The demographics and epidemiology of osteochondritis dissecans of the knee in children and adolescents

Catcher's Knee: Posterior Femoral Condyle Juvenile Osteochondritis Dissecans in Children and Adolescents

BACKGROUND

Juvenile osteochondritis dissecans is an idiopathic condition involving subchondral bone and articular cartilage in skeletally immature patients in whom the growth plates are open, potentially leading to lesion instability. Because of the differing forces experienced by baseball/softball catchers versus position players, the age at which lesions develop and the characteristics of the lesions themselves may differ between these 2 populations. The purpose of the study was to examine relative age and characteristics of osteochondritis dissecans (OCD) knee lesions in catchers compared with position players.

METHODS

Using a text-based search tool that queries clinic notes and operative reports, computerized medical records from 1990 to 2014 from the Sports Medicine Program of a tertiary care Children's Hospital were searched to find children and adolescents who had OCD of the knee, played baseball/softball, had a specified field position, and had magnetic resonance imaging of the knee. Ultimately, 98 knees (78 patients) were identified: 33 knees (29 patients) in catchers and 65 knees (49 patients) in noncatchers. Data collected included position played (catcher/noncatcher), demographics (age, unilateral/bilateral, and sex), lesion severity, and sagittal and coronal lesion location.

RESULTS

When compared with noncatchers, catchers presented at a younger age (P=0.035) but were similar with respect to bilateral involvement (P=0.115), sex (P=0.457), and lesion severity (P=0.484). Lesions in catchers were more posterior on the femoral condyle in the sagittal plane (P=0.004) but similar in location in the coronal plane (P=0.210).

CONCLUSIONS

Catchers developed OCD at a younger age and in a more posterior location on the medial and lateral femoral condyles than noncatchers. These results may represent the effects of repetitive and persistent loading of the knees in the hyperflexed position required of catchers. Increased awareness of this risk may lead to surveillance and prevention programs.

LEVEL OF EVIDENCE

Level III-case-control study.

Childhood Obesity is Associated With Osteochondritis Dissecans of the Knee, Ankle, and Elbow in Children and Adolescents

BACKGROUND

Osteochondritis dissecans (OCD) is a joint disorder of the subchondral bone and articular cartilage whose association with obesity in children is not clearly known. The purpose of this study was to assess the magnitude of the association between childhood obesity and the occurrence of OCD of the knee, ankle, and elbow in children.

METHODS

A retrospective chart review of an integrated health system was performed on OCD patients aged 2 to 19 from 2007 to 2011, with over 1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. The body mass index (BMI) for each patient in the cohort was used to stratify patients into 5 weight classes (underweight, normal weight, overweight, moderately obese, and extremely obese) based on BMI-for-age. The associations between the 5 weight classes and OCD of the ankle, knee, and elbow were assessed using multiple logistic regression models to estimate odds ratios (OR) and 95% confidence intervals using multivariate analysis to adjust for patient demographic variables.

RESULTS

In total, 269 patients fit the inclusion criteria. Mean BMI, both absolute and percentile, was significantly higher for patients with OCD of the knee, elbow, and ankle than patients without OCD. In the multivariate analysis, extremely obese patients were found to have an increased OR of OCD for all patients, with an 86% increased risk of any OCD compared with normal weight patients. In addition, assessment by different types of OCD revealed that extremely obese patients had an increased OR of OCD of the elbow and ankle individually, with a 3.1 times increased OCD elbow risk and 3.0 times increased risk of ankle OCD in extremely obese patients. Although extremely obese patients did not have a statistically significant increased risk of knee OCD, moderately obese patients did have a 1.8 times increased risk of knee OCD as compared with normal weight children. There were no significantly different risks of any type of OCD seen in overweight or underweight patients as compared with normal weight patients.

CONCLUSIONS

In this population-based cohort study, extreme obesity is strongly associated with an increased risk of OCD overall and OCD of the elbow and ankle specifically. In addition, moderate obesity is associated with an increased risk of knee OCD. All types of OCD were also found to have a significantly greater average BMI when compared with patients without OCD.

LEVEL OF EVIDENCE

Level IV-descriptive epidemiology study.

Epidemiology and patient-reported outcome after juvenile osteochondritis dissecans in the knee

BACKGROUND

This study describes the epidemiology and patient reported outcomes following juvenile osteochondritis dissecans (JOCD) of the knee.

METHODS

Medical records and radiographs of patients aged 10-18years diagnosed with JOCD between 2010 and 2016 were retrospectively reviewed. The lesions were classified according to the International Cartilage Repair Society's classification. The results were evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm score and a Visual Analogue Scale (VAS) for pain.

RESULTS

Seventy patients with 87 JOCDs were identified. The annual incidence was 11.5 (95% confidence interval 10.7-12.2) per 100,000 inhabitants younger than 19years. Fifty-two (74.3%) of the 70 patients returned the questionnaires on average 48months (five to 117) after diagnosis. The median Lysholm score was 84 for patients with grade I-II lesions and 80 for patients with grade III-IV lesions. The median Lysholm score was 84.5 for patients who were treated conservatively and 79.5 for patients who were treated operatively. The median VAS score was 2.0 for all groups, except for patients treated conservatively (median score 1.5). Conservative treatment was successful in 78% of grade I-II lesions. There was a fivefold increased risk of failing conservative treatment with a stage III-IV lesion, compared to stage I-II (Odds ratio=5.5, p=0.02).

CONCLUSIONS

The results following JOCD are good to excellent for the majority of patients. Grade I-II lesions are successfully treated conservatively in 78% of cases. Grade III-IV lesions have a high failure rate.

LEVEL OF EVIDENCE

Level III, retrospective cohort.

