Stable Juvenile Osteochondritis Dissecans Research Articles

The "hump" a new arthroscopic phenomenon guiding for reliable therapy of osteochondritis dissecans of variable stability status.

Despite 150years of research, there are currently no reliable morphological characteristics that can be used to differentiate between stable and unstable juvenile osteochondritis dissecans (JOCD) lesions in the knee joint. Arthroscopic probing is still the gold standard. In arthroscopic evaluation, a previously undescribed pattern of a cartilaginous convex elevation ("hump") was identified as a new feature and potential sign of JOCD in transition to instability. The aim of the study was to evaluate the clinical outcomes after surgical intervention (drilling) on the "hump". In a retrospective case series of sixteen patients with an arthroscopically detectable "hump", the analysis of clinical function scores (Lysholm, Tegner) and morphological MRI monitoring of radiological healing were performed. The assessment of lesion healing was based on pre- and postoperative MRI examinations. The "hump" was defined as an arthroscopically impressive protrusion of the femoral articular surface with a minimally softened, discolored, but intact cartilage margin that, is not mobile upon in the arthroscopic palpation hook test. The primary therapy of choice was drilling of all "humps". The "hump" could be detected arthroscopically in 16 of 59 JOCD lesions. Specific MRI correlations with the "hump" or arthroscopic unstable lesions could not be detected. Not all "humps" showed signs of MRI-based healing after the drilling, and in some a dissection of the osteochondral flap occurred within the first postoperative year. As a result, secondary refixation became necessary. In the present study, the "hump" was identified as an important differential diagnostic arthroscopic feature of an arthroscopically primarily stable JOCD lesion, potentially placing the lesion at risk of secondary loosening over time. Therefore, drilling alone may not be appropriate in the event of arthroscopic "hump" discovery, but additional fixation may be required to achieve the healing of the lesion. III.

Arthroscopic Drilling for Stable Juvenile Osteochondritis Dissecans of the Knee Is Safe and Patients Reliably Return to Daily Activities by 3 Months

PurposeTo assess the postoperative timeline for the return to activities of daily living (ADLs) in pediatric patients after arthroscopic drilling of a stable osteochondritis dissecans (OCD) lesion of the knee and to determine the rate of and risk factors for complications after the procedure.MethodsIn a retrospective chart review, data from all patients aged 18 years or younger who underwent arthroscopic drilling for a stable OCD lesion of either femoral condyle from May 2009 through July 2017 were collected. Demographic data, lesion characteristics, operative data, postoperative course, radiographic outcomes, and complications were recorded. Statistical analysis was performed to determine the risk factors for reoperations.ResultsA total of 139 knees in 131 patients were evaluated, with a mean age of 12.7 years, of which 102 (73%) were male knees. The average follow-up period was 17.8 ± 13.2 months after surgery. All patients regained full extension and flexion within 5° of the contralateral knee at a mean of 12.9 ± 3.2 weeks postoperatively, with 95% having returned fully to ADLs by the 3-month postoperative visit. No cases of infection, stiffness, arthrofibrosis, or other procedure-related complications were recorded. A total of 133 knees (95.7%) showed healing on radiographs, whereas 6 knees (4.3%) underwent additional surgical procedures, all of which were performed for treatment failure related to nonhealing lesions (including loose body removal, chondroplasty, and repeated drilling). Lesion size was the only significant risk factor for reoperation (P = .02).ConclusionsOur findings suggest that arthroscopic drilling for stable, intact OCD lesions in the pediatric knee is a safe procedure with reliable outcomes and return to ADLs and a minimal risk of complications. Most patients return to their preoperative daily activity level with a full range of motion of the knee by 3 months after surgery. Complications, including reoperations, are related to the progression of the OCD lesion rather than to the surgical procedure. Each 1-cm2 increase in lesion size increases the likelihood of reoperation by 2.93 times.Level of EvidenceLevel IV, therapeutic case series.

Incidence of Subsequent Surgical Intervention at Short-term Follow-up in Previously Healing and Stable Juvenile Osteochondritis Dissecans of the Knee.

