Osteochondritis dissecans


Osteochondritis dissecans

Description, Causes and Risk Factors:

ICD-10: M93.2

Abbreviation: OCD.

Complete or incomplete separation of a portion of joint cartilage and underlying bone, usually involving the knee, associated with epiphyseal aseptic necrosis.

Osteochondritis dissecans is a disorder in which a fragment of articular (joint surface) cartilage and the bone beneath it separate. The cause is uncertain, however, trauma and a lack of blood supply to the affected bone have been implicated as factors contributing to the onset of the condition. The knee is most commonly affected, but the elbow and ankle joints are vulnerable as well. Most lesions are found on the end of the inner part of the thigh bone, with a small percentage being found on the end of the outer part of the thigh bone or on the kneecap.

The etiology remains obscure despite a mountain of literature. Repetitive trauma (especially) and/or vascular anomalies are predominant. The behavior of osteochondritis dissecans varies from site-to-site. Medial distal femoral lesions, in general, fare better than lateral. Lateral talar lesions fare better than medial. The hip seems less prone to osteoarthritis than the knee. Skeletal immaturity is a definite advantage in prognosis. Younger skeletally immature patients fare better than older. Smaller lesions heal better than large. Stable lesions (with intact overlying cartilage) have a better outlook than unstable (with a defect in the overlying cartilage). Little wonder it is hard to compare results of treatment.

Possible Risk Factors:

    Ischemia - a restriction of blood supply which starves the bone of essential nutrients. The restricted blood supply is usually caused by some problem with blood vessels (vascular problem). The bone undergoes avascular necrosis - deterioration caused by lack of blood supply). Ischemia usually occurs in conjunction with a history of trauma.

  • Genes - some studies have shown that the appearance of OCD in several family members may mean that the susceptibility to the condition is inherited. Others, however, argue that it could be more due to family members having similar sporty lifestyles.

  • Repeated stress - repeated stress to the bone/joint can significantly increase the risk of developing OCD. Individuals involved in competitive sports are more likely to regularly stress their joints.

Symptoms:

Signs and symptoms of osteochondritis dissecans may include:

    The joint catches and locks during movement.

  • The affected joint loses its range of movement.

  • Crepitus - when moving the joint makes a grating, cracking or popping sound.

  • Tenderness in the affected area.

  • Joint feels weak.

  • Limping.

  • Effusion - abnormal collection of fluid in the joint area (swelling).

  • Pain, which is usually more severe after physical activity.

  • Stiffness after a period of inactivity.

Physical findings are sometimes nonspecific; effusion may be present in advanced lesions.Tenderness over the lesion may be elicited if the affected portion of the knee is accessible. TheWilson sign, pain with internal rotation of the tibia and flexion of the knee, is designed to impingethe tibial spine on the medial condylar lesion.

Diagnosis:

Osteochondritis dissecans can be suspected clinically based on a patient's history and clinical examination,but it cannot be confirmed unless diagnostic imaging studies are obtained.

    X-ray: Plain X-raysshould be taken initially. A special view is often necessary to establish the diagnosis(“tunnel view”). This x ray view is frequently not ordered as a routine x ray except byorthopedic surgeons so that the standard 3 views (AP, lateral and skyline) may notdetect the osteochondritis dissecans. These will usually reveal the lesion. The classic finding is an ovalshaped fragment of bone that appears separated from the rest of the thigh bone.

  • MRI (magnetic resonance imaging): An MRI is also useful in determining the stability or instability ofthe bone fragment. If joint fluid is present between the fragment and the subchondralbone, the likelihood of the fragment being unstable is a virtual certainty. An osteochondritis dissecans lesionof this type is unlikely to heal non-surgically.

Treatment:

Once a diagnosis has been made, the treatment goals are to reduce pain, restore the contour of the joint surface and minimize the likelihood of arthritis developing in the future. Nonsurgical treatment is indicated in a younger patient as long as there is no evidence of fragment instability on plain X-rays. The prognosis in skeletally immature adolescents is more favorable than in those individuals who are skeletally mature. A period of rest, activity modification, possible immobilization, and non-weight-bearing of 3-6 weeks is necessary in an effort to promote bone healing at the site of fragment separation. Activities should be modified for 6-12 weeks. High impact activities that involve jumping, landing or twisting should be avoided during this time. Activities of daily living are permitted. Full activities may be resumed once the patient has no complaints of knee pain, physical examination reveals full range of motion and strength, there is no swelling noted and there is radiographic evidence of healing on X-ray.

Surgical treatment may be indicated for younger patients who fail conservative treatment or if there is no evidence of radiographic healing after 3 months. Surgical repair is recommended for adult patients, regardless of the stability of the lesion. Unstable fragments require surgery regardless of the patient's age. Arthroscopy is used for the initial surgical management. For the younger patient, with a stable lesion, arthroscopic drilling through the fragment into the underlying bone may promote healing by promoting a blood flow to the area.

In more complex osteochondritis dissecans conditions joint resurfacing may be required. A variety of techniques are in the surgeon's armamentarium and include bone grafting, transplants of fresh cadaver grafts, or growing and implanting a new joint surface (ACI-articular cartilage implantation). Sometimes the OCD repair may require an open surgical incision rather than an arthroscopic procedure to optimally treat the condition.

NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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