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Ebook Pediatric and adolescent knee surgery: Part 2

SECTION

3

OsteochondritisDissecans




CHAPTER
EricW.Edmonds
HenryG.Chambers



21

OsteochondritisDissecans:Overview,
Epidemiology,Etiology,
Classification,Assessment
INTRODUCTION

AlthoughloosebodieswithinajointwerefirstdescribedbyPaget,1Königlater
suggestedthreemethodsbywhichloosebodiescouldbecreated:(1)direct
traumawithacutefracture,(2)minimaltraumathatdevelopsintoosteonecrosis
andsubsequentfragmentation,or(3)notraumawithspontaneousfragmentation.
Thelattervarietyhecoinedosteochondritisdissecans(OCD).2,3Althoughit
shouldbepointedoutthattheexactpathophysiologyremainsunknown,itis
agreedthatOCDislikelyanacquiredlesionofsubchondralbone.
Beyondthischaracterization,itislessclear.Therearedegreesofosseous
resorption,collapse,andsequestrumformationwithpossibleinvolvementofthe
articularcartilagethroughdelaminationunrelatedtoanacuteosteochondral
fractureofnormalcartilage(Fig.21.1).4,5Thisunderstandingoftheendpointof
thediseaseprocesshasledtomanyetiologiesofOCDbeingpostulated
(particularlyconcerningtheknee)includingtrauma,6,7inflammation,2,8
genetics,9vascularabnormalities,10,11andconstitutionalfactors.12However,the
etiologyremainsunknown,eventhoughourveterinarymedicinecolleagueshave
madesomeleapsinunderstandingoverrecentyears.13,14


Historically,therehasbeenadistinctionbetweenjuvenile-onsetOCDand
adult-onsetOCD.Manysurgeonshavesuggestedthatskeletallyimmature
patients(juvenileonset)haveabetterprognosisthathasbeeninconsistently
definedintheliteratureaseitherradiographichealingormerelyresolutionof
pain.4,5,9,11,12,15Despitethelackofanopenphysisatthetimeofdiagnosisinan
adultOCD,however,manyauthorssuggestthattheonlytruedifferencebetween
juvenile-andadult-onsetOCDispurelyareflectionofpatientageatthetimeof
diagnosis.
ArecentdefinitionofhumanOCDlesions,proposedbytheResearchin
OsteochondritisoftheKnee(ROCK)studygroup,highlightsthefactthatthese
are(1)focal,(2)idiopathic,(3)involvesubchondralbone,and(4)riskinstability
anddisruptionofarticularcartilagewithpotentiallong-termconsequences,such


asprematureosteoarthritis.16Thisdefinitionisthesummaryofepidemiology,
etiology,classification,andassessmentofOCD.

EPIDEMIOLOGY
ThereareonlythreetrueepidemiologypapersregardingkneeOCD.10,17,18The
firstwasperformedbyMarsdenandWiernik18inareviewof18,405radiographs
atamilitaryhospital.TheyfoundanincidenceofsymptomaticOCDof2.3%of
theradiographsandanoverallincidence(includingincidentaldiscovery)of4%


