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Nammour MA, Mauro CS, Bradley JP, Arner JW. Osteochondritis Dissecans Lesions of the Knee: Evidence-Based Treatment. J Am Acad Orthop Surg 2024; 32:587-596. [PMID: 38295387 DOI: 10.5435/jaaos-d-23-00494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 12/22/2023] [Indexed: 02/02/2024] Open
Abstract
Osteochondritis dissecans (OCD) of the knee is a potentially disabling condition in adolescent and young adults, which is likely multifactorial in origin. In recent years, there have been notable improvements in identification and treatment. Clinical presentation varies based mostly on OCD lesion stability. Patients with stable lesions generally present with vague knee pain and altered gait while mechanical symptoms and effusion are more common with unstable lesions. Lesions most commonly occur on the lateral aspect of the medial femoral condyle in patients aged 10 to 20 years. Magnetic resonance imaging is vital to diagnose and predict clinical treatment, which is largely based on stability of the fragment. Conservative treatment of stable lesions in patients with open physis is recommended with protected weight-bearing and gradual progression of activities over the course of 3 to 6 months. Stable OCD lesions which failed a nonsurgical course can be treated with transarticular or retrograde drilling while unstable lesions usually require fixation, autologous chondrocyte implantation (ACI), osteochondral autograft transfer (OATS), or osteochondral allograft transplantation. This review highlights the most current understanding of knee OCD lesions and treatment options with the goal of optimizing outcomes in this difficult pathology.
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Affiliation(s)
- Michael A Nammour
- From the Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center- Shreveport, Shreveport, LA (Nammour), Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA (Mauro, Bradley and Arner)
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Meta F, Clark SC, Tagliero AJ, Hevesi M, Saris DBF, Krych AJ. Athlete-Specific Considerations of Cartilage Injuries. Sports Med Arthrosc Rev 2024; 32:60-67. [PMID: 38978199 DOI: 10.1097/jsa.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Cartilage injuries can present in a diverse setting of anatomic locations, with varying severity, and can impact athletes of all ages and competition levels. Moreover, the timing of when an injury presents introduces an additional dimension to treatment decision-making. Frequently, the level of competition, in conjunction with career trajectory and short-term and long-term athlete goals, will dictate whether a temporary or definitive treatment strategy is ideal. Although indicating the correct therapeutic regimen may prove challenging, understanding the athlete-specific considerations can be essential to meeting the goals of the athlete and other stakeholders involved in the athlete's career. The purpose of this review is to comprehensively present the deliberations a treating physician must consider in managing cartilage injuries within a spectrum of athletic levels ranging from youth to professional levels, with a secondary focus on the presentation of temporizing treatment strategies and associated outcomes.
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Affiliation(s)
- Fabien Meta
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Sean C Clark
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Adam J Tagliero
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Mario Hevesi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Daniel B F Saris
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
- Department of Orthopedic Surgery, University Medical Center, Utrecht University, The Netherlands
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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De Nordenflycht D, Matus G, Aravena JP, Toloza H. Osteochondritis dissecans of the temporomandibular joint: a scoping review. Oral Maxillofac Surg 2024; 28:29-38. [PMID: 36631710 DOI: 10.1007/s10006-022-01134-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE To perform a scoping review to identify the available evidence regarding osteochondritis dissecans (OCD) of the temporomandibular joint (TMJ). METHODS An electronic search of the PubMed, Web of Science and Scopus databases was performed using the following terms: 'Temporomandibular Joint Disorders', 'Osteochondritis Dissecans', 'Joint Loose Bodies' and 'Temporomandibular Joint'. Full-text articles were obtained from the records after applying the inclusion/exclusion criteria. RESULTS Ten articles were included in the analysis - six case reports, one case series, one retrospective study, one comparative study and one correlational study - with a total of 39 patients. The most frequently reported clinical presentation involved TMJ pain, locked jaw and articular noises (clicking and crepitus). The imaging methods used to identify OCD were radiographs, tomography, arthrography and magnetic resonance imaging. The reported imaging findings varied widely, but the most frequent were (single or multiple) calcified intra-articular loose bodies, signs of degenerative osseous changes, disc displacements, widening of the joint space and alterations in condylar morphology. Seven articles reported treatments (surgical or conservative), but the treatment outcome was not reported in all of the articles, which makes it difficult to make comparisons. CONCLUSION OCD of the TMJ may present various non-specific clinical characteristics, and given the heterogeneous imaging findings, multiplanar images are required for an accurate diagnosis. Finally, the results do not allow recommending a standard treatment for OCD of the TMJ.
