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Bone peg fixation of a large chondral fragment in the weight-bearing portion of the lateral femoral condyle in an adolescent: a case report
© Nakayama and Yoshiya; licensee BioMed Central Ltd. 2014
Received: 21 March 2014
Accepted: 1 July 2014
Published: 23 September 2014
Chondral fracture of the knee is relatively rare and the optimal treatment option for this injury is still controversial. In this report, we present the case of a patient with this injury who was treated surgically using the bone peg fixation procedure. There has been no literature reporting the use of this technique for fixation of a detached chondral fragment.
The patient was a 14-year-old Japanese boy who sustained a knee injury while kicking a soccer ball. Although routine radiographs showed no abnormality, magnetic resonance imaging showed a large full-thickness chondral defect in the weight-bearing portion of his lateral femoral condyle and a detached chondral fragment in the anterior region. The size of the defect (fragment) was 2cm by 1.5cm. At surgery, the chondral fragment was fixed with eight cortical bone pegs that were harvested from the anteromedial aspect of his tibia.
The postoperative magnetic resonance imaging at 4 months and the second-look arthroscopy at 12 months revealed apparent healing of the fragment. In the final follow-up examination at 26 months, a physical examination showed no swelling with recovery of full range of motion, and he could play soccer at the pre-injury level with no complaint. Based on the clinical course of this patient, it is thought that bone peg fixation can be a valuable option for fixation of a large chondral fracture of the knee.
Chondral fracture of the femoral condyle is relatively rare and predominantly encountered as a sports-related injury in adolescence due to inferior mechanical properties of the bone–cartilage junction in this age range [1–3]. Impact of the patellar facet or tibial plateau against the femoral condyle during a twisting type of injury is thought to be an injury mechanism [2–6]. Since chondral fragments do not show up in routine radiographs, this injury may not be correctly diagnosed at the initial presentation; however, careful assessment of magnetic resonance images (MRI) can reveal chondral loose bodies as well as full-thickness defects on the articular surface. This injury often extends over a large area, and sometimes involves the weight-bearing portion [4–6]. For large lesions in the weight-bearing portion, restoration of cartilaginous integrity by internal fixation of the chondral fragment should be considered a treatment option. Regarding the surgical procedure, metal and bioabsorbable devices have been utilized to fix the intra-articular fragment in previous studies [2, 4–7]; however, a metal device requires subsequent removal in a secondary surgery, while use of a bioabsorbable material within the joint may induce a foreign body reaction in the process of degradation and reabsorption [8–10]. As an alternative option, bone peg fixation of the intra-articular osteochondral fragment has been reported with favorable results in patients with osteochondritis dissecans [11–13]. Use of the bone peg affords rigid fixation and may provide an additional advantage of biological healing enhancement; however, there has been no literature reporting the use of this technique for fixation of a detached chondral fragment.
In this report, we present the clinical characteristics and outcome of a patient with a chondral fracture in the weight-bearing region of his lateral femoral condyle who was successfully treated with bone peg fixation.
Chondral fracture of the knee is a relatively uncommon injury. In 1985, Hopkinson et al. reviewed their patient records and reported that chondral fractures were identified in eight of the 1095 knees (0.73%) arthroscoped at their institute. In accordance with the routine use of MRI as a part of the examination for knees with sports injuries, diagnostic accuracy for chondral injury has been improved and the incidence of this injury in our current practice is thought to be higher than the value in previous reports.
Regarding the injury mechanism of chondral fractures, Flachsmann et al.  conducted a biomechanical study using bovine cartilage bone laminates. They compared the strength of the osteochondral junction among the different maturation stages and showed that adolescent tissue exhibited significantly reduced fracture toughness under shear loading. Therefore, shear loading at the articular contact during a twisting injury is thought to be a predominant injury mechanism. Since the chondral defect in the reported case was located at the mid-lateral articular edge, patella-femoral contact during shifting motion of the patella may have been a mechanism of the injury. Mashoof et al. reported seven cases with osteochondral injuries to this location that were associated with patella dislocation.
Chondral fractures with detached fragments require surgical intervention. Surgical options include removal and fixation of the fragment. Considering the importance of cartilage integrity, fixation of the fragment is a preferable option for a large lesion in the weight-bearing portion. Conventionally, a metal fixation device was used to fix the fragment ; however, use of metal devices requires reoperation for hardware removal. In recent relevant reports, bioabsorbable pins have become a principal option. Walsh et al. reported the use of polyglycolic acid rods for fixation with successful outcomes in a majority of the cases. Nakamura et al. reported a case with fixation of the fragment using poly-L-lactic acid (PLLA) pins. In this patient, complete healing at the osteochondral junction was accomplished as confirmed by histological examination. Although these reports showed a satisfactory outcome without procedure-related complications, postoperative complications such as foreign body reaction have been reported with the use of bioabsorbable fixation devices in the knee [8–10]. Moreover, chondral injury on the articular surface and hardware breakage have also been reported as other potential complications [14, 15]. Bone pegs have been successfully used to fix osteochondral dissecans lesions and osteochondral fractures [11–13]. This method of fixation has several advantages over other fixation methods. First, secondary surgery for hardware removal is not required. Secondly, complications such as foreign body reaction and chondral injury can be avoided. Finally, insertion of autogenous bone through the interface may biologically enhance the healing process.
In the presented case, conditions for healing were not ideal because of the 6-week time period between injury and surgery and the lack of bony attachment to the fragment. Nevertheless, satisfactory healing was attained as confirmed by the postoperative MRI and the second-look arthroscopy. The use of bone peg as a fixation device in this case may have provided a favorable environment for healing both in a biomechanical and a biological aspect. However, this is a report of only one patient without histological confirmation of healing at the osteochondral junction. Moreover, the follow-up period is still short. Accumulation of further experiences for additional cases and longer term follow-up results are required to prove the efficacy of this procedure.
Bone peg fixation procedure for a chondral fracture of the knee has not been reported in the previous literature. We utilized this fixation method for a patient with a large chondral fracture in the weight-bearing portion of the lateral femoral condyle. Healing at the fracture site was confirmed by MRI and second-look arthroscopy with a satisfactory functional outcome. Thus, it is thought that bone peg fixation can be a good option in surgical treatment of chondral fractures.
Written informed consent was obtained from the patient’s parent for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
The authors would like to thank Mr Devin Casadey for his assistance in the preparation of the article.
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