Osteochondral defects of the femoral head are exceedingly rare, with limited treatment options. Restoration procedures for similar defects involving the knee and ankle have been well described. In this report, we present a young patient who had a symptomatic osteochondral defect of the femoral head develop secondary to trauma and underwent subsequent treatment using a fresh-stored osteochondral allograft via a trochanteric osteotomy. At the 1-year followup, the patient was symptom free with near-complete incorporation of the graft radiographically. Our observations in this case suggest osteoarticular implantation may be an appropriate alternative to consider when treating osteochondral defects of the femoral head.
Osteochondritis dissecans (OCD) of the capitellum is most often seen in adolescents who participate in sports that involve repetitive loading of the elbow. Unstable defects typically require surgical intervention that involves fragment fixation, debridement, or reconstruction with an osteochondral autograft transfer. Optimum surgical management of unstable defects remains controversial.
Type of Study:
Relevant articles published after 1992 were identified using MEDLINE, the EMBASE database, and the Cochrane Library.
Both debridement and osteochondral autograft transfer for treatment of capitellar OCD lesions result in good short- and midterm outcomes with a high rate of return to sports. Larger defects involving more than 50% of the articular surface or involving the lateral margin of the capitellum may have worse outcomes after debridement and may be better treated with fragment fixation or osteochondral autograft transfer.
High-level evidence is lacking to determine the superiority of debridement or osteochondral autograft transfer for the treatment of capitellar OCD lesions. A prospective longitudinal multicenter study, using validated outcome measures, that enrolls a large number of patients is needed to establish optimal treatment for unstable capitellar OCD lesions.
osteochondritis dissecans; elbow; capitellum
Osteochondritis dissecans of the knee primarily affects subchondral bone, with a secondary effect on the overlying articular cartilage. This process can lead to pain, effusions, and loose body formation. While stable juvenile lesions often respond well to nonoperative management, unstable juvenile lesions, as well as symptomatic adult lesions, often require operative intervention. Short-term goals focus on symptomatic relief, while long-term expectations include the hope of preventing early-onset arthritis. Surgical options include debridement, loose body removal, microfracture, arthroscopic reduction and internal fixation, subchondral drilling, osteochondral autograft or allograft transplantation, and autologous chondrocyte implantation. Newer single-stage cell-based procedures have also been developed, utilizing mesenchymal stem cells and matrix augmentation. Proper treatment requires evaluation of both lesional (size, depth, stability) and patient (age, athletic level) characteristics.
Osteochondritis dissecans; Knee; Microfracture; Osteochondral autologous transplant; Drilling; Internal fixation; Allograft; Autologous chondrocyte implantation; Loose body; Surgical treatment; Cartilage
Osteochondritis dissecans is a lesion of subchondral bone with subsequent involvement of the overlying cartilage. Although the etiology of the disease is unknown, mechanical, traumatic, and ischemic etiologies have been suggested, in addition to developmental and genetic factors. There are several treatment options depending on the stage of the disease and surgeon preference. The use of a fresh osteochondral allograft for treatment of a lesion of the femoral condyle is relatively new, and we report its use in a unique situation involving identical twins who both presented with osteochondritis dissecans of the same anatomic location within 2 years of each other. Since these were identical lesions in identical twins, this commonality supports the suggestion that some genetic component may be present in the etiology, especially in this situation where a genetic connection existed. We recommend genetic studies to determine the extent of genetic influence on the disease.
Osteochondritis dissecans (OCD) of both femoral condyles is very rare, with no previously reported cases of bilateral OCD of both knees in two siblings. We report on a brother and sister with both femoral condyle OCD with a description of surgical technique and clinical results. Fixation using headless compressive screws, osteochondral autologous transplantation and autologous chondrocyte implantation were all successful.
Osteochondritis dissecans; Bilateral; Both femoral condyle; Knee; Autologous chondrocyte implantation; Open osteochondral autograft
Over a period of 7 years
(1987 – 1994), 24 cases of osteochondritis dissecans of the knee
were treated with self-reinforced polyglycolic acid (SR-PGA) and
polylactic acid (SR-PLLA) rods. Rods measuring 1.1 mm, 1.5 mm
and 2 mm in diameter, and 20 – 40 mm in length were used in the
fixation of the fragment depending on the size of the lesions.
