Reconstruction of Large Osteochondral Lesions in the Knee: Focus on Fixation Techniques

Abstract

Large (>3 cm2), focal osteochondral lesions (OCL) may result in poor functional outcomes and early secondary osteoarthritis of the knee. The surgical management of these OCL remains challenging. The treatment strategy must be tailored to various aspects, including lesion-specific (e.g., size, location, chronicity), joint-specific (e.g., instability, limb alignment, meniscal status), and patient-specific factors (e.g., age, activity level, comorbidities). Simple chondroplasty and bone marrow stimulation (BMS) techniques should be reserved for smaller lesions, as they only realize midterm clinical benefits, related to inferior wear characteristics of the induced fibrocartilage (type I collagen). Therefore, much attention has been focused on surgical restoration with hyaline cartilage (type II collagen), based on chondrocyte transplantation and matrix-assisted autologous chondrocyte implantation (MACI). Limited graft availability, staged procedures (MACI), and high treatment costs are limitations of these techniques. However, acute traumatic OCL of the femoral condyles and patellofemoral joint may also be suitable for preservation by surgical fixation. Early detection of the fragment facilitates primary repair with internal fixation. The surgical repair of the articular surface may offer promising clinical and cost-effective benefits as a first-line therapy but remains under-investigated and potentially under-utilized. As a unique characteristic, the fixation technique allows the anatomic restoration of the hyaline articular surface with native cartilage and the repair of the subchondral bone. In this manuscript, we present a case series of large OCL around the knee that were preserved by surgical fixation. Furthermore, various implants and techniques reported for this procedure are reviewed.

A Rare Case of Large Osteochondral Fracture of Patella

“…The stability of the patellofemoral joint is extremely crucial to prevent early knee osteoarthritis. Niemeyer et al suggested that any osteochondral flake fracture indicates surgical treatment with the objective of internal fixation in both pediatric and adult patients [ 9 ]. Alosaimi et al and Bhatt et al also reported a similar case report of osteochondral fracture of the patella not associated with patellar dislocation in the adolescent age group [ 7 , 10 ].…”

“…However, our patient had a very large osteochondral fracture fragment involving almost the whole of the medial patellar facet. Hence, due to the improved understanding of patellofemoral pathologies, a variety of arthroscopic and open-surgical concepts for the repair of osteochondral lesions and the restoration of joint stability have been developed [ 9 ]. Multiple treatment options are available for managing osteochondral fractures, including fixation of the displaced fragment, use of the regenerative procedure, or removing the osteochondral fragment [ 7 ].…”

“…Multiple treatment options are available for managing osteochondral fractures, including fixation of the displaced fragment, use of the regenerative procedure, or removing the osteochondral fragment [ 7 ]. Various studies are in favor of fixing the fragment, which seems to be a rational and ideal treatment for a large displaced osteochondral fragment [ 1 , 4 , 9 , 10 ]. The patient has complete and painless restoration of the knee ROM after the procedure.…”

Excellent Clinical and Radiological Outcomes after both Open Flake Refixation and Autologous Chondrocyte Implantation following Acute Patella Dislocation and Concomitant Flake Fractures

“…An important benefit of the refixation is that it can be performed as a one-step procedure in contrast to the 2-step procedure of ACI. In addition, the refixation of the fragment allows preserving the original hyaline cartilage while ACI can form hyaline-like cartilage only [34]. Nevertheless, ACI is an excellent fallback option with similar good clinical and radiological outcome and should always be discussed with the patient before the surgery.…”

Treatment of Knee Osteochondral Fractures

“…When refixation is not possible along with fragment removal, other techniques such as microfracture of the subchondral bone (MF) and autologous chondrocyte implantation (ACI) can also be used [ 18 , 19 ]. The microfracture of the subchondral bone is made in order to harvest bone marrow mesenchymal stem cells to reconstruct the cartilage defect.…”