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Hybrid Treatment of Osteochondral Fracture of the Patella With Particulated Juvenile Cartilage and Fragment Fixation

Open AccessPublished:June 13, 2022DOI:https://doi.org/10.1016/j.eats.2022.02.030

      Abstract

      Acute patellar dislocation can result in osteochondral fracture of the patella, resulting in multiple osteochondral fragments, with only one fragment able to be fixated into the defect effectively. In these cases, we propose a hybrid procedure to repair the defect using the fixation of one of the osteochondral fragments and particulated juvenile articulate cartilage to fill the remaining defect in the patella. This technique maximizes the amount of native articular surface that we can preserve on the patella. The use of fragment fixation in combination with particulated juvenile articulate cartilage will help prevent further articular damage to the patella and reduce the risk of developing osteoarthritis in patients suffering from an osteochondral fracture as a result of acute patellar dislocation.

      Technique Video

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      This video shows the combined MPFL and patellar cartilage repair using PJAC and fixation of osteochondral fragment after acute patellar dislocation in a 19-year-old male patient. The surgical procedure was performed on the left knee in full extension with the patient in the supine position. Initially, diagnostic arthroscopy was performed along with debridement of cartilage flaps and excision of the loose body. The arthrotomy was then carried out with a medial parapatellar approach. The medial retinaculum was separated from the capsule and tagged with a suture to aid the MPFL reconstruction. The patella was then everted to assess the defect and prepare the osteochondral fragment for fixation with 2 Smart Nails. The MPFL reconstruction was then addressed using 2 Q-FIX anchors at approximately the midpoint of the patella, and then the gracilis allograft was tagged, tying it down with the sutures from the anchors. Foil was then used to make a mold of the remaining defect in the patella. That foil mold was then filled with the particulated cartilage and tisseal. Before placement of the cartilage allograft, an incision was made posterior to the medial epicondyle, and a guide pin was placed for the femoral tunnel. The position of the wire was checked using fluoroscopy. The cartilage graft was placed in the remaining defect with tisseal at the base. Excess fibrin glue was removed, and once the tisseal was fully cured, the knee was put through flexion and extension to ensure that the graft was secure. The MPFL reconstruction was then completed fixing the gracilis allograft with a tenodesis screw to the femoral tunnel. (MPFL, medial patellofemoral ligament; PJAC, particulated juvenile articulate cartilage.)

      Technique Video

      See video under supplementary data.

