osteochondritis dissecans of the knee william r. beach, m.d. michael r. magoline, m.d. orthopaedic...
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Osteochondritis Dissecans of the Knee
William R. Beach, M.D.
Michael R. Magoline, M.D.
Orthopaedic Research of Virginia
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Osteochondritis DissecansDefinition
• Localized condition affecting the articular surface of a joint with separation of a segment of cartilage and subchondral bone
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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
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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%
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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
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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%
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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
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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
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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
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Osteochondritis Dissecans of the KneeClinical Presentation
• Pain and swelling (variable)
• Locking, catching, giving way
• Loose body sensation
• Symptoms related to activity
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Osteochondritis Dissecans of the KneePhysical Examination
• Crepitus– Especially noticeable
in medial compartment
• Effusion• Tenderness
– Early: poorly localized
– Late: point tenderness
• Wilson sign
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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
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Osteochondritis Dissecans of the KneeImaging studies
• Plain films– Well circumscribed
area of sclerotic bone with surrounding lucent line
• Bone Scan• MRI
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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)
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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
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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
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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
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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
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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
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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
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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)
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Osteochondritis Dissecans of the Knee Video Case Presentation
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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