A systematic review on the management of idiopathic avascular necrosis of the scaphoid (Preiser's disease)

BACKGROUND

Treatment options for patients with Preiser's disease are challenging and varied. This article thus provides a systematic review of existing studies on the outcomes of the treatments for patients suffering from Preiser's disease in order to investigate the most appropriate management of Preiser's in each stage of the disease.

METHODS

We followed PRISMA guidelines while performing the study, and reviewed 107 papers in all languages from 1981 till November 2020 and included 42 studies that met the eligibility criterion. Studies investigating the outcome of one or more treatment options for Preiser's disease were eligible. Besides, quantitative analysis on 130 individuals (135 wrists) of the included studies was performed.

RESULTS

The results show that in stages II and III, pain score reduces more in surgical approach than in conservative treatment. In stage II of the Preiser's, Vascularized Bone Grafting (VBG) was more effective in pain alleviation and improvement in wrist range of motion (ROM) and Mayo Modified Wrist Score (MMWS) than immobilization. Proximal Row Carpectomy (PRC) in stage III causes more pain relief and ROM improvement than VBG and conservative treatments like prescribing NSAIDs. Inconsistent evidence was found in case studies of stage IV; however, they generally favour PRC and SILASTIC implants. Surgical studies of stage I are not yet enough for making a conclusive assessment.

CONCLUSION

Surgical treatment outcomes seem more satisfactory in all Preiser's disease stages. Specifically, VBG for patients of stage II provided they have no scaphoid degenerative changes, and PRC seems more satisfactory for stage III.

LEVEL OF EVIDENCE

IV; systematic review of case reports and case series on Preiser's disease.

[Juvenile osteochondrosis and osteonecrosis]

BACKGROUND

Juvenile osteonecrosis is an important topic in orthopedics. A wide variety of body regions of the growing patient are affected, predominantly during adolescence. All are characterized by a usually unknown aetiology as well as a stadium-like course. The main problem is a local osseous circulatory disorder, which causes osteonecrosis.

RISK FACTORS

Mechanical overloading due to increased body weight, axial misalignment, and sports activity is discussed as a risk factor. Healing depends on the localization and extent of the osseous necrosis.

DIAGNOSTICS

Diagnostically, radiologic imaging is used, in which the typical bony remodeling can be followed.

THERAPY

The therapeutic procedure depends on the affected region but is usually accompanied by a reduction of mechanical loading. If the clinical and radiological findings worsen, surgical treatment must be considered. The recognition and treatment of juvenile osteonecrosis is important and significantly influences the further development of the patient.

Dual diagnosis of osteogenesis imperfecta (OI) and short stature and advanced bone age with or without early-onset osteoarthritis and/or osteochondritis dissecans (SSOAOD) reveals a cumulative effect on stature caused by mutations in COL1A1 and ACAN genes

Short stature is a feature when a person's height is more than 2 SDS below the corresponding mean height for a given age, gender and population. It can be influenced by many factors essential to growth plate. Here we report a three-generation family with 13 patients affected by osteogenesis imperfecta (OI) type I, short stature and advanced bone age, with or without early-onset osteoarthritis and/or osteochondritis dissecans (SSOAOD) or both. Panel sequencing of the proband revealed mutations in two extracellular matrix related genes: COL1A1 and ACAN. When comparing the quantitative trait, height within the family of different mutation carrier groups, we found an interesting cumulative effect, the ones with both mutations manifest shortest stature. Dual diagnoses of the family also suggest the necessity of a comprehensive molecular diagnosis method, such as panel/exome sequencing, especially encountering patients with novel phenotype or extreme trait.

Osteochondritis Dissecans in the Knee of Skeletally Immature Patients: Rates of Persistent Pain, Osteoarthritis, and Arthroplasty at Mean 14-Years' Follow-Up

OBJECTIVE

Osteochondritis dissecans (OCD) is a knee disorder of predominately pediatric populations. Because of low incidence, it has traditionally been difficult to study OCD. The purpose of this study was to report long-term outcomes of skeletally immature OCD lesions and determine risk factors for persistent knee pain at final follow-up.

DESIGN

A geographic database of more than 500,000 patients was reviewed to identify patients with knee OCD. Clinical course including operative management, persistent knee pain, and total knee arthroplasty (TKA) were analyzed through review of radiographs, magnetic resonance images, and physician notes.

RESULTS

A total of 95 skeletally immature patients (70 male, 25 female, mean age 12.5 ± 2.0 years) were followed for a mean of 14 years (range, 2-40 years). Fifty-three patients were treated operatively and 42 were treated nonoperatively. At final follow-up, 13 patients noted persistent knee pain, 8 treated operatively versus 5 treated nonoperatively. Risk factors for knee pain were female gender, patellar lesions, and unstable lesions. Four patients (8%) treated operatively and 2 patients (5%) treated nonoperatively developed symptomatic osteoarthritis at a mean of 28.6 years following diagnosis. Three patients underwent TKA at a mean age of 52 years, significantly younger than that observed for primary TKA at our institution (P = 0.004).