There were 23 patients with osteochondritis dessicans in the
medial and 1 in the lateral femoral condyle. The average age of
the patients was 25 years (range: 16 – 48). Follow-up was for
3.3 years (range: 1 – 7.6). There were 6 lesions in situ, 3
early separations, 11 were partially detached, and there were 4
loose bodies. SR-PGA rods were used in 12 patients, SR-PLLA rods
in 11 patients, and both SR-PGA and SR-PLLA rods in 1 patient.
The rod in each case was inserted subchondrally and in 9 cases
arthroscopically, using a special instrument. In our study, the
clinical result was excellent in 13 patients, good in 6, fair in
1 and poor in 4. On radiological assessment the fragment had
healed in 19 cases. Synovitis occurred in 1 patient in the
SR-PGA group (1/13): the effusion continued for 6 months
postoperatively but, after treatment by needle aspiration, there
were no symptoms at follow-up 4.2 years later. We conclude that
SR-PGA and SR-PLLA rods can be used intra-articularly for the
adequate fixation of osteochondritis dissecans.
The objective of this study was to determine the clinical outcome of combined bone grafting and matrix-supported autologous chondrocyte transplantation in patients with osteochondritis dissecans of the knee. Between January 2003 and March 2005, 21 patients (mean age 29.33 years) with symptomatic osteochondritis dissecans (OCD) of the medial or lateral condyle (grade III or IV) of the knee underwent reconstruction of the joint surface by autologous bone grafts and matrix-supported autologous chondrocyte transplantation. Patients were followed up at three, six, 12 and 36 months to determine outcomes by clinical evaluation based on Lysholm score, IKDC and ICRS score. Clinical results showed a significant improvement of Lysholm-score and IKDC score. With respect to clinical assessment, 18 of 21 patients showed good or excellent results 36 months postoperatively. Our study suggests that treatment of OCD with autologous bone grafts and matrix-supported autologous chondrocytes is a possible alternative to osteochondral cylinder transfer or conventional ACT.
Osteochondritis dissecans (OD) of the femoral condyles is a vague and often confusing diagnostic entity encountered by many clinicians. Unfortunately, there are several factors that add to this confusion. Chief among these is the proper recognition and understanding of the disease process, which is not well-documented. In addition, OD is often generically grouped together with other femoral condylar lesions that require differing diagnostic and treatment methods for proper care. OD is commonly divided into two categories, juvenile and adult forms. Each requires different methods of correction and rehabilitation. This paper describes the disease process of OD, explains the differences between the juvenile and adult forms (including common symptoms and diagnostic techniques), describes several of the pathologies that OD is mistakenly grouped with, and gives a brief review of the common arthroscopic and surgical techniques used to treat this pathology. In addition, rehabilitation guidelines and suggestions are offered to aid the athlete's return to functional activities.
Two patients presenting with a locked knee are described. In both cases a loose body from an osteochondritis dissecans defect had wedged beneath the anterior horn of the lateral meniscus, creating a block to extension which could not be reduced. Arthroscopy and arthroscopic methods proved unsuccessful in the removal of the loose body.
Osteochondritis dissecans (OD) mostly appears at the knee joint on the weight-bearing part of the medial femoral condyle. A multi-factorial event is most likely responsible for the triggering of OD. The aim of this retrospective study was to carry out long-term assessment of the results of operative treatment. Between 1959 and 1976, 148 patients were treated for OD by an open technique. For this purpose, a total number of 38 patients were analysed after approximately 30 years. Twenty-six patients were evaluated clinically by means of standardised questionnaires and also radiologically; 12 patients were analysed only by questionnaire. In order to verify the clinical findings and the subjective assessment, radiographs were done and analysed according the Kannus score. The Brückl score was used to evaluate the results of the OD. Twenty-four knee joints were analysed by radiographs. Sixty percent of the operated joints showed poor results in the analysis according to Kannus. Only four patients showed an excellent result by using the clinical scoring system. Nevertheless, we were able to prove a markedly higher rate of osteoarthrosis. The causal explanation for this lies in the patient selection. Most of the patients were above average age, and the OD was discovered quite late, and thus the disease had already progressed to a higher degree. In 74% of all cases, an extirpation of the osteochondral fragment was performed, whereas today there are several operative options. In our view, therefore, the need arises to conduct further follow-up examinations with comparative time spans, as well as to conduct a parallel analysis of corresponding control groups in order to evaluate the aetiology of the increased rate of osteoarthrosis.
