Osteochondritis dissecans of the knee

Osteochondri,s Dissecans of the knee Corey R. Troxell, D.O. October 9, 2012 OMED 2012 Osteochondri,s Dissecans   OCD   Condition of joints that affects subchondral bone   Secondary Effects on articular cartilage   With progression may disrupt the integrity of cartilage and bone   Cartilage flaps   Loose bodies   Inflammatory synovitis   Effusion   Secondary joint degeneration Osteochondri,s Dissecans E,ology   Unclear   Repetitive Microtrauma   Vascular insufficiency   Genetic factors   Knee most commonly involved  
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Lateral aspect of medial femoral condyle Ankle   Talus   Recurrent Ankle sprain   Persistent pain following sprain Elbow   Capitellum   Throwing athlete OCD Classifica,on   Location   Fragmentation   Displacement   Growth plate status   X-­‐ray   Bone Scan   MRI   Intraoperative OCD -­‐ Typical Pa,ent   10 to 15 years   Male to female   2:1   Bilateral   15-­‐30%   Screening of contralateral side OCD -­‐ Gene,c Factors   Questionable genetic predispostion   OCD Associated with:   Dwarfism   Tibia vara   Legg-­‐Calve-­‐Perthes   Stickler syndrome OCD -­‐ Vascular Factors   Possible etiology   No evidence of osteonecrosis   Paucity of vascular supply   Medial femoral condyle near PCL insertion   Reparative process arrested at fibrocartilage stage   Poor blood supply? OCD -­‐ Trauma,c Factors   40% Report history of trauma   Shear forces on cartilage and subchondral bone   Repetitive Microtrauma   Difficult to distinguish between OCD and osteochondral fractures   Radiographic   Histological OCD -­‐ Clinical Presenta,on   Open Physes   Juvenile-­‐onset OCD   Closed Physes   Adult-­‐onset OCD   Delayed onset of previously asymptomatic lesion OCD -­‐ Clincal Presenta,on   Pain   Generalized   Anterior   Swelling   Intermittent   Activity related   Mechanical symptoms   Catching   Locking   Giving way OCD -­‐ Clinical Exam   Inspection   Palpation   Medial femoral condyle   Flexion   Range of Motion   Strength   Ligamentous Stability   Mensical testing OCD -­‐ Physical Exam   External rotation of tibia during gait   Avoid impingement of tibial eminence on OCD of medial femoral condyle   Wilson s test   Internal rotation of tibia between 30° and 90°   Reproduces pain   Relieved with external rotation   Poor predictive value OCD -­‐ Radiographs   AP and lateral   Weightbearing   Sunrise   Patellar lesion suspected   Notch view/Tunnel view   Knee bent 30° to 50°   Posterior condyle OCD -­‐ Radiographic Features   Open vs. Closed Physis   Closed poorer   Location of Lesion   Atypical poorer   Size of Lesion   Larger poorer   Presence of Loose Bodies   Sclerosis   Poor predictor of healing   Potential dissection OCD X-­‐Ray Classifica,on   Cahill and Berg   15 alphanumeric zones   5 medial to lateral   3 anterior to posterior OCD Xray and Bone Scan Classifica,on   Cahill and Berg   Stage 0   Normal in both   Stage 1   Defect on plain radiograph   No uptake on bone scan   Stage 2   Increased uptake in lesion but not surrounding condyle   Stage 3   Increased uptake in lesion and condyle OCD -­‐ Xray and Bone Scan   May suggest healing potential   Higher healing potential   Open physes   Uptake on bone scan OCD -­‐ Xray Classifica,on   Berndt and Harty   Initially described talar lesions   Stage I  
Small area of subchondral bone compression   Stage II  
Partially detached fragment   Stage III  
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Completely detached fragment Remains in crater   Stage IV  