CONCLUSIONS

Skeletally immature OCD patients have promising histories, with an estimated 14% risk of persistent knee pain, 6% symptomatic osteoarthritis, and 3% conversion to TKA at 14 years' mean follow-up. Females, patellar lesions, and unstable lesions demonstrated increased persistent knee pain risk. Patients with OCD undergo TKA at a significantly younger age than the general population.

Comparison of sonography and MRI in the evaluation of stability of capitellar osteochondritis dissecans

PURPOSE

To compare the diagnostic accuracies of ultrasonography (US) and magnetic resonance imaging (MRI) with intraoperative capitellar osteochondritis dissecans (COCD) fragment stability findings.

METHODS

Patients whose International Cartilage Repair Society (ICRS) osteochondritis dissecans (OCD) classifications were I/II (stable) or III (unstable) were included. Patients underwent preoperative US and MRI. On US, lesions were evaluated as unstable when irregular contours of the chondral surface were observed. On MRI, lesions were evaluated as unstable when articular bone irregularity, a T2 high signal intensity interface, or a high signal intensity line through the articular cartilage was observed. Using the surgical assessment as the gold standard, accuracies of fragment stability diagnoses were calculated for US and MRI.

RESULTS

Thirty-four patients with OCD classifications of I/II (stable) or III (unstable) were included. Twenty-four patients (stable: 12, unstable: 12) underwent preoperative US; 22 (stable: 11, unstable: 11) underwent preoperative MRI. Preoperative US and MRI stability assessments correctly matched intraoperative fragment findings in 23 of 24 patients and 16 of 22 patients, respectively. US criteria in this study achieved superior accuracy compared with MRI criteria (96% vs. 73%; P < .05).

CONCLUSION

US was a useful tool for evaluating fragment instability in COCD.

The clinical and radiological importance of extraarticular contrast material leakage into adjacent synovial compartments on ankle MR arthrography in patients with OCD and anterolateral impingement

PURPOSE

To evaluate the tibiotalar joint capacity and the localisation, frequency and amount of extravasation in patients with extraarticular contrast material leakage into adjacent synovial compartments on ankle magnetic resonance (MR) arthrography.

MATERIALS AND METHODS

Sites of extravasation were determined in the ankle MR arthrograms of 69 patients. Thirty-four patients without extraarticular contrast material leakage into locations unrelated to the injection path were included as a control group. Volumetric measurements of extraarticular contrast material leakage and the tibiotalar joint capacity were performed on a three dimensional (3D) volume measurement workstation.

RESULTS

Extravasation of contrast material occurred through the anterior, posterior, and anterolateral recesses of the tibiotalar joint. The most common site of extravasation was along the flexor hallucis longus tendon synovium (24.6%). The amount of extravasation was significantly higher in patients with ankle osteochondritis dissecans (OCD) than in patients with a different diagnosis (p=0.039). Loose bodies were detected in all OCD's patients with insufficient tibiotalar joint distention.

CONCLUSIONS

Connections between the ankle joint and neighboring synovial compartments can decrease the diagnostic value of ankle MR arthrography examinations due to inadequate joint distention. Large injection volumes should be used for ankle MR arthrography of patients with OCD (especially OCD's patients with loose body) and impingement syndrome.

Mosaicplasty for femoral osteochondritis dissecans

The authors describe a surgical mosaicplasty technique, with an anterior surgical dislocation approach without trochanterotomy, for osteochondritis dissecans of the hip. A graft was taken from the lateral condyle of the knee. Two adolescents underwent this procedure with good results. No osteonecrosis was observed at the longest follow-up. Mosaicplasty is a useful treatment method for small osteochondritis dissecans (<2cm(2)).

Biomechanical considerations in the pathogenesis of osteoarthritis of the elbow

Osteoarthritis is the most common joint disease and a major cause of disability. Distinct biological processes are considered crucial for the development of osteoarthritis and are assumed to act in concert with additional risk factors to induce expression of the disease. In the classical weightbearing joints, one such risk factor is an unfavourable biomechanical environment about the joint. While the elbow has long been considered a non-weightbearing joint, it is now assumed that the tissues of the upper extremity may be stressed to similar levels as those of the lower limb, and that forces across the elbow are in fact very high when the joint is extended from a flexed position. This review examined the available basic science, preclinical and clinical evidence regarding the role of several unfavourable biomechanical conditions about the elbow on the development of osteoarthritis: post-traumatic changes, osteochondritis dissecans, instability or laxity and malalignment. Post-traumatic osteoarthritis following fractures is well recognized, however, the role of overload or repetitive microtrauma as risk factors for post-traumatic osteoarthritis is unclear. The natural course of untreated cartilage defects in general, and osteochondritis dissecans at the elbow in particular, remains incompletely understood to date. However, larger lesions and older age seem to be associated with more symptoms and radiographic changes in the long term. Instability seems to play a role, although the association between instability and osteoarthritis is not yet clearly defined. No data are available on the association of malalignment and osteoarthritis, but based on force estimations across the elbow joint, it seems reasonable to assume an association.

