Osteochondritis Dissecans

Author: Mark Karadsheh

Topic updated on 02/01/13 9:45am

Introduction

A pathologic lesion affecting articular cartilage and subchondral bone with variable clinical patterns
Epidemiology
- demographics
  - juvenile form (open physes)
  - adult form (skeletal maturity)
- location
  - knee (most common)
    - posterolateral aspect of medial femoral condyle (70% of lesions in knee)
  - capitellum of humerus
  - talus
Pathophysiology
- cause may be
  - hereditary
  - traumatic
  - vascular
- natural history
  - softening of the overlying articular cartilage with intact articular surface -->
  - early articular cartilage separation -->
  - partial detachment of lesion -->
  - osteochondral separation with loose bodies
Juvenile form
- occurs at age 10-15 while the physis is still open
- prognosis correlates with
  - age
    - younger age correlates with better prognosis
    - open distal femoral physes are the best predictor of successful non-operative management
  - location
    - lesions in lateral femoral condyle and patella have poorer prognosis
  - appearance
    - synovial fluid behind the lesion on MRI correlates with a worse prognosis
Adult form
- worse prognosis
- cause is thought to be vascular
- usually symptomatic and leads to DJD if untreated

Classification

Clanton Classification of Osteochondritis (Clanton and DeLee)
Type I	Depressed osteochondral fracture
Type II	Fragment attached by osseous bridge
Type III	Detached non-displaced fragment
Type IV	Displaced fragment

Presentation

Symptoms
- pain
  - activity related pain that is vague and poorly localized
- mechanical symptoms
  - indicates advanced disease
- recurrent effusions of the knee
Physical exam
- localized tenderness
- stiffness
- swelling
- Wilson’s test
  - pain with internally rotating the tibia during extension of the knee between 90° and 30°, then relieving the pain with tibial external rotation

Imaging

Radiographs
- recommended views
  - weight-bearing anteroposterior, lateral radiographs
  - obtain tunnel (notch) view
    - knee bent between 30 and 50 degrees
MRI
- useful for characterizing
  - size of lesion
  - status of subchondral bone and cartilage
  - signal intensity surrounding lesion
  - presence of loose bodies

Treatment

Nonoperative
- restricted weight bearing and bracing
  - indications
    - stable lesions in children with open physes
    - aysmptomatic lesions in adults
  - outcomes
    - 50-75% will heal without fragmentation
Operative
- diagnostic arthroscopy
  - indications
    - impending physeal closure
    - clinical signs of instability
    - expanding lesions on plain films
    - failed non-operative management
- microfracture
  - indications
    - stable lesion seen on arthroscopy
  - outcomes
    - leads to formation of fibrocartilagenous tissue
    - improved outcomes in skeletally immature patients
- fixation of unstable lesion
  - indications
    - unstable lesion seen on arthroscopy or MRI >2cm in size
  - outcomes
    - 85% healing rates in juvenile OCD
- chondral resurfacing
  - indications
    - large lesions, >2cm x 2cm
- knee arthroplasty
  - indications
    - patients > 60 years

Surgical Techniques

Microfracture
- technique
  - tap awl to a depth of 1-1.5cm below articular surface
- post-operative
  - NWB for 4-6 weeks with CPM
Internal fixation
- technique
  - options for fixation
    - cannulated screws
    - Herbert screws
    - bone pegs
    - Kirschner wires
- cons
  - may require hardware removal
Osteochondral grafting
- arthrotomy (vs. arthroscopy) indicated in lesions > 3cm
  - technique
    - open vs. arthroscopic
      - arthroscopy generally used for lesions <3cm
      - arthrotomy used for lesions > 3cm
    - allograft plugs
    - autograft OATS
Periosteal patches

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Qbank (5 Questions)

TAG

(OBQ11.274) Which area of the knee is most likely to be affected by a juvenile osteochondritis dissecans (JOCD) lesion? Topic

Review Topic

1. Lateral aspect of the medial femoral condyle
2. Lateral aspect of the lateral femoral condyle
3. Medial aspect of the lateral femoral condyle
4. Medial facet of the patella
5. Lateral facet of the patella

PREFERRED RESPONSE ▶

DISCUSSION: More than 70% of JOCD lesions are found in the “classic” area of the posterolateral aspect of the medial femoral condyle, with inferior-central lateral condylar lesions accounting for only 15% to 20% of cases and femoral trochlear lesions seen in less than 1%. The knee is the most common site of osteochondrosis in growing children, which is seen in an estimated 0.002% to 0.003% of knee radiographs.

