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Osteochondral Dissecans Print

Osteochondritis dissecans (OCD) is a condition in which a fragment of subchondral bone and its overlying articular cartilage becomes separate from the underlying bone. If the bone fails to heal, progressive changes occur in the articular cartilage. Figure 1 demonstrates this progression. Initially the cartiledge is firm and appears normal. As the condition progresses the cartiledge becomes soft and separates.

Figure 2 Osteochondritis dissecans of the medial femoral condyle.

 

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 1 Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 2
Figure 1 Figure 2

 

 

The etiologic factors of OCD have been a source of considerable debate for the last 100 years. Theories of etiologic factors included growth disorder, epiphyseal abnormality, endocrine imbalance, familial predisposition, trauma, and avascular necrosis. The most plausible theory supported by the literature implicates direct or indirect trauma as the etiology of OCD. 

Linden studied the incidence of OCD in the city of Malmo, Sweden and found an incidence of 0.5% to .08%. Most lesions occur in the medial femoral condyle.

Figure 3 Distribution of osteochondritis dissecans in the knee.

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 3

Figure 3

 

The usual clinical presentation includes symptoms of pain and possibly catching, popping, or locking. Physical examination reveals various findings of effusion, quadriceps atrophy, joint line tenderness, limited motion, or palpable loose bodies. Occasionally, OCD lesions are found as an incidental finding on routine X-ray examination. 

Diagnostic Imaging

Radiologic examination should include anterior posterior, lateral, and tunnel views.

Figure 4 AP and lateral X-rays of a knee with an OCD in the classic location on the medial femoral condyle.

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 4

Figure 4

 

Magnetic resonance imaging (MRI) has been useful in determining whether the articular cartilage over the fragment is intact. MRI may be the best technique for sequential followup of healing lesions. 

Figure 5 MRI Image of OCD of the knee.

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 5

Figure 5

 

Treatment

Osteochondritis dissecans is a spectrum disease. The treatment depends upon the age of the patient and the degree of deterioration and separation of the fragment. Figure 6 demonstrates different degrees of separation. Patients who present as juveniles with an open growth plate may heal with conservative treatment. As patients reach or exceed skeletal maturity, treatment becomes more aggressive. Patients age 12 or younger may respond to limitation of activity. If the lesion does not heal within six months, more aggressive treatment is indicated. 

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 6

Figure 6

 

Arthroscopy is performed to determine the stability of the lesion. If the lesion is stable, antegrade drilling in the younger patient frequently results in successful healing. (Figure 7) We have reevaluated 25 patients who had this treatment at an average 5 year followup and all of these patients healed and their knees were essentially normal. 

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 7

Figure 7

 

If the knee is arthroscoped and the lesion is unstable then, in addition to drilling to improve blood flow, internal fixation is necessary to provide stability. To stablize the ______ are osteochonral plugs. Stabilization may be performed either antegrade or retrograde depending upon the preference of the surgeon The devices that are commonly used now are bioabsorbable screws in an antegrade fashion or threaded pins from a retrograde approach. If a bone is missing, then bone grafting may be necessary to fill the defect. 

Figure 8 demonstrates arthroscopic retrograde fixation with pins.

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 8

Figure 8

 

Figure 9A Large loose ODC of the medial femoral condyle.

The treatment of displaced fragments depends upon the condition of the fragment. If the fragment has bone and the articular cartilage has not deteriorated, it should be replaced with antegrade or retrograde fixation.

Figure 9B After removal of fibrous tissue and drilling to improve blood flow.

Figure 9C After bone grafting, pins are being inserted for stablization.

Figure  9D After fixation with threaded pin.

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 9A

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 9B

Figure 9A Figure 9B

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 9C

Figure 9C Figure 9D

 

Figure 10 demonstrates fixation with bio-absorbable screws.

Figure 10

 

When the fragment has deteriorated and is irreparable, then the lesion may be treated with autologous cartilage transplantation, osteochondral autograft transfer or osteochondral allograft transfer.

Figure 12A and 12B demonstrate a large, deep lesion.

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 12A Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 12B
Figure 12A Figure 12B

 

Figure 12C shows the lesion after treatment with 3 OATS plugs. It is not uncommon for these lesions to take one year to heal.

Osteochondral Dissecans, Injuries of the Knee, Dr. Allen F. Anderson, Nashville, Orthopaedic Surgery, Sports Medicine, Figure 12C

Figure 12C

 

Paper for Download

You may download the paper Management of Osteochondral Dissecans of the Knee. File size is 1.6MB.

 

 
© Allen F. Anderson, M.D. 2017