Osteochondritis dissecans of the knee

What Do We Currently Know About Patellofemoral Osteochondritis Dissecans?

OBJECTIVE

Knee osteochondritis dissecans (OCD) is a still poorly understood pathological condition of the articular subchondral bone and its overlying cartilage. Patellofemoral involvement accounts for less than 1% of cases; tibial plateau and multifocal involvement is an even rarer instance. The purpose of this study is to review what is currently known about patellofemoral OCD (PF-OCD) and to present an unusual case of PF-OCD which progressed to become multifocal in an adult female patient.

METHODS

A comprehensive literature search was conducted on PubMed/Medline, Cochrane, Embase, Web of Science, and Scopus databases on September 2021 for all levels of evidence and English language. After duplicate removal, 234 papers pertaining to PF-OCD were retrieved. Thirty-nine studies met inclusion criteria and were included in the review. As an example, a unique case of delamination of patellar cartilage consistent with PF-OCD with progressive involvement of trochlea and both tibial plateau in a 35-year-old woman is also presented.

RESULTS

PF-OCD is a rare localization of knee OCD. Two hundred eighty-eight cases have been reported in the literature to date. Mean age at time of diagnosis was 16 years and the location could also be bilateral and multifocal. The etiology is still debated but traumatic, vascular, and hereditary mechanisms are likely. Management mirrors that of classical OCD.

CONCLUSIONS

PF-OCD is an uncommon cause of anterior knee pain but should be considered even when physeal plates are closed. Current available evidence on treatment is of low quality, based on single case reports or small retrospective case series.

Neglected Pediatric Osteochondral Fracture Dislocation of the Patella

Pediatric osteochondral fracture dislocation of the patella is sometimes difficult to diagnose on the basis of physical examination or plain film radiography. Magnetic resonance imaging plays an important role in its early diagnosis, and early treatment can prevent damage to the articular cartilage as well as decrease the dislocation rate. Currently, many treatment choices have been reported with good results, but there is no consensus on which treatment option may lead to the best outcome. Herein, we describe the case of a 14-year-old girl with neglected osteochondral fracture dislocation of the patella. The outcome was optimal on the basis of a 2-year postoperative follow-up; thus, we believe that fixation with headless screws is a simple and effective method if the fracture fragment is large enough.

Vertical patellar dislocation: A pediatric case report and review of the literature

Vertical patellar dislocations (VPDs) are a rare event, and even more so among pediatric female patients. There have been less than 30 vertical patellar dislocations reported in the literature since the first in 1844. In this type of dislocation, the patella rotates about its vertical axis with the articular surface facing either medially or laterally. The mechanism of injury for a VPD can be broadly divided into two themes: a twisting injury or direct impact to the medial or lateral edge of the patella. We present a 10-year-old girl with a VPD after experiencing a twisting injury when descending a playground slide. The purpose of this study is to present a case report and review of the literature on vertical patella dislocations, including mechanisms of injury and suggested methods of treatment. We aim to provide a comprehensive understanding of the various categories of patella dislocations to alleviate confusion when classifying patellar dislocations. Furthermore, we provide clear suggestions for reduction methods and techniques with regards to vertical patellar dislocations, including a suggested protocol for an irreducible patella.

Mid and long term outcomes after fixation of osteochondritis dissecans

OBJECTIVE

To assess the longitudinal outcomes of osteochondritis dissecans (OCD) fixation and to detect the influencing factor for the results of OCD.

METHODS

22 OCD fixation using bioabsorbable pins were assessed Lysholm score, Tegner activity scale and KOOS4 at preoperative, postoperative short (3.0 years) and mid-long (11.9 years) term.

RESULTS

Postoperative Lysholm score was significantly better than the preoperative time. There was no factor influencing KOOS4 at mid-long term.

CONCLUSION

OCD fixation contributes good results for a long time regardless of skeletal maturity, the size and the severity of OCD.

A Radiographic Healing Classification for Osteochondritis Dissecans of the Knee Provides Good Interobserver Reliability

Background:

Recent studies have examined radiographic factors associated with healing of osteochondritis dissecans (OCD) lesions of the knee. However, there is still no gold standard in determining the healing status of an OCD lesion.

Purpose:

We examined temporally associated patterns of healing to (1) evaluate the practicality of a classification system and (2) elucidate any associations between healing pattern and patient age, sex, lesion location, treatment type, and physeal patency.

