[Bone and joint diseases in children. Etiology and pathogenesis of osteochondral lesions in children. Osteochondritis dissecans and osteochondrosis]

Osteochondral lesions in children mainly occur in the physeal and epiphyseal cartilage. Osteochondritis dissecans and osteochondrosis (apophysitis) are common and clinically important chronic disorders. These etiology and pathogenesis have also been well investigated in the Veterinary medicine in recent years. One of the most likely causes is proposed as a failure of blood supply to growth cartilage and following focal disturbance of endochondral ossification. Mechanical stress, trauma, rapid growth, anatomic conformation, and dietary imbalances would modify this initial step and break down the normal structure. In human, above-mentioned pathological changes can be detected using recent MRI technology, which contribute quite much in the early diagnosis of lesions in clinic. Another problem in children is acute traumatic growth plate injury, which increases the risk of the early closure of growth plate and following deformity of bone and joint. Early diagnosis and precise treatment are extremely important for children to prevent residual deformity and pain and growth disturbance. In future, less-invasive as well as effective treatments for the focally disturbed or accelerated ossification should be developed.

A volleyball player with bilateral knee osteochondritis dissecans treated with extracorporeal shock wave therapy

We present a case report of a 14-year-old Caucasian sport woman affected by bilateral and symmetrical knee osteochondritis dissecans (OCD) addressed to surgery, in which extracorporeal shock wave therapy determined complete healing. Shock wave is a longitudinal acoustic wave traveling with the speed of ultrasound through the water of the body tissue. Recently, this therapy has been used in the treatment of a number of musculoskeletal pathologies on the basis of the effects produced by the induction of angiogenesis, recruitment of progenitor cells and downregulation of cartilage damage. This therapy is useful, because it is non-invasive, safe, without complications or adverse effects and repeatable. Thus, it could be suggested as a useful strategy for the treatment of OCD prior starting surgery.

Osteochondritis dissecans of the humeral trochlea with cubitus varus deformity. A case report

Osteochondritis dissecans of the elbow primarily involves the capitellum. We report a rare case of osteochondritis dissecans involving the humeral trochlea in a 19-year-old male with a post-traumatic cubitus varus deformity. Biomechanics suggested that the varus malalignment caused repetitive axial force across the medial elbow, which led to microtrauma to the trochlea during the patient's daily work. In adolescents, post-traumatic cubitus varus can gradually progress to subsequent osteochondritis dissecans of the humeral trochlea.

Talar dome fracture repaired using bioabsorbable fixation

We describe a man with an acute osteochondral defect in the lateral talar dome associated with a supination-adduction-type ankle fracture. The osteochondral defect was readily visible on plain film radiographs, and magnetic resonance imaging was ordered to determine the full extent of soft-tissue and articular injury. It was discovered that the patient had a stage IV lesion of the talar dome, with complete inversion of the fragment, and rupture of the anterior talofibular and calcaneofibular lateral ankle ligaments. Furthermore, the patient experienced an oblique fracture of the medial malleolus with comminution. The talar dome lesion was surgically reduced and fixated using bioabsorbable pins. Nine months after surgery, the patient was fully recovered from his injury and had no functional limitations.

Arthroscopic management of talar dome lesions using a transmalleolar approach

Surgical treatment of posteromedial talar dome lesions is frequently necessary for Berndt and Harty grade IV osteochondral defects and nondisplaced osteochondral fragments resistant to conservative modalities. When operative intervention is indicated, the approach and management can be complicated by the location and extent of the injury. The operative technique we advocate allows direct exposure of the lesion and minimizes damage to healthy articular cartilage and surrounding soft tissue. Use of a drill guide assists the surgeon in precisely placing a transmalleolar portal through the tibia for subchondral drilling of osteochondral defects when the lesions are inaccessible through traditional arthroscopic portals.

Autologous osteochondral mosaicplasty for capitellar osteochondritis dissecans in teenaged patients

BACKGROUND

Autologous osteochondral mosaicplasty is a new technique to provide hyaline repair for articular defects. Although recent studies have reported the successful treatment of articular defects in the knee and ankle joints with this surgical procedure, little attention has been given to the surgical efficacy of mosaicplasty in the treatment of osteochondritis dissecans of the humeral capitellum.

