Osteochondritis dissecans of the lateral femoral condyle of the knee joint

[Treatment of osteochondritis dissecans]

Osteochondritis dissecans (OD) is a rare condition with an incidence of 30/100,000. It especially affects male patients aged 10-20 years old. During the staged progression the osteochondral fragments can detach from their base. These can damage the adjacent articular cartilage, which can lead to premature osteoarthritis. Most commonly affected are the knee, ankle and elbow joints. The exact pathogenesis of OD has so far not been clearly confirmed. Several risk factors that can lead to the development of OD are discussed. These include repeated microtrauma and vascularization disorders that can lead to ischemia of the subchondral bone and to a separation of the fragments close to the joint and therefore to the development of free joint bodies. For an adequate clarification patients should undergo a thorough radiological evaluation including X‑ray imaging followed by magnetic resonance imaging (MRI) to assess the integrity of the cartilage-bone formation with determination of the OD stage. The assessment is based on criteria of the International Cartilage Repair Society (ICRS). The instability of the cartilage-bone fragment increases with higher stages. Stages I and II with stable cartilage-bone interconnection can be treated conservatively. For stages III and IV, i.e., instability of the OD fragment or the presence of free fragments, surgical treatment should be performed. Primarily, refixation of a free joint body should be carried out depending on the size and vitality of the fragment. In cases of unsuccessful conservative treatment or fixation, a debridement, if necessary in combination with a bone marrow stimulating procedure, can be employed corresponding to the size of the defect. For larger cartilage defects, an osteochondral graft transplantation should be considered. Overall, OD lesions in stages I and II show a good healing tendency under conservative treatment. In cases of incipient unstable OD, refixation can also lead to good clinical and radiological results.

Wrisberg variant of the lateral discoid meniscus in children: review of the literature and presentation of case series

INTRODUCTION

The Wrisberg variant of the discoid lateral meniscus is a very rare disorder and is characterized by the hypermobility and instability of the meniscus caused by the absence of its posterior tibial attachment, with only its meniscofemoral junction (Wrisberg's ligament) maintained, and inserted in the posterior horn of the meniscus. As a result, the posterior horn of the lateral meniscus is mobile; often subluxing into the joint.

MATERIALS AND METHODS

A total of eight skeletally immature patients with symptomatic Wrisberg variant of the discoid lateral meniscus were included in this study. Each knee was evaluated with MRI and arthroscopy. We graded unstable discoid menisci according to their discoid morphology (complete vs. incomplete), meniscal intra-substance degeneration, and the presence or absence of meniscal tears. All eight menisci were evaluated as degenerated with no meniscal tears. Five of them were evaluated as complete. Due to the severely degenerated meniscus, we considered it unnecessary to repair the detached posterior tibial ligament, so we performed a reshaping of the discoid meniscus, restoring a C-shape, excising the hypertrophied central part of the meniscus, and creating a posterior horn with a remaining rim of 6-8 mm. For evaluation of the knee function preoperatively and postoperatively we used the online International Knee Documentation Committee (IKDC) system. The purpose of this study is to emphasize the importance of MRI in identifying and revealing the unstable (Wrisberg variant) type of discoid meniscus in children.

RESULTS

The mean patient age at the time of surgery was 8.25 ± 2.91 years (range 5-13 years). The average follow-up was 3.75 ± 0.46 years (range 3-4) years. The mean preoperative IKDC score was 22.37 ± 1.50 (range 21-25) points. The mean postoperative IKDC score was 80.50 ± 1.77 (range 79-84) points.

CONCLUSIONS

MRI is a valuable tool in the evaluation of the shape, stability, and consistency of symptomatic discoid menisci. It is helpful for the detection of the unstable Wrisberg variant.

Saucerization of complete discoid lateral meniscus is associated with change of morphology of the lateral femoral condyle and tibial plateau

PURPOSE

To determine the effect of saucerization surgery on knee joint morphology associated with a complete discoid lateral meniscus (DLM) using magnetic resonance (MR) imaging.

METHODS

This retrospective study included cases had undergone saucerization surgery for symptomatic DLM between 2007 and 2022. All cases were divided into two by age group: < 12 (U13) and > 13 (O13). The cases in the match group were randomly selected from preoperative cases in the O13 group matched with the age at the final follow-up (F/U) of cases in the U13 group. The following morphological parameters were evaluated using MR images preoperatively and at the final postoperative F/U in each group: anterior obliquity of the lateral tibial plateau (AOLTP), posterior obliquity of the lateral tibial plateau (POLTP), and the lowest point of the lateral femoral condyle (LPLFC). Each parameter was compared between the U13 preoperative (pre-OP) group and the O13 pre-OP group, the preoperative and final follow-up in the U13, and the U13 group at the final F/U and the match group preoperatively.

RESULTS

A total of 77 cases were evaluated. 31 cases were in the U13 pre-OP group and 46 were in the O13 pre-OP group. With a minimal F/U of 2 years, 27 cases in the U13 group and 36 in the O13 group were included. The mean F/U period was 4.6 years in the U13 group and 3.2 years in the O13 group. 32 cases were included in the match group. In the match group, the inclination of the POLTP was significantly larger (P = 0.042) and the LPLFC was more lateral (P = 0.0034) than at the final F/U in the U13 group.

CONCLUSIONS

Saucerization surgery for DLM in juvenile patients can prevent progression to the characteristic bone morphology DLM. These results could help the surgeon making the decision when the surgery would be performed for symptomatic DLM patients.

LEVEL OF EVIDENCE

Retrospective comparative study; level of evidence, 3.

Refixation of a Large Osteochondral Fragment with Magnesium Compression Screws-A Case Report

INTRODUCTION

Osteochondrosis dissecans (OCD) is a disease affecting the subchondral bone and the overlying articular cartilage. The etiology is most likely a combination of biological and mechanical factors. The incidence is highest in children >12 years old and it predominantly affects the knee. In high-grade OCD lesions, free osteochondral fragments usually are refixed via titanium screws or biodegradable screws or pins. In this case, headless compression screws made from magnesium were used for refixation.

