Osteochondritis Dissecans

By admin On Oct 3, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Susan Park

Basics

Description

Osteochondritis dissecans (OCD) is an acquired defect in the articular cartilage and subchondral bone.
It is classified into juvenile and adult forms, depending on growth plate status.
It often affects the femoral condyles (most common: posterolateral portion of medial condyle), talar dome, and humeral capitellum but can occur in all large joints.

Epidemiology

Incidence estimated to be 15–30/100,000 persons
Predominant gender: Male > Female (5:3).
Occurs most commonly in ages 10–20 yrs but can occur from 5–50 yrs of age

Risk Factors

Repetitive microtrauma or overuse
Familial predisposition
Endocrine abnormalities
Anomalies of ossification
Impaired blood supply
OCD in 1 joint is risk factor for contralateral involvement; 20–30% of patients with OCD of the knee have bilateral involvement.
Sports involving jumping, pivoting, cutting movements
Throwing sports and gymnastics are specific risk factors for OCD of the elbow.

General Prevention

Learning proper mechanics of sports/activities
Strength and stability training

Etiology

Repeated microtrauma may lead to microfractures, which may cause some focal ischemia and may result in alteration of growth.
May lead to cartilage separation and fragmentation

Diagnosis

MRI staging classification:

Stage I: Subchondral lesion of low signal intensity (subchondral compression fracture); stable
Stage II: Hypointense rim on images indicating demarcation but not separation of lesion (osteochondral fragment attached by osseous bridge); stable
Stage III: High signal intensity and underlying cystic changes indicative of instability (detached nondisplaced fragment); unstable
Stage IV: Partial or complete dislocation of osteochondral fragment into the joint space (displaced fragment, loose body); unstable

History

Insidious onset of symptoms
Preceding injury to joint surface seen in <50% of patients
Stiffness after periods of rest
If symptoms in knee, may have pain going up and down stairs or hills

Physical Exam

Signs and symptoms:
- Vague joint pain, aching
- Locking
- Restricted range of motion (ROM)
- Sense of giving way or weakening
- Pain with activity or weight bearing
Physical examination:
- Effusion and/or crepitus may be present.
- Decreased or painful ROM
- Poorly localized joint-line tenderness
- Point of maximal tenderness
- Mild antalgic gait
- Ipsilateral quad atrophy if symptom in knee

Diagnostic Tests & Interpretation

Imaging

X-ray is standard for diagnosis. For knee, obtain anteroposterior (AP), lateral, and tunnel views.
Bone scan occasionally is useful for diagnosis if onset is acute and x-rays are negative; may help to predict healing if physis is open.
US is unreliable.
CT scan can be used.
MRI is “gold standard” for staging after diagnosis; also good for assessment of loose body; may help to predict prognosis of nonoperative management.

Differential Diagnosis

Knee:
- Meniscal or ligamentous injury
- Tendinitis
- Patellofemoral pain syndrome
- Osteoarthritis
- Posttraumatic osteochondral defect
- Spontaneous osteonecrosis of the knee
- Crystal-induced arthropathies
Elbow:
- Panner's disease
- Ligament sprains
- Fractures
- Posttraumatic asteochondral defect, “loose body”
Ankle:
- DJD
- Ligament sprains
- Fractures
- Arthropathies
- Posttraumatic osteochondral defect, “loose body”

P.427

Treatment

Long-term treatment
Acute treatment
Immobilization:
- Stage I OCD is treated nonoperatively with either activity restriction or immobilization. Phase I: Weight bearing is restricted for 6–8 wks. Phase II: If repeat radiographs are stable and patient is pain-free, may proceed to weight bearing as tolerated and physical therapy for ROM. Phase III: If radiographic and clinic signs of healing at 3–4 mos after initial diagnosis, may slowly initiate activities of running, jumping, and cutting.
- Stage II OCD is treated nonoperatively in juveniles with open joint physis. Treatment of adults is controversial but usually requires surgery and may depend on the size of the lesion.
- Stage III–IV patients and those who fail nonoperative therapy should be referred for surgical management.

Additional Treatment

Additional Therapies

Early recognition of condition is important. If not treated, it can lead to degenerative osteoarthritis.
Prognosis depends on growth plate status. Children with open physis should be considered for nonoperative management if lesion is stable.
Progression of symptoms to joint stiffness or locking necessitates arthroscopy to evaluate and treat for possible loose bodies.
NSAIDs are useful adjunctive therapy.
Rehabilitation:
- Physical therapy may be initiated for conservatively managed patients. Stretching, ROM exercises, conditioning exercises, and quadriceps strengthening are beneficial.
- Postoperative physical therapy can be tailored to the procedure.

Surgery/Other Procedures

Patients with larger lesions, greater skeletal maturity, and high signal on MRI likely will do better with surgery.
Arthroscopy has better outcomes than open procedures.
Comparing excision, curettage, and drilling, the highest success rates were seen when all 3 therapies were used together.
Surgical procedures may also include pinning and grafting.

Ongoing Care

Follow-Up Recommendations

Orthopedic referral is indicated for all patients with unstable OCD and for those who fail conservative treatment.

Additional Reading

Bohndorf K. Osteochondritis dissecans: a review and new MRI classification. Eur Radiol. 1998;8:103–112.

Ganley TJ, Flynn JM. Osteochondritis dessicans of knee. The pediatric and adolescent knee. 2006;273–293.

Hixon AL, Gibbs LM. Osteochondritis dissecans: a diagnosis not to miss. Am Fam Physician. 2000;61:151–156, 158.

Kocher MS, Tucker R, Ganley TJ, et al. Management of osteochondritis dissecans of the knee: current concepts review. Am J Sports Med. 2006;34:1181–1191.

Stäbler A, Glaser C, Reiser M. Musculoskeletal MR: knee. Eur Radiol. 2000;10:230–241.

Tol JL, Struijs PA, Bossuyt PM, et al. Treatment strategies in osteochondral defects of the talar dome: a systematic review. Foot Ankle Int. 2000;21:119–126.

Codes

ICD9

732.7 Osteochondritis dissecans

Clinical Pearls

Patients with stable lesions require a break from competitive sports for at least 6–8 wks.
Patients must be pain-free before return to sports.
MRI and/or bone scan may be useful to evaluate healing.
Depending on the severity of the lesion and treatment, healing can take up to 10–18 mos.
The juvenile form of OCD has a good potential for full recovery if treated appropriately but still may lead to early degenerative joint disease.
Adult forms tend to be more complicated and often lead to early degenerative joint disease.