Outcomes of extra-articular,intra-epiphyseal drilling for OCD

lesions of the knee with intact articular cartilage

Eric W Edmonds, MDJay Albright, MD

Scott J Mubarak, MDTracey Bastrom, MA

Henry G Chambers, MD

Introduction• Juvenile Osteochondritis

dissecans (JOCD)– Subchondral lesion with

degrees of osseous resorption, collapse, and sequestrum formation, possible delamination of articular cartilage in the skeletally immature

Guhl Classification

Management• Non-operative

management:– Activity modification, PT,

casting– 50% heal in 10 to 18

months (Cahill, 1989)• Operative techniques:

– Intra-articular drilling– Four outcome studies: 82%

to 95% successful union

Outcomes of Intra-articular Drilling

• Multiple perforations in the previously intact cartilage.

Outcomes of Intra-articular Drilling

• Less perpendicular perforations in the sclerotic rim of the lesion.

Purpose

• Evaluate:– Extra-articular, intra-epiphyseal drilling– Does not damage intact articular cartilage– Increased fenestration of sclerotic rim

Methods• Retrospective review• Years 1997 to 2005• 68 children, 75 knees (76 OCD lesions)• Inclusion criteria

– Open growth plates, failed six months conservative management, arthroscopically confirmed intact articular cartilage

• Exclusion criteria– Arthroscopic drilling through cartilage, detached

cartilage, or closed growth plates.

Technique1. Diagnostic arthroscopy to confirm

Guhl grade2. A 0.062 inch K-wire, percutaneous,

intra-epiphyseal to center of lesion

Technique

1.This center-center “guide” wire is then preserved as a guide for further wire placement.

Technique• A parallel wire

guide is used to direct a subsequent “drilling” K-wire

• 15 to 20 holes are drilled through the sclerotic rim

Outcome Determination• Radiographic

outcomes– Success: complete

resolution of OCD lesion

• Clincial outcomes– Failure: further

intervention

Results

• 59 lesions with complete data–17 lateral condyles and 42

medial condyles

• Mean age 13.4 years (8 to 18.6)

• 15 girls and 36 boys

Results• 52 lesions with

successful healing (87%)

• 7 lesions requiring further intervention (13%)

Pre-drilling

Post-drilling

Duration to complete healing

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

0 10 20 30 40 50 60 70 80

Each lesion

Results• Mean duration to healing:

– 11.8 months (1.3 to 47.3)• Mean follow-up:

– 23.7 months (1.3 to 72)

Each Lesion in Study

Duration to Complete Healing

Time (months)

1263

Failures• 2nd operation, mean 18 months

after index operation:–4 required repeat drillings–2 required repeat drilling with

bone graft–1 required trans-articular drilling

with osteochondral tack

Failures• 3rd operation: requiring

matchstick bone graft and chondroplasty– 39 months after the index

procedure (15 months after the second procedure of repeat drilling)

Complications• No other complications

resulted from this procedure

Comparing Our Results

• Our rate of 87% complete radiographic healing represents comparable outcomes to previous intra-articular drilling reports of 82% to 95% successful union

Discussion• Extra-articular, intra-epiphyseal drilling of

OCD lesions

– Similar rate of healing compared to intra-articular drilling

– Improved fenestration of subchondral rim

– Nullifies damage to the overlying articular cartilage

Conclusion• Less iatrogenic

damage

• A safe and effective technique

Thank You