The optimal treatment option for osteochondritis dissecans of the knee is still controversial. We report the case of a boy who developed osteochondritis dissecans in the lateral femoral condyles of his bilateral knees requiring repeat surgical procedures. There has been no literature reporting juvenile osteochondritis dissecans of bilateral knees requiring repeat surgical procedures.
A 6-year-old Japanese boy presented with pain in his bilateral knees. Although conservative treatment with prohibition of sports activities was continued for 6 months, healing could not be attained. Conservative treatment consisting of prohibition of sports activities that included running and jumping and use of a brace with a locking mechanism at full extension was applied. He was instructed to walk with the brace. Since his lateral femoral osteochondritis dissecans lesion was located at the contact area during flexion, weight bearing with the use of the brace could effectively unload the lesion. Surgery was subsequently conducted on his left knee which had a more advanced stage lesion. Transchondral drilling was performed because the articular surface maintained its smooth continuity. At 9 months after the surgery, no appreciable healing was observed in the follow-up radiographs. Moreover, during the postoperative time course, lesions suggestive of osteochondritis dissecans in his contralateral right knee had become more evident. Based on the diagnosis of delayed union of bilateral osteochondritis dissecans lesions, a second surgery was attempted. The preceding arthroscopic observation of his left knee showed preserved surface continuity with softening and suspected partial detachment. Considering the delayed healing process observed in this patient, autogenous cylindrical osteochondral graft transplantation (8 mm in diameter) was performed as a revision procedure, while transchondral drilling was performed for the stable osteochondritis dissecans lesion in his right knee. Postoperatively, healing was achieved at 6 months.
Following failed conservative treatment, he underwent arthroscopic drilling; however, the osteochondritis dissecans lesion did not heal requiring revision surgery using a cylindrical autogenous osteochondral graft. Finally, clinical and radiological healing was attained 6 months after the second surgery. Initial presentation at a young age with bilateral lesions may be clinical factors related to poor healing response and susceptibility to stress-related subchondral lesions.
Bilateral; Knee; Osteochondritis dissecans
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.
The optimal treatment for combined osteochondritis dissecans (OCD) with considerable bony defect of the lateral femoral condyle (LFC) and torn discoid lateral meniscus is unclear. We present a case of a 15-year-old female who was a gymnast and had a large OCD lesion in the LFC combined with deficiency of the lateral meniscus. The patient underwent the "one-step" technique of osteoperiosteal autologous iliac crest graft and lateral meniscus allograft transplantation after a failure of meniscectomy with repair at another hospital. Twenty-four months postoperatively, clinical results were significantly improved. Follow-up imaging tests and second-look arthroscopy showed well incorporated structured bone graft and fibrous cartilage regeneration as well as stabilized lateral meniscus allograft. She could return to her sport without any pain or swelling. This "one-step" surgical technique is worth considering as a joint salvage procedure for massive OCD lesions with torn discoid lateral meniscus.
Knee; Meniscus; Cartilage; Autograft; Transplantation
An osteochondral lesion in the knee joint is caused by a focal traumatic osteochondral defect, osteochondritis dissecans, an isolated degenerative lesion, or diffuse degenerative disease. An osteochondral lesion with a cleft-like appearance accompanying medial meniscus injury is rare without trauma. We report the case of a 13-year-old boy who complained of right knee pain and swelling, with radiographic findings of an osteochondral defect. Arthroscopic inspection showed an osteochondral lesion in the medial condyle of the femur and tibial plateau accompanying a partial medial meniscus discoid tear. Partial meniscectomy was performed, and a microfracture procedure was carried out on the osteochondral defect. The patient was asymptomatic at 2 years' follow-up. This technique is a relatively easy, completely arthroscopic procedure that spares the bone and cartilage and has yielded a good clinical outcome in a skeletally immature patient who had an osteochondral lesion with a cleft-like appearance.
Several etiological theories have been proposed for the development of osteochondritis dissecans. Cartilage toxicity after fluoroquinolone use has been well documented in vitro. We present a case report of a 10-year-old child who underwent a prolonged 18-month course of ciprofloxacin therapy for chronic urinary tract infections. This patient later developed an osteochondritis dissecans lesion of the medial femoral condyle. We hypothesize that the fluoroquinolone therapy disrupted normal endochondral ossification, resulting in development of osteochondritis dissecans. The etiology of osteochondritis dissecans is still unclear, and this case describes an association between fluoroquinolone use and osteochondritis dissecans development.
