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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”

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Case Presentation: History

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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


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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


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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


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Case Presentation: Exam

  • 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


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Case Presentation: Exam

  • 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


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Case Presentation: Exam

  • 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


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Case Presentation: Exam

  • Right knee (Continued)

    • Distally NV intact

  • Left knee

    • No abnormalities

  • Gait

    • No gross stance or swing phase abnormalities


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Case Presentation

  • Differential Diagnosis?

    • Meniscal injury

    • Extensor mechanism injury

    • Cruciate ligament injury

    • Collateral ligament injury


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Case Presentation

  • What do you want to order / do now?

    • Plain films?

      • Ottawa knee rules?

      • Which views?

    • MRI?

    • Bone scan?

    • Refer to Ortho?

    • Pray?


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Case Presentation: Plain Radiographs

  • Lateral View

  • AP View


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Case Presentation: Plain Radiographs

  • Sunrise View

  • Oblique View

  • (aka: Merchant View)


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Case Presentation: Plain Radiographs

  • Tunnel View


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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


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Osteochondral Defects of the Knee

Garry W. K. Ho, M.D.

VCU / Fairfax Family Practice

April 11, 2005


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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


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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


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Osteochondral Defect: Pathophysiology

  • 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


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Osteochondral Defect: Pathophysiology

  • 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


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    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


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    Osteochondral Defect: Epidemiology in U.S.

    • Medial femoral condyle: 75-85%

      • 70% occur in the posterolateral aspect

    • Lateral femoral condyle: 10-25%


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    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


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    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


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    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


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    Osteochondral Defect : Exam

    • 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


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    Osteochondral Defect : Exam

    • Apley Test (Meniscal)

      • With patient prone, rotate the tibia on the femur and applying axial compression to reproduce joint line pain


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    Osteochondral Defect: Exam

    • Wilson Test (OCD)

    OUCH!


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    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


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    Osteochondral Defect : Imaging

    • MRIs of Knee showing OCD


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    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


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    Osteochondral Defect : Grading Osteochondral Fragment Stability


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    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


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    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


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    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


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    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


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    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


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    Osteochondral Defect : Surgical Therapy

    Arthroscopic views of OCDs


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    Osteochondral Defect : Surgical Therapy

    Debridement & Lavage

    Microfracture


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    Osteochondral Defect : Surgical Therapy

    Fixation


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    Osteochondral Defect : Surgical Therapy

    Osteochondral Allograft Implantation (OCA)


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    Osteochondral Defect : Surgical Therapy

    Osteochondral Autologous Transplantation (OATS)


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    Case Presentation: J.B. Revisited

    • J.B. was seen by Dr. Petrone

    • Arthroscopic OATS performed

      • Tolerated well

    • Physical Therapy

    • Doing well


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    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


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    Thanks!

    Questions ?


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    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


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    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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