Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Current Reviews in Musculoskeletal Medicine
Published in: Current Reviews in Musculoskeletal Medicine 2/2020

01-04-2020 | Osteochondrosis Dissecans | Pediatric Orthopedics (N Pandya, Section Editor)

Management of the Failed OCD

Authors: Crystal A. Perkins, S. Clifton Willimon

Published in: Current Reviews in Musculoskeletal Medicine | Issue 2/2020

Login to get access

Abstract

Purpose of the Review

Osteochondritis dissecans (OCD) is a pathologic condition of subchondral bone most frequently occurring in the medial femoral condyle of the knee in children and adolescents. Salvage techniques are necessary when either nonoperative or typical operative treatments fail, or the OCD presents in an unsalvageable state. The purpose of this review is to describe the evaluation and management of failed OCDs.

Recent Findings

Thorough preoperative planning is essential to the treatment of failed OCDs. Radiographs and advanced imaging such as MRI and CT allow for a detailed assessment of subchondral bone and cartilage. Long-leg alignment radiographs are critical to assess for malalignment which may increase the contact forces on the affected condyle. Malalignment can be corrected with hemiepiphysiodesis or an osteotomy depending on the skeletal maturity of the patient. Osteochondral allografts and autologous chondrocyte implantation treat the defect in both bone and cartilage or solely cartilage and have good short to moderate term outcomes, particularly as compared to the inferior outcomes of microfracture of larger OCDs.