Osteochondritis Dissecans Involving the Trochlear Groove Treated With Retrograde Drilling: A Case Report

Osteochondritis dissecans (OCD) occurs frequently in the humeral capitellum of the upper extremity, whereas OCD involving the trochlear groove (trochlear groove OCD) is rarely reported. A standard treatment for trochlear groove OCD has therefore not been determined, although several methods have been tried.The case of a 14-year-old male gymnast with bilateral trochlear groove OCD is presented. Retrograde drilling from the lateral condyle of the humerus was applied for the OCD lesion of the left elbow, since it was larger in size than that in the right elbow and was symptomatic. Conversely, since the right lesion was small and asymptomatic, it was managed conservatively.After treatment, consolidation of the OCD lesions was observed in both elbows. However, the time to healing was shorter in the left elbow treated surgically than in the right elbow managed conservatively.In conclusion, retrograde drilling is a very simple and minimally invasive treatment. This case suggests that retrograde drilling for trochlear groove OCD may be a useful procedure that may accelerate the healing process for OCD lesions.

Surgical management of osteochondritis dissecans lesions of the patella and trochlea in the pediatric and adolescent population

BACKGROUND

There is a paucity of published data regarding the management of osteochondritis dissecans (OCD) lesions of the patellofemoral joint in children and adolescents.

PURPOSE

To evaluate the functional outcomes of surgical management of OCD lesions of the patella and trochlea in children and adolescents. Secondary aims included elucidating predictors for higher functional outcomes and determining complication rates, surgical satisfaction, and ability to return to sports.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients aged 18 years and younger who were surgically treated for OCD of the patella or trochlea were identified. Charts were queried to record patient/lesion data, surgical procedure, results, and complications. Pre- and postoperative imaging was reviewed. Patients were asked to complete a follow-up athletic questionnaire and a Pediatric International Knee Documentation Committee (Pedi-IKDC) questionnaire. Statistical analysis was conducted to look for predictors for reoperation, residual pain, ability to return to sports, and lower Pedi-IKDC scores.

RESULTS

A total of 26 children (9 females, 17 males, 3 with bilateral lesions; thus, 29 lesions) were identified. The mean age was 14.7 years (range, 9-18, years), 21 of the 29 knees with lesions (72%) had open physes, and median follow-up was 3.8 years (range, 1-9 years). The most common location was the trochlea (17/29 lesions; 59%). Twenty-two lesions (76%) underwent transarticular drilling (n = 14) or drilling with fixation (n = 8), while 7 underwent excision and marrow stimulation. Four patients (14%) required unplanned reoperation. Internal fixation was predictive of reoperation (odds ratio [OR] = 8.7; 95% CI, 2.8-26.9; P = .04). At final follow-up, 14 knees (48%) were pain free, and 14 (48%) had mild residual pain. Female sex was predictive of residual pain (OR, 9; 95% CI, 2-56; P = .02). Twenty-two patients (85%) returned to sports. Longer duration of preoperative pain negatively affected return to sports (OR, 0.32; 95% CI, 0.05-0.97; P = .04). On postoperative MRI, the lesion appeared completely healed in 2 cases (18%) and partially healed in 9 cases (82%). All 15 survey respondents were satisfied with surgery. The mean Pedi-IKDC score was 82.4 ± 17.8 (range, 40.2-100).

CONCLUSION

Surgical treatment of patellofemoral OCD in children and adolescents produces a high rate of satisfaction and return to sports. Female sex, prolonged duration of symptoms, and internal fixation may be associated with worse outcomes.

Osteochondritis dissecans of the lateral tibial condyle associated with agenesis of both cruciate ligaments

Osteochondritis dissecans is a rare cause of painful knees in children. Only 10 cases of lateral tibial condyle involvement have been reported in the literature. Congenital agenesis of both cruciate ligaments has been described even less, and its prevalence is unknown. The authors report an atypical association of osteochondritis dissecans of the tibia with congenital absence of both cruciate ligaments. A 12-year-old male soccer player presented with a painful right knee. Magnetic resonance imaging revealed the diagnosis. The child was treated conservatively. At 18-month follow-up, radiographs showed osseointegration of the osteochondritis dissecans, and the patient had resumed normal athletic activity without pain. To the authors' knowledge, this is the only report describing such an association. The authors discuss the possible etiology of osteochondritis dissecans associated with agenesis of the cruciate ligaments and highlight the possibility of this association when osteochondritis dissecans of the tibia is diagnosed in a child with a painful knee. In this patient, the strain due to anteroposterior instability may have been the cause of osteochondritis. Conservative treatment should be considered in this setting.