Pediatric Pain Syndromes and Noninflammatory Musculoskeletal Pain

Chronic musculoskeletal pain (CMP) is one of the main reasons for referral to a pediatric rheumatologist and is the third most common cause of chronic pain in children and adolescents. Causes of CMP include amplified musculoskeletal pain, benign limb pain of childhood, hypermobility, overuse syndromes, and back pain. CMP can negatively affect physical, social, academic, and psychological function so it is essential that clinicians know how to diagnose and treat these conditions. This article provides an overview of the epidemiology and impact of CMP, the steps in a comprehensive pain assessment, and the management of the most common CMPs.

Bilateral Bicondylar Osteochondritis Dissecans in a Child with Spastic Diplegia and Crouch Gait: A Case Report

CASE

The cause of osteochondritis dissecans is unknown. Various hypotheses suggest mechanical, ischemic, and hereditary causes. We describe a 13-year-old girl with spastic diplegia, a form of cerebral palsy, who had an associated crouch gait and presented with bilateral osteochondral defects of the medial and lateral femoral condyles.

CONCLUSION

This case highlights the potential role of repetitive microtrauma, likely due to the poor biomechanical forces in a crouch gait, and provides support for a mechanical cause of osteochondritis dissecans.

Incidence of Osteochondritis Dissecans in Adults

BACKGROUND

Osteochondritis dissecans (OCD) has frequently been described in children and adolescents, but cases of OCD in adults are certainly encountered. Little has been published on the epidemiology of OCD in adult patients.

PURPOSE

To assess the frequency of OCD lesions in adults and assess the risk by age, sex, and ethnicity.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

The authors assessed all patients aged 20 to 45 years from the entire database of patients enrolled as members of Kaiser Permanente Southern California from January 2011 until December 2013. Kaiser Southern California is an integrated health care system serving a racially, ethnically, and socioeconomically diverse population of >3.5 million patients. A retrospective chart review was done on OCD during this period. Inclusion criteria included OCD of any joint. Exclusion criteria included traumatic osteochondral fractures and coexistence of intra-articular lesions other than OCD. Joint involvement/location, laterality, and all patient demographics were recorded.

RESULTS

Among 122 patients, a total of 124 OCD lesions were found. The majority of lesions were in the ankle (n = 76) and knee (n = 43), with 3 foot lesions and 2 elbow lesions identified. OCD lesions were identified in 75 men (62%) and 47 women (38%). Overall incidence rates per 100,000 person-years were 3.42 for all OCD, 2.08 for ankle OCD, and 1.21 for knee OCD. The relative risk of adult OCD for men was twice that of women. The relative risk of adult OCD for white patients was 2.3 that of Asians and 1.7 that of Hispanics. Risk of knee OCD was 3.6 times higher for men than women. As compared with women, men had a higher risk for lateral femoral condyle OCD lesions versus the medial femoral condyle ( P = .05; odds ratio [OR], 5.19).

CONCLUSION

This large cohort study of Southern California adults with OCD demonstrated an increased OR for men (vs women) of OCD in all joints. The majority of symptomatic lesions were present in the ankle rather than the knee, as previously found in children. White and black patients had the highest OR of OCD; men had a significantly greater OR of lateral femoral condyle knee lesions as compared with women.

Predictive factors for osteochondritis dissecans of the lateral femoral condyle concurrent with a discoid lateral meniscus

PURPOSE

Osteochondritis dissecans (OCD) of the lateral femoral condyle is relatively rare, and it is often reported in combination with discoid lateral meniscus. However, little is known about the mechanism underlying this connection. Predictive factors for OCD coinciding with discoid lateral meniscus in Japanese children and adolescents were assessed.

METHODS

During 2000-2015, 152 knees in 133 patients aged 5-15 years were diagnosed with symptomatic complete discoid lateral meniscus. Patients were evaluated using radiography and magnetic resonance imaging (MRI). OCD was radiographically graded using the Brückl classification. Based on Ahn's MRI classifications, discoid lateral meniscus was divided into four types of meniscal shift: no shift (N), anterocentral (AC), posterocentral (PC), or central (C). Relationships between OCD and patient sex, age and Ahn's shift type were analysed.

RESULTS

OCD of the lateral femoral condyle was associated with discoid lateral meniscus in 22 (14.5%) of 152 knees. OCD was classified as Brückl's stage 1 in 5 knees, stage 2 in 12, stage 3 in 3, stage 4 in 1, and stage 5 in 1. OCD was found in 12 of 96 knees (12.5%) with type N meniscal shift, 4 of 24 knees (16.7%) with type AC, 0 of 21 knees (0%) with type PC, and 6 of 11 knees (54.5%) with type C. Multivariate logistic regression analysis showed that males had a significantly increased odds ratio (OR) [14.8; 95% confidence interval (CI) 2.6-83.4]. Those aged 5-11 years had a significantly higher OR (12.5; 95% CI 2.8-55.9) than those aged 12-15 years. The OR for type C coinciding with OCD was significantly elevated (13.4; 95% CI 2.3-78.7).

CONCLUSIONS

Concurrent OCD was found in 22 (14.5%) of 152 knees with discoid lateral meniscus. Male sex, young age (5-11 years), and having a type C meniscal shift of the discoid lateral meniscus as shown by MRI were found to be predictive factors for OCD of the LFC.

LEVEL OF EVIDENCE

III.

Age Predicts Disruption of the Articular Surface of the Femoral Condyles in Knee OCD: Can We Reduce Usage of Arthroscopy and MRI?

BACKGROUND

The purpose of this study was to determine if patient age could accurately identify disrupted articular cartilage overlying an osteochondritis dissecans (OCD) lesion of the femoral condyle in adolescents. This could have important implications for imaging and treatment decisions.

METHODS

All patients from 2001 to 2014 who were arthroscopically treated for a femoral condyle OCD were included in this Institutional Review Board-approved study. Exclusion criteria were trochlear and patellar OCD lesions, idiopathic arthritis, and traumatic osteochondral injuries. Arthroscopy was performed to visualize and probe the articular surface. Arthroscopic and magnetic resonance imaging (MRI) findings were recorded as "intact" or "disrupted" cartilage. Extra-articular drilling was performed when the articular cartilage was intact.