PURPOSE

To clarify the clinical outcomes of mosaicplasty for teenaged patients with advanced lesions of capitellar osteochondritis dissecans.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Eight teenaged patients with advanced lesions of capitellar osteochondritis dissecans underwent mosaicplasties. All patients were baseball players who were affected on the right side, which was also their throwing side. The surgical technique involves obtaining small-sized cylindrical osteochondral grafts from the lateral periphery of the femoral condyles and transplanting them to prepared osteochondral defects. At a mean follow-up of 24 months, all patients were evaluated clinically and radiographically.

RESULTS

Seven of the 8 patients were free from elbow pain, and the remaining patient had mild pain occasionally. The mean clinical score described by Timmerman and Andrews (a maximum of 200 points) significantly improved from 140 points to 183 points postoperatively. All patients except one had excellent or good clinical results. Radiographically, the graft incorporation and a normal contour of the subchondral cortex were found in all patients. Magnetic resonance imaging showed that the preoperative heterogeneity of the lesion had disappeared and the signal intensity returned to normal. Six of the 8 patients, including all 3 pitchers, returned to competitive-level baseball.

CONCLUSION

Mosaicplasty for advanced lesions of capitellar osteochondritis dissecans in teenaged baseball players can provide satisfactory clinical and radiographic results.

Management of osteochondritis dissecans of the knee: current concepts review

Osteochondritis dissecans of the knee is being seen with increased frequency in pediatric and young adult athletes and is thought to be, in part, owing to earlier and increasingly competitive sports participation. Despite much speculation, the cause of both juvenile and adult osteochondritis dissecans remains unclear. Early recognition is essential. Whereas adult osteochondritis dissecans lesions have a greater propensity to instability, juvenile osteochondritis dissecans lesions are typically stable, and those with an intact articular surface have a potential to heal with nonoperative treatment through cessation of repetitive impact loading. The value of adjunctive immobilization, protected weightbearing, and unloader bracing has not been established. Skeletally immature patients with stable lesions that have not healed with nonoperative treatment should have consideration given to arthroscopic drilling to promote healing before the lesion progresses and requires more involved treatment with a less optimistic prognosis. Magnetic resonance imaging may allow early prediction of lesion healing potential. The majority of adult osteochondritis dissecans cases as well as those skeletally immature patients with unstable lesions and secondary loose bodies require fixation and possible bone grafting. Many unstable lesions will heal after stabilization, but long-term prognosis is not clear. Chronic loose fragments can be difficult to fix and have poor healing potential. Results of excision of large lesions from weightbearing zones are poor. Chondral resurfacing techniques have limited long-term data for cases of osteochondritis dissecans in skeletally immature patients.

Current concepts: treatment of osteochondral ankle defects

Osteochondral ankle defects cause various symptoms including pain, swelling, and limited range of motion. When surgical treatment is necessary, several treatment options exist. Arthroscopic debridement and drilling, arthroscopic autologous osteochondral transplantation (mosaiclasty), and autologous chondrocyte transplantation are discussed more extensively. Treatment results of each technique are discussed, and a guideline for treatment is presented.

A case of osteochondritis dissecans in rickets

Rickets and the decreased ossification associated with it can give rise to abnormally low bone density and weakened osseous structures. Despite this association, rickets has rarely been associated with osteochondral defects, and the imaging findings of this association have not been previously described on magnetic resonance (MR) imaging. This case report presents an adolescent male with a clinical history of rickets and recent-onset knee pain that was determined to be caused by bilateral osteochondritis dissecans. Prompt recognition of osteochondritis dissecans is important, as this entity is a treatable cause of knee pain.

Osteochondritis dissecans after rotational acetabular osteotomy for dysplastic hip

We encountered a rare case of osteochondritis dissecans of the femoral head after rotational acetabular osteotomy that recovered with conservative treatment 4 years after the detection of characteristic radiological findings.

Are bone bruises a possible cause of osteochondritis dissecans of the capitellum? A case report and review of the literature

A 17-year old soccer-player sustained a fracture and dislocation of the ulnar epicondyle combined with a bone bruises at the radial head and the capitellum. An open reduction and internal fixation was performed using two K-wires. Initial recovery was uneventful. After the operation he was discharged home and reviewed on a regular basis. When bony union had occurred the two K-wires were removed. However, on follow up he continued to complain of pain on the radial aspect of the joint and did not regain his normal range of movement. A further MRI was performed. Now a grade II osteochondritis dissecans not visible on the previous MRI taken 12 weeks earlier was clearly visualised. Treatment was continued conservatively with physiotherapy but avoiding aggressive mobilisation. On final review 6 months later he was able to move painfree with residual limitation of movement (ROM 0-5-130 degrees). Another MRI taken now was assessed as normal.