The review article by Kocher et al states that nonoperative initial management consisting of non-weight-bearing with crutches, continued knee range-of-motion exercises, and close follow-up is indicated for stable lesions in skeletally immature patients. Operative treatment is indicated for any detached or unstable lesions in which physeal closure is imminent or completed and nonoperative management has failed.

Cahill presents Level 5 evidence including his criterion for operative indications including: (1) detachment or instability of the fragment while the patient is under treatment (2) persistence of symptoms in a compliant patient (3) persistently elevated or worsening bone scan activity and (4) approaching epiphyseal closure. He reports his personal series of 204 JOCD patients and reports that 50% of JOCD patients ultimately required surgery. He cites fragment detachment occurred in 34% and persistent symptoms or combined indications comprised 26% of the failures.

Illustration A and B show a skeletally immature patient with a JOCD lesion in the classic position of the lateral aspect of the medial femoral condyle.

Illustrations: A

REFERENCES:

1. Kocher MS, Tucker R, Ganley TJ, Flynn JM. Management of osteochondritis dissecans of the knee: current concepts review. Am J Sports Med. 2006 Jul;34(7):1181-91. Review PMID:16794036 (Link to Abstract)

2. Cahill BR. Osteochondritis dissecans of the knee: treatment of juvenile and adult forms. J Am Acad Orthop Surg. 1995 Jul;3(4):237-247. PMID:10795030 (Link to Abstract)

Question Authors:

Michael Hughes MD, John Badylak MD, Patrick McCulloch MD,

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TAG

(OBQ09.101) A 10-year-old boy has had atraumatic progressive right knee pain for 2 months. He denies fevers or mechanical knee symptoms. His exam is completely normal and symmetric to his left knee. Radiographs of the right knee demonstrate open growth plates and a well circumscribed 1x1cm area of sclerotic subchondral bone with a radiolucent halo separating this area from his femoral epiphysis. MRI is shown in Image A. What is the best initial treatment plan? Topic

Review Topic

FIGURES: A

1. arthroscopic micro-fracture
2. activity modification
3. antergrade drilling
4. arthroscopic reduction and fixation
5. arthroscopic excision

PREFERRED RESPONSE ▶

DISCUSSION: This child has osteochondritis dissecans (OCD) of lateral femoral condyle with open growth plates. The cited review by Schenck concluded that the outcomes of distal femur OCD in skeletally immature patients are good and these lesions usually heal without surgical treatment. Limitation of activity may diminish stresses across the OCD lesion and prevent displacement. Only about 15% of juvenile OCD cases present in lateral femoral condyle with the majority occur in the lateral aspect of the medial femoral condyle. In adult patients, the rate of non-operative healing is very low. Other indications in this child for operative intervention would be failure of non-operative treatment, mechanical locking from a loose body, or radiographic evidence of a displaced fragment.

REFERENCES:

1. Schenck RC Jr, Goodnight JM: Osteochondritis dissecans. J Bone Joint Surg Am 1996;78:439-456 PMID:8613454 (Link to Abstract)

2. Herring JA: Disorders of the knee, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 919-971

Question Authors:

Charles Jobin MD, Patrick McCulloch MD,

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TAG

(OBQ08.137) Which of the following factors is the best predictor of successful non-operative management of an osteochonditis dissecans lesion in the knee? Topic

Review Topic

1. Open femoral physis
2. Location in the knee
3. High signal behind the lesion on MRI
4. Articular cartilage thickness
5. Body mass index

PREFERRED RESPONSE ▶

DISCUSSION: Osteochondritis dissecans (OCD) is an acquired, potentially reversible idiopathic lesion of subchondral bone resulting in delamination and sequestration with or without articular cartilage involvement and instability. While there is a typical location (medial femoral condyle) and thickness, these do not appear to be predictive of healing. A fluid signal on MRI behind the lesion indicates that the fragment is unstable and is less likely to heal according to DeSmet et al. The correct answer comes from a 12-patient study where Paletta et al reviewed quantitative bone scans to find that 100% of patients with open femoral physes that had activity behind the lesions went on to heal but none of in adolescents with closing physes.