Paediatrics (drugs and medicines); Drugs and medicines; Musculoskeletal and joint disorders; Drugs and medicines
Several aetiological theories have been proposed for the development of osteochondritis dissecans. Cartilage toxicity after fluoroquinolone use has been well documented in vitro. We present a case report of a 10-year-old child who underwent a prolonged 18-month course of ciprofloxacin therapy for chronic urinary tract infections. This patient later developed an osteochondritis dissecans lesion of the medial femoral condyle. We hypothesise that the fluoroquinolone therapy disrupted normal endochondral ossification, resulting in development of osteochondritis dissecans. The aetiology of osteochondritis dissecans is still unclear, and this case describes an association between fluoroquinolone use and osteochondritis dissecans development.
Symptomatic osteochondritis dissecans lesions of the knee frequently occur in skeletally immature patients. When conservative treatment fails, retro-articular drilling, also known as intraepiphyseal extra-articular drilling, becomes a viable treatment option. The purpose of this article is to describe our surgical technique and postoperative management of patients with stable osteochondritis dissecans lesions involving the femoral condyles. This technique is reproducible, uses readily available equipment, and has yielded good clinical outcomes with high healing rates and relatively early return to sports.
Describe the clinical characteristics, image findings, and outcomes of patients with juvenile osteochondritis dissecans (JOCD) of the knee. To our knowledge, this is the largest single-surgeon cohort of JOCD patients.
Retrospective cohort study of knee JOCD patients assessed by a single pediatric orthopaedic surgeon at a tertiary care center between 2005-2015. All diagnoses were confirmed by magnetic resonance imaging (MRI). Patients with patellar dislocations or osteochondral fractures were excluded. Demographic data, sports played, comorbidities, surgical procedures, and clinical data were extracted from charts. Images were analyzed to identify the location and size of lesions. Chi-square or Fisher’s exact tests were used to compare discrete variables, and Mann-Whitney U and Kruskal Wallis tests to compare continuous variables between groups. P-values of <0.05 were considered significant.
Sample consisted of 180 patients (207 knees), 124 boys and 56 girls. Average age at diagnosis was 12.8 years (7.5-17.5). Majority were active in sports (80.8%), primary soccer (36.7%) and basketball (29.4%). JOCD was present bilaterally in 27 patients (15%), 14 knees had bifocal OCD (6.8%), and only 1 patient had bifocal lesions in both knees. Most common location was medial femoral condyle (56.3%) followed by lateral femoral condyle (23.1%), trochlea (11.4%), patella (9%), and tibia (0.5%). In the sagittal view, most common location was the middle third of the condyles (48.7%). Surgery was performed in 72 knees (34.8%), with an average age at surgery of 14.1 years (9.3-18.1). Bilateral JOCD was present in 13 surgical patients (18.8%), but only 3 patients had bilateral surgery. Two operative patients had bifocal JOCD (2.7%) and surgery on both lesions. Location distribution did not differ between surgical and non-surgical lesions. The average normalized area of non-surgical JOCD lesions was 6.8 (0.1-18), whereas surgical lesions averaged a significantly higher area of 7.7 (0.5-17) (p=0.023). Average BMI was 21.6 versus 20.2 for surgical and non-surgical patients, respectively, significantly higher for those who underwent surgery (p=0.002). Most common procedure was fixation with 1.6 mm bioabsorbable nails (54.2%), using an average of 4 nails (1-9). Only 2 cases were fixed using metallic headless screws. Other surgical treatments were drilling (13.9%), microfracture (13.9%), microfracture + fixation (6.9%), removal of loose body/chondroplasty (6.9%), and allograft transplantation (4.2%). Fixation was achieved all-arthroscopic in 43.1% of the cases, and 61.3% of the lesions that were fixed underwent curettage of the subchondral bone. Revision surgery was required in 14 knees (19.4%). The most common revision procedures were microfracture, removal of hardware, chondroplasty and allograft implantation, where some revisions had combined procedures. Most surgical patients had postoperative MRIs (55 knees), with an average radiological follow-up of 14.5 months (range 2.1-55.4).