Study Design:

Cohort study (diagnosis); Level of evidence, 3.

Methods:

We retrospectively screened 489 patients from 2006 to 2010 for a total of 41 consecutive knee OCD lesions that met inclusion criteria, including at least 3 consecutive radiographic series (mean patient age, 12.8 years; range, 7.8-17.1 years; mean follow-up, 75.1 weeks). Radiographs were arranged in sequential order for ratings by 2 orthopaedic sports medicine specialists. Healing patterns were rated as boundary resolution, increasing radiodensity of progeny fragment, combined, or not applicable. Repeat ratings were conducted 3 weeks later.

Results:

Patients were most commonly adolescent males aged 13 to 17 years, with a medial femoral condyle lesion that was treated operatively. Interobserver reliability of the healing classification was good (intraclass correlation coefficient, 0.67; 95% CI, 0.55-0.79). Boundary and radiodensity healing was observed for all ages, sexes, lesion locations, treatment types, and physeal patency states.

Conclusion:

This study evaluated a valuable radiographic paradigm—boundary resolution, increasing radiodensity of progeny fragment, or combined—for assessment of OCD lesion healing. The proposed system of healing classification demonstrated good inter- and intraobserver reliability. Healing patterns were not significantly associated with any particular age, sex, lesion location, treatment type, or physeal patency status. The development of a classification system for knee OCD may eventually improve clinical assessment and management of OCD lesions.

All-Arthroscopic Suture Fixation of Patellar Osteochondritis Dissecans

Osteochondritis dissecans of the knee, despite its cause, is characterized by the impairment of the subchondral bone. Failure of its spontaneous healing makes surgical fixation often necessary. The patella is less affected than other locations in the knee. Its surgical treatment remains a challenge due to the thickness of the lesion and the complex approach of the retropatellar cartilage. Arthroscopy has the theoretical advantage to avoid a possible arthrotomy; however, the retrograde application of fixation materials does not guarantee good fragment compression and may lead to cartilage penetration and damage. The purpose of this Technical Note is to present a reproducible, full arthroscopic suture fixation technique for patellar osteochondritis dissecans lesions. By using the posterior cruciate tibial drill guide, absorbable sutures are passed through the center and the peripheral borders of the lesion resulting in a "spider-parachute-type" fixation with direct fragment compression.

Femoral osteochondritis of the knee: prognostic value of the mechanical axis

PURPOSE

Femoral osteochondritis dissecans (OCD) is a disorder of unknown aetiology and variable prognosis that causes knee pain. In this paper, the authors study the impact of lower limb malalignment on the development and prognosis of OCD.

METHODS

After anteroposterior (AP) and lateral radiograph and MRI of the knee, 53 cases of OCD were diagnosed. All patients were studied by standing full-length AP radiograph of the lower extremities in order to analyse the relationship between the femorotibial and mechanical axis and the location and stability of the osteochondritis.

RESULTS

The OCD lesion was located in the medial condyle (zone 2) in 75.5% of cases (40 cases). The lateral condyle was affected in 24.5% of cases (zone 4 in nine cases and zone 5 in four cases). The femorotibial angle (anatomical axis) was normally aligned in 68% of cases. A valgus deformity was observed in 9.5% of cases and a varus deformity in 22.5%. The mechanical axis of the limb appeared normal in only 32% of cases, with medial deviation in 53%, and lateral deviation in 15% of cases. When the OCD lesion was located in the medial condyle (40 cases), the mechanical axis also crossed the knee through the medial zone in 28 cases. When the OCD lesion was located in the lateral condyle (13 cases), the mechanical axis crossed the knee through zones 1 or 2 in four cases. In stable OCD, the mechanical axis and location of the lesion coincided in 19 of 36 cases (52%), compared with 16 of 17 cases (94%) in unstable OCD.

CONCLUSIONS

There is a high correlation between OCD location and lower limb mechanical axis deviation. The convergence of the mechanical axis with the location of the OCD lesion may be considered an associated factor in fragment instability. This convergence is more common in unstable OCD.

Drilling juvenile osteochondritis dissecans: retro- or transarticular?

BACKGROUND

Early diagnosis and successful treatment of juvenile osteochondritis dissecans (JOCD) is essential in preventing articular degeneration at a young age. Surgical treatment of stable JOCD lesions failing nonoperative treatment involves retroarticular or transarticular drilling to induce revascularization and healing. Multiple case series report high healing rates and infrequent complications for both retroarticular and transarticular drilling modalities; however, it is unclear from these individual reports whether one mode of drilling provides higher healing rates.

