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1.  Surgical treatment for osteochondritis dessicans of the knee 
Osteochondritis dissecans (OCD) of the knee is a disease of the subchondral bone with secondary injury to the overlying articular cartilage. OCD lesions are generally categorized as juvenile—growth plates open—or adult—growth plates closed. This maturity-based classification scheme has a prognostic value in that many juvenile OCD lesions will heal with conservative care while most symptomatic adult OCD lesions need surgical intervention. OCD can result in pain, knee joint effusions, loose body formation, and arthritis. Short-term treatment goals include pain and symptom resolution while the long-term goal is to minimize arthritis. Surgical options include debridement, drilling, microfracture, reduction and fixation, autograft osteochondral transplantation, autologous chondrocyte implantation, and allograft osteochondreal transplantation.
PMCID: PMC4630227  PMID: 26409885
Osteochondritis dissecans; Cartilage; Knee; Drilling; Microfracture; Juvenile; Chondrocyte
2.  Osteochondritis Dessicans- Primary Fixation using Bioabsorbable Implants 
Osteochondritis dessicans (OCD) is a localized condition where a section of articular cartilage and underlying subchondral bone separate from the joint surface. It is important to diagnose unstable OCD early and fix the fragments primarily as the results of any surgical management at late presentations are guarded. Use of bioabsorbable implants for fixing OCD is recent and we report one such case in grade IV OCD.
Case Report:
We present a 14 year old girl who came with a history of acute pain, swelling, inability to bear weight on the right knee following a dance practice. MRI showed stage IV osteochondral fragment measuring 20x 8mm lying free. This was primarily fixed with bioabsorbable implants. 10 months follow up showed excellent clinical and functional results.
This case highlights the advantages of early primary fixation whenever possible. By far, to our knowledge, this is the first case of successful treatment of stage IV OCD using bioabsorbable implants.
PMCID: PMC4719179
Osteochondritis Dessicans; bioabsorbable implants; osteochondral fractures; adolescent knee injuries; arthroscopy
3.  Systematic Review and Meta-analysis of Osteochondral Autograft Transplantation versus Debridement in the Treatment of Osteochondritis Dessicans of the Capitellum 
Orthopaedic Journal of Sports Medicine  2016;4(7 suppl4):2325967116S00103.
The purpose of this systematic review and meta- analysis is to compare clinical results and functional outcomes in patients with osteochondritis dessicans (OCD) lesions of the capitellum treated with either osteochondral autograft transplantation (OATS) or debridement with or without microfracture.
Systematic review of multiple medical databases was performed after PROSPERO registration and using PRISMA guidelines. A literature search was performed using the multiple medical databases and the methodological quality of the individual studies was assessed by two review authors using the Cochrane Collaboration’s “Risk of Bias” tool. Case reports were excluded and only case series of more than five patients and higher level of evidence were included. All study, subject, and surgery parameters were collected. Data was analyzed using statistical software. Odds ratios (OR) were calculated when possible. Data were compared using Pearson Chi-Square and independent sample T tests when applicable.
Fifteen studies were included involving 368 patients (326 males and 42 females). There were a total of 197 patients in the debridement group and 171 patients in the OATS group. The mean age was 16.9 +/-4.1 for the debridement group and 14.6 +/-1.2 for the OATS group. Mean follow up was 29.0 +/-24.3 and 38.0 +/-12.8 for the debridement and OATS groups, respectively. Patients that underwent an OATS procedure had a statistically significant improvement in overall arc range of motion compared to patients that had a debridement (P≤0.001). When compared to patients with debridement, patients with OATS were 5.6 times more likely to return to at least their pre-injury level of sports participation (p≤0.002).
Post-operative range of motion was significantly improved in patients undergoing an OATS procedure versus a debridement for OCD lesions of the capitellum. Patients with an OATS were 5.7 times more likely to return to at least the pre-injury level of sports participation compared to patients undergoing a debridement. Further studies are necessary in order to directly compare functional outcomes in patients undergoing a debridement procedures versus and OATS procedure.
PMCID: PMC4968244
4.  Omics technologies provide new insights into the molecular physiopathology of equine osteochondrosis 
BMC Genomics  2014;15(1):947.
Osteochondrosis (OC(D)) is a juvenile osteo-articular disorder affecting several mammalian species. In horses, OC(D) is considered as a multifactorial disease and has been described as a focal disruption of endochondral ossification leading to the development of osteoarticular lesions. Nevertheless, OC(D) physiopathology is poorly understood. Affected horses may present joint swelling, stiffness and lameness. Thus, OC(D) is a major concern for the equine industry. Our study was designed as an integrative approach using omics technologies for the identification of constitutive defects in epiphyseal cartilage and/or subchondral bone associated with the development of primary lesions to further understand OC(D) pathology. This study compared samples from non-affected joints (hence lesion-free) from OC(D)-affected foals (n = 5, considered predisposed samples) with samples from OC-free foals (n = 5) considered as control samples. Consequently, results are not confounded by changes associated with the evolution of the lesion, but focus on altered constitutive molecular mechanisms. Comparative proteomics and micro computed tomography analyses were performed on predisposed and OC-free bone and cartilage samples. Metabolomics was also performed on synovial fluid from OC-free, OC(D)-affected and predisposed joints.
Two lesion subtypes were identified: OCD (lesion with fragment) and OC (osteochondral defects). Modulated proteins were identified using omics technologies (2-DE proteomics) in cartilage and bone from affected foals compare to OC-free foals. These were associated with cellular processes including cell cycle, energy production, cell signaling and adhesion as well as tissue-specific processes such as chondrocyte maturation, extracellular matrix and mineral metabolism. Of these, five had already been identified in synovial fluid of OC-affected foals: ACTG1 (actin, gamma 1), albumin, haptoglobin, FBG (fibrinogen beta chain) and C4BPA (complement component 4 binding protein, alpha).
