Management

Natural History

 

Seigall et al. J Paediatr Orthop 2018

- instability 3% in patients < 13 years

- instability 100% in patients > 17 years

- not predictive 13-17 years

 

Non Operative Management

 

Indications

 

1.  Open growth plates  / Juvenile OCD

- > 2 years of growth remaining

- age 12 or less

 

2.  Stable lesion / cartilage intact / no fluid on MRI

 

3.  Smaller lesions

 

Technique

 

No impact sports

Consider unloader brace first 3 months

After 3 months can swim or bike

 

Tepolt et al. J Pediatr Orthop 2020

- retrospective study of 333 stable JOCD treated nonoperatively

- treatment successful in 57% at 9 months

- unloader bracing did not improve outcomes and was more often associated with need for surgery

 

Assessment of healing

 

Xray

 

Signs of reossification

 

MRI

 

Reduction in size of lesion

Reduction in edema around lesion on T2

Reossification on T1

 

OCD T2 edema preOCD T2 edema post

MFC OCD on presentation                                T2 image 6 months later

 

OCD T1 preOCD T1 post

T1 sagittal on presentation                               T1 sagittal six months later

 

Results

 

Overall

 

Andriolo et al. Cartilage 2019

- systematic review of 27 studies and 908 knees undergoing nonoperative treatment

- mix of adult and juvenile, stable and unstable OCD

- overall healing rate of 61%

- poorer prognosis was larger lesion size, worse OCD stage, skeletal maturity

 

Krause et al. Am J Sports Med 2013

- stable JOCD treated nonoperatively in 62 patients

- girls mean age 11 and boys mean age 12

- after 6 months, 67% showed no progression towards healing or signs of instability

- after 12 months, 51% showed no progression towards healing

- larger lesions and the presence of cyst like lesions associated with increased failure rates

- the presence and size of cyst like lesions >1.3mm was most important predictor of failure

 

Stable OCD no cystsStable lesion with cysts

Stable lesion with no cysts                                   Stable lesion with cysts

 

Lateral femoral condyle

 

Nakayama et al. Knee 2016

- 43 knees in 37 patients with stable LFC JOCD undergoing nonoperative treatment

- 33% failed to heal at 6 months

- all those with associated discoid meniscus failed

 

Takigami et al. J Paediatr Orthop 2022

- 44 knees in 37 patients with stable LFC JOCD (average age 9) undergoing nonoperative treatment

- no difference in healing rates between those with normal lateral meniscus and incomplete discoid meniscus

 

Operative Management

 

Algorithm

 

1. Stable lesions

- stable, no cartilage breach, no fluid behind lesion

- anterograde or retrograde drilling

 

2. Unstable and salvageable lesions

- fluid behind lesion on MRI

- cartilage breach on arthroscopy

- screw fixation

 

Unstable OCD MRICartilage breach arthroscopy OCD

 

Unstable and unsalvageable OCD

- fragment removal

- cartilage restoration procedure +/- realignment if needed

 

OCD fragmented

 

Drilling in situ

 

Indications

 

Failure non operative management > 6 months

Stable on MRI - no fluid behind lesion

Cartilage intact on arthroscopy

 

Concept

 

Aim to stimulate vascular ingrowth and subchondral healing

 

Antegrade v retrograde

 

Antegrade

- easy to do

- damages cartilage

 

Retrograde

- image intensifier or PCL guide

- more difficult but preserves cartilage

 

Results

 

Gunton et al CORR 2013

- SR of JOCD treated with retrograde v antegrade drilling

- 86% radiographic healing with retrograde drilling by 5.6 months

- 91% radiographic healing with anterograde drilling by 4.5 months

- no significant difference

 

Baghdadi et al. Arthrosc Sports Med Rehab 2022

- 139 knees in 131 patients average age 13

- 16% bilateral

- 91% transarticular

- 96% healing rate

 

Technique

 

In a stage 1 lesion there is no cartilage breach

- the MFC / LFC looks normal

- use MRI to identify site of lesion

- i.e. usually adjacent to PCL insertion for MFC OCD

- central LFC for LFC OCD

 

5 - 10 drill holes

- 20 mm deep

 

OCD Antegrade Drilling

Transarticular drilling of LFC OCD

 

Rehabilitation

 

Crutches and protected weight bearing 4 - 6 weeks

No sports 6 months

MRI 3 and 6 months

 