RESULTS

There were 119 patients (81 male, 68%) with 139 OCD lesions in 136 knees. The mean age at time of surgery was 13.0 years (range, 7.2 to 19.3 y). At arthroscopy, 115 knees had intact cartilage and 24 had disrupted cartilage. There was a significant difference in age between patients with intact versus disrupted cartilage at arthroscopy (12.5 vs. 15.3 y; P<0.0001). Eighty-eight OCD lesions had MRIs preoperatively, showing 69 as intact and 19 (24%) disrupted. MRI reading for cartilage status had 94% sensitivity and 97% specificity. Multivariable regression analysis revealed that age (P<0.01) and MRI status (P<0.0001) were strong predictors of cartilage status. Sixteen years was the critical age in which both sensitivity was maximized and false positive probability was minimized. Over the age of 17 years, 7 of 7 (100%) had disrupted cartilage. Age alone was 100% sensitive for children below the age of 10, and 96% sensitive below the age of 13.

CONCLUSIONS

Age was a good predictor of cartilage status in both younger (<13 y) and older (≥17 y) patients in this study. For patients in the mid-range group (13 through 16 y), age alone is not an adequate predictor of cartilage status, but adding MRI increased accuracy.

SIGNIFICANCE

Age can be used to stratify patients and thereby influence diagnostic and treatment strategies.

LEVEL OF EVIDENCE

Level IV.

Vessel architecture in human knee cartilage in children: an in vivo susceptibility-weighted imaging study at 7 T

Objectives

To evaluate the clinical feasibility of ultrahigh field 7-T SWI to visualize vessels and assess their density in the immature epiphyseal cartilage of human knee joints.

Methods

7-T SWI of 12 knees (six healthy volunteers, six patients with osteochondral abnormalities; mean age 10.7 years; 3 female, 9 male) were analysed by two readers, classifying intracartilaginous vessel densities (IVD) in three grades (no vessels, low IVD and high IVD) in defined femoral, tibial and patellar zones. Differences between patients and volunteers, IVDs in different anatomic locations, differences between cartilage overlying osteochondral abnormalities and corresponding normal zones, and differences in age groups were analysed.

Results

Interrater reliability showed moderate agreement between the two readers (κ = 0.58, p < 0.001). The comparison of IVDs between patients and volunteers revealed no significant difference (p = 0.706). The difference between zones in the cartilage overlying osteochondral abnormalities to corresponding normal zones showed no significant difference (p = 0.564). IVDs were related to anatomic location, with decreased IVDs in loading areas (p = 0.003). IVD was age dependent, with more vessels present in the younger participants (p = 0.001).

Conclusions

The use of SWI in conjunction with ultrahigh field MRI makes the in vivo visualization of vessels in the growing cartilage of humans feasible, providing insights into the role of the vessel network in acquired disturbances.

Key Points

• SWI facilitates in vivo visualization of vessels in the growing human cartilage.

• Interrater reliability of the intracartilaginous vessel grading was moderate.

• Intracartilaginous vessel densities are dependent on anatomical location and age.

Electronic supplementary material

The online version of this article (10.1007/s00330-017-5290-1) contains supplementary material, which is available to authorized users.

What's New in Pediatric Sports Conditions of the Knee?

BACKGROUND

Sports injuries are common in pediatric and adolescent patients and the evaluation and treatment of these injuries continues to evolve. The purpose of this review is to provide a comprehensive appraisal of the literature, highlighting recent updates on sports-related knee injuries in the pediatric athlete. We specifically examined literature on tibial spine fractures, osteochondritis dissecans (OCD) of the knee, and patellar instability. Because of the volume of literature on the subject, pediatric, and adolescent anterior cruciate ligament injuries were not included in this review.

METHODS

An electronic search of the PubMed, EMBASE, and Google Scholar databases was performed for keywords related to pediatric: tibial spine fractures, patellar instability, and osteochondritis dissecans (OCD). Search results were filtered by publication date to yield articles published electronically or in print on or after January 1, 2013. Papers were selected based on expert opinion and consensus by the authors and included if deemed to have contributed important findings to the above topics.

RESULTS

A total of 31 articles were deemed to have contributed significant findings to the literature: 5 tibial spine, 17 patellar instability, and 9 OCD. The level of evidence for most studies was either level III or IV.

CONCLUSIONS

The optimal treatment for tibial spine fractures remains controversial. The evaluation of risk factors for recurrent patellar instability is important in determining the optimal treatment strategy following first-time patellar dislocation. Future multicenter studies on pediatric OCD have the potential to further understanding of this difficult problem. High-level, comparative outcomes research on a variety of pediatric sports related injuries is lacking and this review may help inform topics for future study.

LEVEL OF EVIDENCE

Level IV-literature review.

Osteochondritis dissecans of the knee

Osteochondritis dissecans (OCD) of the knee is an idiopathic, focal, subchondral-bone abnormality that can cause instability or detachment of a bone fragment and overlying articular cartilage, with subsequent progression to osteoarthritis. The diagnosis is usually made during adolescence. Mechanical factors play a major role in the pathophysiology of OCD. When the radiographic diagnosis is made early in a patient with open physes, healing can often be obtained simply by restricting sports activities. The degree of lesion instability can be assessed by magnetic resonance imaging. When the lesion remains unstable and the pain persists despite a period of rest, surgery is indicated. Arthroscopic exploration is always the first step. Drilling of the lesion produces excellent outcomes if the lesion is stable. Unstable lesions require fixation and, in some cases, bone grafting. Defects must be filled, depending on their surface area. Although many surgical techniques are available, the therapeutic indications are now standardized.

Grade I Osteochondritis Dissecans in a Young Professional Athlete

BACKGROUND

Osteochondritis dissecans (OCD) is a disorder primarily affecting subchondral bone, with secondary effects on the overlying articular cartilage. Knee joint (75%) and radiocapitellar joint (6%) are the most common sites for OCD lesions. The presence of an open growth plate differentiates juvenile osteochondritis dissecans from adult form of osteochondritis. Early diagnosis and treatment produce best long term results. The objective of this study is to determine the best mode of management of a Grade I osteochondritis lesion in a young athlete.