This study suggests that OCD lesions may result from a cartilage defect whereas OC lesions may be triggered by both bone and cartilage defects, suggesting that different molecular mechanisms responsible for the equine osteochondrosis lesion subtypes and predisposition could be due to a defect in both bone and cartilage. This study will contribute to refining the definition of OC(D) lesions and may improve diagnosis and development of therapies for horses and other species, including humans.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2164-15-947) contains supplementary material, which is available to authorized users.
PMCID: PMC4233069  PMID: 25359417
Equine osteochondrosis; Cartilage; Subchondral bone; Proteomics; Metabolomics; μCT
5.  An international multi-centre prospective study on the efficacy of an intraarticular polyacrylamide hydrogel in horses with osteoarthritis: a 24 months follow-up 
Polyacrylamide hydrogel (PAAG) was evaluated recently to treat osteoarthritis (OA) in horses with highly encouraging results; however no long term field-study was done to explore its clinical efficacy and lasting effect. The objective of this study was to evaluate the efficacy of PAAG in improving clinical signs of OA in horses. We hypothesized that lameness grade would significantly improve and the effect would last at least 2 years in osteoarthritic joints treated with PAAG. Forty three horses older than 2 years with OA in only one joint based on clinical evaluation, intra-articular anaesthesia and imaging (radiography) were included in this study. Horses were injected with 2 ml of PAAG into the affected joint and were followed up at 1, 3, 6, 12 and 24 months. Efficacy of PAAG was evaluated by blinded clinical assessment of lameness. Adverse reactions to joint injection were assessed. Data relating to case details, type of activity, joint and limb involved, lameness duration, lameness grading, previous joint treatment, joint effusion grading, radiographic grading, and owner assessment were recorded. Factors associated with the outcome measure “lameness grading” were analyzed using generalized linear mixed model for logistic regression.
At 1, 3, 6, 12 and 24 months follow-up, 59%, 69%, 79%, 81/% and 82.5% of horses were non-lame respectively. Reduction of joint effusion was observed over time. No side effect was observed in the treated joints. There was a significant decrease in lameness grade from baseline to 1, 3, 6, 12 and 24 months (P < 0.0001) and a significant positive association with joint effusion (P < 0.0001). Estimates for odds ratio (OR) showed that the effect of treatment increased over time (OR for lower lameness from month 1 to month 24 relative to baseline increased from 20 to 58).
PAAG significantly alleviated lameness and joint effusion in osteoarthritic joints. PAAG is a safe and lasting (at least 24 months) OA treatment in horses. PAAG is a promising new treatment for OA in horses.
PMCID: PMC4403890  PMID: 25887429
Osteoarthritis; Horse; Treatment; Polyacrylamide hydrogel; 2 years follow-up
6.  Osteochondral Autograft Plug Transfer for Treatment of Osteochondritis Dissecans of the Capitellum in Adolescent Athletes 
Orthopaedic Journal of Sports Medicine  2014;2(2 Suppl):2325967114S00036.
Osteochondritis dissecans (OCD) of the capitellum is a condition most commonly seen in adolescents involved in repetitive over-head sports and can profoundly affect both ability to return to play and long-term elbow function. Large, unstable defects, defined as those greater than 1 cm in size, have unproven or poor long term outcomes with surgical interventions such as fragment excision, microfracture or attempted fixation. Treatment of similarly sized OCD lesions in the knee with osteochondral autograft plug transfer has proven both effective and safe. While interest has developed for expansion of its use to the elbow, it has yet to be adequately studied. The goal of this study is to evaluate clinical outcomes and return to play in adolescent athletes treated with osteochondral autograft plug transfer from the knee for large, unstable OCD defects of the capitellum.
Inclusion Criteria: 1) Inability to participate in competitive sports 2) OCD defect of the capitellum that was either unstable on MRI or in patients who had failed 6 months of conservative treatment 3) Defect measuring at least 1 cm in area on diagnostic arthroscopy 4)Reconstruction of capitellar OCD with osteochondral autograft plug transfer 5) Minimum of 6 months post-operative follow-up. Data collection included chart review, determination of return to play, elbow range of motion, and DASH outcomes. The surgical technique was the same for all patients. It included initial diagnostic elbow arthroscopy, including loose body removal, followed by posterolateral approach to the elbow with lateral collateral ligament takedown from lateral epicondyle and eventual suture anchor repair, preparation of the capitellar osteochondral defect and appropriate plug transfer from the lateral trochlear ridge of the ipsilateral knee through a lateral approach. All patients followed the same post operative protocol, consisting of splint immobilization for 2 weeks, conversion to a hinged elbow brace for 4 weeks with progressive range of motion, and resumption of throwing and strengthening exercises at 3 months.
A cohort of 11 patients with a minimum of 6 months post procedure was identified. All patients were available for evaluation at an average 22.7 months follow up (range 6-49 months). Average age at the time of surgery was 14.5 years (range 13-17 years). The group consisted of 10 males and 1 female, all of which were involved in competitive athletics. Average return to play was 4.4 months (range 3-7 months). All athletes returned to at least their same level of play as pre-operatively. 3 have received Division 1 college scholarships (gymnastics, lacrosse and baseball pitcher). Of the 5 pitchers, 4 returned to pitching. The average DASH score was 1.36 (95% CI 0.59-2.12) and the average Sport Specific DASH score was 1.7 (95% CI -1.78-5.17). There were statistically significant improvements in elbow flexion from 125.45 degrees to 141.36 degrees (p=0.009) and extension from 20.45 degrees to 4.55 degrees (p=0.006). There was one adverse event. This consisted of a superficial wound infection, which resolved with surgical debridement and antibiotics and did not adversely affect eventual return to play. There were no complications or donor site morbidity related to graft harvest.
Treatment of large, unstable osteochondritis dissecans lesions of the capitellum in adolescent athletes allows reliable return to high level of sports, is safe and has excellent long-term clinical outcomes.
PMCID: PMC4597502
7.  The Demographics, Epidemiology, and Incidence of Progression to Surgery of Osteochondritis Dissecans of the Knee in Children and Adolescents 
Orthopaedic Journal of Sports Medicine  2013;1(4 Suppl):2325967113S00075.