OCDintheircohort.
AclassicstudybyLinden10in1977fromMalmo,Swedendemonstratedan
incidenceof29per100,000boysand19per100,000girls.Moreimportantly,
afterhereviewedradiographsandobtainedfollow-upwithmanyofthese
patients33yearslater,hediscoveredthattherewasan“accumulatedriskof
roentgenographicgonarthrosisinpatientswhohavehadosteochondritis
dissecans.”Ifheassumedtheriskofarthritistobe0%atthestartoflife,this
wasunchangedatage40yearswithanOCD;buttheriskincreasedto70%at
age48yearsandcontinuedtoincreaseto95%at70yearsofage.However,in
thoseinitiallydiscoveredwithjuvenile-onsetOCD,hecouldnotdirectly
correlateanypathologysuchasgonarthritiswiththeirOCDdirectly.
Theonlyotherstudywaspublishedin2014andincludedareviewofjustover
1millionchildrenaged2to19yearswithinaclosedhealthsystem.17These
authorsfound192childrenwith206OCDlesionsoftheknee.Themajority
(64%)ofthelesionsinvolvedthemedialfemoralcondyle,andtheoverall
incidenceseeninthecohortwas18.1per100,000boysand3.9per100,000
girls.TheincidenceofkneeOCDvariedbyethnicity:non-Hispanicwhitewas
10.3per100,000overall(17.3and3.0per100,000forboysandgirls,
respectively),non-Hispanicblackwas10.3per100,000overall(17.3and3.0per
100,000forboysandgirls,respectively),Hispanicwas8.6per100,000overall
(14.3and2.8per100,000forboysandgirls,respectively),andAsianwas4.7
per100,000overall(9.1and0.0per100,000forboysandgirls,respectively).
Theseauthorsperformedmultivariablelogisticregressionanalysisthatrevealed
a3.3-foldincreasedriskofOCDofthekneeinchildrenaged12to19years
comparedwiththoseaged6to11years.Moreover,boyshad3.8timesgreater
riskofOCDthangirls.


Finally,thereisthediscretepossibilitythatkneeOCDmayoccurinboth
knees.Intheliterature,thereisarelativelywiderangeofbilateralitynotedwith
abouta3%to30%chanceofdiscoveringitinbothkneesbyx-ray.5,18–23

ETIOLOGY
NodefinitiveetiologyhasyetbeendeterminedfortheoriginofkneeOCD.
Thereare,ofcourse,manyhypothesesthathavebeenpresentedandtested
primarilyviaexvivohistology.Thepotentialetiologiesincludeinflammation,
spontaneousosteonecrosisandvasculardeficiency,geneticpredisposition,and
repetitivetrauma.Eachofthesewillbediscussed.
Assuggestedbythename“osteochondritis,”thefirstdescriptionin1888by
König,2bydefinitionwasatraumaticanditwaspostulatedtobearesultof
inflammation.However,histologicstudieshavenotsupportedthisetiology7,24;
instead,theseworksappeartohighlightfindingsofnecrosiswithintheOCD
lesionsratherthaninflammation.
Basedontheirhistologyfindings,GreenandBanks12,19proposedthat
ischemiawastheprimaryetiology,andMilgram,22identifyingrevascularization
inpartiallydetachedOCDlesion,furtherpromotedthisconceptofpoor
vascularity.Yet,Yonetaniandcolleagues25foundnoevidenceofnecrosison
biopsies.Uozumiandcolleagues26discoveredadiscreteabsenceofsubchondral
boneinmanyoftheirbiopsysamplesand,inthosewhohadanosseous
componentpresent,onlytwodemonstratednoviableosteocytes.Thedifference
betweenthefirsttwostudiesandthesecondtwoisstateoftheOCDlesionprior
tobiopsy.Whenthelesionwasunstable(orevenaloosebody)atthetimeof
biopsy,thennecrosiswasfoundbymicroscopicevaluation.However,ifthe
lesionwasfullyintactandinsitu,thentherewaslessdefinitiveevidencefor
avascularnecrosis.
AnotherhypothesisoftheetiologyisfamilialinheritanceofOCDlesions.A
mildformofskeletaldysplasiawithassociatedshortstaturehasevenbeen
proposed.9,23,27–29Twodifferentauthors,viadifferentfamilytreeassessments,
haveidentifiedwhattheybelievetobeanautosomaldominantinheritance
pattern.9,28Incontrast,Petrie30reportedonaradiographicexaminationoffirstdegreerelativesofthosepatientswithknownOCDanddiscoveredonly1.2%


