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Osteochondral Defect Knee

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Other Names

  • Osteochondritis Dissecans
  • Osteochondritis Dissecans of the Knee
  • Osteochondral Defect of the Knee
  • Osteochondral Lesion
  • Osteochondral Fracture

Background

  • This page refers to osteochondral defects (OCD) of the knee
  • Definition
    • Articular cartilage is damaged, removed from the surface of a joint
    • With or without a portion of the underlying bone

History

Epidemiology

  • Up to 10% of people over 40 will have osteochondral lesions (need citation)
  • A review of 1000 knee arthroscopies showed 61% had an OCD[1]
  • A polish registry of 5233 found[2]
    • Half of patients undergoing knee arthroscopy had chondral defects; 5.2% having Outerbridge Grade III or IV lesions. ** Of those with OCD, 37.5% were in the patella alone
  • Curl et al reviewed 31,516 knee arthroscopies[3]
    • Over 53,000 hyaline cartilage lesions in over 19,000 patients
    • Most of the lesions found were actually grade III defects in the patella
  • Among asymptomatic asymptomatic professional basketball players, MRI found[4]
    • 57% of all players had an abnormal chondral signal
    • 35% having high grade patella, 25% with high grade trochlea signal

Pathophysiology

  • See: Osteochondral Defect (Main)
    • The most common site of OCD in both children and adults is the knee
  • General
    • Broad term referring to the morphological change of a localized gap in the articular cartilage and subchondral bone
    • Can occur acutely or develop as a result of several chronic conditions
    • Etiology of symptomatic chondral/osteochondral pathology is complex and often multifactorial
    • Impaction forces greater than 24 MPa will disrupt normal cartilage (need citation)
  • Pediatric Considerations
    • Bilateral knee involvement is reported in up to 25% of the cases
    • Most juvenile OCDs are stable lesions that will heal without surgical intervention, long-term consequences

Etiology

  • Acute Trauma
  • Other Trauma
    • Overuse leading to repetitive micro trauma
    • Osteochondral Impaction Fracture
    • Post-surgical
  • Biological factors
    • Osteochondritis dissecans
    • Osteonecrosis or Avascular necrosis
    • Subchondral Insufficiency Fracture (SIF)
  • Osteochondritis Dissecans
    • Pathology involving the osteochondral unit
    • Resulting in sequestration of subchondral bone
    • With or without articular cartilage involvement and instability.

Histology

  • General
    • These defects typically results in the production of type I collagen in the form of Fibrocartilage
    • Fibrocartilage has poorer characteristics with regard to resilience, stiffness and wear properties
    • As opposed to type II collagen normally found in articular, hyaline cartilage

Associated Pathology


Risk Factors


Differential Diagnosis


Clinical Features

  • History
    • Patients often have a history of trauma, depending on etiology may be mild or substantial
    • Patients will endorse pain, locking of the knee
    • Swelling is often present
    • Inability to walk, run or participate in sport
  • Physical Exam: Physical Exam Knee
    • Quad muscle atrophy may occur in chronic cases
    • Important to perform thorough structural exam
    • Evaluate for effusion, mechanical symptoms
  • Special Tests

Evaluation

Coronal MRI of an osteochondral lesion, demonstrating fluid signal behind the articular cartilage and edema within the subchondral bone[5]

Radiographs

  • Standard Radiographs Knee
    • Recommended views include AP, Lateral and notched/ tunnel view
    • Frequently normal in early stages
    • Easily diagnoses large or displaced defects
  • Findings
    • Abnormal bone contour (most commonly the lateral aspect of the medial femoral condyle)

MRI

  • Imaging modality of choice
    • Most sensitive/ specific modality for evaluating lesions
    • Useful to stage lesion
    • Evaluates other soft tissue structures
  • Can evaluate
    • Soft tissue competence
    • Chondral status
    • Trochlear morphology
    • Presence of loose bodies
    • Acuity of injury (i.e., bone bruise pattern)
    • Alignment parameters in multiple planes

CT

  • Benefits
    • Better evaluate bone loss
    • Measure tibial tubercle-trochlear groove (TT-TG)
    • Measure tibial tubercle-posterior cruciate ligament (TT-PCL)

Classification

International Cartilage Repair Society Classification

  • Grade 0: Normal
  • Grade 1: Nearly normal (superficial defect with soft indentation, fissures or cracks)
  • Grade 2: Abnormal (defect extending to < 50% of cartilage depth)
  • Grade 3: Severely abnormal (defect extending > 50% of cartilage, but not through subchondral bone)
  • Grade 4: Severely abnormal (defect penetrating through subchondral bone)

Outerbridge Arthroscopic Grading System

  • Grade 0: Normal cartilage
  • Grade I: Softening and swelling
  • Grade II: Superficial fissures
  • Grade III: Deep fissures, without exposed bone
  • Grade IV: Exposed subchondral bone