JOCD occurs more frequently in young adolescent athlete boys, affecting the middle third of the medial femoral condyle. In our cohort, 1/3 of the patients had surgery, where bigger lesions and higher BMI were risk factors for operative treatment. At short-term follow up, the success rate following surgery was above 80%.
Although good clinical outcomes of autologous osteochondral plug grafts for capitellar osteochondritis dissecans (OCD) have been reported, the timing of return to sports was various and still controversial. The period of graft incorporation and the lesion healing at repair site is important to establish the rehabilitation protocol, however there is little information. The aim of this study was to investigate early postoperative magnetic resonance imaging (MRI) findings and clinical outcomes after autologous osteochondral plug grafts for capitellar OCD.
Fifteen young baseball players with advanced lesions of capitellar OCD underwent a procedure using autologous osteochondral plug grafts and underwent MRI (1.5 T) scan at 3 and 6 months, postoperatively. Their mean age at the time of surgery was 13.5 years (range, 13-15 years). Four lesions were classified as International Cartilage Repair Society (ICRS) OCD III and 11 lesions as OCD IV. The mean size of the lesions (sagittal × coronal) was 16 × 14 mm and the mean surface area was 181 mm2. One to two osteochondral plug grafts, with a mean diameter of 7 mm (range, 6-8 mm), were harvested from the lateral femoral condyle and transplanted to the defects. The mean reconstruction rate was 41% (range, 12%-65%), which was calculated as (total surface area of the grafts × 100%)/ (surface area of the lesion). Patients were allowed to begin throwing after 3 months and to return to sports after 6 months. The mean follow-up was 21 months (range, 12-36 months). The MRI findings were assessed graft incorporation, which was indicated by no T1-low-signal-intensity at the graft and no fluid surrounding the graft on T2-weighted fat-suppression (Figure 1), and the lesion healing according to the scoring system of Henderson (4, complete healing; 16, no healing). MRI were blinded and randomized, and two observers reviewed independently and conferred when they differed. Clinical outcomes were evaluated as elbow pain, Timmerman and Andrews (T&A) scores, and return to baseball. We also analyzed the relationship between complete healing at 6 months and each factor: graft size, lesion size, reconstruction rate.
Grafts were incorporated in 11 patients at 3 months and 13 patients (87%) at 6 months, postoperatively (Table 1). Mean Henderson score were 4.6 at 3 months and 4.5 at 6 months, and complete healing was in 9 patients at 3 months and 11 patients (73%) at 6 months. The mean T&A score improved significantly from 141 to 184 (P < .05). Thirteen patients had no elbow pain and one patient had occasional mild throwing pain, and all these patients (93%) returned to a competitive level at 6 months. The remaining one patient whose reconstruction rate was 24% and MRI showed incomplete healing at 6 months was difficult to throw because of elbow pain and underwent revision surgery. There were no relationships between complete healing and graft or lesion size (mean graft size: complete 7.4 mm, incomplete 6.8 mm, P = .16, mean lesion size: complete 166 mm2, incomplete 220 mm2, P = .13). On the other hand, all nine patients whose reconstruction rate was 36% or more were achieved complete healing, whereas two of six patients (33%) less than 36% did (P < .05).
These results indicated that our rehabilitation protocol was appropriate for young baseball players after autologous osteochondral plug grafts for capitellar OCD. Although it is not clinically required to reconstruct the entire articular defect, more than 36% of the area should be reconstructed.
Osteochondrosis dissecans is a disorder of the subchondral bone potentially affecting the adjacent articular cartilage. There remains disunity with regard to treatment methods.