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Affiliation(s)
- Diego De Nordenflycht
- Universidad Andres Bello, Faculty of Dentistry, Quillota # 980 Torre E, Viña del Mar, Chile.
| | | | | | - Héctor Toloza
- Universidad Andres Bello, Faculty of Dentistry, Quillota # 980 Torre E, Viña del Mar, Chile
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Korthaus A, Meenen NM, Pagenstert G, Krause M. The "hump" a new arthroscopic phenomenon guiding for reliable therapy of osteochondritis dissecans of variable stability status. Arch Orthop Trauma Surg 2023; 143:1513-1521. [PMID: 35366091 DOI: 10.1007/s00402-022-04409-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/27/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite 150 years of research, there are currently no reliable morphological characteristics that can be used to differentiate between stable and unstable juvenile osteochondritis dissecans (JOCD) lesions in the knee joint. Arthroscopic probing is still the gold standard. In arthroscopic evaluation, a previously undescribed pattern of a cartilaginous convex elevation ("hump") was identified as a new feature and potential sign of JOCD in transition to instability. The aim of the study was to evaluate the clinical outcomes after surgical intervention (drilling) on the "hump". MATERIALS AND METHODS In a retrospective case series of sixteen patients with an arthroscopically detectable "hump", the analysis of clinical function scores (Lysholm, Tegner) and morphological MRI monitoring of radiological healing were performed. The assessment of lesion healing was based on pre- and postoperative MRI examinations. The "hump" was defined as an arthroscopically impressive protrusion of the femoral articular surface with a minimally softened, discolored, but intact cartilage margin that, is not mobile upon in the arthroscopic palpation hook test. The primary therapy of choice was drilling of all "humps". RESULTS The "hump" could be detected arthroscopically in 16 of 59 JOCD lesions. Specific MRI correlations with the "hump" or arthroscopic unstable lesions could not be detected. Not all "humps" showed signs of MRI-based healing after the drilling, and in some a dissection of the osteochondral flap occurred within the first postoperative year. As a result, secondary refixation became necessary. CONCLUSION In the present study, the "hump" was identified as an important differential diagnostic arthroscopic feature of an arthroscopically primarily stable JOCD lesion, potentially placing the lesion at risk of secondary loosening over time. Therefore, drilling alone may not be appropriate in the event of arthroscopic "hump" discovery, but additional fixation may be required to achieve the healing of the lesion. LEVEL OF EVIDENCE III.
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Affiliation(s)
- A Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - N M Meenen
- Pediatric Sports Medicine, Sports Traumatology, Asklepios Clinic St. Georg, Lohmühlenstraße 5, 20099, Hamburg, Germany.
| | - G Pagenstert
- CLARAHOF Clinic of Orthopaedic Surgery, University of Basel, Clarahofweg 19a, 4058, Basel, Switzerland
| | - M Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Chau MM, Tompkins MA. Osteochondritis Dissecans of the Knee in Young Athletes. Clin Sports Med 2022; 41:579-594. [DOI: 10.1016/j.csm.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Baghdadi S, Isaacs D, Chan CT, Wells L, Ganley TJ, Lawrence JTR. Arthroscopic Drilling for Stable Juvenile Osteochondritis Dissecans of the Knee Is Safe and Patients Reliably Return to Daily Activities by 3 Months. Arthrosc Sports Med Rehabil 2022; 4:e645-e651. [PMID: 35494308 PMCID: PMC9042903 DOI: 10.1016/j.asmr.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 12/01/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose To assess the postoperative timeline for the return to activities of daily living (ADLs) in pediatric patients after arthroscopic drilling of a stable osteochondritis dissecans (OCD) lesion of the knee and to determine the rate of and risk factors for complications after the procedure. Methods In a retrospective chart review, data from all patients aged 18 years or younger who underwent arthroscopic drilling for a stable OCD lesion of either femoral condyle from May 2009 through July 2017 were collected. Demographic data, lesion characteristics, operative data, postoperative course, radiographic outcomes, and complications were recorded. Statistical analysis was performed to determine the risk factors for reoperations. Results A total of 139 knees in 131 patients were evaluated, with a mean age of 12.7 years, of which 102 (73%) were male knees. The average follow-up period was 17.8 ± 13.2 months after surgery. All patients regained full extension and flexion within 5° of the contralateral knee at a mean of 12.9 ± 3.2 weeks postoperatively, with 95% having returned fully to ADLs by the 3-month postoperative visit. No cases of infection, stiffness, arthrofibrosis, or other procedure-related complications were recorded. A total of 133 knees (95.7%) showed healing on radiographs, whereas 6 knees (4.3%) underwent additional surgical procedures, all of which were performed for treatment failure related to nonhealing lesions (including loose body removal, chondroplasty, and repeated drilling). Lesion size was the only significant risk factor for reoperation (P = .02). Conclusions Our findings suggest that arthroscopic drilling for stable, intact OCD lesions in the pediatric knee is a safe procedure with reliable outcomes and return to ADLs and a minimal risk of complications. Most patients return to their preoperative daily activity level with a full range of motion of the knee by 3 months after surgery. Complications, including reoperations, are related to the progression of the OCD lesion rather than to the surgical procedure. Each 1-cm2 increase in lesion size increases the likelihood of reoperation by 2.93 times. Level of Evidence Level IV, therapeutic case series.
