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Journal of Clinical Medicine Jan 2024Musculoskeletal disorders, standing as the fifth leading cause of disability-adjusted life years globally, present significant challenges in orthopedics. Osteochondritis... (Review)
Review
Musculoskeletal disorders, standing as the fifth leading cause of disability-adjusted life years globally, present significant challenges in orthopedics. Osteochondritis dissecans (OCD) and avascular necrosis (AVN) are distinct but closely related conditions within this spectrum, impacting patients' quality of life with pain, limited mobility, and dysfunction. OCD, involving cartilage and bone detachment in joints, predominantly affects young athletes, but its exact etiology and optimal management remain subjects of ongoing research. Conversely, AVN, marked by bone tissue death due to compromised blood supply, is linked to systemic factors like corticosteroid use and traumatic injuries. Diagnosis for both conditions relies on radiography and magnetic resonance imaging. Conservative treatment for AVN includes the use of a cane or crutches, pharmacological therapy, or physical therapy. On the other hand, in OCD, the primary approach is activity/sports restriction. Surgical treatment options for AVN patients encompass core decompression, bone grafting, or, in the most advanced cases, total hip arthroplasty. OCD may be surgically treated through subchondral drilling or fixation of unstable lesions. Advanced cases of OCD involve cartilage salvage with resurfacing techniques. The presentation of differences between these conditions enhances our understanding, facilitating improved diagnosis and management strategies.
PubMed: 38202294
DOI: 10.3390/jcm13010287 -
The American Journal of Sports Medicine Feb 2024Open reduction and internal fixation (ORIF) has been widely performed because the osteochondral component of the osteochondritis dissecans (OCD) lesion is the most...
Association of Stability and Size of Unhealed Area With Failure After Internal Fixation for Osteochondritis Dissecans Lesions of the Knee: Radiological Evaluation Using Computed Tomography.
BACKGROUND
Open reduction and internal fixation (ORIF) has been widely performed because the osteochondral component of the osteochondritis dissecans (OCD) lesion is the most suitable for reconstructing the joint structure.
PURPOSE
To evaluate radiological healing in terms of reconstructed bony structure after ORIF with bone graft by computed tomography (CT), to identify preoperative prognostic factors for failure, and to determine the cutoff value of radiological healing for risk of failure.
STUDY DESIGN
Case-control study; Level of evidence, 3.
METHODS
A retrospective cohort study of 42 patients (44 knees) who underwent internal fixation with bone graft for OCD lesions of the knee from 2004 to 2018 was conducted. All patients were evaluated 6 months postoperatively, and if not healed 6 months after surgery, they were evaluated by CT periodically thereafter. Radiological healing was judged according to the following 3 criteria: (1) reossification of the OCD lesion, (2) bony continuity between the OCD lesion and basal floor, and (3) reconstructed bony surface of the femoral condyle reconstructed to match the normal joint. Then, the percentage of the radiological healing area was calculated as the ratio of the healing length to the total lesion length. The nonhealing area was calculated by multiplying the sum of the total nonhealing length. Clinical failure was defined as any definitive reoperation for the same OCD lesion, such as fragment excision, or a cartilage restoration procedure. After 6 months, all eligible patients underwent arthroscopy to check for protrusion of the absorbable pin into the joint; the removal of an absorbable pin protruding into the joint was not considered a failure.
RESULTS
Clinical failure was recorded for 4 cases (9.1%). The mean overall percentage of the radiological healing area of OCD 6 months after ORIF with bone graft was 79.5% ± 24.4%, and the mean overall nonhealing area at 6 months was 87.8 ± 107.9 mm. The percentages of radiological healing area of stable (International Cartilage Regeneration & Joint Preservation Society OCD II) lesions and femoral condylar (lateral femoral condyle + medial femoral condyle) lesions were significantly lower than unstable lesions and femoral groove lesions, respectively ( = .01 and = .03, respectively). On receiver operating characteristic curve analysis, the cutoff points for predicting a significantly increased risk of failure were 33.9% (sensitivity, 100%; specificity, 100%; area under the curve, 1) for the percentage of radiological healing area and 222.9 mm (sensitivity, 95%; specificity, 100%; area under the curve, 0.956) for the nonhealing area 6 months postoperatively.
CONCLUSION
A stable lesion and a femoral condylar lesion were the predictors of poor radiological healing on CT images 6 months after ORIF with bone graft. The risk of failure was increased significantly in cases with only approximately one-third of the lesion healed or in cases with large nonhealing areas at 6 months postoperatively.