withOCDthemselves.ThissuggeststhatthemajorityofkneeOCDdoesnot
followapredictableinheritancepattern.However,itdoesnotexcludethe
possibilitythatgeneticsmaystillplayaroleinOCDetiology.
Whethertheaforementionedetiologiesareprimaryorsecondaryremainsa
questionuntoitself,andtheconceptofrepetitivemicrotraumaisanotherdistinct
possibility.Forexample,despitetheoriginaldescriptionbyKönig,therecould
beasignificanttraumaticeventleadingtoavascularnecrosisortherecouldbe
repetitivetraumaticeventsthatprogressivelydevelopvasculardisruption.In
1933,Fairbanks31proposedtraumaticcontactbetweenthelateralaspectofthe
medialfemoralcondyleandthetibialspine;yet,thistheorywouldonlyexplain
OCDlesionsonthelateralaspectofthemedialfemoralcondyle.However,the
ideaofrepetitivetraumastillholdsourattentionfortheotherlocationsofOCD
aswell.Aichroth6demonstratedthat60%ofthepatientswithkneeOCDinhis
cohortwereinvolvedinhigh-level,competitivesports.Moreover,Linden11
showedanassociationbetweentheincidenceofOCDandtheincreased
involvementinorganizedsportsinSwedenbetween1965and1974.Alarge
multicenterstudyconductedbytheEuropeanPediatricOrthopaedicSociety
demonstratedthatnearly55%ofthosewithOCDwereregularlyactiveinsports
orperformed“strenuousathleticactivity.”20Evidencetosupportrepetitive
traumaasanetiologyforOCDismostlyconjectureandcircumstantialatbest.
Perhapsabnormalpressureonthecartilageanlageisabetterwayof
describing“microtrauma,”asseveralstudieshavenotedassociationsbetween
lateralfemoralcondyleOCDlesionsanddiscoidmenisci.32–34Moreover,there
isanapparentassociationwithpoormechanicalaxisalignmentandthepresence
ofkneeOCD.35Infact,theassociationbetweenalignmentshiftsandlocationof
OCDdevelopmentwaspredictive,withvarusmalalignmentpredictingmedial
OCDlesionsandvalgusmalalignmentpredictinglateralOCDlesions.35These
findingssuggestthataberrantmechanicalpressureonthecondylesmaybean
etiologytotheformationofOCD(atleastintheknee).
Perhapstheunifyingtheorycanbefoundintheworkbyourveterinary
colleaguesonhorseandpigcomparativemodels.TheybelievethattheOCD
lesionsintheseanimalsoriginatewithinthecartilageanlageofthesubchondral
bone.13,14TheyhaveactuallybeenabletocreateananimalmodelforOCDby
descriptionofthecartilagecanals(whichisthebloodsupplytotheepiphyseal


anlagecartilage).Thisfurtherhintstowardapossibletraumaticinjurythat
disruptsthebloodsupply.Theyalsosuggestmodifyingthetermosteochondritis
toosteochondrosisgiventhecompletelackofinflammationbeingseenasa
possibleetiology.Furthermore,theywouldincludethemodifier“dissecans”
whenthearticularcartilagebecomesinvolvedbutrecommendusingtheterms
latenswhenthereisonlynecrosisoftheanlagecartilageormanifestainthe
presenceoffocalfailureofenchondralossificationtodifferentiatethetimingof
discovery.Inotherwords,theseauthorsbelievethatbythetimethispathologic
processbecomesclinicallyevidentintheknee,ithasalreadyevolvedthroughall
threestagesandisinthefinalnecroticformofOCD(Fig.21.2).

Thisconceptisnotnewtohumanphysicians,buttheconceptofdisrupted
cartilagecanalsisnoveltotheprevioushypothesisofRibbing36in1937.His
thesiswaspresentedina107-pagesupplementtothejournalActaRadiologica
discussingabnormalitiesofendochondralossificationoftheepiphysis.His
hypothesiswasthenfurthermodifiedbyBarrie7,24tofurtherdefinepossible
etiologiesofOCDformationviaepiphysealsecondarygrowth.Basically,atan
indexevent,thereisaninsult(singleorrepetitive)totheendochondral
epiphysealgrowthplateorperhapstothecartilagecanalsjustdeepto
subchondralbone.Withskeletaldevelopment,theuninjuredregionof
endochondralepiphysealossificationcontinuestoossifyunhindered,creatingan


everenlargingOCDcentraltothenormalgrowth.
Althoughtheconceptsofdisruptedcartilagecanalsorendochondral
epiphysealgrowthplatesareappealingetiologies,thereremainsagapinthe
explanationregardinghowandwhythesestructuresbecomeinjuredinthefirst
place.Allchildrenarequiteactive,jumping,playing,running,andfalling.So
whydosomedevelopanOCDandsomedonotdevelopanOCD?Thisquestion
isyettobeanswered.

