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OsteochondritisDissecans

VIVEK PANDEY


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Osteochondritis Dissecans

Condition characterized by separationof segment of articular cartilagetogether with subchondral bone either

completely or partially from jointsurface.


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It is found most commonly in kneealthough other joints can be affected,notably the elbow, ankle & hip.


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The condition was first described bySir James Paget (1870) who called it quiet necrosis ; term osteochondritis

dissecans was first suggested byKonig (1888).

He thought that trauma causednecrosis of part of articular surface, &

that this was followed by a dissectinginflammation which eventuallycaused a fragment to separate.


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Clinical features

Commonly seen in children &adolescents b/w 10 & 20 yrs of age.

Boys> girls

Can also occur after skeletal maturity

Juvenile Osteochondritis Dissecans &Osteochondritis Dissecans are not

equivalent lesions. Patient have high healing chances

with conservative treatment in

Juv.OCD.


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Clinical features

Predominantly affects lateral aspect ofmedial femoral condyle nearattachment of Posterior cruciate

ligament. Can occur elsewhere on articular

surface of condyle.

Lateral femoral condyle is involved inapprox. 15 % of all knees.


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Clinical Features

Vague & intermittent low grade pain.

Recurrent swelling, catching, locking,joint irritability.

O/E: localized tenderness overaffected area, effusion, quadricepsatrophy, crepitus & restriction of knee

movements. On internally rotating tibia & extending

knee slowly may produce pain at 30

degrees.


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Clinical features

Patient walks with foot externallyrotated to relieve pain.

Loose body may ocassionally be

palpated in knee joint.


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Investigations

Plain radiograph: well circumscribedfragment of subchondral boneseparated from underlying femoral

condyle by radiolucent crescentshaped line.

As fracture gradually separates, crater

or depression may be seen. B/L in 30-40% cases, mandatory to

obtain Xray both knees.

T l I d l h


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Tunnel or Intercondylar notchview

Demonstrates:posterior aspect offemoral condyles,intercondylar notch,

intercondylareminence of tibia

Position: prone, kneeflexed 40

Beam directedcaudally toward knee

joint at a 40 anglefrom vertical.


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Flattening & irregularity of weight-bearing surface of lateralfemoral condyle, consistent with osteochondritis dissecans.There is subchondral sclerosis, & a lucent area suggestingsubchondral cyst formation.


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Investigations

Bone scan will demonstrate obscureactive lesions not seen on routinefilms & also rule out active B/L

diseases. SPECT: in monitoring treatment ofjuvenile osteochondritis.

Provides architechtural description oflesion, but unable to assist inevaluating healing or status of

cartilage.


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Investigations

MRI: sensitive technique for earlydiagnosis. Investigation of choice.

Demonstrates extent of lesion

because changes in marrow &cartilage can be seen.

Used PO to assess healing & articular

cartilage integrity.


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Arthroscopy

Gives most accurate appraisal ofarticular cartilage integrity & conditionof underlying bone fragment.

Best method to stage these lesions:


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Stage I: intact lesion with no break inarticular cartilage. Catilage may bediscolored or softened. Careful probingdemonstrates intact underlying bone.

Stage II: separated lesion where bonemoves under articular surface. Stage III: detached lesion, presents as

portion of surface articular cartilage

flaking into joint Stage IV: completely detached lesion- a

loose body.


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Treatment

Depends on site, size & stability offragment & age of patient.

If fragment does not heal before

physis closes there is overall poorprognosis.


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Non Operative Treatment

In young child with OCD, with lesion insitu & minimally symptomatic.

Limitation of activity & non weight

bearing crutch walking for 8-10 wks. Activity is restricted till lesion heals.


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Operative tratment

Drilling: skeletally immature patientswho are symptomatic & stable lesions i.edoesnt

Move when arthroscopically probed. Can be done artrosopically or

arthrotomy.

Smooth K wires are used. Done through articular cartilage & bone

fragment into underlying trabecularbone.

Hel s b recvascularization of lesion b


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Operative tratment

Internal fixation: stable childsymptomatic lesion.

K wires or pins are used to fixed OCD

fragment. Care must be taken that screw may

not cross the growth plate.

Knee is immobilized till removal ofpins for 6-8 weeks.

In adults where healing is difficult toobtain, compression screws are used


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Operative tratment

Bone grafting: with tibial bone pegswith or without pinning is used.

Graft obtained from proximal tibia or

iliac crest.


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Excision of osteochondritisdissecans If lesion is severely fragmented, or

unstable or if it is a loose body of longstanding duration, the fragment must be

removed. Resultant crater should be prepared with

a curette or burr or debrided down tobleeding subchondral bone.

Crater left after fragment excision shouldbe reinspected arthroscopically 6-9months later to assess fibrocartilagenous

repair.


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