Osteochondritis Dissecans

VIVEK PANDEY

Osteochondritis Dissecans

Condition characterized by separation of segment of articular cartilage together with subchondral bone either completely or partially from joint surface.

Osteochondritis Dissecans

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

Osteochondritis Dissecans
The condition was first described by Sir James Paget (1870) who called it quiet necrosis ; term osteochondritis dissecans was first suggested by Konig (1888). He thought that trauma caused necrosis of part of articular surface, & that this was followed by a dissecting inflammation which eventually caused a fragment to separate.

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.

Clinical features
Predominantly affects lateral aspect of medial femoral condyle near attachment of Posterior cruciate ligament. Can occur elsewhere on articular surface of condyle. Lateral femoral condyle is involved in approx. 15 % of all knees.

Osteochondritis Dissecans

Osteochondritis Dissecans

Clinical Features
Vague & intermittent low grade pain. Recurrent swelling, catching, locking, joint irritability. O/E: localized tenderness over affected area, effusion, quadriceps atrophy, crepitus & restriction of knee movements. On internally rotating tibia & extending knee slowly may produce pain at 30 degrees.

Clinical features
Patient walks with foot externally rotated to relieve pain. Loose body may ocassionally be palpated in knee joint.

Investigations
Plain radiograph: well circumscribed fragment of subchondral bone separated from underlying femoral condyle by radiolucent crescent shaped line. As fracture gradually separates, crater or depression may be seen. B/L in 30-40% cases, mandatory to obtain Xray both knees.

Tunnel or Intercondylar notch view

Demonstrates: posterior aspect of femoral condyles, intercondylar notch, intercondylar eminence of tibia Position: prone, knee flexed 40 Beam directed caudally toward knee joint at a 40 angle from vertical.

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

Investigations
Bone scan will demonstrate obscure active lesions not seen on routine films & also rule out active B/L diseases. SPECT: in monitoring treatment of juvenile osteochondritis. Provides architechtural description of lesion, but unable to assist in evaluating healing or status of cartilage.

Investigations
MRI: sensitive technique for early diagnosis. Investigation of choice. Demonstrates extent of lesion because changes in marrow & cartilage can be seen. Used PO to assess healing & articular cartilage integrity.

Arthroscopy
Gives most accurate appraisal of articular cartilage integrity & condition of underlying bone fragment. Best method to stage these lesions:

Stage I: intact lesion with no break in articular cartilage. Catilage may be discolored or softened. Careful probing demonstrates intact underlying bone. Stage II: separated lesion where bone moves 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.

Treatment
Depends on site, size & stability of fragment & age of patient. If fragment does not heal before physis closes there is overall poor prognosis.

Non Operative Treatment

In young child with OCD, with lesion in situ & minimally symptomatic. Limitation of activity & non weight bearing crutch walking for 8-10 wks. Activity is restricted till lesion heals.

Operative tratment

Includes Drilling, Internal fixation with pins & screws, bone grafting & excision of fragment with or without curetting crater.

Operative tratment
Drilling: skeletally immature patients who are symptomatic & stable lesions i.e doesnt Move when arthroscopically probed. Can be done artrosopically or arthrotomy. Smooth K wires are used. Done through articular cartilage & bone fragment into underlying trabecular bone. Helps by recvascularization of lesion by

Operative tratment
Internal fixation: stable child symptomatic 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 of pins for 6-8 weeks. In adults where healing is difficult to obtain, compression screws are used

Operative tratment
Bone grafting: with tibial bone pegs with or without pinning is used. Graft obtained from proximal tibia or iliac crest.

Excision of osteochondritis dissecans

If lesion is severely fragmented, or unstable or if it is a loose body of long standing duration, the fragment must be removed. Resultant crater should be prepared with a curette or burr or debrided down to bleeding subchondral bone. Crater left after fragment excision should be reinspected arthroscopically 6-9 months later to assess fibrocartilagenous repair.

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