Fresh Femoral Condyle Allograft Transplant for Knee Osteonecrosis in a Young, Active Patient

Joseph Cusano; Emily J. Curry; Akira M. Murakami; Xinning Li

摘要

Osteonecrosis is caused by diminished microperfusion of bone resulting in subsequent joint collapse. Estimates suggest that roughly 20,000 to 30,000 new cases are diagnosed annually in the United States, with even higher rates in other countries. ~( 32 ) Osteonecrosis most commonly presents secondary to fractures or from nontraumatic means, such as prolonged glucocorticoid use, alcohol consumption, pancreatitis, or lipid disorders. ~( 6 , 10 , 28 , 31 , 34 ) These latter conditions are believed to lead to the accumulation of fat emboli in the microcirculation or in the bone marrow, which can compromise blood flow and ultimately cause cellular death. ~( 19 , 35 ) The disorder most often affects the hip and can also be seen in the knee joint at an incidence that is an order of magnitude less than the incidence in the femoral head. ~( 27 , 32 ) Osteonecrosis can affect other joints as well, such as the shoulder, ankle, mandible, and spine. ~( 7 , 14 , 15 , 23 , 30 ) Nonoperative management involves rest, limited weightbearing, and pharmacologic therapy, such as the use of bisphosphonates. ~( 20 ) Surgical options in young patients consist of joint-preserving techniques including microfracture, autologous chondrocyte implantation, and autograft or allograft transplant; total joint arthroplasty (TJA) remains a last option. ~( 1 , 22 ) Given that TJA is generally contraindicated in young patients, further investigation has been aimed at measuring the clinical outcomes associated with using allografts to repair large defects that may have otherwise been managed with TJA in older patients. While some success has been demonstrated in the literature, ~( 13 ) investigators have not assessed graft incorporation using sequential postoperative magnetic resonance imaging (MRI). Furthermore, transplant of the entire medial femoral condyle for a large defect is very rare, and a paucity of clinical outcome data are available in the literature. Here we describe a 25-year-old woman with a history of alcohol abuse and a course of glucocorticoids, in whom 2 previous surgeries failed. She underwent fresh hemicondyle allograft transplant of the right knee to treat osteonecrosis of the medial femoral condyle. To our knowledge, this is the first report to describe a case of medial femoral condyle osteonecrosis managed with large hemicondyle allograft transplant that also includes repeat MRI follow-ups at both 6 months and 1 year from surgery to evaluate for graft incorporation. Case Presentation Preoperative Evaluation A 25-year-old woman was referred to our outpatient clinic to obtain a second opinion regarding her right knee. The patient had developed an insidious onset of knee pain approximately 2 years prior with a diagnosis of osteonecrosis following a 1-week course of high-dose prednisone treatment for an upper respiratory infection. Her medical history was also significant for heavy alcohol consumption of approximately 6 beers per day. As an initial course of management, microfracture surgery was performed at an outside hospital. The patient had persistent pain and underwent a second surgery that consisted of retrograde drilling at the same hospital 1 year before her surgery at our clinic. At initial presentation in our clinic, the patient reported difficulty completing several activities of daily living, specifically walking up and down stairs, in addition to subjective knee weakness and an associated clicking or catching sensation. Using a 10-point visual analog scale (VAS) for pain, she indicated pain at rest (5/10) and pain with activities (8/10) and was able to ambulate only 50 feet before stopping due to pain. Her knee had moderate effusion, range of motion (ROM) 0° to 140°, and stable to varus-valgus stress of 0° and 30°. Lachman and anterior-posterior drawer tests were negative, and she remained neurovascularly intact. Physical examination revealed neutral mechanical alignment with a moderate effusion and tenderness to palpation along the medial joint line but was otherwise unremarkable. Radiographic imaging demonstrated a 5.1 × 2.1–cm osteochondral lesion involving the entire medial femoral condyle ( Figure 1 ) with associated subchondral collapse. Figure 1. (A) Anteroposterior, (B) tunnel, and (C) lateral radiographs of the right knee demonstrating a large osteochondral lesion of the medial femoral condyle with associated subchondral collapse (yellow arrows). MRI revealed multifocal areas of osteonecrosis in both the medial and lateral femoral condyles. As seen on the radiograph, the medial femoral condyle lesion was associated with subchondral plate collapse and marrow changes on T1-weighted imaging. Imaging showed no collapse and no marrow changes of the lateral femoral condyle lesion ( Figure 2 ). The patient was counseled for alcohol cessation and was provided with services to help her quit drinking prior to any surgical intervention. Figure 2. (A) Coronal proton density, (B) coronal T2-weighted, fat-suppressed