To present the case of an intercollegiate swimmer with a stage IV lateral talar dome injury and associated bony fragments.
Lack of distinct diagnostic symptoms, low index of clinical suspicion, and the difficulty of visualizing the early stages of this injury on standard x-rays cause frequent misdiagnosis of talar dome lesions.
Ganglion cyst, with inflammatory synovitis secondary to rupture of cyst; loose bodies from previous occult fracture; osteochondral fracture.
Initial treatment with nonsteroidal antiinflammatory drugs and a posterior splint for comfort, followed by arthroscopic excision of loose bodies with abrasion and drilling arthroplasty.
Patient presented to the team physician for care of acute left medial ankle pain after the athletic trainer had attempted to rupture a ganglion cyst on the anterolateral aspect of the patient's ankle.
Increased clinical suspicion is necessary to correctly diagnose osteochondral lesions, particularly in the early stages. Aggressive treatment of talar dome lesions has a good success rate and may be an attractive option for competitive athletes.
ganglion cyst; inflammatory synovitis; osteochondral fracture
Stickler syndrome is among the most common autosomal dominant connective tissue disorders but is often unrecognised and therefore not diagnosed by clinicians. Despite much speculation, the cause of osteochondrosis in general and osteochondritis dissecans (OCD) and Osgood Schlatter syndrome (OSS) in particular remain unclear. Etiological understanding is essential. We describe a pair of family subjects presented with OCD and OSS as a symptom complex rather than a diagnosis.
Detailed clinical and radiographic examinations were undertaken with emphasis on the role of MRI imaging. Magnetic resonance imaging may allow early prediction of articular lesion healing potential in patients with Stickler syndrome.
The phenotype of Stickler syndrome can be diverse and therefore misleading. The expectation that the full clinical criteria of any given genetic disorder such as Stickler syndrome will always be present can easily lead to an underestimation of these serious inheritable disorders. We report here two family subjects, a male proband and his aunt (paternal sister), both presented with the major features of Stickler syndrome. Tall stature with marfanoid habitus, astigmatism/congenital vitreous abnormality and submucus cleft palate/cleft uvula, and enlarged painful joints with early onset osteoarthritis. Osteochondritis dissecans (OCD) and Osgood Schlatter syndrome (OSS) were the predominating joint abnormalities.
We observed that the nature of the articular and physeal abnormalities was consistent with a localised manifestation of a more generalised epiphyseal dysplasia affecting the weight-bearing joints. In these two patients, OCD and OSS appeared to be the predominant pathologic musculoskeletal consequences of an underlying Stickler's syndrome. It is empirical to consider generalised epiphyseal dysplasia as a major underlying causation that might drastically affect the weight-bearing joints.
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.
Osteochondritis dissecans; Hughston scale; knee; mosaicplasty
This paper presents a clinical and functional assessment of the cases of osteochondritis dissecans (OCD) treated with small mosaicplasty type osteochondral grafts. Between 1999 and 2004, we operated on 12 knees with OCD stages III and IV. They were assessed using the International Cartilage Research Society (ICRS) scale, the Visual Analogue Scale (VAS) scale, X-ray and magnetic resonance imaging (MRI). The study was carried out using a clinical series, was retrospective and had a level of evidence of 4. Before surgery, all patients were in classes III and IV on the ICRS scale (four in class III and eight in class IV). At the time of surgery, the patient age was 27.5 ± 7.9 years, with male predominance (75%). Eleven of the cases were assessed as classes I and II on the ICRS scale (seven in class I and four in class II), with one patient in class IV. X-ray assessment was less favourable, revealing alterations in the articular space in 75% of cases. The results show that this technique enables the biological fixation of fragments and, functionally, the clinical results obtained were very good. The osteochondral grafts avoid the implantation of foreign material and make use of bone fragments of the same rigidity as the OCD fragment. We conclude that the technique described is an excellent alternative to the techniques normally used for the fixation of stage III and IV OCD.