MATERIALS AND METHODS

A PubMed search was made using the keywords "OCD" and "athlete". Articles that were based on participants between the ages of 6-24 years (children, adolescent and young adult) and early stages of OCD were included in this study. A total of 25 articles were thus included for the review.

RESULTS

The healing potential is based on the age of the patient, status of physis, and stage of the lesion. Most authors have observed good to excellent results of drilling of early OCD in skeletally mature patients. Similarly, most authors also reported equally successful outcomes of nonoperative treatment for early OCD in skeletally immature patients.

CONCLUSIONS

We recommend initial nonoperative line of management in patients with open physis. In case of progression of the lesion or failure of conservative treatment a reparative, restorative or palliative surgical intervention can be done. For Stage I OCD lesions in patients with closed physis, we advocate reparative surgery either by means of retro- or trans-articular drilling.

Incidence of symptomatic osteochondritis dissecans lesions of the knee: a population-based study in Olmsted County

OBJECTIVE

To (1) define population-based incidence of knee Osteochondritis dissecans (OCD) lesions using the population of Olmsted County, (2) examine trends over time, and (3) evaluate rate of surgical management over time.

METHOD

Study population included 302 individuals who were diagnosed with knee OCD lesions between January 1, 1976 and December 31, 2014. Complete medical records were reviewed to extract injury and treatment details. Age- and gender-specific incidence rates were calculated and adjusted to the 2010 US population. Poisson regression analyses were performed to examine incidence and surgery trends by age, gender, and calendar period.

RESULTS

Overall age- and gender-adjusted incidence annual incidence of knee OCD lesions was 6.09 per 100,000 person-years. The incidence was significantly higher (P < 0.001) in males (8.82, 95% CI 7.63 to 10.00 per 100,000) compared to females (3.32, 95% CI 2.61 to 4.04 per 100,000). Age- and gender-specific incidence was highest in both males and females in the 11-15 years old at 39.06 and 16.15 per 100,000, respectively. In males aged 11-15 years, OCD incidence increased significantly over the study period from 20.68 in 1976-1985 to 48.16 in 2006-2014 (per 100,000).

CONCLUSIONS

Overall age- and gender-adjusted annual incidence of knee OCD lesions in the Olmsted Country Population was 6.09 per 100,000 person-years with a significantly higher incidence in males compared to females. The highest incidence for both males and females occurred between the ages 11-15 years. Trends indicate increasing OCD incidence in younger males and decreasing surgical management in females over the last decade.

Osteochondritis Dissecans Lesions in Family Members: Does a Positive Family History Impact Phenotypic Potency?

BACKGROUND

Although repetitive microtrauma and athletic overuse patterns are most commonly associated with osteochondritis dissecans (OCD), recent studies have identified a potential genetic predisposition for OCD. Several case series have documented family pedigrees that support autosomal-dominant inheritance, but the families in these studies were all selected as a result of unique histories that may not accurately represent OCD inheritance patterns at large. Because there has been little investigation beyond these case reports, we aimed to describe a broader, more representative pattern of OCD inheritance applicable to all affected patients.

QUESTIONS/PURPOSES

(1) What proportion of patients treated for OCD of the knee have one or more immediate and/or extended family members with a history of OCD lesions? (2) Do patients with more phenotypically potent lesions, which we defined as patients with bilateral OCD lesions or patients who have undergone multiple procedures for OCD, have a higher frequency of affected relatives than those with less potent lesions?

METHODS

This retrospective study queried patient databases, diagnosis codes (International Classification of Diseases, 9th Revision), and surgical logs at a regional, tertiary care children's hospital to identify all patients treated over a 10-year period (March 2004-March 2014) by the senior author for OCD of the knee. All patients aged 0-18 years at the time of diagnosis were included. At our institution, patients with intact lesions are treated with a trial of conservative therapy; conversely, patients with a break in the articular cartilage and/or loose fragments of bone/cartilage are treated surgically. There were no OCD-specific contraindications to surgery. This search identified 543 patients. After patient identification, a questionnaire was designed that asked for the number, age, and gender of all immediate family members and the history of OCD lesions in any family member (immediate or extended). For all positive family members, patients were further queried regarding relevant clinical details to affirm a history of OCD. Patients were contacted by mailed questionnaires and phone calls for survey completion. All 543 patients received the survey, of which 103 (19%) responded to it and were included here. Responders were approximately 1 year younger than nonresponders; there was no difference in gender distribution. A retrospective chart review was then conducted to collect demographic information, phenotypic disease severity, and treatment details. Of the 103 included patients, 20 patients (19%) with unilateral lesions were managed nonoperatively ("conservative" group), 50 patients (49%) had unilateral lesions advanced to surgery ("unilateral" group), 21 patients (20%) had bilateral lesions managed either conservatively or surgically ("bilateral" group), and 12 patients (12%) underwent multiple procedures for the same lesion ("multiple" group). Of those included, 75 patients (73%) were treated surgically. With the numbers available, there were no baseline differences among the groups in terms of gender, lesion laterality, lesion location, or number of secondary procedures at the time of the initial surgical intervention.

RESULTS

In total, 14 of 103 (14%) patients treated for OCD in this study had an immediate and/or extended family member with a history of OCD lesions. This included four of 20 (20%) patients in the conservative group, five of 50 (10%) in the unilateral group, four of 21 (19%) in the bilateral group, and one of 12 (8%) in the multiple group. With the numbers available, we did not identify a higher proportion of immediate and/or extended family members with a positive history of OCD in those patients with phenotypically potent lesions (bilateral and multiple) as compared with those with patients phenotypically less potent lesions (conservative and unilateral; five of 33 [15%] versus nine of 70 [13%]; odds ratio, 1.2; 95% confidence interval, 0.4-3.9; p = 0.751).

