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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
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 history2
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
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
case presentation exam4
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
case presentation exam5
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
case presentation exam6
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
case presentation exam7
Case Presentation: Exam
  • Right knee (Continued)
    • Distally NV intact
  • Left knee
    • No abnormalities
  • Gait
    • No gross stance or swing phase abnormalities
case presentation
Case Presentation
  • Differential Diagnosis?
    • Meniscal injury
    • Extensor mechanism injury
    • Cruciate ligament injury
    • Collateral ligament injury
case presentation9
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 radiographs11
Case Presentation: Plain Radiographs
  • Sunrise View
  • Oblique View
  • (aka: Merchant View)
case presentation radiographs mri
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

Osteochondral Defects of the Knee

Garry W. K. Ho, M.D.

VCU / Fairfax Family Practice

April 11, 2005

osteochondral defect what it be
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
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
osteochondral defect pathophysiology17
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
osteochondral defect pathophysiology18
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
osteochondral defect epidemiology in u s
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 s20
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
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
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 exam23
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
osteochondral defect exam24
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
osteochondral defect exam25
Osteochondral Defect : Exam
  • Apley Test (Meniscal)
      • With patient prone, rotate the tibia on the femur and applying axial compression to reproduce joint line pain
osteochondral defect exam26
Osteochondral Defect: Exam
  • Wilson Test (OCD)


osteochondral defect imaging
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 imaging28
Osteochondral Defect : Imaging
  • MRIs of Knee showing OCD
osteochondral defect grading osteochondral fragment stability
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 treatment categories
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
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 treatment33
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
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 treatment35
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
Osteochondral Defect : Surgical Therapy

Arthroscopic views of OCDs

osteochondral defect surgical therapy37
Osteochondral Defect : Surgical Therapy

Debridement & Lavage


osteochondral defect surgical therapy39
Osteochondral Defect : Surgical Therapy

Osteochondral Allograft Implantation (OCA)

osteochondral defect surgical therapy40
Osteochondral Defect : Surgical Therapy

Osteochondral Autologous Transplantation (OATS)

case presentation j b revisited
Case Presentation: J.B. Revisited
  • J.B. was seen by Dr. Petrone
  • Arthroscopic OATS performed
    • Tolerated well
  • Physical Therapy
  • Doing well
in conclusion
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

Questions ?

  • 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
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