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Cartilage defects associated with knee pain in adolescents EPOS


									Cartilage defects associated with knee pain in
       adolescents with cerebral palsy

   Karin Schara, M.D., M.Sc. 1, Arabella I. Leet, M.D. 2

               Department of Orthopedics
          1 University Medical Centre Ljubljana

                    Ljubljana, Slovenija
                2 Johns Hopkins University

                Baltimore, Maryland, USA
The aim of our retrospective study is to report on a small
case series of four young adults with cerebral palsy and
cartilage defects in the knee joint as the etiology of knee

Most children and adolescents with knee pain are thought
to have the pain secondary to contractures, patella alta, or
malalignment syndrome (femoral anteversion with
compensatory external tibial torsion).

Although early degenerative changes have been reported in
the hip joint, no description of loss of articular cartillage in
the knee as the etiology of knee pain has been previously
described in children with cerebral palsy.
Patients and Methods.

Two centers were involved in the study: one in Ljubljana,
Slovenija and the other in Baltimore, USA. All four
patients presented during the last three years.

Patient Characteristics:
• 3 male and one female patient
• 3 ambulatory spastic diplegic, one spastic quadriplegic
• age 14 to 16 years
• all presented with severe knee pain and effusion

In 3/4 patients moderate trauma preceeded the onset of
clinical signs.
Patients and Methods.
Clinical findings:
•Knee flexion contractures developed over time and
 were present in all patients (flexion contacture from minimum
40 ° to 60 ° )
•Pain and effusion
•Moderate contractures were seen on the opposite knee.

Radiographic and Diagnostic findings:
•X-ray: patella alta and knee flexion, no evidence of subchondral
   bone changes (4 patients)
• MRI unable to be tolerated and non diagnostic (one patient, not
   under general anesthesia); meniscal tear (one patient)
•Diagnostic arthroscopy in one patient (chondral lesion 2x2 cm)
Cartilage loss in the distal femoral condyle of the knee was
seen during arthroscopy or patella stabilization in the study
• range of denuded area varied in diameter from a minimum of 1
cm to maximum of 4 cm
Patient 1.
• medial meniscal tear was present - partial menisectomy was
performed, defect observed but not treated
Patient 2.
•chondroplasty of the medial femoral condyle (4 cm ) and

hamstring lengthening
Patient 3 and 4.
• patella stabilization and hamstring lengthening, chondral lesions
treated with subchondral drilling
Case presentation. D.R.
• boy, spastic diplegia, age 12
• walking with support for short distances

Initial Presentation: outpatient clinic, 2001:
• pain in his right knee
• minor trauma 6 months before
• X-ray – no fracture

Clinical evaluation:
• moderate crouch and flexion contractures on
  both knees (Right knee: 20/130 °, Left knee15/130 °)
• pain on the right side more pronounced than on the left
• no treatment
Case presentation. D.R.

Next visit in 2002:
• pain in the right knee accompanied by
  progressive flexion contractures
• MRI was performed – due to patient movement was of no
diagnostic value, knee arthroscopy was proposed

Follow-up 1 year:
• severe pain and effusion of the right knee
• ambulation ceased
• crying when changing positions from the bed
     to chair
• Knee range: R: 60-130 °
               L: 40-130 °
Case presentation. D.R.
• 2x2 cm cartilage defect of
the right medial femoral
Followed by surgery:
• hamstring lengthening
• chondroplasty of the defect
 Technique :                       Postoperative X-ray:

• no postoperative complications
D.R. a year ago:

walking with support
on short distances
transfer to chair
without pain!

Loss of cartilage surface in the knee can cause
severe knee pain with loss of ambulatory function, but the pain
may be attributed to other etiologies instead. The prevalence is
unknown, but should be considered in differential diagnosis of
knee pain in patients with cerebral palsy.

Adolescents may have cartilage defects in the knee causing pain
and loss of function. Surgical intervention is of benefit to return
patients to a better functional level.
We are not sure if this is a rare pathology, or is simply missed
with knee pain being contributed to other etiologies.

1.Abel MF, Damiano DL, Pannunzio M, Bush J (1999). Muscle-tendon surgery in diplegic
cerebral palsy: functional and mechanical changes.
2. Gage JR (1990). Surgical treatment of knee dysfunction in cerebral palsy. Clin Orthoped
3. Lloyd-Roberts GC, Jackson Am, Albert JS (1985). Avulsion of the distal pole of patella in
cerebral palsy. A cause of deteriorating gait. J Bone Joint Surg Br 67:252-254.
4. Topoleski TA, Kurtz CA, Grogan DP (2000). Radiographic abnormalities and clinical
symptoms associated with patella alta in ambulatory children with cerebral palsy. J Pediatr
Orthop 20(5):636-639.

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