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Osteochondritis Dissecans (OCD) Results in the Destruction of Subchondral Bone with Secondary Damage to Overlying Articular Cartilage (1,2)

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Osteochondritis Dissecans (OCD) Results in the Destruction of Subchondral Bone with Secondary Damage to Overlying Articular Cartilage (1,2) Copy Editor: Selvi S Osteochondritis 45 Dissecans Cecilia Pascual-Garrido, Taylor M. Southworth, Mark A. Slabaugh, Neal B. Naveen, Nicole A. Friel, Ben U. Nwachukwu, and Brian J. Cole prohibited. INTRODUCTION is Osteochondritis dissecans (OCD) results in the destruction of subchondral bone with secondary damage to overlying articular cartilage (1,2). The prevalence of this condition is estimated to contentbe between 11.5 and 21 per 100,000 (3,4). OCD is classically divided into juvenile and adult forms based on the patient’s skeletal maturity (1). Juvenile OCD (JOCD) lesions occur in childrenthe and young adolescents with open growth plates. Although adult OCD lesions may arise de ofnovo, they more commonly result from an incompletely healed and previously asymptomatic JOCD lesion (5). JOCD lesions have a better prognosis and higher rates of spontaneous healing with conservative treatment than do adult OCD lesions (6). Adult OCD lesions have a greater propensity for instabil- ity and, once symptomatic, typically follow a clinical course that is progressive and unremitting (7). While lesions most frequently occur on the femoral condyles, they are also found in the elbow, wrist, ankle, and femoral head (8–12). The highest incidence rates in JOCDreproduction are among patients ages 10 and 15 years old, ranking among the most common causes of knee pain and dysfunction in young Fig. 45-1 adults (6,7,13) (Fig. 45-1). The typical presentation of OCD in the knee includes pain and swelling related to activity. Instability is not usually reported, though mechanical symptoms, such as catching and locking, ­usually occur in the presence of a loose body and are frequently the initial presenting symptoms. The patient may walk with an antalgic gait or with Unauthorizedthe leg externally rotated to decrease pressure over the lesion, known as Wilson sign (14). Effusion, decreased range of motion, and quadriceps atrophy are variably present depending upon theInc. severity and duration of the lesion (15). Patients typically have tenderness localized over the lesion. More than 70% of OCD lesions are found in the lateral aspect of the medial femoral condyle (MFC), intersecting the intercondylar notch near the posterior cruciate ligament (PCL).Kluwer, Central lateral condylar lesions account for 15% to 20% and femoral trochlear lesions for <1%. Patellar involvement is uncommon (5%–10%) and, if present, is typically located in the inferior medial area (7). INDICATIONS Wolters Operative treatment2019 for OCD lesions is focused on improving the blood supply to the lesion, restoring the joint© surface, and providing rigid fixation (16). Surgery is indicated both for young patients with detached or unstable lesions as well as for those approaching physeal closure whose lesions have been unresponsive to nonoperative management (1,17). Operative treatment may also be considered in patients who are unable to participate in a prolonged nonoperative course. CopyrightSpecifically, interventions such as drilling or internal fixation are indicated for the symptomatic juvenile patient who has failed a course of 3 to 6 months of nonoperative treatment. However, when the presence of significant mechanical symptoms dominates the clinical presentation, the decision to operate might occur earlier. Drilling is generally limited to young patients with open physes and low-grade lesions, Guhl grades I and II, respectively, that are not grossly unstable with palpation. Higher grade OCD lesions with articular cartilage flaps or loose bodies, Guhl grades III and IV, respectively, are generally not amenable to conservative treatment. Ananthaharan and Randsborg 1 0003628368.INDD 1 10/22/2018 10:17:57 AM 2 PART III Knee OCD lesion Intact articular Partial detachment cartilage No Unstable? Ye s or loose body (Guhl I or II) (Guhl III or IV) prohibited. Open is physes? Drilling Ye s Fragment can be internal fixation repair? Ye s No content the No Conservative Fragment removal treatment Failed? with restorativeof Fragment 3–6 months procedures removal Lesion Lesion No Symptoms 2 <2–3 cm >2–3 cm2 relief? reproduction Microfracture OA graft OATS ACI FIGURE 45-1 Unauthorized Algorithm for surgical treatment of JOCD/OCD. Surgical goals should always try to reestablish the joint Inc. surface and conserve the osteochondral fragment. If not, restorative treatment should be implemented. found that Kluwer,patients with grade III and IV lesions were five times more likely to fail conservative treatment when compared to those with grades I and II lesions (3). Thus, fixation of partially detached lesions or loose