Is vitamin D insufficiency or deficiency related to the development of osteochondritis dissecans?

Osteochondritis dissecans of the knee: Epidemiology, etiology, and natural history

Osteochondritis dissecans of the knee is a disease that typically affects skeletally immature patients. Clinically manifested with knee pain, limping, and joint disfunction, this condition has remained misunderstood and undervalued for a long period. Although being a rare condition, its awareness is of utmost clinical interest because of the possible severe consequences it can bring when misrecognized or inadequately treated. Its etiology remains unclear and is still debated. Many theories have been proposed, including inflammation, local ischemia, subchondral ossification abnormalities, genetic factors, and repetitive mechanical microtrauma, with a likely interplay of the same. This review article aims to deliver and discuss current and up-to-date concepts on epidemiology, etiology, and natural history of this pediatric condition. Level of evidence: level V.

Knee osteochondritis dissecans-treatment technical aspects

Purpose and objective

Current treatments of different stages of knee osteochondritis Dissecans (OCD) are depending on the age of the patients and the stability of the diseased osteochondral area. The purpose of this paper was to summarize the treatment alternatives in order to simplify the choice for the treating surgeon.

Background and principle results

Osteochondritis dissecans (OCD) of the knee is an idiopathic and local osteochondral abnormality that affects mainly children and adolescents with risk of loosening of osteochondral fragments. A good clinical result can be expected when the physes are still open, when the osteochondritis is small and when the osteochondritis can be assessed as stable by MRI. Unstable OCD lesions most often need to be treated operatively by different fixation methods and when the osteochondral cannot be refixated, different local chondral and osteochondral repairs are available to fill up the defect area to congruity.

Summary and major conclusions

The final choice of which treatment to use is depending on fragment viability and forms. Viable fragments are refixated while poor quality fragments are removed followed by a local biological osteochondral repair. Such osteochondral resurfacing may be single bone marrow stimulation with or without scaffold augmentation or different cell seeded grafts.

Gel-Based Autologous Chondrocyte Implantation in a Patient with Noncontained Osteochondral Knee Defect at 9-Year Follow-Up

Osteochondritis dissecans (OCD) is a disorder of the subchondral bone affecting the adjacent articular cartilage that may lead to cartilage and bone fragment detachment. It commonly occurs in the knee joint, elbow, wrist, and ankle. Although several surgical concepts have been described to treat OCD (fragment fixation, microfracture, autologous chondrocyte implantation (ACI), and mosaicplasty), no gold standard treatment has been accepted for managing OCD. Multiple factors like age, stability of defect, and defect size should be considered while selecting a specific treatment for OCD. Here, we discuss the case of an 18-year-old patient with horizontal and noncontained OCD. The MRI and CT scan evaluations of condylar notch view showed a defect ( $23\text{mm}\times 19\text{mm}\times 8\text{mm}$ ) with ICRS grade IV lateral femoral condyle OCD that was successfully managed by gel-based ACI. After 9 years of ACI, the patient was asymptomatic with full range of motions at the knees. Improvement in visual analog scale score, International Knee Documentation Committee score, and Magnetic Resonance Observation of Cartilage Repair Tissue score was also seen at 9 years post-ACI. No further surgical interventions were needed post-ACI.

Osteochondritis Dissecans Lesion of the Trochlear Groove: A Case of Nonsurgical Management for a Rare Lesion

Osteochondritis dissecans (OCD) lesions are potential causes of knee pain in pediatric patients, with lesions most frequently found on the lateral and medial femoral condyles. This case discusses an OCD lesion of the trochlear groove, a rare location for OCD lesions, in an 11-year-old female athlete. The patient presents after several years of knee pain that had acutely worsened, and both X-ray and MRI demonstrated the lesion, with MRI confirming a stable lesion. While previous literature has leaned towards surgical management, this patient was successfully managed nonoperatively in a locked knee brace for 12 weeks. She then went through 4 weeks of physical therapy and a 4 week progression back into soccer activity with return to full activity in 5 months.

Osteochondral Lesions of the Talus: A Review on Talus Osteochondral Injuries, Including Osteochondritis Dissecans

This is a review on talus osteochondritis dissecans and talus osteochondral lesions. A majority of the osteochondral lesions are associated with trauma while the cause of pure osteochondritis dissecans is still much discussed with a possible cause being repetitive microtraumas associated with vascular disturbances causing subchondral bone necrosis and disability. Symptomatic nondisplaced osteochondral lesions can often be treated conservatively in children and adolescents while such treatment is less successful in adults. Surgical treatment is indicated when there is an unstable cartilage fragment. There are a large number of different operative technique options with no number one technique to be recommended. Most techniques have been presented in level II to IV studies with a low number of patients with short follow ups and few randomized comparisons exist. The actual situation in treating osteochondral lesions in the ankle is presented and discussed.

