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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 Objectives. 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 pain. 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) Results. Cartilage loss in the distal femoral condyle of the knee was seen during arthroscopy or patella stabilization in the study population. • 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 2 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. Arthroscopy: • 2x2 cm cartilage defect of the right medial femoral condyle 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 and transfer to chair without pain! Conclusion: 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. Significance. 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. Literature. 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 253:45-54. 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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