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Affiliation(s)
| | | | | | | | | | - J. Todd R. Lawrence
- Address correspondence to J. Todd R. Lawrence, M.D., Ph.D., Department of Orthopaedic Surgery, Division of Orthopedics, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Second Floor, Wood Bldg, Philadelphia, PA 19104, U.S.A.
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Effect of Activated Platelet-Rich Plasma on Chondrogenic Differentiation of Rabbit Bone Marrow-Derived Mesenchymal Stem Cells. Stem Cells Int 2021; 2021:9947187. [PMID: 34484349 PMCID: PMC8413060 DOI: 10.1155/2021/9947187] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/07/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022] Open
Abstract
We aimed to evaluate the effect of activated platelet-rich plasma (PRP) on proliferation and chondrogenic differentiation of bone marrow-derived mesenchymal stem cells (BMSCs). Six mature male rabbits were included in this study. PRP was obtained by two-step centrifugation from whole blood, and it was activated using CaCl2 solution. BMSCs were isolated and proliferated from bone marrow of rabbits and characterized by flow cytometry. Passage 3 BMSCs were cultured in high-glucose Dulbecco's modified Eagle's medium (HG-DMEM) with the four different compositions for consecutive 7 days, including 10% fetal bovine serum, 5% PRP, 10% PRP, and 15% PRP. Cell counting assays were performed to evaluate the cell proliferation of BMSCs. BMSCs (5 × 105 cells/well in 6-well plates) were induced in four conditions for 21 days to chondrogenic differentiation evaluation, including commercial chondrogenic medium (control), 5% PRP (HG-DMEM+5% PRP), 10% PRP (HG-DMEM+10% PRP), and 15% PRP (HG-DMEM+15% PRP). The gene expression levels of ACAN, COL2A1, and SOX9 in pellets were detected. Morphological and pathological assessments were performed by the blind observer. After purifying, the percentages of cells with CD105(+)/CD34(-) and CD44(+)/CD45(-) were 96.5% and 92.9%, respectively. The proliferation of BMSCs was enhanced in all groups, and 10% PRP revealed more significant outcome than the others from day 5. The levels of ACAN, COL2A1, and SOX9 were lower in the three PRP groups than control group, but the levels of ACAN and SOX9 were higher in 10% PRP group than 5% and 15% PRP groups. Histological examinations showed that 10% PRP-treated pellets had more regular appearance, larger size, and abundant extracellular matrix than 5% or 10% PRP groups, but still inferior to commercial chondrogenic medium. In conclusion, our results show that PRP may enhance the proliferation of rabbit BMSCs. However, PRP have limited effect on chondrogenic differentiation in comparison with commercial chondrogenic medium in pellets culture.
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Chau MM, Klimstra MA, Wise KL, Ellermann JM, Tóth F, Carlson CS, Nelson BJ, Tompkins MA. Osteochondritis Dissecans: Current Understanding of Epidemiology, Etiology, Management, and Outcomes. J Bone Joint Surg Am 2021; 103:1132-1151. [PMID: 34109940 PMCID: PMC8272630 DOI: 10.2106/jbjs.20.01399] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ 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.
