracture healing and articular cartilage integrity. Arthroscopic examination of one of two patients at 6 months followup showed the gross appearance of a healed, anatomically reduced fracture. With 1 year followup for one patient and 2 years for the other, the patients have resumed activity as tolerated with full, painless range of motion at the knee. Longer-term outcomes are unknown. However, the suture bridge is an alternative means of fixation with encouraging early results for treatment of traumatic osteochondral fragments in the knee.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Arthroscopic reduction and fixation of osteochondral fracture of the patellar ridge

A method of arthroscopic reduction and anterograde fixation of osteochondral fracture of the patella ridge is described. This type of fracture was previously treated through arthrotomy. An arthroscopic approach is possible using manipulation of the patella in a loosened medial retinaculum. This method was used in a 14-year-old patient with an osteochondral fracture following the dislocation of the patella.

Suture fixation as a treatment for acute traumatic osteochondral lesions

This is a report on the treatment of traumatic osteochondral lesions with suture fixation. Equivocal results from traditional, conservative treatment modalities have resulted in a recent surge in research in this area. Literature reports of treatments for these lesions often rely on a fibrocartilage healing response that exhibits inadequate weight bearing, lubricating, and durability qualities. We describe here a method by which a large, intact osteochondral fragment over the articulating, weight-bearing portion of the patella may be repaired using suture. This method allows for the preservation of the articular topography without many of the complications seen using other fixation techniques.