1. Bilateral Lateral Condyle Lesion with Valgus Deformities of Lower Extremities
Hank Chambers, MD
Professor of Clinical Orthopedic Surgery
University of California, San Diego
Rady Children’s Hospital, San Diego

2. History
11 y.o. female who presented to clinic with b/l knee pain and difficulty ambulating. 2+ effusion, locking and catching
PE: unable to ambulate L side with 15° loss of extension, TTP over b/l LFC

3. Imaging
Right knee: Deformity and flattening of the lateral femoral condyle similar to the left side. – old trauma or OCD

4. Imaging

5. Standing EOS Imaging Left more than right valgus.
MECHANICAL AXIS OF LOWER EXTREMITY.
A standard method for determining normal alignment
of the knee is by drawing a line in the A/P plane that
begins at the center of the femoral head, passes through
the center of the knee, and continues to the center of
the ankle.
If the line passes medially to the knee center, a varus
deformity is present; if the line passes laterally to the
knee center or center of the distal femur, a valgus
deformity exists.
Frontal views of both lower extremities reveals right-sided
neutral with slight valgus alignment at the knee in normal
limits. On the left side however, the valgus is somewhat
exaggerated. There is deformity of the left lateral femoral
condyle as seen on the x-ray from earlier. Deformity on
the right side is also present.

6. MRI
Right Knee
R KNEE -- Osteochondritis dissecans involving weightbearing portion of the lateral femoral condyle measuring 2.2 cm from anterior/posterior by 2cm from medial/lateral. With
flattening of the subchondral bone plate, deformity of the
lateral femoral condyle, and significant overlying cartilage
thinning. Reactive bone marrow changes adjacent to OCD.
NO DISPLACED osteochondral fragment.
Shallow trochlea and increased tibial tuberosity trochlear groove
distance.

7. MRI
Right Knee

8. Treatment Bilateral lower extremities:
Diagnostic arthroscopy with findings of complete delamination of the cartilage or lateral compartment almost like a rolled up rug
Findings of a cartilage covered ridge in mid portion of the tibial weight bearing surface bilaterally
lateral femoral condyle vascular stimulation
temporary hemiepiphysiodesis with application of plates to medial distal femur and proximal tibia
The classic treatment of pathological angular deformities
of the extremities is corrective osteotomy; however, osteotomies
require hospitalization, pain management, immobilization, and
delayed weight bearing. The associated risks, inconvenience, and
cost of osteotomy make hemiepiphysiodesis or guided growth an
attractive option.

9. 1. Arthroscopy – L Knee
Patellofemoral joint was good. There was some synovitis. ACL was intact.
Medial compartment demonstrated intact cartilage, with an intact meniscus. The
lateral compartment demonstrated extensive cartilage delamination of the
posterior lateral femoral condyle, with exposed subchondral bone. Meniscus was
intact. There was a large rigid convexity of the lateral tibial plateau.
Decision was made to perform a lateral arthrotomy. The scope was removed. Knee
was drained.
Lateral parapatellar arthrotomy was then performed with a 15-blade. Dissection
of the joint with electrocautery. Retractors were then placed. The knee was
flexed. The cartilage lesion was then removed with a 15-blade. The perimeter
of the lesion was then debrided of any areas of delamination. Total size of the
defect was approximately 2 x 3 cm. The lesion was not able to be contained and
extended all the way to the edge of the lateral femoral condyle posteriorly. We
curetted the subchondral bone, used a basket to debride the edges back to
stable. Rim we then performed a microfracture with a 2.5 drill bit, placing
multiple drill holes. The knee was then irrigated.

10. 1. Arthroscopy – R Knee The cartilage overriding the
patellofemoral joint was normal. The medial compartment was normal. The medial
meniscus and lateral meniscus were both intact. Her ACL was intact. PCL was
intact. In the lateral compartment, she had a large OCD lesion of the posterior
aspect of the lateral femoral condyle. There was also a bony prominence
creating increased convexity of the tibial plateau. The cartilage overlying the
OCD lesion was very soft and clearly did not have sufficient amount of
underlying bone. It was nearly folded over and imbricated on itself. We thus
made the determination to attempt to refixate the cartilage via open approach;
thus, the arthroscope was removed, and a lateral parapatellar incision was made.
Dissection was carried down through the skin and subcutaneous tissues. Bovie
cautery was used for hemostasis. We sharply incised the knee capsule and
synovium as well as the fat pad distally and entered the knee joint. Care was
taken to protect the lateral meniscus. We flexed up the knee. We attempted to
place multiple smart nails within the OCD lesion to refixate the cartilage, the
underlying bone. However, these did not provide any stable fixation. We thus
made the determination that the cartilage was not going to be stable and would
not be suitable for fixation. It was thus sharply excised, creating
approximately 1.5 cm x 2 cm defect in the femoral condyle. This had good stable
edges around it. We performed a microfracture with a 2.0 mm drill bit. The
wound was then irrigated.