Femoral OCD Healing Before DrillingFemoral OCD Healing Post DrillingKnee Healed OCD Post Drilling

Progression of reossification over 6 months following drilling

 

Screw fixation

 

Indications

 

Unstable lesion

Salvageable

 

OCD unstable 1OCD unstable 2

 

Options

 

Open or arthroscopic

 

Cannulated headless variable pitch compression screws

- metal or bioabsorble

 

Consider bone graft

 

Yellin et al. J Paediatr Orthop 2017

- survey of 129 members of the Pediatric Orthopedic Society of North America

- majority use a metal or bioabsorble screw with no bone graft

 

Arthroscopic Screw Fixation in situ

 

Femoral OCD in situ Femoral OCD K wireFemoral OCD Screw InsertionFemoral OCD Pinned in Situ

 

Arthroscopic bone graft and screw fixation

 

Adult OCD LargeAdult OCD Burr Base

 

Open bone graft and screw fixation

 

Open OCD 1Knee OCD Hinged open & Base drilled

 

OCD Open 3OCD open final

 

Arthroscopic Mosaicplasty / OATS

 

Lateral femoral OCDMosaicplasty plugsMosaicplasty plugs in OCD

 

Results

 

Miura et al Am J Sports Med 2007

- 12 unstable OCD treated with mosaicplasty plugs

- complete union on MRI in all cases

- 8 excellent and 3 good outcomes

- no donor site morbidity

 

Miniaci et al. Arthroscopy 2007

- 20 patients with unstable OCD treated with mosaicplasty

- MRI demonstrated bony healing in all patients at 6 months

- cartilage healing by 9 months

 

Assessing Union

 

Xray

 

OCD preopOCD post op

Some reossification and evidence of union

 

MRI

 

MRI OCD HealingMRI OCD Healing 2

Reossification and evidence of bony bridging

 

CT

 

OCD Healing CT 1CT healing OCD 2

Evidence of bony union on CT

 

Results

 

Wu et al. AJSM 2018

- 87 patients undergoing screw fixation for unstable OCD

- 76% union rate at 2 years

- no difference between open or closed growth plates

- increased nonunion for LFC OCD

 

Komnos et al. Cartilage 2021

- retrograde drilling and bioabsorble pins in 40 patients mean age 13

- 84% union stage 3

 

Barrett et al. Cartilage 2016

- metal compression screws in 22 patients mean age 22

- union seen in 82%

 

Risk factors for non union

 

Fragmentation of piece

Thin bony fragment

 

Unsalvageable OCD / failed OCD fixation

 

OCD Failed FixationDisplaced ocdOCD fragmentedDetached OCD

Failure of fixation                                Chronic displaced fragment              Fragmented OCD                   Fully detached OCD

 

Issue

 

Important to address osteochondral defect

 

Sanders et al. AJSM 2017

- OCD fixation:         OA 7% at 10 years,   25% at 20 years, 50% at 30 years

- fragment excision:  OA 17% at 10 years, 40% at 20 years, 70% at 30 years

 

Options

 

Microfracture

 

Usually inappropriate for osteochondral defects

 

Mosaicplasty +/- osteotomy

 

Defect often too large for 4.5 mosaicplasty plugs

Number required to fill defect often results in donor site morbidity

 

LFC chondral defectChondral defect mosaciplasty

 

Autologous chondrocyte implantation (ACI) +/- osteotomy

 

Carey et al. AJSM 2020

- 55 patients with 61 unsalvageable OCD treated with ACI

- average 19 year follow up

- 61% reached pre-injury level function

- 85% 15 year survival

 

Autologous Matrix Induced Chondrogenesis (AMIC) +/- osteotomy

 

Microfracture base +/- bone graft

Application of collagen patch - secured with sutures or Tisseal fibrin glue

 

AMIC collagen patchAMIC kneeAMIC HTO

 

Bertho et al. Orthop Traumatol Surg Res 2018

- 13 patients with large osteochondral defects treated with AMIC and bone grafting
- 11/13 had satisfactory outcomes

 

Osteochondral Allograft +/- osteotomy

 

OCA knee 1OCA knee 2Osteochondral Allograft APOsteochondral Allograft Lateral

 

Sadr et al. AJSM 2016

- 135 patients with 149 knees

- osteochondral allograft for unsalvageable OCD

- 93% 10 year survival (based on revision allograft, or arthroplasty)