Type IX collagen gene mutations can result in multiple epiphyseal dysplasia that is associated with osteochondritis dissecans and a mild myopathy

Multiple epiphyseal dysplasia (MED) is a clinically variable and genetically heterogeneous disease that is characterized by mild short stature and early onset osteoarthritis. Autosomal dominant forms are caused by mutations in the genes that encode type IX collagen, cartilage oligomeric matrix protein, and matrilin-3: COL9A1, COL9A2, COL9A3, COMP, and MATN3, respectively. Splicing mutations have been identified in all three genes encoding type IX collagen and are restricted to specific exons encoding an equivalent region of the COL3 domain in all three alpha(IX) chains. MED has been associated with mild myopathy in some families, in particular one family with a COL9A3 mutation and two families with C-terminal COMP mutations. In this study we have identified COL9A2 mutations in two families with MED that also have osteochondritis dissecans and mild myopathy. This study therefore extends the range of gene-mutations that can cause MED-related myopathy. (c) 2010 Wiley-Liss, Inc.

Lameness and effusion of the tarsocrural joints after arthroscopy of osteochondritis dissecans in horses

The presence and degree of tarsocrural joint effusion and lameness, and the result of a hindlimb flexion test were scored subjectively in 79 horses before, and six weeks to 20 months after, arthroscopic surgery to remove osteochondritis dissecans fragments. The scores of all three variables improved significantly after surgery. The score reductions for the right and left hindlimbs, respectively, were 82 per cent and 95 per cent for lameness, 48 per cent and 41 per cent for joint effusion, and 89 per cent and 84 per cent for reaction to flexion (P < or = 0.01). The oldest horses reacted more favourably to the operation, as measured by the reaction to the flexion test, but age was not significantly related to changes in lameness or joint effusion. There was no significant correlation between the time of follow-up examination and the effect of surgery on lameness and reaction to flexion, but an increased time to follow-up was associated with decreased joint effusion.

Joint mice migration into the deep digital flexor tendon sheath in dogs. Clinical cases and anatomical study

This study describes the appearance of 'joint mice' in the sheath of the deep digital flexor muscle tendon (DDFT) due to osteochondritis dissecans (OCD) lesions in the talocrural joint of 12 dogs. Surgical excision of all free fragments in the DDFT sheath was performed in five dogs, and their clinical progression was documented. The excision of free fragments from the DDFT sheath, but not arthro-tomy, proved clinically beneficial despite the presence of degenerative joint disease. The anatomical communication between the talocrural joint and the DDFT sheath and its dimensions are further illustrated with the use of contrast media and dissection of cadaver limbs.

[Treatment of chondral lesions from knee injuries in the professional soccer players. Review of 34 cases]

OBJECTIVE

Evaluate the results of Pridie chondroplasty as an efficient treatment to recover the complete activity in soccer players and compare this with others chondral repair techniques.

MATERIAL AND METHODS

The patients were professional soccer players, all with a knee cartilage injury treated with the Pridie technique in an arthroscopic surgery between March 1999--December 2004. The age of the patients and the presence of a simple meniscal tear wasn't a fact to exclude a patient. Complex meniscal tear and a ACL rupture were an exclusion criteria. We deferred the support by 6 to 8 weeks. We initiated rehabilitation to the 4-5 post operating day. The follow up average was of 30 months.

RESULTS

We included 34 patients, age rank 19-31 years (average 24.6), 11 of them with meniscal injury Degree I associated with chondral damage. In 26 patients (76.47%) the outcomes were good allowing them to take up again their high level sport activity. The rest (23.53%) had regular or bad results with decrement in the game level, 4 of which (11%) they retired of the professional practice in relation to the found injuries.

CONCLUSIONS

The follow up time give us a good validation to establish that the used technique is a treatment of low cost, surgically simple with favorable outcomes and low morbidity comparable to the results obtained with other useful techniques of condral repair in the professional soccer player.

Radiographic changes and clinical results of osteochondral defects of the talus with and without subchondral cysts

BACKGROUND

Subchondral cysts are a type of osteochondral defect of the talus and can be a source of chronic ankle pain. The treatment modality of this cystic lesion is similar to that of other osteochondral defects, but results from previous reports are controversial. Therefore, we compared the clinical results and radiographic changes in small subchondral talar cystic lesions (less than 1.5 cm2) to other noncystic defects after arthroscopic operations without bone grafting.

METHODS

The review covered about 2 years (January, 2001 to April, 2003) and included 38 patients with an average age of 36.9 years. Followup ranged from 24 to 36 months. Arthroscopic microfracture or abrasion arthroplasty was performed on 20 defects with subchondral cysts and 18 defects without cysts. Clinical results were assessed by the ankle-hindfoot scale of the American Orthopaedic Foot and Ankle Society (AOFAS); radiographic changes were assessed by the transverse long diameter and the area (mm2) of the cyst on digital radiographs using a PACS (Picture Archiving Communication System).