QUESTIONS/PURPOSES

We asked whether transarticular or retroarticular drilling of stable JOCD lesions results in differing patient-oriented outcomes, rates of radiographic healing, time to radiographic healing, and complication rates.

METHODS

We systematically reviewed the short-term clinical outcomes of retroarticular and transarticular drilling of stable OCD lesions. PubMed and additional sources identified 65 studies; 12 studies met inclusion criteria.

RESULTS

Heterogeneity and quality of studies limited review to qualitative analysis. No clear differences were seen in patient-oriented outcomes after treatment with either drilling modality. Radiographic healing for JOCD lesions drilled retroarticularly occurred in 96 of 111 (86%) lesions in an average of 5.6 months. Transarticular drilling of JOCD lesions resulted in 86 of 94 (91%) lesions healing by radiography in an average of 4.5 months. No complications were reported for either drilling modality.

CONCLUSIONS

Retroarticular and transarticular drilling of stable lesions results in comparable short-term patient-oriented outcomes and radiographic healing. Further high-quality comparative studies are required to adequately compare drilling modalities, clearly define radiographic healing, and patient-oriented outcomes after nonoperative treatment.

Oligo[poly(ethylene glycol)fumarate] hydrogel enhances osteochondral repair in porcine femoral condyle defects

BACKGROUND

Management of osteochondritis dissecans remains a challenge. Use of oligo[poly(ethylene glycol)fumarate] (OPF) hydrogel scaffold alone has been reported in osteochondral defect repair in small animal models. However, preclinical evaluation of usage of this scaffold alone as a treatment strategy is limited.

QUESTIONS/PURPOSES

We therefore (1) determined in vitro pore size and mechanical stiffness of freeze-dried and rehydrated freeze-dried OPF hydrogels, respectively; (2) assessed in vivo gross defect filling percentage and histologic findings in defects implanted with rehydrated freeze-dried hydrogels for 2 and 4 months in a porcine model; (3) analyzed highly magnified histologic sections for different types of cartilage repair tissues, subchondral bone, and scaffold; and (4) assessed neotissue filling percentage, cartilage phenotype, and Wakitani scores.

METHODS

We measured pore size of freeze-dried OPF hydrogel scaffolds and mechanical stiffness of fresh and rehydrated forms. Twenty-four osteochondral defects from 12 eight-month-old micropigs were equally divided into scaffold and control (no scaffold) groups. Gross and histologic examination, one-way ANOVA, and one-way Mann-Whitney U test were performed at 2 and 4 months postoperatively.

RESULTS

Pore sizes ranged from 20 to 433 μm in diameter. Rehydrated freeze-dried scaffolds had mechanical stiffness of 1 MPa. The scaffold itself increased percentage of neotissue filling at both 2 and 4 months to 58% and 54%, respectively, with hyaline cartilage making up 39% of neotissue at 4 months.

CONCLUSIONS

Rehydrated freeze-dried OPF hydrogel can enhance formation of hyaline-fibrocartilaginous mixed repair tissue of osteochondral defects in a porcine model.

CLINICAL RELEVANCE

Rehydrated freeze-dried OPF hydrogel alone implanted into cartilage defects is insufficient to generate a homogeneously hyaline cartilage repair tissue, but its spacer effect can be enhanced by other tissue-regenerating mediators.

Surgical treatment options for osteochondritis dissecans of the knee

Osteochondritis dissecans of the knee is identified with increasing frequency in the young adult patient. Left untreated, osteochondritis dissecans can lead to the development of osteoarthritis at an early age, resulting in progressive pain and disability. Treatment of osteochondritis dissecans may include nonoperative or operative intervention. Surgical treatment is indicated mainly by lesion stability, physeal closure, and clinical symptoms. Reestablishing the joint surface, maximizing the osteochondral biologic environment, achieving rigid fixation, and ensuring early motion are paramount to fragment preservation. In cases where the fragment is not amenable to preservation, the treatment may include complex reconstruction procedures, such as marrow stimulation, osteochondral autograft, fresh osteochondral allograft, and autologous chondrocyte implantation. Treatment goals include pain relief, restoration of function, and the prevention of secondary osteoarthritis.