      Patellar dislocation is a common injury in the pediatric and young adult patient population and may be associated with osteochondral and ligament injuries. Patellar dislocations and chronic instability can lead to acute injuries such as osteochondral fractures of the patella and femoral condyle and cartilage-only injuires.
      • Uimonen M.
      • Ponkilainen V.
      • Paloneva J.
      • Mattila V.M.
      • Nurmi H.
      • Repo J.P.
      Characteristics of osteochondral fractures caused by patellar dislocation.
      ,
      • Höhne S.
      • Gerlach K.
      • Irlenbusch L.
      • Schulz M.
      • Kunze C.
      • Finke R.
      Patella dislocation in children and adolescents.
      Adolescents are at the greatest risk for osteochondral fracture because the articulate cartilage is incompletely formed.
      • Kramer D.E.
      • Pace J.L.
      Acute traumatic and sports-related osteochondral injury of the pediatric knee.
      The osteochondral fracture can be successfully treated by fixating the fragment back to the donor site if it is large enough or treating the defect with other cartilage restoration procedures.
      • Małecki K.
      • Pruchnik–Witosławska K.
      • Gwizdała D.
      • Grzelak P.
      • Flont P.
      • Niedzielski K.R.
      Clinical results and MRI evaluation of patellar osteochondral fracture fixation following patellar dislocation.
      Cartilage restoration has been extensively described with procedures such as microfracture, autologous chondrocyte implantation, matrix-induced autologous chondrocyte implantation, particulate cartilage grafts, and osteochondral grafts.
      Selection of the appropriate cartilage-restoration procedure is dependent on the patient’s age, the severity of the chondral defect, osteochondral lesion size, history of previous failed surgical interventions, and available implants or allograft tissue.
      • Brophy R.H.
      • Wojahn R.D.
      • Lamplot J.D.
      Cartilage restoration techniques for the patellofemoral joint.
      • Shanmugaraj A.
      • Coughlin R.P.
      • Kuper G.N.
      • et al.
      Changing trends in the use of cartilage restoration techniques for the patellofemoral joint: A systematic review.
      • Hinckel B.B.
      • Pratte E.L.
      • Baumann C.A.
      • et al.
      Patellofemoral cartilage restoration: A Systematic review and meta-analysis of clinical outcomes.
      A patient who sustains an acute dislocation may have an osteochondral fracture amenable to fixation of the fragment, which may not completely restore the entire articular cartilage surface. Inadequate articular surface repair may result from only partial repair either due to fragmentation of the loose body or from the degradation of the fragment over time.
      • Touten Y.
      • Adachi N.
      • Deie M.
      • Tanaka N.
      • Ochi M.
      Histologic evaluation of osteochondral loose bodies and repaired tissues after fixation.
      Despite this, partial repair can allow the defect to go from uncontained to contained and leave a smaller residual defect.
      • Pascual-Garrido C.
      • Tanoira I.
      • Muscolo D.L.
      • Ayerza M.A.
      • Makino A.
      Viability of loose body fragments in osteochondritis dissecans of the knee. A series of cases.
      To prevent further dislocations and additional osteochondral fractures, the patient’s patella instability needs to be addressed during cartilage repair. Patients who undergo combined tibial tubercle osteotomy and medial patellofemoral ligament (MPFL) or isolated MPFL reconstruction show reduced frequency of patellar instability.
      • Allen M.M.
      • Krych A.J.
      • Johnson N.R.
      • Mohan R.
      • Stuart M.J.
      • Dahm D.L.
      Combined Tibial tubercle osteotomy and medial patellofemoral ligament reconstruction for recurrent lateral patellar instability in patients with multiple anatomic risk factors.
      We suggest that some patients who sustain an acute patellar dislocation and an osteochondral fracture may benefit from a hybrid procedure involving fragment fixation and concomitant particulated juvenile articulate cartilage (PJAC) reconstruction to treat the remaining articular defect. After the osteochondral fragment is fixated to the defect, the juvenile cartilage allograft fills the residual articular defect. Upon successfully repairing the articular defect, MPFL reconstruction or a combined tibial tubercle osteotomy with MPFL reconstruction will be performed to treat the patient’s chronic patellar instability.

      Surgical Technique (With Video Illustration)

