PMC9946755_01
Preoperative radiographs. (a) Posterior-anterior weight-bearing view. (b) Anterior-posterior weight-bearing view. (c) Lateral view.
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Preoperative radiographs demonstrated underlying genu varum with large medial femoral OCD lesions and a right knee Kellgren-Lawrence (KL) grade 2 and left knee KL grade 1 (Figures 2(a), 2(b), and 2(c)).
(a) Hip-to-ankle views. (b) Merchant's patellofemoral view.
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Hip-to-ankle radiographs demonstrated femoral-tibial angles of 8  on the right and 3  on the left (Figure 3(a)). There was no patellofemoral involvement on Merchant's views (Figure 3(b)).
Arthroscopy. (a) Loose body removal. (b) Lateral compartment view.
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At arthroscopy, a loose body was removed from the lateral compartment (Figures 4(a) and 4(b)).
Arthroscopy. (a) Fragmentation medial OCD. (b) Irreparable fragment. (c) Medial posterior OCD. (d) Bone defect/medial wear.
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Cartilage biopsy. (a) Lateral intercondylar notch. (b) Needle biopsy. (c) Initial biopsy site. (d) Completed biopsy.
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A cartilage biopsy from the right knee intercondylar notch was obtained (Figures 6(a), 6(b), 6(c), and 6(d)), and due to the large defect size, two MACI membranes were automatically ordered.
High tibial osteotomy X-rays. (a) Intra-operative mechanical axis. (b) Alignment HTO guide. (c) HTO fixation anterior view. (d) HTO fixation lateral view.
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HTO, lesion characteristics. (a) High tibial osteotomy. (b) OCD poorly contained lesion. (c) Prepared lesion site. (d) Bleeding created base lesion.
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A large, poorly contained lesion measuring 3 x 4.5 cm was demonstrated (Figure 8(b)). Sclerotic bone and intralesional osteophytes were removed with a high-speed burr creating a healthy bleeding base (Figure 8(c)). The site was drilled with a 1.5 mm drill bit at 3 mm increments to increase blood flow into the lesion (Figure 8(d)).
Bone grafting and first MACI stabilization. (a) Bone graft defect. (b) Fibrin glue base lesion. (c) MACI graft # 1 cell layer up. (d) MACI graft # 1 suture stabilization.
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Iliac crest ABG was obtained, and bone impacted into the defect up to, but not above, the subchondral bone plate level demarcated by the previously created shelf (Figure 9(a)). Fibrin sealant was placed over the base of the lesion (Figure 9(b)). The first graft was placed smooth-side facing towards the bone graft and sewn into position using the micro-anchors along the intercondylar notch region (Figure 9(c)); additional 5-0 vicryl sutures were placed using the osseous tunnels previously created with the Keith needle, and 6-0 vicryl sutures were placed proximally and distally at the normal articular cartilage margins (Figure 9(d)).
Second MACI stabilization. (a) MACI graft # 2 cell layer down. (b) MACI graft # 2 suture stabilization. (c) MACI graft # 2 sewn. (d) MACI grafts sewn with fibrin glue.
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The second graft was placed with the cell layer facing into the defect and sewn into position using the same sutures (Figures 10(a), 10(b), and 10(c)). Fibrin sealant was placed around the periphery of the lesion (Figure 10(d)).
(a) 3-month post-operative posterior-anterior (PA) weight-bearing (WB) view. (b) 3-month post-operative lateral view.
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(a) 6-month post-operative PA WB view. (b) 6-month hip-to-ankle WB view.
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(a) Right knee IKDC and Lysholm. (b) Right knee KOOS.
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Knee Documentation Committee (IKDC) scores improved by 37 and 54 points, respectively (Figure 13(a)). Knee Injury and Osteoarthritis Outcome Score (KOOS) pain and symptom scores improved 47 and 35 points, respectively, while KOOS sports improved by 75 points and quality of life increased by 81 points at the 13-month follow-up (Figure 13(b)).
Right knee pain VAS.
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(a) Left knee IKDC and Lysholm. (b) Left knee KOOS.
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