Osteochondritis Dissecans of the Knee

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					Osteochondritis Dissecans of the Knee

          William R. Beach, M.D.
         Michael R. Magoline, M.D.
      Orthopaedic Research of Virginia
              Osteochondritis Dissecans
                     Definition

• Localized condition
  affecting the articular
  surface of a joint with
  separation of a segment
  of cartilage and
  subchondral bone
              Osteochondritis Dissecans
                      History
• Pare (1840) described
  removal of loose bodies
  from the knee
• Paget (1870) described a
  “quiet necrosis”
• Konig (1888) coined
  “osteochondritis
  dissecans” from latin
  “dissec”, to separate
              Osteochondritis Dissecans
                   Joints involved

• Knee by far the most
  common joint involved
  (75% of all OCD lesions)
  with the ankle, elbow,
  wrist and other joints
  accounting for the
  remaining 25%
        Osteochondritis Dissecans of the Knee
                  Epidemiology
• Two forms
   – Juvenile (open physes,
     better prognosis)
   – Adult (closed physes,
     poorer prognosis)
• Males affected 2-3 times as
  often as females
• Rarely occurs in patients
  <10 or >50 years of age
• Typically seen in young
  athletic males
       Osteochondritis Dissecans of the Knee
               Sites of involvement


• Most common: Lateral           Patella > 1%
                                 Patella >1%


  aspect of medial femoral
  condyle
• Weightbearing surfaces of
  medial and lateral femoral
  condyles also affected
       Osteochondritis Dissecans of the Knee
                     Etiology
• Trauma/Ischemia
  – Impingement of tibial
    spine on femur
  – Repetitive stress injury to
    subchondral bone leading
    to vascular compromise
• Abnormal ossification
• Genetic
  – Rule out multiple
    epiphyseal dysplasia
         Osteochondritis Dissecans of the Knee
                Associated Conditions
•   Endocrinopathies         • Sinding-Larsen-Johanssen
•   Ligamentous laxity         disease
•   Genu valgum              • Osgood-Schlatter disease
•   Carpal tunnel syndrome   • Sports participation
•   Patellar malalignment      starting at a young age
        Osteochondritis Dissecans of the Knee
         Classification (Clanton and DeLee)

•   Grade I: Depressed osteochondral fracture
•   Grade II: Partially detached fragment
•   Grade III: Detached fragment, nondisplaced
•   Grade IV: Loose body
        Osteochondritis Dissecans of the Knee
                Clinical Presentation

•   Pain and swelling (variable)
•   Locking, catching, giving way
•   Loose body sensation
•   Symptoms related to activity
       Osteochondritis Dissecans of the Knee
              Physical Examination
• Crepitus
  – Especially noticeable in
    medial compartment
• Effusion
• Tenderness
  – Early: poorly localized
  – Late: point tenderness
• Wilson sign
      Osteochondritis Dissecans of the Knee
                  Wilson sign

• Extend knee from 90 degrees of flexion with
  tibia internally rotated
  – Positive: pain at 30 degrees of flexion relieved
    by external rotation of tibia
• Pain is due to impingement of tibial spine
  against OCD lesion
       Osteochondritis Dissecans of the Knee
                 Imaging studies

• Plain films
   – Well circumscribed area of
     sclerotic bone with
     surrounding lucent line
• Bone Scan
• MRI
         Osteochondritis Dissecans of the Knee
                      Bone Scan
• Sensitive for osteoblastic
  activity
   – Determines potential for
     repair
• Stages (Cahill & Berg)
   – I: x-ray +, bone scan –
   – II: x-ray +, bone scan +
   – III: bone scan + with
     increased uptake of entire
     femoral condyle
   – IV: increased uptake in
     ipsilateral tibial plateau
     (suggests increase stress
     transfer across joint)
        Osteochondritis Dissecans of the Knee
                        MRI
• Visualizes loose bodies,
  degree of displacement of
  lesion
• More sensitive than plain
  films
   – Better correlation with
     arthroscopic findings
• Distinguishes grade II vs.
  grade III lesions
         Osteochondritis Dissecans of the Knee
       Treatment: Juvenile Form (open growth plates)

• Goal: To obtain healing of the
  lesion before physeal closure
• Nondisplaced lesions
  generally heal with
  conservative management
   – Protected weightbearing to an
     activity level where knee is
     asymptomatic
   – Cessation of sports activities
   – Casting/bracing usually not
     necessary
       Osteochondritis Dissecans of the Knee
      Treatment: Juvenile Form (open growth plates)

• Displaced lesions generally require surgical
  intervention
  – Occurred in 34% of lesions in one series (Cahill)
• Excise fragment if in nonweightbearing zone
• Reduce and fix lesion if large and in weightbearing
  zone
  – Goal: Restore congruity of joint surface
        Osteochondritis Dissecans of the Knee
       Treatment: Adult Form (Closed growth plates)

• Lesions rarely heal with nonoperative treatment
• Progression may lead to secondary degenerative
  arthritis
• Surgical Goals
  –   Restore congruity of joint surface
  –   Enhance blood supply to fragment
  –   Rigidly fix unstable fragments
  –   Early motion with protected weightbearing
      Osteochondritis Dissecans of the Knee
      Treatment: Adult Form (Closed growth plates)

• Surgical Options
  – Drilling
  – Arthroscopic or open
    reduction and fixation
    (+/- bone graft)
  – Reconstruction with
    allograft or ACI
          Osteochondritis Dissecans of the Knee
               Surgical Treatment: Adult Form
• Articular surface intact (nondisplaced lesion)
   – Retrograde drilling under arthroscopic guidance
        • Stimulates vascular response/promotes healing
• Articular surface disrupted (displaced fragment)
   –   Drill/curettage base of lesion
   –   Replace fragment in crater
   –   Fix fragment as anatomic as possible
   –   Add bone graft if necessary to restore articular congruity
      Osteochondritis Dissecans of the Knee
          Surgical Treatment: Adult Form

• Excision of fragment
  – Reserved for smaller fragments or lesions that cannot
    be reconstructed
• Newer techniques of reconstruction
  – Osteochondral allografts
  – Autogenous osteochondral grafts
  – Autologous cartilage implantation (Carticel)
Osteochondritis Dissecans of the Knee
        Video Case Presentation
        Osteochondritis Dissecans of the Knee
                            Summary

• Juvenile and adult OCD lesions are frequently encountered by
  orthopaedic surgeons
   – Knee most common site involved
• Lesion is most commonly encountered in an athletically
  active young male
• Pathology is thought to be due to repetitive stress injury to
  subchondral bone
• 50% of juvenile OCD cases will respond to conservative
  management
• Goals of surgical management are to restore normal joint
  congruity and promote healing of the lesion

				
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posted:5/7/2011
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