Management of Osteochondritis Dissecans of the Knee

Abstract

Osteochondritis dissecans of the knee is being seen with increased frequency in pediatric and young adult athletes and is thought to be, in part, owing to earlier and increasingly competitive sports participation. Despite much speculation, the cause of both juvenile and adult osteochondritis dissecans remains unclear. Early recognition is essential. Whereas adult osteochondritis dissecans lesions have a greater propensity to instability, juvenile osteochondritis dissecans lesions are typically stable, and those with an intact articular surface have a potential to heal with nonoperative treatment through cessation of repetitive impact loading. The value of adjunctive immobilization, protected weightbearing, and unloader bracing has not been established. Skeletally immature patients with stable lesions that have not healed with nonoperative treatment should have consideration given to arthroscopic drilling to promote healing before the lesion progresses and requires more involved treatment with a less optimistic prognosis. Magnetic resonance imaging may allow early prediction of lesion healing potential. The majority of adult osteochondritis dissecans cases as well as those skeletally immature patients with unstable lesions and secondary loose bodies require fixation and possible bone grafting. Many unstable lesions will heal after stabilization, but long-term prognosis is not clear. Chronic loose fragments can be difficult to fix and have poor healing potential. Results of excision of large lesions from weightbearing zones are poor. Chondral resurfacing techniques have limited long-term data for cases of osteochondritis dissecans in skeletally immature patients.

A Review of Knowledge in Osteochondritis Dissecans: 123 Years of Minimal Evolution from König to the ROCK Study Group

“…Surgery is generally indicated for unstable OCD lesions and stable OCD lesions that fail nonoperative treatment [12,40]. The variability in surgeon preference for surgical treatment is reflected by the variability in surgical methods.…”

“…In the past, many surgeons suggested skeletally immature patients (juvenile OCD) had a better prognosis, inconsistently defined as either radiographic healing or resolution of pain [5,9,14,40,47,58]. However, despite differences in prognosis based on age, many of these authors believed juvenile and adult-onset OCD reflected the same pathologic processes but merely discovered at different points of skeletal maturity.…”

“…unrelated to an acute osteochondral fracture of normal cartilage [14,40]. This understanding of the end point of the disease process has led to many etiologies of OCD being postulated (particularly concerning the knee), including trauma [1,3], inflammation [41,70], genetics [58], vascular abnormalities [47,48], and constitutional factors [9]; but, again, the cause remains unknown.…”

Treatment of a Lateral Tibial Plateau Osteochondritis Dissecans Lesion With Subchondral Injection of Calcium Phosphate

“…1 Although the etiology is not clearly understood, OCD is characterized by avascular subchondral bone with or without separation and instability of the overlying articular cartilage. 2,3 OCD may affect any joint, but the knee is the most common location, with most lesions affecting the medial femoral condyle, 3 although lateral condyle 4 and patellar lesions 5 have also been reported.…”

Oligo[poly(ethylene glycol)fumarate] Hydrogel Enhances Osteochondral Repair in Porcine Femoral Condyle Defects

“…Juvenile OCD lesions with an intact articular surface have a potential for healing through cessation of repetitive impact loading and have a higher potential of healing in children with open physis [2,5,33,46]. However, surgery is considered with detached lesions in patients who do not have pain relief from nonoperative treatment [5,16,59].…”