To assess the demographics and epidemiology of osteochondritis dissecans (OCD) of the knee in patients age 2-19 and the frequency with which these lesions progress to surgery.
A retrospective EMR chart review of an integrated health system was done on OCD between 2007 and 2011. Inclusion criteria included OCD of the knee and patients aged 2-19, with approximately 1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. OCD incidence was determined for the group as a whole and by age group (divided into age 2-5, group A=6-11, group B=12-19). Differences in progression toward surgery were compared between age groups, gender, and joint location.
192 patients with a total of 206 OCD lesions fit the inclusion criteria. No OCD lesions were found in 2-5 year olds. 53.4% of lesions were right-sided, 46.6% left-sided. The medial femoral condyle was the most commonly affected location with 63.6% of the knee OCD lesions, followed by the lateral femoral condyle with 32.5%. Lesions of the femoral trochlea, patella, and lateral tibial plateau represented less than 4% of the total combined. No OCD lesions were found in the 2-5 year-olds. The incidence of knee OCD for patients aged 6-19 was 9.6 per 100,000 for all patients, and 15.7 and 3.3 per 100,000 for males and females, respectively. Group B represented the vast majority of OCD, with an incidence of 21.8 per 100,000 in 12-19 year olds versus 8.7 in group A. Females in group A and B had an incidence of 4.6 and 13.3 per 100,00, respectively, while males had an incidence of 12.5 and 30.1 per 100,00 for group A and B, respectively. The overall male/female ratio for knee OCD was 3.7/1. 33.8% of all lesions progressed to surgery. Lesion location did correlate with progression to surgery, with rare trochlear lesions and tibial lesions more likely to undergo surgery (100%, 100%) than lateral and medial femoral condyle lesions (40.3% and 28.7%) and patellar lesions (33.3%).
In this population-based cohort study of pediatric OCD in nearly 1 million children, males had a much greater incidence of OCD and the majority were right sided lesions. Teenagers had nearly 3 times the incidence of OCD as compared to the 6-11 year old group. Although most OCD lesions were located on the medial femoral condyle, lateral femoral condyle lesions were also common. The incidence of OCD in this study was similar to a smaller Swedish study by Linden et al 40 years previously. The knowledge of likelihood of progression to surgery of OCD by location, sex, and age is useful in counseling patients and in planning treatment. To our knowledge, this is the largest study of the demographics, epidemiology, and incidence of progression to surgery of OCD of the knee in children ever reported.
PMCID: PMC4588926
8.  The Incidence of Surgery in Osteochondritis Dissecans in Children and Adolescents 
Orthopaedic Journal of Sports Medicine  2016;4(3):2325967116635515.
The frequency of osteochondritis dissecans (OCD), a disorder of the subchondral bone and articular cartilage, is not well described.
To assess the frequency of pediatric OCD lesions that progress to surgery based on sex, joint involvement, and age.
Study Design:
Descriptive epidemiology study.
A retrospective chart review (2007-2011) was performed on OCD. Inclusion criteria included OCD of any joint and patients aged 2 to 19 years. Exclusion criteria included traumatic osteochondral fractures or coexistence of non-OCD intra-articular lesions. Differences in progression toward surgery were compared between age groups, sex, and joint location. Logistical regression analysis was performed by sex, age, and ethnicity.
Overall, 317 patients with a total of 334 OCD lesions were found. The majority of lesions (61.7%) were in the knee, with ankle, elbow, shoulder, and foot lesions representing 25.4%, 12.0%, 0.6%, and 0.3% of all lesions, respectively. The majority of joints needing surgery were in the knee (58.5%), with ankle and elbow lesions representing 22.9% and 18.6% of surgeries performed, respectively. The percentage of all OCD lesions progressing to surgery was 35.3%; surgical progression for knee, ankle, and elbow joints was 33.5%, 31.8%, and 55.0%, respectively. Logistic regression analysis found no statistically significant different risk of progressing to surgery for OCD of the knee, elbow, and ankle between sexes. Patients aged 12 to 19 years had a 7.4-times greater risk of progression to surgery for knee OCD lesions than 6- to 11-year-olds. Patients aged 12 to 19 years were 8.2 times more likely to progress to surgery for all OCD lesions than patients aged 6 to 11 years. Progression to surgery of ankle OCD did not significantly differ based on location. Three of 4 trochlear lesions progressed to surgery, along with 1 of 1 tibial, 1 of 3 patellar, 40.3% of lateral femoral condylar, and 28.2% of medial femoral condylar lesions.
In this large cohort study of pediatric OCD patients, 35% progressed to surgery. Progression to surgery did not differ significantly between sexes with OCD of any joint. Progression to surgery for OCD of the knee, elbow, and ankle strongly correlated with patient age at the time of diagnosis.
Clinical Relevance:
The knowledge of likelihood of progression to surgery of OCD by location, sex, and age is useful in counseling patients and in planning treatment. This study confirms a worse prognosis in the nonoperative treatment of older patients with OCD.
PMCID: PMC4797230  PMID: 27047984
osteochondritis dissecans; OCD; surgery; pediatric; child
9.  Incidence of osteochondrosis (dissecans) in Dutch warmblood horses presented for pre-purchase examination 
Irish Veterinary Journal  2008;61(1):33-37.
Data are lacking in the literature regarding the incidence of osteochondrosis (dissecans) [OC(D)] in relation to lameness evaluation in Dutch Warmblood horses. The objective of this retrospective study was to assess the incidence of radiological abnormalities consistent with osteochondrosis or osteochondrosis dissecans in 1,231 sound Dutch Warmblood (DW) horses presented for pre-purchase examination. Standardised (Dutch) pre-purchase examination protocols were evaluated. The pre-purchase examination included a clinical, lameness and radiological evaluation, performed at a private equine clinic in the Netherlands. Radiographical examination included views of the distal (DIP) and proximal (PIP) interphalangeal, metacarpo- and metatarsophalangeal (MCP/MTP), tarsocrural (TC) and femoropatellar (FP) joints. Radiographical evidence of OC(D) was found in 44.3% of clinically sound DW horses. In this study, 443 horses (36%, n = 1,231) had evidence of OCD and 102 horses (8.3%, n = 1,231) had evidence of OC on pre-purchase radiographs. The results also indicated that the TC joints were significantly more likely to be affected. A considerable number of horses did not demonstrate any lameness, although radiographs revealed OC(D).