Juvenile osteochondritis dissecans (OCD) of the knee is a defect of subchondral bone seen primarily in active children and adolescents. Studies have evaluated the incidence of surgery in knee OCD, but the incidence of subsequent surgery in patients with stable, healing lesions cleared to return to activities is unknown. This study sought to determine the incidence of surgery in participants with knee OCD lesions cleared to return to activities and evaluate predictors of subsequent surgery. A single center, retrospective review was performed of participants aged 7 to 18 with knee OCD. Inclusion criteria were stable lesion, skeletal immaturity, no history of previous knee surgery, release to activity without surgery, and at least 12 months of follow-up. Documentation of subsequent surgery was queried in the electronic health record. Participants with no recorded surgery were contacted through phone. Analysis included bivariate and logistic regression. Twenty-five individuals were included in this study, with 7 undergoing surgery after returning to activity. Medial femoral condyle lesions were less likely to undergo surgery (B=-2.6, P=0.038). Average lesion size for the Surgery and No Surgery groups was 1.76±0.65 and 1.32±0.81 cm2, respectively, though not significantly different (P=0.21). The Surgery group returned to activity sooner (3.7 mo, range 1.1 to 6.4) than the No Surgery group (8.1 mo, range 1.8 to 35.4), though not significantly different (P=0.18). Mean follow-up time for the study was 42.7 (range 12.6 to 77.6) months. No participants contacted by phone progressed to surgery or reported symptoms that limited their activities. While the majority of participants with stable, healing, and asymptomatic knee OCD lesions have favorable outcomes with nonoperative management, some lesions may progress to surgery. Lesions on the medial femoral condyle may be predictive of lower likelihood of progression to surgery. Our study provides insight on the outcomes of nonoperative management of OCD lesions. Level IV-prognostic study.

Nonoperative treatment of stable juvenile osteochondritis dissecans of the knee: effectiveness of unloader bracing.

The purpose of this study was to compare the treatment outcomes of stable juvenile osteochondritis dissecans (JOCD) of the knee in a large cohort treated nonoperatively with unloader bracing versus other nonoperative treatment modalities without unloader bracing. This retrospective study assessed the clinical course of skeletally immature patients who underwent a minimum of 3 months nonoperative treatment for stable JOCD of the femoral condyle at a single institution (2001-2014). Treatment was based on physician preference. Unloader bracing was compared with other 'non-unloader' modalities, with successful nonoperative treatment defined as the avoidance of subsequent surgical intervention. Two hundred ninety-eight patients were included, 219 (73%) of whom were male. The mean ± SD age at diagnosis was 11.5 ± 1.6 years. Thirty-five patients were diagnosed with bilateral OCD, resulting in 333 knees in total. One hundred eighty-seven (56%) knees were treated with unloader bracing for a minimum of 3 months, whereas 146 (44%) were treated with other nonoperative modalities. All patients were treated with activity restrictions. Weight-bearing restrictions were applied for a total of 83 (25%) cases, for durations ranging from 19 to 196 days (median: 46 days) and at similar rates across groups. Nonoperative treatment was successful in 189 (57%) knees with a median follow-up of 9.5 months (interquartile range: 5.9-15.7 months). Surgical intervention was required in 144 (43%) knees at a median time of 6.0 months (interquartile range: 4.1-10.5 months). The unloader bracing group more often required surgical intervention when compared with the nonunloader group [93/187 (50%) vs. 51/146 (35%) knees, respectively; P = 0.02]. Male sex (P = 0.05) and Hefti stage I (P = 0.05) showed possible associations with nonoperative treatment success. Nonoperative treatment for stable JOCD of the knee leads to the avoidance of subsequent surgical intervention in 57% of cases. Unloader bracing is not associated with significantly improved outcomes when compared with other nonoperative modalities. Level of Evidence: III Retrospective Comparative Case Series.

