para>Although still idiopathic, the mean age in JOCD is decreasing, and the prevalence in girls is increasing with changes in childhood sports participation (1). � �
GENERAL PREVENTION
There is no demonstrated way to avoid developing OCD. � �
DIAGNOSIS
HISTORY
- Insidious (most common) or posttraumatic onset of pain, which improves with rest
- Pain usually is described as a deep and vague ache.
- Pain may be associated with clicking, swelling, locking (usually with a loose body), and stiffness.
PHYSICAL EXAM
- May be associated with secondary muscle atrophy, mild effusion, decreased range of motion (ROM), joint line tenderness, or tenderness over the lesion
- Wilson test (femoral condyle OCD) is poorly sensitive " �only 16% of positive exams in patients with radiographically proven OCD lesions (4)[A]. Wilson test: Knee is placed in 90 degrees of flexion. Examiner internally rotates tibia and extends knee " �test is positive if there is pain on extension that is relieved with flexion.
DIFFERENTIAL DIAGNOSIS
- Meniscal tear
- Patellofemoral pain syndrome
- Gout
- Osteoarthritis
- Stress fracture
- Tendinopathy
- Avascular necrosis
- Acute fracture
- Neoplasm
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
No specific laboratory tests for the diagnosis of OCD. � �
- The diagnosis is usually radiographic (4)[C].
- Typical findings include small articular surface radiolucency/irregularity with bony fragmentation and partial/complete separation of the articular cartilage.
- Knee: anteroposterior (AP), lateral, sunrise, and tunnel views (posterolateral portion of the medial femoral condyle [4])
- Elbow: routine AP and lateral elbow series (humeral capitellum)
- Ankle: AP, lateral, and mortise views (posteromedial or anterolateral talar dome)
- MRI can delineate the bony lesion, involvement of cartilage, and fluid behind the fragment. MRI helps assess the stability (fractured cartilage or separation from underlying subchondral bone) of the lesion (4)[C].
- MRI also allows for staging of adult lesions (2)[C].
- Current MRI classification systems lack validity in evaluating juvenile OCD (3)[C],(4)[B].
- CT scan provides architectural description of the bony lesion but is clinically less helpful than MRI.
- Bone scan may help evaluate healing potential (controversial).
TREATMENT
GENERAL MEASURES
- Goals of treatment
- Maintain a smooth, congruous joint surface.
- Alleviate pain.
- Prevent degenerative joint disease.
- Promote revascularization of necrotic fragment and regeneration of affected cartilage.
- There are no randomized, controlled trials comparing treatment modalities and outcomes. In JOCD, initial nonsurgical treatment is the standard of care (4)[C].
- Treatment options include periods of immobilization (potential casting), activity modification, and non " �weight bearing. Type and duration of immobilization are controversial (4)[C].
- Follow closely for at least 12 weeks to ensure healing (4,5)[C].
MEDICATION
First Line
- Symptomatic treatment
- Acetaminophen 650 mg q4 " �6h PRN; peds: (15 mg/kg/dose q4 " �6h PRN)
- NSAIDs (e.g., ibuprofen 600 to 800 mg q6 " �8h PRN; peds: 10 mg/kg/dose q6 " �8h PRN)
ISSUES FOR REFERRAL
- Physeal closure (2)[C]
- Unstable lesions with mechanical symptoms (4)[C]
- Failure of conservative treatment after 3 to 6 months (4)[C]
SURGERY/OTHER PROCEDURES
- Surgical treatment is used when:
- Conservative measures have failed (4)[C].
- Physeal closure (adult form) present (2)[C]
- Unstable lesions with mechanical symptoms (4)[C]
- Arthroscopic surgery is preferred. Arthroscopy can evaluate lesion stability and visualize articular cartilage (4,5)[C].
- Surgical treatments include fragment excision, microfracture technique (drilling) to increase blood supply, screw fixation of the loose fragment, allograft insertion, and autologous chondrocyte implantation. No single technique is superior (4)[C].
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Outpatient care is the usual course.
- Inpatient treatment for surgical intervention
Patient Monitoring
- 6-weeks intervals are appropriate to assess for fragment displacement on radiographs (4)[C].
- Healing is often seen within 6 months (4)[C].
- Symptomatic postoperative patients can be followed using MRI or SPECT/CT to evaluate healing.
DIET
Consider vitamin D supplementation. � �
PATIENT EDUCATION
Encourage patients to comply with rehabilitation recommendations in both nonoperative and operative cases. � �
PROGNOSIS
- Factors associated with good prognosis
- Younger age
- Open growth plate
- Stable lesions
- Non " �weight-bearing location of the lesion
- An incongruous joint surface may lead to degenerative changes in the future.
- Clinical improvement may proceed radiographic healing.