机译：骨折是由于骨微粒枯竭导致随后的关节塌陷引起的。估计表明，在美国每年诊断大约20,000至30,000例新案件，其他国家的利率甚至更高。〜（32）骨膜坏死最常见于骨折或非非创伤手段，例如长期糖皮质激素使用，饮酒，胰腺炎或脂质疾病。〜（6,10,28,31,34）这些后一种条件被认为导致微循环或骨髓中脂肪栓塞的积累，这可以损害血液流动并最终引起细胞死亡。〜（19,35）最常常影响髋关节的病症，也可以在膝关节中看到的发病率，该发病率小于股骨头的发病率。〜（27,32）Osteonecross也会影响其他关节，例如肩部，脚踝，下颌骨和脊柱。〜（7,14,15,33,30）非术语管理涉及休息，有限的重量和药理学治疗，例如双膦酸盐的使用。〜（20）年轻患者的外科选择包括关节保存技术，包括微折衷，自体软骨细胞植入和自体移植或同种异体移植物;总关节关节造身术（TJA）仍然是最后一个选择。〜（1,22）鉴于TJA通常在年轻患者中禁止，进一步调查旨在测量与使用同种异体移植物相关的临床结果，以修复可能在老年患者中使用TJA进行管理的大缺陷。虽然在文献中已经证明了一些成功，但〜（13）调查人员使用顺序术后磁共振成像（MRI）没有评估移植物掺入。此外，整个内侧股骨髁的移植到大缺陷是非常罕见的，并且文献中可以获得临床结果数据的缺乏。在这里，我们描述了一个25岁的女性，具有酗酒史和糖皮质激素的疗程，其中2个以前的手术失败。她接受了右膝关节的新鲜半乳头同种异体移植治疗内侧股骨髁的骨折。为了我们的知识，这是第一份描述用大型半胱氨酸同种异体移植移植管理的内侧股骨髁骨折病症的报告，该表案也包括在手术中重复MRI随访，从手术中进行一次评估贪污融合。案例介绍术前评价一名25岁的女性被推荐给我们的门诊诊所，以获得有关她的右膝关节的第二次意见。在高剂量泼尼松治疗后患者对上呼吸道感染后，患者大约2年发育了严重的膝关节疼痛发病。她的病史对每天大约6瓶的重饮酒也是重要的。作为初始管理课程，微折衷手术在外部医院进行。患者持续疼痛，并经历了第二次手术，其中包括在我们的诊所手术前的同一家医院的逆行钻探。在我们诊所的初步介绍时，患者报告难以完成日常生活的几项活动，特别是在上下楼梯上，除了主观的膝盖虚弱和相关的点击或捕捉感觉。使用10点视觉模拟量表（VAS）进行疼痛，她表明休息（5/10）和活动疼痛（8/10），并且能够在由于疼痛停止前行动50英尺。她的膝盖具有适度的积液，运动范围（ROM）0°至140°，稳定为0°和30°的差异 - 旋流应力。拉克曼和前后抽屉试验是阴性的，她仍然是神经血管完整的。体格检查显示中性机械对准，沿着内侧接合线触诊，但否则不起眼。射线照相成像证明了5.1×2.1-cm的骨质色神经病变，涉及整个内侧股骨髁（图1），具有相关的副脚下塌陷。图1.（a）前膝关节，（c）右侧膝关节的横向射线照相，展示中间股骨髁的大型骨关节病变与相关的subchondral崩溃（黄色箭头）。 MRI在内侧和侧向股骨髁上揭示了骨折的多焦点区域。如在射线照相上所见，内侧股骨髁病病变与骨髓板塌陷和骨髓变化有关的T1加权成像。成像显示侧向股骨髁病变的崩溃和没有骨髓变化（图2）。患者被咨询用于酒精戒烟，并提供服务，帮助她在任何手术干预之前戒烟。图2.（a）冠状质子密度，（b）冠状T2加权，脂肪抑制

Fresh Femoral Condyle Allograft Transplant for Knee Osteonecrosis in a Young, Active Patient

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