CASE REPORT

A thirteen-year-old female patient with a two-year history of knee pain was diagnosed with an OCD lesion of the medial femoral condyle. After initial conservative treatment, displacement of the osteochondral fragment occurred. Refixation was performed using two headless magnesium compression screws. At the 6 months follow up, the patient was pain free, and the fragment showed progressive healing while the implants were biodegrading.

DISCUSSION

Existing implants for refixation of OCD lesions either require subsequent removal or show less stability and possible inflammatory reactions. The new generation of magnesium screws used in this case did not lead to a gas release, as described for previous magnesium implants, while maintaining stability during continuous biodegradation.

CONCLUSIONS

The data available to date on magnesium implants for the treatment of OCD are promising. However, the evidence on the magnesium implants in refixation surgery of OCD lesions is still limited. Further research needs to be conducted to provide data on outcomes and possible complications.

Effect of the volume of resected discoid lateral meniscus on the contact stress of the tibiofemoral joint: A finite element analysis

BACKGROUND

Partial meniscectomy is commonly performed for symptomatic patients with discoid lateral meniscus (DLM) if conservative treatment fails. However, the development of knee osteoarthritis and osteochondral lesion are detrimental postoperative complications. This study aimed to evaluate the effect of the volume of resected DLM on the contact stress of the tibiofemoral joint using a finite element analysis.

METHODS

Subject-specific finite-element models of the knee joint of a patient with DLM were developed from computed tomographic and magnetic resonance images. To evaluate the effect of partial meniscectomy on the contact stress in the lateral tibiofemoral joint, six knee models were created in the study (the native DLM, and five partially meniscectomized DLMs (according to the preserved width of the meniscus: 12 mm, 10 mm, 8 mm, 6 mm, and 4 mm)).

RESULTS

As the volume of resected DLM increased, higher contact stress was applied to the lateral tibiofemoral joint. Greater contact stress was applied to the preserved lateral meniscus than to the native DLM.

CONCLUSIONS

From a biomechanical viewpoint, the native DLM was the most protective against lateral tibiofemoral contact stress in comparison to partially meniscectomized DLMs.

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.

Comparison of the Healing Outcomes of Conservative Treatment for Stable Juvenile Osteochondritis Dissecans of the Lateral Femoral Condyle With Normal Lateral Meniscus and Incomplete Discoid Lateral Meniscus

BACKGROUND

This study aimed to compare the healing outcomes of conservative treatment for osteochondritis dissecans (OCD) of the lateral femoral condyle with normal lateral meniscus and incomplete discoid lateral meniscus (DLM).

METHODS

Forty-four knees in 37 juvenile patients (mean age 9.9 y) with stable OCD and whose lateral meniscus shape was normal or incomplete DLM were enrolled. All patients underwent conservative treatment with physical activities prohibited. For each lateral meniscus group, patient demographics including pretreatment Tegner activity scale, OCD stage, and Lysholm score, radiographic healing status; complete or incomplete healing at 3 months, 6 months, and 1 year, time to complete healing and post-treatment clinical scores were evaluated.

RESULTS

There were 21 (47.8%) and 23 (52.3%) knees with normal menisci and incomplete DLM, respectively. At 3 months, 6 months, and 1 year after conservative treatment, healed OCD status was noted in 3 (14.3%), 12 (57.1%), and 19 (90.5%) knees of the normal type and in 3 (13.0%), 12 (52.2%), and 20 (86.9%) knees of the incomplete DLM type, respectively (P>0.05). The mean time to healing in each group was 198 and 181 days, respectively. No significant differences in terms of OCD healing rate at each time, time to healing, and post-treatment clinical scores were found between the groups.

CONCLUSION

No significant differences in the OCD healing rate or time to healing were found between the normal and incomplete DLM type. Therefore, treatment strategy for OCD with stable and asymptomatic incomplete DLM should be the same as that for those occurring with a normal meniscus.

T2 Relaxation Time Changes in the Distal Femoral Condylar Cartilage of Children and Young Adults with Discoid Meniscus

OBJECTIVE

To investigate compositional changes in the distal femoral condylar cartilage (FCC) of children and young adults with and without discoid meniscus by T2 relaxation time mapping.

DESIGN

We retrospectively reviewed knee magnetic resonance images including sagittal T2 maps of distal FCC performed in patients with or without discoid meniscus. Combined meniscal pathology such as degeneration or tears was also reviewed. Regions of interest were selected, and T2 relaxation time profiles were generated according to medial and lateral and FCC and according to weight-bearing and non-weight-bearing FCC. Nonparametric comparison tests using median values were performed.

RESULTS

Seventy-nine knees from 73 patients (2-20 years) including 45 knees with lateral discoid meniscus (discoid group) were studied. T2 values of FCC showed negative correlation with age in both the discoid and nondiscoid groups (P < 0.01), except for medial weight-bearing FCC. In the discoid group, T2 relaxation times of lateral weight-bearing FCC (median, 46.5 ms) were lower than those of lateral non-weight-bearing (median, 53.2 ms; P < 0.001) and medial weight-bearing (median, 50.5 ms; P = 0.012) FCC. Lateral weight-bearing FCC also showed lower T2 values than other areas in patients with meniscal pathology in the discoid group. However, T2 relaxation times did not differ between the discoid and nondiscoid groups in patients without meniscal pathology.

CONCLUSIONS

Children and young adults with discoid meniscus have lower T2 relaxation times in lateral weight-bearing FCC compared with non-weight-bearing or medial FCC, suggesting compositional changes have occurred in these patients.

An adult case of spontaneous healing of concurrent osteochondritis dissecans of the lateral femoral condyle after saucerization with meniscal repair for discoid lateral meniscus: A case report

BACKGROUND

The treatment strategy for osteochondritis dissecans (OCD) with discoid lateral meniscus (DLM) in adults remains unclear.

CASE PRESENTATION

A 22-year-old man presented with left knee pain after spraining his knee. Physical examination revealed lateral joint line tenderness and a positive McMurray test. Radiographic imaging showed OCD of the lateral femoral condyle classified as stage 3 on Brückl's classification. Magnetic resonance imaging showed complete DLM with anterocentral shift based on Ahn's classification and an OCD of 11 mm × 8 mm, grade 2 based on Nelson's classification. On computed tomography (CT), a demarcated fragment was observed in the lesion. Based on these findings, saucerization with meniscal repair was performed for unstable DLM. The OCD lesion presented with softening without any fissure and was diagnosed as grade 1. No surgical procedure was added. One year after surgery, the union of the fragment was confirmed on radiograph and CT. At the final follow-up five years after surgery, the Lysholm score had improved from 58 to 100 points.