REFERENCES:

1. Paletta GA Jr, Bednarz PA, Stanitski CL, Sandman GA, Stanitski DF, Kottamasu S. The prognostic value of quantitative bone scan in knee osteochondritis dissecans: a preliminary experience. Am J Sports Med. 1998;26:7–14. PMID:9474395 (Link to Abstract)

2. De Smet AA, Ilahi OA, Graf BK. Untreated osteochondritis dissecans of the femoral condyles: prediction of patient outcome using radiographic and MR findings. Skeletal Radiol. 1997;26:463–467. PMID:9297750 (Link to Abstract)

3. Flynn JM, Kocher MS, Ganley TJ. Osteochondritis dissecans of the knee. J Pediatr Orthop 2004 24:434-443. PMID:15205627 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Derek Moore, Guillem Lomas MD,

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TAG

(OBQ07.91) An 11-year-old boy complains of 4 weeks of medial knee pain that began while playing tennis. Examination shows reproduction of pain with internal rotation of the tibia during extension of the knee, and relief of pain with tibial external rotation. A radiograph and MRI is shown in Figures A and B. Which of the following is the most appropriate initial treatment? Topic

Review Topic

FIGURES: A

1. Arthroscopic removal of fragment
2. Arthroscopic open reduction and internal fixation
3. Arthroscopic microfracture drilling
4. Non-weight bearing for 6-8 weeks
5. Full weight bearing with avoidance of athletic acticity

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph and MRI show an osteochondritis dissecans (OCD) lesion on the medial femoral condyle. On the MRI image, the cartilage appears to be intact and the lesion is not displaced. A clear fluid line behind the fragment would indicate a poorer prognosis for healing with non-operative treatment. However, an initial period of non-operative treatment would be recommended for an intact lesion in a skeletally immature patient.

Safran et al describes Wilson's test of the knee. External rotation of the tibia during gait indicates compensation for impingement of the tibial eminence on an OCD lesion of the medial femoral condyle. Wilson’s test involves reproduction of pain on examination by internally rotating the tibia during extension of the knee between 90° and 30°, then relieving the pain with tibial external rotation. External rotation moves the eminence away from the lesion, relieving the pain. This patient has open physes and a stable appearing lesion. Thus nonoperative treatment should be tried initially.

REFERENCES:

1. Crawford DC, Safran MR. Osteochondritis dissecans of the knee. J Am AcadOrthop Surg. 2006 Feb;14(2):90-100. PMID:16467184 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD,

Please Rate Educational Value!

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TAG

(OBQ06.200) An 11-year-old boy presents with recurrent knee effusions and discomfort with athletic activity. A radiograph of the knee is shown in Figure A. What is the most important determinant of a successful outcome with nonoperative treatment? Topic

Review Topic

FIGURES: A

1. Weight of the patient
2. Presence of open physes
3. Gender
4. Location of the lesion within the knee
5. A history of trauma to the affected joint

PREFERRED RESPONSE ▶

DISCUSSION: The radiograph is consistent with an osteochondritis dissecans (OCD) lesion in the most common location on the medial femoral condyle.

The reference by Cain et al presents an overview of the treatment options available for osteochondral defects in the knee in both adolescents and adults, and proposes a treatment algorithm for both patient populations. In the adolescent with OCD the presence of adequate remaining skeletal growth (open physes) is the most important determinant of treatment. Typically, in the presence of open physes, these lesions are treated non-operativley with a 6 week trial of non-weight bearing. Indications for surgery include near growth plate completion, loose fragments, or severe symptoms that do not improve with nonoperative management.