Summary

Osteochondritis dissecans of the knee that fails to heal with initial operative measures can result in a large defect of bone and cartilage in the knee of adolescents. Treatment of the bone and cartilage defect can be accomplished with either osteochondral allograft transplantation or matrix-assisted autologous chondrocyte implantation can be performed with good outcomes. Assessment and correction of lower extremity malalignment is a critical component of treatment. Durable long-term solutions are necessary for the treatment of these difficult lesions.
Literature
1.
Kessler JI, Nikizad H, Shea KG, Jacobs JC Jr, Bebchuk JD, Weiss JM. The demographics and epidemiology of osteochondritis dissecans of the knee in children and adolescents. Am J Sports Med. 2014;42(2):320–6.PubMedCrossRef
2.
Hefti F, Beguiristain J, Krauspe R, Möller-Madsen B, Riccio V, Tschauner C, et al. Osteochondritis dissecans: a multicenter study of the European pediatric orthopedic society. J Pediatr Orthop B. 1999;8(4):231–45.PubMed
3.
Cahill BR, Phillips MR, Navarro R. The results of conservative management of juvenile osteochondritis dissecans using joint scintigraphy. A prospective study. Am J Sports Med. 1989;17(5):601–5 discussion 605-6.PubMedCrossRef
4.
Krause M, Hapfelmeier A, Möller M, Amling M, Bohndorf K, Meenen NM. Healing predictors of stable juvenile osteochondritis dissecans knee lesions after 6 and 12 months of nonoperative treatment. Am J Sports Med. 2013;41(10):2384–91.PubMedCrossRef
5.
Chambers HG, Shea KG, Anderson AF, Jojo Brunelle TJ, Carey JL, Ganley TJ, et al. American Academy of Orthopaedic surgeons clinical practice guideline on: the diagnosis and treatment of osteochondritis dissecans. J Bone Joint Surg Am. 2012;94(14):1322–4.
6.
Gunton MJ, Carey JL, Shaw CR, Murnaghan ML. Drilling juvenile osteochondritis dissecans: retro- or transarticular? Clin Orthop Relat Res. 2013;471(4):1144–51.PubMedCrossRef
7.
Adachi N, Deie M, Nakamae A, Okuhara A, Kamei G, Ochi M. Functional and radiographic outcomes of unstable juvenile osteochondritis dissecans of the knee treated with lesion fixation using bioabsorbable pins. J Pediatr Orthop. 2015;35(1):82–8.PubMedCrossRef
8.
Chun KC, Kim KM, Jeong KJ, Lee YC, Kim JW, Chun CH. Arthroscopic bioabsorbable screw fixation of unstable Osteochondritis Dissecans in adolescents: clinical results, magnetic resonance imaging, and second-look arthroscopic findings. Clin Orthop Surg. 2016;8(1):57–64.PubMedPubMedCentralCrossRef
9.
Camathias C, Gögüs U, Hirschmann MT, Rutz E, Brunner R, Haeni D, et al. Implant failure after biodegradable screw fixation in osteochondritis dissecans of the knee in skeletally immature patients. Arthroscopy. 2015;31(3):410–5.PubMedCrossRef
10.
Kocher MS, et al. Internal fixation of juvenile osteochondritis dissecans lesions of the knee. Am J Sports Med. 2007;35(5):712–8.PubMedCrossRef
11.
Tabaddor RR, Banffy MB, Andersen JS, McFeely E, Ogunwole O, Micheli LJ, et al. Fixation of juvenile osteochondritis dissecans lesions of the knee using poly 96L/4D-lactide copolymer bioabsorbable implants. J Pediatr Orthop. 2010;30(1):14–20.PubMedCrossRef
12.
Wu IT, et al. Internal fixation of unstable Osteochondritis Dissecans: do open growth plates improve healing rate? Am J Sports Med. 2018;46(10):2394–401.PubMedCrossRef
13.
Leland DP, Bernard CD, Camp CL, Nakamura N, Saris DBF, Krych AJ. Does internal fixation for unstable Osteochondritis Dissecans of the skeletally mature knee work? A Systematic Review. Arthroscopy. 2019;35(8):2512–22.PubMedCrossRef
14.
Quatman CE, Quatman-Yates CC, Schmitt LC, Paterno MV. The clinical utility and diagnostic performance of MRI for identification and classification of knee osteochondritis dissecans. J Bone Joint Surg Am. 2012;94(11):1036–44.PubMedPubMedCentralCrossRef
15.
Heywood CS, Benke MT, Brindle K, Fine KM. Correlation of magnetic resonance imaging to arthroscopic findings of stability in juvenile osteochondritis dissecans. Arthroscopy. 2011;27(2):194–9.PubMedCrossRef
16.
Rossbach BP, et al. Discrepancy between morphological findings in juvenile osteochondritis dissecans (OCD): a comparison of magnetic resonance imaging (MRI) and arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1259–64.PubMedCrossRef
17.
