Osteochondritis concerns the bone located just below the cartilage in general at the level of the femur. A fragment of bone breaks up, the ssure sometimes reaches the cartilage just above it, and at the extreme this osteo-cartilaginous block detaches itself and is released in the joint, posing then the double problem of the presence of a foreign body and an articular lesion. While surgery can, in many cases, treat it, postoperative pain, long rehabilitation and the chance of not returning to sports participation, are reasons to consider Platelet Rich Plasma as an alternative.
We report the case of a primitive knee osteochondritis in a young 20-year-old footballer. Initial CT scan and MRI demonstrated osteochondral lesion of the internal femoral condyle classi ed as grade III.
The patient received ultrasound-guided intra-articular knee platelet rich plasma injections ve months apart, focusing on the lesion of osteochondritis dissecans. The nal MRI and CT scan showed a total healing of his lesion.
Journal of Prolotherapy. 2017;9:e978-e981.
Osteochondritis concerns the bone located just below the cartilage in general at the level of the femur. A fragment of bone breaks up, the fissure sometimes reaches the cartilage just above it, and at the extreme this osteocartilaginous block detaches itself and is released in the joint, posing then the double problem of the presence of a foreign body and an articular lesion.
Osteochondritis can be of traumatic origin, or essential. In adults, grades II and III are encountered in 50% of cases (although there are differences according to age) and grade II appear the most frequent. In children, there is a higher proportion of grade I and II.
Treatment depends on the stage of the lesion and the age of the patient. In the beginner stages, an articular rest with support protected by one or two canes can be decided, with a monitoring of the evolution. In the intermediate forms, the treatment is discussed. The attachment of the fragment associated with stimulation of the revascularization therefore replaces mostly the simple fixation. Finally, when the fragment is detached in the joint, it is rarely possible to reattach it.
Platelet Rich Plasma is defined as a volume of the plasma fraction of autologous blood having a platelet concentration above baseline. PRP provides a promising alternative to surgery by promoting safe and natural healing. All data in the literature agree on the absence of side effects, safety and excellent tolerance of PRP injections.
In this case, the final radiological results of a young patient footballer were presented, in which the only therapeutic option was surgery. Injections of PRP, gave after 9 months, complete revascularization with attachment of the fragment leading to a total cure of his lesion.
A 20-year-old young patient, footballer presented with pain in his right knee during walking and playing football progressively worsening over time, with the appearance of an effusion of the knee. Clinical examination found pain in the antero-internal aspect of the knee, muscle strength was normal, and there was no limitation of joint movement. The patient did not undergo any surgery and had no family history of bone disease or other disease.
Initial CT scan and MRI demonstrated osteochondral lesion of the internal femoral condyle classified as grade III. (See Figure 1.)
FIRST PRP SESSION 21/01/2017
One week prior to the first PRP session, the patient received an intra-articular injection of Prolotherapy and ozone
(10 cc of serum glucose to 30%, ozone 20 cc to 20 μg).
PRP was prepared after taking 30 ml of venous blood from the patient and centrifuged at 400 G for 10 minutes. 10 ml of PRP (Autologous conditioned plasma) obtained manually was injected into the knee under ultrasound guidance, anteriorly into the articular space and at the contact of the lesion, visible in ultrasound.
One month after PRP, the patient received 10 ampoules of calcitonin 50 ui, the first 05 ampoules intramuscularly, and then the remaining ampoules subcutaneously every three days, on the antero-internal surface of the knee.
Following the procedure, the patient was advised to walk with two walking sticks for three months.
MRI and CT scan at the end of the third month showed decreased lesion size compared with the initial size, appearance of revascularization and formation of bone bridges between the fragment and the femoral condyle. (See Figure 2.)
SECOND PRP SESSION 15/06/2017
The same PRP procedure was repeated, with the same intra-articular Prolotherapy injection and ozone performed one week prior.
Six weeks after the PRP procedure, the patient was allowed to walk with one walking stick. Then after two months, without the walking stick.
After another three months of follow-up, MRI and CT scan showed complete revascularization of the fragment and attachment of 95%. (See Figure 3.)
The patient was allowed to gradually return to his sport.
PATIENT FOLLOW-UP 12/12/2017
The patient has completely returned to football for 01 months (matches and full training) without pain and without effusion (ultrasound).
Osteochondritis dissecan of the femoral condyles is a rare condition. Its precise etiology is not known. It is certainly multifactorial, the mechanical and vascular factors being at the first plan.1 There is a juvenile form having a healing capacity and an adult form where surgery is often required. It is an arthrogenic condition when healing has not been acquired.2
MRI confirms the extension of the lesion, the vitality of the osteochondral fragment and the condition of the cartilage. The standard spin echo sequences with fat suppression are used to study the cartilage.3 The arthroscanner is an invasive method which allows to check the lesions of grade 3 and 4 and to analyze their extent.