CONCLUSIONS

We experienced an adult case of stable OCD with concurrent DLM that achieved spontaneous healing after undergoing reshaping surgery for DLM, mimicking normal meniscal morphology, without additional treatment for the stable OCD lesion.

Osteochondritis Dissecans: Current Understanding of Epidemiology, Etiology, Management, and Outcomes

➤

Osteochondritis dissecans occurs most frequently in the active pediatric and young adult populations, commonly affecting the knee, elbow, or ankle, and may lead to premature osteoarthritis.

➤

While generally considered an idiopathic phenomenon, various etiopathogenetic theories are being investigated, including local ischemia, aberrant endochondral ossification of the secondary subarticular physis, repetitive microtrauma, and genetic predisposition.

➤

Diagnosis is based on the history, physical examination, radiography, and advanced imaging, with elbow ultrasonography and novel magnetic resonance imaging protocols potentially enabling early detection and in-depth staging.

➤

Treatment largely depends on skeletal maturity and lesion stability, defined by the presence or absence of articular cartilage fracture and subchondral bone separation, as determined by imaging and arthroscopy, and is typically nonoperative for stable lesions in skeletally immature patients and operative for those who have had failure of conservative management or have unstable lesions.

➤

Clinical practice guidelines have been limited by a paucity of high-level evidence, but a multicenter effort is ongoing to develop accurate and reliable classification systems and multimodal decision-making algorithms with prognostic value.

Osteochondritis Dissecans of the Tibial Plateau in Children and Adolescents: A Case Series

Background:

Osteochondritis dissecans (OCD) of the knee is a relatively well-known condition, most commonly arising in the femoral condyle. Lesions arising in the tibial plateau are rarely described.

Purpose:

To present a case series of OCD lesions of the tibial plateau.

Study Design:

Case series; Level of evidence, 4.

Methods:

Medical records and diagnostic imaging of patients <20 years of age with confirmed diagnosis of OCD of the tibial plateau from a single institution were retrospectively reviewed. Characteristic and radiographic features as well as details of both nonoperative and surgical management were investigated. Lesion characteristics and treatment outcomes were also analyzed.

Results:

A total of 9 lesions were identified in 9 patients (5 females, 4 males) who fit the inclusion criteria. The mean age at diagnosis was 14.2 years (range, 9-17 years). Knee pain (8/9) of longer than 1 year in duration was the most common presenting symptom. All 9 lesions were located on the lateral tibial plateau, and concomitant lateral compartment pathology was present in 5 of 9 patients (4 lateral femoral condyle OCDs, 3 lateral meniscal tears [1 discoid], and 1 discoid meniscus). Only 2 lesions were visible on initial radiographs; all 9 were visible on magnetic resonance imaging. All patients underwent initial nonoperative treatment; 2 patients demonstrated resolution of symptoms. Two patients underwent surgery for concomitant pathology, and the OCD was not addressed surgically. A total of 5 patients continued to be symptomatic after nonoperative treatment, prompting surgical intervention, which consisted of microfracture and chondroplasty in all 5 cases. A total of 2 of the 5 microfracture patients had resolution of symptoms, while another 2 patients had continued symptoms ultimately responsive to steroid injection treatment. One patient had revision microfracture, followed by autologous chondrocyte implantation and an arthroscopic lysis of adhesions. At final follow-up, ranging from 7 months to 10 years, 8 patients were asymptomatic, while 1 patient had developed early osteoarthritis.

Conclusion:

OCD of the tibial plateau in young patients is rare, usually involves the lateral side, and may have significant long-term implications for knee function. Presenting symptoms are often vague, and lesions may not always be visible on initial radiographs, which may lead to delayed treatment and adversely affect outcomes.

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.

The Fate of the Contralateral Knee in Patients With a Lateral Discoid Meniscus

PURPOSE

To analyze the survivorship of the lateral meniscus (LM) in the contralateral knee after surgery for symptomatic torn discoid lateral meniscus (DLM) and to determine its associated factors.

METHODS

Two hundred ninety-six patients who underwent arthroscopic meniscectomy for torn symptomatic DLM were reviewed retrospectively. Patients were classified into subgroups based on demographic, clinical, and radiologic variables. The survivorship analysis of the LM on the contralateral knee was calculated using the Kaplan-Meier method, and comparison among the subgroups was conducted using the log-rank test. The predicted prognostic factors associated with survivorship were determined using Cox proportional hazard regression analysis.

RESULTS

Of the 296 patients, 51 (17%) had arthroscopic surgery in the contralateral knee during the study period. The group ≥40 years old had significantly worse survival than the group <40 (log-rank test, P < .001). In terms of radiologic variables, the group with Kellgren-Lawrence grade 3 or 4 had significantly poorer survivorship than that with grade 1 or 2 (log-rank test, P = .045). Age ≥40 years was associated with poorer survivorship (hazard ratio, 3.235; 95% confidence interval, 1.782-5.875; P < .001). Kellgren-Lawrence grades 3 and 4 in the contralateral knee were associated with poorer survival (hazard ratio, 2.071; 95% confidence interval, 1.061-4.043; P = .033). The cumulative survival rate at 10 years of the LM in the contralateral knee after surgery for symptomatic torn DLM was 81%.

CONCLUSIONS

Patients with a lateral discoid meniscus have a risk of a similar condition in the contralateral knee. Increased risks of symptomatology are associated with age and degenerative changes.

LEVEL OF EVIDENCE

Level IV, retrospective uncontrolled case series.

Internal Fixation of Unstable Osteochondritis Dissecans: Do Open Growth Plates Improve Healing Rate?

BACKGROUND

Osteochondritis dissecans (OCD) is a disorder of unknown origin that can affect knees in skeletally mature and immature patients. Surgical management is an important cornerstone of treatment for unstable OCD lesions.