11. 1. Post-op Imaging 1 week
The right and left knees show tension plates and screws
applied over the medial distal femur and proximal tibia spanning
the physes. Postoperative changes are seen in adjacent soft tissues.

12. 1. Post-op Imaging 1 week

13. 1. Post-op Imaging 8 months
LEFT KNEE
Frontal and lateral radiographs of the left
knee were obtained. There are tension bands with screws spanning
the distal femoral and proximal tibial growth plates. The
lateral femoral condyle appears stable with flattening and
irregularity. I do not see an acute fracture. The overall
alignment is maintained. No hardware fracture is noted.
RIGHT KNEE
there is a stable appearance of flattening and some sclerosis involving the
right lateral femoral condyle. Stranding of Hoffa fat pad

14. 1. Post-op Imaging 8 months

15. 1. Post-op Imaging 8 months

16. 1. Post-op Imaging 8 months
8 months post-op
Pre-op
As before, there are bilateral tension
bands along the medial metaphysis of the bilateral femur and
proximal tibia. No hardware complication is seen. There is
persistent bilateral genu valgum. Flattening and mild
irregularity of the bilateral lateral femoral condyles, better
demonstrated on the dedicated knee radiographs.

17. 1 year later
12 yr old female with severe b/l lateral femoral condyle OCD and genu valgum who is 1 year s/p open b/l OCD vascular stimulation, b/l fem/tib medial 8 plates.
Recovered well from surgery w/ weekly PT. Swims and rides bike, but does not participate in sports.
Her RLE has responded well to guided growth but left continued to have a valgus alignment.

18. 2. Pre-op Imaging Femoral shaft axis (FShA):
A line drawn from the center of the proximal femur
to the center of the distal femur or center of the knee,
indicating the overall position of the femoral shaft.
Tibial shaft axis (TShA) and Mechanical axis
of the tibia (MAT):
These 2 terms are often used interchangeably, and
both describe a line extending from the center of the
proximal tibia to the center of the ankle
Anatomic tibiofemoral angle: --- here it is
The angle formed when the line that forms the femoral
shaft axis is extended through the distal femur to
form an angle between the femoral shaft axis and the
tibial shaft axis (Figure 1.6). The angle is represented
by numbers that supplement the normal angle of
alignment (e.g., 3°, 6°, etc.) and indicates the extent
of anatomic misalignment or deformity.
XR Bone length
EXAM# TYPE/EXAM RESULT
EOS/LOWER EXTREMITY BOTH
Accession:
LOWER EXTREMITY BOTH
HISTORY: Genu valgum.
COMPARISON: 2/20/2013.
FINDINGS: Standing frontal views of the bilateral lower
extremities were obtained. This examination demonstrates minimal
leg-length discrepancy with the right lower extremity
approximately 5 mm longer than the left. Mild genu valgum is
noted on the left, improved since the prior study. Physeal
tension bands are noted in the medial distal femur and proximal
tibia bilaterally. No acute or healing fracture is noted. No
significant pelvic tilt is seen.
IMPRESSION:
Mild left-sided genu valgum, slightly improved since prior study.
No hardware complication or failure.

19. 2. Treatment
Bilateral lower extremities: removal of temporary guided growth tension band plates from the medial distal femur /proximal tibia.
LLE: lateral distal femoral opening wedge osteotomy

20. 2. Post-op Imaging 1 month There has been interval removal of the
tension bands previously noted medially along the distal femur
and proximal tibia. Wedge osteotomy on the distal left femur
laterally is seen with sclerotic material currently identified.
This is transfixed with a cortical side-plate and intervening
screws. Decreasing irregularity of the lateral femoral condyle
is noted. Ghost tracts from the cannulated screws of the
proximal tibia are seen.
The overall alignment is maintained. No acute findings noted.
Of note, hyperdense material is present along the posterior
medial soft tissues. This is presumably post- surgical.