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Complete detachment Loose body MRI Features of OCD   Valuable for OCD assesment   Fluid behind lesion   Partial/Complete detachment   Cartilage breech   Low signal intensity on rim   Fibrous tissue   Instability criteria   Increased signal ≥5 mm diameter beneath lesion   Focal defect ≥5mm in articular surface MRI -­‐ OCD   MR Arthrogram   May aid in detecting instability   Cartilage-­‐specific sequence MRI   Distinguish between synovial fluid, fibrocartilage, and degenerated or lytic subchondral bone Larsen et al OCD -­‐ MRI Classifica,on   Dipaola et al   Grade I   No break in articular cartilage   Thickening of articular cartilage   Grade II   Articular cartilage breached   Low signal rim behind fragment  
Fibrous attachment   Grade III   Articular cartilage breached   High signal behind fragment  
Fluid   Grade IV   Loose body with defect of articular surface The clinical u,lity and diagnos,c performance of MRI for iden,fica,on and classifica,on of knee osteochondri,s dissecans Quatman CE, Quatman-­‐Yates CC, SchmiK, SchmiK LC, Paterno MV J Bone Joint Surg Am 2012 Jun 6;945(11):1036-­‐44   Systematic search   Limited available evidence   Supports use of MRI to detect stability or instability of lesion OCD -­‐ Intraopera,ve Classifica,on   Guhl   Cartilage integrity and stability   Type I   Softening of cartilage   No breech of cartilage   Type II   Breeched cartilage   Stable   Type III   Definable fragment/Flap   Partially attached   Type IV   Loose body   Osteochondral defect OCD Intraopera,ve Assessment   Size   Number of loose fragments   Bone associated with fragment   Quality of underlying bone OCD Prognosis   No randomized, controlled clinical trials   Predictors for surgical intervention   Physeal maturation   Dissection of lesion from subchondral bone   Size and location of lesion   Integrity of articular surface OCD Prognosis   Hefti et al 1999   Large multicenter review   509 knees in 452 patients  
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No dissection better prognosis Pain and swelling not indicative of dissection Xray and CT do not predict dissection Sclerois has a poor repsonse to drilling Lesions ≥2 cm have worse prognosis Surgery outcomes better than nonoperative in dissection Lesions in classic location better prognosis Adult onset  
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42% abnormal radiographs after treatment Juvenile onset  
22% abnormal radiographs after 3 years OCD Treatment   Nonsurgical   Promote healing   Prevent displacement   Surgical   Repair native cartilage   Restoration procedures OCD Nonsurgical Management   Activity modification   Crutches/Restricted weightbearing   Allow range of motion exercises   Braces or casting   Noncompliant   Symptom control   Acetaminophen   Theoretical negative influence of NSAIDs on bone healing OCD Surgical treatment   Drilling   Transchondral drilling   Retrograde drilling   Repair   Debridement/Excision   Reconstructive Techniques   Evolving Surgical management of juvenile osteochondri,s dissecans of the knee Trinh TQ, Harris JD, Flanigan DC. Knee Surg Sports Traumatol Arthrosc. 2012 Feb 11   39 studies systematic review   Significant improvements (nearly all)   Clinical   Radiographic   Short, mid, and long-­‐term follow-­‐up.   Isolated excision of weight-­‐bearing OCD   Poorer clinical and radiographic results   Outcomes better with juvenile OCD versus adult OCD Drilling   Stable lesions failed conservative treatment   Normal articular cartilage   Stimulate vascular ingrowth for subchondral bone healing   Anterograde technique   Transchondral drilling   Retrograde technique   Fluoroscopic assisted to avoid penetrating articular cartilage Func,onal and Radiographic Outcomes of Juvenile Osteochondri,s Dissecans of the Knee Treated With Extra-­‐Ar,cular Retrograde Drilling Boughanem J, Riaz R, Patel RM, Sarwark JF. American Journal of Sports Medicine. 