      The patient is placed in the supine position, the knee in full extension, and with a tourniquet applied throughout the procedure. An inferolateral arthroscopic portal is made, followed by an inferomedial instrument portal under direct visualization. Diagnostic arthroscopy is performed to identify and excise the loose bodies as well as to visualize and measure the chondral defect on the patella and or the lateral femoral condyle (Figs 1 and 2).
      Figure thumbnail gr1
      Fig 1This is an arthroscopic image viewed through an inferolateral portal of a right knee in full extension. The image shows an ostechondral defect located on the medial patellar facet.
      Figure thumbnail gr2
      Fig 2Three excised loose bodies are shown on the sterile table of the operating room. These osteochondral fragments were a result of osteochondral fracture due to acute patellar dislocation. The fragments are shown next to a ruler for scaling purposes.
      Attention is then turned to the arthrotomy. The limb is exsanguinated with an elastic Esmarch. A lateral parapatellar approach is used to identify the soft-tissue interval between the capsule, the retinaculum, and the iliotibial band fascia. The arthrotomy is then completed far laterally for later repair or lateral lengthening. On the medial side of the patella, through the same incision, the layer is found between capsule and retinaculum to tunnel the MPFL; electrocautery is used to remove the soft tissue from the superior 50% of the patella (Video 1). Two Q-FIX anchors (Smith & Nephew, Andover, MA) are inserted 6 to 8 mm apart just proximal to the midpoint of the patella, and then the hamstring allograft is sutured down to the suture anchors (Fig 3).
      Figure thumbnail gr3
      Fig 3This image shows an everted patella through a lateral parapatellar incision of a right knee in full extension. There is a medial patellar facet osteochondral defect measuring approximately 2 cm by 1.5 cm. The Q-FIX anchors are also shown proximal to the midpoint of the patella, which are used to secure the hamstring allograft for MPFL reconstruction. (MPFL, medial patellofemoral ligament.)
      The base of the chondral defect of the patellar is sharply debrided with both a scalpel and curette. The loose body’s bony surface is also sharply debrided and sculpted to fit into the inferior aspect of the patellar defect (Video 1). The osteochondral fragment is reduced and stably fixed with 2 SmartNails (ConMed, Largo, FL) (Figs 4 and 5). One packet of DeNovo PJAC (Zimmer Biomet, Warsaw, IN) is prepared using a foil mold of the defect and then glued into the proximal defect with fibrin glue (Fig 6).
      Figure thumbnail gr4
      Fig 4This image shows an everted patella through a lateral parapatellar incision of a right knee in full extension. Three ostechondral fragments were excised from this patient and only one was sufficient for fixation into the defect. This image shows fixation of the suitable ostechondral fragment in the superior aspect of the ostechondral defect in the medial patellar facet.
      Figure thumbnail gr5
      Fig 5This image shows an everted patella through a lateral parapatellar incision of a right knee in full extension. 2 SmartNails are shown through the chondral surface of the osteochondral fragment into the superior aspect of the ostechondral defect in the medial patellar facet.
      Figure thumbnail gr6
      Fig 6This image shows an everted patella through a lateral parapatellar incision of a right knee in full extension. Particulate juvenile articulate coartilage (PJAC) is shown filling the remaining ostechondral defect inferior to the fixated ostechondral fragment on the medial patellar facet.
      The MPFL is then fixed to the femur in 30° of flexion with a PEEK (polyether ether ketone) tenodesis screw (Arthrex, Naples, FL). Upon completing the patella realignment, the patient’s range of motion, extension endpoint, and articular surface reconstruction are evaluated. Before closing the arthrotomy, the arthroscope is used to confirm the graft position and stability. Wounds are closed in layers in a routine fashion.
      The patient is placed in a hinged knee orthosis, locked in full extension, and taken to the recovery room. Patients are instructed to be non–weight-bearing with the brace locked in full extension while ambulating for the first 4 weeks postsurgery if an osteotomy is performed. Physical therapy, including passive and active range of motion and isometric strengthening, should begin one week after surgery. The patient should focus on regaining 0 to 90° of motion by the first 2 to 3 weeks. The patient is advised to begin weight-bearing as tolerated after four weeks with their knee brace locked in full extension. After 6 weeks, the patient is full weight-bearing, only using the brace when needed.