MODERN TRENDS IN THE TREATMENT OF FOCAL CARTILAGE DEFECTS OF THE KNEE

The article is devoted to the current trend of modern orthopedics – the surgical treatment of local full-thickness defects in the hyaline cartilage of the knee joint. This pathology is diagnosed in 5-10% of patients with diseases and injuries of the knee joint.Materials and methods: The authors of the article presented one of the most modern and available technologies for the restoration of cartilage defects – the technology of matrix-induced autochondrogenesis (AMIC – autologous matrix-induced chondrogenesis). This operation technique was used in 63 patients. The article presents the indications and technique of surgery, considers possible errors, complications, criteria for evaluating treatment outcomes.Results: treatment outcomes in terms of up to 13 years were studied in 56 patients. Good treatment results were observed in 53 patients. In all cases, high-quality and regeneration of the cartilaginous surface of the femoral condyles was achieved.Conclusion: Analysis of the outcomes of treatment of patients after implantation of collagen membranes in various modifications allows the authors of the article to recommend this technique for widespread use in clinical practice.

Prevalence of hypovitaminosis D in patients with juvenile osteochondritis dissecans

BACKGROUND

Juvenile osteochondritis dissecans (JOCD) is an acquired joint disease of unknown etiology that affects skeletally immature patients and has the potential to progress to osteoarthritis. Recent studies have reported a high prevalence of vitaminD deficiency in patients with osteochondral lesions. The aim of our study was to determine serum vitaminD levels in patients diagnosed with JOCD.

METHODS

Serum 25(OH)D levels of 31 patients (22 males) presenting 40 lesions (29 JOCD of the knee, and 11 of the ankle) were evaluated. The average age was 11.9±2.9years. HypovitaminosisD was defined as a value less than 30ng/mL and was divided into vitaminD insufficiency (20 to 30ng/mL) and vitaminD deficiency (<20ng/mL).

RESULTS

HypovitaminosisD was present in 45.2% of the evaluated patients (32.2% insufficiency and 13% deficiency). No significant differences were found in the mean values and incidence of hypovitaminosis between those patients in which the sample was taken in warm or cold season (P=.267 and P=.875, respectively). Patients who required surgery had a higher incidence of hypovitaminosis than those treated conservatively (60% versus 31%, P=.054). There was no correlation in the incidence of hypovitaminosis with sex, location, stability of the lesion, or if the lesion was uni- or bilateral.

CONCLUSION

In our series, almost half of the patients diagnosed with JOCD presented abnormal serum levels of vitaminD. A two-fold incidence of hypovitaminosis was observed in patients requiring surgical treatment compared to patients managed conservatively. The association found in this study does not imply causation, but it should be considered within the set of actions for the treatment of these injuries.

Vitamin D and the athlete-patient: state of the art

Vitamin D deficiency is common in athletes. The conventional measurement of vitamin D levels provides a general indicator of body stores. However, there are nuances in its interpretation as values of 25(OH)D do not correlate absolutely with the amount of 'bioavailable' vitamin to the cells. Vitamin D should be regarded as a hormone and influences between 5% and 10% of our total genome. Determining the precise effect of the vitamin, isolated from the actions of other cofactors, is not straightforward and restricts our complete understanding of all of its actions. Deficiency has harmful effects on not only bone and muscle but also wider areas, including immunity and respiratory and neurological activities. More caution should be applied regarding the ability of supranormal vitamin D levels to elevate athletic performance. Hopefully, future research will shed more light on optimal levels of vitamin D and supplementation regimes, and improved understanding of its intracellular control of our genetic mechanisms and how extrinsic influences modify its activity.

Osteochondritis Dissecans of the Knee: Etiology and Pathogenetic Mechanisms. A Systematic Review

OBJECTIVE

The purpose of this manuscript is to analyze the evidence regarding etiopathogenesis of knee osteochondritis dissecans (OCD) lesions through a systematic review, so to summate the current understanding of the origin and progression of this pathologic articular processes.

DESIGN

A systematic review of the literature was performed on the PubMed and Cochrane databases on October 2017 by 2 independent authors and included all levels of evidence. This included all English language literature, pertaining specifically to etiopathology of knee OCD with exclusions for review articles and expert opinion. Of 965 identified records, 154 full-text articles were assessed for eligibility and 86 studies met the inclusion criteria.

RESULTS

According to these studies, the etiology of OCD can be of a biological or mechanical origin: 40 articles proposed a biological hypothesis, including genetic causes (27), ossification center deficit (12), and endocrine disorders (9); conversely, 52 articles supported a mechanical hypothesis, including injury/overuse (18), tibial spine impingement (5), discoid meniscus (16), and biomechanical alterations (20) as the cause of the onset of OCD. The pathogenic processes were investigated by 36 of these articles, with a focus on subchondral bone fracture and ischemia as the ultimate events leading to OCD.

