Ortho on the go
Ortho on the go
Case discussion regarding recurrent Effusion in young athlete
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Welcome to the Ortho on the Go podcast. My name is Chuck Dowell, host of the podcast. This is an educational orthopedic podcast focused on discussing both clinical and functional orthopedics. We will discuss a variety of topics within the field of orthopedics, including reviewing interesting cases, hearing from different professionals throughout the orthopedic profession, and discussing common musculoskeletal injuries and complaints. This podcast is meant for anyone that wants a better understanding of orthopedics, including all levels of practitioners, coaches, parents, and athletes themselves. Hello everyone, welcome back to the podcast. My name's Chuck Dowell. Doing a case of the week this week. So our case this week is a 15-year-old gentleman who I saw in clinic. He came in complaining of swelling within his knee. He and his father had stated that for the last one to two weeks, every time he would participate in lacrosse activities, he would notice some increased swelling throughout the knee with occasional pain within the knee. The swelling had gotten progressively worse over the last few weeks, and now is getting some mechanical symptoms such as some catching and locking within the knee. The swelling would reduce if he took a day or two off of these activities, but then would reoccur uh right after participating in uh the sports activities. His father originally thought this was associated with um IT band syndrome and therefore sent him for andor started some physical therapy regarding this, and he was not noticing improvement of his symptoms. Um, if you are following this along uh on the YouTube channel, uh I do have the images uh for this patient when I saw him in clinic, so definitely go check those out. I'll try to put um all of the images on um that as well. So again, when I saw him in clinic, uh his examination at that time was a fairly large um palpable effusion noted within the knee. He had some diffuse tenderness noted throughout the patello femoral area with a slightly positive ballotment sign. His range of motion was slightly limited. He was able to obtain full extension, but due to the significance of the effusion within the knee, he could only flex his knee at about 60 to 80 degrees. Um he thought this was necessarily uh a locking as he didn't want andor started to contract when I started to flex his knee past this 80 degree point, but it did have a soft end point, so I think likely related to the effusion. Uh the limited ligaments' exam I could get due to the limited range of motion showed that he didn't have any varisor valgus instability at this kind of 10, 30 and then loosely 50, 60 degrees. Uh his Lockman's test was negative at this time. Uh was not able to get him up into that kind of hyperflex position for those menisco rotation type testing or posterior draw testing. But again, he didn't have a necessary mechanism related to this. Um, we discussed with him that because it had been going on one to two weeks, because of his age and uh the recurrent effusion or swelling he was having within his knee, um, I was very concerned that he possibly had some kind of cartilage defect within the knee. In my past experience, most of the time when young, healthy athletic kids come in complaining of swelling within the knee and not associated with trauma or sometimes associated with trauma such as patella dislocations, it's usually related to cartilage issues, um, whether they have a congenital cartilage issue or some progressive patellophemoral syndrome, typically recurrent effusions, especially with higher level activities in young patients, are related to cartilage issues. So, as you can see, um, if you're following along again on the YouTube, the x-rays, including um AP weight-bearing films, um, show that he had open physis, uh, but no acute fractures were seen. The lateral view also shows that he has some soft tissue edema with a joint diffusion noted. Um, a small flobellum is noted, but again, no cartilage andor fractures are seen. Um the sunrise view again shows uh joint diffusion with uh some soft tissue edema diffusely out uh around the knee area. So, again, because of the concern of possible cartilage uh injury, we ordered an MRI on him. So a few days later, he was able to obtain this MRI. Again, the MRI views could be seen on the um YouTube channel and uh as the video associated with this. So looking through the MRI, this is our kind of um axial cuts. He coming down initially, you can see there's a large um loose body uh noted within that kind of superpatellar recess area. So as discussed, um he has a loose body, which is probably causing the varying of his symptoms, but does have a large joint diffusion. So anytime you do see a loose body in the MRI, you want to find uh where the source, where the donor site for that loose body is. So if we keep scrolling through, um kind of going down into the patello femoral area, you can see his patellar articular cartilage looks quite uh well intact. Um he doesn't have a trauma related that would make us concerned for an MPFL type injury. His patella is sitting slightly laterally, but that's likely related to the joint diffusion he has. If we keep scrolling through, we could see here's our donor site. So this lateral aspect of the trochlea shows a large articular cartilage defect noted. So uh in this patient, he had an osteochondrial defect. Um, and for this patient, because it wasn't associated with a trauma, we would call this osteochondritis disiccins. So uh for those of you that don't remember, uh, osteochondritis disciplins is a pathologic lesion affecting the articular cartilage and typically the subchondrial bone uh and has variable clinical patterns. Most of the time, uh it's picked up on MRI, but occasionally can be seen on radiographs. A lot of the times this is picked up as an incidental finding. A patient comes in and you see it within the normal and most common area, which is the medial femoral condyle. If it doesn't have a loose body, if the cartilage is intact and there's not a lot of subchondral edema, then we can typically treat these uh non-operatively with restricted weight-bearing activities, especially in patients with open physis where we don't want to have any effect and/or cause any trauma to that physis with surgical intervention. In patients with closed physis and they do have an obvious defect and/or there's a loose body, we can treat this surgically. This does typically occur in uh kids, usually between the ages of 10 to 15 years old, with the median age being 13. Again, 70% of the lesions are typically seen within the mediofemoral condyle. And often this will cause softening over the overlying articular cartilage. Um the articulocartilus is intact, and that's why frequently we can treat these non-operatively. So, in this patient, unfortunately, you can see he did have the defect, and the defect did create a loose body. So we weren't able to treat this non-operatively, so we did take him to surgery. Um, so the surgery photos you can see here, there is a large uh articular cartilage defect uh noted. Uh, the donor site can be seen here uh within the trochlea, and you can see there's some kind of you know scar tissue, you know, within that area or fibrin tissue within that area. So this is more chronic in nature. A lot of the times when this is acute in nature, you'll see that this bed within the area of that donor site will have kind of bleeding subchondral bone. So that kind of indicates the chronicity of this. Um he may have had this loose body that was synovialized, and with his higher level activities, potentially, um, that's what created it to displays. So the surgeon went in, uh, uh, was able to measure the two loose bodies, and then was able to create a bleeding bed and fixate um the loose body. So you can see the surgical photo here. They put three darts and/or you know, um, bioabsorbable screws in the area to hold down that articular cartilage defect. And oftentimes, if we have subchondral bone attached to that articular cartilage, these can heal quite well. Um so as a follow-up, uh, this patient was doing quite well. Um, he at his three-month appointment had full range of motion, had discharged from physical therapy, and was able to start participating back into some low-impact exercise activities. Uh, because the cartilage is involved, these often take a long time to heal. So these can be four to six months before they're able to fully participate uh all the way back into these exercise-related activities. Um, we did end up getting an MRI on this patient because he came back in complaining of some increased pain. Uh, the MRI did show that the uh articular cartilage defect was stable and was doing quite well. Thank you for listening to this case of the week. I think this was a very interesting case uh regarding recurrent effusion in a young, healthy, athletic gentleman, which turned out to be osteochondratus disciplins. Uh, I hope you enjoyed this. Uh we will try to do a couple more cases of the week with the x-rays um and MRIs if available, uh, so you guys uh that are following along on the YouTube channel can get um both the visual evaluation of the x-rays as well as uh talking through the case. Um thanks again for listening. Uh please go ahead and follow us on both our YouTube podcast, Ortho on the go podcast. Uh, we're also on both Facebook and Instagram. Again, please feel free to leave comments regarding possible cases or uh discussions you would like to have reviewed. Um again, thanks again for listening, and we'll talk to you soon.