RESULTS

At the last followup, AOFAS clinical scores improved similarly in cystic and noncystic defects. The average diameter of the cysts decreased from 8 +/- 2 mm to 6 +/- 2 mm (p < 0.01). The area attributed to the cyst also decreased, from 49 +/- 17 mm2 (24 to 84 mm2) to 23 +/- 8 mm2 (4 to 34 mm2) (p < 0.01). There were no differences in the clinical results between the cystic and noncystic defects.

CONCLUSIONS

Good clinical and radiographic results were obtained after arthroscopic treatment of osteochondral defects with a small subchondral cyst. Our results suggest that a small cystic lesion can be treated by arthroscopic microfracture or abrasion arthroplasty and that the existence of a small cyst in an osteochondral defect lesion may not affect the postoperative prognosis.

Estimation of genetic parameters for the prevalence of osseous fragments in limb joints of Hanoverian Warmblood horses

Genetic parameters were estimated for the prevalence of osseous fragments in distal (DIJ) and proximal interphalangeal (PIJ), fetlock (FJ) and hock joints (HJ) of Hanoverian Warmblood horses by using residual maximum likelihood (REML) with linear animal models. The analyses were based on the results of 10 standardized radiographs of all four limbs of 3725 young riding horses selected for sale at auction. Transformation factors onto the underlying liability scale were verified by a simulation study. The heritability estimates of osseous fragments on the liability scale were in the range of h2 = 0.19-0.60. Further analyses of osseous fragments in FJ and HJ were performed separately in males and females. In both sexes, the heritabilities of osseous fragments in HJ were higher (h2 = 0.41 in males, h2 = 0.25 in females) than those of osseous fragments in FJ (h2 = 0.21 in males, h2 = 0.23 in females). Osseous fragments in the phalangeal joints (DIJ, PIJ, FJ) were genetically correlated moderately positive (r(g) = 0.19-0.41). The genetic correlations between osseous fragments in the phalangeal joints and in HJ were negative (r(g) = -0.27 to -0.67). Particularly, this applied to osseous fragments in FJ in both sexes, to those in front FJ in males and to osseous fragments in front and hind FJ of females (up to r(g) = -1). The heritability of height at withers was estimated at h2 = 0.27-0.28. Genetic correlations between height at withers and osseous fragments in equine limb joints were mostly moderately positive (up to r(g) = 0.75). We conclude from our results that osseous fragments in phalangeal and hock joints are genetically different traits but sex-specific expression of osseous fragments was unlikely.

Osteosarcoma of the Humeral Head Associated With Osteochondritis Dissecans in a Dog

A 6-year-old, male Labrador retriever was presented for lameness of the right forelimb. The lameness occurred 5 years after the dog was surgically treated for osteochondritis dissecans (OCD) of the caudal right humeral head. Radiographs revealed an expansile, osteolytic lesion occupying the entire caudal half of the right humeral head, and biopsy confirmed the diagnosis of osteosarcoma. Forelimb amputation was performed. Histopathology of the lesion and associated articular cartilage revealed neoplastic osteoblasts extensively infiltrating the marrow space adjacent to scar tissue associated with the previous OCD lesion. This is the first report of an epiphyseal osteosarcoma in the area of a previous OCD lesion in a dog.

Osteochondritis dissecans: Wilson's sign revisited

BACKGROUND

In 1967, Wilson described a clinical sign that he thought was diagnostic of medial femoral osteochondritis dissecans. He postulated that impingement of the tibial eminence on the osteochondritic lesion caused pain and a resultant compensatory lateral rotation during gait. He described reproducing the pain by internally rotating the patient's tibia during knee extension between 90 degrees and 30 degrees of flexion and then relieving that pain by externally rotating the tibia. He correlated healing of the lesion with conversion of the sign from positive to negative.

PURPOSE

To assess the validity of Wilson's assertions.

STUDY DESIGN

Retrospective clinical and radiographic case analysis.

METHODS

Case records from 17 juvenile patients (ages 9 to 12) and 15 adolescent patients (ages 13 to 17) with medial femoral osteochondritis dissecans were reviewed for the presence or absence of Wilson's sign at initial and subsequent visits.

RESULTS

Of the 32 patients, 24 (75%) with radiographically evident osteochondritis dissecans at the initial visit had negative signs. The remaining eight patients with positive signs had conversion of the sign to negative with lesion resolution.

CONCLUSIONS

In this series, Wilson's sign was of minimal clinical diagnostic value. When positive, the sign is useful as a clinical monitor during treatment.