CONCLUSIONS

Biological and mechanical factors are found to result in subchondral bone remodeling alterations, acting independently or more likely synergically in the progression of knee OCD. The former includes genetic causes, deficit of ossification centers and endocrine disorders; the latter, tibial spine impingement, discoid meniscus, and biomechanical alterations, together with injuries and overuse. The resultant subchondral bone ischemia and/or fracturing appears to determine the onset and progression of OCD.

LEVEL OF EVIDENCE

Systematic review of level II-IV studies, level IV.

Vitamin D Deficiency in Patients With Idiopathic and Traumatic Osteochondritis Dissecans of the Talus

BACKGROUND

Low vitamin D levels are common in patients with foot and ankle disorders. We have previously demonstrated that juveniles diagnosed with osteochondritis dissecans (OCD) have a high prevalence of vitamin D deficiency. Moreover, there is evidence that OCD might be related to vitamin D deficiency in general. However, whether or not hypovitaminosis D is associated with OCD of the talus has yet to be elucidated.

METHODS

The aim of this study was to determine serum vitamin D levels [25(OH)D] of patients diagnosed with traumatic and idiopathic OCD of the talus. The vitamin D status of patients was measured and correlated to age, sex, season, etiology, laterality, degree of disease, and nicotine abuse. Moreover, parathyroid hormone and serum calcium levels of patients were obtained to assess for severe vitamin D deficiency and secondary hyperparathyroidism. Between January 2015 and December 2017, 65 patients with a mean age of 38.9 years and a total of 68 lesions were identified.

RESULTS

In total, 75.4% of patients had low vitamin D levels with a mean overall 25(OH)D level of 24.2 ng/mL. Specifically, 35.4% of patients were vitamin D deficient; another 40% were vitamin D insufficient, and only 24.6% of patients presented with sufficient vitamin D levels. Statistical analysis showed no significant difference comparing vitamin D levels of patients with idiopathic OCD to patients with traumatic OCD.

CONCLUSION

We could not find any significant differences in the vitamin D status of patients with OCD of the talus compared with patients with foot and ankle disorders in general. However, we found that vitamin D deficiency was frequent in patients presenting with traumatic and idiopathic OCD of the talus. We believe it might be beneficial to routinely assess and treat the vitamin D status of patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Obtaining Vitamin D Levels in Children With Fractures Improves Supplementation Compliance

BACKGROUND

Obtaining ideal serum 25-vitamin D (25VitD) levels (>30 ng/mL) is imperative in childhood to achieve peak bone mass. Supplementation compliance in children recommended to take vitamin D postfracture was evaluated. The questions we sought to answer were: Is there (1) a compliance difference between patients with known versus unknown 25VitD levels; (2) an association between compliance and age; and (3) an association between fracture severity and initial 25VitD level.

METHODS

One physician analyzed compliance in 1818 fracture patients 2 to 18 years (42% female) with known (48%) and unknown 25VitD. Patient/caregiver's self-reported adherence to supplementation as "yes" (4 d/wk minimum) or "no" defined compliance. Compliance relating to fracture severity via Abbreviated Injury Scale (AIS), 25VitD level, and age, was analyzed.

RESULTS

Patients with 25VitD levels were more compliant than patients without (61%, n=532/872; 21%, n=206/946; P<0.001). In total, 83% (n=104/125) of AIS 3 patients were compliant, compared with 49% (n=628/1292) of AIS 1/2 patients (P<0.001). Compliance increased with age (odds ratio: 1.09, 95% confidence interval: 1.061-1.120, P<0.001).

CONCLUSIONS

Compliance increased when 25VitD levels were obtained, improving with fracture severity. Clinicians should order 25VitD levels on fracture patients to improve supplementation compliance.

LEVEL OF EVIDENCE

This is a level IV prognostic study which aims to investigate the effects of various patient characteristics on compliance.

Juvenile osteochondritis dissecans (JOCD) of the knee: current concepts review

Juvenile osteochondritis dissecans (JOCD) is a joint disorder of the subchondral bone and articular cartilage that affects skeletally immature patients.

The aetiology of JOCD is unknown and the natural history is poorly characterized in part due to inconsistent and largely retrospective literature.

Most OCD in children and adolescents presents as a stable lesion amenable to non-operative treatment or minimally invasive drilling. However, unstable forms can require a more aggressive approach.

This article reviews the most recent literature available and focuses on the pathophysiology, diagnosis and treatment of JOCD of the knee.