PURPOSE

To determine the (1) healing rate after internal fixation of unstable OCD between skeletally immature and mature knees, (2) risk factors for failure, and (3) patient-reported outcomes among healed patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A multicenter retrospective cohort study was conducted with patients who underwent internal fixation of unstable knee OCD lesions from 2000 to 2015. Skeletal immaturity was defined as open or partially open physes. Healing was assessed through clinical findings and imaging. Definitive reoperation for the same OCD lesion was classified as failure.

RESULTS

Among 87 patients included, 66 (76%) had healed lesions at ≥2 years postoperatively, while 21 (24%) failed. Skeletal maturity made no significant difference in failure rate (risk ratio, 0.68; 95% CI, 0.29-1.72; P = .40). For skeletally immature patients, lateral versus medial condylar location conferred an increased hazard of 18.2 (95% CI, 1.76-188.07; P < .01). Multivariate analysis factoring in skeletal maturity showed that lateral condylar location was an independent risk factor for failure (hazard ratio, 4.25; 95% CI, 1.47-19.85; P < .01). Mean patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) increased significantly after surgery, except the KOOS symptoms score for the skeletally mature group. Final scores (mean ± SD) were as follows at a mean follow-up of 60 months (range, 24-166): IKDC, 83.5 ± 20.2; KOOS pain, 89.7 ± 14.1; KOOS symptoms, 87.4 ± 18.4; KOOS activities of daily living, 93.9 ± 12.7; KOOS sports, 80.7 ± 25.9; KOOS quality of life, 78.9 ± 23.1.

CONCLUSION

Skeletally immature and mature patients heal at comparable rates after internal fixation of OCD lesions, resulting in functional and subjective improvement. Lateral femoral condylar lesion location is an independent risk factor for failure.

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.

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.

Evolution of Osteochondritis Dissecans of the Lateral Femoral Condyle Combined with Discoid Meniscus

The discoid meniscus is a rare anomaly of the knee that affects mostly the lateral meniscus and is often asymptomatic. The osteochondritis dissecans is a disorder of the subchondral bone and articular cartilage and occurs frequently associated with the discoid lateral meniscus. In the present case, we showed the evolution of this association related to surgical treatment. A patient with lateral knee pain and a magnetic resonance depicting a torn discoid lateral meniscus and osteochondritis dissecans of the lateral femoral condyle was treated with partial meniscectomy and meniscal sutures. After 1 year, the symptoms reappeared, and a new meniscal repair was performed to treat a bucket-handle tear, while cartilage was apparently intact. After 4 years, there was a new recurrence of symptoms, and the knee developed a valgus deformity. Cartilage was treated with microfractures, and a subsequent distal femoral osteotomy associated with lateral meniscal scaffold was performed. The patient was followed up clinically, with radiographs and magnetic resonance for 5 years with an improvement of the results up to 2 years and no signs of deterioration of results over time.

Analysis of risk factors for poor prognosis in conservatively managed juvenile osteochondritis dissecans of the lateral femoral condyle

BACKGROUND

The purpose of this study was to examine factors affecting the prognosis of conservative treatment for stable juvenile osteochondritis dissecans (OCD) of the lateral femoral condyle based on review of our patient population.

METHODS

A consecutive series of 43 knees in 37 patients with stable OCD of the lateral femoral condyle with open physes undergoing conservative treatment were included in the study. The mean age of the included subjects was 10.7±2.5years (range, seven to 16years) with the mean follow-up period of 33.3±15.1months (range, 12 to 67months). Conservative treatment consisting of prohibition of sports activities and use of a brace locking the knee in full extension was applied to all included patients. Potential prognostic factors examined were the presence of discoid meniscus, radiographic stage, lesion size on radiographs, time period from onset of symptoms to evaluation/consultation, number of hours of sporting activity per week, and age at starting sports activities. Prognosis of a patient was deemed to be poor when an apparent healing response was not detected in follow-up radiographic studies within six months.

RESULTS

The prognosis was defined to be poor for 14 knees (32.6%). The presence of discoid meniscus was identified in 100% of the knees in the poor prognosis group and time-period from onset to consultation of six months or more was shown to be a risk factor with statistical significance.

CONCLUSIONS

A majority of patients with juvenile OCD in the lateral femoral condyle could be managed with conservative treatment. The presence of discoid meniscus and longer time-period from onset to consultation were significantly related with poor prognosis.

LEVEL OF EVIDENCE

IV (case series).

Unique Anatomic Feature of the Posterior Cruciate Ligament in Knees Associated With Osteochondritis Dissecans

Background:

Osteochondritis dissecans (OCD) of the knee is a disorder in juveniles and young adults; however, its etiology still remains unclear. For OCD at the medial femoral condyle (MFC), it is sometimes observed that the lesion has a connection with fibers of the posterior cruciate ligament (PCL). Although this could be important information related to the etiology of MFC OCD, there is no report examining an association between the MFC OCD and the PCL anatomy.

Purpose:

To investigate the anatomic features of knees associated with MFC OCD, focusing especially on the femoral attachment of the PCL, and to compare them with knees associated with lateral femoral condyle (LFC) OCD and non-OCD lesions.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We retrospectively reviewed 39 patients (46 knees) with OCD lesions who had undergone surgical treatment. Using magnetic resonance imaging (MRI) scans, the PCL attachment at the lateral wall of the MFC was measured on the coronal sections, and the knee flexion angle was also measured on the sagittal sections. As with non-OCD knees, we reviewed and analyzed 25 knees with anterior cruciate ligament (ACL) injuries and 16 knees with meniscal injuries.

Results:

MRIs revealed that the femoral PCL footprint was located in a significantly more distal position in the patients with MFC OCD compared with patients with LFC OCD and ACL and meniscal injuries. There was no significant difference in knee flexion angle among the 4 groups.

Conclusion:

The PCL in patients with MFC OCD attached more distally at the lateral aspect of the MFC compared with knees with LFC OCD and ACL and meniscal injuries.