In the treatment of osteochondritis dissecans involving the elbow, we have used a bone-peg graft taken from the proximal part of the ulna and inserted into the defect. Thirty-two patients were followed from 2 to 10.5 years. The graft was utilised in 20 elbows, and 6 of these also had concomitant removal of a loose body. Another 6 elbows had removal of a loose body only. Ten elbows were treated conservatively in 5 of these the outcome was unsatisfactory, including 4 in which a bone-peg graft was later necessary. The bone-peg graft gave the best short-term results. Bony union of the dissecans site and reconstitution of subchondral bone required an average of 6.5 months. In 15 patients followed for a minimum of 5 years, the bone-peg graft was effective in limiting the development of osteoarthritis. Bone-peg grafting is a reliable method for treating osteochondritis dissecans of the elbow.
The case of a 15-year-old boy, a high-performance motocross rider, who developed bilateral osteochondritis dissecans of the elbow is described. Both lesions were successfully treated by Herbert screw internal fixation.
Osteochondral fracture (OCF) of the lateral femoral condyle has a low incidence and old OCF is even more rarely seen; it is difficult to differentiate from late osteochondritis dissecans (OCD).
In this report, we present the case of a 20-year-old male patient with an old OCF of the lateral femoral condyle. The possible etiology of OCF is discussed, along with its clinical manifestation, diagnosis, and treatment. He underwent arthroscopically-assisted reduction and fixation with cannulated screws. Four months after the surgery, arthroscopy showed good osteochondral healing, and screws were removed. He had achieved good functional recovery by the follow-up visit.
Old OCF should be distinguished from OCD in clinical practice, and osteochondral bodies should be preserved as much as possible. Osteochondral reduction and fixation under arthroscopy was minimal and the clinical effect was good.
osteochondral fracture (OCF); arthroscopy; femoral condyle
Osteochondritis dissecans of the knee is identified with increasing frequency in the young adult patient. Left untreated, osteochondritis dissecans can lead to the development of osteoarthritis at an early age, resulting in progressive pain and disability. Treatment of osteochondritis dissecans may include nonoperative or operative intervention. Surgical treatment is indicated mainly by lesion stability, physeal closure, and clinical symptoms. Reestablishing the joint surface, maximizing the osteochondral biologic environment, achieving rigid fixation, and ensuring early motion are paramount to fragment preservation. In cases where the fragment is not amenable to preservation, the treatment may include complex reconstruction procedures, such as marrow stimulation, osteochondral autograft, fresh osteochondral allograft, and autologous chondrocyte implantation. Treatment goals include pain relief, restoration of function, and the prevention of secondary osteoarthritis.
osteochondritis dissecans; knee; cartilage; surgical treatment
Limb joint soundness was examined in 40 pigs loaded into a wooden box cart and 40 control pigs not subjected to loading. On postmortem examination, eight loaded pigs showed osteochondritis dissecans in their medial humeral condyles, suggesting that porcine joints are vulnerable to osteochondral lesions when mechanically overloaded. Prevention of trauma by careful handling of pigs during penning and transportation should help to control joint lesions and lameness.
The purpose of this study was to determine if the cartilage from loose osteochondral fragments remains viable. Five patients with OCD of the knee who had undergone surgical treatment (arthroscopic reduction and internal fixation of the loose body) were included. The average age of patients was 13 years (range 10–14 years). Cartilage samples were obtained from the loose body fragments before reattachment was performed (study group) and from the healthy native cartilage (intercondyle area, control group) from each of the five patients. Tissue viability was assessed using live-dead assay in both groups. All five loose osteochondral fragments showed similar viability to the healthy native cartilage group, with 88% cell viability (95% CI 50–100) in loose body fragments versus 92% viability (95% CI 50–100) from healthy cartilage. This study showed that cartilage from detached OCD fragments remains viable before reattachment is performed.
To determine the clinical outcome of arthroscopic debridement for osteochondritis dissecans of the elbow.
A prospective cohort study was started in 2000; between 2000 and 2005, 15 patients (six male, nine female, mean age 28 years (range 16–49)) were treated for osteochondritis dissecans of the elbow with arthroscopic debridement. The lesion was graded during surgery using the classification of Baumgarten. The dominant side was operated on in seven of 15 patients, and all patients were involved in a sport in which the elbow is used extensively. Elbow function was assessed before and after surgery using the modified Andrews elbow scoring system (MAESS); pain was scored on a visual analogue scale (0, no pain; 10, severe pain). Evaluation was performed an average of 45 (range 18–59) months after surgery. Statistical analysis (Student's t test) was carried out using SPSS statistical software. p<0.005 was considered significant.
