Osteochondritis Dissecans of the Knee William R. Beach, M.D. Michael R. Magoline, M.D. Orthopaedic...
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Transcript of Osteochondritis Dissecans of the Knee William R. Beach, M.D. Michael R. Magoline, M.D. Orthopaedic...
Osteochondritis Dissecans of the Knee
William R. Beach, M.D.
Michael R. Magoline, M.D.
Orthopaedic Research of Virginia
Osteochondritis DissecansDefinition
• Localized condition affecting the articular surface of a joint with separation of a segment of cartilage and subchondral bone
Osteochondritis DissecansHistory
• 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 DissecansJoints 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 KneeEpidemiology
• 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 KneeSites of involvement
• Most common: Lateral aspect of medial femoral condyle
• Weightbearing surfaces of medial and lateral femoral condyles also affected
Patella >1%Patella > 1%
Osteochondritis Dissecans of the KneeEtiology
• 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 KneeAssociated Conditions
• Endocrinopathies• Ligamentous laxity• Genu valgum• Carpal tunnel
syndrome• Patellar malalignment
• Sinding-Larsen-Johanssen disease
• Osgood-Schlatter disease
• Sports participation starting at a young age
Osteochondritis Dissecans of the KneeClassification (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 KneeClinical Presentation
• Pain and swelling (variable)
• Locking, catching, giving way
• Loose body sensation
• Symptoms related to activity
Osteochondritis Dissecans of the KneePhysical Examination
• Crepitus– Especially noticeable
in medial compartment
• Effusion• Tenderness
– Early: poorly localized
– Late: point tenderness
• Wilson sign
Osteochondritis Dissecans of the KneeWilson 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 KneeImaging studies
• Plain films– Well circumscribed
area of sclerotic bone with surrounding lucent line
• Bone Scan• MRI
Osteochondritis Dissecans of the KneeBone 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 KneeMRI
• 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 KneeTreatment: 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