OCDoftheKnee

Case Presentation: History

• J.B. is an 18 year old male football, ice hockey, and lacrosse player

• 3-4 year h/o medial right knee pain– S/p blunt trauma to the medial right knee– Cleared to return to play by Ortho– No MRI done

• Intermittent “giving out… pretty often”• Occasional “locking”

– Unable to fully extend

Case Presentation: History

• Right knee becomes painful, “swollen, and red” after ice hockey practice x 1 week– Pain localized to medial aspect

• Ambulates without problems otherwise– Denies day-to-day functional impairment

• Denies numbness, tingling, or motor weakness in either LE

• Otherwise healthy; ROS negative otherwise

Case Presentation: Exam

• Right knee– Mild ecchymosis overlying anterio-medial

aspect of the knee– Mild quadriceps atrophy compared to L knee– Moderate joint effusion– Medial joint line TTP– Increased pain with full flexion– Extension ~ 5° less than left knee


• Right knee (Continued)– Valgus stress testing

• No ligamentous laxity• Increased pain

– Varus stress testing• No laxity or increased pain

– Lachman’s, anterior drawer, and posterior drawer testing all without laxity

– Equivocal pivot shift


• Right knee (Continued)– Positive Steinman’s test

medially• Joint line pain when the tibia

is rotated internally and externally while the knee is flexed over the examination table


• Right knee (Continued)– Medial joint pain with

McMurray’s Testing• Flexing the patient's hip

and knee and palpating for a pop or click along the joint line as the tibia is internally and externally rotated, while extending & flexing the knee


• Right knee (Continued)– Distally NV intact

• Left knee– No abnormalities

• Gait– No gross stance or swing phase abnormalities

Case Presentation

• Differential Diagnosis?– Meniscal injury– Extensor mechanism injury– Cruciate ligament injury– Collateral ligament injury

Case Presentation

• What do you want to order / do now?– Plain films?

• Ottawa knee rules?• Which views?

– MRI?– Bone scan?– Refer to Ortho?– Pray?

Case Presentation: Plain Radiographs

• AP View• Lateral View


• Oblique View• Sunrise View

• (aka: Merchant View)


• Tunnel View

Case Presentation: Radiographs & MRI

• Right Knee Plain Radiographs– OCD involving lateral half of the articular surface of the

medial femoral condyle, with associated 1 cm loose body

• Right Knee MRI– OCD @ inner edge of medial femoral condyle, 2 cm in

diameter, with adjacent bone edema– Mild thinning of tibial ACL insertion– Tiny tear at the undersurface if the posterior horn of the

medial meniscus– Joint effusion

Osteochondral Defects of the Knee

Garry W. K. Ho, M.D.VCU / Fairfax Family Practice

April 11, 2005

Osteochondral Defect: What It Be• A fragment of cartilage and subchondral bone

separates from the articular surface• 2 distinct populations of patients

– Differentiated by the status of their physes• Juvenile Knee OCD

– 5-15 year olds who have open physes • Adult Knee OCD

– Older teens & adults with closed physes

• Symptoms depend on stage of the lesion• Untreated, may lead to early OA with chronic pain

and functional impairment

Osteochondral Defect: Pathophysiology

• Cause unclear & debated• Many etiologies proposed• Trauma

– Direct (less likely) trauma transchondral fracture?

– Indirect trauma more likely• Predilection for the posterolateral portion of the

medial femoral condyle• Repetitive impingement of the tibial spine on the

lateral aspect of the medial femoral condyle during internal rotation of the tibia


• Ischemia– 1990: Enneking described the vascular supply to the

subchondral bone with poor anastomoses to surrounding arterioles, predisposing it to forming sequestra, making it vulnerable to traumatic insult, fracture, and separation

– Rogers and Gladstone: found numerous anastomoses to intramedullary cancellous bone in the distal femur

– Chiroff and Cooke: found no signs of avascular necrosis in sections of excised osteochondral loose bodies


• Other proposed etiologies & predisposing conditions

– Skeletal maturation (accessory centers of ossification)– Genetic conditions (e.g., multiple epiphyseal dysplasias)– Metabolic factors– Hereditary factors– Anatomic variation

• Currently believed to be multifactorial– Trauma as the starting point in predisposed individual

• Single traumatic event or repetitive microtrauma may interrupt the vascular supply

– Vascular insufficiency ultimately leads to fragment separation

Osteochondral Defect: Epidemiology in U.S.