PMCID: PMC3113880  PMID: 21851701
Osteochondrosis; dissecans; lameness; pre-purchase; examination
10.  Midterm results of biologic fixation or mosaicplasty and drilling in osteochondritis dissecans 
Indian Journal of Orthopaedics  2011;45(5):445-449.
Osteochondritis dissecans (OCD) primarily affects subchondral bone. Multiple drilling, fixation implant or autogenous osteochondral grafts are reported as treatment options. We present the midterm results of cases in which an OCD lesion was treated by osteochondral autograft transfer and drilling.
Materials and Methods:
Between 2002 and 2006, 14 knees with International Cartilage Repair Society (ICRS-OCD) type II and III lesions were treated in our clinic using osteochondral autograft transfer and drilling by arthroscopic or open surgery. The average age of our patients was 22.14 years (range 17-29 years) and average followup was of 24.3 months (range 11-40 months). Lesion type was ICRS type II in five patients (35.7%) and ICRS type III in nine patients (64.3%). In cases with ICRS-OCD type II lesions, in situ fixation was applied following circumferential multiple drilling, while mosaicplasty was done following debridement and multiple drilling in cases with ICRS-OCD type III lesion. Mosaicplasty was performed in the lesion area by an average of 2.5 (range 1-3) cylindrical osteochondral autografts. Patients were not allowed to perform loading activities for 3 weeks in the postoperative period; movement was initiated by using CPM device in the early phase; full range of motion was achieved in third week, and full weight bearing was permitted in 6 to 8 weeks
While 6 and 8 patients were classified preoperatively as fair and poor, respectively, according to Hughston scale, excellent and good results were obtained postoperatively in 10 and 4 patients, respectively. During the followup, no problems were detected in any of the patients in the regions where osteochondral graft was harvested.
Biologic fixation or mosaicplasty and drilling as a technique to treatment of the lesion in OCD by osteochondral autograft transfer has resulted in good and excellent clinical outcomes in our patients and it is considered that providing blood flow to subchondral bone by circumferencial drilling leads to an increase in the robustness of biological internal fixation and shortens the duration of recovery.
PMCID: PMC3162682  PMID: 21886927
Osteochondritis dissecans; Hughston scale; knee; mosaicplasty
11.  Radiographic closure time of appendicular growth plates in the Icelandic horse 
The Icelandic horse is a pristine breed of horse which has a pure gene pool established more than a thousand years ago, and is approximately the same size as living and extinct wild breeds of horses. This study was performed to compare the length of the skeletal growth period of the "primitive" Icelandic horse relative to that reported for large horse breeds developed over the recent centuries. This information would provide practical guidance to owners and veterinarians as to when the skeleton is mature enough to commence training, and would be potentially interesting to those scientists investigating the pathogenesis of osteochondrosis. Interestingly, osteochondrosis has not been documented in the Icelandic horse.
The radiographic closure time of the appendicular growth plates was studied in 64 young Icelandic horses. The results were compared with previously published closure times reported for other, larger horse breeds. The radiographs were also examined for any signs of developmental orthopaedic diseases. In order to describe further the growth pattern of the Icelandic horse, the total serum alkaline phosphatase (ALP) activity was determined and the height at the withers was measured.
Most of the examined growth plates were fully closed at the age of approximately three years. The horses reached adult height at this age; however ALP activity was still mildly increased over baseline values. The growth plates in the digits were the first to close at 8.1 to 8.5 months of age, and those in the regions of the distal radius (27.4 to 32.0 months), tuber olecrani (31.5 to 32.2 months), and the stifle (27.0 to 40.1 months) were the last to close. No horse was found to have osteochondrosis type lesions in the neighbouring joints of the evaluated growth plates.
The Icelandic horse appears to have similar radiographic closure times for most of the growth plates of its limbs as reported for large new breeds of horses developed during the past few centuries. It thus appears that different breeding goals and the intensity of breeding have not altered the length of the growth period in horses. Instead, it can be assumed that the pristine and relatively small Icelandic horse has a slower rate of growth. The appendicular skeleton of Icelandic horses has completed its bone growth in length at approximately 3 years of age, and therefore may be able to enter training at this time.
PMCID: PMC1950711  PMID: 17640333
12.  Three Osteochondritis Dissecans Lesions in One Knee: A Case Report 
Osteochondritis dissecans (OCD) has been defined as a localized process in which a focus of subchondral bone and adjacent articular cartilage separates from the surrounding bone. With the knee being the most common location for OCD development and the propensity for this lesion to be found in those who participate in sports, a repetitive microtrauma hypothesis for its cause has gained favor. However, the cause of OCD remains controversial, as does the most appropriate treatment for the varying degrees of OCD lesions.
Case Description
We present a unique case of three OCD lesions in one knee. The patient was a young, athletic boy who developed three separate OCD lesions in his right knee over the course of 4 years. Temporally, the OCD lesions developed first in the lateral femoral condyle, then in the medial femoral condyle, and finally in the trochlea.
Literature Review
Our literature review yielded a few reports of bicondylar OCD lesions. We identified no previous reports of three separate OCD lesions found in a single joint.
Purposes and Clinical Relevance
This report illustrates how a uniquely affected knee with three OCD lesions was treated in three different ways with resolution of symptoms. Each of the OCD lesions was evaluated individually and treatment for each based on the severity of the lesion from the physical examination, imaging studies, and arthroscopic findings.
PMCID: PMC3586005  PMID: 22453935
13.  Development of a Large Animal Model of Osteochondritis Dissecans of the Knee 
Orthopaedic Journal of Sports Medicine  2015;3(2):2325967115570019.
