Knee Joint Osteochondral Reconstruction Using Fresh Femoral Head Autograft
Following chemotherapy for acute lymphocytic leukemia (ALL) in a young woman, the articular surfaces of both femoral heads and the right knee lateral femoral condyle collapsed, resulting in significant pain and disability. Using a novel technique, the articular surface of the knee was reconstructed using fresh bulk osteochondral autograft harvested from the ipsilateral femoral head during a simultaneous total hip arthroplasty. Fresh osteochondral autografting enabled rapid osseous integration and articular surface reconstruction using living host cartilage, resulting in an excellent clinical outcome. Although uncommon, concurrent avascular necrosis of multiple large joints is occasionally encountered and management options are particularly limited in young patients. We recommend that this innovative technique be considered in those patients who satisfy the criteria for bulk osteochondral grafting procedures where total hip replacement is also required.
KeywordsFemoral Head Acute Lymphocytic Leukemia Articular Surface Lateral Femoral Condyle Osteochondral Allograft
1 Brief Clinical History
A young girl, initially 14 years old, presented for evaluation of bilateral hip osteonecrosis she developed following chemotherapy used in the management of ALL. She reported multiple other complications due to chemotherapy including bilateral humeral head osteonecrosis , bilateral distal femoral osteonecrosis, peripheral sensory and motor neuropathy, and a bowel perforation requiring partial resection and ileostomy. She was intermittently wheelchair bound on the basis of her hip pathology (Fig. 1), superimposed upon the ataxia secondary to her peripheral motor neuropathy. Over the preceding months both hips had become persistently symptomatic with moderate pain on a daily basis, with a significant reduction in function and difficulty with ambulation (Weinrauch et al. 2013).
Hip replacement was delayed due to the high risk of infection related to her ongoing chemotherapy and the presence of an ileostomy. Nonoperative therapy had included intravenous bisphosphonate infusions and analgesia. She reported increasing pain at the lateral aspect of her right knee with radiographic evidence of osteonecrosis of the lateral femoral condyle (Figs. 2 and 3). Three years later, now 17 years old, after recovering from chemotherapy she was a better candidate for reconstructive surgery. Despite drill decompression, and subsequent arthroscopic debridement of the lateral condyle, the right knee continued to deteriorate with increasing pain, stiffness, and mechanical symptoms (Fig. 4).
2 Preoperative Clinical Photos and Radiographs
3 Preoperative Problem List
Seventeen year old Female, history of ALL, prior chemotherapy
Osteonecrosis bilateral femoral heads, requiring total hip replacement
Osteonecrosis lateral femoral condyle right knee, with disabling pain and instability
Difficulties procuring a suitable fresh osteochondral allograft to reconstruct knee
4 Treatment Strategy
Total hip replacement provides a very predictable reconstruction alternative for destructive arthropathy of the hip, even in young patients; total knee replacement is a far less attractive option. Harvest and salvage of the remaining intact cartilage on the femoral head during a simultaneous hip arthroplasty provided a unique opportunity to reconstruct the destroyed portions of the lateral femoral condyle using fresh osteochondral autograft .
5 Basic Principles
By the time she turned 17, she described increasing symptoms attributable to both hip joints , as well as pain and instability in the right knee. Chemotherapy had been ceased with no recurrence of leukemia, the ileostomy had been reversed and the peripheral neuropathy resolved. Considering the marked pain and significant disability, bilateral total hip arthroplasty was recommended. Preoperative imaging demonstrated the posterior and inferior aspect of the right femoral head was relatively unaffected by avascular necrosis with an overall shape potentially suitable for osteochondral reconstruction of the right knee lateral femoral condyle. This procedure was preceded by uncemented left total hip arthroplasty; however, the left femoral head was considered unsuitable for use in osteochondral autografting on the basis of global articular surface damage (Weinrauch et al 2013).
6 Images During Treatment
7 Technical Pearls
During total hip replacement surgery, the femoral head was found to have undamaged cartilage surfaces in the inferior aspect (Fig. 4). A second surgical team prepared the graft maintaining 10 mm of thickness, while the total hip arthroplasty procedure was completed. Exposure of the right knee was achieved through a midline incision and a medial parapatellar arthrotomy (Fig. 5). The involved areas of the lateral femoral condyle were resected, resulting in a trapezoidal defect; native bone was retained where viable, creating a vascular bed of cancellous bone (Fig. 6). The trapezoidal shape of the resection facilitated primary stability of the bulk auto-graft; the graft was prepared to best match the shape of the defect. The intact articular surface of the femoral head was unfortunately discontinuous, and the autograft was therefore harvested in two distinct sections (Fig. 7). The thickness of the autograft was maintained at a minimum of 10 mm throughout. After graft impaction and final seating, internal fixation was performed using four headless compression screws (Fig. 8; Weinrauch et al. 2013).
8 Outcome Clinical Photos and Radiographs
The right knee and hip underwent a graduated program of protected activity with touch weight bearing for a period of 6 weeks, progressing to partial weight bearing for a further 6 weeks. Early knee range of motion exercises were permitted as tolerated without restriction. At 12 months postoperative both hips remained pain free and radiographs demonstrated that the hip implants were stable and integrated (Fig. 9). The Modified Harris Hip Score (mHHS) improved from 37.4/100 (preoperatively) to 100/100 (postoperatively). The right knee was causing only very minor and occasional discomfort about the medial aspect. There was no effusion and the range of motion was almost equal to the contralateral side, with full extension and flexion to 160° (Figs. 10 and 11). The Knee Outcome Score (KOS) 12 months after the procedure was 113/125. The knee remained stable to varus/valgus stress, patellar tracking was unremarkable, and there was no ligamentous instability (Weinrauch et al 2013). Further review, 2 years after the procedure, confirmed that the clinical outcome had not deteriorated appreciably.
9 Avoiding and Managing Problems
This procedure is preferably performed with two separate teams, one completing the hip arthroplasty while the other reconstructing the knee. An MRI of the hip preoperatively can help determine if adequate cartilage is intact; however, the decision regarding the suitability of the remaining cartilage must be made based on its macroscopic appearance. Exposure of the knee was not begun until the quality of the intact cartilage on the femoral head was first confirmed visually. If the cartilage on the femoral head is unsuitable, an alternative reconstruction strategy must be considered.
References and Suggested Reading
- Weinrauch P, Steer R, Kermeci S, Tetsworth K (2013) Knee joint osteochondral reconstruction using fresh femoral head autograft. J Med Cases 4:803–810Google Scholar