• OCD of femoral condyles– 6 cases per 10,000 men– 3 cases per 10,000 women

• Average age: 10-20 years old, but may occur in any age

• Males-to-Female ratio 2-3:1• Bilateral in 30-40% • 21-40% have some history of trauma

Osteochondral Defect: Epidemiology in U.S.

• Medial femoral condyle: 75-85%– 70% occur in the posterolateral aspect

• Lateral femoral condyle: 10-25%

Osteochondral Defect: Symptomatology

• History of trauma• Vague and poorly localized knee pain, swelling,

and stiffness in varying degrees– Especially activity-related swelling

• Possible clicking or popping• Symptoms often intermittent & exacerbated by

activity or twisting / cutting movements• “Locking” or “catching” may occur• “Giving way” of the knee may occur

– Due to quadriceps weakness• Prolonged course leads to progressive

degenerative arthritis

Osteochondral Defect: Exam• Joint effusion may be present• Quadriceps atrophy and weakness may be evident

– Quad Girth measured @ 10 cm proximal to superior pole of the patella

• Palpable loose body, occasionally• Decreased ROM

– Especially in knee extension • Joint line tenderness • Gait abnormalities

– External rotated tibia on stance phase• Quadriceps disuse atrophy or weakness

Osteochondral Defect : Exam

• Meniscal Tests may be positive

• Steinman’s Test (Meniscal)– Joint line pain when the tibia

is rotated internally and externally while the knee is flexed over the examination table


• McMurray’s Test (Meniscal)

• Flexing the patient's hip and knee and palpating for a pop or click along the joint line as the tibia is internally and externally rotated, while extending & flexing the knee


• Apley Test (Meniscal)• With patient prone, rotate the tibia on

the femur and applying axial compression to reproduce joint line pain

Osteochondral Defect: Exam• Wilson Test (OCD)

OUCH!

Osteochondral Defect : Imaging• Plain Radiographs: useful 1st line imaging

– AP & lateral views: OCD on the condyles– Sunrise or Merchant View: patellar OCD– Notch or Tunnel AP View: medial femoral condyle OCD

• MRI with gadolinium• Technetium bone scan

– Occult bilateral OCD– Estimates prognosis with conservative vs. operative treatment

• CT scanning: helpful in preop planning when MRI is contraindicated or not available

• Sonography: only advantage is cost

Osteochondral Defect : Imaging

• MRIs of Knee showing OCD

Osteochondral Defect : Grading Osteochondral Fragment Stability

• Grade / Stage 1: Depressed OCD– Small area of compressed subchondral bone

• Grade / Stage 2: Partial OCD – Partially detached osteochondral fragment– Sclerotic subchondral bone

• Grade / Stage 3: Complete nondisplaced OCD– Completely detached fragment that remains within

the underlying crater (nondisplaced)– Most common

• Grade / Stage 4: Displaced OCD– Completely detached & displaced fragment– Loose body

Osteochondral Defect : Grading Osteochondral Fragment Stability

Osteochondral Defect : Treatment Categories

• Based on physeal status and OCD size & stability• Category 1

– females < 11 y/o, males < 13 y/o, no loose body on X-Ray– Do well with non-operative treatment

• Category 2– females 11-15 y/o, males 13-17 y/o– Near skeletal maturity; treatment depends on location, size, and

stability of the lesion• Category 3

– Physeal closure and skeletal maturity have occurred– Treatment based on the location, size, and stability of the lesion

Osteochondral Defect : Treatment

• Conservative treatment– Category 1 patients & no loose bodies (Juvenile Type)– Category 2 patients with Grade 1 lesions– Questionable: Category 2 patients with Grade 2 lesions