Arthroscopic Fixation of Osteochondritis Dissecans of the Knee Using a Motorized Pick and Headless Compression Screws

Osteochondritis dissecans (OCD) of the knee affects children and adolescents. The condition is characterized by sterile osteonecrosis of the subchondral bone. The cause is unknown. OCD is divided into juvenile or adult type, depending on whether the physis is open or closed at the time of diagnosis. Stable juvenile OCD lesions have substantial healing potential and are treated conservatively, with a healing potential of up to 75%. However, in unstable lesions and in all symptomatic adult OCD lesions, surgical treatment is indicated. The purpose of this article was to present our method of arthroscopic fixation of an unstable OCD in the knee, using a motorized pick to stimulate the bed of the lesion, and firm fixation with headless screws. The advantage of this method is the controlled and meticulous debridement and stimulation of the sclerotic necrosis behind the OCD fragment and the firm compression achieved with the screws, enabling an intensive and early rehabilitation.

Limitation of in-situ arthroscopic fixation for stable juvenile osteochondritis dissecans in the knee.

Level IV, case series.

Juvenile Osteochondritis Dissecans: Cartilage T2 Mapping of Stable Medial Femoral Condyle Lesions.

Purpose To determine whether a T2 mapping sequence could depict early changes in the composition and microstructure of cartilage overlying stable lesions of the medial femoral condyle in patients with juvenile osteochondritis dissecans (JOCD). Materials and Methods This retrospective study analyzed a sagittal T2 mapping sequence performed between September 1, 2015, and March 31, 2017, on 16 patients (10 boys and six girls; median age, 11.5 years) with 18 stable medial femoral condyle JOCD lesions and 18 age-, sex-, and skeletal maturation-matched control participants (11 boys and seven girls; median age, 11.5 years). Cartilage T2 values were quantitatively measured within regions of interest placed around the cartilage within and overlying the JOCD lesion in patients with JOCD and around the cartilage on the weight-bearing medial femoral condyle in patients with JOCD and controls. Wilcoxon signed rank and Wilcoxon rank sum tests were used to compare T2 values. Results T2 values were significantly higher (P < .001) for cartilage within the JOCD lesion than for cartilage overlying the JOCD lesion in patients with JOCD. However, there were no significant differences in T2 values between cartilage overlying the JOCD lesion and cartilage on the weight-bearing medial femoral condyle in patients with JOCD (P = .67) or in T2 values of the cartilage on the weight-bearing medial femoral condyle between patients with JOCD and controls (P = .30). Conclusion There were no significant quantifiable differences in T2 values of cartilage overlying stable JOCD lesions and normal cartilage on the medial femoral condyle, suggesting no substantial changes in cartilage composition and microstructure.

Analysis of risk factors for poor prognosis in conservatively managed juvenile osteochondritis dissecans of the lateral femoral condyle

BackgroundThe purpose of this study was to examine factors affecting the prognosis of conservative treatment for stable juvenile osteochondritis dissecans (OCD) of the lateral femoral condyle based on review of our patient population. MethodsA consecutive series of 43 knees in 37 patients with stable OCD of the lateral femoral condyle with open physes undergoing conservative treatment were included in the study. The mean age of the included subjects was 10.7±2.5years (range, seven to 16years) with the mean follow-up period of 33.3±15.1months (range, 12 to 67months). Conservative treatment consisting of prohibition of sports activities and use of a brace locking the knee in full extension was applied to all included patients. Potential prognostic factors examined were the presence of discoid meniscus, radiographic stage, lesion size on radiographs, time period from onset of symptoms to evaluation/consultation, number of hours of sporting activity per week, and age at starting sports activities. Prognosis of a patient was deemed to be poor when an apparent healing response was not detected in follow-up radiographic studies within six months. ResultsThe prognosis was defined to be poor for 14 knees (32.6%). The presence of discoid meniscus was identified in 100% of the knees in the poor prognosis group and time-period from onset to consultation of six months or more was shown to be a risk factor with statistical significance. ConclusionsA majority of patients with juvenile OCD in the lateral femoral condyle could be managed with conservative treatment. The presence of discoid meniscus and longer time-period from onset to consultation were significantly related with poor prognosis. Level of evidenceIV (case series).

