SUBMITTED 6 APR 22 1 REVISION REQ. 8 JUN 22; REVISION RECD. 14 JUN 22 2 ACCEPTED 20 JUL 22 3 ONLINE-FIRST: AUGUST 2022 4 DOI: https://doi.org/ 10.18295/squmj.8.2022.047 5 6 Simple arthroscopic technique to perform retrograde drilling for 7 osteonecrosis of the femoral condyles with the use of ACL guide 8 Nikolaos Koukoulias,1 *Angelo V. Vasiliadis,2 Theofilos Dimitriadis1 9 10 1 Orthopaedic Department, Saint Luke’s Hospital, Thessaloniki, Greece; 2 2nd Orthopaedic 11 Department, General Hospital of Thessaloniki “Papageorgiou”, Thessaloniki, Greece. 12 *Corresponding Author’s e-mail: vasiliadis.av@gmail.com 13 14 Abstract 15 A simple arthroscopic technique was introduced without the need for further staff 16 during the operation. A 2.4 mm pin is positioned through the sleeve of an ACL tibial 17 guide and it is marked with a steri-strip at its body, aiming at 5-10 mm distance between 18 the tips of guide and the pin. The steri-strip serves as a mark and as a stop for 19 inadvertent violation of the cartilage. The tip of the ACL is positioned just over the 20 bone lesion, while the marked 2.4 mm pin is inserted through the ACL tibial guide from 21 anterior surface of the femur. A stab incision is made and without advancing the sleeve 22 to the bone, the pin is drilled to the marked position while cartilage integrity is 23 confirmed arthroscopically. Our arthroscopic technique is simple, fast and effective and 24 it is performed without the need of a special equipment. 25 Keywords: Avascular necrosis; Osteonecrosis; Knee joint; Arthroscopic; 26 Decompression. 27 28 Introduction 29 Osteonecrosis of the femoral condyle is the second most common affected anatomic 30 location, following the femoral head and accounts for approximately 10% of all cases.1 31 It was first described by Ahlback et al. in 1968 as a distinct clinical entity primarily 32 affecting older adulthood woman.2 Following the classification of the osteonecrosis by 33 Ficat3 and Mont,4 the disease progresses through four stages and is based on a 34 combination of clinical and radiographic findings. Although several risk factors for the 35 pathogenesis of osteonecrosis have been identified, three main theories of 36 pathophysiology have been advanced. The traumatic theory is based on a history of 37 repetitive trauma over time, causing interruption of blood flow, critical ischemia and 38 finally bone collapse.5,6 The ischemic theory in which ischemia can result from an 39 occlusion of the epiphyseal vessels, causing bone necrosis and collapse.5,6 Another 40 theory is that there is an association with altered biomechanics of the knee joint 41 following meniscal root tear and meniscectomy, which often occur in younger and 42 active male.6 43 44 Like the pathophysiology, there is still debate concerning the current treatment options 45 for this disease. In general, treatment include non-operative management with 46 pharmacologic agents, such as non-steroidal anti-inflammatory drugs (NSAIDs) and 47 bisphosphonates, as well as operative treatment with joint preserving and joint-replacing 48 surgeries.6 The operative treatment with core decompression is suggested for early and 49 pro-collapse stages of the disease.6-8 In this regard, there have been described various 50 techniques for performing femoral condyle core decompression with the majorities 51 aided by arthroscopy, fluoroscopy and navigation systems, in order to safe drill the 52 necrotic area.1-3 Thus, the purpose of this technical note is to present a simple technique, 53 which enables retroarticular core decompression with an anterior cruciate ligament 54 (ACL) tibial guide and a marked pin, without the need of fluoroscopic or/and navigation 55 assistance. 