Large Osteochondral Fragment Research Articles

Arthroscopic Fixation of a Large Osteochondral Fragment From the Glenoid After First Episode Dislocation

Osteochondral lesions of the glenoid are not so uncommon after traumatic cases of shoulder dislocation and can be a challenge to the shoulder surgeon because of the technical difficulty and the potential to progression to shoulder arthritis. An all-arthroscopic technique of fixation of a large osteochondral fragment is used to allow optimal visualization and reduction, minimize the morbidity of the open approach, and provide good functional results.

Patellofemoral Instability in Active Adolescents

Patellofemoral instability is a common problem in the adolescent population. Patellar stability depends on a dynamic interplay between bony and soft tissue restraints. Several pathoanatomical factors increase the likelihood of patellar instability: patella alta, trochlear dysplasia, malalignment, and deficient proximal medial restraints. Treatment for first-time patella dislocations is typically nonoperative and includes bracing, early range of motion, and physical therapy. The only absolute indication for early surgery is a large osteochondral fragment that can be fixed. Surgical stabilization is indicated for chronic patellar instability and includes both proximal and distal realignment options. Medial patellofemoral ligament reconstruction is the treatment of choice in most adolescent patients with patella instability. Distal bony realignment procedures are reserved for skeletally mature adolescents.

Coronal Shear Fracture of the Humeral Trochlea

To review records of 5 patients with anterior coronal trochlear fractures. Four men and one woman aged 25 to 46 (mean, 34) years underwent cancellous screw (n=3) or Kirschner wire (n=2) fixation for anterior coronal fractures of the humeral trochlea after falling on a flexed elbow. Patients were operated on through a medial approach. Three patients who had a large osteochondral fragment underwent fixation using 4-mm AO partially threaded cancellous screws. Two patients who had a small un-amenable osteochondral fragment (with articular cartilage damage) underwent fixation using Kirschner wires. Patients were evaluated using the Mayo Elbow Performance Index (MEPI) based on pain, arc of motion, stability, and functional disability. The mean time from injury to surgery was 7 (range, 5-10) days. The mean follow-up period was 2.7 years. No patient had any wound-related problems, postoperative neurovascular compromise, or avascular necrosis. Radiographic union was noted after a mean of 14 weeks. Outcome was excellent in 4 patients and good in one. The mean arc of flexion-extension was 101º and the mean arc of supination-pronation was 130º. The mean MEPI was 92. The MEPI was relatively low in the 2 patients with a small osteochondral fragment who underwent Kirschner wire fixation. One patient with articular cartilage damage developed mild degenerative changes and had to change his occupation. The remaining 4 patients were pain-free and had returned to their occupations within 4 months. Open reduction and screw fixation restores articular congruency and enables early mobilisation. Small coronal shear fractures of the trochlea not amenable to screw fixation should be fixed with Kirschner wires.

Fixation of a Posteromedial Osteochondral Lesion of the Talus Using a Three-Portal Posterior Arthroscopic Technique

Fixation of a large osteochondral fragment on the posteromedial talus can be performed using medial malleolar osteotomy or an arthroscopic technique with a transmalleolar portal. However, osteotomy can be associated with some morbidity, such as longstanding pain and tenderness at the osteotomy site. Also, it requires longer immobilization. However, the transmalleolar portal damages the tibial articular cartilage, which can later cause pain. In young patients, it can injure the epiphyseal plate. We describe a posterior arthroscopic technique using 3 posterior portals that allow access to a posteromedial osteochondral lesion of the talus and fixation of the osteochondral fragment without malleolar osteotomy or transmalleolar drilling.

A large laterally displaced osteochondral fragment from dislocated patella: Case report and possible mechanism

Dislocation of the patella is not a common disorder of the knee joint and is seen most frequently in the adolescent population. Osteochondral fractures account for approximately 5-74% of all acute patellar dislocations and are easy to overlook. The mechanism of injury and presentations of fractured fragments were seldom well describe in published studies. The case reported here is that of a 17-year-old baseball player who suffered an acute patellar dislocation with a large osteochondral fragment fracture, where the fragment presented over the lateral supracondylar aspect of the distal femur. Open reduction and fixation with Kirschner wires gave a good result. Osteochondral fracture of patella is usually regarded as a dislocation phenomenon. However, we review and discuss here three injury mechanisms, and suggest the possible mechanisms by which patellar relocation could have caused our patient’s injury and the rare occurrence of a laterally displaced osteochondral fragment over the distal femur.

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.

Total posterior condylar separation in a juvenile knee: open fixation through a posterior arthrotomy

The authors report a case of separation involving the posterior aspect of the lateral femoral condyle in a 13-year-old boy. The patient presented with a 2-year history of vague knee discomfort and recurrent knee effusions in the absence of a single acute traumatic event. A large mobile osteochondral fragment involving most of the posterior aspect of the lateral condyle was refixed surgically with two screws via a posterolateral arthrotomy. The knee has recovered full function and the lesion is radiologically stable.

