We report the first case of osteochondritis dissecans (OCD) affecting a large area of lateral and medial femoral condyles with adult-onset in the same knee of the 22-year old professional athlete with respect to result of applied therapeutic procedure. After a clinical examination, radiograph and magnetic resonance imaging showed a huge bicondylar OCD. Through arthrotomy, the osteochondral fragment was fixed with biodegradable pins combined with two threaded 4 mm cobalt-chrome cancellous screws. By using this surgical fixation procedure, osteochondral fragments healed completely, which is evidenced artroscopically one year after a new trauma episode which resulted in the lateral meniscus reinjury. According to our knowledge this is the first reported case of bicondylar OCD affecting adult knee. In the rare case of such a large osteochondral defect, when fixation with biodegradable pins could be insufficient, a combination with cancellous screws can bring good results, even in professional athletes

Ante Bandalović

Bore Bakota

Gordan Gulan

Hrvoje Mokrović

Jagoda Ravlić-Gulan

Marin Marinović

Tedi Cicvarić

Gulan, Gordan

Mokrović, Hrvoje

Ravlić-Gulan, Jagoda

Cicvarić, Tedi

Marinović, Marin

Bakota, Bore

Bandalović, Ante

Repository of the University of Rijeka

Coll. Antropol. 38 (2014) Suppl. 1: 249–252Original scientific paperOsteochondritis Dissecans of the Medial andLateral Femoral Condyles affecting Adult KneeGordan Gulan1, Hrvoje Mokrovi}1, Jagoda Ravli}-Gulan2, Tedi Cicvari}3, Marin Marinovi}3,Bore Bakota4 and Ante Bandalovi}51 University of Rijeka, School of Medicine, Clinic for Orthopaedic Surgery Lovran, Lovran, Croatia2 University of Rijeka, School of Medicine, University Hospital Rijeka, Department of Physiology, Immunology andPathophysiology, Rijeka, Croatia3 University of Rijeka, School of Medicine, University Hospital Rijeka, Department of Traumatology, Rijeka, Croatia4 General Hospital Karlovac, Department of Traumatology, Karlovac, Croatia5 University of Split, University Hospital Centre Split, Department of Traumatology, Split, CroatiaA B S T R A C TWe report the first case of osteochondritis dissecans (OCD) affecting a large area of lateral and medial femoral condy-les with adult-onset in the same knee of the 22-year old professional athlete with respect to result of applied therapeuticprocedure. After a clinical examination, radiograph and magnetic resonance imaging showed a huge bicondylar OCD.Through arthrotomy, the osteochondral fragment was fixed with biodegradable pins combined with two threaded 4 mmcobalt-chrome cancellous screws. By using this surgical fixation procedure, osteochondral fragments healed completely,which is evidenced artroscopically one year after a new trauma episode which resulted in the lateral meniscus reinjury.According to our knowledge this is the first reported case of bicondylar OCD affecting adult knee. In the rare case of sucha large osteochondral defect, when fixation with biodegradable pins could be insufficient, a combination with cancellousscrews can bring good results, even in professional athletes.Key words: osteochondritis dissecans, bicondylar osteochondral defects, adult onset, therapyIntroductionOsteochondritis dissecans (OCD) is a condition char-acterised by a localised lesion of the articular cartilageand underlying subchondral bone with partial or com-plete separation of the fragment. In 80% of cases it oc-curs in the knee, and is usually unilateral (74%). Themost common localisation is the posterolateral section ofthe medial femoral condyle (80%). Other sites includethe ankle, elbow and wrist1,2. Various theories have beenproposed regarding the etiology of the OCD includingtrauma3, subchondral ischemia4, ossification defects5 andgenetic causes6.There are two forms of OCD – the juvenile and theadult form. Usually, OCD occurs before the age of 18 andis twice as common in males as it is in females.Patients with focal cartilage lesions have major prob-lems with pain and functional impairment. Their com-plaints are worse than