10-Jahres-Ergebnisse knochenmarkstimulierender Therapie der Osteochondrosis dissecans tali

The optimal operative therapy for the treatment of osteochondritis dissecans tali is still controversial. Beside bone marrow-stimulating techniques like abrasion arthroplasty, drilling and microfracturing, new techniques like autologous osteochondral transplantation and autologous chondrocyte transplantation are increasingly used. This study reviewed the clinical, radiological and subjective long-term outcome of bone marrow-stimulating therapy for 45 ankles with an osteochondritis dissecans tali stage 3 or 4 according to the classification by Berndt and Harty. All ankles were treated by the removal of the dissecate and abrasion of the subchondral bone. In 67%, an additional antegrade drilling of the defect was performed. The average maximum size of the lesion was 1.1 cm. At follow-up examination, 10.4 years (7.1-13.5 years) postoperatively, the average AOFAS-score was 91 points (66-100 points). Using the score of Mazur, the outcome of 28 ankles (62%) was rated excellent, 12 ankles (27%) were rated good and five ankles (11%) fair or poor. Progressive osteoarthritic changes, according to the classification of van Dijk, were seen in seven ankles (16%). Reoperations were necessary in eight cases (18%). Obesity, age older than 40 years and preoperative osteoarthritic changes had a significant negative impact on the clinical outcome. Bone marrow stimulating therapy is an inexpensive, low invasive therapy and a good therapeutic option at least for small Berndt/Harty stage 3 and 4 ODT lesions. Autologous chondrocyte transplantation and osteochondral autografts yield encouraging 2- and 4-year results, but still have to prove their superiority in long-term follow-up studies.

Meniscal and articular cartilage injury in the skeletally immature knee

Meniscal and articular cartilage injuries in skeletally immature patients appear to be occurring with increased frequency, particularly in athletically active children. The orthopaedic surgeon should understand the principles of diagnosis and management, as well as be aware of current surgical treatment options available.

Computed tomographic appearance of osteochondritis dissecans-like lesions of the proximal articular surface of the proximal phalanx in a horse

A 6-year-old Thoroughbred gelding presented with a left forelimb lameness. The results of lameness examination, radiography, nuclear scintigraphy, and computed tomography are presented. Based on the diagnostic imaging, subchondral fractures and osteochondritis dissecans lesions of the proximal articular surface of the proximal phalanx were diagnosed. A brief discussion of osteochondritis dissecans is presented.

Observations on the growth of loose bodies in joints

The categorization, origin, natural history, and histopathology of loose bodies in joints are well described in the literature. Clinical and basic science data have indirectly concluded that loose bodies grow over time; however, to date, there is no clearly documented published clinical example. This case report demonstrates the dramatic enlargement of 2 osteochondral loose bodies in a patient's knee over the course of a decade. The loose bodies possess a large number of viable cells; and growth appears to have occurred through encapsulation of the niduses by multiple layers of fibrocartilagenous tissue, thus confirming the findings of earlier studies.

A fresh osteochondral allograft alternative

Fresh osteochondral allografts were used for post-traumatic knee defects >3 cm in diameter and 1 cm in depth. Harvesting of the grafts was carried out within 24 hours of the death of the donor, and implantation into the recipient was carried out within 72 hours. The grafts were unipolar, fixed by screws, and combined with realignment osteotomy if a deformity existed. Meniscal transplantation also was performed if indicated. The survivorship of all grafts (plateaus and condyles) at 7.5 years was 85%. The survivorship of femoral condyle grafts at 10 years was 85%. Viable hyaline cartilage has been confirmed at 17 years.

A 2-staged method for treatment of deep osteochondral lesions of the knee joint

We performed a 2-staged arthroscopic-assisted surgical procedure to treat a patient with a large osteochondral lesion of the knee joint. The osteochondral lesion was too comminuted to reattach; in addition, the underlying bony defect was too deep. In the first stage, autogenous cortical bone was used for grafting the bony defect along with screw fixation. The second stage consisted of screw removal and transplantation of autogenous osteochondral graft overlying the chondral defect. The osteochondral grafts were taken from the non-weight bearing areas of the same knee.

Treatment of type V osteochondral lesions of the talus with ipsilateral knee osteochondral autografts

Treatment of symptomatic large cystic lesions of the talus has had mixed results. A technique of treatment using a cored osteochondral graft taken from the ipsilateral knee is presented. Preliminary results in ten consecutive patients show significant improvement in all patients with an average increase of 27 points in the AOFAS Hindfoot score.

Potential complication of bioabsorbable screw fixation for osteochondritis dissecans of the knee

The 3 cases presented describe loosening or failure of bioabsorbable screws in the treatment of osteochondritis dissecans (OCD). In case 1, a 17-year-old boy with OCD of the medial femoral condyle was treated with bioabsorbable screw fixation. Six months after surgery, the patient had an acute episode of pain with effusion. Arthroscopic examination revealed 2 of the 4 screws backed out, causing cartilage damage to the corresponding tibial plateau. The shafts of the remaining 2 screws had completely absorbed, leaving the unabsorbed screw heads as intra-articular loose bodies in the knee. Unpredictable and inconsistent degradation of the screws is believed to be the mechanism for screw back-out and cartilage damage.