OSTEOCHONDRITIS DISSECANS OF THE KNEE: DIAGNOSIS AND TREATMENT

Osteochondritis dissecans (OCD) is a pathological process affecting the subchondral bone of the knee in children and adolescents with open growth plates (juvenile OCD) and young adults with closed growth plates (adult OCD). It may lead to secondary effects on joint cartilage, such as pain, edema, possible formation of free bodies and mechanical symptoms, including joint locking. OCD may lead to degenerative changes may develop if left untreated. This article presents a review and update on this problem, with special emphasis on diagnosis and treatment. The latter may include either conservative methods, which show more predictable results for juvenile OCD, or various surgical methods, which include reparative techniques like isolated removal of the fragment, bone drilling and fixation of the osteochondral fragments, and restorative techniques like microfractures, autologous osteochondral transplantation (mosaicplasty), autologous chondrocyte implantation and fresh osteochondral allograft, depending on lesion stability, lesion viability, skeletal maturity and OCD process location. Recent assessments on the results from several types of treatment have shown that there is a lack of studies with reliable levels of evidence and have suggested that further multicenter prospective randomized and controlled studies on management of this disease should be conducted.

Meniscoplasty for stable osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus: a case report

INTRODUCTION

Osteochondritis dissecans of the lateral femoral condyle is relatively rare, and it is reported to often be combined with a discoid lateral meniscus. Given the potential for healing, conservative management is indicated for stable osteochondritis dissecans in patients who are skeletally immature. However, patients with osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus often have persistent symptoms despite conservative management.

CASE PRESENTATION

We present the case of a seven-year-old Korean girl who had osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus, which healed after meniscoplasty for the symptomatic lateral discoid meniscus without surgical intervention for the osteochondritis dissecans. In addition, healing of the osteochondritis dissecans lesion was confirmed by an MRI scan five months after the operation.

CONCLUSIONS

Meniscoplasty can be recommended for symptomatic stable juvenile osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus when conservative treatment fails.

Meniscoplasty for stable osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus: a case report

Introduction

Osteochondritis dissecans of the lateral femoral condyle is relatively rare, and it is reported to often be combined with a discoid lateral meniscus. Given the potential for healing, conservative management is indicated for stable osteochondritis dissecans in patients who are skeletally immature. However, patients with osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus often have persistent symptoms despite conservative management.

Case presentation

We present the case of a seven-year-old Korean girl who had osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus, which healed after meniscoplasty for the symptomatic lateral discoid meniscus without surgical intervention for the osteochondritis dissecans. In addition, healing of the osteochondritis dissecans lesion was confirmed by an MRI scan five months after the operation.

Conclusions

Meniscoplasty can be recommended for symptomatic stable juvenile osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus when conservative treatment fails.

Does operative fixation of an osteochondritis dissecans loose body result in healing and long-term maintenance of knee function?

BACKGROUND

Osteochondritis dissecans (OCD) can progress to loose body formation, resulting in a grade IV defect. The decision to fix versus excise the loose body is controversial. Published operative fixation outcomes are small case series with short follow-up.

HYPOTHESIS

Operative fixation (ORIF) of the loose body into the grade IV defect will heal and approximate "normal" knee function at long-term follow-up.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Twelve patients were identified who underwent ORIF of a knee OCD loose body into the grade IV osteochondral defects ranging in size from 2.0 to 8.0 cm(2) (mean, 3.5 cm(2)). After 12 weeks, hardware was removed, and healing was assessed. Long-term outcomes were assessed with a Knee injury and Osteoarthritis Outcome Score (KOOS) and a Marx activity score.

RESULTS

Arthroscopy for screw removal revealed stable healing in 92% (11 of 12) of patients. No patients required subsequent surgery for a loose body. At an average of 9.2 years' follow-up (range, 3.8-15.8 years), 83% (10 of 12) of patients completed the KOOS. The KOOS subscale scores for pain (mean, 87.8; range, 67-100), other symptoms (mean, 81.8; range, 61-96), function in activities of daily living (mean, 93.1; range, 72-100), and sports and recreation function (mean, 74.0; range, 40-100) were not significantly lower than those of published age-matched controls. However the KOOS subscale score for knee-related quality of life (mean, 61.9; range, 31-88) was significantly lower (P = .003).

CONCLUSION

Operative fixation of grade IV OCD loose bodies results in stable fixation. At an average 9 years after surgery, patients did not have symptoms of osteoarthritis pain and had normal function in activities of daily life. However, patients reported significantly lower knee-related quality of life. Operative fixation of OCD loose bodies is a better alternative to lesion excision.