Arthroscopic Treatment for Symptomatic Discoid Meniscus in Children: Midterm Outcomes and Prognostic Factors

PURPOSE

To investigate the clinical and radiologic outcomes and prognostic factors of arthroscopic partial meniscectomy with or without suture repair of the remnant rim and subtotal meniscectomy in children with discoid menisci.

METHODS

We retrospectively reviewed all consecutive patients aged younger than 18 years who underwent arthroscopy between 2003 and 2012, excluding patients with follow-up less than 2 years, concomitant injuries, underlying diseases, or a lost videotape. Patients were grouped by treatment method: partial meniscectomy with or without suture repair and subtotal meniscectomy. Clinical outcomes were determined based on symptoms, complications, and Lysholm scores. Degenerative changes were assessed radiologically. Risk factors for a lower Lysholm score were investigated.

RESULTS

Of 100 knees (86 patients; mean age, 10.7 years), 87 underwent partial meniscectomy with (n = 42) or without (n = 45) suture repair and 13 underwent subtotal meniscectomy. The Lysholm score at a mean of 4.7 years (range, 2.0 to 10.9 years) improved to more than 90, regardless of meniscectomy method (P = .767; 95% confidence interval [CI], -5.1 to 6.9) or the addition of suture repair (P = .797; 95% CI, -3.5 to 4.6). Early degenerative changes were found in 11 knees. Patients aged younger than 10 years at surgery had a 2.37 times higher chance of having excellent Lysholm scores (P = .032; 95% CI, 1.1 to 5.1). A reoperation history was associated with lower Lysholm scores with a marginal significance (P = .054; 95% CI, -0.9 to 12.3).

CONCLUSIONS

Arthroscopic partial meniscectomy with stabilization of the unstable remnant rim was effective in preserving knee function with few early degenerative changes during the midterm follow-up period. Subtotal meniscectomy appears to be a valid treatment for unsalvageable cases. There was no difference in outcomes among the partial meniscectomy, partial meniscectomy with suture repair, and subtotal meniscectomy groups. Less satisfactory functional outcomes may follow in children aged 10 years or older or when a reoperation has been performed.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Prevalence of bilateral Discoid Lateral Menisci (DLM) in patients operated for symptomatic DLM with a follow-up study on their asymptomatic contralateral knees: a Magnetic Resonance Imaging (MRI) assessment

Background

The purpose was to investigate prevalence of bilateral discoid lateral menisci (DLM) in Han Chinese patients who received surgery for symptomatic DLM, as well as a follow-up study of their asymptomatic contralateral knees using magnetic resonance imaging (MRI).

Methods

A total of 110 patients [50 males and 60 females; average age: 21.95 ± 12.77 years (range: 6 to 67 years)] admitted to our hospital with symptomatic DLM were treated with arthroscopic surgery. The contralateral asymptomatic knees were evaluated for DLM by MRI. Postoperative clinical evaluation was performed using the Lysholm knee scoring scale and International Knee Documentation Committee subjective knee evaluation.

Results

Eighty (72.73 %) of 110 symptomatic DLM patients had bilateral DLM, of which 68 (85 %) were of homotype (same type). Fourteen of 80 bilateral DLM patients were symptomatic and received operations in both knees. Twelve of remaining 66 bilateral DLM patients with asymptomatic one knee underwent a second arthroscopic surgery as their asymptomatic knees became symptomatic over the five-year interim. Of these 12 cases, seven exhibited no shift and five showed posterocentral meniscal shift. Furthermore, at least two cases showed progression from asymptomatic grade II to symptomatic grade III over the interim. All patients showed significant improvement after surgery.

Conclusions

The bilateral DLM rate of Han Chinese patients with symptomatic DLM was relatively high at 72.7 %, and 85 % of those were of homotype.

Bilateral Wrisberg discoid menisci mimicking bucket handle tears associated with osteochondritis dissecans: case report

Discoid menisci are frequently associated with osteochondritis dissecans (OCD) of the knee and are often bilateral. Patients usually present with no or few symptoms disproportionate to the size of the lesions. We report the case of a 14-year-old boy who had bilateral unstable lateral discoid menisci with unilateral stage 3 OCD treated with meniscoplasty, meniscal rim stabilization, and fixation of the OCD.

An Osteochondral Lesion of the Lateral Femoral Condyle with Arthroscopic Appearance Resembling a Fried Egg: A Case Report

CASE

We encountered an unusual case of an osteochondral lesion of the lateral femoral condyle with a detached osteochondral fragment that was reversed and became reattached to its bed; examination by arthroscopy depicted this lesion with a unique resemblance to a fried egg. Because the excised osteochondral fragment showed little damage or degeneration and had relatively good compatibility with the site of origin, we selected the treatment option of reduction and suture fixation.

CONCLUSION

The pathological presentation of this osteochondral lesion that resembled a fried egg was an unusual and rare occurrence.

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.

Meniscal pathology in children: differences and similarities with the adult meniscus

The normal meniscus undergoes typical developmental changes during childhood, reaching a mature adult appearance by approximately 10 years of age. In addition to recognizing normal meniscal appearances in children, identifying abnormalities - such as tears and the different types of discoid meniscus and meniscal cysts, as well as the surgical implications of these abnormalities - is vital in pediatric imaging. The reported incidence of meniscal tears in adolescents and young adults has increased because of increased sports participation and more widespread use of MRI. This review discusses the normal appearance of the pediatric meniscus, meniscal abnormalities, associated injuries, and prognostic indicators for repair.

A review of knowledge in osteochondritis dissecans: 123 years of minimal evolution from König to the ROCK study group

BACKGROUND

Osteochondritis dissecans (OCD) was first described to provide an explanation for the nontraumatic development of loose bodies within a joint. Despite many reports on the subject, there remains no clear understanding of the etiology, natural history, or treatment.

QUESTIONS/PURPOSES

This review was undertaken to delineate (1) the etiology of OCD; (2) the presentation and locations; (3) the most appropriate imaging modalities; and (4) the most effective treatment strategies.

METHODS

We reviewed the English literature using a database compiled from a Medline search for "osteochondritis dissecans". We identified 1716 publications, 1246 of which were in English. After exclusions, we reviewed 748 articles and of these cited 85. The observations of each study were then synthesized into this report.