bodies is appropriate for large fragments containing sufficient subchon- dral bone to provide union and support of the fixation system. Lower grade lesions, Guhl grades I orWolters II, may also be fixed if conservative treatment has failed or there is clinical suspicion of instabil- ity. Additionally, unstable “trap door” lesions that are partially elevated from the subchondral bed 2019 require fixation (18,19). © Many patients function well despite having OCD lesions and only become symptomatic when the OCD fragment becomes unstable. In these cases, fragment removal is indicated and can lead to symptomatic relief. For example, if the defect is relatively small, from an area with less contact pressure (20), such as the “classic” OCD lesion located near the PCL origin on the “upslope” of the MFC, and is associated with the acute onset of mechanical symptoms in Copyright a skeletally mature adult, fragment removal and observation are indicated. In contrast, com- plaints of “achy discomfort,” effusions unrelated to mechanical symptoms, and weight-bearing pain over the lesion may be indicative of symptoms that are due to the defect itself rather than the unstable or displaced fragment. These lesions are an indication for a cartilage restoration procedure, such as a marrow stimulation technique, osteochondral autograft, osteochondral allograft (OCA), or autologous chondrocyte implantation (ACI). Specifically, microfracture is indicated in patients with a localized cartilage defect (<2–4 cm2). Patients with low demand 0003628368.INDD 2 10/22/2018 10:17:57 AM 45 Osteochondritis Dissecans 3 and bigger lesions can also improve with this technique. The indications and optimal patient population for osteochondral autograft remain narrow. A single plug autograft is preferred for defects smaller than 1 cm2. However, some authors perform mosaicplasty with multiple smaller plugs on defects as large as 4 cm2 with encouraging results (21). Larger OCD lesions (>2 cm2) may be treated with OCA transplantation (22). OCA transplantation provides the ability to resurface larger and deeper defects with mature hyaline cartilage, while addressing the underlying bone deficiency. ACI is ideal for symptomatic, unipolar, well-contained chon- dral and osteochondral defects measuring between 2 and 10 cm2 with bone loss <6 to 8 mm (Fig. 45-1). In contrast to JOCD where nonoperative treatment is usually first line, adult OCD typically requires early surgical intervention (5). Additionally, in cases of chondral separation, surgical results are better than those with nonsurgical treatments (23,24). prohibited. CONTRAINDICATIONS is Surgical decision-making is based on patient age, skeletal maturity, lesion appearance, and clinical symptoms. The ideal goal of conservative treatment is to obtain lesion healing before physeal clo- sure. Stable OCD lesions in young patients have a favorable prognosis when treated initially withcontent nonoperative treatment. A large multicenter review of the European Pediatric Orthopedic theSociety study (509 knees, 318 juvenile, and 191 adult in 452 patients) suggests an improved prognosisof with conservative treatment in young patients with a small lesion (<2 cm2) in the classic location with no signs of dissection or effusion (23). Ananthaharan and Randsborg noted that 78% of grade I and II lesions were successfully treated with conservative management (3). Moreover, spontaneous heal- ing of JOCD lesions has been reported when the lesion is not in the classical location of the lateral aspect of the MFC (25). Traditional nonoperative treatment for JOCD consists of an initialreproduction phase of knee immobiliza - tion with partial weight bearing (4–6 weeks) in those patients in whom no detachment is noted on MRI. Once the patient is pain free, weight bearing as tolerated is permitted and a rehabilitation program emphasizing knee range of motion and low-impact strengthening exercises ensues. If there are radiographic and clinical signs of healing at 3 or 4 months after the initial diagnosis, patients may participate in a gradual return to sports with increasing intensity allowed in the absence of knee symptoms. The likelihood that the lesion will heal withUnauthorized this management is approximately 50% at 10 to 18 months (9). Q1 Neither the literature nor our experience allowsInc. us to definitively determine whether untreated OCD, either with the fragment in situ or following fragment excision, has a more significant likeli- hood of developing into symptomatic degenerative joint disease in the future. For example, Linden performed a long-term retrospective follow-up study of patients with OCD of the femoral condyles with an average follow-up of 33 yearsKluwer, after initial diagnosis (13). It was concluded that while indi- viduals who are older when the osteochondritis manifests, such as those with adult OCD, have an increasing incidence of knee osteoarthritis (OA), JOCD is not
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