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Affiliation(s)
- Michael M Chau
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Mikhail A Klimstra
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Kelsey L Wise
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Jutta M Ellermann
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, Minnesota
| | - Ferenc Tóth
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, Minnesota
| | - Cathy S Carlson
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, Minnesota
| | - Bradley J Nelson
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
- TRIA Orthopedic Center, Bloomington, Minnesota
| | - Marc A Tompkins
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
- TRIA Orthopedic Center, Bloomington, Minnesota
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Osteochondritis dissecans of the glenoid: an analysis of grades, treatment, and outcomes. JSES Int 2021; 5:745-753. [PMID: 34223425 PMCID: PMC8246000 DOI: 10.1016/j.jseint.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Osteochondritis dissecans (OCD) is an idiopathic disorder of subchondral bone that causes focal articular cartilage disruption with the potential long-term consequence of premature osteoarthritis. Glenoid OCD is exceedingly rare. This case series aims to identify the grades of glenoid OCD and report its grade-specific treatment with clinical, radiological, and functional outcomes. Methods Prospectively collected data of consecutive patients diagnosed with a symptomatic glenoid OCD, who had a minimum 2-year follow-up, following nonoperative or surgical treatment, was retrospectively analyzed. Osteochondral defects secondary to acute trauma, instability, and primary osteoarthritis were excluded. Pretreatment and posttreatment clinical, radiological, and sports participation data were collected. This included pretreatment MRI for grading of glenoid OCD according to the International Cartilage Research Society (ICRS) OCD staging system, and postoperative MRI for grading of articular cartilage repair using the MOCART (MRI observation of cartilage repair tissue) scoring system. Results The study identified 7 competitive overhead athletes with symptomatic unilateral glenoid OCD, with a post-treatment minimum 2-year follow-up. Of 4 patients with ICRS OCD I, 3 healed with nonoperative treatment, whereas 1 progressed to ICRS OCD II. This patient along with another 3 patients with unstable glenoid OCD underwent arthroscopic OCD excision with bone marrow stimulation cartilage repair. All patients improved following treatment and had full passive and active range of shoulder movements, with normal strength and stability at the 2- year follow-up. The mean MOCART score on MRI at 2 years for the 4 patients who underwent surgery was 82.5 (range, 75-90). MRI documented healing in all 3 patients with ICRS OCD I who underwent nonoperative treatment. All patients returned to the same or higher level of sport following treatment, with mean time to return to sports being 8.0 months (range, 6-11 months) for nonoperative treatment, and 6.8 months (range, 5-10 months) for operative treatment. This difference was not statistically significant (P value .55). No patient had recurrence of symptoms till latest follow-up. Conclusion Despite the glenoid being a concave non–weight-bearing articular surface, OCD at this site has pathological grades similar to other convex weight-bearing articular surfaces. Notwithstanding the limited number of cases, it would appear that ICRS OCD I can often be successfully treated with nonoperative treatment, whereas ICRS OCD II, III, IV, warrant operative treatment. Bone marrow stimulation is a safe and predictable option for glenoid OCD cartilage repair and allows athletes a quick and successful return to sports.
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Abstract
Bone marrow edema (BME) is a descriptive term used to describe high-signal intensity changes detected on magnetic resonance fluid-sensitive sequences that could be attributed to a number of underlying pathologies. Regardless of the cause, physiologic remodeling of the subchondral bone can be limited because of ongoing joint forces, increased focalization of stress, and reduced healing capacity of the subchondral bone. BME is a known prognostic factor associated with pain, dysfunction, and progressive cartilage damage. This review summarizes the current known causes of BMEs, theories related to histopathological changes, and current treatment options including novel biologic surgical options.
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Contact force between the tibial spine and medial femoral condyle: A biomechanical study. Clin Biomech (Bristol, Avon) 2018; 60:9-12. [PMID: 30292063 DOI: 10.1016/j.clinbiomech.2018.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 07/31/2018] [Accepted: 09/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Contact between the tibial spine and medial femoral condyle with internal tibial rotation (ITR) has been proposed as a factor for the development of osteochondritis dissecans lesions. We hypothesized that tibial spine contact force (CF) would increase significantly with applied internal tibial torque (IT). METHODS A 20 mm diameter cylinder of bone encompassing the tibial spine was cored and attached to a load cell. The isolated bone cylinder included the tibial attachments of the anterior cruciate ligament (ACL) and anterior horn of the lateral meniscus (AHLM). Eleven human cadaveric knees were flexed from 0°-50° under 200 N of tibiofemoral compression (TFC), without and with 2 N-m IT. Tests were repeated with the AHLM cut, and again with both AHLM and ACL cut, where the load cell recorded CF alone without contributions from any ligamentous attachments. FINDINGS There were no significant differences in CF, ITR, or valgus tibial rotation (VTR) after sectioning the AHLM, without or with applied IT. With no tibial torque, mean CFs were less than 20 N throughout the flexion range. Addition of IT significantly increased 1) mean CF by 44.4 N(SD 15.8 N) at 0°(+240%) and 27.2 N(SD 5.0 N) at 20°(+675%), 2), mean ITR by 10.2°(SD 0.8°) at 0° flexion and 18.6°(SD 2.0°) at 20° flexion, and 3) mean VTR by 1.3°(SD 0.4°) at 0° flexion and 4.4°(SD 0.8°) at 20° flexion. INTERPRETATION Our hypothesis was confirmed only between 0° and 20° of knee flexion, where the intercondylar separation distance is relatively small and the possibility of tibial spine contact with ITR is greater.
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