Arthroscopy-assisted retrograde drilling of osteochondral lesions of the talar dome

Traumatic ankle conditions can lead to long-term sequelae if a pathologic process is misdiagnosed. The clinical presentation of an osteochondral lesion of the talar dome requires the clinician to have a high index of suspicion, and advanced imaging is often necessary to make the final diagnosis. Treatment should be initiated once the lesion is appropriately staged by radiologic or magnetic resonance imaging. We discuss the use of arthroscopy-assisted retrograde drilling of the medial talar dome that spares the articular cartilage within the talotibial articulation.

Nutraceutical Therapies for Degenerative Joint Diseases: A Critical Review

There is growing recognition of the importance of nutritional factors in the maintenance of bone and joint health, and that nutritional imbalance combined with endocrine abnormalities may be involved in the pathogenesis of osteoarthritis (OA) and osteochondritis dissecans (OCD). Despite this, dietary programs have played a secondary role in the management of these connective tissue disorders. Articular cartilage is critically dependent upon the regular provision of nutrients (glucose and amino acids), vitamins (particularly vitamin C), and essential trace elements (zinc, magnesium, and copper). Therefore, dietary supplementation programs and nutraceuticals used in conjunction with non-steroidal, anti-inflammatory drugs (NSAIDs) may offer significant benefits to patients with joint disorders, such as OA and OCD. This article examines the available clinical evidence for the efficacy of nutraceuticals, antioxidant vitamin C, polyphenols, essential fatty acids, and mineral cofactors in the treatment of OA and related joint disorders in humans and veterinary species. This article also attempts to clarify the current state of knowledge. It also highlights the need for additional targeted research to elucidate the changes in nutritional status and potential alterations to the expression of plasma membrane transport systems in synovial structures in pathophysiological states, so that current therapy and future treatments may be better focused.

Radiologic case study. Spontaneous osteonecrosis of the knee reclassified as insufficiency fracture

Three questions need to be answered. First, does spontaneous osteonecrosis of the knee in fact exist? The answer is "probably," but much more rarely than initially believed. In five of the authors' most recent MRIs in patients with clinically diagnosed or radiographically suggested spontaneous osteonecrosis of the knee, only one patient's images fulfilled the criteria for spontaneous osteonecrosis (Figure 3). Three of the five had subchondral changes of either insufficiency fractures or true fractures, while one patient had equivocal findings. Second, will the actual diagnosis influence the treatment? The answer appears to be "no" because early subchondral fractures and early spontaneous osteonecrosis of the knee are treated conservatively and only the later changes of subchondral surface collapse are treated more aggressively with joint replacement. Third, is there any method of halting the progression of early subchondral changes before they progress into collapse, flattening, and loose-body formation? The answer appears to be "maybe" as non-weight-bearing conservative therapy has not consistently prevented progression of the disease. Whether new arthroscopic techniques can provide the necessary intervention to halt osteoarthritic sequelae remains unanswered. Thus, it appears most patients with what has been called spontaneous osteonecrosis of the knee actually have subchondral insufficiency fractures. The histologic findings of avascular areas in biopsy specimens appear to be a secondary phenomenon and not the primary cause. If diagnosed early enough, conservative therapy may lead to healing without subsequent collapse and fragmentation of the subchondral bone.

Osteochondral autogenous transplantation for an osteochondral defect of the first metatarsal head: a case report

A case of an isolated, traumatic, osteochondral injury to the articular surface of the first metatarsal head, which was successfully treated with an autogenous transplant of an osteochondral plug from the ipsilateral knee, is reported. After a 2-year follow-up, the patient reported no persistent symptoms, full resumption of preinjury activities, and was satisfied with her outcome.

Ergebnisse der Refixation der Osteochondrosis Dissecans des Talus mit Kirschnerdrähten

INTRODUCTION

Etiology of osteochondral lesions of the talus remains uncertain, a myriad of treatment options exists. The purpose of this study is to evaluate the clinical and radiological results of fixation of osteochondral lesions of the talus using K-wires. An unstable osteochondral fragment or osteosclerotic changes in the bed of the talus were regarded as indications for the procedure.