CLASSIFICATION
ThesimplestformofkneeOCDclassificationisthatsetforthbyHeftiand
colleagues20thatmerelydescribeslocationoftheOCD.Themostcommonsite
ofOCDisthelateralaspectofthemedialfemoralcondyle(51%involvement),
withothersitesbeinginvolvedwithlessfrequency:19%centralmedialfemoral
condyle,17%lateralfemoralcondyle,7%medialsideofthemedialfemoral
condyle,and7%patella.Itmaybeimportanttonotethatirregularossification
centersofthedistalfemoralcondyletendtobefoundmoreposteriorlyonthe
condyle(althoughtheycanbeanywhereonthecondyle)andareassociatedwith
youngerage.Cahill12wroteareviewofOCDandidentifiedmultipleother
authorswhohavesimilarlyclassifiedkneeOCDbylocation,buthemakesno
mentionofclassifyingthelesionsinanyothermethod(stability,outcomes,etc.).
DeSmetandcolleagues37tookthingstothenextlevelandclassifiedtheOCD
eitherstableorunstableandcorrelatedtheirmagneticresonanceimaging(MRI)
findingswitharthroscopicfindings.Theyreportedthatahighsignalinterface
betweentheOCDlesionandthenormalfemoralbonewasindicativeof
instabilitybyarthroscopy.Thissameauthorthenlaterimprovedhisassessment
byMRIandaddedthreeothersignsofinstabilitythatarediscussedinthe
followingtext(Fig.21.3).38


ThearthroscopicclassificationofOCDlesionsisthegoldstandardin
understandingthelesion,yetevenhere,wedonothaveassociatedoutcomes.
Guhl39wasthefirsttosetanarthroscopyclassificationandithasbeenusedasa
templateforotherauthors:(1)intactlesions,(2)lesionsshowingsignsofearly
separation,(3)partiallydetachedlesions,and(4)craterwithloosebodies
(salvageableorunsalvageable)(Fig.21.4).Tothispoint,nocorrelationwith
outcomeshasbeenmade.

ASSESSMENT
Mostauthors20,40suggestthattreatmentforkneeOCDshouldbebasedon


skeletalmaturityandlesionstability.Anumberofclassificationsystems
mentionedearlierincludesthesetwoprinciples.12,37–39Therefore,itisimportant
toidentifyOCD,identifyskeletalmaturity,andidentifyOCDstability.
ChildrenwithOCDmayhavetwodifferentpresentations,eithertheOCDis
anincidentalradiographicfindingsoritmaybethoughttobethecauseoftheir
symptoms.41,42CahillandAhten43reportedthat80%ofthechildrenhadmild
painandlimpforameanof14monthspriortopresentation—suggestingthatthe
symptomsassociatedwithkneeOCDmaynotdiffergreatlyfromidiopathic
adolescentkneepain.However,theremaybesubstantialsymptomsassociated
withtheOCDlesion,suchasmechanicalsymptomsoflockingandpopping.
Effusionispresentinlessthan20%atpresentation.20Wilson53describedatest
onphysicalexaminationtodiagnoseOCD:Thekneeisflexedto90degrees,the
tibiaisexternallyrotated,andthekneeisgraduallyextendedto30degreesof
flexion.Apositivetestischaracterizedbypainovertheanteromedialaspectof
thekneeasthekneeisextendedto30degreeswithreliefofpainwithinternal
rotationofthetibia.Anatomically,thismaneuverisbelievedtocause
impingementofthetibialspineonthelateralaspectofthemedialfemoral
condyle(andthereforewouldonlybepositiveonthoseparticularOCDlesions).
TheWilsontestisoflimiteddiagnosticvaluewithareportedpositivetestin
only16%ofkneeswithradiographicallyprovenOCDlesions.20
ThediagnosisofOCDistrulydependentonimagingratherthanhistoryor
physicalexamination.EspeciallyconsideringthatmanyOCDlesionsmaybe
asymptomaticuntilseparationordislodgmentoccursresultinginsignificant
effusionandpain—thisisconsideredalatefindinginthetreatmentofthese
lesions.Mostlesionscanbeidentifiedbyplainradiographsandwillusuallynot
bemissedaslongasfourviewsareobtained,includinganteroposterior(AP),
lateral,tunnel(notch),andMerchant(sunrise)views.Todate,thereisno
historicalliteratureassessingthesensitivityorspecificityofradiographsto
identifyOCDlesions,andtheAmericanAcademyofOrthopaedicSurgeons
(AAOS)clinicalpathwayguidelinetaskforcerecommendedthattherewasonly
limitedevidencetosupportobtaininginitialplainradiographsintheassessment
ofkneeOCD(andinconclusiveevidencetoobtaincontralateralfilmsatinitial
evaluation).40IntheassessmentofchildrenwithanOCDlesion,itappearstobe
clinicallyacceptabletoobtaincontralateralfilmstoevaluateforbilateral