We present the case of a 21-year-old Swiss woman who presented with clinically symptomatic bilateral osteochondrosis dissecans lesions at both medial femoral condyles. She underwent sequential surgical intervention and was prospectively monitored using clinical scores and magnetic resonance imaging. Her left knee was treated with an open refixation of the osteochondrosis dissecans lesion with two 2.0 mm screws in combination with a cancellous bone graft and subchondral drilling since the cartilage of the osteochondrosis dissecans lesion was intact. On her right knee, she underwent open removal of the defective bone and cartilage, cancellous bone graft with subchondral drilling and coverage with a bilayered collagenous membrane (autologous matrix-induced chondrogenesis technique) since the cartilage of the osteochondrosis dissecans lesion was not intact. At final follow-up 12 months after surgery her Lysholm score had improved from 79 to 95 on her left side and from 74 to 78 on her right. Magnetic resonance imaging displayed good integration of the cancellous bone graft with a slight irregularity at the articular surface on her left side (magnetic resonance observation of cartilage repair tissue (MOCART) 75). The magnetic resonance imaging of her right knee depicted satisfying bony reconstitution with yet more irregularity at the joint surface (magnetic resonance observation of cartilage repair tissue 65) in comparison to her left femoral condyle.
In cases of failed conservative treatment of osteochondrosis dissecans lesions of the knee joint surgery should be taken into consideration. Considering this case, we believe that the focus should be the preservation of the cartilaginous layer whenever possible or at least replacement with high quality replacement tissue, such as autologous chondrocyte implantation.
Knee; OCD; OD; Osteochondrosis dissecans; Reconstruction; Refixation; Single patient
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 (OCD) can progress to loose body formation, with or without subchondral bone attachment to the lesion. The efficacy of internal fixation of chondral loose bodies has not been determined.
Operative fixation of cartilaginous loose bodies would result in (1) healed OCD at second-look arthroscopy, (2) restored cartilage appearance on magnetic resonance imaging (MRI), and (3) nearly normal knee function, as determined by patient-reported outcome scores.
Retrospective case series; Level of evidence, 4.
Five patients who underwent cartilaginous loose body fixation were identified. Lesions were located on the lateral trochlea (n = 2) and medial femoral condyle (n = 3) (mean size, 2.5 cm2). Loose bodies were reattached with compression screws through mini-arthrotomy or arthroscopy. Patients were nonweightbearing for 12 weeks postoperatively. After 12 weeks, screws were removed arthroscopically, and OCD stability was evaluated. Three patients underwent MRI to determine articular cartilage status. Images were evaluated using the magnetic resonance observation of cartilage repair tissue (MOCART) score. Patients were interviewed and completed the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire.
Four patients had stable lesions at 12 weeks after surgery. One patient had slight motion to one-third of the lesion and stability to the remaining two-thirds. Three patients underwent an MRI. The mean time from surgery to MRI was 3.1 years. Mean MOCART score was 72.0 ± 10.4. One patient required repeat arthroscopy 1 year after initial fixation for debridement and arthroscopic drilling of an incompletely healed area of the lesion. Four patients completed the KOOS questionnaire. The mean time to KOOS completion was 4.6 years. Mean KOOS subscales for knee pain (91.0 ± 8.9), knee symptoms (83.0 ± 7.9), and function in activities of daily living (91.9 ± 10.6) were similar to published age-matched controls; however, scores for sports and recreation function (70.0 ± 17.8) and knee-related quality of life (67.2 ± 12.9) were lower.
Operative fixation of chondral loose bodies, without macroscopically visible subchondral bone attachment, resulted in lesion stability at second-look arthroscopy. At final follow-up, patients had no substantial pain and normal function in activities of daily life compared with controls; however, knee-related quality of life and sport and recreation function were reduced, and 1 patient required reoperation for an unhealed portion of the lesion.
osteochondritis dissecans; OCD; knee; chondral loose body; operative fixation; functional outcome
Failure of initial treatment for juvenile osteochondritis dissecans (OCD) may require further surgical intervention, including microfracture, autograft chondrocyte implantation, osteochondral autografting, and fresh osteochondral allografting. Although allografts and autografts will restore function in most adults, it is unclear whether fresh osteochondral allograft transplantations similarly restore function in skeletally immature patients who failed conventional treatment.
Therefore, we determined function in (1) daily activity; (2) sports participation; and (3) healing (by imaging) in children with juvenile OCD who failed conventional therapy and underwent fresh osteochondral allograft transplantation.