PATIENTS AND METHOD

We report a retrospective study of 20 patients who underwent fixation of osteochondritis dissecans of the talus between 1.1.1995 and 31.12.2000. There were 14 men and 6 women. The average age was 18 years (range, 11 to 52 years). The average duration of symptoms prior to surgery was 30 weeks (range, 8 to 100 weeks).

RESULTS

The average duration of follow-up was 46 months (range, 18 to 93 months). The overall clinical result was rated good in 4 cases and excellent in 16 cases according to the Ogilvie-Harris score. There were no surgical complications. All osteochondral lesions healed.

CONCLUSION

Using K-wires for fixation of osteochondral lesions of the talus repair of the articular surface and stability of the lesion can be achieved even in unstable chronic lesions.

Increased external tibial torsion and osteochondritis dissecans of the knee

In the past, osteochondritis dissecans of the knee was associated with increased tibial exotorsion, established with a clinical measuring method. Now the gold standard for determining tibial torsion is computed tomography. The aim of the current study was to establish whether the abovementioned association could be confirmed in the current patients, measured with computed tomography. Confounding aberrations of femoral torsion were ruled out. Twenty-three patients with osteochondritis dissecans in 27 knees were treated between 1991 and 1999. Symptoms and treatment results were comparable with those reported in the literature. Femoral and tibial torsion were measured with a computed tomography scan. The average femoral antetorsion was comparable with that in the literature. The average tibial exotorsion was significantly higher than the control value. Exotorsion was increased more in patients with bilateral osteochondritis, and extremely high in patients with persisting complaints. Increased tibial exotorsion could play a role in development of osteochondritis dissecans of the knee. Extreme exotorsion might be prognostic for persistent complaints.

Osteochondritis dissecans of the elbow

Osteochondritis dissecans of the elbow is a localized condition of the articular surface that is commonly seen in the young athlete. This disorder refers primarily to lesions of the capitellum and can be difficult to treat. Although trauma and ischemia play significant roles, the exact etiology remains unknown. The natural history is poorly understood and long-term sequelae include degenerative arthritis. The integrity of the articular surface and the stability of the lesion can be carefully evaluated with MRI and arthroscopy. Management is based mainly upon these two factors, yet no good universal outcomes exist among the varied treatment options. Stable lesions identified early appear to have the best prognosis with conservative management. Indications for surgery include persistent or worsening symptoms despite prolonged conservative care, loose bodies, or evidence of instability. Whether to excise and débride or to fix an unstable fragment is a highly controversial topic. The clinician should recognize osteochondritis dissecans of the elbow as a potentially disabling condition where the prognosis for return to sport is guarded.

[Osteochondritis dissecans of the scaphoid (Preiser's syndrome): 2 case reports]

Preiser's syndrome is a rare osteochondrosis affecting the carpal scaphoid, frequently related with an avascular necrosis. Osteoarthritic changes of the articular cartilage, local synovitis, and loose fragments are the most common findings associated with this syndrome. We report here two patients with Preiser's syndrome, one with and one without a traumatic history, both presenting with pain, swelling and functional impairment of the wrist. In one patient radiography was sufficient for the diagnosis, in the other NMR was necessary to clearly establish type and extension of the lesion. Differential diagnosis may be sometimes difficult and the therapeutic approach depends on several aspects, including etiology and type of occupational activity.

[Osteochondral transplantation (mosaicplasty) in the treatment of knee joint cartilage defects]

Between 1998 and 2001 thirty-five patients underwent osteochondral transplantation (mosaicplasty) and 35 patients (controls) - microfracture procedure for osteochondral or chondral knee joint pathology treatment. Average age of patients was 24.74+/-7.20 years. Patients were evaluated through International Cartilage Repair Society (ICRS) and modified Hospital for special Surgery (HSS) scales, arthroscopically, histologically, with MRI and x-rays. Modified HSS and ICRS evaluation showed statistically significantly better results in the mosaicplasty group 12 months post operation (p=0.005). Last follow-up showed deterioration in microfracture group (p=0.0005).

Juvenile osteochondritis dissecans

JOCD has better potential for healing than adult OCD, but several series have shown up to a 50% failure to heal with nonsurgical techniques. JOCD poses a therapeutic dilemma for the pediatric sports specialist because the healing potential is unpredictable at the disease onset. There are no controlled prospective studies on this condition to accurately gauge the effect of different treatments, or even if treatment affects the natural history of JOCD.