Topics: Humans; Osteochondritis Dissecans; Retrospective Studies; Case-Control Studies; Radiography; Knee Joint; Tomography, X-Ray Computed
PubMed: 38197165
DOI: 10.1177/03635465231217252 -
Orthopadie (Heidelberg, Germany) Jan 2024Osteochondritis 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...
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.
Topics: Humans; Male; Child; Adolescent; Young Adult; Adult; Osteochondritis Dissecans; Conservative Treatment; Ankle Joint; Cartilage, Articular; Chondrogenesis; Intra-Articular Fractures; Joint Loose Bodies
PubMed: 38189958
DOI: 10.1007/s00132-023-04461-8 -
Archives of Orthopaedic and Trauma... Mar 2024Osteochondrosis dissecans (OCD) at the capitellum is a common pathology in young patients. Although arthroscopic interventions are commonly used, there is a lack of...
INTRODUCTION
Osteochondrosis dissecans (OCD) at the capitellum is a common pathology in young patients. Although arthroscopic interventions are commonly used, there is a lack of information about the accessibility of the defects during elbow arthroscopy by using standard portals.
MATERIALS AND METHODS
An elbow arthroscopy using the standard portals was performed in seven fresh frozen specimens. At the capitellum, the most posterior and anterior cartilage surface reachable was marked with K-wires. Using a newly described measuring method, we constructed a circular sector around the rotational center of the capitellum. The intersection of K-wire "A" and "B" with the circular sector was marked, and the angles between the K-wires and the Rogers line, alpha angle for K-Wire "A" and beta angle for K-wire "B", and the corridor not accessible during arthroscopy was digitally measured.
RESULTS
On average, we found an alpha angle of 53° and a beta angle of 104°. Leaving a sector of 51° which was not accessible via the standard portals during elbow arthroscopy.
CONCLUSION
Non-accessible capitellar lesions during elbow arthroscopy should be considered preoperatively, and the informed consent discussion should always include the possibility of open procedures or the use of flexible instruments.
Topics: Humans; Arthroscopy; Elbow; Elbow Joint; Osteochondritis Dissecans; Bone Wires
PubMed: 38172435
DOI: 10.1007/s00402-023-05172-7 -
The American Journal of Sports Medicine Jan 2024Osteochondritis dissecans (OCD) of the knee is a rare but potentially incapacitating disorder in which subchondral bone detaches, leading to an osteochondral fragment...
BACKGROUND
Osteochondritis dissecans (OCD) of the knee is a rare but potentially incapacitating disorder in which subchondral bone detaches, leading to an osteochondral fragment that can become unstable and progress into a loose body. The exact cause is unknown, although several biological and mechanical factors have been described.
PURPOSE
To provide insight into epidemiological data of a large cohort of patients affected by OCD of the knee and to identify potential factors contributing to the cause of this disorder.
STUDY DESIGN
Cross-sectional study; Level of evidence, 3.
METHODS
A total of 236 patients (259 knees) affected by OCD were included in our Knee Registry (2005-2022) and retrospectively analyzed. Patient characteristics were extracted from the medical records. Location and International Cartilage Regeneration & Joint Preservation Society grade (1-4) of OCD were assessed using magnetic resonance imaging. If available, a full-leg standing radiograph was used to assess alignment. Additionally, a statistical scoring system for instability risk was created.
RESULTS
A total of 263 OCD lesions were identified in 259 knees, 66.2% on the medial femoral condyle (MFC), 26.6% on the lateral femoral condyle (LFC), 3.8% on the trochlea, 2.7% on the patella, and 0.8% on the lateral tibia plateau. Male patients made up 57.6% of the sample, which had a mean age of 21.8 years. A very high percentage of patients (77.1%; n = 182) practiced sports, of whom 67.6% (n = 123) were engaged in high-impact sports. The location of the OCD lesions and the leg alignment (n = 110) were significantly correlated: MFC lesions were associated with more varus than valgus alignment (47.5% vs 11.3%) and patients with LFC lesions had more valgus than varus alignment (46.7% vs 20.0%; = .002). Based on age, smoking, sports activity, and preceding trauma, a multivariable scoring system (0-11 points) was created. An increased risk of lesion instability was associated with an increased score: 29.0% at 0 points and 97.0% at 11 points.
CONCLUSION
This study provides detailed epidemiological data for 236 patients affected by OCD of the knee. Older age, smoking, inactivity, and preceding trauma were predictive for instability of OCD lesions. There was an association between OCD of the MFC and varus malalignment and between OCD of the LFC and valgus malalignment. This finding, in combination with the high percentage of patients practicing high-impact sports, suggests an important role for mechanical overload in the pathogenesis of OCD.