56 57 Technique Details 58 The arthroscopic procedure was performed by the senior author. Two grams of 59 prophylactic cephalosporine was administered intravenously within 1 hour before the 60 surgery. The surgery was carried out with the patient in a supine position, while two 61 posts were attached to the surgical table to facilitate access by the surgeon and the 62 assistant. The first post lateral to the proximal thigh and the second as a foot rest to 63 maintain a 90 degrees of knee flexion. After the patient was positioned, cotton cast was 64 wrapped around the thigh in order to avoid wrinkles and a tourniquet was then applied 65 circumferentially at a pressure of 300 mmHg. 66 67 Retrograde drilling is performed utilizing an ACL tibial guide. The pin sleeve is placed 68 and secured into the guide leaving enough space for the extra articular course of the 69 ACL guide. The 2.4 mm pin is positioned through the sleeve and is marked with a steri-70 strip at its body, aiming at 5-10 mm distance between the tips of guide and the pin, to 71 avoid articular cartilage blow-out [Figure 1]. The steri-strip serves as a mark and as a 72 stop for inadvertent violation of the cartilage. 73 74 The integrity of the cartilage is confirmed arthroscopically. The ACL tibial guide is 75 inserted through the antero-medial or antero-lateral portal for the medial and the lateral 76 femoral condyle lesions respectively. The tip of the tibial ACL guide is positioned just 77 over the bone lesion, without touching the healthy cartilage [Figure 2]. The pin is 78 inserted through the anterior surface of the femur. A stab incision is made and without 79 advancing the sleeve to the bone, the pin is drilled to the marked position while 80 cartilage integrity is confirmed arthroscopically. The procedure can be repeated several 81 times and at different knee angles, depended to the size and location of the lesion treated 82 [Figure 3]. Advantages and limitations of this technique are listed in Table 1. 83 84 Case Study 85 A 47-year-old male visited our department with right knee pain and gradually 86 uncomfortable for 6 months. He had a history of a previous sports injury in the previous 87 year. Symptoms rapidly worsened with limited activity in the last month. Physical 88 examination showed focal tenderness over the medial femoral condyle and slight 89 limitation in the range of motion of the knee with positive McMurray’s and Thessaly 90 test. Magnetic resonance imaging (MRI) showed characteristic high intensity portions in 91 the subchondral area of medial femoral condyle, surrounded by diffuse high signal 92 intensity and a medial meniscal tear [Figure 4]. The diagnosis was avascular necrosis of 93 the medial femoral condyle. Due to the presence of a large lesion limited to the medial 94 femoral condyle, core decompression by retrograde drilling was recommended as an 95 effective treatment option in initial osteonecrosis of the knee (still radiographically 96 invisible). Written informed consent was obtained from the patient in order to use his 97 images for publication purposes. The inclusion criteria for this study were the presence 98 of secondary osteonecrosis of stage I or stage II disease according to Ficat3 and Mont4 99 as modified for the knee. Exclusion criteria included a history of major trauma, the 100 presence of radiological collapse (stage III and IV) and post-arthroscopic osteonecrosis. 101 102 Post-operatively, patient was encouraged to do passive and active range of motion as 103 tolerated. Partial weightbearing restriction for 6 weeks, in combination with pain killers 104 and muscle strengthening exercises were recommended, followed by a gradual return to 105 activities based on symptoms. Six months post-operatively, the patient remains 106 asymptomatic with full participation in sport activities. 107 108 Discussion 109 The pathophysiology of the osteonecrosis of the femoral condyles is not well 110 understood but there are a number of risk factors outlined in the literature which 111 indicate that the pathogenesis of avascular necrosis is likely multifactorial.5,6 Common 112 risk factors include sickle cell disease, myeloproliferative disorders, alcohol 113 consumption, long-term corticosteroid use, tobacco smoking, prior trauma and 114 meniscectomy.5 115 116 Over the past 2 decades, several treatment options for early stages of osteonecrosis have 117 been proposed, including core decompression, vascularized and non-vascularized bone 118 graft, cell-based therapies (bone marrow mesenchymal stem cells and/or platelet-rich 119 plasma) and osteotomies.5,8 The use of vascularized bone grafts has been associated 120 with possible disadvantages, including the extensive surgical time, prolonged 121 rehabilitation and possible donor site morbidity, such as numbness, weakness and ankle 122 pain (e.g. fibula bone graft).8 Also, high tibial osteotomy requires careful pre-operative 123 planning and an experienced surgeon, with the potential risk of non-union, tibial plateau 124 fracture, lateral cartilage degeneration and a further operation for elective hardware 125 removal.9 Therefore, retrograde core decompression remains an accepted treatment 126 option by most orthopaedic surgeons as the preferred option for the treatment of 127 avascular necrosis of the femoral condyles. 