Ankle stiffness and osteoarthritis in fracture-dislocation: an avoidable complication or natural history

Dear Editor, We read the article “Ankle stiVness after Bosworth fracture dislocation of the ankle” by Lui et al. [1] with great interest. They presented four cases who had ankle stiVness after Bosworth fracture dislocation. In their study, three of the four cases were transferred to hospital late, and the authors suggest that delayed treatment in these patients was the cause of stiVness or ankle osteoarthritis or both. One early case that was treated immediately did not have such problems. Hockenbury and Friermood [2] reported a patient with dislocation of the intact Wbula, small avulsion fracture of the medial malleolus, rupture of the deltoid ligament and tarsal injury. Although the patient was treated by open reduction and internal Wxation without delay, he subsequently developed talar avascular necrosis and degenerative arthritis. In fracture-dislocation cases, there may also be some additional intra-articular pathology like osteochondral injuries. Hoblitzell et al. [3] described a large osteochondral fragment from posterior malleolus after such injury. The authors also found osteochondral lesions in three out of their four patients. Therefore, they commented that “this may have some bearing on the prognosis, as ankle degeneration developed in all three patients.” Bosworth fracture dislocation is characterized with the Wxed displacement of the Wbula behind the tibia; however, anatomic conWguration may change. For instance, in our series of ankle osteoarthritis patients that were treated with total ankle arthroplasty, a patient had a fracture dislocation without Wbular entrapment who was operated immediately after the injury (Fig. 1). The ankle anatomy was restored (Fig. 2). However, in the follow-up, degenerative arthritis was seen (Fig. 3). We have been performing ankle replacement for advanced osteoarthritis, and during our observations regarding the natural history and etiology of our series, we observed that despite the early motion that can be obtained after early reduction and stable internal Wxation some

The treatment of an osteochondral shearing fracture-dislocation of the head of the proximal phalanx: A case report

We report the morphology and treatment of a proximal interphalangeal joint dislocation resulting in an injury to the articular surface of the proximal phalanx and avulsion of the radial collateral ligament from its proximal origin. A large osteochondral fragment was sheared from the radial articular surface of the proximal phalanx and remained displaced volarly after reduction of the joint. Plain radiographs and 2- and 3-dimensional computed tomography images were used to evaluate this unusual injury before surgery. Open reduction and internal fixation using a small K-wire and figure-of-eight wire technique restored the articular surface of the head of the proximal phalanx and gave a satisfactory functional result.

Fragment fixation with a bone graft and dynamic staples for osteochondritis dissecans of the humeral capitellum

To attain bony union of the fragment in osteochondritis dissecans of the humeral capitellum, fragment fixation was performed with a bone graft and dynamic staples in 4 patients. The staples were inserted not from the articular surface but from the lateral aspect of the capitellum. All patients achieved bony union without complication, and 3 of them returned to playing competitive baseball. At final follow-up after surgery (mean, 7.5 years [range, 2.1-11 years]), 3 patients were able to throw a ball without pain and the remaining patient felt elbow dullness after he played recreational-level baseball as a pitcher. These results suggest that the procedure of fragment fixation with a bone graft and dynamic staples can provide satisfactory results for osteochondritis dissecans of the humeral capitellum with a large osteochondral fragment. (J Shoulder Elbow Surg 2002;11:368-372)

Isolated avulsion of the popliteus tendon

We have reported a rare case of an isolated avulsion of the popliteus tendon. In this case the avulsed tendon was associated with a large osteochondral fragment that was easily relocated and fixed anatomically. We believe that the popliteus tendon is important to the mechanics of the knee. We would recommend the treatment as presented in this case should one of these rare cases be encountered.

Management of Posterior Fracture-Dislocations of the Shoulder

Posterior fracture-dislocation of the shoulder is rare. Comprehensive treatment guidelines for posterior fracture-dislocation of the shoulder with fracture of the humeral head have not been previously published. Although open reduction and internal fixation of the proximal humerus for posterior fracture-dislocation has been reported in several series, the successful reconstruction of the articular surface by rigid internal fixation of a large osteochondral fragment has not been reported. This paper describes two cases of posterior fracture-dislocation of the shoulder with a substantial defect of the anteromedial humeral head resulting from the cleavage of a large osteochondral fragment. Preoperative computed axial tomographic (CAT) scanning of the injured shoulders helped in operative planning by precisely defining the extent of the articular injury. Accurate reconstruction of the articular surface restored joint stability and gave excellent clinical results. Large humeral head osteochondral fracture fragments require accurate reduction and internal fixation.

MR imaging of the knee. Part II. Chronic disorders.

Sixty patients with symptoms of chronic disease of the knee joint were evaluated with high-resolution, thin-section magnetic resonance (MR) imaging. MR imaging depicted a wide variety of knee joint abnormalities including osteochondritis dissecans, medullary infarcts, epiphyseal osteonecrosis, intraarticular osteochondral fragments, synovial cysts, joint effusions, intraarticular soft-tissue tumors, synovial disease, leukemic infiltration of bone marrow, Osgood-Schlatter disease, and nonossifying fibroma. In two cases MR imaging depicted bone infarcts not seen on both radionuclide bone scans and standard radiographs. The highly detailed depiction of the articular cartilage was of particular importance in predicting arthroscopic findings in cases of osteochondritis dissecans. In two cases, a soft-tissue mass (pigmented villonodular synovitis) and a large osteochondral fragment undetected at arthroscopy were accurately localized with MR imaging. The results indicate that MR imaging is capable of providing information that might otherwise require multiple, sometimes invasive diagnostic procedures.