PROCEDURE 36

Osteochondritis Dissecans Fixation

Matthew Diltz and Mininder S. Kocher

Indications

 Stable osteochondritis dissecans (OCD) lesions that have failed nonoperative management

 Initial treatment of unstable lesions

 OCD in patient with closed physis

Pitfalls

• Healing rates are much worse in adults. Most authors recommend operative treatment for OCD in patients with closed growth plates.

Examination/Imaging

 The patient often reports aching, activity-related anterior knee pain. The presentation can be quite similar to patellofemoral syndrome. The presence of OCD should be considered when making the diagnosis of patellofemoral stress syndrome.

 Other findings on physical examination include an antalgic gait.

• With unstable lesions, effusion and mechanical symptoms may be present as well.

 Lesions of the medial femoral condyle can present with external rotation gait and pain with internal rotation (Wilson’s sign)

 It is important to remember that 25% of these chondral lesions occur bilaterally, stressing the importance of checking both knees for symptoms.

 Radiographs, bone scans, and magnetic resonance imaging (MRI) are useful to determine the presence and stage of the OCD lesion.

• Radiographic grading (Berndt and Harty)—anteroposterior, lateral, sunrise, and notch views

 I—subchondral compression

 II—partially detached

 III—detached in situ

 IV—free fragment

• Bone scan grading (Cahill and Berg) useful for determining healing potential

 I—visible on radiograph, normal bone scan

 II—increased uptake in lesion only

 III—increased uptake in lesion + femoral condyle

 IV—increased uptake in lesion + tibial plateau

• MRI staging (Hefti et al.) (Figs. 1–3)

 Stage I—small signal change, no clear margins

 Stage II—fragment with clear margins without fluid between fragment and bone

 Stage III—fluid partially visible between fragment and bone

 Stage IV—fluid completely surrounds fragment

 Stage V—fragment displaced

• Arthroscopic grading (Ewing and Voto/International Cartilage Repair Society)

 Grade 1—intact

 Grade 2—early cartilage separation

 Grade 3—partially attached

 Grade 4—loose body + crater

Treatment Options

Three-Phase Nonoperative Management Protocol (Flynn and Kocher, 2004)

• Phase 1 (first 6 weeks)

 Baseline MRI

 Crutch-protected partial weight bearing

 Child should be pain free at the end

 Repeat radiographs at the end

• Phase 2 (weeks 6–12)

 Weight bearing as tolerated without immobilization

 No impact activities

 Physical therapy for knee range of motion, quad strengthening

• Phase 3 (begins at 3 months)

 Supervised increase in activities

 Restrict high-impact and shear activities until several months’ pain free

 Consider repeat MRI

 Repeat immobilization for lesion progression

Other Treatment Options

• Drilling

• Internal fixation

• Fragment removal

• Chondral resurfacing

Surgical Anatomy

 Most common locations:

• Posterolateral medial femoral condyle—70% (often only seen on notch view) (Figs. 4 and 5)

• Inferocentral lateral femoral condyle—20%

• Patellar—10%

• Trochlear—1%

• 25% bilateral

 It is important to perform a complete arthroscopic survey of the knee when evaluating OCD. Fissuring of the chondral surface can lead to loose bodies. These loose bodies should be removed at the time of the operation (Fig. 6)

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