128 129 Knee arthroscopy is currently the gold standard for diagnosing concomitant intra-130 articular knee pathology.6 MRI, computed tomography and various adaptive 131 segmentation of knee radiographs have assisted for texture analysis of soft-tissue and 132 subchondral bone pathology, while can increase the diagnostic performance for 133 detecting the presence of knee osteonecrosis.10 Although, knee arthroscopy is a common 134 and safe surgical procedure without associated major complications, the overall 135 complication rate was up to 2% varying with the age of the patient, the duration of the 136 tourniquet time and the complexity of the procedure.11,12 However, knee arthroscopy at 137 the time of core decompression of femoral condyles provides an accurate way to 138 confirm the presence or absence of osteochondral defects, collapsed lesions of the 139 femoral condyle, and combined disorders, such as cruciate ligament and meniscal 140 injuries.13 141 142 Over the last years, many different procedures have been proposed for the treatment of 143 avascular necrosis of the femoral condyles.5,7,14 Regarding retrograde core 144 decompression by precise drilling into ischemic lesions of the femoral condyle, while 145 remaining articular cartilage intact is always challenge. In conventional technique, the 146 exact locating of the drill was made by multiple checks of drilling course and depths 147 with the use of digital fluoroscopy.15 The advantage of using fluoroscopy is to detect the 148 exact position of the drill bit in which the drill has to be properly inserted in order to 149 avoid damage of articular cartilage and of extra-articular soft tissues.15 On the other 150 hand, the use of digital fluoroscopy exposes both the patient and operative staff to 151 enormous radiation, while it puts sterility at risk.5,15 In order to minimize this risk, 152 computer-assisted and navigation based techniques have been developed, regarding 153 retrograde core decompression of avascular necrosis of femoral condyle. These 154 techniques have been showed that improve intra-operative precision with the less 155 possible radiation.5,15 156 157 Our surgical technique is a commonly performed arthroscopic surgical procedure in our 158 institution and makes it easy to perform retrograde core decompression of the femoral 159 condyles with the use of ACL guide and a 2.4 mm pin marked with a steri-strip at its 160 body. This method reduces the overall surgical time of the procedure, eliminate the 161 expose in radiation and there is no need for further staff during the operation. 162 163 Conclusion 164 We present a technical note of case with avascular necrosis of the medial femoral 165 condyle, which is treated with retrograde core decompression. Fluoroscopy- and 166 navigation-based techniques require extra space, have radiation exposure and they are 167 time consuming. Our technique is simple, fast and effective, without the need of special 168 equipment. Nevertheless, future studies should include more patients, in order to better 169 evaluate the results of this arthroscopic technique and to clarify possible complications 170 during this procedure. 171 172 Conflict of Interest 173 The authors declare no conflicts of interest. 174 175 Funding 176 No funding was received for this research. 177 178 Author Contribution 179 NK, AVV and TD was involved in conceptualization, design, data collect and analysis 180 and drafting the manuscript. All authors approved the final version of the manuscript. 181 182 References 183 1. Mankin HJ. Nontraumatic necrosis of bone (osteonecrosis). N Eng J Med 1992; 184 326:1473-9. doi: 10.1056/NEJM1992055283262206 185 2. Ahlback S, Bauer G, Bohne W. Spotaneous osteonecrosis of the knee. Arthritis 186 Rheum 1968; 11:705-33. doi: 10.1002/art.1780110602. 