involvement,giventhehighrateofbilateralinvolvementseeninpast
studies.45,46
Often,MRIisthenextstepintheassessmentoftheOCD,lookingfor
instabilityofthelesionaswellasbetterdefiningthesizeandextentofthe
pathologicchanges.MRIcanalsobehelpfulindistinguishingirregularcenters
ofossificationfromOCD,andsomeauthorshavesuggestedthattheimproved
outcomesseeninjuvenileOCDmayberelatedtoanincorrectdiagnosisof
OCD.However,onceagain,theAAOSclinicalguidelinestaskforcefound
limitedevidenceforobtaininginitialMRIforevaluationandinconclusive
evidenceforusingMRIinsubsequentfollow-upevaluation.40MRI
characteristicsconsistentwithirregularossificationincludeslowsignalintensity
ofthelesionbonebeingsimilartothesurroundingsubchondralboneandhigh
signaldemarcationbeingequaltothesurroundingarticularcartilage.48The
characteristicsofOCDarevaried,butthereareafewfindingstonote:Thereis
oftensurroundingbonemarrowedema,thereisascleroticrimofbone
demarcatingthelesion±highsignalintensitylayerhighlightingthedemarcation,
theremayormaynotbebonewithintheprogenyfragment,theremaybecystlikeformationsalongthedemarcation,andtherecouldbearticularcartilage
disruption.
Radiographicassessmentshouldbeobtainedatintervalsdependingonthe
treatmentbeingrenderedbutshouldbecontinueduntilthereisaclear
demonstrationoflesionresolutionbecausesymptomsarenottrustworthyguides
inthestabilityofthelesion.Ifthelesionexhibitsanyradiographicsignsof
worsening(enlargementorincreasedscleroticborder),orthelesionfailsto
resolveasthechildgrows,thennotonlyisadiagnosisofOCDappropriateover
irregularossificationbutalsoachangeininterventionmaybewarranted.The
definitionofhealingbyplainfilmorMRIisnotwelldefined.Thevarious
definitionsusuallytrytotakeintoaccounttheconversionofcartilaginouslesion
toosseousdensity,orsomepercentageofthatprocess,whereasothersdefine
healingbyresolution,orresorption,ofthescleroticmargin.49Unfortunately,
someauthorsstilldefinehealingastheresolutionofsymptomsregardlessofany
radiographicchanges.44,47Noone,asyet,correlatedradiographicfindingswith
healingbecausehealinghasnotyetbeendefined.
ThereissomeagreementregardingthedefinitionofanunstableOCDlesion:


eitherfracturedcartilageorseparationoftheunderlyingsubchondralbone.50
Thisdistinction,stableversusunstable,isimportantbecauseitcanoftendictate
thetreatmentandprognosis.Ingeneral,stablelesionsarebelievedtohavebetter
outcomesandstableOCDlesionsmaybeconsideredfornonoperative
management,whereasunstablelesionsarebettertreatedwithsurgical
intervention.20,40Thereare37,38fourcriteria(onT2weightedmagnetic
resonance[MR]images)thatcorrelatewithinstabilitywhencomparedwith
arthroscopyfindings:(1)ahighsignallinebeneaththelesion,(2)afocaldefect
inthearticularcartilage,(3)afractureofthearticularcartilage,and(4)the
presenceofsubchondralcysts.ThepresenceofahighT2signallinebetweenthe
lesionandtheremainderofthenormalbonewasthemostpredictivefactorfor
instabilityinamixedagecohortofpatients,butYoshidaetal.34evaluateda
skeletallyimmaturecohortwiththissamehighT2signallineseparatingthe
lesionandhefoundnocorrelation.However,hereportedthatthislinecouldnot
predictstabilitybecausethemajorityofthejuvenileOCDlesionshealed.
Anotherstudy51suggestedthatifthecriteriaforinstabilityincludedboththe
highT2signalseparatingthelesionandabreachofthearticularcartilageonT1
weightedimages,thentheaccuracyinpredictinginstabilityshiftedfrom45%to
85%.Kijowskiandcolleagues52examinedtheaforementionedcriteriaofMRI
stabilityandappliedittopredictingarthroscopicinstability(definedascartilage
disruptionormotionoftheoverlayingcartilageattheOCD)andfoundthatall
fourcriteria(together)had100%sensitivityand100%specificityforinstability
inadultOCDand100%sensitivitybutonly11%specificityforjuvenileOCD
lesions.

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study.AmJSportsMed.1989;17:601–605;discussion605–606.


46.GarrettJC.Freshosteochondralallograftsfortreatmentofarticulardefectsin
osteochondritisdissecansofthelateralfemoralcondyleinadults.Clin
OrthopRelatRes.1994;(303):33–37.
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2005;35:880–886.
48.NawataK,TeshimaR,MorioY,etal.Anomaliesofossificationinthe
posterolateralfemoralcondyle:assessmentbyMRI.PediatrRadiol.
1999;29:781–784.
49.EdmondsEW,AlbrightJ,BastromT,etal.Outcomesofextra-articular,
intra-epiphysealdrillingforosteochondritisdissecansoftheknee.JPediatr
Orthop.2010;30:870–878.
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Am.2003;34:341–353.
51.O’ConnorMA,PalaniappanM,KhanN,etal.Osteochondritisdissecansof
thekneeinchildren.AcomparisonofMRIandarthroscopicfindings.J
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52.KijowskiR,BlankenbakerDG,ShinkiK,etal.Juvenileversusadult
osteochondritisdissecansoftheknee:appropriateMRimagingcriteriafor
instability.Radiology.2008;248:571–578.
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JointSurgAm.1967;49:477–480.


CHAPTER

22

SamirK.Trehan
BentonE.Heyworth



TransarticularDrillingof
OsteochondritisDissecans
INTRODUCTION
Osteochondritisdissecans(OCD)isapathologicprocessaffectingsubchondral
boneandtheadjacentarticularcartilage,whichcanadvancetoosteochondral
fragmentinstabilityandloosebodyformation.1Thepathophysiologicbasisfor
theconditionhasnotbeendefinitivelyestablishedbut,inmostcasesisfeltto
involveimpairedvascularsupplyand/orhealingresponseinafocalareaof
subchondralbone.Thekneeisthemostcommonlyaffectedjointinthebody,
withthemedialfemoralcondylebeingmostfrequentlyaffectedlocationinthe
knee.Althoughdescribedinadults,OCDmostcommonlyaffectsskeletally
immaturepatients(whichhastraditionallybeenreferredtoasjuvenileOCD,a
termmostauthorsnowdonotfavor),whichgenerallyhaveabetterprognosis
thanOCDinadults.
PresentingsymptomsofOCDarevariablebutmayincludelimp,kneepain,
mechanicalsymptomssuchasclickingorlocking,and/oreffusion.Obtaining
standardanteroposterior(AP)(Fig.22.1)andlateralkneeradiographs,withthe
additionofatunnelornotchview,toallowforbetterassessmentofthe
commonlyaffectedposterioraspectofthecondylerepresentstheprimaryinitial
diagnosticstep.However,magneticresonanceimaging(MRI)hasemergedas
thegoldstandardforclassifyingOCDlesionsaseitherstable(Fig.22.2A,B)or


unstable,adistinctionthatdictatestheapproachtotreatment.Stablelesionsare
generallycharacterizedbyanintactarticularcartilagesurfaceoverlyingthe
subchondralbonelesion.Thischapterfocusesonthemostcommonlyused
techniqueofsurgicaltreatmentforstablejuvenileOCDlesionstransarticular
drilling.