those of patients with anteriorcruciate ligament–deficient knees, and quality of life isaffected to the same extent as in patients scheduled forknee replacement. If not diagnosed in time, it can prog-ress to degenerative joint disease7.Herewith we describe the case of the adult form ofOCD affecting both condyles of the same knee, and theresults of applied method of treatment. As far as weknow, bicondylar OCD in the same knee has already beendescribed only in one paper8, but it refers to two cases ofa juvenile form. Our paper is, to the best of our knowl-edge, the first to describe an adult form of bicondylarOCD in the same knee.Case reportsA 22-year old male presented to the orthopaedic sur-geon with a history of recurring episodes of pain and249Received for publication November 29, 2013swelling of the right knee. The symptoms started threeyears earlier with no history of direct trauma to the knee.Episodes of lock-in occurred in the right knee followed bymore intense episodes of pain and swelling. At this stagethe patient came to our clinic. Upon clinical examination,the knee showed pain and tenderness on both sides, witha positive balottement test. The range of motion was re-duced. Radiograph and magnetic resonance imaging(MRI) of the right knee were carried out. The radiographshowed OCD lesion affecting both femoral condyles (Fig-ure 1).The MRI showed a larger defect in the lateral femoralcondyle occupying zones 4th and 5th according to Cahill9on the antero-posterior view, and zone C in the lateralview. The defect of the medial femoral condyle was smal-ler (Cahill’s 2nd zone on the antero-posterior view andzone B in the lateral view) comparing to lateral femoralcondyle lesion. Arthroscopy of the right knee was per-formed and a deep unstable osteochondral fragment in-volving almost the entire weight-bearing surface of thelateral femoral condyle was revealed. Lesion of the lat-eral meniscus was also present. Arthroscopic partial lat-eral meniscectomy was performed.Because the osteochondral defect was very large, ar-throtomy was done (Figure 2). After debriding the baseof the defects, we fixed the lateral osteochondral frag-ment with two cancellous screws and one biodegradablepin, while fixation of the medial osteochondral fragmentwas done with one screw (Figure 3).After surgical treatment the patient started with earlyrehabilitation. Rehabilitation exercises with emphasis onlimb function and muscle recruitment were initiated af-ter 48 hours and continued for 8 weeks. Weight bearingwas gradually introduced into the patient’s rehabilita-tion schedule, and the patient progressed to full weightbearing after 8 weeks.Three months after arthroscopy, radiographs showedsatisfactory healing on the site of the osteochondral frag-ments and the screws were removed.One year after the operation the patient had full--range motion in the right knee with no effusion or dis-comfort. But, during a sports activity he twisted his rightknee which started to lock again limiting the range ofmovement. He was again referred to our clinic. The ra-diograph was unremarkable (Figure 4). Arthroscopy wasperformed. The operation revealed the lesion of the lat-eral meniscus which had been partially removed duringthe first arthroscopy; this time subtotal meniscectomy oflateral meniscus was performed. The osteochondral frag-ments on both condyles were healed and there were nosigns of new cartilage defect. After 2 years, neither kneepain nor arthrosis has occurred.G. Gulan et al.: Osteochondritis Dissecans of Femoral Condyles Affecting Adult Knee, Coll. Antropol. 38 (2014) Suppl. 