Non-operative Treatment Outcomes of Stable Juvenile Osteochondritis Dissecans Lesions of the Knee

Abstract

Objectives:Osteochondritis dissecans (OCD) of the knee most commonly occurs in skeletally-immature pre-adolescent or adolescent patients. Stable juvenile OCD lesions are initially treated via non-operative methods, with varying rates of successful healing reported in the literature. Unloader bracing has been introduced as a relatively new method designed to reduce weight-bearing stress and promote healing for femoral condyle lesions, although the outcomes of unloader bracing compared to other forms of non-operative treatment have not been established.Methods:A retrospective case series was designed to include all patients initially treated non-operatively for stable juvenile OCD of the femoral condyle at a single institution from 2002-2014. Following IRB approval, patient medical records were reviewed for demographic and clinical data, including symptom duration, prior conservative treatment, non-operative treatment modality prescribed and clinical outcome.Results:223 knees of 196 patients (146/196 (74%) male) underwent non-operative treatment for stable OCD of the medial or lateral femoral condyle. Mean age at presentation 11.5 +/- 1.7 years (range 6-16 years). 27/196 patients (14%) were diagnosed with bilateral OCD at presentation, while 169/196 (86%) presented with unilateral OCD. 180/223 knees (81%) were medial femoral condyle lesions, while 39/223 (17%) were lateral femoral condyle lesions and 4/223 (2%) bicondylar. Reported symptom duration was 10.4 +/- 8.8 months (range 0.1 - 38 months). 222/223 (99.6%) knees presented with knee pain, 68/223 (30%) with one or more mechanical symptoms (swelling, giving-way, locking, clicking). 87/223 (39%) had undergone previous non-operative treatment for an average of 2.1 months. On exam at presentation, 130/223 (58%) had tenderness to palpation noted over the associated femoral condyle or ipsilateral joint line. Treatment was based on physician preference. 121/223 (54%) were treated with unloader bracing with activity restriction and physical therapy for a minimum of 3 months, while 102/223 (46%) were treated with other (i.e. “non-unloader”) conservative therapy. In the non-unloader group, all patients were treated with activity restriction with physical therapy and 32% (33/102) had additional non-unloader bracing or immobilization. Treatment of 26/121 (21%) knees in the unloader group included weight-bearing restrictions compared with 30/102 (29%) knees in the non-unloader group. Unloader bracing was associated with healing in 57/121 (47%) knees, while non-unloader treatment led to healing in 60/102 (59%) (p=0.082). Surgical intervention was pursued for 64/121 (53%) knees in the unloader group, at mean 11.0 months after presentation (range 1.9 - 62 months), all of which included OCD drilling and 12/121 (10%) of which included OCD fixation. Subsequent surgical intervention was pursued for 42/102 (41%) knees in the non-unloader group, at mean 6.6 months after presentation (range 0.2 - 40 months), all of which required OCD drilling and 11/102 of which included (11%) OCD fixation.Conclusion:Non-operative treatment for stable OCD of the knee in skeletally-immature patients led to healing in approximately half (52%) of cases. No significant difference was seen between outcomes of patients treated with non-operative methods that included unloader bracing versus non-unloader bracing or other modalities.