2011;39(10):2212-­‐17   31 patients   4 year follow up   Knee scores significantly improved   Radiographs showed stable or improved lesions   Avoid drilling through articular cartilage Drilling Juvenile Osteochondri,s Dissecan: Retro-­‐ or Transar,cular? Gunton MJ, Caren JL, Shaw CR, Murnahan ML Clin Orthop Relat Res. 2012 Jan 25   Systematic Review   65 studies   12 met inclusion criteria   No clear differences in patient oriented outcomes   Radiographic healing   86% retroarticular   91% transarticular   No complication reported for either Surgical Repair   Unstable lesions   Fixation choices   K-­‐wires, cannulated screws, Herbert (Headless) screws, bone pegs   Metal hardware requires removal   Biodegradable implants   Pins/darts, screws   No need for removal   May cause reaction/synovitis Case 1 OCD Repair   History   18 yo male with sudden pain and swelling after twisting knee playing football   Minor intermittent pain and swelling for preceding 6 months   Exam   Large Effusion   Decreased Range of Motion   No obvious Ligamentous Instability   Medial tenderness Case 1 X-­‐rays Case 1 _ MRI   Unstable lesion   Cartilage disrupted laterally   Fluid tracking  
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Laterally Behind bone Case 1 IntraOp   Lesion identified   Unstable anterior and lateral   Hinged   Slight fragmentation   Anterior and posterior   Proceed with open repair Case 1 IntraOp   Repaired with combination of Bioabsorbable headless screws and darts Reconstruc,on   Microfracture   Osteochondral Autologous  
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Transplantation (OATS) Autologous Chondrocyte Implantation Osteochondral allograft Articular Cartilage allograft Evolving   Biomimetic Osteochondral Scaffold   Bone Marrow Derived Cell Transplantation   Bone Cartilage Paste Graft Microfracture   Performed for area of  
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articular cartilage defect Multiple penetration hole through to subchondral bone Stimulate healing response Fibrocartilage is formed Does not create new hyaline cartilage Most useful in small lesions Bedi et al Osteochondral Autologous Transplanta,on (OATS)   Non-­‐articulating cartilage moved to defect area   Harvested as plug of cartilage and subchondral bone   Useful in medium sized lesions   <2 cm2 Bedi et al A Prospec,ve, Randomized Clinical Study of Osteochondral Autologous Transplanta,on Versus Microfracture for the Treatment of Osteochondri,s Dissecans in the Knee Joint in Children. Gudas R, Simonaityte R, Cekanauskas E, Tamosiunas R. J Pediatr Orthop. 2009 Oct-­‐Nov;29:741-­‐8   50 patients   25 each group   Both groups improved   More patients in OAT group maintained good or excellent results.   MRI showed good or excellent repairs in more OAT patients at 18 month follow up Autologous Chondrocyte Implanta,on (ACI)   Non-­‐articulating cartilage is harvested   Chondrocytes grown in lab   Chondrocytes re-­‐implanted   Patch sewn over defect  
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Periosteum Commercially available membrane   Chondrocytes injected behind patch Outcomes of Autologous Chondrocyte Implanta,on in Study of the Treatment of Ar,cular Repair (STAR) Pa,ents with Osteochondri,s Dissecans Cole BJ, Deberardino T, Brewster R, Farr J, Levine DW, Nessen C, Roaf P, Zaslav K Am J Sports Med 2012 Sep;40(9):2015-­‐22 Epup 2012 Jul 19  
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Case Series 40 patients with one failed non-­‐ACI treatment 32 patients completed 48 month followup 85% successful   Clinically and statistically significant improvements   Pain   Symptoms   Sports and recreation ability   Activities of daily living   Knee-­‐related quality of life   35% had subsequent surgical procedure   Debridement of lesion Fresh Frozen Osteochondral Allograj   Large plug from cadaveric femoral condyle implanted in defect   Size matched Bedi et al Can Fresh Osteochondral Allograjs Restore Func,on in Juveniles With Osteochondri,ts Dissescans of the Knee? Lyon R, Nissen