Osteochondral Defect : Treatment

• Referral to orthopaedics for surgical therapy– Lesions > 1 cm in size– Category 3 patients– Loose bodies– Mechanical symptoms (e.g. locking, giving way)– Lateral femoral condyle OCDs– Failure of conservative therapy

• No evidence of union after 12 weeks– Children approaching physeal closure within 6 months

Osteochondral Defect : Conservative Treatment

• Pain control• Relative rest for 1-2 weeks

– Limit activity– Protected weight bearing – Knee immobilizer– Check serial X-Rays Q 3-6 months

• Modified activity for 6-12weeks– Low impact activity only

• Full activity, quads strengthening if:– No pain, normal exam, and X-Rays show evidence of

healing

Osteochondral Defect : Conservative Treatment

• If still symptomatic or X-Rays do not show improvement after 12 weeks– Refer to Ortho for surgery

• Incidental OCDs in asymptomatic patients – Refer Category 3 patients– Follow with serial X-Rays Q 4-6 months until the lesion

has healed or until skeletal maturity achieved– If still asymptomatic at skeletal maturity and the X-Rays

have not progressed• Reassure patient• No further treatment is indicated

Osteochondral Defect : Surgical Therapy

Arthroscopic views of OCDs


MicrofractureDebridement & Lavage


Fixation


Osteochondral Allograft Implantation (OCA)


Osteochondral Autologous Transplantation (OATS)

Case Presentation: J.B. Revisited

• J.B. was seen by Dr. Petrone

• Arthroscopic OATS performed– Tolerated well

• Physical Therapy

• Doing well

In Conclusion• When you think of meniscal injuries, consider

osteochondral injuries as well– Pain & swelling associated with activity is abnormal &

your tip-off for OCDs

• While using the Ottawa rules are helpful, don’t be afraid to order X-rays when the Dx isn’t clear– “Extension of the physical exam”

• There’s more to knee X-rays than the standard “Knee series”– Order the views you need

Thanks!

Questions ?

References• Rogers WM, Gladstone H: Vascular foramina and arterial supply of the distal

end of the femur. J Bone Joint Surg Am 1950 Oct; 32 (A:4): 867-74 • Schenck RC, Goodnight JM: Osteochondritis dissecans. J Bone Joint Surg Am

1996 Mar; 78 (3): 439-56 • Ralston BM, Williams JS, Bach BR, Bush-Joseph CA, Knopp WD:

Osteochondritis Dissecans of the Knee. Phys Sportsmed 1996 Jun; 24 (6)• Pappas AM: Osteochondrosis dissecans. Clin Orthop 1981; Jul-Aug (158):59-69 • Garrett JC: Osteochondritis dissecans. Clin Sports Med 1991;10 (3):569-593 • Osteochondritis Dissecans of the Knee• Wang TW, Knopp WD, Bush-Joseph CA, Bach BR: Osteochondritis Dissecans

of the Knee. Phys Sportsmed 1998 Aug; 26 (8)• 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 Sep-Oct; 17(5): 601-606

Osteochondral Defects: A Brief History

• 1558: Ambrose Pare removed loose bodies from the knee joint• 1870: Paget described quiet necrosis within the knee• 1888: König coined the term "osteochondritis dissecans," proposing

this condition was caused by spontanous inflammation (osteochondritis) to necrosis & a separation (dissecans) of the fragment

• Advent of X-rays: osteochondrotic conditions in other joints, primarily the hip, were recognized

– 1910: Legg, Calve, and Perthes independently identified a condition of the hip joint in children, which is now known as Legg-Calve-Perthes disease.

– 1921: Waldenström introduced the term coxa plana (ie, disintegration of capital femoral epiphysis.)

– Since the introduction of radiographs, 50 additional anatomic sites within the body where OCD can occur have been identified

• Investigators have failed to identify inflammatory cells in histologic sections of excised osteochondral loose bodies. Nevertheless, the name “osteochondritis dissecans” has persisted

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