Osteochondral Repair

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS

Osteochondritis dissecans of the knee

CONTRAINDICATIONS
  • Very fragmented lesion
  • Lesions larger than 3 cm in diameter
  • Lesions that are inaccessible by arthroscopy
  • Concomitant medical illness that increases the anesthesia risk
  • Inability to comply with postoperative weight-bearing restrictions
  • Knee infection
EQUIPMENT
  • Arthroscopy table
  • X-ray or fluoroscopy unit
  • Arthroscopy tower
  • Arthroscopy set, including cannulas, bur, baskets, shavers, and graspers
  • Drill
  • Kirschner wires
  • Absorbable pins (Bionx SmartNail, Bionx Implants, Blue Bell, Pa)
  • 1.5-mm diameter SmartNail arthroscopic drill
  • Herbert screws
  • Herbert screw guide
ANATOMY
  • Articular cartilage: water, collagen, proteoglycans, and chondrocytes; layers include a superficial gliding zone, a middle transitional zone, and a deep radial zone.
  • Cortical bone (compact bone): haversian systems connected by canals containing arterioles, capillaries, venules, and nerves
  • Cancellous bone (spongy or trabecular bone): less dense with higher turnover rate
  • Metaphyseal and epiphyseal blood supply: periarticular vascular plexus, which arises from the geniculate arteries
  • The distal femur is composed of two condyles, of which the medial is larger.
    • The medial aspect of the lateral femoral condyle is the most common location for OCD lesions.
    • Lesions on the weight-bearing surface are the most symptomatic, but the degree of involvement can change as the knee moves through its normal range of motion.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Procedure: Arthroscopic Drilling of Intact Lesion of the Femoral Condyle
  • Procedure: Arthroscopic Screw Fixation for Osteochondritis Lesions in the Medial Femoral Condyle
  • Procedure: Arthroscopic Screw Fixation for Larger Osteochondritis Dissecans Lesions (>2.5 cm)

Procedure: Arthroscopic Drilling of Intact Lesion of the Femoral Condyle


POST-PROCEDURE CARE
  • Restricted range of motion in a brace for 4 to 6 weeks
  • Partial weight-bearing with crutches for 4 to 6 weeks, although this may be extended to 10 weeks for larger lesions
  • Range-of-motion exercises for 15 to 20 minutes, 2 to 3 times a day
COMPLICATIONS
  • Infection
  • Fragmentation of lesion
  • Continued symptoms
  • Vascular injury
  • Thrombophlebitis
  • Reflex sympathetic dystrophy
  • Neurologic injury
ANALYSIS OF RESULTS
  • Drilling of intact OCD has a very high success rate in skeletally immature patients (90% or higher), with slightly lower rates of success in skeletally mature patients (75% or higher).
  • Lesions requiring internal fixation also have high success rates (85% or more).
OUTCOMES AND EVIDENCE
  • Intact lesions treated with drilling:
    • Aglietti et al: 100% radiographically healed at 4 years
    • Kocher et al: 100% radiographically healed by 4.4 years
    • Bradley and Dandy: 10/11 healed by 2 years; 1 failure
    • Anderson et al: 18/20 healed
  • Lesions treated with fixation:
    • Kocher et al: 84.6% healing regardless of fixation used
    • Guhl (1982): 90% healing within 5 months
    • Makino et al: Herbert screw fixation showed 14/15 lesions had healed at the time of second-look arthroscopy.
    • Weckstrom et al: Bioabsorbable self-reinforced poly-L-lactide pins and nails were used with superior functional results (73% excellent or good) in the nail group compared with the pin group (35% excellent or good).
Procedure: Arthroscopic Drilling of Intact Lesion of the Femoral Condyle

Procedure: Arthroscopic Screw Fixation for Osteochondritis Lesions in the Medial Femoral Condyle


POST-PROCEDURE CARE
  • Restricted range of motion in a brace for 4 to 6 weeks
  • Partial weight-bearing with crutches for 4 to 6 weeks, although this may be extended to 10 weeks for larger lesions
  • Range-of-motion exercises for 15 to 20 minutes, 2 to 3 times a day
COMPLICATIONS
  • Infection
  • Fragmentation of lesion
  • Continued symptoms
  • Vascular injury
  • Thrombophlebitis
  • Reflex sympathetic dystrophy
  • Neurologic injury
ANALYSIS OF RESULTS
  • Drilling of intact OCD has a very high success rate in skeletally immature patients (90% or higher), with slightly lower rates of success in skeletally mature patients (75% or higher).
  • Lesions requiring internal fixation also have high success rates (85% or more).
OUTCOMES AND EVIDENCE
  • Intact lesions treated with drilling:
    • Aglietti et al: 100% radiographically healed at 4 years
    • Kocher et al: 100% radiographically healed by 4.4 years
    • Bradley and Dandy: 10/11 healed by 2 years; 1 failure
    • Anderson et al: 18/20 healed
  • Lesions treated with fixation:
    • Kocher et al: 84.6% healing regardless of fixation used
    • Guhl (1982): 90% healing within 5 months
    • Makino et al: Herbert screw fixation showed 14/15 lesions had healed at the time of second-look arthroscopy.
    • Weckstrom et al: Bioabsorbable self-reinforced poly-L-lactide pins and nails were used with superior functional results (73% excellent or good) in the nail group compared with the pin group (35% excellent or good).
Procedure: Arthroscopic Screw Fixation for Osteochondritis Lesions in the Medial Femoral Condyle

Procedure: Arthroscopic Screw Fixation for Larger Osteochondritis Dissecans Lesions (>2.5 cm)



POST-PROCEDURE CARE
  • Restricted range of motion in a brace for 4 to 6 weeks
  • Partial weight-bearing with crutches for 4 to 6 weeks, although this may be extended to 10 weeks for larger lesions
  • Range-of-motion exercises for 15 to 20 minutes, 2 to 3 times a day
COMPLICATIONS
  • Infection
  • Fragmentation of lesion
  • Continued symptoms
  • Vascular injury
  • Thrombophlebitis
  • Reflex sympathetic dystrophy
  • Neurologic injury
ANALYSIS OF RESULTS
  • Drilling of intact OCD has a very high success rate in skeletally immature patients (90% or higher), with slightly lower rates of success in skeletally mature patients (75% or higher).
  • Lesions requiring internal fixation also have high success rates (85% or more).
OUTCOMES AND EVIDENCE
  • Intact lesions treated with drilling:
    • Aglietti et al: 100% radiographically healed at 4 years
    • Kocher et al: 100% radiographically healed by 4.4 years
    • Bradley and Dandy: 10/11 healed by 2 years; 1 failure
    • Anderson et al: 18/20 healed
  • Lesions treated with fixation:
    • Kocher et al: 84.6% healing regardless of fixation used
    • Guhl (1982): 90% healing within 5 months
    • Makino et al: Herbert screw fixation showed 14/15 lesions had healed at the time of second-look arthroscopy.
    • Weckstrom et al: Bioabsorbable self-reinforced poly-L-lactide pins and nails were used with superior functional results (73% excellent or good) in the nail group compared with the pin group (35% excellent or good).
Procedure: Arthroscopic Screw Fixation for Larger Osteochondritis Dissecans Lesions (>2.5 cm)
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