There were no complications. The range of motion did not improve significantly. The mean MAESS score improved from 65.5 (poor) before surgery to 90.8 (excellent) after (p<0.001). The mean level of pain at rest decreased from 3 to 1, and the level of pain after provocation decreased from 7 to 2 (p<0.001). All patients were able to return to work 3 months after surgery, and 80% were able to resume their pre‐injury level of sport activity.
The clinical outcome after arthroscopic debridement for osteochondritis dissecans of the elbow shows good results, with pain relief during activities of daily living and sport. The function of the elbow, as reflected by the MAESS score, improved from poor to excellent. All patients in this series will be reviewed after 5 years to determine long‐term results.
arthroscopic debridement; elbow; osteochondritis dissecans
Extrusion of the lateral meniscus has been reported after posterior root tear or radial tear, partial meniscectomy, and meniscoplasty of discoid meniscus. It has also been shown to be associated with the development of osteoarthritis. This technical note describes a new arthroscopic technique to centralize and stabilize the mid body of the lateral meniscus to restore and maintain the lateral meniscus function by repairing/preventing extrusion of the meniscus. A JuggerKnot Soft Anchor (Biomet, Warsaw, IN), loaded with a MaxBraid suture (Biomet), was placed on the lateral edge of the lateral tibial plateau, just anterior to the popliteal hiatus, through a midlateral portal. A Micro Suture Lasso Small Curve with Nitinol Wire Loop (Arthrex, Naples, FL) was used to pass 2 limbs of the MaxBraid suture through the meniscus at the margin between the meniscus and the capsule. Another anchor was inserted on the lateral edge of the lateral tibial plateau, 1 cm anterior to the first anchor, and the same procedure was repeated. The sutures were then tied by use of a self-locking sliding knot, achieving centralization and secure stabilization of the lateral meniscus.
Osteochondritis dissecans (OCD) of the humeral capitellum is a disorder affecting mainly boys between the ages of 12 and 15 years. The exact etiology of OCD is not clear, but it is believed that repetitive trauma is the primary cause. Genetic factors are thought to play a secondary role in the pathogenesis. We present 17-year-old identical twins with similar MRI and arthroscopic findings, suggesting that genetic components are involved in the etiology of OCD of the humeral capitellum.
Osteochondritis dissecans; elbow; MR imaging; identical twins
Current treatments for osteochondral injuries often result in suboptimal healing. We hypothesized that the combination of hyperbaric oxygen (HBO) and fibrin would be superior to either method alone in treating full-thickness osteochondral defects.
Osteochondral repair was evaluated in 4 treatment groups (control, fibrin, HBO, and HBO+fibrin groups) at 2-12 weeks after surgical injury. Forty adult male New Zealand white rabbits underwent arthrotomy and osteochondral surgery on both knees. Two osteochondral defects were created in each femoral condyle, one in a weight-bearing area and the other in a non-weight-bearing area. An exogenous fibrin clot was placed in each defect in the right knee. Left knee defects were left empty. Half of the rabbits then underwent hyperbaric oxygen therapy. The defects in the 4 treatment groups were then examined histologically at 2, 4, 6, 8, and 12 weeks after surgery.
The HBO+fibrin group showed more rapid and more uniform repair than the control and fibrin only groups, but was not significantly different from the group receiving HBO alone. In the 2 HBO groups, organized repair and good integration with adjacent cartilage were seen at 8 weeks; complete regeneration was observed at 12 weeks.
HBO significantly accelerated the repair of osteochondral defects in this rabbit model; however, the addition of fibrin produced no further improvement.
Osteochondral fractures of lateral femoral condyle are common in adolescents and young adults. They are usually caused by direct trauma or twisting injuries of the knee. We present a case of large osteochondral fracture of lateral femoral condyle involving the articular surface in a fifteen-year-old male with a positive history of significant weight gain of 5 kilograms in last six months. Blood investigations reported low vitamin D and testosterone levels with elevated alkaline phosphatase. Adequate exposure was achieved by doing Z-plasty of quadriceps apparatus. The fracture was treated with open reduction and internal fixation using Herbert's screws. Medical management in the form of vitamin D and calcium along with testosterone was given. After the surgery, full weight-bearing was allowed at three months. At one year followup, patient has good quadriceps function without any weakness of the muscle.