Prolotherapy is an alternative injection-based therapy for chronic musculoskeletal pain. Three different proliferants, D-glucose dextrose, phenol-glucose-glycerine (P2G), and sodium morrhuate. The injection of a proliferant mixture causes low level inflammation, which acts as a rejuvenating stimulus generating a repair and healing process.4
Although bone and joint pathologies were not one of the first indications of ozone, after the documents of Dr. Verga5 and Dr. Riva Sanseverino6, several physicians began using ozone to treat this type of pathology. Once ozone dissolves in the synovial fluid after intra articular injection, as usual, it reacts with biomolecules (antioxidants, PUFA, proteins), generates ROS and LOPs responsible for stimulation of the proliferation of chondrocytes (probably via H2O2) and fibroblasts, with increased synthesis of matrix and possibly of articular cartilage. Induction of the synthesis of antioxidant enzymes (SOD, GSHPx and catalase) may be a crucial event as an adaptive response to COS and to ozone.7 ROS are able to augment neutrophil chemotaxis. Activated inflammatory cells themselves produce cytokines and growth factors such as IGF, leucocyte growth factor, IL-1, IL-2, TNF, TGF-α, TGF-β, VEGF, PDGF and lactate. VEGF and PDGF are both potent chemoattractants and mitogens for fibroblasts and angiogenic growth factors.8
The injection of Platelet Rich Plasma or PRP into the injured tissue has become widespread in recent years, particularly for joint and peri-articular pathologies. Once activated, platelets release, in situ, several active molecules whose growth factors (PDGF, insulin-like growth factor-1 (IGF-1), TGF-, endothelial vascular growth factor (VEGF), basic fibroblast growth factor (bFGF)…) contained in the granules, which stimulate angiogenesis, promote collagen formation, modulate matrix formation and lead to the proliferation of fibroblasts secondary to tissue healing.9,10
Calcitonin gene-related peptide (CGRP) has been considered as the causative neuropeptide for callus angiogenesis allowing its maturation and ossification.11
A previous work on the use of PRP for osteochondral knee injury was published by Budak Akman.12 Our PRP was proposed directly, given the age of the patient and the low percentage chance of the success of the conservative treatment.
The objective of any treatment in case of lesion OC grade III is to allow fixation of the lesion while avoiding the later appearance of osteoarthritis, and return as early as possible to the sport. Surgery was previously the only therapeutic option possible in these advanced stages. PRP is minimally invasive, with very few adverse effects. The PRP can be proposed from the beginning with a functional and an anatomical result satisfactory for the patient, even the athlete, as was the case of our patient.
- Federico DJ, et al. Osteochondritis dissecans of the knee: a historical review of etiology and treatment. Arthroscopy. 1990;6(3):190-7.
- B. Moyen D, et al. Ostéochondrite disséquante des condyles fémoraux. EMC Appareil locomoteur. 14-028-A-20.Elsevier; 2006.
- Dipaola JD, et al. Characterizing osteochondral lesions by magnetic resonance imaging. Arthroscopy. 1991;7(1):101-4.
- Jensen KT, et al. Early inflammatory response of knee ligaments to Prolotherapy. J Orthop Res. 2008 Jun; 26(6):816–823.
- Riva Sanseverino E. Knee joint disorders treated by oxigen-ozone therapy. Europa Medicophysica. 1989;3(25):163–70.
- Verga C. Nuovo approccio terapeutico alle ernie e protusioni discali lombari. Rivista Di Neuroradiologia. 1989;(2):148.
- Bocci V. The paradoxical effect of ozone in orthopaedic diseases. The problem of backache. OZONE. A New Medical Drug. Springer Netherlands; 2011.
- S. Schreml RM, et al. Oxygen in acute and chronic wound healing. The British Journal of Dermatology. 2010;163(2):257-268.
- De Mos M, et al. Can platelet-rich plasma enhance tendon repair? A cell culturestudy. Am J Sports Med. 2008 Jun;36(6):1171-8. doi: 10.1177/0363546508314430.
- Molloy, et al. The roles of growth factors in tendon and ligament healing. Sports Med. 2003;33(5):381-94.
- Lyritis G, Boscainos PJ. Calcitonin effects on cartilage and fracture healing. J Musculoskelet Neuronal Interact. 2001 Dec;2(2):137-42.
- Budak Akman, MD, Melih Güven, MD. MRI documented improvement in patient with juvenile osteochondritis dissecans treated with platelet rich plasma. Journal of Prolotherapy. 2016;8:e966-e970.