A volleyball player with bilateral knee osteochondritis dissecans treated with extracorporeal shock wave therapy

Transcription

1 Musculoskelet Surg (2009) 93:37 41 DOI /s CASE REPORT A volleyball player with bilateral knee osteochondritis dissecans treated with extracorporeal shock wave therapy Biagio Moretti Æ Angela Notarnicola Æ Lorenzo Moretti Æ Paola Giordano Æ Vittorio Patella Received: 26 August 2008 / Accepted: 2 December 2008 / Published online: 28 April 2009 Ó Springer-Verlag 2009 Abstract We present a case report of a 14-year-old Caucasian sport woman affected by bilateral and symmetrical knee osteochondritis dissecans (OCD) addressed to surgery, in which extracorporeal shock wave therapy determined complete healing. Shock wave is a longitudinal acoustic wave traveling with the speed of ultrasound through the water of the body tissue. Recently, this therapy has been used in the treatment of a number of musculoskeletal pathologies on the basis of the effects produced by the induction of angiogenesis, recruitment of progenitor cells and downregulation of cartilage damage. This therapy is useful, because it is non-invasive, safe, without complications or adverse effects and repeatable. Thus, it could be suggested as a useful strategy for the treatment of OCD prior starting surgery. Keywords Osteochondritis dissecans Extracorporeal shock wave therapy Knee Case report B. Moretti A. Notarnicola L. Moretti V. Patella Orthopaedics Section, Department of Clinical Methodology and Surgical Technique, University of Bari, Bari, Italy b.moretti@ortop2.uniba.it L. Moretti lorenzo.moretti@libero.it V. Patella v.patella@ortop2.uniba.it A. Notarnicola (&) II Clinica Ortopedica, Policlinico Consorziale, Piazza Giulio Cesare, 11, Bari, Italy angelanotarnicola@yahoo.it P. Giordano Department of Biomedicine of Evolutive Age, University of Bari, Bari, Italy giordano@bioetaev.uniba.it Introduction In osteochondritis dissecans (OCD), a fragment of articular cartilage together with subchondral bone becomes an avascular segment separated, partly or completely, from the joint surface; it is very common in the knee, often unilateral, but bilateral or symmetrical cases are not unusual. In 1870, Paget [1] published the first classical description of this disease and his first patient was a girl who had the habit of breaking thick pieces of wood through her thigh and knee. Clanton and DeLee [2] distinguished two groups of patients: children under 15 and adults up to 50 years. Many patients had taken part in top class sports and the most commonly affected site was lateral aspect of the medial femoral condyle of knee. The causes of fragment separation could be focal microtrauma due to repetitive contact with the tibial spine, ischemia and abnormal ossification within epiphyses, genetic and endocrine factors or a combination of some of these. Radiographically, the diagnosis is difficult because even large osteochondral fragments can have a very small, ossified layer that would be difficult to see; therefore, CT scan or MRI is very useful tools. MRI is more sensitive in detecting osteochondral and cancellous bone lesions associated with bone edema. Case presentation A 14-year-old Caucasian girl (height 1.45 m, weight 40 kg) came to our observation complaining of pain, swelling and functional restriction of both knees (0 80 of flexion) dating 2 years back.

