OCD: igure 1.

Enlarge Figure 2.

Enlarge The patient's age and activity in high-performance sports point to the possibility of an osteochondral defect. The plain x-ray shows a narrow, wellcalcified lesion off the femoral condyle, which could support this diagnosis. The intraoperative photo confirms the diagnosis (Figure 2).

Osteochondritis dissecans (OCD) is characterized by the formation of cracks in articular cartilage and the underlying subchondral bone. This is followed by separation of the osteochondral fragment from the epiphysis.[1] Although the name "osteochondritis" implies inflammation, the lack of inflammatory cells in histological examination suggests a noninflammatory cause. The pathophysiology of OCD is not yet clear, as both trauma and ischemia have been thought to be involved. Separation of an osteochondral fragment from the articular surface occurs, which can be present in situ, partially detached, or entirely detached.[1] A completely detached fragment becomes a loose body. Injury of the articular cartilage allows an influx of synovial fluid into the epiphysis, creating a subchondral cyst.

In humans, OCD is a rare disease, occurring in 15-30 per 100,000 persons in the general population each year.[2] OCD tends to affect young patients, with an average age at presentation of 10-20 years (but it may occur in persons of any age). It is more common in the male population, with a male-to-female ratio of 2:1.[2-4] Other studies quote a male-to-female ratio of 5:3.[5] The number of reported cases has increased along with an increasing level of participation in competitive sports among both boys and girls.[5] There are 2 forms: a juvenile form, which appears before closure of the physes, and an adult form.[5] High-impact sports, such as gymnastics, soccer, basketball, lacrosse, football, tennis, and baseball, have been associated with a higher risk for OCD in stressed joints.[5,6] Other factors, such as rapid growth during

puberty, deficiencies and imbalances in the ratio of calcium to phosphorus, and anomalies of bone formation, have been suggested to have a role in the development of OCD, but clear evidence is lacking.[7-9] Some case reports have suggested a genetic predisposition.[8,10,11]

The knee is the most commonly affected joint; OCD affects the knee in 75% of cases, the elbow in 6% of cases, and the ankle in 4% of cases. In the knee, OCD involves the lateral aspect of the medial femoral condyle in 75% of cases, the weight-bearing surface of the medial condyle in 10% of cases, the weightbearing surface of the lateral condyle in 10% of cases, and the anterior intercondylar groove or patella in 5% of cases.[5,12-20] Some authors underline that OCD of the talus is being diagnosed more frequently, as CT and MRI are becoming widely used and, in future series, may represent the most frequent site of OCD.[20]

The symptoms of OCD include joint pain, crepitation, swelling, and stiffness. Symptoms may be aggravated with physical activities, such as playing sports. When a lower extremity is involved, patients often present with a limp. With complete fragment separation, locking symptoms may occur. Symptoms usually improve with protected immobilization of the joint. Clinical signs include effusion, tenderness over the lesion, quadriceps atrophy, and weakness. The patient may lack full knee extension when compared with the contralateral knee. Occasionally, a loose body may be palpable. The Wilson test is sometimes performed as part of the examination of the knee when OCD is suspected. The examiner flexes the knee to 90 while internally rotating the tibia. A positive Wilson sign occurs when pain is elicited at 30 of flexion and is relieved with external rotation.[21] However, one study found it to be of very little clinical value as 24 of 32 study patients with OCD lesions on x-rays had negative Wilson signs.[21]

Several diagnostic methods are available for the diagnosis and staging of OCD, including plain films (anteroposterior, lateral, and notch/tunnel views), arthrography, ultrasonography, MRI (with or without gadolinium contrast), CT scanning, technetium bone scanning, and knee arthroscopy. Plain films may be normal early in the course. Notch views are the most effective view for evaluating the lateral aspect of the medial femoral condyle.[4] MRI is the best noninvasive imaging modality and can assess for lesion stability. Intra-articular gadolinium may improve lesion characterization.[16,22,23] CT can be performed if MRI is not available. Knee arthroscopy can be used both diagnostically and therapeutically.[3,4,20] Arthroscopic OCD stages are defined

by the International Cartilage Repair Society.[24] MRI has proven useful in evaluating lesion instability in adults but is less accurate in children.[25,26]

The treatment of OCD of the knee depends on the age of the patient and the grade of the disease. The general rule is that the younger the patient, the better the prognosis; this is especially true in children with open physes, who are generally felt to do better than adolescent or adult patients in whom the physes are already closed. Nonetheless, it is possible for children with open physis to experience long-term problems from their lesions.[5] In skeletally immature children with nondisplaced fragments, initial treatment includes limitation of activity with the use of crutches and restricted range of motion (eg, knee immobilizer, range-of-motion brace), cryotherapy, and oral analgesics.[5] Earlier surgical intervention should be considered for lesions in children who are approaching physeal closure and with a higher grade of OCD. A trial of nonsurgical treatment can be recommended for 3-6 months. If symptoms persist or failure to unite is observed on x-rays, patients should be treated surgically. Adults may also be given a trial of conservative treatment for knee OCD; however, they are less likely to improve without surgical intervention. Therefore, in adults, the threshold for surgery should be lower.[5] Surgery can be arthroscopic or open. Currently, there are several surgical options, including drilling of the fragment to stimulate healing, pin or screw fixation of the fragment, removal of loose bodies, osteochondral autograft or allograft transplantation, and autologous chondrocyte implantation.[5] The success rates of the above-mentioned procedures vary in different studies and depend on the patient's age and OCD grade.

In this case, the patient underwent arthroscopy, as MRI was unavailable. On arthroscopy, a large defect of the patella was found (3 x 1 cm), so conversion to mini arthrotomy was performed (Figure 2). The bone fragment was fixed with 2 screws and 2 resorptive pins. Control x-rays during follow-up showed normal healing of the fracture, and after physical therapy, the patient recovered full functioning of the knee.

You examine a teenage athlete with progressive elbow pain and trouble with elbow movement. Among other conditions, you suspect OCD. If this patient were diagnosed with OCD, which of the following statements about his condition would be correct? Answer: OCD mainly occurs in the knee

The knee is the most affected joint as OCD occurs in the knee 75% of the time, the elbow 6% of the time, and the ankle 4% of the time. However, as CT and MRI are becoming widely used, some authors consider that OCD of the talus may represent the most frequent site of OCD in the future. You examine a teenage athlete with x-ray findings that are highly suspicious of OCD. What is the next diagnostic method you will suggest? Answer: If MRI is unavailable, CT is the preferred method If MRI is unavailable, CT scanning is the method of choice. Scintigraphy has been used as an indicator of potential healing of the osteochondral fragment. Greater uptake means higher osteoblastic activity and the greater the likelihood for healing with conservative management. Technetium imaging may also reveal occult bilateral involvement. The advantages of sonography are decreased cost compared with MRI and CT scanning, and dynamic scanning with motion of the affected joint. However, sonography is not widely available.