Treatment of osteochondritis dissecans (OCD) of the knee is challenging, and evidence for stage-dependent treatment options is lacking. Basic science approaches utilizing animal models have provided insight into the etiology of OCD but have yet to produce a reliable and reproducible large animal model of the disease on which to test new surgical strategies.
The purpose of this study was to develop an animal model featuring an OCD-like lesion in terms of size, location, and International Cartilage Repair Society (ICRS) grading. The hypothesis was that surgical creation of an osteochondral defect followed by placement of a barrier between parent bone and progeny fragment would generate a reproducible OCD-like lesion.
Study Design:
Controlled laboratory study.
Bilateral osteochondral lesions were created in the medial femoral condyles of 9 Yucatan minipigs. After lesion creation, a biodegradable membrane was interposed between the progeny and parent bone. Five different treatment groups were evaluated at 2 weeks: a control with no membrane (ctrl group; n = 4), a slowly degrading nanofibrous poly(∊-caprolactone) membrane (PCL group; n = 4), a fenestrated PCL membrane with 1.5-mm holes covering 25% of surface area (fenPCL group; n = 4), a collagen membrane (Bio-Gide) (CM group; n = 3), and a fenestrated CM (fenCM group; n = 3). Five unperturbed lateral condyles (1 from each treatment group) served as sham controls. After euthanasia on day 14, the lesion was evaluated by gross inspection, fluoroscopy, micro–computed tomography (micro-CT), and histology. To quantify changes between groups, a scoring system based on gross appearance (0-2), fluoroscopy (0-2), and micro-CT (0-6) was established. Micro-CT was used to quantify bone volume per total volume (BV/TV) in a defined region surrounding and inclusive of the defect.
The no scaffold group showed healing of the subchondral bone at 2 weeks, with continuity of subchondral bone elements. Conversely, condyles treated with PCL or CM showed substantial remodeling, with loss of bone in both the progeny fragment and surrounding parent bone. When these membranes were fenestrated (fenPCL and fenCM groups), bone loss was less severe. Histological analysis showed no integration in the cartilage layer in any treatment group, while fibrous tissue formed between the parent and progeny fragments. Micro-CT showed significant differences in mean BV/TV between the PCL (27.4% ± 2.3%) and the sham (47.7% ± 1.4%) or no scaffold (54.9% ± 15.1%) groups (P < .01 and P < .05, respectively). In addition, a significant difference in bone loss was evident between the PCL and fenPCL groups (mean BV/TV, 46.6% ± 15.2%; P < .05), as well as between the PCL and fenCM (mean BV/TV, 50.9% ± 3.5%) and fenPCL groups (P < .01). Grading by 6 blinded reviewers using an OCD scoring system with 3 subcategories showed a significant difference between control and PCL groups.
This study successfully developed a large animal model of OCD-like lesions in the knee joint of Yucatan minipigs. The lesions generated matched characteristics of an ICRS grade 3 OCD lesion in humans. These findings set the stage for ongoing model refinement as well as exploration of novel interventional therapies to restore function and bone and cartilage patency in individuals affected by this rare but significant disease.
Clinical Relevance:
This developed model will serve as a platform on which to further investigate the natural course as well as emerging treatment options for OCD.
PMCID: PMC4555612  PMID: 26535380
Knee; osteochondritis dissecans; biology of bone; biology of cartilage; tissue engineering
14.  Clinicopathological findings in horses with a bi- or tripartite navicular bone 
Navicular bone partition is a rare condition reported in horses, which is during the evaluation of a lameness or prepurchase examination often misinterpreted for a parasagittal fracture. In this report, the clinicopathological findings of three cases of navicular bone partition are evaluated. The possible pathomechanisms underlying the condition are hypothesised, focusing on a potential origin of foetal vascular disturbance. This study is furthermore aiming at a clearer and earlier recognition of navicular bone partition, since this condition would finally predispose for a clinical lameness with a poor prognosis.
Case presentations
Case 1 was a 10-year-old Belgian Warmblood gelding with a Grade 3/5 chronic, recurrent left-forelimb lameness that had persisted for 4 months. Perineural palmar digital nerve block of the distal foot abolished the lameness. Radiographic examination revealed a bipartite navicular bone in the left forelimb. Unfortunately, the animal was lost to follow-up. Case 2 was a 7-year-old Quarter Horse stallion with a Grade 3/5 recurrent right forelimb lameness that had persisted for 2 years. The lameness switched to the contralateral left forelimb with a palmar digital nerve block. Radiographic examination identified a tripartite navicular bone in both forelimbs. Pathological examination additionally revealed chronic degenerative changes of the cartilage and subchondral bone with marked cystic changes. Case 3 was a 5-year-old Dutch Warmblood gelding with a Grade 3/5 recurrent left hindlimb lameness that had persisted for 6 months. Owing to the uncooperative behaviour of the horse, only a combined peroneal and tibial nerve block could be performed, which abolished the lameness. Radiographic examination revealed a bipartite navicular bone in the left hindlimb. Pathological examination showed a navicular bipartition in the left hindlimb, with microscopic changes comparable to those evident in Case 2; additionally, cartilage indentations were also found in the navicular bones of the right front- and hindlimb at a similar location as the partition site in the left hindlimb.
It is speculated that a navicular bone partition has a congenital origin and is caused by vascular disturbance during foetal development. This may lead to aberrant endochondral ossification or the formation of multiple ossification centres resulting in navicular bone partitioning. In the adult horse, chronic repetitive biomechanical challenges at the partition sites may induce local degenerative changes with subchondral cyst formation and thus would cause a gradually developing chronic lameness with a poor prognosis.
PMCID: PMC4826531  PMID: 27061802
Bi-tripartite navicular bone; Bi-tripartite sesamoids; Partitioning; Navicular fracture; Navicular pathology
15.  Osteochondral lesions in children with juvenile idiopathic arthritis 
Joint pain and swelling are typical symptoms in children with juvenile idiopathic arthritis (JIA) and these are often related to inflammation of the joint. Juvenile osteochondritis dissecans (JOCD), that is separation of a bone-cartilage segment from the articular surface, can manifest with similar symptoms.