We retrospectively reviewed 11 children with OCD of the knee treated with a fresh stored osteochondral allograft between 2004 and 2009 (six males and five females). The average age of the children at the time of their allograft surgery was 15.2 years (range, 13–20 years). The clinical assessments included physical examination, radiography, MRI, and a modified Merle D’Aubigné-Postel score. The size of the allograft was an average of 5.11 cm2. The minimum followup was 12 months (average, 24 months; range, 12–41 months).
All patients had returned to activities of daily living without difficulties at 6 months and returned to full sports activities between 9 and 12 months after surgery. The modified Merle D’Aubigné-Postel score improved from an average of 12.7 preoperatively to 16.3 at 24 months postoperatively. Followup radiographs at 2 years showed full graft incorporation and no demarcation between the host and graft bone.
Our observations suggested fresh osteochondral allografts restored short-term function in patients with juvenile OCD who failed standard treatments.
Level of Evidence
Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.
The aim of this study is to compare the hold in bone of Meniscus Arrows® and Smart Nails®, followed by the report of the results of the clinical application of Meniscus Arrows® as fixation devices. First, pull-out tests were performed to analyse the holdfast of both nails in bone. Statistical analysis showed no significant difference; therefore, the thinner Meniscus Arrow® was chosen as fixation device in the patient series of two patients with a symptomatic Osteochondritis dissecans fragment and three patients with an osteochondral fracture of a femur condyle. The cartilage margins were glued with Tissuecoll®. All fragments consolidated. Second look arthroscopy in three patients showed fixed fragments with stable, congruent cartilage edges. At an average follow-up period of 5 years no pain, effusion, locking, restricted range of motion or signs of osteoarthritis were reported. Based on the results of the pull-out tests and available clinical studies, Meniscus Arrows® and Smart Nails® are both likely to perform adequately as fixation devices in the treatment of Osteochondritis dissecans and osteochondral fractures in the knee. They both provide the advantage of one stage surgery. However, based on their smaller diameter, the Meniscus Arrows® should be preferred for this indication.
Osteochondritis dissecans; Osteochondral fragments; Biodegradable; Fixation devices; Meniscus Arrows®
Severe osteochondritis dissecans (OCD) in children and adolescents often necessitates surgical interventions (ie, drilling, excision, or débridement). Since extracorporeal shock wave therapy (ESWT) enhances healing of long-bone nonunion fractures, we speculated ESWT would reactivate the healing process in OCD lesions.
We asked whether ESWT would enhance articular cartilage quality, bone and cartilage density, and histopathology of osteochondral lesions compared to nontreated controls in an OCD rabbit model.
We harvested a 4-mm-diameter plug of the weightbearing osteochondral surface on the medial femoral condyle of each knee in 20 skeletally immature (8-week-old) female rabbits. We placed a piece of acellular collagen-glycosaminoglycan matrix into the cavity and then replaced the plug. Two weeks after surgery, we sedated each rabbit and treated the right knee in a single setting with shock waves: 4000 impulses at 4 Hz and 18 kV. The left knee was a sham control. Ten weeks after surgery, we assessed cartilage morphology of the lesion using a modified Outerbridge Grading System, bone and cartilage density using histologic imaging, bone and cartilage morphology using the histopathology assessment system, and radiographic bone density and union and compared these parameters between ESWT-treated and control knees.
Histologically, we observed more mature bone formation and better healing (1.1 versus 3.4) and density of the cartilage (60 versus 49) on the treated side. Radiographically, we noted an increase in bony density (154 versus 138) after ESWT.
ESWT accelerated the healing rate and improved cartilage and subchondral bone quality in the OCD rabbit model.
This therapeutic modality may be applicable in OCD treatment in the pediatric population. Future research will be necessary to determine whether it may play a role in healing of human osteochondral defects.
Osteochondritis dissecans (OCD) of the knee is a disorder in juveniles and young adults; however, its etiology still remains unclear. For OCD at the medial femoral condyle (MFC), it is sometimes observed that the lesion has a connection with fibers of the posterior cruciate ligament (PCL). Although this could be important information related to the etiology of MFC OCD, there is no report examining an association between the MFC OCD and the PCL anatomy.