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

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.

Reliability of predictive models for non-operative healing potential of stable juvenile osteochondritis dissecans knee lesions

BackgroundWhile juvenile osteochondritis dissecans (JOCD) lesions have greater healing potential than equivalent lesions in adults, only 50% of JOCD lesions demonstrate radiographic healing after six months of non-operative treatment. Two previous studies have produced nomograms to predict a patient's probability of healing with non-operative treatment based on patient and lesion characteristics. The purpose of this study was to determine inter- and intra-observer reliability of the predictive nomograms. MethodsA consecutive series of 34 skeletally immature patients (40 knees), who underwent non-operative treatment for stable JOCD lesions was retrospectively reviewed. At two time points at least one week apart, two medical students, two orthopaedic surgeons, and a radiologist made measurements of the JOCD lesions. These measurements, along with patient ages and pain type, were used to generate a point value for each lesion based on both nomograms. Intra-class correlations (ICCs) were calculated to determine inter- and intra-rater reliability. ResultsWe found near perfect intra-rater correlation (ICC) for all raters' individual OCD measurements, as well as total point score for the two nomograms (ICC range, 0.780–0.929). Additionally, there was near perfect inter-rater reliability among raters for total scores and individual components of each nomogram (ICC range, 0.721–0.974). ConclusionsThere is high inter- and intra-rater reliability for both point systems for predicting healing of JOCD lesions. Clinicians should be aware of these as tools to help guide decision making in patients with JOCD lesions.

Inter- and Intra-Rater Reliability of Predictive Models for the Non-Operative Healing Potential of Stable Juvenile Osteochondritis Dissecans (JOCD) Knee Lesions

Objectives:While juvenile osteochondritis dissecans (JOCD) lesions have greater healing potential than equivalent lesions in adults, only 50% of JOCD lesions demonstrate radiographic healing after 6 months of non-operative treatment. Krause et al. (2013) and Wall et al. (2008) have described models to predict a patient's probability of healing with non-operative treatment based on patient and lesion characteristics. The Wall et al. nomogram incorporates normalized lesion length, normalized lesion width, and pain type, while the Krause et al. model includes normalized lesion width, patient age, and the size of concurrent cyst-like lesions. The purpose of this study was to determine inter- and intra-observer reliability of the predictive nomograms.Methods:We retrospectively evaluated a consecutive series of children with open physes, who underwent non-operative treatment for stable JOCD lesions. Thirty-four patients (40 knees) were included in the study. At two time points at least one week apart, two medical students, two orthopaedic surgeons, and a radiologist made measurements of the JOCD lesions as described by Wall and Krause. These measurements, along with patient ages and pain type, were used to generate a point value for each lesion based on both the Krause and Wall models. Intra-class correlations (ICC) were calculated using the point value data obtained from the nomograms to determine inter- and intra-rater reliability.Results:Based on the Landis & Koch (1977) threshold, we found near perfect intra-rater correlation for all raters in terms of individual OCD measurements, as well as total point score as calculated by both Krause and Wall methods (Table 1). Additionally, amongst the five raters there was near perfect inter-rater reliabilities in total scores, as well as substantial to near perfect reliability in measuring the individual components of the scores (Table 2).Conclusion:There is high inter- and intra-rater reliability for both the Krause and Wall point systems for predicting healing of JOCD lesions. These models appear to be important tools for helping doctors and patients reliably predict the healing potential of non-operative management of JOCD lesions.

Management strategies for osteochondritis dissecans of the knee in the skeletally immature athlete.