1: 249–252250Fig. 1. Antero-posterior (a) and lateral (b) plain radiographs ofthe right knee that showed existence of huge osteochondritis dis-secans defects in both femoral condyles.Fig. 2. A view on osteochondral fragment that occupied almostentire lateral femoral condyle of the right knee before fixation.Fig. 3. A view on lateral femoral condyle after the fixation of theosteochondral fragment was done by two cancellous screws andone resorbable pin.Fig. 4. Antero-posterior (a) and lateral (b) plain radiographs ofthe right knee one year after fixation of osteochondral fragmentsdemonstating good results of healing process in both femoralcondyles.DiscussionThe exact etiology of OCD is presently unknown. Re-ported incidence of OCD is between 0.02–0.03% on a sur-vey of knee radiographs1,10. The highest rates appearamong patients aged between 10–15 years, affecting ma-le twice common than female. In 15% of the cases bothknees are involved, but typically in different phases ofdevelopment11.The separation of OCD of the knee into juvenile andadult form is clinically relevant as the two pathologicconditions have distinctly different clinical courses. Ju-venile OCD has a much better prognosis than does adultOCD, with higher rates of spontaneous healing after con-servative therapy11–14.As far as we know, until now there was no publishedpaper describing adult form of OCD of both condyles inthe same knee. Hanna SA et al8 reported two cases de-scribing bicondylar OCD in the same knee affectingyoung boys with opened physis.In our case, there is one more feature yet undes-cribed. The localization of OCD in medial femoral condy-le in our patient corresponds with most frequently re-ported location in the knee. On the other hand, the OCDof lateral femoral condyle was huge affecting almost allweight-bearing surface and was loose. Until now, all re-ported OCD of lateral femoral condyle were juvenileform, and in combination with lateral discoid meniscus.Mizuta H. et al15 reported the development of OCD afterlateral meniscectomy in all patients that underwent me-niscectomy of lateral discoid meniscus. Mitsuoka T. etal.16 studied the features of the OCD affecting lateral andmedial femoral condyles and observed that all patientswith lateral OCD were in growing period, average youn-ger than group with medial OCD, and all had damagedlateral discoid meniscus. Three of them were ruptured,while in other three the lesion were intrasubstantialy.The other studies also observed the development of OCDafter lateral discoid meniscectomy17,18. In our patient,adult form of OCD in the lateral femoral condyle wascombined with the damage of previously normal-shapedmeniscus. It could be only speculative disscusion whatfirst developed, but the damage of lateral meniscus wasnot extensive. Only middle part of lateral meniscus wasdamaged.Exact factors causing lateral OCD are unknown andremain speculative. Various etiology were proposed. So-me authors suggested that damaged discoid meniscuscould cause repetitive stress on weaker osteochondralstructure15, but Oni DB et al19 studied the characteristicsof lateral femoral condyle in the presence of discoid me-niscus and found no difference in articular cartilagethickness comparing to the medial condyle and con-cluded that mechanical disturbances wrought by the dis-coid shape do not have a »Wolff law« effect.There are various proposed treatment methods of theosteochondral defect, which include fixation of the frag-ment with Herbert screws or cancellous screws20 and bio-degradable pins21, mosaicplasty22, autologous chondro-cyte implantation23,24, anterograde and retrograde dril-ling25 and osteochondral allograft transplantation26–29. Ifthe fragment is unstable and large, restoration of the ar-ticular surface should be attempted by fixation, as in ourcase. We used fixation with compression by cancellousscrews and biodegradable pins which showed good re-sults, and the osteochondral fragments healed comple-tely. After a further trauma episode arthroscopically con-firmed by the lateral meniscus injury, the fixed osteo-chondral fragment showed no lesion.ConclusionWe can conclude that in the rare case of such a largeosteochondral defect, when fixation with biodegradablepins could be insufficient, a combination with cancellousscrews can bring good results, even in professional ath-letes. We hope that some of uniques features that we ob-served in our patient could possibly help in understand-ing and explaining the etiology of OCD in future as