Management

Nonoperative

  • Indications
    • Not universally agreed upon
    • Mild symptoms
    • Absence of mechanical features (locking, swelling, instability, etc)
  • Restriction of physical activity
    • Stop activities that cause excessive repetitive, compressive stress on the affected knee
    • Includes all strenuous contact sports, running, jumping, squatting and long periods of standing
  • Physical Therapy
  • Modalities including Iontophoresis, Extracorporeal Shock Wave Therapy
  • Restricted weightbearing
    • partial with crutches
    • Total with wheelchair
  • Immobilization with cast or brace
  • Medications including NSAIDS
  • Viscosupplementation
    • Controversial due to unknown benefits
    • Considered safe for articular cartilage, should be considered
  • Corticosteroid Injections
    • Use is controversial
    • Should be used sparingly, especially in younger patients
    • Concerns over deleterious effects on articular cartilage over time[6]
  • Platelet Rich Plasma
    • Growing in popularity
    • Has shown promise, especially with leukocyte poor formulations

Operative

  • Objectives[7]
    • Re-establish the joint surface with hyaline cartilage
    • Provide a congruent joint with correct alignment
    • Symptomatic relief
    • Reduce the risk of progressive arthritic changes
  • Indications
    • High risk features
    • Mechanical symptoms (locking, swelling, instability, etc)
    • Large defect size (range in literature is 0.75 to 1.5 cm)
  • Technique
    • Debridement / Chondroplasty
    • Palliation (e.g. chondroplasty or microfracture)
    • Repair or Fixation of Unstable Fragments
    • Osteochondral autograft transplant (OAT) / Mosaicplasty
    • Osteochondral allograft transplant
    • Autologous matrix induced-chondrogenesis (AMIC)
    • Autologous chondrocyte implantation (ACI)
    • Subchondral bone drilling
    • Marrow Stimulation Techniques
    • Patellar cartilage unloading procedures
    • Arthroplasty may be considered in patients who are older with advanced osteoarthritis

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications and Prognosis

Prognosis

  • Poor Prognosis
    • Larger lesion size > 12 mm2
    • Lesion stability
    • Age (open physis)
  • Conservative treatment
    • Restricting physical activity and physiotherapy, have yielded average healing rates of 61% (range 10–95%)[8]
  • Knee Osteoarthritis
    • Risk is inevitable with grade 3/4 ICRS[9]

Complications

  • Knee Osteoarthritis
    • Untreated defects can lead to early onset arthritis[10]
    • Larger defects appear to confer more risk[11]
  • Chronic Knee Pain
  • Inability to return to sport

See Also


References

  1. Hjelle, Karin, et al. "Articular cartilage defects in 1,000 knee arthroscopies." Arthroscopy: The Journal of Arthroscopic & Related Surgery 18.7 (2002): 730-734.
  2. Widuchowski W, Lukasik P, Kwiatkowski G, et al. Isolated full thickness chondral injuries. Prevalance and outcome of treatment. A retrospective study of 5233 knee arthroscopies. Acta Chir Orthop Traumatol Cech 2008;75:382-6.
  3. Curl WW, Krome J, Gordon ES, et al. Cartilage injuries: a review of 31,516 knee arthroscopies. Arthroscopy 1997;13:456-60.
  4. Kaplan LD, Schurhoff MR, Selesnick H, et al. Magnetic resonance imaging of the knee in asymptomatic professional basketball players. Arthroscopy 2005;21:557-61.
  5. Scully, William F., Stephen A. Parada, and Edward D. Arrington. "Allograft osteochondral transplantation in the knee in the active duty population." Military medicine 176.10 (2011): 1196-1201.
  6. Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthop J Sports Med 2015;3:2325967115581163.
  7. O'Driscoll SW, Salter RB. The repair of major osteochondral defects in joint surfaces by neochondrogenesis with autogenous osteoperiosteal grafts stimulated by continuous passive motion. An experimental investigation in the rabbit. Clin Orthop Relat Res. 1986 Jul;(208):131-40. PMID: 3522020.
  8. Andriolo L, Candrian C, Papio T, Cavicchioli A, Perdisa F, Filardo G. Osteochondritis dissecans of the knee—conservative treatment strategies: a systematic review. Cartilage. 2019;10(3):267–77.
  9. Sanders TL, Pareek A, Obey MR, Johnson NR, Carey JL, Stuart MJ, et al. High rate of osteoarthritis after osteochondritis dissecans fragment excision compared with surgical restoration at a mean 16-year follow-up. Am J Sports Med. 2017;45:1799–805.
  10. Linden, B. Osteochondritis dissecans of the femoral condyles: a long-term follow-up study. J Bone Joint Surg Am. 1977; 59: 769–776.
  11. Convery, FR , Akeson, WH , Keown, GH . The repair of large osteochondral defects. Clin Orthop. 1972; 82: 253–262.
Created by:
John Kiel on 28 February 2021 10:34:02
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Last edited:
6 April 2022 15:58:04
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