To investigate the anatomic features of knees associated with MFC OCD, focusing especially on the femoral attachment of the PCL, and to compare them with knees associated with lateral femoral condyle (LFC) OCD and non-OCD lesions.
Case-control study; Level of evidence, 3.
We retrospectively reviewed 39 patients (46 knees) with OCD lesions who had undergone surgical treatment. Using magnetic resonance imaging (MRI) scans, the PCL attachment at the lateral wall of the MFC was measured on the coronal sections, and the knee flexion angle was also measured on the sagittal sections. As with non-OCD knees, we reviewed and analyzed 25 knees with anterior cruciate ligament (ACL) injuries and 16 knees with meniscal injuries.
MRIs revealed that the femoral PCL footprint was located in a significantly more distal position in the patients with MFC OCD compared with patients with LFC OCD and ACL and meniscal injuries. There was no significant difference in knee flexion angle among the 4 groups.
The PCL in patients with MFC OCD attached more distally at the lateral aspect of the MFC compared with knees with LFC OCD and ACL and meniscal injuries.
osteochondritis dissecans; posterior cruciate ligament; femoral footprint; anatomic feature
Discoid meniscus is an anatomical congenital anomaly more often found in the lateral meniscus. A discoid medial meniscus is a very rare anomaly, and even more rare is to diagnose a bilateral discoid medial meniscus although the real prevalence of this situation is unknown because not all the discoid medial menisci are symptomatic and if the contralateral knee is not symptomatic then it is not usually studied. The standard treatment of this kind of pathology is partial meniscectomy. Currently the tendency is to be very conservative so suture and saucerization of a torn discoid meniscus when possible are gaining support. We present the case of a 13-year-old patient who was diagnosed with symptomatic torn bilateral discoid medial meniscus treated by suturing the tear and saucerization. To the best of our knowledge this is the first case reported of bilateral torn discoid medial meniscus treated in this manner in the same patient.
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.
Treatment decision making for chondral defects in the knee is multifactorial. Articular cartilage pathology, malalignment, and meniscal deficiency must all be addressed to optimize surgical outcomes.
To determine whether significant clinical improvements in validated clinical outcome scores are observed at minimum 2-year follow-up after articular cartilage repair of focal articular cartilage defects of the lateral compartment of the knee with or without concurrent distal femoral osteotomy and lateral meniscus transplant.
Case series; Level of evidence, 4.
Symptomatic adults who underwent surgical treatment (microfracture, autologous chondrocyte implantation [ACI], osteochondral autograft or allograft) of full-thickness lateral compartment chondral defects of the knee with or without a postmeniscectomy compartment or valgus malalignment by a single surgeon with minimum 2-year follow-up were analyzed. Validated patient-reported and surgeon-measured outcomes were collected pre- and postsurgery. Pre- and postoperative outcomes were compared via Student t tests.
Thirty-five subjects (mean age, 29.6 ± 10.5 years) were analyzed. Patients had been symptomatic for 2.51 ± 3.52 years prior to surgery and had undergone 2.11 ± 1.18 surgeries prior to study enrollment, with a mean duration of follow-up of 3.65 ± 1.71 years. The mean defect size was 4.42 ± 2.06 cm2. Surgeries included ACI (n = 18), osteochondral allograft (n = 14), osteochondral autograft (n = 2), and microfracture (n = 1). There were 18 subjects who underwent concomitant surgery (14 lateral meniscus transplant, 3 distal femoral osteotomy, and 1 combined). Statistically significant (P < .05) and clinically meaningful improvements were observed at final follow-up in Lysholm, subjective International Knee Documentation Committee (IKDS), Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales, Short Form–12 (SF-12) scores, and patient satisfaction. At follow-up, patients undergoing isolated articular cartilage surgery had a significantly higher KOOS quality of life subscore than did those undergoing articular cartilage surgery and lateral meniscus transplant (P = .039). Otherwise, there were no significant postoperative differences between the isolated and combined surgery groups in any outcome score. Five patients underwent 6 reoperations (1 revision osteochondral allograft, 5 chondroplasties). No patient was converted to knee arthroplasty.
