1. Osteochondritis Dissecans of the Knee
William R. Beach, M.D.
Michael R. Magoline, M.D.
Orthopaedic Research of Virginia

2. Osteochondritis Dissecans Definition
Localized condition affecting the articular surface of a joint with separation of a segment of cartilage and subchondral bone

3. Osteochondritis Dissecans History
Pare (1840) described removal of loose bodies from the knee
Paget (1870) described a “quiet necrosis”
Konig (1888) coined “osteochondritis dissecans” from latin “dissec”, to separate

4. Osteochondritis Dissecans Joints involved
Knee by far the most common joint involved (75% of all OCD lesions) with the ankle, elbow, wrist and other joints accounting for the remaining 25%

5. Osteochondritis Dissecans of the Knee Epidemiology
Two forms
Juvenile (open physes, better prognosis)
Adult (closed physes, poorer prognosis)
Males affected 2-3 times as often as females
Rarely occurs in patients <10 or >50 years of age
Typically seen in young athletic males

6. Osteochondritis Dissecans of the Knee Sites of involvement
Most common: Lateral aspect of medial femoral condyle
Weightbearing surfaces of medial and lateral femoral condyles also affected
Patella > 1%
Patella >1%

7. Osteochondritis Dissecans of the Knee Etiology
Trauma/Ischemia
Impingement of tibial spine on femur
Repetitive stress injury to subchondral bone leading to vascular compromise
Abnormal ossification
Genetic
Rule out multiple epiphyseal dysplasia

8. Osteochondritis Dissecans of the Knee Associated Conditions
Endocrinopathies
Ligamentous laxity
Genu valgum
Carpal tunnel syndrome
Patellar malalignment
Sinding-Larsen-Johanssen disease
Osgood-Schlatter disease
Sports participation starting at a young age

9. Osteochondritis Dissecans of the Knee Classification (Clanton and DeLee)
Grade I: Depressed osteochondral fracture
Grade II: Partially detached fragment
Grade III: Detached fragment, nondisplaced
Grade IV: Loose body

10. Osteochondritis Dissecans of the Knee Clinical Presentation
Pain and swelling (variable)
Locking, catching, giving way
Loose body sensation
Symptoms related to activity

11. Osteochondritis Dissecans of the Knee Physical Examination
Crepitus
Especially noticeable in medial compartment
Effusion
Tenderness
Early: poorly localized
Late: point tenderness
Wilson sign

12. Osteochondritis Dissecans of the Knee Wilson sign
Extend knee from 90 degrees of flexion with tibia internally rotated
Positive: pain at 30 degrees of flexion relieved by external rotation of tibia
Pain is due to impingement of tibial spine against OCD lesion

13. Osteochondritis Dissecans of the Knee Imaging studies
Plain films
Well circumscribed area of sclerotic bone with surrounding lucent line
Bone Scan
MRI

14. Osteochondritis Dissecans of the Knee Bone Scan
Sensitive for osteoblastic activity
Determines potential for repair
Stages (Cahill & Berg)
I: x-ray +, bone scan –
II: x-ray +, bone scan +
III: bone scan + with increased uptake of entire femoral condyle
IV: increased uptake in ipsilateral tibial plateau (suggests increase stress transfer across joint)

15. Osteochondritis Dissecans of the Knee MRI
Visualizes loose bodies, degree of displacement of lesion
More sensitive than plain films
Better correlation with arthroscopic findings
Distinguishes grade II vs. grade III lesions

16. Osteochondritis Dissecans of the Knee Treatment: Juvenile Form (open growth plates)
Goal: To obtain healing of the lesion before physeal closure
Nondisplaced lesions generally heal with conservative management
Protected weightbearing to an activity level where knee is asymptomatic
Cessation of sports activities
Casting/bracing usually not necessary

17. Osteochondritis Dissecans of the Knee Treatment: Juvenile Form (open growth plates)
Displaced lesions generally require surgical intervention
Occurred in 34% of lesions in one series (Cahill)
Excise fragment if in nonweightbearing zone
Reduce and fix lesion if large and in weightbearing zone
Goal: Restore congruity of joint surface

18. Osteochondritis Dissecans of the Knee Treatment: Adult Form (Closed growth plates)
Lesions rarely heal with nonoperative treatment
Progression may lead to secondary degenerative arthritis
Surgical Goals
Restore congruity of joint surface
Enhance blood supply to fragment
Rigidly fix unstable fragments
Early motion with protected weightbearing

19. Osteochondritis Dissecans of the Knee Treatment: Adult Form (Closed growth plates)
Surgical Options
Drilling
Arthroscopic or open reduction and fixation (+/- bone graft)
Reconstruction with allograft or ACI

20. Osteochondritis Dissecans of the Knee Surgical Treatment: Adult Form
Articular surface intact (nondisplaced lesion)
Retrograde drilling under arthroscopic guidance
Stimulates vascular response/promotes healing
Articular surface disrupted (displaced fragment)
Drill/curettage base of lesion
Replace fragment in crater
Fix fragment as anatomic as possible
Add bone graft if necessary to restore articular congruity

21. Osteochondritis Dissecans of the Knee Surgical Treatment: Adult Form
Excision of fragment
Reserved for smaller fragments or lesions that cannot be reconstructed
Newer techniques of reconstruction
Osteochondral allografts
Autogenous osteochondral grafts
Autologous cartilage implantation (Carticel)

22. Osteochondritis Dissecans of the Knee Video Case Presentation

23. Osteochondritis Dissecans of the Knee Summary
Juvenile and adult OCD lesions are frequently encountered by orthopaedic surgeons
Knee most common site involved
Lesion is most commonly encountered in an athletically active young male
Pathology is thought to be due to repetitive stress injury to subchondral bone
50% of juvenile OCD cases will respond to conservative management
Goals of surgical management are to restore normal joint congruity and promote healing of the lesion