Ithurburn MP, et al. Lower patient-reported function at 2 years is associated with elevated knee cartilage T1rho and T2 relaxation times at 5 years in young athletes after ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2019;27(8):2643–52.PubMedCrossRef
18.
Nozaki T, Kaneko Y, Yu HJ, Kaneshiro K, Schwarzkopf R, Hara T, et al. T1rho mapping of entire femoral cartilage using depth- and angle-dependent analysis. Eur Radiol. 2016;26(6):1952–62.PubMedCrossRef
19.
Greulich WW, Pyle SI. Radiographic atlas of skeletal development of the hand and wrist: Standford University Press; 1959.
20.
Heyworth BE, Osei DA, Fabricant PD, Schneider R, Doyle SM, Green DW, et al. The shorthand bone age assessment: a simpler alternative to current methods. J Pediatr Orthop. 2013;33(5):569–74.PubMedCrossRef
21.
Ballal MS, Bruce CE, Nayagam S. Correcting genu varum and genu valgum in children by guided growth: temporary hemiepiphysiodesis using tension band plates. J Bone Joint Surg (Br). 2010;92(2):273–6.CrossRef
22.
Bowen JR, et al. Partial epiphysiodesis at the knee to correct angular deformity. Clin Orthop Relat Res. 1985;198:184–90.
23.
Blount WP, Clarke GR. Control of bone growth by epiphyseal stapling; a preliminary report. J Bone Joint Surg Am. 1949;31A(3):464–78.PubMedCrossRef
24.
De Brauwer V, Moens P. Temporary hemiepiphysiodesis for idiopathic genua Valga in adolescents: percutaneous transphyseal screws (PETS) versus stapling. J Pediatr Orthop. 2008;28(5):549–54.PubMedCrossRef
25.
Mesa PA, Yamhure FH. Percutaneous hemi-epiphysiodesis using transphyseal cannulated screws for genu valgum in adolescents. J Child Orthop. 2009;3(5):397–403.PubMedPubMedCentralCrossRef
26.
Nouth F, Kuo LA. Percutaneous epiphysiodesis using transphyseal screws (PETS): prospective case study and review. J Pediatr Orthop. 2004;24(6):721–5.PubMedCrossRef
27.
Stevens PM. Guided growth for angular correction: a preliminary series using a tension band plate. J Pediatr Orthop. 2007;27(3):253–9.PubMedCrossRef
28.
Eastwood DM, Sanghrajka AP. Guided growth: recent advances in a deep-rooted concept. J Bone Joint Surg (Br). 2011;93(1):12–8.CrossRef
29.
Lykissas MG, Jain VV, Manickam V, Nathan S, Eismann EA, McCarthy J. Guided growth for the treatment of limb length discrepancy: a comparative study of the three most commonly used surgical techniques. J Pediatr Orthop B. 2013;22(4):311–7.PubMedCrossRef
30.
•• Funk SS, et al. Hemiepiphysiodesis Implants for Late-onset Tibia Vara: A Comparison of Cost, Surgical Success, and Implant Failure. J Pediatr Orthop. 2016;36(1):29–35 Hemiepiphysiodesis is a powerful technique for correction of coronal alignment and can be performed with several different implants. PubMedCrossRef
31.
Fujisawa Y, Masuhara K, Shiomi S. The effect of high tibial osteotomy on osteoarthritis of the knee. An arthroscopic study of 54 knee joints. Orthop Clin North Am. 1979;10(3):585–608.PubMed
32.
Anderson AF, Pagnani MJ. Osteochondritis dissecans of the femoral condyles. Long-term results of excision of the fragment. Am J Sports Med. 1997;25(6):830–4.PubMedCrossRef
33.
Murray JR, Chitnavis J, Dixon P, Hogan NA, Parker G, Parish EN, et al. Osteochondritis dissecans of the knee; long-term clinical outcome following arthroscopic debridement. Knee. 2007;14(2):94–8.PubMedCrossRef
34.
Wright RW, et al. Osteochondritis dissecans of the knee: long-term results of excision of the fragment. Clin Orthop Relat Res. 2004;424:239–43.CrossRef
35.
Gudas R, Simonaityte R, Cekanauskas E, Tamosiūnas R. A prospective, randomized clinical study of osteochondral autologous transplantation versus microfracture for the treatment of osteochondritis dissecans in the knee joint in children. J Pediatr Orthop. 2009;29(7):741–8.PubMedCrossRef
36.
Arshi A, et al. Can biologic augmentation improve clinical outcomes following microfracture for symptomatic cartilage defects of the knee? A Systematic Review. Cartilage. 2018;9(2):146–55.PubMedCrossRef
37.
Horas U, Pelinkovic D, Herr G, Aigner T, Schnettler R. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am. 2003;85(2):185–92.PubMedCrossRef
38.
Wang CJ. Treatment of focal articular cartilage lesions of the knee with autogenous osteochondral graftsA 2- to 4-year follow-up study. Arch Orthop Trauma Surg. 2002;122(3):169–72.PubMedCrossRef