MR appearances of the locked knee

This review illustrates the MR appearances of commonly encountered problems that can present as a "locked knee", as well as several unusual causes. Internal derangement of menisci, particularly bucket handle tears, predominate. Loose bodies as a result of trauma/degeneration and lesions such as cysts of the cruciate ligaments and focal pigmented villonodular synovitis are also illustrated. While meniscal tears are the major cause of "locked knee" in clinical practice, interference with normal knee kinematics is non-specific with regard to the diagnosis. Emphasis is therefore given to less frequently seen abnormalities that lead to a mechanical block of knee extension.

"Dem bones": osteochondral injuries of the knee

MR imaging plays a valuable role in the diagnosis and staging of osteochondral injuries of the femorotibial joint. Bone contusions may be the source of a patient's pain, and MR imaging characteristics of certain types may help to predict which contusions might progress to more serious osteochondral lesions. MR imaging also is vital in the diagnosis of occult osteochondral fractures and in accurately classifying displaced intra-articular fractures. Although osteochondral dissecans usually is diagnosed radiographically, MR imaging is the best noninvasive test for determining if an osteochondral fragment is unstable. Unstable lesions are a treatable cause of knee pain.

Treatment of unstable osteochondritis dissecans lesions of the knee using autogenous osteochondral grafts (mosaicplasty)

Symptomatic osteochondritis dissecans lesions with minimal fragmentation that may be replaced within their crater have classically been treated by reattachment. The choice for internal fixation is varied. This article reports on the treatment of unstable osteochondritis dissecans lesions using autogenous osteochondral plugs as a means of biological internal fixation. The appearance on magnetic resonance imaging of osteochondral plugs at 6 and 9 months after transplantation is also presented.

Congenital conditions that lead to osteoarthritis in the dog

Several congenital arthropathies exist in the canine that can lead to the development of degenerative joint disease. Nevertheless, early diagnosis and treatment generally will afford the patient a favorable prognosis for limb function. There is still a great need to develop controlled studies to evaluate the long-term efficacy of many of the surgical and medical treatment modalities that are currently available and will be made available in the future to treat the patient with a congenital arthropathy.

Osteochondral lesions in the radiocapitellar joint in the skeletally immature: radiographic, MRI, and arthroscopic findings in 13 consecutive cases

Radiography, magnetic resonance imaging (MRI), and arthroscopy were performed in 13 consecutive cases of osteochondral lesions of the radiocapitellar joint in 12 patients aged 11-16 years. Nine patients had a high activity level, and two patients had a significant trauma before the onset of symptoms. Symptoms were limited range of motion, pain, and catchings or lockings. Clinical findings were decreased range of motion and lateral elbow tenderness. Radiography revealed loose body, flattening of the humeral capitellum, or subchondral cysts (or a combination of these) in all cases but three. There was a good correlation between MRI and arthroscopic examination. Nine lesions were located in the humeral capitellum, one lesion in the radial head, and in three cases, lesions were found in both sites. Loose-body removal, shaving, or subchondral drilling (or a combination of these) was performed in 11 cases. All surgically treated patients improved in the short run. Awareness of the typical clinical and radiologic picture will allow identification of the cases suitable for arthroscopy and surgical treatment. In these cases, MRI can be omitted.

Osteochondritis dissecans as a cause of developmental dislocation of the radial head

Osteochondritis dissecans of the capitellum produces an area of focal necrosis that may result in a potentially unstable relationship between the capitellum and the radial head. Seven patients with developmental instability of the radial head secondary to osteochondritis dissecans of the capitellum treated between 1984 and 1995 were studied. All patients were male with an average age of 13 years. The most common symptom was pain with a decrease in range of motion. Patients lacked an average of 24.3 degrees extension. Initial plain radiographs were most helpful for evaluating the relationship of the radial head to the capitellum, and tomography or magnetic resonance imaging were helpful for the detection of loose bodies. The most common direction for instability was posterolateral. Treatment varied from conservative management with nonsteroidal antiinflammatory medication to open reduction and internal fixation of an osteochondral fragment. The average followup was 3.2 years. At latest followup, 11 patients were pain free; however, they lacked an average of 17 degrees extension. Only 2 patients progressed to complete dislocation of the radial head. Developmental instability of the radial head may occur secondary to osteochondritis dissecans of the capitellum. Plain radiographs are sufficient for initial detection and followup. Treatment is determined by the presence of loose bodies and the characteristics of the osteochondral defect. Initial symptoms will resolve; however, lack of extension may persist.

The long-term prognosis for severe damage to weight-bearing cartilage in the knee: a 14-year clinical and radiographic follow-up in 28 young athletes

We examined 28 young athletes with isolated severe chondral damage in the weight-bearing area of the knee joint clinically and radiographically 14 years after arthroscopic diagnosis. Except for Pridie drilling in 3 cases and occasional cartilage shaving or removal of free bodies, no special treatment was given initially. 21 patients were able to return to preinjury team sport activity levels. During the follow-up period, only 3 patients needed repeat surgery with removal of free bodies, and another 2 underwent diagnostic arthroscopy because of persistent pain. At the latest follow-up evaluation, 22 patients had excellent or good knee function. At this time, the patients were mainly involved in individual sports on a physical fitness level. 12 cases had radiographic joint space reduction (< 50%) which was limited to the compartment concerned.