In patients with lateral compartment focal chondral defects with or without lateral meniscal deficiency and valgus malalignment, surgical cartilage repair and correction of concomitant pathology can significantly improve clinical outcomes at 2-year follow-up with no significant differences between isolated and combined surgery and a low rate of complications and reoperations.
knee; articular cartilage repair; meniscus transplantation; distal femoral osteotomy; lateral compartment
the unstable osteochondritis dissecans (OCD-type II and III according to the ICRS classification) of the knee largher than > 2.5 cm2 in adults are uncommon lesions and there is no consensus on how to treat them. Medium-term studies have reported good results using autogenous osteochondral plugs (mosaicplasty). The aim of this study is to analyze the long-term results of this technique for the treatment of unstable OCD in a selected group of adult patients.
four patients with OCD at either one of the femoral condyles were included in this prospective study. The average age was 21.2 years (range, 18–24 years). The OCD lesions were classified as type II in three patients and type III in one patient and the average size was 3.8 cm2 (range, 2.55–5.1 cm2). The lesions were treated in situ with a variable number of autogenous osteochondral plugs (Ø 4.5 mm2). The Modified Cincinnati, Lysholm II and Tegner scores were used for clinical and functional evaluation. Magnetic resonance arthrography (MRA) was performed before surgery and at 2, 5 and 10 years after surgery. A modified MOCART score was used to evaluate MRA findings.
the average follow-up duration was ten years and 6 months (range, 10–11 years). No complications occurred. At the final follow-up, all scores (clinical, functional and MOCART) improved. In all but one of the patients MRA showed complete osteochondral repair.
the fixation of large and unstable OCD lesions with mosaicplasty may be a good option for treating type II or III OCD lesions in adults. The advantages of this technique include stable fixation, promotion of blood supply to the base of the OCD fragment, and grafting of autologous cancellous bone that stimulates healing with preservation of the articular surface.
Level of evidence
Level IV, therapeutic case series.
osteochondritis dissecans; osteochondral graft; adults; MR arthrography
Background. A discoid meniscus is a thickened variant of the normal C-shaped meniscus prone to injury. Discoid medial meniscal tears have rarely been reported within families and may suggest familial or developmental origins. Methods. We report the cases of two Caucasian brothers with symptomatic discoid medial meniscus tears. A literature review was conducted addressing discoid medial meniscus and cases of familial meniscus tears. Case Presentation. Physically active brothers presented with progressively worsening knee pain. MRI revealed medial meniscus tears in both brothers. The family history of medial meniscus tears in their mother and the discoid medial meniscus injuries found on arthroscopy suggested evidence for familial discoid medial meniscus tears. Conclusions. Discoid medial meniscus tears within a family have not been previously reported. Two cases of families with discoid lateral meniscus tears have been reported. Discoid medial meniscus is rare relative to the discoid lateral meniscus and predisposes children to symptomatic tears.
Approximately 30-50% of skeletally immature patients with stable osteochondritis dissecans (OCD) lesions of the knee fail to heal with non-operative treatment, and about 30% of patients who undergo surgery fail to heal radiographically. Unfortunately it is nearly impossible to predict which patients will heal with non-surgical or surgical treatment. We identified multiple OCD features on standard radiographs that may help to predict healing rates. In this study, we test the inter- and intra- rater reliability of orthopaedic surgeons from multiple institutions on classifying these specific OCD radiographic features.
Pre-treatment anteroposterior, lateral, and notch radiographs (Figure) of 45 pediatric knees containing OCD lesions of the medial or lateral femoral condyle were reviewed by 7 physician raters at different medical institutions at two time points. Images were viewed over a secure internet portal. Classifications included lesion location (medial/lateral), growth plate maturity (open/closing/closed), visibility of the progeny bone including fragmentation (yes/no), fragment displacement (none/partial/total), boundary (distinct/indistinct), shape (convex/linear/concave), and comparative radiodensity of the center and rim (more/same/less). Condylar width and lesion size were measured on all views. Inter-observer reliability was measured using free-marginal kappa (kf) and intraclass correlations. Intra-observer reliability was measured using Cohen’s kappa (kc), linear-weighted kappa (klw), and intraclass correlations depending on measurement type.