Osteochondritis dissecans (OCD) is a disorder resulting in focal breakdown of the subchondral bone, with potential disruption of the overlying articular cartilage. The femoral condyles of the knee are the most common locations for OCD, and the incidence of OCD appears to be increasing among active children. Juvenile OCD (JOCD) can be distinguished from adult OCD by the presence of open growth plates. Due to a lack of evidence on its early diagnosis, optimal treatment, and long-term course of healing, JOCD presents a unique challenge for the health care team. Approximately 50% to 67% of stable JOCD lesions heal successfully with nonoperative treatment. For unstable lesions and stable lesions that fail nonoperative treatment, a variety of surgical interventions can be utilized to stimulate bony healing and address articular cartilage lesions. It is recommended that rehabilitation of JOCD be tailored to the individual patient, based on the stage and radiographic status of the lesion and the mode of surgery employed when surgically addressed. Although there is a growing body of literature on this condition, the etiology and optimal methods for treatment, rehabilitation, and evaluating outcomes remain inconclusive due to a lack of quality evidence. Therapy, level 5.

Healing Predictors of Stable Juvenile Osteochondritis Dissecans Knee Lesions After 6 and 12 Months of Nonoperative Treatment

Background: Nonoperative treatment of stable juvenile osteochondritis dissecans (JOCD) lesions of the knee fails in up to 50% of cases. Healing predictors are needed to identify potential failures and thus determine treatment options. Purpose: A predictive model for healing potential after 6 and 12 months of nonoperative treatment of stable JOCD lesions based on sensitive magnetic resonance imagining (MRI) follow-up measurements was developed. Study Design: Cohort study (diagnosis); Level of evidence, 2. Methods: A retrospective cross-sectional study was conducted to analyze 62 white patients (76 stable JOCD lesions) who were initially treated by restriction of activity until they were free of pain. The primary end point was healing investigated on MRI with follow-up measurements after 6 and 12 months of nonoperative treatment. Multivariate logistic regression was used to determine the influence of age, sex, JOCD lesion size, clinical symptoms, and the occurrence of cystlike lesions (CLLs) on healing potential. Additionally, optimal prognostic cutoffs were defined to differentiate failures from nonfailures. Results: After 6 months of nonoperative treatment, 51 (67%) of 76 stable JOCD lesions showed no progression toward healing or showed signs of instability. Normalized lesion width and area and CLL occurrence differed significantly between failures and nonfailures (P < .05). A multivariate logistic regression best-predictors model that included age, CLL size, and normalized lesion width best predicted healing after 6 months and resulted in an area under the curve (AUC) of 0.779 (P < .001). A cutoff at 48% healing probability, as predicted by a nomogram based on age, normalized lesion width, and CLL size, differentiated failures from nonfailures (sensitivity, 60.0%; specificity, 83.7%). After 12 months, 37 lesions (49%) had progressed toward healing, and the sole observation of CLL size had the highest predictive validity (AUC, 0.766). The optimal cutoff was a healing probability of 61% (lesion size, 1.3 mm; sensitivity, 70.3%; specificity, 74.1%). Conclusion: A 6-month period of nonoperative treatment with or without casting might be appropriate if the healing potential is >48%. A 12-month period of nonoperative treatment may be successful if the CLL is <1.3 mm in length as assessed on MRI.

Local Morphological Response of the Distal Femoral Articular–Epiphyseal Cartilage Complex of Young Foals to Surgical Stab Incision and Potential Relevance to Cartilage Injury and Repair in Children

Objective: Describe the local morphological response of the articular–epiphyseal cartilage complex to surgical stab incision in the distal femur of foals, with emphasis on the relationship between growth cartilage injury, enchondral ossification, and repair. Design: Nine foals were induced into general anesthesia at the age of 13 to 15 days. Four full-thickness stab incision defects were created in the cartilage on the lateral aspect of the lateral trochlear ridge of the left distal femur. Follow-up examination was carried out from 1 to 49 days postoperatively, including examination of intact bones, sawed slabs, and histological sections. Results: Incision defects filled with cells displaying fibroblast-, chondrocyte-, and osteoblast-like characteristics, potentially validating the rationale behind the drilling of stable juvenile osteochondritis dissecans lesions in children. Incisions induced necrosis within the cartilage on the margins at all depths of the defects. Sharp dissection may therefore be contraindicated in cartilage repair in young individuals. Incisions caused a focal delay in enchondral ossification in 2 foals, apparently related to the orientation of the incision defect relative to the direction of ossification. Defects became progressively surrounded by subchondral bone, in which granulation tissue containing clasts and foci of osteoblast-like cells was observed. Continued enchondral ossification was therefore likely to result in healing of uncomplicated defects to morphologically normal bone. Conclusions: Epiphyseal growth cartilage injury had the potential to exert a negative effect on enchondral ossification. Enchondral ossification exerted a beneficial effect on repair. This relationship warrants consideration in future studies of cartilage injury and repair within the articular–epiphyseal cartilage complex of all species.