RESULTS

There appears to be no consensus concerning the etiology of OCD lesions. The presentations and locations are variable, but the knee, ankle, and elbow are most commonly involved. Although plain film assessment is important in OCD, there appears to be a trend toward the use of MRI, but the preferred sequences are in evolution. We found no consensus on the treatment of these lesions, related in part to the lack of agreement of methods for assessing outcomes.

CONCLUSIONS

Despite more than a century of study, we have made little advancement in our understanding of OCD. A study group has been formed to address this issue and actively seeks to answer these unknown issues regarding OCD.

Drilling juvenile osteochondritis dissecans: retro- or transarticular?

BACKGROUND

Early diagnosis and successful treatment of juvenile osteochondritis dissecans (JOCD) is essential in preventing articular degeneration at a young age. Surgical treatment of stable JOCD lesions failing nonoperative treatment involves retroarticular or transarticular drilling to induce revascularization and healing. Multiple case series report high healing rates and infrequent complications for both retroarticular and transarticular drilling modalities; however, it is unclear from these individual reports whether one mode of drilling provides higher healing rates.

QUESTIONS/PURPOSES

We asked whether transarticular or retroarticular drilling of stable JOCD lesions results in differing patient-oriented outcomes, rates of radiographic healing, time to radiographic healing, and complication rates.

METHODS

We systematically reviewed the short-term clinical outcomes of retroarticular and transarticular drilling of stable OCD lesions. PubMed and additional sources identified 65 studies; 12 studies met inclusion criteria.

RESULTS

Heterogeneity and quality of studies limited review to qualitative analysis. No clear differences were seen in patient-oriented outcomes after treatment with either drilling modality. Radiographic healing for JOCD lesions drilled retroarticularly occurred in 96 of 111 (86%) lesions in an average of 5.6 months. Transarticular drilling of JOCD lesions resulted in 86 of 94 (91%) lesions healing by radiography in an average of 4.5 months. No complications were reported for either drilling modality.

CONCLUSIONS

Retroarticular and transarticular drilling of stable lesions results in comparable short-term patient-oriented outcomes and radiographic healing. Further high-quality comparative studies are required to adequately compare drilling modalities, clearly define radiographic healing, and patient-oriented outcomes after nonoperative treatment.

Massive osteochondritis of the lateral femoral condyle associated with discoid meniscus: management with meniscoplasty, rim stabilization and bioabsorbable screw fixation

Discoid menisci without tears and before surgical intervention may be an aetiological factor in the development of osteochondritis dissecans (OCD). We present the case of a massive OCD lesion in the lateral femoral condyle of a 12-year-old boy who presented with relatively few symptoms despite the size of the lesion. This was treated with meniscoplasty and rim stabilization, which has become established as the gold standard treatment for symptomatic discoid menisci. This was combined with bioabsorbable screw fixation of the OCD lesion, resulting in rapid resolution of symptoms and a return to normal magnetic resonance image appearances after 6 months. It is likely that instability of discoid menisci is a key causal component when present concurrently with OCD lesions. Therefore, stabilization of this is required as well as saucerization of the meniscus. OCD lesions which are of a sufficient size such that if they became unstable or dislocated would result in a significant defect should also be stabilized. We believe that bioabsorbable screw fixation presents a good solution for fixation in these cases and this combination of treatment should result in a satisfactory outcome.

Review of discoid meniscus

Discoid lateral meniscus is an intra-articular knee disorder that typically presents in children and adolescents. The natural history depends on the type of anomaly and the nature and presence of symptoms. Management of this disorder should be directed toward resolution of the symptoms while preserving meniscal tissue and function. Modern surgical techniques make suturing and preservation of meniscal tissue feasible. In the present article, the clinical manifestations, diagnostic criteria and practical management considerations are reviewed.

Characteristic shape of the lateral femoral condyle in patients with osteochondritis dissecans accompanied by a discoid lateral meniscus

BACKGROUND

There are various indirect signs of a discoid lateral meniscus in radiographs, for example lateral joint space widening, hypoplasia of the LFC, etc. There has, however, been no previous report of the characteristic shape of the lateral femoral condyle (LFC) in patients with osteochondritis dissecans (OCD) accompanied by a discoid lateral meniscus. The purpose of this study was to evaluate the characteristic shape of the LFC in patients with OCD accompanied by a discoid lateral meniscus, and sex differences associated with the shape of the LFC in those patients.

METHODS

This study included 29 males (31 knees) and 29 females (32 knees) of average age 17.7 years. There were 15 knees in 15 patients that were accompanied by OCD of the LFC (9 males, 9 knees; 6 females, 6 knees; average age 14.9 years; OCD group). There were 48 knees in 43 patients that were not accompanied by OCD of the LFC (20 males, 22 knees; 23 females, 26 knees; average age 17.6 years; non-OCD group). Standardized Rosenberg view radiographs of the knee were obtained for all patients. We evaluated the shape of LFC using the Rosenberg view and measured the condylar prominence ratio of the medial and lateral condyles adjacent to the intercondylar notch, in accordance with Ha's procedure.

RESULTS

The OCD group had a significantly larger prominence ratio than the non-OCD group. The prominence ratio for males was significantly larger than that for females.

CONCLUSION

We clearly demonstrated that the prominence ratio in the OCD group was significantly larger than that in the non-OCD group, indicating that the shape of the LFC and OCD in the LFC may be associated with the development of these lesions.

Long-term results of arthroscopic excision of unstable osteochondral lesions of the lateral femoral condyle

The purpose of this study was to evaluate the long-term functional and radiological outcomes of arthroscopic removal of unstable osteochondral lesions with subchondral drilling in the lateral femoral condyle. We reviewed the outcome of 23 patients (28 knees) with stage III or IV osteochondritis dissecans lesions of the lateral femoral condyle at a mean follow-up of 14 years (10 to 19). The functional clinical outcomes were assessed using the Lysholm score, which improved from a mean of 38.1 (sd 3.5) pre-operatively to a mean of 87.3 (sd 5.4) at the most recent review (p = 0.034), and the Tegner activity score, which improved from a pre-operative median of 2 (0 to 3) to a median of 5 (3 to 7) at final follow-up (p = 0.021). The radiological degenerative changes were evaluated according to Tapper and Hoover’s classification and when compared with the pre-operative findings, one knee had grade 1, 22 knees had grade 2 and five knees had grade 3 degenerative changes. The overall outcomes were assessed using Hughston’s rating scale, where 19 knees were rated as good, four as fair and five as poor.