We studied thirteen cases of osteochondritis dissecans lesions (OCD) in children with JIA. There were nine girls and four boys with a mean age of 6.5 (2–12) years at the time of diagnosis of JIA. Mean time between diagnosis of JIA and manifestation of OCD was 5.5 (1–11) years. Indications for MRI were the presence of pain or discomfort in the joint, despite otherwise effective treatment, with no evidence from ultrasound examination of any obvious signs of active inflammation. The most common location of osteochondral lesion was the knee, although the ankle joint was affected in one case. Five patients had lesions in both knees. Operative treatment was needed in eight cases (joints).
Pain, and minor dysfunction of the joint are common complaints of children suffering from JIA. Earlier research has discounted the possibility of children who were not athletes presenting with this condition. However, this study demonstrates that these lesions also seem to be relatively common in patients with JIA. When there is no sign of inflammation, the possibility of OCD must therefore be considered in these children.
PMCID: PMC3648357  PMID: 23634779
Juvenile arthritis; JIA; Osteochondritis; Joint; Pain
16.  A randomised, double-blinded, placebo-controlled clinical study on intra-articular hyaluronan treatment in equine lameness originating from the metacarpophalangeal joint 
Intra-articular inflammation resulting in lameness is a common health problem in horses. Exogenous intra-articular hyaluronic acid has been shown to provide an analgesic effect and reduce pain in equine and human osteoarthritis. High molecular weight non-animal stabilized hyaluronic acid (NASHA) has gained popularity in the treatment of human arthritic conditions due to its long-acting pain-relieving effects. The aim of this study was to compare the response to treatment of lameness localized in the equine metacarpophalangeal joint injected with non-animal stabilized hyaluronic acid (NASHA) and placebo (saline). Twenty-seven clinically lame horses with a positive response to diagnostic intra-articular anaesthesia of the metacarpophalangeal joint and with no, or at most mild, radiographic changes in this joint were included in the study. Horses in the treatment group (n = 14) received 3 mL of a NASHA product intra-articularly, and those in the placebo group (n = 13) received an equivalent volume of sterile 0.9 % saline solution.
The change in the lameness score did not significantly differ between NASHA and placebo groups (P = 0.94). Scores in the flexion test improved more in the NASHA group compared with placebo (P = 0.01). The changes in effusion and pain in flexion were similar (P = 0.94 and P = 0.27, respectively) when NASHA and placebo groups were compared. A telephone interview follow-up of the owners three months post-treatment revealed that 14 of the 21 horses (67 %) were able to perform at their previous level of exercise.
In the present study, a single IA NASHA injection was not better than a single saline injection for reducing lameness in horses with synovitis or mild osteoarthritis. However, the results of this study indicate that IA NASHA may have some beneficial effects in modifying mild clinical signs but more research is needed to evaluate whether the positive effect documented ie. reduced response in the flexion test is a true treatment effect.
PMCID: PMC4804525  PMID: 27005478
Double-blinded; Clinical study; Lameness; Metacarpophalangeal joint; Non-animal stabilized hyaluronic acid (NASHA); Placebo-controlled
17.  Non-operative Treatment Outcomes of Stable Juvenile Osteochondritis Dissecans Lesions of the Knee 
Orthopaedic Journal of Sports Medicine  2016;4(7 suppl4):2325967116S00198.
Osteochondritis dissecans (OCD) of the knee most commonly occurs in skeletally-immature pre-adolescent or adolescent patients. Stable juvenile OCD lesions are initially treated via non-operative methods, with varying rates of successful healing reported in the literature. Unloader bracing has been introduced as a relatively new method designed to reduce weight-bearing stress and promote healing for femoral condyle lesions, although the outcomes of unloader bracing compared to other forms of non-operative treatment have not been established.
A retrospective case series was designed to include all patients initially treated non-operatively for stable juvenile OCD of the femoral condyle at a single institution from 2002-2014. Following IRB approval, patient medical records were reviewed for demographic and clinical data, including symptom duration, prior conservative treatment, non-operative treatment modality prescribed and clinical outcome.
223 knees of 196 patients (146/196 (74%) male) underwent non-operative treatment for stable OCD of the medial or lateral femoral condyle. Mean age at presentation 11.5 +/- 1.7 years (range 6-16 years). 27/196 patients (14%) were diagnosed with bilateral OCD at presentation, while 169/196 (86%) presented with unilateral OCD. 180/223 knees (81%) were medial femoral condyle lesions, while 39/223 (17%) were lateral femoral condyle lesions and 4/223 (2%) bicondylar. Reported symptom duration was 10.4 +/- 8.8 months (range 0.1 - 38 months). 222/223 (99.6%) knees presented with knee pain, 68/223 (30%) with one or more mechanical symptoms (swelling, giving-way, locking, clicking). 87/223 (39%) had undergone previous non-operative treatment for an average of 2.1 months. On exam at presentation, 130/223 (58%) had tenderness to palpation noted over the associated femoral condyle or ipsilateral joint line. Treatment was based on physician preference. 121/223 (54%) were treated with unloader bracing with activity restriction and physical therapy for a minimum of 3 months, while 102/223 (46%) were treated with other (i.e. “non-unloader”) conservative therapy. In the non-unloader group, all patients were treated with activity restriction with physical therapy and 32% (33/102) had additional non-unloader bracing or immobilization. Treatment of 26/121 (21%) knees in the unloader group included weight-bearing restrictions compared with 30/102 (29%) knees in the non-unloader group. Unloader bracing was associated with healing in 57/121 (47%) knees, while non-unloader treatment led to healing in 60/102 (59%) (p=0.082). Surgical intervention was pursued for 64/121 (53%) knees in the unloader group, at mean 11.0 months after presentation (range 1.9 - 62 months), all of which included OCD drilling and 12/121 (10%) of which included OCD fixation. Subsequent surgical intervention was pursued for 42/102 (41%) knees in the non-unloader group, at mean 6.6 months after presentation (range 0.2 - 40 months), all of which required OCD drilling and 11/102 of which included (11%) OCD fixation.