2 38 Musculoskelet Surg (2009) 93:37 41 She played volleyball thrice a week at a top level and she needed to stop these activities because of symptoms without any trauma correlation. Upon physical examination, the patient demonstrated quadriceps ipotrophy and tenderness on bilateral medial femoral condyles. X rays did not present pathologic images; MRI (03/02/ 2007) revealed a 16 mm-long defect in the medial femoral condyle at the right knee and 2 cm-long defect at the medial femoral contralateral condyle (Figs. 1, 2). At the left knee, there was also a line of high signal clearly extending through subchondral bone with faint extension through cartilage and small amount of fluid in joint space. The size was 4,800 mm 3 ( mm) at the left knee and 1,920 mm 3 ( mm) at the right one. The patient was diagnosed with OCD of the medial femoral condyles at both knees. She was visited by several orthopedic doctors, who recommended only rest and she was immobilized for 4 weeks in a cylinder cast in extension, respectively, for both knees. After 2 months, the clinical situation had not changed and we confirmed the diagnosis of OCD and submitted her to extracorporeal shock wave therapy (ESWT). The protocol consisted of a course of three sessions (every 72 h), with 4,000 pulses being delivered at each session at flux density of 0.04 mj/mm 2, using an electromagnetic lithotripter (MINILITH-SL1 by STORZ-MEDICAL) with cylindrical coil, parabolic focus and ultrasound in-line scanning. No local anesthetic was used during the treatment. We focused the device directly to medial femoral condyle, around the point of pain. She was permitted to ambulate with weight-bearing to stimulate healing and chondrocyte nutrition by cyclic compression; sport activity Fig. 2 MRI revealed a 2 cm-long defect at the medial femoral condyle at the right knee and also a line of high signal clearly extending through subchondral bone with faint extension through the cartilage and small amount of fluid in joint space was forbidden. The patient was invited to come back after 1, 5, 3 and 6 months since her last ESWT session. At the follow-up, we evaluated pain, function and RMI images of both knees. After 45 days, she referred a lower pain and swelling and an improvement of active ROM of the knees (0 100 of flexion). This condition was supported by MRI images (08 June 2007) that showed, in particular at the left knee, a reduction of the extension of the focus of OCD associated with the appearance of bone repair phenomena at subchondral level. This was an indication to continue the stoppage of sport activities. At 3 months since ESWT, she had no pain, neither spontaneous nor under local finger pressure; the active flexion extension of the knees was complete (0 130 ) and painless. MRI (08 September 2007) presented a further improvement of the image in relationship with the healing of OCD focus and the good evolution of bone repair signs in subchondral sites bilaterally (Figs. 3, 4). She received indication to return to sport gradually. At 6 months since the ESWT, the patient referred a complete absence of pain without functional restriction. Discussion Fig. 1 MRI revealed a 16 mm-long defect in the medial femoral condyle at the right knee Treatments of OCD involve wait-and-watch therapy. Some authors proposed brace or cast, limitation of activities until the patient is symptom-free and protected weight-

3 Musculoskelet Surg (2009) 93: Fig. 3 After ESWT, the MRI images showed at the right knee a reduction of the extension of the focus of OCD Fig. 4 After ESWT, the MRI images showed at the left knee a reduction of the extension of the focus of OCD associated with the appearance of the bone repair phenomena at subchondral level bearing with use of crutches. It has been published that non-surgical treatment is more successful in younger, skeletally immature patients, as they have a much greater potential to heal. If symptoms persist, a variety of surgical options may be indicated, including the debridement, drilling, fragment internal fixation, transplantation and autologous chondrocyte implantation, depending on the patient s age, stage and site of the lesion. When the fragment is smaller than 1 cm and located in a non-weightbearing area, it is proposed to remove it arthroscopically; if the fragment is larger and in a weight-bearing area, it must be fixed in place [3]. Some OCD follow-up reports underline that pathology can heal completely, but, on the other hand, it can also lead to long-term disability and even to osteoarthritis [4]. Initially, OCD knee patient is immobilized for 6 weeks in cast; this treatment is generally unsuccessful when the lesion is unstable in immature skeletal. If it is persistently symptomatic, unstable, with loosen body or if physeal close is predicted within 1 year, the operative treatment is advised [5]. A recent study reports four criterions predicting outcome of OCD patients: prognosis and management depend on patient s age, stability, size and localization of the lesion [6]. The first criterion is based on De Smet s study [7]. He proposed the presence of at least one instability on T2- weighted MRI images is predicted for failure of nonoperative treatment. MRI criteria are the following (1) a line of high-signal intensity at least 5 mm in length between the OCD and underlying bone, (2) an area of increased homogeneous signal at least 5 mm in diameter beneath the lesion, (3) a focal defect of 5 mm or more in the articular surface, and (4) a high-signal line traversing the subchondral plate into the lesion. Although the first criterion is most frequently observed in unstable OCD lesions, the others have been reported up to 100% specific for instability [8]; in agreement with these criteria, in this case report, there is a third sign of instability in both knees and also the fourth in the left knee predicting to fail in the non-operative treatment [6]. The second criterion is the size of the lesion [8, 9]. In Pill s study [6], a review of 24 juvenile OCD lesions, the largest lesions were more likely to fail non-surgical treatment, as determined by medial-lateral diameter (17.4 vs. 11 mm), depth (7.8 vs. 4.8 mm) and volume of the lesion (3,250 vs. 892 mm 3 ); a greater anteroposterior diameter was found not to be significant (18.7 vs mm) [6]. In agreement with this paper, we should consider the patient s lesions were large and likely to fail wait-and-watch treatment. The third criterion is the localization of the lesion, according to Cahill [5]; distal femur is divided by four lines into five columns (from 1 medial to 5 lateral) on the anteroposterior view and both condyles are divided by two lines into three halves (from A upon to C down). More common lesions requiring surgery are in weight-bearing area (B2 area), where there are compressive forces during standing [5]; according to that, the lesions were located in area B2. The fourth criterion is the age; children for whom surgery therapy is needful are older (13.9 vs years; P \ ) and with greater skeletal maturity (closing/ closed vs. open physis; P = ) [6]. In consideration with the physical maturation of 14-year-old girl, the nonsurgical therapy would be destined to continue to fail. On the basis of these four criteria, we say in our patient, a simply wait-and-watch approach would be insufficient for the recovery of the OCD as it was during the past 2 years.