CONCLUSIONS

In this broad, heterogeneous cohort of pediatric patients with OCD, the proportion of patients with a positive family history of OCD was 14%, which appeared to be much higher than the reported prevalence of OCD in the general population according to prior research. Therefore, our data provide preliminary support for a familial inheritance pattern for OCD, suggesting that further clinical, biologic, and genomic investigation might help to improve our understanding of who is at highest risk for OCD and what moderating factors might influence their disease severity and risk of progression. Furthermore, our data suggest that expanded patient education and screening regarding inheritance patterns might enhance identification of potential familial disease burden and improve access to timely and appropriate treatment.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Risk Factors Associated With Knee Joint Degeneration After Arthroscopic Reshaping for Juvenile Discoid Lateral Meniscus

BACKGROUND

Although arthroscopic meniscal reshaping for discoid lateral meniscus (DLM) has better outcomes than total or subtotal meniscectomy, degenerative changes on radiographs are still seen in some patients with meniscal reshaping.

PURPOSE

To assess the risk factors associated with knee joint degeneration after reshaping surgery for juvenile DLM.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Forty patients (45 knees) with a mean age of 12.0 years who underwent arthroscopic meniscal reshaping for DLM were enrolled at a mean of 39.6 months after surgery. For all patients, meniscal saucerization was performed first. Then, if the residual meniscus was unstable, stabilization was provided with suture fixation. At final follow-up, we obtained radiographs to assess degenerative changes to the knee joint using the classification by Tapper and Hoover. Residual meniscal width and meniscal extrusion (defined as a relative percentage of extrusion [RPE]) were measured with magnetic resonance imaging (MRI). Then, the correlation between radiographic evidence of degenerative changes (Tapper and Hoover grade), residual meniscal width, and RPE were assessed with Pearson and Spearman correlation analyses. Logistic regression analysis was used to examine whether preoperative characteristics correlated with degeneration and residual meniscal width.

RESULTS

The mean residual meniscal width was 4.6 mm (range, 3.8-6.0 mm), and the mean ± SD RPE was 25.5% ± 21.8% at the final follow-up. There were 28 knees with Tapper and Hoover grade 0, 10 knees with grade 1, and 7 knees with grade 2. The residual meniscal width and RPE were significantly correlated with Tapper and Hoover grade (ρ = -0.489, P = .0007; ρ = 0.414, P = .005, respectively). The residual meniscal width was also significantly correlated with RPE ( r = -0.416, P = .004). The receiver operating characteristic curve showed that a 5.0-mm residual meniscal width was the cutoff value leading to evidence of degeneration. Multiple logistic regression analysis showed that an anterocentral shift on preoperative MRI was a risk factor for degeneration (odds ratio, 27.2; 95% CI, 1.1-360.5; P = .012) and residual meniscal width less than 5.0 mm (odds ratio, 20.9; 95% CI, 1.5-281; P = .022).

CONCLUSION

Smaller meniscal width and greater severity of meniscal extrusion correlated with knee joint degeneration. An anterocentral shift on preoperative MRI was a risk factor for degenerative changes and smaller residual meniscal width.

Candidate Loci are Revealed by an Initial Genome-wide Association Study of Juvenile Osteochondritis Dissecans

BACKGROUND

Osteochondritis dissecans (OCD) is a condition that oftentimes causes significant knee pain in pediatric patient populations. If left untreated, OCD significantly increases the risk of developing degenerative osteoarthritis along with its associated consequences and costs. Although a genetic component has been suggested to play a role in this disorder, few studies have been carried out in order to determine the underlying genetic etiology of this relatively common complex trait. The goal of our study was to perform an initial genome-wide association study (GWAS) to uncover candidate loci associated with the pathogenesis of OCD.

METHODS

Blood samples were acquired from 2 cohorts, aged 0 to 18 years old, consisting of 209 OCD cases and 1855 population-matched controls. Agencourt Genfind DNA isolation technology was used to isolate high-quality DNA from each sample. Genotype data was then generated utilizing the Illumina Infinium BeadChip array to examine single-nucleotide polymorphisms (SNPs).

RESULTS

In an initial GWAS analysis of our cohort, where a SNP was excluded if the Hardy-Weinberg Equilibrium test P<0.0001, the minor allele frequency<5%, and the genotyping call rate<90%, we obtained our first results for OCD. Although there was no SNP strictly reaching the threshold for genome-wide significance at this early stage, multiple SNPs (35) at several loci revealed evidence of suggestive association with OCD (P<5.0×10).

CONCLUSIONS

The results from our preliminary study are encouraging. Herein we not only discuss the relevance and applicability of GWAS in studying a genetic basis for OCD, but have also identified top signals that may suggest loci involved in coordinated expression as well as a transcription factor involved in development that may be highly relevant to this trait.

CLINICAL RELEVANCE

If genetic predispositions for OCD are detected early enough in life, attempts at activity modification, counseling, and orthopaedic monitoring may successfully reduce progression of this condition, which may lead to progressive osteoarthritis in the third to fourth decade in at-risk patients.

Matrix based autologous chondrocyte implantation in children and adolescents: a match paired analysis in a follow-up over three years post-operation

PURPOSE

The aim of this study is the investigation of the clinical results after third generation autologous chondrocyte implantation in the knee in a follow-up over three years post-operation. Our primary focus is on the effects of this procedure on children and adolescent patients as there is a lack of knowledge regarding the clinical outcomes in children/adolescents in particular when compared with adults.

METHODS

A total of 40 patients (43 defects) <20 years with cartilage defects of the knee were treated with third generation ACI (Novocart® 3D). These defects were caused by osteochondritis dissecans (n = 13), acute trauma (<12 months) (n = 9), old trauma (>12 months) (n = 5) or unknown pathology (n = 13). The mean defect size was 5.2 cm². IKDC subjective score and VAS (at rest and during activity) were used for clinical evaluation after 6, 12, 24 and 36 months post-operatively. The results of these patients were compared with 40 matched adult patients. Match paired analysis was performed by numbers of treated defects, defect location and defect size. All cartilage defects were arthroscopically classified with IKDC grade III-IV. All adult patients in the control group were treated with matrix based autologous chondrocyte implantation.