Retro-articular drilling and bone grafting of juvenile knee osteochondritis dissecans: a technical description

The goal of the surgery in stable juvenile osteochondritis dissecans (OCD) is to promote revascularization and reossification of the osteochondral fragment by creating channels, linking the subchondral bone to the OCD lesion. Retro-articular and trans-articular drilling of OCD lesions has up to a 33 % failure rate based on complete radiographic healing. Healing may be improved with the delivery of pluripotent mesenchymal stem cells into the lesion. We describe a technically simple procedure for retro-articular drilling with the addition of percutaneous iliac crest bone graft placement for stable juvenile OCD lesions of the knee. By using a bone marrow biopsy needle, the bone grafting can be performed in a reproducible manner and in shorter time than in previously described techniques. The proposed technique represents a promising adjunct for the management of stable juvenile OCD lesions that fail to heal after 3-6 months of non-operative treatment and for non-displaced, unstable OCD lesions that undergo internal fixation.

Drilling juvenile osteochondritis dissecans: retro- or transarticular?

Early diagnosis and successful treatment of juvenile osteochondritis dissecans (JOCD) is essential in preventing articular degeneration at a young age. Surgical treatment of stable JOCD lesions failing nonoperative treatment involves retroarticular or transarticular drilling to induce revascularization and healing. Multiple case series report high healing rates and infrequent complications for both retroarticular and transarticular drilling modalities; however, it is unclear from these individual reports whether one mode of drilling provides higher healing rates. We asked whether transarticular or retroarticular drilling of stable JOCD lesions results in differing patient-oriented outcomes, rates of radiographic healing, time to radiographic healing, and complication rates. We systematically reviewed the short-term clinical outcomes of retroarticular and transarticular drilling of stable OCD lesions. PubMed and additional sources identified 65 studies; 12 studies met inclusion criteria. Heterogeneity and quality of studies limited review to qualitative analysis. No clear differences were seen in patient-oriented outcomes after treatment with either drilling modality. Radiographic healing for JOCD lesions drilled retroarticularly occurred in 96 of 111 (86%) lesions in an average of 5.6months. Transarticular drilling of JOCD lesions resulted in 86 of 94 (91%) lesions healing by radiography in an average of 4.5months. No complications were reported for either drilling modality. Retroarticular and transarticular drilling of stable lesions results in comparable short-term patient-oriented outcomes and radiographic healing. Further high-quality comparative studies are required to adequately compare drilling modalities, clearly define radiographic healing, and patient-oriented outcomes after nonoperative treatment.

Transarticular drilling for stable juvenile osteochondritis dissecans of the medial femoral condyle

Drilling is the most common operative treatment for stable juvenile osteochondritis dissecans (OCD) of the knee. However, prognostic factors remain unclear because of lack of precise radiographic and histopathologic investigations. The purpose of this study was to evaluate the clinical results and prognostic factor of the arthroscopic drilling for juvenile OCD lesions at the medial femoral condyle (MFC), using computed tomography (CT) images. Eighteen skeletally immature patients (boys, n=16; girls, n=2, mean age, 12years) underwent arthroscopic antegrade transarticular drilling for a total of 19 OCD lesions of MFC. Functional outcomes were evaluated with the Lysholm score at follow-up (mean, 30months). Preoperative osteochondral condition and postoperative healing were evaluated by CT images. All 18 patients returned to their previous level of sports activity and showed excellent functional outcomes (mean Lysholm score, 77.2±9.4 preoperative vs. 99.5±1.6 postoperative). There were 10 osteochondral lesions and 9 subchondral bone defect lesions under preoperative CT examination. Postoperatively, 15 of 19 lesions healed completely at a mean of 6months; however, the remaining four lesions (all osteochondral types) did not achieve complete radiographic healing after 2years. Transarticular drilling for stable juvenile OCD produced excellent functional outcomes. However, the osteochondral type may influence radiographic outcome. Case series, Level IV.