COMPLICATIONS
- Failure to revascularize and heal
- Displacement of a fragment becoming a loose body within a joint
- Predisposition for early osteoarthritis in the affected joint
REFERENCES
11 Abouassaly � �M, Peterson � �D, Salci � �L, et al. Surgical management of osteochondritis dissecans of the knee in the paediatric population: a systematic review addressing surgical techniques. Knee Surg Sports Traumatol Arthrosc. 2014;22(6):1216 " �1224.22 Pape � �D, Filardo � �G, Kon � �E, et al. Disease-specific clinical problems associated with the subchondral bone. Knee Surg Sports Traumatol Arthrosc. 2010;18(4):448 " �462.33 McKay � �S, Chen � �C, Rosenfeld � �S. Orthopedic perspective on selected pediatric and adolescent knee conditions. Pediatr Radiol. 2013;43(Suppl 1):S99 " �S106.44 Edmonds � �EW, Polousky � �J. A review of knowledge in osteochondritis dissecans: 123 years of minimal evolution from K � �nig to the ROCK study group. Clin Orthop Relat Res. 2013;471(4):1118 " �1126.55 Kocher � �MS, Tucker � �R, Ganley � �TJ, et al. Management of osteochondritis dissecans of the knee: current concepts review. Am J Sports Med. 2006;34(7):1181 " �1191.
ADDITIONAL READING
- Chambers � �HG, Shea � �KG, Anderson � �AF, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: the diagnosis and treatment of osteochondritis dissecans. J Bone Joint Surg Am. 2012;94(14):1322 " �1324.
- Hirschmann � �MT, Davda � �K, Rasch � �H, et al. Clinical value of combined single photon emission computerized tomography and conventional computer tomography (SPECT/CT) in sports medicine. Sports Med Arthrosc. 2011;19(2):174 " �181.
- Jacobi � �M, Wahl � �P, Bouaicha � �S, et al. Association between mechanical axis of the leg and osteochondritis dissecans of the knee: radiographic study on 103 knees. Am J Sports Med. 2010;38(7):1425 " �1428.
- Parikh � �SN, Allen � �M, Wall � �EJ, et al. The reliability to determine "healing " � in osteochondritis dissecans from radiographic assessment. J Pediatr Orthop. 2012;32(6):e35 " �e39.
- Quatman � �CE, Quatman-Yates � �CC, Schmitt � �LC, et al. The clinical utility and diagnostic performance of MRI for identification and classification of knee osteochondritis dissecans. J Bone Joint Surg Am. 2012;94(11):1036 " �1044.
- Ramirez � �A, Abril � �JC, Chaparro � �M. Juvenile osteochondritis dissecans of the knee: perifocal sclerotic rim as a prognostic factor of healing. J Pediatr Orthop. 2010;30(2):180 " �185.
- Shea � �KG, Jacobs � �JCJr, Carey � �JL, et al. Osteochondritis dissecans knee histology studies have variable findings and theories of etiology. Clin Orthop Relat Res. 2013;471(4):1127 " �1136.
CODES
ICD10
- M93.20 Osteochondritis dissecans of unspecified site
- M93.269 Osteochondritis dissecans, unspecified knee
- M93.229 Osteochondritis dissecans, unspecified elbow
- M93.279 Osteochondritis dissecans, unsp ankle and joints of foot
- M93.271 Osteochondritis dissecans, r ankle and joints of right foot
- M93.231 Osteochondritis dissecans, right wrist
- M93.222 Osteochondritis dissecans, left elbow
- M93.29 Osteochondritis dissecans multiple sites
- M93.28 Osteochondritis dissecans other site
- M93.272 Osteochondritis dissecans, l ankle and joints of left foot
- M93.219 Osteochondritis dissecans, unspecified shoulder
- M93.262 Osteochondritis dissecans, left knee
- M93.261 Osteochondritis dissecans, right knee
- M93.26 Osteochondritis dissecans knee
- M93.251 Osteochondritis dissecans, right hip
- M93.252 Osteochondritis dissecans, left hip
- M93.221 Osteochondritis dissecans, right elbow
- M93.232 Osteochondritis dissecans, left wrist
- M93.239 Osteochondritis dissecans, unspecified wrist
- M93.259 Osteochondritis dissecans, unspecified hip
- M93.24 Osteochondritis dissecans of joints of hand
- M93.211 Osteochondritis dissecans, right shoulder
- M93.212 Osteochondritis dissecans, left shoulder
ICD9
732.7 Osteochondritis dissecans � �
SNOMED
- Osteochondritis dissecans
- osteochondritis dissecans of the patella (disorder)
- osteochondritis dissecans of the capitellum (disorder)
- Osteochondritis dissecans of the talus (disorder)
- osteochondritis dissecans of the humeral head (disorder)
- osteochondritis dissecans of the femoral head (disorder)
- osteochondritis dissecans of the wrist (disorder)
CLINICAL PEARLS
- OCD is an acquired lesion of the subchondral bone, causing separation of the overlying articular cartilage; it may become unstable and require surgical intervention; the knee is the most commonly affected joint.
- Stable juvenile OCD lesions often heal without surgical intervention if patients adhere to appropriate conservative rehabilitation program.
- Compliance with conservative therapy and avoidance of further trauma are important elements to ensure proper healing, especially with younger athletes.
- 6-week follow-up intervals are appropriate to assess treatment progress.
- In adult patients with unstable lesions, surgery may be considered as an early treatment option.