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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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