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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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(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

3%

(61/2358)

2

Arthroscopic open reduction and internal fixation

7%

(169/2358)

3

Arthroscopic microfracture drilling

4%

(91/2358)

4

Non-weight bearing for 6-8 weeks

76%

(1789/2358)

5

Full weight bearing with avoidance of athletic acticity

10%

(241/2358)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(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

5%

(79/1453)

2

Activity modification

82%

(1193/1453)

3

Antegrade drilling

3%

(39/1453)

4

Arthroscopic reduction and fixation

6%

(91/1453)

5

Arthroscopic excision

3%

(45/1453)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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

6%

(58/1040)

2

Presence of open physes

76%

(793/1040)

3

Gender

1%

(8/1040)

4

Location of the lesion within the knee

15%

(161/1040)

5

A history of trauma to the affected joint

2%

(17/1040)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

(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

72%

(3007/4177)

2

Lateral aspect of the lateral femoral condyle

3%

(120/4177)

3

Medial aspect of the lateral femoral condyle

23%

(978/4177)

4

Medial facet of the patella

1%

(31/4177)

5

Lateral facet of the patella

1%

(26/4177)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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

81%

(1334/1654)

2

Location in the knee

11%

(186/1654)

3

High signal behind the lesion on MRI

2%

(30/1654)

4

Articular cartilage thickness

4%

(64/1654)

5

Body mass index

2%

(36/1654)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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