21. 2. Post-op Imaging 4 months
4 months post-op
Pre-op before 1st surgery
XR BONE LENGTH-SINGLE FILM
HISTORY: Acquired genu valgum, postop.
REFERENCE EXAMINATION: 5/30/13.
FINDINGS: Since the previous exam, the medially placed tension
band plate and screws of both knees have been removed. There has
been interval osteotomy of the left distal femur supported by a
side plate and multiple cortical screws. Some minimal residual
genu valgum is seen of the left knee; however, there has been
significant improvement since the previous study. No appreciable
leg-length discrepancy is seen. There is no fracture of the
hardware. No acute fracture of the lower extremities is seen.
IMPRESSION: Interval osteotomy of the left distal femur.

22. 2. Post-op Imaging 4 months
EXAMINATION: XR KNEE BILATERAL 3 VIEWS
Left knee: The patient is status post fixation of the distal left femur with a cortical
sideplate, and intervening screws. There is unchanged sclerosis of the supracondylar region. I
do not see an acute fracture. There are likely post surgical changes of the proximal tibia as
well. Irregularity of the lateral femoral condyle is noted.
Right knee: Ghost tracts from prior hardware instrumentation noted along the distal femur,
and proximal tibia. There is flattening, and irregularity of the lateral femoral condyle. No
acute fracture noted.

23. 2. Post-op Imaging 4 months

24. 2. Post-op Imaging 4 months

25. 2 years later
MS is a 13 yo female who is 1 year s/p left distal femoral osteotomy with retained implant.
Implant removal

26. 3. Post-op Imaging 1 month
All screws been removed. The prior osteotomy is healing. There are no acute changes noted.
IMPRESSION:
Healing osteotomy

27. Current Condition No pain Full range of motion No effusion
No clicking, popping or locking
Able to ride a bicycle and swim
Avocations are art and music

28. The American Journal of Sports Medicine, July 2010 Background:
Prevalence 0.01 – 0.06%, 2:1 males, 75% involve knee, thereof 70-80% medial femoral condyle.
Etiology unknown – mechanical, vascular, genetic, inflammatory, ossification problems?
Purpose: Relationship b/n localization of OCD & mechanical axis of leg?
Study Design: Retrospective study of case series between January 1993 and December 2007 in single ortho dept.
Say this first: MAIN POINT: case example of correcting mechanical axis of leg to off load an ocd rather than just treating the OCD.

29. Mechanical axis was calculated by the method of Fujisawa et al*:
Methods: Used b/l full-leg standing radiographs in 93 adolescent and adult patients (103 knees) with OCD of medial or lateral femoral condyle.
Mechanical axis was calculated by the method of Fujisawa et al*:
0% represents knee center
100% represents medial
and lateral border of the joint
*Fujisawa Y, Masuhara K, Shiomi S. The effect of high tibial osteotomy on osteoarthritis of the knee: an arthroscopic study of 54 knee joints. Orthop Clin North Am. 1979;10(3):

30. Results: Location of OCD and position of mechanical axis in same knee compartment was significantly correlated for both medial (P< 0.001) as well as lateral (P< 0.012) compartment OCD.
Significant lateral shift compared to unaffected side. Statistically insignificant medial shift with respect to unaffected side.
In the medial OCD group, the mean mechanical axis was located in the medial knee compartment (28% medial +/- 2.8%; range, 100% medial to 14% lateral) with a statistically insignificant medial shift with respect to the unaffected side. In lateral OCD, the mean mechanical axis was located laterally (13% lateral +/- 3.9%; range, 13% medial to 60% lateral) with a significant shift from the medial into the lateral knee compartment when comparing unaffected with affected knees.

31. Results: No significant difference between adolescents with open growth plates compared with adults with closed growth plates (P > .05).

32. Conclusion: Limitations:
Association between medial condyle OCD and varus axis and between lateral condyle OCD and valgus axis.
Higher loading of the affected than of the unaffected knee compartment.
Axial alignment may be a cofactor in OCD of the femoral condyles.
Limitations:
9 b/l cases in medial OCD -- affecting shift calculations?
Single institution
Relatively small subgroups in sample – bias?
The full-leg standing radiographs are not done uniformly at the onset of symptoms – many patients were referred later to their institution