39.
Williams SK, et al. Analysis of cartilage tissue on a cellular level in fresh osteochondral allograft retrievals. Am J Sports Med. 2007;35(12):2022–32.PubMedCrossRef
40.
Langer F, Gross AE. Immunogenicity of allograft articular cartilage. J Bone Joint Surg Am. 1974;56(2):297–304.PubMedCrossRef
41.
42.
•• Ackermann J, et al. Decreased Graft Thickness Is Associated With Subchondral Cyst Formation After Osteochondral Allograft Transplantation in the Knee. Am J Sports Med. 2019;47(9):2123–9 Osteochondral allograft transplantation requires attention to technical detail. Grafts with less than 5mm of bone thickness had a higher rate of developing cystic changes. PubMedCrossRef
43.
•• Ambra LF, de Girolamo L, Gomoll AH. Pulse Lavage Fails to Significantly Reduce Bone Marrow Content in Osteochondral Allografts: A Histological and DNA Quantification Study. Am J Sports Med. 2019;47(11):2723–8 Prior literature supported the use of pulse lavage to remove allogenic bone marrow from the subchondral bone in hopes of decreasing the immunogenicity of the graft and facilitating revascularization. This article demonstrates that this technique did not result in a decrease in DNA as compared to untreated plugs. PubMedCrossRef
44.
Cotter EJ, Hannon CP, Christian DR, Wang KC, Lansdown DA, Waterman BR, et al. Clinical outcomes of multifocal Osteochondral allograft transplantation of the knee: an analysis of overlapping grafts and multifocal lesions. Am J Sports Med. 2018;46(12):2884–93.PubMedCrossRef
45.
Emmerson BC, Görtz S, Jamali AA, Chung C, Amiel D, Bugbee WD. Fresh osteochondral allografting in the treatment of osteochondritis dissecans of the femoral condyle. Am J Sports Med. 2007;35(6):907–14.PubMedCrossRef
46.
Sadr KN, Pulido PA, McCauley J, Bugbee WD. Osteochondral allograft transplantation in patients with Osteochondritis Dissecans of the knee. Am J Sports Med. 2016;44(11):2870–5.PubMedCrossRef
47.
Murphy RT, Pennock AT, Bugbee WD. Osteochondral allograft transplantation of the knee in the pediatric and adolescent population. Am J Sports Med. 2014;42(3):635–40.PubMedCrossRef
48.
Bartlett W, et al. Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective, randomised study. J Bone Joint Surg (Br). 2005;87(5):640–5.CrossRef
49.
Basad E, et al. Matrix-induced autologous chondrocyte implantation versus microfracture in the treatment of cartilage defects of the knee: a 2-year randomised study. Knee Surg Sports Traumatol Arthrosc. 2010;18(4):519–27.PubMedCrossRef
50.
•• Brittberg M, et al. Matrix-Applied Characterized Autologous Cultured Chondrocytes Versus Microfracture: Five-Year Follow-up of a Prospective Randomized Trial. Am J Sports Med. 2018;46(6):1343–51 Symptomatic cartilage defects of 3cm of larger in the knee have clinically imporved outcomes at 5 years with MACI as compared to microfracture. Large chondral injuries should not be treated with microfracture alone. PubMedCrossRef
Metadata
Title
Management of the Failed OCD
Authors
Crystal A. Perkins
S. Clifton Willimon
Publication date
01-04-2020
Publisher
Springer US
Published in
Current Reviews in Musculoskeletal Medicine / Issue 2/2020
Electronic ISSN: 1935-9748
DOI
https://doi.org/10.1007/s12178-020-09611-5

Other articles of this Issue 2/2020

Current Reviews in Musculoskeletal Medicine 2/2020 Go to the issue

Stem Cells in Orthopaedic Surgery (J Dragoo and KJ Jones, Section Editors)

Amniotic Product Treatments: Clinical and Basic Science Evidence

Compressive Neuropathies in the Upper Extremity (E Shin, Section Editor)

Non-operative Treatment of Carpal Tunnel Syndrome

The Use of Technology in Orthopaedic Surgery—Intraoperative and Post-Operative Management (C Krueger and S Bini, Section Editors)

How New Technology Is Improving Physical Therapy

Reverse Shoulder Arthroplasty (E Craig and C Chambers, Section Editors)

Reverse Total Shoulder Arthroplasty: Technique, Decision-Making and Exposure Tips

Injuries in Overhead Athletes (J Dines and C Camp, Section Editors)

Step by Step Guide to Understanding the Kinetic Chain Concept in the Overhead Athlete

Pediatric Orthopedics (N Pandya, Section Editor)

Management of Recurrent Anterior Shoulder Instability After Surgical Stabilization in Children and Adolescents