Artikel
Reconstruction of a large osteochondral lesion of the distal tibia with an Iliac Crest Graft and Autologous Matrix Induced Chondrogenesis (AMIC) – Case report
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Veröffentlicht: | 24. Oktober 2011 |
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Objective: Joint preserving treatment of osteochondral lesions (OCL) in younger sportive patients remains a big challenge for the orthopaedic surgeon. Isolated OCL of the distal tibia are rare and no clear treatment guidelines have been established. We developed a novel surgical treatment method using a stable bone plug harvested from the iliac crest combined with the implantation of a collagen I/III membrane. With this case we report the successful use of Autologous Matrix Induced Chondrogenesis (AMIC) aided reconstruction for OCL of the distal tibia.
Material/Methods: Preoperative management: A 29 year old male patient (sports teacher) complained about persisting pain and recurrent swelling of the left ankle joint 12 months after an ankle sprain. Sport activities were no longer possible. The painful ankle presented a distinct anteroposterior and inversion instability. Flatfoot deformity was present. Pain measured by the Visual Analogue Scale (VAS) was 4. The AOFAS Ankle-Hindfoot Scale was poor with 61 points. Imaging revealed edema of the subchondral bone and thinning of the cartilage above the osseous defect at the lateral distal tibia. Surgical course: The osteochondral defect was debrided followed by microfracturing of the underlying sclerotic bone. A cancellous bone plug was harvested from the iliac crest and impacted into the defect. A collagen membrane (Chondro-Gide, Geistlich, Wolhusen, Switzerland) was cut to match the chondral defect and fixed on the defect with fibrin glue. The medial ankle ligament complex was repaired directly anatomically as described by Karlsson and al. Finally, a calcaneus lengthening osteotomy was performed through the sinus tarsi, to correct the hindfoot valgus.
Results: At 12 and 36 months the patient had a VAS of 0 points and returned to a full time job. AOFAS hindfoot score increased from 61 points preoperatively to 100 points after 12 months and remained 100 points after 36 months. At 12 months he returned to full sports. Conventional radiographs at one year showed successful osseous integration of the plug, osseous consolidation of the calcaneal osteotomy and a nearly anatomic shape of the tibial joint line. MRI dGEMRIC scans at 36 months showed intact cartilage layer over the defect and glycosaminoglycan content indicating fibrous cartilage repair.
Conclusion: This case demonstrates AMIC aided reconstruction of large osteochondral lesions of distal tibia to be a promising treatment method. Future research needs to compare this new technique to other available treatment methods in terms of radiological, clinical and histological outcome. Early return to full sporting activity after treatment with AMIC technique is possible.