Osteochondritis Dissecans

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Introduction
  • A pathologic lesion affecting articular cartilage and subchondral bone with variable clinical patterns
  • Epidemiology
    • demographics
      • juvenile form (open physes)
        • occurs at age 10-15 while the physis is still open
      • adult form (skeletal maturity)
    • location
      • knee (most common)
        • posterolateral aspect of medial femoral condyle (70% of lesions in knee)
      • capitellum of humerus
      • talus
  • Pathophysiology
    • mechanism/etiology may be
      • hereditary
      • traumatic
      • vascular
        • cause of adult form is thought to be vascular
    • pathoanatomic cascade
      • softening of the overlying articular cartilage with intact articular surface 
      • early articular cartilage separation 
      • partial detachment of lesion 
      • osteochondral separation with loose bodies
  • Prognosis
    • juvenile form
      • 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  
          • sclerosis on xrays correlates with poor prognosis 
          • synovial fluid behind the lesion on MRI correlates with a worse prognosis
    • adult form
      • worse prognosis
      • 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  
        • asymptomatic 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
    • subchondral drilling with K-wire or drill
      • indications
        • stable lesion seen on arthroscopy
        • performed either transchondral or retrograde
      • 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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Questions (5)

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

QID:3697
1

Lateral aspect of the medial femoral condyle

73%

(2071/2856)

2

Lateral aspect of the lateral femoral condyle

3%

(80/2856)

3

Medial aspect of the lateral femoral condyle

23%

(661/2856)

4

Medial facet of the patella

1%

(18/2856)

5

Lateral facet of the patella

1%

(19/2856)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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:

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(OBQ09.101) A 10-year-old boy has 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? Review Topic

QID:2914
FIGURES:
1

Arthroscopic micro-fracture

6%

(47/770)

2

Activity modification

80%

(615/770)

3

Antegrade drilling

3%

(22/770)

4

Arthroscopic reduction and fixation

6%

(50/770)

5

Arthroscopic excision

4%

(33/770)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

This child has osteochondritis dissecans (OCD) of lateral femoral condyle with open growth plates.

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 cited review by Schenck and Goodnight 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 the lateral femoral condyle with the majority occuring 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.


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Question COMMENTS (3)

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

QID:523
1

Open femoral physis

82%

(672/820)

2

Location in the knee

10%

(86/820)

3

High signal behind the lesion on MRI

2%

(13/820)

4

Articular cartilage thickness

4%

(32/820)

5

Body mass index

2%

(16/820)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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 healed in adolescents with closing physes.


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Question COMMENTS (3)

(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? Review Topic

QID:752
FIGURES:
1

Arthroscopic removal of fragment

2%

(31/1702)

2

Arthroscopic open reduction and internal fixation

6%

(104/1702)

3

Arthroscopic microfracture drilling

4%

(60/1702)

4

Non-weight bearing for 6-8 weeks

78%

(1333/1702)

5

Full weight bearing with avoidance of athletic acticity

10%

(169/1702)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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.


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Question COMMENTS (7)

(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? Review Topic

QID:386
FIGURES:
1

Weight of the patient

7%

(34/454)

2

Presence of open physes

70%

(319/454)

3

Gender

1%

(3/454)

4

Location of the lesion within the knee

19%

(88/454)

5

A history of trauma to the affected joint

2%

(8/454)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.


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