We found radiological evidence of degenerative changes in the third or fourth decade of life at a mean of 14 years after arthroscopic excision of the loose body and subchondral drilling for an unstable osteochondral lesion of the lateral femoral condyle. Clinical and functional results were more satisfactory.

Meniscoplasty for stable osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus: a case report

INTRODUCTION

Osteochondritis dissecans of the lateral femoral condyle is relatively rare, and it is reported to often be combined with a discoid lateral meniscus. Given the potential for healing, conservative management is indicated for stable osteochondritis dissecans in patients who are skeletally immature. However, patients with osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus often have persistent symptoms despite conservative management.

CASE PRESENTATION

We present the case of a seven-year-old Korean girl who had osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus, which healed after meniscoplasty for the symptomatic lateral discoid meniscus without surgical intervention for the osteochondritis dissecans. In addition, healing of the osteochondritis dissecans lesion was confirmed by an MRI scan five months after the operation.

CONCLUSIONS

Meniscoplasty can be recommended for symptomatic stable juvenile osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus when conservative treatment fails.

Meniscoplasty for stable osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus: a case report

Introduction

Osteochondritis dissecans of the lateral femoral condyle is relatively rare, and it is reported to often be combined with a discoid lateral meniscus. Given the potential for healing, conservative management is indicated for stable osteochondritis dissecans in patients who are skeletally immature. However, patients with osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus often have persistent symptoms despite conservative management.

Case presentation

We present the case of a seven-year-old Korean girl who had osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus, which healed after meniscoplasty for the symptomatic lateral discoid meniscus without surgical intervention for the osteochondritis dissecans. In addition, healing of the osteochondritis dissecans lesion was confirmed by an MRI scan five months after the operation.

Conclusions

Meniscoplasty can be recommended for symptomatic stable juvenile osteochondritis dissecans of the lateral femoral condyle combined with a discoid lateral meniscus when conservative treatment fails.

An observational study on MR images of the effect of the discoid meniscus on articular cartilage thickness

The discoid meniscus is known to affect the morphology and mechanics of the knee compartment in which it is housed. To determine whether it also is determinative of the articular cartilage thickness, measurements were made on MR images. There was no statistically significant difference in femoral or tibial articular cartilage thickness between compartments with normal meniscus and compartments with discoid meniscus. These findings suggest that mechanical disturbances wrought by the discoid shape do not have a 'Wolff law' effect.

Histological evaluation of juvenile osteochondritis dissecans of the knee: a case series

Osteochondritis dissecans (OCD) is an acquired, potentially reversible idiopathic disease of subchondral bone resulting in delamination and sequestration. Although juvenile-type OCD lesions typically appear stable on superficial examination, conservative treatment results in cure in approximate 50% of patients. We hypothesized that juvenile-type OCD lesions exhibit an underlying instability despite stability at the articular surface and this underlying instability might underlie the lack of effectiveness of conservative treatment. In this study, osteochondral cylindrical tissue samples obtained from stable juvenile OCD lesions located at the medial femoral condyle (classical site) were examined. Eight patients with symptomatic juvenile-type OCD at the classical site underwent arthroscopy. Osteochondral cylindrical tissue samples were obtained from the central portion using a biopsy needle. The samples underwent macroscopic and microscopic examination. All cylindrical samples demonstrated macroscopic separation. On microscopic examination, no degenerative changes in articular cartilage and no bone necrosis were observed. Histological examination revealed two distinct patterns in the samples: (1) thick homogeneous hyaline cartilage alone with little fibrous tissue surrounding areas of separation and (2) nearly normal, thin hyaline cartilage above a mixed layer of hyaline cartilage and subchondral trabeculae and fibrous/fibro-cartilaginous tissue at the areas of separation, indicating delayed or nonunion. Pathological findings in stable juvenile OCD lesions indicate an underlying instability at deeper layers of articular cartilage and poor healing at areas of separation. Improved knowledge of the histology of juvenile-type OCD lesions may support surgical treatment. Early marrow stimulation and/or fixation may be the treatment of choice to promote healing even in macroscopically stable juvenile-type OCD lesions.

Total posterior condylar separation in a juvenile knee: open fixation through a posterior arthrotomy

The authors report a case of separation involving the posterior aspect of the lateral femoral condyle in a 13-year-old boy. The patient presented with a 2-year history of vague knee discomfort and recurrent knee effusions in the absence of a single acute traumatic event. A large mobile osteochondral fragment involving most of the posterior aspect of the lateral condyle was refixed surgically with two screws via a posterolateral arthrotomy. The knee has recovered full function and the lesion is radiologically stable.

Functional and radiographic outcome of stable juvenile osteochondritis dissecans of the knee treated with retroarticular drilling without bone grafting

PURPOSE

The purpose of this study was to evaluate the functional and radiographic outcome of retroarticular drilling for patients with juvenile osteochondritis dissecans after 6 months of unsuccessful nonoperative treatment.

METHODS

A total of 20 osteochondritis dissecans lesions in 12 skeletally immature patients were treated with retroarticular drilling without bone grafting. There were 10 boys and 2 girls with a mean age of 12.0 years (range, 9 to 15 years). The functional outcomes were evaluated by use of the Lysholm score at a mean follow-up of 2.7 years after drilling, and healing of the lesions was confirmed by use of plain radiographs and magnetic resonance imaging.

RESULTS

The mean Lysholm score significantly improved postoperatively (from 72.3 to 95.8). All lesions except 1 healed after retroarticular drilling. Healing was achieved at a mean of 4.4 months on plain radiographs and 7.6 months on magnetic resonance imaging.

CONCLUSIONS

This study shows that retroarticular drilling without bone grafting leads to improved clinical outcomes and high healing rates. We advocate retroarticular drilling for patients with stable juvenile osteochondritis dissecans of the knee whose initial nonoperative treatment has failed.