Non-operative treatment for stable OCD of the knee in skeletally-immature patients led to healing in approximately half (52%) of cases. No significant difference was seen between outcomes of patients treated with non-operative methods that included unloader bracing versus non-unloader bracing or other modalities.
PMCID: PMC4968300
18.  Culling Rate of Icelandic Horses due to Bone Spavin 
Acta Veterinaria Scandinavica  2003;44(4):161-169.
A survival analysis was used to compare the culling rate of Icelandic horses due to the presence of radiographic and clinical signs of bone spavin. A follow-up study of 508 horses from a survey five years earlier was performed. In the original survey 46% of the horses had radiographic signs of bone spavin (RS) and/or lameness after flexion test of the tarsus. The horse owners were interviewed by telephone. The owners were asked if the horses were still used for riding and if not, they were regarded as culled. The owners were then asked when and why the horses were culled. During the 5 years, 98 horses had been culled, 151 had been withdrawn (sold or selected for breeding) and 259 were still used for riding. Hind limb lameness (HLL) was the most common reason for culling (n = 42). The rate of culling was low up to the age of 11 years, when it rose to 0.05 for horses with RS. The risk ratio for culling was twice as high for horses with RS compared with horses without RS and 5.5 times higher for culling because of HLL. The risk of culling (prognostic value) was highest for the combination of RS with lameness after flexion test, next highest for RS and lowest for lameness after flexion test as the only finding.
It was concluded that bone spavin affects the duration of use of Icelandic horses and is the most common cause of culling due to disease of riding horses in the age range of 7–17 years.
PMCID: PMC1831549  PMID: 15074629
Icelandic horses; bone spavin osteoarthroses; survival analysis; questionnaire
Revista Brasileira de Ortopedia  2015;47(5):553-562.
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.
PMCID: PMC4799442  PMID: 27047865
Knee Joint; Cartilage, Joint; Osteochondritis Dissecans
20.  Development of an Equine Groove Model to Induce Metacarpophalangeal Osteoarthritis: A Pilot Study on 6 Horses 
PLoS ONE  2015;10(2):e0115089.
The aim of this work was to develop an equine metacarpophalangeal joint model that induces osteoarthritis that is not primarily mediated by instability or inflammation. The study involved six Standardbred horses. Standardized cartilage surface damage or “grooves” were created arthroscopically on the distal dorsal aspect of the lateral and medial metacarpal condyles of a randomly chosen limb. The contralateral limb was sham operated. After 2 weeks of stall rest, horses were trotted 30 minutes every other day for 8 weeks, then evaluated for lameness and radiographed. Synovial fluid was analyzed for cytology and biomarkers. At 10 weeks post-surgery, horses were euthanized for macroscopic and histologic joint evaluation. Arthroscopic grooving allowed precise and identical damage to the cartilage of all animals. Under the controlled exercise regime, this osteoarthritis groove model displayed significant radiographic, macroscopic, and microscopic degenerative and reactive changes. Histology demonstrated consistent surgically induced grooves limited to non-calcified cartilage and accompanied by secondary adjacent cartilage lesions, chondrocyte necrosis, chondrocyte clusters, cartilage matrix softening, fissuring, mild subchondral bone inflammation, edema, and osteoblastic margination. Synovial fluid biochemistry and cytology demonstrated significantly elevated total protein without an increase in prostaglandin E2, neutrophils, or chondrocytes. This equine metacarpophalangeal groove model demonstrated that standardized non-calcified cartilage damage accompanied by exercise triggered altered osteochondral morphology and cartilage degeneration with minimal or inefficient repair and little inflammatory response. This model, if validated, would allow for assessment of disease processes and the effects of therapy.
PMCID: PMC4332493  PMID: 25680102
21.  Non-terminal animal model of post-traumatic osteoarthritis induced by acute joint injury 
Develop a non-terminal animal model of acute joint injury that demonstrates clinical and morphological evidence of early post-traumatic osteoarthritis (PTOA).
An osteochondral (OC) fragment was created arthroscopically in one metacarpophalangeal (MCP) joint of 11 horses and the contralateral joint was sham operated. Eleven additional horses served as unoperated controls. Every 2 weeks, force plate analysis, flexion response, joint circumference, and synovial effusion scores were recorded. At weeks 0 and 16, radiographs (all horses) and arthroscopic videos (OC injured and sham joints) were graded. At week 16, synovium and cartilage biopsies were taken arthroscopically from OC injured and sham joints for histologic evaluation and the OC fragment was removed.
Osteochondral fragments were successfully created and horses were free of clinical lameness after fragment removal. Forelimb gait asymmetry was observed at week 2 (P=0.0012), while joint circumference (P<0.0001) and effusion scores (P<0.0001) were increased in injured limbs compared to baseline from weeks 2 to 16. Positive flexion response of injured limbs was noted at multiple time points. Capsular enthesophytes were seen radiographically in injured limbs. Articular cartilage damage was demonstrated arthroscopically as mild wear-lines and histologically as superficial zone chondrocyte death accompanied by mild proliferation. Synovial hyperemia and fibrosis were present at the site of OC injury.
Acute OC injury to the MCP joint resulted in clinical, imaging, and histologic changes in cartilage and synovium characteristic of early PTOA. This model will be useful for defining biomarkers of early osteoarthritis and for monitoring response to therapy and surgery.
PMCID: PMC3624059  PMID: 23467035
osteoarthritis; PTOA; animal model; cartilage; trauma; equine
22.  Palliative therapy of osteochondrosis dessicans in a Duroc boar 
A 2-year-old, 210-kg, Duroc boar manifested with a grade II–III left front lameness. The boar was treated systemically with isolfupredone acetate and a 5-week course of ketoprofen. The lameness resolved and the ketoprofen was discontinued; however, the lameness returned and the boar was euthanized humanely. Postmortem examination was consistent with osteochondrosis dessicans.