Cahill et al review conservative management of juvenile OCD, specifically focusing on the important role of compliance in successful outcomes. They define the interdependent roles of the parents, patient, and the physician, referred to as the "compliance triad". They specifically discuss how to develop compliance in the triad, the importance of early diagnosis, and the results of conservative treatment.

REFERENCES:

1. Cain EL, Clancy WG: Treatment algorithm for osteochondral injuries of the knee. Clin Sports Med 2001; 20:321-342. PMID:11398361 (Link to Abstract)

2. Cahill BR, Ahten SM: The three critical components in the conservative treatment of juvenile osteochondritis dissecans (JOCD): Physician, Parent, and Child. Clin Sports Med 2001; 20: 287-298. PMID:11398359 (Link to Abstract)

Question Authors:

Joshua Blomberg MD, Patrick McCulloch MD, Ben Taylor MD,

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4.0

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Cases

	Osteochondritis dissecans (OCD) lesion (C1015) General - - Osteochondritis Dissecans HPI - A 35-year-old man presented with a painful locked knee following a minor twistin... Besides an arthroscopic removal of the OCD fragment, what secondary procedu...	2/4/2011 5 responses
	Trochlear OCD (C1135) Sports - - Osteochondritis Dissecans HPI - 38 year old fairly athletic male with continued painful clicking/popping of righ... What treatment would you recommend for a large (>3 cm2) well-shouldered tro...	1/23/2012 64 responses 5
	Lateral Tibial plat osteochondral defect (C1340) Sports - Treatment Consult - Osteochondritis Dissecans HPI - 37 yr old very active female with knee pain. What are further options?	11/29/2012 166 responses
	Knee OCD lesion (C1392) Sports - Treatment Consult - Osteochondritis Dissecans HPI - right knee pain for 6 months. What is your planned surgical treatment	1/23/2013 196 responses 3

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Groups

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Evidence & References Show References

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Kocher MS, Tucker R, Ganley TJ, Flynn JM. Management of osteochondritis dissecans of the knee: current concepts review. Am J Sports Med. 2006 Jul;34(7):1181-91. Review PMID:16794036 (Link to Abstract)
Cahill BR. Osteochondritis dissecans of the knee: treatment of juvenile and adult forms. J Am Acad Orthop Surg. 1995 Jul;3(4):237-247. PMID:10795030 (Link to Abstract)
Crawford DC, Safran MR. Osteochondritis dissecans of the knee. J Am AcadOrthop Surg. 2006 Feb;14(2):90-100. PMID:16467184 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Schenck RC Jr, Goodnight JM: Osteochondritis dissecans. J Bone Joint Surg Am 1996;78:439-456 PMID:8613454 (Link to Abstract)
Herring JA: Disorders of the knee, in Herring JA (ed): Tachdjian’s Pediatric Orthopaedics, ed 4. Philadelphia, PA, WB Saunders, 2008, pp 919-971
Paletta GA Jr, Bednarz PA, Stanitski CL, Sandman GA, Stanitski DF, Kottamasu S. The prognostic value of quantitative bone scan in knee osteochondritis dissecans: a preliminary experience. Am J Sports Med. 1998;26:7–14. PMID:9474395 (Link to Abstract)
De Smet AA, Ilahi OA, Graf BK. Untreated osteochondritis dissecans of the femoral condyles: prediction of patient outcome using radiographic and MR findings. Skeletal Radiol. 1997;26:463–467. PMID:9297750 (Link to Abstract)
Flynn JM, Kocher MS, Ganley TJ. Osteochondritis dissecans of the knee. J Pediatr Orthop 2004 24:434-443. PMID:15205627 (Link to Abstract)
Cain EL, Clancy WG: Treatment algorithm for osteochondral injuries of the knee. Clin Sports Med 2001; 20:321-342. PMID:11398361 (Link to Abstract)
Cahill BR, Ahten SM: The three critical components in the conservative treatment of juvenile osteochondritis dissecans (JOCD): Physician, Parent, and Child. Clin Sports Med 2001; 20: 287-298. PMID:11398359 (Link to Abstract)

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Osteochondritis Dissecans

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