Inter- and intra-observer reliability were excellent for classification of lesion location (kf=0.96, kc=0.97, respectively) and skeletal maturity (ICC=0.86, klw=0.84, respectively) and for measuring knee and lesion size on all views (ICC=0.92-0.98, ICC=0.84-0.95, respectively). The visibility, fragmentation, and displacement of the progeny bone were classified with substantial reliability over time (kc=0.67, kc=0.64, klw=0.80, respectively) and moderate reliability between raters (kf=0.45, kf=0.54, ICC=0.52, respectively). The progeny bone boundary demonstrated substantial reliability between raters (kf=0.62) and moderate reliability over time (kc=0.55). Fair to moderate inter- and intra-observer reliability was obtained for classifying the shape (ICC=0.33, klw=0.53, respectively) and comparative radiodensity of parent and progeny bone (ICC=0.11-0.52, klw=0.32-0.57, respectively).
Most of the specific OCD radiographic features tested showed good to excellent reliability. Lesion shape and density had only fair to moderate reliability. The results of the current study support the use of OCD radiographic feature classification in multi-center investigations. Each reliable feature may be correlated with healing in future studies and help to predict OCD outcome at the start of treatment.
Osteochondritis dissecans (OCD) occurs frequently in the humeral capitellum of the upper extremity, whereas OCD involving the trochlear groove (trochlear groove OCD) is rarely reported. A standard treatment for trochlear groove OCD has therefore not been determined, although several methods have been tried.
The case of a 14-year-old male gymnast with bilateral trochlear groove OCD is presented. Retrograde drilling from the lateral condyle of the humerus was applied for the OCD lesion of the left elbow, since it was larger in size than that in the right elbow and was symptomatic. Conversely, since the right lesion was small and asymptomatic, it was managed conservatively.
After treatment, consolidation of the OCD lesions was observed in both elbows. However, the time to healing was shorter in the left elbow treated surgically than in the right elbow managed conservatively.
In conclusion, retrograde drilling is a very simple and minimally invasive treatment. This case suggests that retrograde drilling for trochlear groove OCD may be a useful procedure that may accelerate the healing process for OCD lesions.
The purpose of this study was to evaluate the clinical outcomes of osteochondral autograft transplantation (OAT) for juvenile osteochondritis dissecans (JOCD) lesions of the knee, especially time to return to sports.
Twelve knee JOCD lesions with OCD grade 3 and 4 categorised by magnetic resonance imaging (MRI) were treated with OAT. Nine male and two female skeletally immature patients averaging 13.7 years old were included. The OCD lesions were assessed arthroscopically and then fixed in situ using multiple osteochondral plugs harvested under fluoroscopy from the distal femoral condyle without damaging the physis. International Cartilage Repair Society (ICRS) score and Lysholm score were assessed pre- and postoperatively.
After a mean follow-up of 26.2 ± 15.1 months, the International Knee Documentation Committee (IKDC) subjective score significantly improved (p < 0.01). According to the IKDC score, objective assessment showed that ten of 12 (83 %) had excellent results (score: A) after OAT and significantly improved (p < 0.01). Based on ICRS criteria, results were satisfactory in all patients. No patients experienced complications at the graft harvest site. All patients returned to their previous level of athletic activity at an average of 5.7 months after the surgery.
OAT for JOCD of the knee provided satisfactory results in all patients at a mean follow-up of 26.2 months.
Numerous procedures exist to treat osteochondritis dissecans (OCD); however, it remains a topic of debate which procedure is most ideal. When restoring a massive osteochondral defect, the use of only one procedure may not always allow complete filling of the defect. This case report presents a massive OCD with displaced osteochondral fragment and loose body in the knee joint that occupied almost all of the weight bearing area of the medial femoral condyle and was treated with concomitant osteochondral autograft transplantation and fixation of displaced osteochondral fragment. To our knowledge, this is a rare report on OCD treated with concomitant osteochondral autograft transplantation and fixation of displaced osteochondral fragment. At 8 years after surgery, the clinical outcome was excellent, and radiographs revealed congruence of the medial femoral condyle. The patient returned to sports activities. In massive and complex OCD lesions, individual techniques have limitations. Two or more techniques are needed to increase the rate of success.
Osteochondritis dissecans; Autologous transplantation; Internal fixation