Topics: Humans; Male; Young Adult; Adult; Osteochondritis Dissecans; Retrospective Studies; Cross-Sectional Studies; Knee Joint; Patella
PubMed: 38164681
DOI: 10.1177/03635465231211497 -
Arthroscopy, Sports Medicine, and... Feb 2024To compare the cost-effectiveness of an initial trial of nonoperative treatment to that of early arthroscopic debridement for stable osteochondritis dissecans (OCD)...
PURPOSE
To compare the cost-effectiveness of an initial trial of nonoperative treatment to that of early arthroscopic debridement for stable osteochondritis dissecans (OCD) lesions of the capitellum.
METHODS
A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 simulated patients undergoing nonoperative management versus early arthroscopic debridement for stable OCD lesions of the capitellum. Health utility values, treatment success rates, and transition probabilities were derived from the published literature. Costs were determined on the basis of the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER).
RESULTS
Mean total costs resulting from nonoperative management and early arthroscopic debridement were $5,330 and $21,672, respectively. On average, early arthroscopic debridement produced an additional 0.64 QALYS, resulting in an ICER of $25,245/QALY, which falls well below the widely accepted $50,000 willingness-to-pay (WTP) threshold. Overall, early arthroscopic debridement was determined to be the preferred cost-effective strategy in 69% of patients included in the microsimulation model.
CONCLUSION
Results of the Monte Carlo microsimulation and probabilistic sensitivity analysis demonstrated early arthroscopic debridement to be a cost-effective treatment strategy for the majority of stable OCD lesions of the capitellum. Although early arthroscopic debridement was associated with higher total costs, the increase in QALYS that resulted from early surgery was enough to justify the cost difference based on an ICER substantially below the $50,000 WTP threshold.
LEVEL OF EVIDENCE
Level III, economic computer simulation model.
PubMed: 38162589
DOI: 10.1016/j.asmr.2023.100836 -
Journal of Pediatric Orthopedics Feb 2024Previous research on patellar and trochlear groove osteochondritis dissecans (OCD) is limited by small sample sizes. This study aims to describe the presentation of...
OBJECTIVE
Previous research on patellar and trochlear groove osteochondritis dissecans (OCD) is limited by small sample sizes. This study aims to describe the presentation of patients with OCD lesions of the patella and trochlea and characterize the outcomes of operative and nonoperative treatments.
METHODS
This retrospective cohort study identified all patients from a single institution from 2008 to 2021 with patellar and/or trochlear OCD lesions. Patients were excluded from the study if surgical records were unavailable or if the patient had knee surgery for a different injury at index surgery or in the 12 months postoperative. Minimum follow-up was 12 months. Outcomes included a return to sports (RTS), pain resolution, radiographic healing, and treatment "success" (defined as full RTS, complete pain resolution, and full healing on imaging).
RESULTS
A total of 68 patients (75 knees) were included-45 (60%) with patellar OCD and 30 (40%) with trochlear. Of the patients, 69% were males. The median age at knee OCD diagnosis was 14 years. At the final follow-up, 62% of knees (n = 44) recovered sufficiently to allow a full RTS and 54% of knees (n = 39) had full pain resolution. Of the 46 knees with radiographic imaging at least 1 year apart, 63% had full healing of the lesion. There was no significant difference in RTS, pain resolution, radiographic healing, or overall success when comparing treatments.
CONCLUSIONS
This study provides valuable epidemiologic demographic and outcome data regarding the scarcely reported patellar and trochlear OCD. While over half of patients fully returned to sports and reported full pain resolution, a large proportion continued to experience symptoms over a year after presentation. Future research should aim to better define the treatment algorithms for these OCD subtypes.
LEVEL OF EVIDENCE
Level III.
Topics: Male; Humans; Adolescent; Female; Osteochondritis Dissecans; Patella; Retrospective Studies; Pain; Knee Joint; Demography
PubMed: 38108383
DOI: 10.1097/BPO.0000000000002588 -
Orthopaedic Surgery Feb 2024Treatment of osteochondral defects (OCDs) of the knee joint remains challenging. The purpose of this study was to evaluate the clinical and radiological results of...
Osteochondral Regeneration in the Knee Joint with Autologous Peripheral Blood Stem Cells plus Hyaluronic Acid after Arthroscopic Subchondral Drilling: Report of Five Cases.
BACKGROUND
Treatment of osteochondral defects (OCDs) of the knee joint remains challenging. The purpose of this study was to evaluate the clinical and radiological results of osteochondral regeneration following intra-articular injections of autologous peripheral blood stem cells (PBSC) plus hyaluronic acid (HA) after arthroscopic subchondral drilling into OCDs of the knee joint.
