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Updated: Sep 2 2023

Osteochondritis Dissecans

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  • Summary
    • Osteochondritis Dissecans is a pathologic lesion affecting articular cartilage and subchondral bone with variable clinical patterns.
    • Diagnosis may be made radiographically (notch view) but MRI usually required to determine size and stability of lesion, and to document the degree of cartilage injury.
    • Treatment may be nonoperative with restricted weight bearing in children with open physis. Surgical treatment may be indicated in older patients (closed physis), lesions that are unstable and patients who have failed conservative management. 
  • Epidemiology
    • Demographics
      • juvenile form (open physes)
        • occurs at age 10-15 while the physis is still open
      • adult form (skeletal maturity)
    • Anatomic location
      • knee (most common)
        • posterolateral aspect of medial femoral condyle (70% of lesions in knee)
      • capitellum of humerus
      • talus
  • Etiology
    • 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
  • 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
          • acute, 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
  • 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
          • autograft OATS
    • Periosteal patches
  • 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
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