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Large Osteochondral Fractures of the Lateral Femoral Condyle in the Adolescent: Outcome of Bioabsorbable Pin Fixation
Stewart J. Walsh, MD1; Matthew J. Boyle, MD1; Vicki Morganti, MD2
1 Department of Orthopaedic Surgery, Starship Children's Hospital, Private Bag 92024, Auckland 1142, New Zealand. E-mail address for S.J. Walsh: stewartw@adhb.govt.nz
2 Department of Radiology, Auckland City Hospital, Private Bag 92024, Auckland 1142, New Zealand
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the Wishbone Trust, New Zealand. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Starship Children's Hospital, Auckland, and the Department of Radiology, Auckland City Hospital, Auckland, New Zealand

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jul 01;90(7):1473-1478. doi: 10.2106/JBJS.G.00595
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Abstract

Background: Large osteochondral fractures of the lateral femoral condyle of the knee in adolescent patients can be diagnostically and therapeutically challenging. Historically, management has involved removal of the fragment, leaving a large area of bone devoid of articular cartilage on the weight-bearing surface of the lateral femoral condyle. This study assessed open reduction and internal fixation of the osteochondral fragments with use of multiple polyglycolic acid rods.

Methods: Eight patients, between twelve and fifteen years old, with a large (>4 cm2) osteochondral fracture of the lateral femoral condyle were treated with open reduction and internal fixation with use of multiple polyglycolic acid rods. Each patient was evaluated at more than five years (a mean of nine years) after the index procedure with a clinical assessment, during which the knee was scored according to the International Knee Documentation Committee and Cincinnati knee rating systems, plain radiographs were made, and magnetic resonance imaging scans were acquired.

Results: The majority of patients scored well on both knee rating systems, with no poor results. Five of the eight patients had normal findings on knee radiographs, and three had radiographs that showed minor changes. Magnetic resonance imaging scans of all cpatients demonstrated intact articular cartilage in the lateral compartment with no area of full-thickness articular cartilage loss. No evidence of articular cartilage thinning was seen in two knees; a small area of <2 cm2 of cartilage thinning, in four; a moderate area of 2.7 cm2 of cartilage thinning, in one; and a large area of 11.2 cm2 of abnormal cartilage signal, in one knee.

Conclusions: Osteochondral fracture of the lateral femoral condyle is an injury to which adolescents with ligamentous laxity of the knee are prone. Our results show that internal fixation of these osteochondral fragments with bioabsorbable implants is possible and is a worthwhile option.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Stewart J Walsh
    Posted on September 15, 2008
    Dr. Walsh and colleagues respond to Drs. Meiss and Placzek
    Starship Children's Hospital, Auckland, New Zealand

    We were interested to read the comments provided by Drs. Meiss and Placzek in response to our article(1) and we thank them for their letter. We also appreciate their drawing our attention to their abstract, outlining the management of a large osteochondral lesion involving the posterior weight-bearing surface of the lateral femoral condyle in an eleven year old boy(2).

    The diagnosis in this case was delayed by approximately one year and the management involved bone grafting in addition to repair of the osteochondral lesion with absorbable sutures. Although this case was not published at the time that our article was submitted for publication, it raises two important points. Firstly, the case demonstrates that healing of large traumatic osteochondral lesions of the lateral femoral condyle in the adolescent is possible and repair should therefore be considered. Second, the need for a high degree of clinical suspicion is highlighted as a diagnostic delay in this patient may have led to the development of subchondral bony irregularities and alteration in the size and shape of the chondral fragment making reduction more difficult.

    We suspect that these traumatic injuries to the lateral femoral condyle occur more frequently than has previously been appreciated. The method of fixation that Dr Meiss and Dr Placzek describe is another option for surgeons encountering this problem.

    References

    1. Walsh SJ, Boyle MJ, Morganti V. Large osteochondral fractures of the lateral femoral condyle in the adolescent. Outcome of bioabsorbable pin fixation. J Bone Joint Surg Am. 2008;90:1473-1478.

    2. Meiss AL, Placzek R. Cystic lesions in the lateral femoral condyle of an 11-year-old boy – of tumorous, parasitic or traumatic origin? 4 ½ year follow-up. J Child Orthop. 2008;2:160-162.

    A. Ludwig Meiss
    Posted on July 30, 2008
    Fixation of osteochondral fractures of the lateral femoral condyle in the adolescent
    University Hospital Hamburg-Eppendorf, Germany

    To the Editor:

    Dr. Walsh and colleagues describe successful internal fixation of osteochondral fragments of the lateral femoral condyle with bioabsorbable pins (1). We believe that fixation by absorbable sutures can also be an option.

    In this context we would like to draw the authors' attention to the successful resuturing of a large osteocartilagenous flake involving the posterior weight-bearing portion of the lateral femoral condyle in an 11- year-old boy (2). There was a delay of diagnosis of about a year. A posterior and anterior approach was necessary to allow placement of the sutures (with 5-0 Vicryl). In addition a debridement of the site of reimplantation was performed followed by cancellous bone transplantation. This may have favored the healing of the fragment to the underlying bone.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Walsh StJ, Boyle MJ, Morganti V. Large osteochondral fractures of the lateral femoral condyle in the adolescent: outcome of bioabsorbable pin fixation. J Bone Joint Surg Am. 2008;90:1473-1478.

    2. Meiss AL, Placzek R. Cystic lesions in the lateral femoral condyle of an 11-year-old boy - of tumorous, parasitic or traumatic origin? 4 1/2 year follow-up. J Child Orthop. 2008;2:160-162

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