C, Liu XC, Cur,ne B Clin Orthop Relat Res 2012 Sep 13 Epub ahead of print   Retrospective Review   11 Children with OCD treated with fresh osteochondral allografting   All returned to activities of daily living at 6 months   All returned to full sports activities between 9 and 12 months   Followup radiographs at 2 years showed full graft incorportation Allograj Juvenile Car,lage   Minced cadaveric cartilage tissue   Donors 2 years old and younger   Chondrocytes with Proliferation Potential   Early promising results   May be equal or superior to ACI   No independent studies   Company driven studies availiable Case 2 Juvenile Car,lage Allograj   30 yo male   Large 6 cm2 osteochondral defect   6 month postop scope unrelated lateral pain   Healed hyaline or hyaline like cartilage How to Treat Osteochondri,s Dissecans of the Knee: Surgical Techniques and New Trends Kon E et al. AAOS Exhibit Selec,on. Journal of Bone and Joint Surgery 2012;94:e1(1-­‐8)   60 patients   5 techniques   OATS   ACI with bone graft   Biomimetic nanostructured osteochondral scaffold   Bone Cartilage Paste Graft   Bone Marrow derived Cell Transplantation Technique   All achieved good clinical and radiographic results   Trend towards better results with ACI Addi,onal Techniques Kon et al Osteochondri,s Dissecans Summary   Etiology still not fully understood   Preserving native cartilage and bone best (if possible)   Conservative  
Stable lesions   Repair  
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Stable lesions that do not heal Unstable lesions   Reconstructive techniques have good results if repair not possible or if repair fails  Thank You! References  
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Crawford CC, Safran MR: Osteochondritis Dissecans of the Knee. J Am Acad Orthop Surg 2006;14:90-­‐100 Linden B: The incidence of osteochondritis dissecan in the condyle of the femur. Acta Orthop Scand 1976;47:664-­‐667 Bradley J, Dandy DJ: Osteochondritits disseccans and other lesions of the femoral condyles. J Bone Joint Surg Br 1989;71:518-­‐22 Hefti F, Beguiristain J, Krauspe R, et al; Osteochondritis dissecans: A multicenter study of the European Pediatric Orthopedic Society. J Pediatric Orthop B 1999;8:231-­‐45 Chiroff RT, Cooke CPIII: Osteochondritis dissecans: A histologic and microscopic analysis of surgically escised lesions. J Trauma 1975;15:689-­‐96 Wilson JN: A diagnostic sign in osteochondritis dissecans of the knee. J Bone Joint Surg Br 1967;49:477-­‐80 Kocher MS, Tucker R, Ganley TJ, Flynn JM. Management of Osteochondritis Dissecans of the Knee: Current Concepts Review. The American Journal fo Sports Medicine 2006 34(7):1181 Kon E, Vannini F, Buda R, Filardo G, Cavallo M, Ruffilli A, Nanni M, DiMartino A, Marcacci M, Giannini S. How to Treat Osteochondritis Dissecans of the Knee: Surgical Techniques and New Trends. AAOS Exhibit Selection. J Bone Joint Surg 2012;94 e1(1-­‐8) Bedi A, Feeley BT, Williams RJ. Management of Articular Cartilage Defects of the Knee. J Bone Joint Surg 2010;92:994-­‐1009 Dipaola J, Nelson DW, Coleville MR. Characterisitic osteochondral lesions by magnetic resonance imaging. Arthoscopy 1991;7:101-­‐4. Guhl JF. Arthroscopic treatment of osteochondritis dissecans. Clin Orthop 1982;167:65-­‐74 Larsen MW, Pietrzak WS, DeLee JS. Fixation of Osteochondritis Dissecans Lesions Using Poly(l-­‐lactic)/Poly(glycolic acid) Copolymer Bioabsorbable Screws. American Journal of Sports Medicine. 2005;33(1):68-­‐76 References (cont)  
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Cahill, BR, Bert BC: 99M-­‐Technetium phosphate compound scintigraphy in the management of juvenile osteochondritis dissecans of the femoral condyles. Am J Sports Med 1983;11:329-­‐35. Berndt AL, Harty M: Transcondylar fractures (osteochondritis dissecans) of the talus. J Bone Joint Surg Br 1959;41:988-­‐1020