RESULTS

All patients showed significantly better clinical results compared with the pre-operative findings in the follow-up over three years. We observed significantly better results in the IKDC score and VAS during the whole postoperative follow-up in children and adolescents after six, 12, 24 and 36 months compared with the adult control group. The IKDC score improved from 46.5 preoperative to 77.5 (+31) after three years in children and adolescents. Similarly, significantly lower stress pain after six months and one, two and three years was found in this group.

CONCLUSION

This study showed that third generation autologous chondrocyte implantation is a suitable method for the treatment of full cartilage defects in children and adolescents.

Pediatric Knee Osteochondritis Dissecans Lesions

Osteochondritis dissecans (OCD) can cause knee pain and dysfunction in children. The etiology of OCD remains unclear; theories on causes include inflammation, ischemia, ossification abnormalities, genetic factors, and repetitive microtrauma. Most OCD lesions in skeletally immature patients will heal with nonoperative treatment. The success of nonoperative treatment decreases once patients reach skeletal maturity. The goals of surgical treatment include maintenance of articular cartilage congruity, rigid fixation of unstable fragments, and repair of osteochondral defects with cells or tissues that can adequately replace lost or deficient cartilage. Unsalvageable OCD lesions can be treated with various surgical techniques.

Running Injuries During Adolescence and Childhood

The popularity of running among young athletes has significantly increased over the past few decades. As the number of children who participate in running increases, so do the potential number of injuries to this group. Proper care of these athletes includes a thorough understanding of the unique physiology of the skeletally immature athlete and common injuries in this age group. Treatment should focus on athlete education, modification of training schedule, and correction of biomechanical deficits contributing to injury. Early identification and correction of these factors will allow a safe return to running sports.

Osteochondritis dissecans of the knee

Osteochondritis Dissecans (OCD) is a condition for which the aetiology remains unknown. It affects subchondral bone and secondarily its overlying cartilage and is mostly found in the knee. It can occur in adults, but is generally identified when growth remains, when it is referred to as juvenile OCD. As the condition progresses, the affected subchondral bone separates from adjacent healthy bone, and can lead to demarcation and separation of its associated articular cartilage. Any symptoms which arise relate to the stage of the disease. Early disease without separation of the lesion results in pain. Separation of the lesion leads to mechanical symptoms and swelling and, in advanced cases, the formation of loose bodies.

Early identification of OCD is essential as untreated OCD can lead to the premature degeneration of the joint, whereas appropriate treatment can halt the disease process and lead to healing. Establishing the stability of the lesion is a key part of providing the correct treatment. Stable lesions, particularly in juvenile patients, have greater propensity to heal with non-surgical treatment, whereas unstable or displaced lesions usually require surgical management.

This article discusses the aetiology, clinical presentation and prognosis of OCD in the knee. It presents an algorithm for treatment, which aims to promote healing of native hyaline cartilage and to ensure joint congruity.

Take home message: Although there is no clear consensus as to the best treatment of OCD, every attempt should be made to retain the osteochondral fragment when possible as, with a careful surgical technique, there is potential for healing even in chronic lesions

Cite this article: Bone Joint J 2016;98-B:723–9.

Prevalence of childhood and adolescent soccer-related overuse injuries

OBJECTIVE

To investigate the prevalence of osteochondrosis in children and adolescent soccer players.

MATERIALS AND METHODS

A questionnaire was distributed to players of all 113 junior soccer teams participating in a regional summer championship in August 2012 inquiring about pain in the body during or after training or a match. Physical examination of the lumbar spine or legs was recommended to players who complained of pain on the questionnaire, and for those who had positive findings on the physical examination, radiographic or ultrasonic examination at our hospital was recommended.

RESULTS

Questionnaires were collected from 1162 players of 97 teams, and 547 players (47.1%) complained of pain in the lumbar spine or legs. Physical examination was performed on 494 players, 394 of whom were referred for physical examination (79.8%). Of these 494 players, 20 (4.0%) had positive lumbar spine findings, 26 (5.3%) had hip findings, 198 (40.1%) had knee findings, 117 (23.7%) had ankle findings, 226 (45.7%) had heel findings, and 90 had findings in other parts of foot (18.2%). Radiographic or ultrasonic examination was performed in 106 (26.9%) players at our hospital and 80 (75.5%) players were diagnosed with osteochondrosis. Sever's disease was diagnosed in 49 players, Osgood-Schlatter disease in 13, bipartite patella was in 12, Sinding-Larsen-Johansson disease in 10, osteochondritis dissecans of the distal femur in 1, and spondylolysis in 3.

CONCLUSIONS

The majority of players who had experienced pain and were found to have osteochondrosis had severe injuries such as osteochondritis dissecans or lumbar spondylolysis. We suggest many of the players involved in this study receive further radiographic or ultrasonic examination.

The Incidence of Surgery in Osteochondritis Dissecans in Children and Adolescents

Background:

The frequency of osteochondritis dissecans (OCD), a disorder of the subchondral bone and articular cartilage, is not well described.

Purpose:

To assess the frequency of pediatric OCD lesions that progress to surgery based on sex, joint involvement, and age.

Study Design:

Descriptive epidemiology study.

Methods:

A retrospective chart review (2007-2011) was performed on OCD. Inclusion criteria included OCD of any joint and patients aged 2 to 19 years. Exclusion criteria included traumatic osteochondral fractures or coexistence of non-OCD intra-articular lesions. Differences in progression toward surgery were compared between age groups, sex, and joint location. Logistical regression analysis was performed by sex, age, and ethnicity.