TREATMENT
Indications
PatientswithstableOCDlesionsofthekneeandopenphysesshouldbeinitially
managednonoperatively.Conservativemodalitiesmayrangefromsimple
activitymodification(i.e.,avoidingoffendingactivitiessuchasrunning,
competitivesports,orimpactactivities)toprotectedweightbearingwith
crutches,bracing,and/orimmobilization.Althoughthetraditionalapproachof
immobilizationthroughcastingisrarelypursuedtoday,useofalockedhinged
kneebraceorkneeimmobilizermaybeareasonablesubstitute.Alternatively,
valgusunloaderbracinghastheadvantageofallowingkneemotionwhilestill
decreasingloadsontheaffectedmedialfemoralcondyle.Incomplete,transient,
orlackofradiographicorMRI-basedhealingafterapproximately3to6months
ofnonoperativetreatmentisgenerallyanindicationforsurgicalintervention.2

OPERATIVE
DrillingoftheOCDlesionisconsideredthegoldstandardofsurgicaltreatment
ofstableOCDinskeletallyimmatureknees.Drillingisthoughttodisruptthe
scleroticmarginofthelesionandconsequentlypromotehealingviagrowth
factorsreleasedfromhealthyunderlyingcancellousbone.Therearetwoprimary
methodsofdrillingkneeOCDlesions:transarticular(orretrograde)and
retroarticular(alsoreferredtoasanterograde).
Transarticulardrillinginvolvesperforationofthearticularcartilageunder
directvisualizationoftheOCDlesion,whereasretroarticulardrillingthroughthe
affectedcondylesparesthearticularcartilageandusedintraoperative
fluoroscopytoperforatetheOCDfromthebacksideofthelesion.Theoretical
advantagesofthetransarticulardrillingtechniqueincluderelativetechnical
simplicityanddirectvisualizationandassessmentoftheOCDlesionandK-wire
entrysitesduringdrilling(Fig.22.3).Consequently,drillingpassescanbe
optimallyspacedrelativetothelesion’sbordersandrelativetoeachother(Fig.
22.4).Finally,intraoperativefluoroscopyisrarelyrequiredtolocalizelesion(in
contrasttoretroarticulardrilling).Thetheoreticaldisadvantageoftransarticular
drillingisthedirectarticularsurfaceperforationanduncertainlong-term
implicationsoftheseperforations.Also,fromapracticalstandpoint,farposterior


condylarlesionsmaybedifficulttoaccessfromtransarticularapproachdueto
requiredkneehyperflexion.

Althoughhigh-qualitystudiescomparingtransarticularandretroarticular
drillingarelacking,arecentsystematicreviewconcludednodifferencein
patientoutcomesorradiographichealingforskeletallyimmaturepatientswith
stablekneeOCDlesionstreatedwiththesetechniques.Intotal,12studieswere
includedwhichdemonstrateda91%radiographichealingrateinaverageof4.5
monthsfortransarticulardrillingversus86%inaverageof5.6monthsfor


retroarticulardrillingwithnodifferencesinclinicalresponse.3
Asummaryofthecurrentlypublishedliteratureontransarticulardrillingin
isolationforthetreatmentofjuvenilekneeOCDlesionsissummarizedinTable
22.1.4–9Acrossallstudies,thereisagreementontheindicationsfordrilling,in
thatalmosteverypatienthadastableOCDlesionwhichhadfailedatleast3
monthsofnonoperativemanagement.Theclinicalandradiographicoutcomes
reportedareexcellentoverall.Significantvariabilityexistsintermsof
intraoperativedrillingtechniqueandpostoperativerehabilitation.