PMCID: PMC2147703  PMID: 18320984
23.  Effects of lesion size and location on equine articular cartilage repair. 
The mechanisms and completeness of equine articular cartilage repair were studied in ten horses over a nine month period. Large (15 mm square) and small (5 mm square) full-thickness lesions were made in weight bearing and nonweight bearing areas of the radiocarpal, middle carpal and femoropatellar joints. The horses were euthanized in groups of two 1, 2.5, 4, 5 and 9 months later. Gross pathology, microradiography, and histopathology were used to evaluate qualitative aspects of articular repair. Computer assisted microdensitometry of safranin-O stained cartilage sections was used to quantitate cartilage matrix proteoglycan levels. Structural repair had occurred in most small defects at the end of nine months by a combination of matrix flow and extrinsic repair mechanisms. Elaboration of matrix proteoglycans was not complete at this time. Statistically better healing occurred in small weight bearing lesions, compared to large or nonweight bearing lesions. Synovial and perichondrial pannus interfered with healing of osteochondral defects that were adjacent to the cranial rim of the third carpal bone. Clinical and experimental experience suggests that these lesions are unlikely to heal, whereas similar lesions in the radiocarpal and femoropatellar joints had satisfactory outcomes. Observations made in this study support the use of early postoperative ambulation, passive flexion of operated joints, and recuperative periods of up to a year for large cartilage defects.
PMCID: PMC1255413  PMID: 3349393
24.  Short- and long-term racing performance of Standardbred pacers and trotters after early surgical intervention for tarsal osteochondrosis 
Equine veterinary journal  2014;47(4):438-444.
Reasons for Performing Study
Osteochondrosis (OC) is commonly diagnosed in young Standardbred racehorses, but its effect on performance when surgically treated at a young age is still incompletely understood. This is especially true for Standardbred pacers, which are underrepresented in the existing literature.
To characterise the short- (2-year-old) and long-term (through 5-year-old) racing performance in Standardbred pacers and trotters after early surgical intervention (<17 months of age) for tarsal OC.
Study Design
Retrospective clinical study.
The study population consisted of related, age-matched Standardbred racehorses (n = 278; 151 pacers, 127 trotters) with (n = 133) or without (n = 145) one or more tarsal OC lesions. All OC-affected horses were treated surgically prior to being sold as yearlings. Data obtained from publicly available race records for each horse included starts, wins, finishes in the top 3 (win, place, or show), earnings, and fastest time. Comparisons between OC-affected and unaffected horses were made for the entire population and within gaits. A smaller related population (n = 94) had these performance measures evaluated for their 2- through 5-year-old racing seasons.
Osteochondrosis status was associated with few performance measures. Trotters were at higher risk for lesions of the medial malleolus, but lower risk for lesions of the distal intermediate ridge of the tibia compared to pacers. Horses with bilateral OC lesions and lateral trochlear ridge (LTR) lesions started fewer races at 2 years of age than those with unilateral lesions or without LTR lesions.
Osteochondrosis seemed to have minimal effect on racing performance in this cohort, although horses with bilateral and LTR lesions started fewer races at 2 years. There was evidence for different distribution of OC lesions among pacers and trotters, which should be explored further. Standardbreds undergoing early removal of tarsal OC lesions can be expected to perform equivalently to their unaffected counterparts.
PMCID: PMC4229490  PMID: 24819047
horse; osteochondrosis; performance; Standardbred; racing; arthroscopy
25.  The Use of Micronized Allograft Articular Cartilage (BioCartilage) and Platelet Rich Plasma to Augment Marrow Stimulation in an Equine Model of Articular Cartilage Defects 
Orthopaedic Journal of Sports Medicine  2015;3(7 suppl2):2325967115S00044.
Microfracture continues to be a dominant treatment strategy for symptomatic articular cartilage defects. Improving the histologic and clinical outcomes with biologic adjuncts offers promise to enhance this widely utilized technique. Specifically, the use of a novel scaffold that is potentially conductive and inductive such as micronized allograft articular cartilage (BioCartilage-BC) combined with platelet rich plasma (PRP) was investigated as an adjunct to microfracture in an equine model of articular cartilage defects.
Five adult horses were anesthetized and 2 - 10mm diameter full thickness cartilage defects were created in the trochlear ridge in both knees; one proximal (high load) and another distal (low load). In one knee, microfracture (MFx) followed by grafting with BioCartilage(BC). BioCartilage was mixed with PRP and injected into the defect with a touhey needle and sealed with fibrin under CO2 arthroscopy. The opposite limb served as a control and received MFx only. Horses were euthanized at 13 months post-operatively. Outcome was assessed with serial arthroscopy, 3T T2 and T1rho MRI, microCT, and histology. Statistics were performed using a mixed effect model with response variable contrasts. P≤0.05 was considered significant.
No complications such as joint inflammation, infection or lameness were encountered. The score for overall repair (12=normal, 0=complete degeneration) in both the proximal and distal defects was significantly better in the BC group compared to MFx (proximal BC 7.4±0.51, MFx 4.8±.1; p=0.041)(distal BC 5.6±0.98, MFx 2.6±1.5; p=0.022). All significant findings on histology (100=normal, o=complete degeneration) were confined to the proximal, high load defects. Graft perimeter integration (BC 96±8.9, MFx 68±19; p=0.02), graft base integration (BC 100+/- 0.0, MFx 70±37;p=0.044), subchondral bone architecture under the graft (BC 66±18, MFx 34±16; p=0.050) and collagen type II BC 82+/-8, MFx 58±11; p=0.051. There were no significant differences between BC and MFx in MRI or uCT analyses.
Micronized allograft articular cartilage (BioCartilage) and PRP improve cartilage repair compared to marrow stimulation alone in an equine model of articular cartilage defects. This technology offers promise for the use of homologous allograft tissue as a low-cost and safe augmentation procedure for traditional microfracture surgery.
PMCID: PMC4901600

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