wellas for future treatment.R E F E R E N C E S1. LINDON B, Acta Orthop Scand, 47 (1976) 664. — 2. SCHENCKRC, Jr, GOODNIGHT JM. J Bone Joint Surg Am, 78 (1996) 439. — 3.SMILLIE IS, Osteochondritis dissecans: Loose bodies in joints: Etiology,pathology, treatment. (E and S Livingstone, Edinburgh, 1960) — 4. RED-DY AS, FREDERICK RW, Am J Sports Med, 26 (1998) 415. — 5. RIB-BING S. Acta Orthop Scand, 24 (1955) 286. — 6. CRAWFORD DC, SA-FRAN MR, J Am Acad Orthop Surg, 14 (2006) 90. — 7. HEIR S, NER-HUS TK, RØTTERUD JH, LØKEN S, EKELAND A, ENGEBRETSENL. Am J Sports Med, 38 (2010) 231. — 8. HANNA SA, ASTONWJ, GIKASPD, BRIGGS TW, J Bone Joint Surg, 90 (2008) 232. — 9. CAHILL BR. JAm Acad Orthop Surg, 3 (1995) 237. — 10. BRADLEY J, DANDY DJ, JBone Joint Surg Br, 71 (1989) 518. — 11. HEFTI F, BEGUIRISTAIN J,KRAUSPE R, MOLLER-MADSEN B, RICCIO V, TSCHAUNER C, JPediatr Orthop B, 8 (1999) 231. — 12. CAHILL BR, PHILLIPS MR,NAVARRO R, Am J Sports Med, 17 (1989) 601. — 13. CLANTON TO,DELEE JC, Clin Orthop Relat Res, 167 (1982) 50. — 14. TWYMAN RS,DESAI K, AICHROTH PM, J Bone Joint Surg Br, 73 (1991) 461. — 15.MIZUTA H, NAKAMURA E, OTSUKA Y, KUDO S, TAKAGI K, Arthros-copy, 17 (2001) 608. — 16. MITSUOKA T, SHINO K, HAMADA M, HO-RIBE S, Arthroscopy, 15 (1999) 20. — 17. LIM HC, BAE JH, J Med CaseReports, 5 (2011) 434. — 18. STANITSKI CL, BEE J, Am J Sports Med,32 (2004) 797. — 19. ONI DB, JEYAPALAN K, ONI OO, Knee, 18 (2011)202. — 20. CETIK O, TURKER M, USLU M, Knee Surg Sports Trau-matol Arthrosc, 13 (2005) 468. — 21. DIN R, ANNEAR P, SCADDAN J, JBone Joint Surg Br, 88 (2006) 900. — 22. MINIACI A, TYTHERLEIGHSTRONG G, Arthroscopy, 23 (2007) 845. — 23. KRISHNAN SP,SKINNER JA, CARRINGTON RW, FLANAGAN AM, BRIGGS TW, BEN-TLEY G, J Bone Joint Surg Br, 88 (2006) 203. — 24. PETERSON L, MI-NAS T, BRITTBERGM, LINDHAL A, J Bone Joint Surg Am, 85-A (2003)17. — 25. AGLIETTI P, BUZZI R, BASSI PB, FIORITI M, Arthroscopy, 10(1994) 286. — 26. BEAVER RJ, MAHOMED M, BACKSTEIN D, DAVISA, ZUKOR DJ, GROSS AE, J Bone Joint Surg Br, 74 (1992) 105. — 27.GHAZAVI MT, PRITZKER KP, DAVIS AM, GROSS AE, J Bone JointSurg Br, 79 (1997) 1008. — 28. MAHOMED MN, BEAVER RJ, GROSSAE, Orthopedics, 15 (1992) 1191. — 29. MARCACCI M, KON E, ZAFFA-GINI S, VISANI A, Orthopedics, 22 (1999) 595.G. Gulan et al.: Osteochondritis Dissecans of Femoral Condyles Affecting Adult Knee, Coll. Antropol. 38 (2014) Suppl. 1: 249–252251G. GulanClinic for Orthopaedic Surgery Lovran, M. Tita 1, 51415 Lovran, Croatiae-mail: gordang@medri.hrDISECIRAJU]I OSTEOHONDRITIS MEDIJALNOG I LATELARNOG KONDILA BEDRENE KOSTIU KOLJENU ODRASLE OSOBES A @ E T A KPrikazali smo prvi slu~aj diseciraju}eg osteohondritisa (OHD) koji je zahvatio veliku povr{inu lateralnog i medijal-nog kondila bedrene kosti u odrasle osobe. Promjene su se dogodile u istostranom koljenu kod 22-godi{njeg profesio-nalnog sporta{a. Nakon klini~kog pregleda, radiolo{ka obrada i magnetska rezonancija pokazali su izra`en bikondilarniDOH. Artroskopskim postupkom, osteohondralni fragment je fiksiran s biorazgradivim pinom u kombinaciji s dva 4mm kobalt-krom spongiozna vijka. Kori{tenjem ovog kirur{kog postupka fiksacije, osteohondralni fragmenti su u pot-punosti zacijelili, {to se potvrdilo artroskopski nakon godinu dana od prve ozljede. Tada je pacijent uslijed nove trau-matske epizode zadobio leziju lateralnog meniska. Prema na{im saznanjima ovo je prvi slu~aj bikondilarnog OHD uodraslom koljenu. U rijetkim slu~ajevima velikog osteohondralnog defekta, kada fiksacija biorazgradivim pinom mo`ebiti nedovoljna, kombinacija sa spongioznim vijcima mo`e donijeti dobre rezultate, ~ak i kod profesionalnih sporta{a.G. Gulan et al.: Osteochondritis Dissecans of Femoral Condyles Affecting Adult Knee, Coll. Antropol. 38 (2014) Suppl. 1: 249–252252

Osteochondritis Dissecans of the Medial and Lateral Femoral Condyles affecting Adult Knee

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Osteochondritis Dissecans of the Medial and Lateral Femoral Condyles affecting Adult Knee

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