Reassessment of the MR criteria for stability of osteochondritis dissecans in the knee and ankle

OBJECTIVE

T2-weighted MR images has been reported to be an accurate method for assessing osteochondritis dissecans. We reviewed our MR experience to confirm the accuracy of the published criteria of instability. We also assessed the value of each of four MR signs of instability.

DESIGN

We reviewed the original MR interpretations, arthroscopic reports, and MR examinations of 40 patients with osteochondritis dissecans of the talar dome or femoral condyles. Arthroscopy was used as the gold standard for stability. The MR examinations were reviewed retrospectively for a high-signal-intensity line or cystic area beneath the lesion, a high-signal-intensity line through the articular cartilage, or a focal articular defect.

PATIENTS

All patients who had undergone MR imaging for osteochondritis dissecans from 1990 to 1993 were reviewed. Forty patients were identified who had arthroscopy after the MR examination. There were 30 male and 10 female patients with an average age of 25.7 years. Thirty-one lesions were in femoral condyle and nine were in the talar dome.

RESULTS AND CONCLUSIONS

The original MR interpretations correctly identified 35 of the 36 unstable lesions and all 4 stable lesions, giving a sensitivity of 0.97 and specificity of 1.0. There was a 98% agreement between the original and retrospective diagnoses. A high-signal-intensity line was seen beneath 72% of the 36 unstable lesions. The other three signs were noted in 22-31% of the unstable lesions. Fifty-six percent of the unstable lesions showed only one sign of instability. MR imaging is a highly sensitive method for detection of unstable osteochondritis dissecans. The presence of any one sign indicates instability, the most frequent sign being an underlying high-signal-intensity line. Because we examined only four stable lesions, our 95% confidence interval of 0.40-1.0 for a specificity of 1.0 gives only a limited estimate of the specificity of MR.

Arthroscopic osteochondral autograft transplantation in anterior cruciate ligament reconstruction: a preliminary clinical study

The high incidence of chondral defects of the femoral condyles associated with chronic ACL tears is widely recognised. However, treatment is difficult and controversial. This preliminary report presents our experience with arthroscopic osteochondral autograft transplantation in ACL-deficient knees. The series consists of 12 cases of arthroscopic osteochondral autograft transplantation in conjunction with ACL reconstruction using bone-patellar tendon-bone autograft; eight procedures were primary, and four were revisions of failed synthetic grafts. The patients' ages ranged from 22 to 42 years. There were ten male and two female patients. Chondral lesions in this series ranged from 10 to 22 mm in diameter. Donor site was selected prior to notchplasty, and three to five osteochondral cylinders, 5-10 mm in diameter, 10-15 mm long, were harvested. Improved surgical technique, tubular cutting instruments enabling minimal damage to harvested articular cartilage, and press-fit insertion yielded promising uniform results in ten of 12 cases with 2 years' follow-up. This study addresses the important issue of articular cartilage defects in ACL-deficient knees and possible prevention of premature joint degeneration. The aim of arthroscopic osteochondral autograft transplantation is to slow down the development of osteoarthrosis.

Radiology rounds. Osteochondritis dissecans

Images

[Growth plate in primary osteochondritis dissecans of the hip: a prospective study with MRI]

INTRODUCTION

In Perthes' disease, epiphyseal necrosis impairs the function of the growth plate and may result in growth disturbances of the femoral neck. The physeal changes during active disease were prospectively evaluated with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

MRI was performed and radiographs were obtained with six-month intervals from the time of diagnosis up to two years in nine hips (eight patients).

RESULTS

Normal growth plate was seen in MRI as a stripe of low signal intensity between areas of high signal intensity from the epiphysis and the metaphysis. Distortion, widening and partial disappearance of the growth plate were noted in the hips classified into Catterall groups 3 and 4. The physeal distortion was seen as anterior curling, and, in some hips, as a W-shaped abnormality projecting down into the metaphysis. Delayed growth of the femoral neck, due to premature physeal closure, was noted in hips where the physeal deformation involved more than half of the growth plate. All pathological changes appeared on the MRI scans three to fifteen months after the first symptoms. The extent of the MRI changes did not correlate directly with Catterall's plain film staging.

DISCUSSION

The distortion and widening of the growth plate seen in MRI probably reflect histological disarrangement of the physis due to an extensive epiphyseal necrosis. The physeal W-formation in MRI may represent a radiographic "metaphyseal cyst". Disappearance of the growth plate in MRI seems to indicate premature closure of the physis.

CONCLUSION

It seems possible to predict premature closure with MRI even within fifteen months after the onset of Perthes' disease.