Meniscoplasty for stable osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus: a case report.

Osteochondritis dissecans of the lateral femoral condyle is relatively rare, and it is reported to often be combined with a discoid lateral meniscus. Given the potential for healing, conservative management is indicated for stable osteochondritis dissecans in patients who are skeletally immature. However, patients with osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus often have persistent symptoms despite conservative management. We present the case of a seven-year-old Korean girl who had osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus, which healed after meniscoplasty for the symptomatic lateral discoid meniscus without surgical intervention for the osteochondritis dissecans. In addition, healing of the osteochondritis dissecans lesion was confirmed by an MRI scan five months after the operation. Meniscoplasty can be recommended for symptomatic stable juvenile osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus when conservative treatment fails.

Juvenile Osteochondritis Dissecans

Juvenile osteochondritis dissecans (JOCD) has been a recognized entity for more than 100 years. Despite our long recognition of OCD, the natural history and most effective therapies are poorly understood. Although conclusive evidence of an exact cause is lacking, there is widespread agreement that JOCD is related to repetitive trauma. Patients with JOCD present with vague pain and occasionally, mechanical symptoms. The diagnosis of JOCD can be confirmed on plain radiographs. Magnetic resonance imaging has emerged as the study of choice to evaluate the stability of the lesion and integrity of the overlying articular cartilage. Treatment decisions are based on the stability of the lesion. Stable JOCD lesions should be treated initially with activity modification and possibly, immobilization. Unstable lesions and stable lesions not responding to an initial course of nonoperative therapy should be surgically treated. Surgical treatment is based on the radiographic and arthroscopic characteristics of the lesion. Multiple techniques from simple arthroscopic drilling and fixation to salvage techniques for cartilage restoration are discussed.

Extraarticular Drilling for Stable Osteochondritis Dissecans in the Skeletally Immature Knee

Osteochondritis dissecans of the knee is an increasingly frequent diagnosis in the skeletally immature, in whom it is known as juvenile osteochondritis dissecans (JOCD). Although many stable lesions heal with nonoperative treatment, surgical management may be necessary when this treatment fails. Our objective is to determine if extraarticular drilling is an effective treatment for JOCD. Patients who underwent extraarticular drilling for stable JOCD of the knee at the authors' institution between 1998 and 2006 were identified. Demographic information, the location of the lesion, duration of symptoms before surgery, occurrence of complications, postoperative course, and length of follow-up were documented from each patient's medical record. The outcome measures were normal examination, radiographic evidence of healing, and full return to activity. Fifteen skeletally immature patients (16 knees) were identified. There were 8 boys and 7 girls, with 8 right and 8 left knees. One girl had bilateral lesions. The lesions were located in the medial femoral condyle in 12 knees and in the lateral femoral condyle in 4 knees. The average duration of symptoms before surgery was 21 months (range, 3 months-9 years). The average age at the time of surgery was 12 years, 4 months (range, 9-15 years). There were no intraoperative or postoperative complications. The average follow-up was 21 months (range, 8-38 months). Three of the 15 patients were lost to follow-up. In the remaining 12 patients, 12 knees had excellent outcomes with full return to activities, normal examinations, and radiographic evidence of healing. One knee had fair results. On average, these criteria were met at 8.5 months after surgery. When nonoperative management of stable JOCD fails, arthroscopic extraarticular drilling is an effective treatment to protect the articular surface and promote bone healing. Level IV case series.