Results:

Overall, 317 patients with a total of 334 OCD lesions were found. The majority of lesions (61.7%) were in the knee, with ankle, elbow, shoulder, and foot lesions representing 25.4%, 12.0%, 0.6%, and 0.3% of all lesions, respectively. The majority of joints needing surgery were in the knee (58.5%), with ankle and elbow lesions representing 22.9% and 18.6% of surgeries performed, respectively. The percentage of all OCD lesions progressing to surgery was 35.3%; surgical progression for knee, ankle, and elbow joints was 33.5%, 31.8%, and 55.0%, respectively. Logistic regression analysis found no statistically significant different risk of progressing to surgery for OCD of the knee, elbow, and ankle between sexes. Patients aged 12 to 19 years had a 7.4-times greater risk of progression to surgery for knee OCD lesions than 6- to 11-year-olds. Patients aged 12 to 19 years were 8.2 times more likely to progress to surgery for all OCD lesions than patients aged 6 to 11 years. Progression to surgery of ankle OCD did not significantly differ based on location. Three of 4 trochlear lesions progressed to surgery, along with 1 of 1 tibial, 1 of 3 patellar, 40.3% of lateral femoral condylar, and 28.2% of medial femoral condylar lesions.

Conclusion:

In this large cohort study of pediatric OCD patients, 35% progressed to surgery. Progression to surgery did not differ significantly between sexes with OCD of any joint. Progression to surgery for OCD of the knee, elbow, and ankle strongly correlated with patient age at the time of diagnosis.

Clinical Relevance:

The knowledge of likelihood of progression to surgery of OCD by location, sex, and age is useful in counseling patients and in planning treatment. This study confirms a worse prognosis in the nonoperative treatment of older patients with OCD.

A suspected genetic form of bilateral osteochondritis dissecans of the knee in a Dutch family

Osteochondritis dissecans (OCD) mostly has an idiopathic origin, but syndromic and familial forms have been reported. Mutations of the aggrecan (ACAN) and COL9A2 genes are associated with familial OCD, but these patients present with syndromic features. This article describes a mother and a daughter who both have bilateral OCD of the medial femoral condyles, and the monozygotic twin sister of the mother who has confirmed unilateral OCD (and possible bilateral OCD) of the medial femoral condyle. No short stature or any other syndromic features were present. None of the syndromic features associated with ACAN or COL9A2 mutations or any other known syndromes were present in this case. This case suggests a possible unknown genetic anomaly.

Managing monoarthritis in children

Monoarthritis, defined as inflammation of a single joint, requires a thorough physical examination in children, as pain may be lacking in 10% to 30% of cases and joint stiffness may be the only symptom. Joint aspiration is a crucial diagnostic tool that remains markedly underused. Joint aspiration may be unnecessary, however, when the family history or other investigations provide the diagnosis. Radiographs of the involved joint may supply information on the severity of the lesions. In doubtful cases and in patients with arthralgia, B-mode and Doppler ultrasound or magnetic resonance imaging (MRI) may confirm the presence of synovitis. Although suspected septic arthritis is an emergency and occurs frequently, particularly before 2 years of age, acute monoarthritis is often a post-infectious manifestation and therefore associated with a good outcome. Lyme disease should be sought, particularly when a lower limb joint is involved, as tick bites often go unnoticed. Chronic monoarthritis is very often a manifestation of juvenile idiopathic arthritis (JIA), which exists as several variants. Oligoarthritis is a specifically pediatric joint disease, whereas the other patterns of JIA have corresponding forms in adults, despite a number of specific features due to their onset during childhood. Tests for antinuclear antibodies should be performed routinely in children with monoarthritis persisting longer than 3 weeks. A decline in general health or a fever should suggest arthritis revealing a malignancy, which is a hematological disease in most cases. Finally, suggestive symptoms are often present in patients with less common causes such as auto-inflammatory diseases and connective tissue diseases.

Knee hemarthros secondary to osteochondritis dissecans (König disease)

A case is presented of a hemarthrosis associated with osteochondritis dissecans in a young man who arrived in the Emergency unit due to tender and swelling of his right knee one hour after a slightly rotational gesture of the lower limb. Many years before the patient suffered a sports injury in the same knee, but it was never assessed. Radiography studies showed bone fragments inside the synovial capsule, and the joint aspiration was compatible with hemarthrosis. A review of the available information of this uncommon condition is also presented.

Development of a Large Animal Model of Osteochondritis Dissecans of the Knee: A Pilot Study

Background:

Treatment of osteochondritis dissecans (OCD) of the knee is challenging, and evidence for stage-dependent treatment options is lacking. Basic science approaches utilizing animal models have provided insight into the etiology of OCD but have yet to produce a reliable and reproducible large animal model of the disease on which to test new surgical strategies.

Purpose/Hypotheses:

The purpose of this study was to develop an animal model featuring an OCD-like lesion in terms of size, location, and International Cartilage Repair Society (ICRS) grading. The hypothesis was that surgical creation of an osteochondral defect followed by placement of a barrier between parent bone and progeny fragment would generate a reproducible OCD-like lesion.

Study Design:

Controlled laboratory study.

Methods:

Bilateral osteochondral lesions were created in the medial femoral condyles of 9 Yucatan minipigs. After lesion creation, a biodegradable membrane was interposed between the progeny and parent bone. Five different treatment groups were evaluated at 2 weeks: a control with no membrane (ctrl group; n = 4), a slowly degrading nanofibrous poly(∊-caprolactone) membrane (PCL group; n = 4), a fenestrated PCL membrane with 1.5-mm holes covering 25% of surface area (fenPCL group; n = 4), a collagen membrane (Bio-Gide) (CM group; n = 3), and a fenestrated CM (fenCM group; n = 3). Five unperturbed lateral condyles (1 from each treatment group) served as sham controls. After euthanasia on day 14, the lesion was evaluated by gross inspection, fluoroscopy, micro–computed tomography (micro-CT), and histology. To quantify changes between groups, a scoring system based on gross appearance (0-2), fluoroscopy (0-2), and micro-CT (0-6) was established. Micro-CT was used to quantify bone volume per total volume (BV/TV) in a defined region surrounding and inclusive of the defect.