4 40 Musculoskelet Surg (2009) 93:37 41 Extracorporeal shock wave therapy is used in the treatment of musculoskeletal conditions. Shock waves (SW) is a longitudinal acoustic wave that exerts cavitation effect (a micrometer sized violent collapse of bubble inside the cells) inducing localized impulses on cell membranes that resembles shear stress. The rational of treatment is the stimulation of tissue healing, reduction of calcification, inhibition of pain receptors or denervation to achieve pain relief [10]. In avascular bone necrosis, it can significantly upregulate the expression of VEGF, inducing the ingrowth of neovascularization and improving the blood supply [11]. Yet, the application on immature epiphysis was contraindicated because it could affect subsequent bone growth [12], but new studies demonstrated that there was no damage to the growing epiphysis at low-middle energy [13]. Based on the recent knowledge, we proceeded to apply ESWT in the treatment of this cartilage morbility in order to enhance the capacity of tissue healing [14]. It helps in the release of nitric oxide and the synthesis of PGE2 and GAG from cartilage that induces proliferation of chondrocytes. Our previous study about the application of the SW on the healthy and osteoarthritic human chondrocytes demonstrates downregulation of TNF-a and IL-10 production by chondrocytes, interfering with pathological mechanisms causing cartilage damage [15]. Besides, ESWT has been established as a method to improve bone repair via stimulation of mesenchymal stem cell recruitment and differentiation into bone-forming cells; it induces the production of growth factors that play a chemotactic and mitogenic role in the recruitment and differentiation of mesenchymal stem cells. The application of ESWT in the treatment of OCD in younger patients, where the surgery is necessary, can modify the therapeutic protocol of this pathology. A major advantage of SW therapy is that it is non-invasive and safe, without any procedural complications or adverse effects, and, if necessary, we can treat patients repeatedly. Our strategy was to shoot 4,000 impulses, three times every 72 h at a flux density of 0.04 mj/mm 2. Further studies are required not only to increase the number of patients and to give a statistical value to this application, but also to determine the best treatment strategy. Conclusion In our case, a bilateral knee OCD in a volleyball player girl, the wait-and-watch treatment failed during the past 2 years. The presence of several at risk features addressed during surgery. Considering OCD is classically a condition of fracture involving cartilage and underlying bone, we speculate that low-energy ESWT, recently applied in musculoskeletal pathologies to stimulate the tissue healing, can upregulate the proliferation of chondrocytes. The application is useful, non-invasive, safe, without complications or adverse effects and repeatable. The clinical and MRI valuation showed improvement after 45 days and healing after 3 months. Thus, SW therapy could be a useful strategy for the treatment of OCD prior starting the surgery. Acknowledgment The authors thank the coworkers for the support in clinical and experimental applications of the ESWT. Conflict of interest statement The authors declare that they have no conflict of interest related to the publication of this manuscript. They have full control of all primary data and they agree to allow the journal to review their data if requested. 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