AUTHORS’PREFERREDTREATMENT


SurgicalTechnique
Thepatientispositionedsupineonoperatingroomtablewithanonsterilethigh
tourniquet.Standardanterolateralandanteromedialkneearthroscopicportalsare
establishedandadiagnosticarthroscopyisperformed.TheOCDlesionisthen
assessedforsizeandstability.Thelatterisespeciallyimportant,giventhatin
rareinstances,a“stable”lesionmayhaveprogressedsincethetimeoflast
imagingthatmayalteroperativeplan.Drillingisperformedwitheithera0.062or0.045-inK-wire.WeprefertousethesmallersizedK-wiretominimize
disruptionofthearticularcartilage.TheK-wireisdirectedperpendiculartothe
chondralsurfaceandadvancedwithapowerwiredrivertoanappropriatedepth
throughtheaffectedsubchondralbone.Withdrawalofthewirefromthearticular
surfacemayoccasionallybefollowedbyvisualizationoffatbubblesand/orbone
marrowbleeding,indicatingadequateperforationintothedeeperhealthy
cancellousbone.Althoughinjurytothedistalfemoralphysisisaconcernwith
overpenetrationduringdrilling,thiscanbeavoidedbymeasuringthedistance
fromthearticularsurfacetothephysisonpreoperativeMRIandensuring
penetrationnodeeperthantheshorteddistance.However,wearenotawareof
anypublishedcasesdetailingthiscomplication.Inordertosuccessfullyaccess
thelesionandappropriatelyorienttheK-wireperpendiculartothechondral
surface,thewiremayneedtobeintroducedpercutaneouslyatseveralsitesand
kneepositionmayneedtobeadjustedinvaryingdegreesofflexion.Thenumber
anddistributionofdrillingpassesvariesconsiderablyintheliterature.
Dependingonlesionsize,wewillgenerallyuse6to10drillingpasseswith
articularcartilageperforationsbeingevenlydistributedandseparatedbyatleast
severalmillimeterssoasnottopromotelesioninstability.10

Rehabilitation
TheoptimalapproachtopostoperativerehabilitationafterOCDdrillingisnot
wellestablishedintheliterature.Theauthors’preferenceistoprotectweight
bearingwithcrutchesfor6weekswhileperformingnon–weight-bearingknee
rangeofmotionexercisestooptimizethehealingenvironmentforthe
subchondralbonewhileminimizingchanceoflesionprogressionorinstability.
Rangeofmotionispursuedasearlyaspossiblepostoperatively.Postoperative


radiographsareobtainedatfollow-upvisitsevery6to12weekstoassess
healing,whichischaracterizedbyprogressivedecreaseinthescleroticmarginof
thelesionandincreaseintheopacificationofthepriorlucency(Fig.22.5).
Returntosportisdictatedbybothclinicalandradiographicimprovement.
Specifically,significantsubchondralbonehealingonradiographsorMRI,as
wellasresolutionofpain,effusion,andanyquadricepsorhamstringweakness,
shouldbeobservedpriortoallowingreturntoathletics.Thesecriteriaare
especiallyimportantforpatientsplanningtoreturntosportsrequiringcutting,
pivoting,andimpactactivities.Finally,patientsarefollowedforatleast1year
afterreturntoplaytoensurecontinuedsymptomaticimprovementandno
radiographicevidenceoflesionprogression.

Complications/PearlsonAvoiding
Complicationratesforthisprocedureareverylowwithnoreported
complicationsinthecaseseriesreferencedinTable22.1.Theoretical
intraoperativeconsiderationsincludekeepingthedrillperpendiculartothe
chondralsurfacewitheachdrillpasstoavoidiatrogenicinjuryaswellashaving


fluoroscopyavailableintraoperativelyincaselesionmarginscannotbe
ascertainedfromprobe-basedpalpation.Postoperatively,patientscandevelop
stiffness,whichiswhywefavorimmediatepostoperativerangeofmotionas
opposedtoimmobilizationinacast,forexample.

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