Bilateral osteochondritis dissecans of the lateral femoral condyle following bilateral total removal of lateral discoid meniscus: a case report

Osteochondritis dissecans (OCD) of the lateral femoral condyle sometimes occurs with a discoid lateral meniscus. Recently, it was reported that OCD of the lateral femoral condyle occurred after total removal of the lateral meniscus. We report the case of a 12-year-old boy with bilateral OCD of the lateral femoral condyle following bilateral total removal for discoid lateral meniscus. Valgus deviation of the knee after total removal and increased sporting activity might have concentrated excessive stress on the lateral condyles in the standing position. As a result, bilateral OCD might have occurred. Drilling of the areas of OCD on the bilateral lateral femoral condyles was done and the patient wore inner wedge arch supports postoperatively. After 2 years, neither knee pain nor arthrosis has occurred so far, but long-term follow-up of this patient is considered to be necessary.

Osteochondritis dissecans of the medial femoral condyle associated with malformation of the menisci

Osteochondritis dissecans is a form of osteochondrosis limited to the articular epiphysis and the relationship of osteochondritis dissecans and discoid lateral meniscus has been clearly identified. This article presents a 10-year-old boy with osteochondritis dissecans of the medial femoral condyle associated with hypoplastic medial and partial deficient lateral menisci. The patient presented with activity-related pain and intermittent swellings of his left knee for 2 months without any evidence of significant knee trauma. Magnetic resonance imaging revealed anomalous medial meniscus mimicking displaced bucket-handle tear and partially deficient lateral meniscus with osteochondritis dissecans at the lateral aspect of medial femoral condyle without any significant bone loss with a non-dislocated fragment. Arthroscopy of the knee revealed an incomplete separated osteochondral flap with partial discontinuity that was unstable on probing on the lateral aspect of the medial femoral condyle. The medial meniscus was hypoplastic without a body and only the meniscal rim could be seen. The lateral meniscus had an anomalous vertical insertion of the posterior horn, normal body, but an absent anterior horn. The anterior cruciate ligament was intact, but looked like a peacock's tail. Arthroscopic fixation of the chondral lesion was performed. At 30-months follow-up, the boy had no limitation in his daily and sports activity. The present case is the first description of congenital anomaly of the both menisci and osteochondritis dissecans together. Meniscal or ligamentous anomalies of the knee may be associated with osteochondritis dissecans.

The discoid meniscus

Discoid lateral meniscus is an intra-articular knee disorder typically presented in the young population and during adolescence. Different types of meniscal disorders and varied forms of presentation have been reported. The natural history depends on the type of anomaly and the presence of symptoms. Management of the disorder should be directed toward the resolution of the symptoms while preserving meniscal tissue and function. Modern surgical techniques enable suturing and preservation of meniscal tissue. The clinical manifestations, diagnostic modalities and criteria, accompanying conditions and practical management considerations are reviewed.

Relationship between osteochondritis dissecans of the lateral femoral condyle and lateral menisci types

The purpose of this study was to examine the relationship between osteochondritis dissecans (OCD) of the lateral femoral condyle and lateral menisci. From 1993 to 2002, 38 knees (28 patients) were diagnosed with OCD of the lateral femoral condyle. OCD locations were graded by the Cahill and Berg classification. The types of lateral menisci were classified by Watanabe's classification. The relationship between OCD of the lateral femoral condyle and lateral menisci was examined. On the anterior-posterior view, 25 OCDs were located in zone 4 and 13 in zone 5. The types of lateral menisci were complete discoid in 19 knees, incomplete discoid in 15, and normal in 4. Ten of the 19 complete discoid menisci were damaged. Complete discoid menisci without tears were found in OCDs located in zone 4; incomplete discoid menisci were found in OCDs located in zone 5. The authors found a relationship between the type of OCD and the state of the lateral meniscus.

An arthroscopic analysis of lateral meniscal variants and a comparison with MRI findings

We reviewed 164 consecutive cases (158 patients) of arthroscopic examinations for lateral meniscal variants during the last 10 years. We classified lateral meniscal variants into four types by arthroscopic appearance, into six tear patterns by modifying O'Connor's classification, and compared magnetic resonance images (MRI) with arthroscopic findings. Regarding the four types, 131 cases were complete, 25 cases were incomplete, 4 cases were Wrisberg, and 4 cases were ring-shaped meniscus. The six tear patterns were as follows: 33 simple horizontal, 21 combined horizontal, 37 longitudinal, 27 central, 14 complex, and 12 radial tear. Among the 31 knees with a central tear or ring-shaped meniscus, we reviewed 25 MR images. Fifteen (60%) MRI findings were interpreted to represent a bucket-handle (displaced) tear of the normal C-shaped meniscus; 7(28%) MRI findings, a discoid meniscal tear; and the remaining 3(12%) MRI findings, a simple meniscal tear. Moreover, all ring-shaped menisci were interpreted as a displaced lateral meniscal tear on the MRI findings. Twelve patients (13 knees, 7.9%) had osteochondritis dissecans: Nine patients (10 knees) of them had a central tear, two patients (2 knees) of them had a simple horizontal tear of the discoid meniscus, and one patient (1 knee) had a ring-shaped meniscus. Twenty three patients (92.6%) with a central tear of the discoid meniscus did not have any traumatic events. For the differential diagnosis of a central tear or a ring-shaped meniscus from a bucket-handle tear of the normal C-shaped meniscus, we should take a careful history, in particular any traumatic events, we should also consider the possibility of misinterpreting the MR images though these images can provide additional information about associated abnormalities and probe carefully in the arthroscopic operations.

Bilateral osteochondritis dissecans of lateral femoral condyle

A 20-year-old male with bilateral osteochondritis dissecans (OD) of the distal lateral femoral condyle is presented. OD can occur in many joints; however, the medial femoral condyle of the knee is the most common. Bilateral OD of the distal lateral femoral condyle is extremely rare. In our case, the lesion on the right side was traumatic and the lesion on the left side was self-induced. We performed open surgery for both knees. The fragments were stabilized with multiple Herbert screws. This case supports the theory that a defect in the ossification center of the distal lateral femoral condyle plays a role in the etiology of osteochondritis dissecans.