Cite this article: EFORT Open Rev 2019;4:201-212. DOI: 10.1302/2058-5241.4.180079

Surgical Considerations for Vitamin D Deficiency in Foot and Ankle Surgery

Vitamin D deficiency affects nearly one-sixth of the world's population and is common in patients undergoing foot and ankle surgery. Vitamin D is critical for calcium homeostasis and plays an important role in the maintenance of bone health. Patients undergoing foot and ankle procedures can be evaluated preoperatively with vitamin D level testing, and deficiencies can be addressed with either preoperative or postoperative supplementation. Current data suggest that patients with adequate vitamin D levels may have better outcomes, but the details are not yet clear. Vitamin D supplementation is well tolerated with rare side effects.

Vitamin D Deficiency: The Missing Etiological Factor in the Development of Juvenile Osteochondrosis Dissecans?

BACKGROUND

Vitamin D deficiency can result in rickets and hypocalcemia during infant and childhood growth. There is an increasing interest in the role of vitamin D with regards to childhood bone health. Osteochondrosis dissecans (OD) is a common disease affecting different joints. To date, the exact etiology of OD still remains unclear. The aim of this study was to evaluate a possible association of vitamin D deficiency and juvenile OD.

METHODS

A retrospective chart review of the years 2010 to 2015 of all orthopaedic patients with an initial diagnosis of juvenile OD admitted to undergo operative treatment of the OD was performed. Patient demographics, medical history, information on sports activity (if available) and serum vitamin D (25-OH-D) level on admission date were obtained. For statistical comparison, we measured baseline prevalence of vitamin D insufficiency in age-matched orthopaedic patients presenting at the department of pediatric orthopaedics.

RESULTS

A total of 80 patients were included in this study. Overall, 97.5% (n=78) of tested patients in the OD group had serum vitamin D levels below the recommended threshold of 30 ng/mL (mean value of 10.1 ng/mL (±6.7 ng/mL)). Over 60% (n=49) were vitamin D deficient, 29 patients (37%) showed serum levels below 10 ng/mL corresponding to a severe vitamin D deficiency. Of note, only 2 patients (2.5%) reached serum vitamin D levels above the recommended threshold of 30 ng/mL. No statistical difference was found in respect to sports activity level before onset of the symptoms (P=0.09). Statistical analysis found a significant difference in vitamin D levels between patients with OD and patients without an OD (P=0.026).

CONCLUSIONS

We found an unexpected high prevalence of vitamin D deficiency in juveniles diagnosed with OD presenting with significant lower mean 25-OH-D level compared with a control group. These results suggest that vitamin D deficiency is potentially associated with the development of OD. Thus, vitamin D deficiency might be an important cofactor in the multifactorial development of juvenile OD. For this reason, supplementation of vitamin D might not only be a potential additional therapy but also be a possible preventative factor in patients with juvenile OD. However, future prospective studies are needed to confirm this preliminary data.

LEVEL OF EVIDENCE

Level III-this is a case-control study.

Direct comparison of different surgical approaches in a woman with bilateral osteochondrosis dissecans of her knees: a case report

BACKGROUND

Osteochondrosis dissecans is a disorder of the subchondral bone potentially affecting the adjacent articular cartilage. There remains disunity with regard to treatment methods.

CASE PRESENTATION

We present the case of a 21-year-old Swiss woman who presented with clinically symptomatic bilateral osteochondrosis dissecans lesions at both medial femoral condyles. She underwent sequential surgical intervention and was prospectively monitored using clinical scores and magnetic resonance imaging. Her left knee was treated with an open refixation of the osteochondrosis dissecans lesion with two 2.0 mm screws in combination with a cancellous bone graft and subchondral drilling since the cartilage of the osteochondrosis dissecans lesion was intact. On her right knee, she underwent open removal of the defective bone and cartilage, cancellous bone graft with subchondral drilling and coverage with a bilayered collagenous membrane (autologous matrix-induced chondrogenesis technique) since the cartilage of the osteochondrosis dissecans lesion was not intact. At final follow-up 12 months after surgery her Lysholm score had improved from 79 to 95 on her left side and from 74 to 78 on her right. Magnetic resonance imaging displayed good integration of the cancellous bone graft with a slight irregularity at the articular surface on her left side (magnetic resonance observation of cartilage repair tissue (MOCART) 75). The magnetic resonance imaging of her right knee depicted satisfying bony reconstitution with yet more irregularity at the joint surface (magnetic resonance observation of cartilage repair tissue 65) in comparison to her left femoral condyle.

CONCLUSIONS

In cases of failed conservative treatment of osteochondrosis dissecans lesions of the knee joint surgery should be taken into consideration. Considering this case, we believe that the focus should be the preservation of the cartilaginous layer whenever possible or at least replacement with high quality replacement tissue, such as autologous chondrocyte implantation.