      Discussion

      Osteochondral fractures of the patella secondary to acute patella dislocation should be treated surgically to address loose bodies and osteochondral defects leading to post-traumatic osteoarthritis. We outline a novel technique that repairs the osteochondral fragment to the defect and uses PJAC to reconstruct the remaining articular defects, as the fragment, in some cases, will not fill the articular gap in its entirety. Using our hybrid technique will promote the restoration of a homogenous articular cartilage surface. In contrast, isolated fixation of the available osteochondral fragment may leave a significant residual defect, and failure to fix part of the defect may leave an uncontained defect.
      Alternative reduction and fixation techniques also have been described to treat osteochondral fractures effectively. Ng et al.
      • Ng W.M.
      • Al-Fayyadh M.Z.M.
      • Kho J.
      • Seow Hui T.
      • Mohamed Ali M.R.B.
      Crossing suture technique for the osteochondral fractures repair of patella.
      describe a crossing suture technique to stabilize the intra-articular osteochondral fragments to the patella. The reduction and fixation technique uses a suture repair performed with four drill holes placed at the defect’s borders perpendicular to the anteroposterior surface of the patella. Sutures are passed through these drill holes, creating 4 suture loops, 2 diagonal to and the other 2 parallel to the osteochondral fragment. The fragment is then reduced to the patella and secured by tying the four suture loops. Nuelle et al.
      • Nuelle C.W.
      • Nuelle J.A.V.
      • Balldin B.C.
      Open reduction internal fixation of a traumatic osteochondral lesion of the patella with bioabsorbable screw fixation.
      describe a similar method for fixation of the osteochondral fragment using bioabsorbable screws. The main difference in this technique and the technique described in this Technical Note is the addition of microfracture in the osteochondral defect. A literature search reveals a paucity of reports comparing the efficacy of biodegradable screws or tacks and the cross-suture method of osteochondral fragment repair to the patella. Studies have shown that both fixation methods are effective in restoring articular cartilage after an osteochondral fracture. Schlechter et al.
      • Schlechter J.A.
      • Nguyen S.V.
      • Fletcher K.L.
      Utility of bioabsorbable fixation of osteochondral lesions in the adolescent knee: outcomes analysis with minimum 2-year follow-up.
      reviewed 38 adolescent patients who underwent fixation of osteochondral lesions due to osteochondral fracture or osteochondritis dissecans. The osteochondral lesions were fixed using bioabsorbable screws. At a minimum of 2-year follow-up, the authors identified 32 patients with good functional outcomes, none requiring a revision cartilage procedure.
      • Schlechter J.A.
      • Nguyen S.V.
      • Fletcher K.L.
      Utility of bioabsorbable fixation of osteochondral lesions in the adolescent knee: outcomes analysis with minimum 2-year follow-up.
      Malecki et al. analyzed a group of 17 patients who suffered an osteochondral fracture of the patella following dislocation.
      • Shanmugaraj A.
      • Coughlin R.P.
      • Kuper G.N.
      • et al.
      Changing trends in the use of cartilage restoration techniques for the patellofemoral joint: A systematic review.
      This group was treated surgically using a transpatellar suture technique to fixate the osteochondral fragment.
      • Shanmugaraj A.
      • Coughlin R.P.
      • Kuper G.N.
      • et al.
      Changing trends in the use of cartilage restoration techniques for the patellofemoral joint: A systematic review.
      After clinical and magnetic resonance imaging follow-up, the patients were found to have restored patellar articular surface.
      • Shanmugaraj A.
      • Coughlin R.P.
      • Kuper G.N.
      • et al.
      Changing trends in the use of cartilage restoration techniques for the patellofemoral joint: A systematic review.
      Therefore, the fixation technique could potentially be at the surgeon’s discretion and experience to accomplish the hybrid reconstruction. Whether a bioabsorbable screw or cross suture is used, if the fragment is not sufficient to provide complete patella osteochondral reconstruction, PJAC can fill the remaining chondral defect.
      In cases similar to the one described here, alternative cartilage repair techniques should be considered when the osteochondral fragments have broken off into smaller pieces that cannot all reliably be reduced and stabilized. Using both autologous bone grafts and PJAC will allow for the restoration of quality articular cartilage of the patella. Hybrid patellar osteochondral reconstruction will theoretically prevent further chondral damage and reduce the risk of future osteoarthritis, especially in adolescents. Pearls and pitfalls as well as advantages and disadvantages are outlined in Tables 1 and 2, respectively.
      Table 1Pearls and Pitfalls of the Hybrid Procedure Including Fixation of an Osteochondral Fragment and Use of Particulated Juvenile Cartilage for the Treatment of Osteochondral Fracture of the Patella
      PearlsPitfalls
      • Use a curette to debride the base of cartilage defect and the hematoma/fibrinous tissue on the bony side of the osteochondral fragment.
      • Use a small k-wire to hold the fragment in place before securing the fragment with an absorbable tack.
      • Place the tack in the central aspect of fragment to minimize the risk of fragmentation.
      • Avoid debridement of adjacent fat pad in order to protect particulated cartilage graft if the lesion is uncontained.
      • If the fragment moves during placement of the absorbable tack, it is difficult to locate the drill hole on far cortex.
      • If eversion of the patella is insufficient, reduction of the fragment will be difficult.
      • The patient may develop arthrofibrosis, use a continuous passive motion device immediately.
      Table 2Advantages and Disadvantages of Using the Hybrid Procedure Including Fixation of the Osteochondral Fragment and Particulated Juvenile Cartilage to Treat Osteochondral Fracture of the Patella
      AdvantagesDisadvantages
      • This technique can turn an uncontained defect into a contained defect
      • Hybrid technique requires less allograft tissue, thus is cheaper
      • The surgeon is prepared if loose body cannot be fixated as they have allograft tissue on hand (PJAC)
      • PJAC is expensive
      • PJAC is not available on the shelf at all hospitals and must be ordered in advance
      • Need to have absorbable tacks on the shelf.
      PJAC, particulated juvenile articulate cartilage.

      Supplementary Data

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