187 3. Ficat RP. Idiopathic bone necrosis of the femoral head: early diagnosis and 188 treatment. J Bone Joint Surg Br 1985; 67:3-9. doi: 10.1302/0301-189 620X.67B1.3155745. 190 4. Mont MA, Baumgarten KM, Rifai A, Bluemke DA, Jones LC, Hungerford DS. 191 Atraumatic osteonecrosis of the knee. J Bone Joint Surg Am 2000; 82:1279-90. 192 doi: 10.2106/00004623-200009000-00008. 193 5. Beckmann L, Goetz J, Bathis H, Kalteis T, Grifka J, Perlick L. Precision of 194 computer-assisted core decompression drilling of the knee. Knee 2006; 13:211-195 5. doi: 10.1016/j.knee.2006.02.005. 196 6. Karim AR, Cherian JJ, Jauregui JJ, Pierce T, Mont MA. Osteonecrosis of the 197 knee: a review. Ann Transl Med 2015; 3:6. doi: 10.3978/j.issn.2305-198 5839.2014.11.13. 199 7. Forst J, Forst R, Heller KD, Adam G. Spotaneous osteonecrosis of the femoral 200 condyle: causal treatment by early core decompression. Arch Orthop Trauma 201 Surg 1998; 117:18-22. doi: 10.1007/BF00703433. 202 8. Moya-Angeler J, Gianakos AL, Villa JC, Ni A, Lane JM. Current concepts on 203 osteonecrosis of the femoral head. World J Orthop 2015; 6:590-601. doi: 204 10.5312/wjo.v6.i8.590. 205 9. Liu X, Chen Z, Gao Y, Zhang J, Jin Z. High tibial osteotomy: Review of 206 techniques and biomechanics. J Healthc Eng 2019; 2019:8363128. doi: 207 10.1155/2019/8363128. 208 10. Ciliberti FK, Guerrini L, Gunnarsson AE, Recenti M, Jacob D, Cangiano V, et 209 al. CT- and MRI-based 3D reconstruction of knee joint to assess cartilage and 210 bone. Diagnostics (Basel) 2022; 12:279. doi: 10.3390/diagnostics12020279. 211 11. Reigstad O, Grimsgaard C. Complications in knee arthroscopy. Knee Surg 212 Sports Traumatol Arthrosc 2006; 14:473-7. doi: 10.1007/s00167-005-0694-x. 213 12. Degen RM, Lebedeva Y, Birmingham TB, Marsh JD, Getgood AMJ, Giffin JR, 214 et al. Trends in knee arthroscopy utilization: a gap in knowledge translation. 215 Knee Surg Sports Traumatol Arthrosc 2020; 28:439-47. doi: 10.1007/s00167-216 019-05638-5. 217 13. Ma J, Ren Y, Wang B, Yue D, Sun W, Wang W. Autologous osteochondral 218 transplantation for young patients with postcollapse osteonecrosis of the knee: A 219 retrospective cohort study with an average 7-year follow-up. Cartilage 2021; 220 13:1291S-7S. doi: 10.1177/19476035211023566. 221 14. Hernigou P, Gerber D, Auregan JC. Knee osteonecrosis: Cell therapy with 222 computer-assisted navigation. Surg Technol Int 2020; 36:281-7. 223 15. Spadari A, Forni G, Del Mango S, Tagliavia C, Canova M, Grandis A, 224 Rinnovati R. The comparison of latero-medial versus dorso-palmar/plantar 225 drilling for cartilage removal in the proximal interphalangeal joint. Animals 226 2021; 11:1838. doi: 10.3390/ani11061838. 227 228 Table 1: Advantages and limitations of the surgical technique 229 Advantages The procedure is minimally invasive The operation time is minimized due to the absence of intra-operative fluoroscopy use Both the patient and the operative staff do not expose in extra radiation There is no need for extra staff to use the C-arm fluoroscopy machine Minimize the sterility risk from the use of C-arm fluoroscopy machine Limitations The procedure is not indicated in later stages of avascular necrosis (bone collapse) An additional assistance is needed during the surgery 230 231 232 233 234 235 236 237 238 239 240 241 242 243 Figure 1: Calibrated tibial guide. The pin was positioned through the transtibial ACL 244 guide and was marked with the use of a steri-strip. 245 246 247 Figure 2: Retroarticular core decompression of the medial femoral condyle with 248 avascular necrosis. Care is taken to prevent damage to the articular surface of the 249 femoral condyle with the tip of the transtibial ACL guide. View from the anterolateral 250 portal showing the tip of the ACL guide placed over different areas (A and B) of the 251 affected medial femoral condyle. 252 253 Figure 3: Illustration (A) and intraoperative pictures (B and C) of the surgical technique 254 with retroarticular core decompression for avascular necrosis (also known as 255 osteonecrosis) of the medial femoral condyle. 256 257 258 Figure 4: Magnetic resonance imaging of the right knee showing extensive avascular 259 necrosis in sagittal (A), coronal (B) and transverse (C) views. The bone marrow edema 260 was located in the medial femoral condyle. 261 262