Successful Fixation of Traumatic Articular Cartilage-Only Fragments in the Juvenile and Adolescent Knee: A Case Series

Abstract

Background: Some surgeons are now considering fixation of traumatic chondral-only fragments in juvenile knees, but few data remain to guide treatment.

Purpose: To determine if surgical fixation of chondral-only fragments in the juvenile knee results in an adequate healing response with successful imaging and clinical outcomes.

Study design: Case series; Level of evidence, 4.

Methods: Data were collected on 16 skeletally immature patients treated with fixation of chondral-only fragments with a minimum 1-year follow-up. Patients were selected by the operating surgeons based on the quality and size of the chondral fragment. Demographic data, lesion characteristics, surgical procedure details, complications, and postoperative imaging were assessed. Validated outcome measures were collected pre- and postoperatively and included the following scores: International Knee Documentation Committee (IKDC), Marx Activity Scale, Knee injury and Osteoarthritis Outcome Score (KOOS), Hospital for Special Surgery Pediatric Functional Activity-Brief Scale (HSS Pedi-FABS), Patient-Reported Outcomes Measurement Information System (PROMIS)-Physical Health and PROMIS-Psychological Health, and Tegner.

Results: The mean age of our patient cohort was 14.9 years. The mean size of the repaired defects measured 3.2 cm². Injury sites included the patella (n = 1), medial femoral condyle (n = 3), trochlea (n = 4), and lateral femoral condyle (n = 8). Within the mean follow-up time of 42.3 months (range, 15-145), there was 1 clinical failure with loosening of the chondral fragment and the need for reoperation. At a mean follow-up of 3.5 years, the mean (interquartile range) patient-reported outcome scores were as follows: IKDC, 95.2 (94.3-100); Marx Activity Scale, 11.5 (11.5-16); KOOS, 95.81 (93.5-95.81); HSS Pedi-FABS, 16.94 (11.5-26); PROMIS-Physical Health, 93.75% (90%-100%); PROMIS-Psychological Health, 90% (88.75%-100%); and Tegner, 5.69 (4.75-7). All patients who were engaged in sports before injury returned to the same or higher level of competition with the exception of 1 patient.

Conclusion: Primary repair of chondral-only injuries with internal fixation can be a successful treatment option in selected patients. Clinical and imaging results at final follow-up suggest that reintegration of the cartilage fragment is achievable and leads to excellent clinical function and a high return-to-sports rate.

Keywords: cartilage fragment; chondral injury; chondral-only fragment; fixation; osteochondral defect.

Figure 1.

Large full-thickness cartilage defect (16 × 16 mm) of the anterior aspect of the lateral femoral condyle with a displaced cartilage fragment within the anterior intercondylar fossa in a 12-year-old boy. (A) Sagittal T2-weighted magnetic resonance imaging obtained preoperatively. The arrow indicates the displaced fragment. (B) Intraoperatively visible lesion with intact subchondral bone. (C) Lesion bed after preparation. (D) The chondral fragment in situ. (E) The chondral fragment fixated with 6 chondral darts. (F) Fibrin glue was added to prevent synovial fluid ingress at the edges.

Figure 2.

Large full-thickness displaced chondral fragment repaired back to the lateral trochlea with 2 bioabsorbable headless compression screws and 2 bioabsorbable chondral darts. (A) Loose fragment in magnetic resonance imaging. (B) Prepared lesion bed. (C) Fragment on back table. (D) Fragment fixated in situ.

Figure 3.

Fixation of a large chondral fragment with 1 bioabsorbable compression screw and 4 bioabsorbable chondral pins in a 11-year-old girl. (A) Intraoperative lesion. (B) Fixated chondral fragment in situ. (C) Radiograph at 16-month follow-up. The arrow indicates the region of cartilage fixation.