Results:

The no scaffold group showed healing of the subchondral bone at 2 weeks, with continuity of subchondral bone elements. Conversely, condyles treated with PCL or CM showed substantial remodeling, with loss of bone in both the progeny fragment and surrounding parent bone. When these membranes were fenestrated (fenPCL and fenCM groups), bone loss was less severe. Histological analysis showed no integration in the cartilage layer in any treatment group, while fibrous tissue formed between the parent and progeny fragments. Micro-CT showed significant differences in mean BV/TV between the PCL (27.4% ± 2.3%) and the sham (47.7% ± 1.4%) or no scaffold (54.9% ± 15.1%) groups (P < .01 and P < .05, respectively). In addition, a significant difference in bone loss was evident between the PCL and fenPCL groups (mean BV/TV, 46.6% ± 15.2%; P < .05), as well as between the PCL and fenCM (mean BV/TV, 50.9% ± 3.5%) and fenPCL groups (P < .01). Grading by 6 blinded reviewers using an OCD scoring system with 3 subcategories showed a significant difference between control and PCL groups.

Conclusion:

This study successfully developed a large animal model of OCD-like lesions in the knee joint of Yucatan minipigs. The lesions generated matched characteristics of an ICRS grade 3 OCD lesion in humans. These findings set the stage for ongoing model refinement as well as exploration of novel interventional therapies to restore function and bone and cartilage patency in individuals affected by this rare but significant disease.

Clinical Relevance:

This developed model will serve as a platform on which to further investigate the natural course as well as emerging treatment options for OCD.

Trochlear groove osteochondritis dissecans of the knee patellofemoral joint

BACKGROUND

The trochlear groove is the rarest location for osteochondritis dissecans (OCD) of the knee, with only about 50 previously reported cases, most of which were treated before the advent of magnetic resonance imaging (MRI) and modern techniques of cartilage fixation or osteochondral transplantation. The purpose of this multicenter study was to assess the patient presentation and clinical, radiographic, and functional results of treatment for trochlear groove OCD lesions.

METHODS

Hospital records from 5 institutions of the Research in Osteochondritis of the Knee (ROCK) study group were retrospectively reviewed for cases of trochlear groove OCD. Demographics, clinical presentation, diagnosis, treatment, time to pain resolution, and return to sports were recorded. Lesion appearance, size, stability, and time to radiographic healing were evaluated on plain x-rays and MRIs.

RESULTS

Trochlear groove OCD lesions were evaluated in 24 knees in 21 adolescents (17 male, 4 female), with an average age of 14 years (range, 10 to 18 y). Fifty-four percent (13/24) of the lesions were identifiable on radiographs, and all were identifiable on MRI, 38% of which (9/24) was unstable. One fourth (6/24) of knees had coexistent femoral condyle OCD lesions. Treatment outcomes were evaluated in patients with a minimum of 1-year follow-up (average: 3 y; range: 1 to 12 y) or healing before 1 year. Half of the knees (2/4) treated nonoperatively and two thirds (8/12) treated operatively showed radiographic signs of healing with patients returning to full activity without pain. Operative treatment success rates were as follows: drilling (3/3), fixation (3/3), microfracture (1/2), drilling with subsequent delayed microfracture (1/1), and drilling with fixation (0/3).

CONCLUSIONS

MRI aids in the diagnosis and staging of trochlear groove OCD lesions, as almost one half may not be identifiable on radiographs, and one quarter are associated with OCD lesions in other locations of the same knee. Multiple operative treatments can be used to achieve healing or resolution of symptoms in stable and unstable lesions; however, a larger comparative study is needed to make specific recommendations.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Osteochondritis dissecans of the ankle in children and adolescents: demographics and epidemiology

BACKGROUND

Osteochondritis dissecans (OCD) of the ankle is a disorder of the talar or distal tibial subchondral bone and articular cartilage whose incidence in children is not clearly known.

PURPOSE

To assess the demographics and epidemiology of OCD of the ankle in children.

STUDY DESIGN

Descriptive epidemiologic study.

METHODS

A retrospective chart review of an integrated health system was conducted on patients with ankle OCD aged 2 to 19 years from 2007 to 2011, with >1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. Ankle OCD incidence was determined for the group as a whole and by both sex and age group (divided into age groups of 2-5, 6-11, and 12-19 years). The risk for ankle OCD for age group, sex, and ethnicity was assessed using multivariate logistic regression models.

RESULTS

A total of 85 patients fit the inclusion criteria, and 71.8% of lesions found were in the medial talus, 56.5% of lesions were right sided, and none were bilateral. No ankle OCD lesions were found in 2- to 5-year-olds. The incidence of ankle OCD in patients aged 6 to 19 years was 4.6 per 100,000 overall and 3.2 and 6.0 per 100,000 for male and female patients, respectively. Patients aged 12 to 19 years represented the vast majority of those with OCD, with an incidence of 6.8 per 100,000 compared with 1.1 per 100,000 in those 6 to 11 years of age. In those aged 6 to 11 and 12 to 19 years, female patients had a respective incidence of 1.5 and 8.9 per 100,000, whereas male patients had a respective incidence of 0.7 and 4.8 per 100,000. The overall female/male ratio of ankle OCD was 1.6:1. Multivariate logistic regression analysis revealed a 6.9 times increased risk for ankle OCD in patients aged 12 to 19 years compared with those aged 6 to 11 years (95% CI, 3.8-12.5; P < .0001), and female patients had a 1.5 times greater risk for ankle OCD than male patients (95% CI, 1.0-2.3; P = .06). On the basis of race and ethnicity, non-Hispanic whites had the highest relative risk for disease and African Americans the lowest risk.

CONCLUSION

In this population-based cohort study of pediatric ankle OCD, female patients had a greater incidence of OCD and a 1.5 times greater risk for ankle OCD compared with male patients. Teenagers had nearly 7 times the risk for ankle OCD compared with children 6 to 11 years of age.

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

SYNOPSIS

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.

LEVEL OF EVIDENCE

Therapy, level 5.