The healing potential of stable juvenile osteochondritis dissecans knee lesions

BACKGROUND

The purpose of the present study was to determine if patient age, lesion size, lesion location, presenting knee symptoms, and sex predict the healing status after six months of a standard protocol of nonoperative treatment for stable juvenile osteochondritis dissecans of the knee.

METHODS

Forty-two skeletally immature patients (forty-seven knees) who presented with a stable osteochondritis dissecans lesion were included in the present study. All patients were managed with temporary immobilization followed by knee bracing and activity restriction. The primary outcome measure of progressive lesion reossification was determined from serial radiographs every six weeks, for up to six months of nonoperative treatment. A multivariable logistic regression model was used to determine potential predictors of healing status from the listed independent variables.

RESULTS

After six months of nonoperative treatment, sixteen (34%) of forty-seven stable lesions had failed to progress toward healing. The mean surface area (and standard deviation) of the lesions that showed progression toward healing (208.7 +/- 135.4 mm(2)) was significantly smaller than that of the lesions that failed to show progression toward healing (288.0 +/- 102.6 mm(2)) (p = 0.05). A logistic regression model that included patient age, normalized lesion size (relative to the femoral condyle), and presenting symptoms (giving-way, swelling, locking, or clicking) was predictive of healing status. Age was not a significant contributor to the predictive model (p = 0.25).

CONCLUSIONS

In two-thirds of immature patients, six months of nonoperative treatment that includes activity modification and immobilization results in progressive healing of stable osteochondritis dissecans lesions. Lesions with an increased size and associated swelling and/or mechanical symptoms at presentation are less likely to heal.

[Treatment of osteochondritis dissecans of the knee joint]

Osteochondritis dissecans (OD) is a lesion of the subchondral bone which can result in sequestration of the osteochondral lesion. It is categorized into 4 stages, and juvenile and adult forms depending on the distal femoral physis maturity. Prognosis and treatment depends on age and stage. Prognosis is favorable in stable lesions (stage I and II) at typical location (medial femoral condyle) in a child with open physes. Therefore non-operative treatment is indicated. If there is no response to non-operative treatment drilling to create channels for potential revascularization can be done. In unstable lesions (stage III and IV) operative treatment is necessary. Long-term results after excision of the fragment with or without drilling of the defect site are poor. Therefore refixation of an intact osteochondral fragment or biologic reconstruction should be tried.

Joint disorder; a contributory cause to reproductive failure in beef bulls?

The lame sire, unsound for breeding, can cause substantial economic loss due to reduced pregnancies in the beef-producing herd. To test the hypothesis that joint disorder is a possible cause of infertility in beef sires, right and left hind limb bones from 34 beef sires were examined postmortem to identify lesions in the femorotibial, femoropatellar (stifle), tarsocrural, talocalcaneus, and proximal intertarsal (tarsal) joints. The bulls were slaughtered during or after the breeding season due to poor fertility results. Aliquots of the cauda epididymal contents taken postmortem from 26 bulls were used for sperm morphology evaluation. As a control, hind limbs (but no semen samples) from 11 beef bulls with good fertility results were included. Almost all infertile bulls (30/34) had lesions in at least one joint. Twenty-eight bulls (28/30, 93%) had lesions in the stifle joint, and 24 (24/28, 86%) of these were bilateral. Fourteen bulls (14/30, 47%) had lesions in the tarsal joint, and 10 (10/14, 71%) of these were bilateral. Four bulls (4/34, 12%) had no lesions, three bulls (3/34, 9%) had mild osteoarthritis (OA), 5 (5/34, 15%) moderate OA, 17 (17/34, 50%) severe OA and 5 (5/34, 15%) deformed OA. Almost all OA lesions (97%) were characterized as lesions secondary to osteochondrosis dissecans. All the bulls with satisfactory sperm morphology (n = 12/34) had joint lesions, with mostly severe or deformed bilateral lesions (83%). Consequently, the most likely cause of infertility in these 12 bulls was joint disease. Almost all control bulls (10/11) had OA lesions, but most of them were graded as mild (55%) or moderate (36%). None of the control bulls had severe lesions or deformed OA. We suggest that joint lesions should be taken into consideration as a contributory cause of reproductive failure in beef sires without symptoms of lameness.