CASE PRESENTATION
Five patients with OCDs of the knee joint are presented. The etiology includes osteochondritis dissecans, traumatic knee injuries, previously failed cartilage repair procedures involving microfractures and OATS (osteochondral allograft transfer systems). PBSC were harvested 1 week after surgery. Patients received intra-articular injections at week 1, 2, 3, 4, and 5 after surgery. Then at 6 months after surgery, intra-articular injections were administered at a weekly interval for 3 consecutive weeks. These 3 weekly injections were repeated at 12, 18 and 24 months after surgery. Each patient received a total of 17 injections. Subjective International Knee Documentation Committee (IKDC) scores and MRI scans were obtained preoperatively and postoperatively at serial visits. At follow-ups of >5 years, the mean preoperative and postoperative IKDC scores were 47.2 and 80.7 respectively (p = 0.005). IKDC scores for all patients exceeded the minimal clinically important difference values of 8.3, indicating clinical significance. Serial MRI scans charted the repair and regeneration of the OCDs with evidence of bone growth filling-in the base of the defects, followed by reformation of the subchondral bone plate and regeneration of the overlying articular cartilage.
CONCLUSION
These case studies showed that this treatment is able to repair and regenerate both the osseous and articular cartilage components of knee OCDs.
Topics: Humans; Hyaluronic Acid; Tissue Scaffolds; Arthroplasty, Subchondral; Peripheral Blood Stem Cells; Knee Joint; Cartilage, Articular
PubMed: 38087402
DOI: 10.1111/os.13949 -
BMC Pediatrics Dec 2023Hoffa fractures are challenging coronally-oriented articular injuries of the femoral condyle. These fractures are rare in adults and extremely rare in the skeletally... (Review)
Review
INTRODUCTION
Hoffa fractures are challenging coronally-oriented articular injuries of the femoral condyle. These fractures are rare in adults and extremely rare in the skeletally immature, with few cases reported in literature. To prevent mal- or non-union, Hoffa fractures require prompt surgical stabilisation with anatomic reduction and internal fixation.
CASE REPORT
We discuss the case of a lateral distal femoral condyle cartilaginous Hoffa fracture in a ten-year-old male patient. The patient presented after a football non-contact "twist and pop" injury with radiographic imaging described as an osteochondritis dissecans lesion. An MRI was obtained which demonstrated a lateral distal femoral condyle osteochondral fracture. An operative plan was formulated to perform arthroscopic reduction and bio-compression screw fixation to minimize damage to the physis and surrounding tissues. Hyperflexion of the knee allowed for anatomic fracture reduction with the placement of 2 bio-compression screws serving as maintenance of fixation. The patient did well postoperatively and returned to full activity after 6 months.
CONCLUSION
Hoffa fractures in the pediatric population are rare and can occur not only through bone but also through the thick chondral layer in younger patients. These are extremely difficult to diagnose through X-Ray alone. The prompt use of MRI imaging allows for operative fixation in a timely fashion, while an arthroscopic-only approach allows for minimal tissue damage. With an appropriate fracture type, hyper-flexion reduces and stabilizes the fracture, permitting the placement of minimally invasive bio-compression fixation.
Topics: Child; Humans; Male; Femoral Fractures; Femur; Fracture Fixation, Internal; Hoffa Fracture; Radiography
PubMed: 38082258
DOI: 10.1186/s12887-023-04448-6 -
Diagnostics (Basel, Switzerland) Dec 2023On-field screening for 'elbow injury in baseball', a condition commonly seen in youth baseball players, was conducted over two years on 160 elementary school students in...
On-field screening for 'elbow injury in baseball', a condition commonly seen in youth baseball players, was conducted over two years on 160 elementary school students in Ibaraki Prefecture, Japan. This on-field screening was conducted in collaboration with the Ibaraki Prefecture High School Baseball Federation. Pitchers, catchers, symptomatic players, and players who had previously experienced elbow pain were given a comprehensive evaluation that included a physical exam and ultrasound. Out of the 135 students who were successfully screened, 10 were diagnosed with osteochondritis dissecans of the humeral capitellum (OCD). Notably, seven among these were asymptomatic. This assessment identified limited range of motion and pain when extending their elbow as significant risk factors for OCD. An attempt at on-field screening for baseball elbow injuries in collaboration with the local baseball federation was introduced. The risk factors for OCD were identified. Considering these factors, more efficient screening will be possible in the next attempt.
PubMed: 38066830
DOI: 10.3390/diagnostics13233589