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Case Presentation: History

Case Presentation: History. J.B. is an 18 year old male football, ice hockey, and lacrosse player 3-4 year h/o medial right knee pain S/p blunt trauma to the medial right knee Cleared to return to play by Ortho No MRI done Intermittent “giving out… pretty often” Occasional “locking”

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Case Presentation: History

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  1. Case Presentation: History • J.B. is an 18 year old male football, ice hockey, and lacrosse player • 3-4 year h/o medial right knee pain • S/p blunt trauma to the medial right knee • Cleared to return to play by Ortho • No MRI done • Intermittent “giving out… pretty often” • Occasional “locking” • Unable to fully extend

  2. Case Presentation: History • Right knee becomes painful, “swollen, and red” after ice hockey practice x 1 week • Pain localized to medial aspect • Ambulates without problems otherwise • Denies day-to-day functional impairment • Denies numbness, tingling, or motor weakness in either LE • Otherwise healthy; ROS negative otherwise

  3. Case Presentation: Exam • Right knee • Mild ecchymosis overlying anterio-medial aspect of the knee • Mild quadriceps atrophy compared to L knee • Moderate joint effusion • Medial joint line TTP • Increased pain with full flexion • Extension ~ 5° less than left knee

  4. Case Presentation: Exam • Right knee (Continued) • Valgus stress testing • No ligamentous laxity • Increased pain • Varus stress testing • No laxity or increased pain • Lachman’s, anterior drawer, and posterior drawer testing all without laxity • Equivocal pivot shift

  5. Case Presentation: Exam • Right knee (Continued) • Positive Steinman’s test medially • Joint line pain when the tibia is rotated internally and externally while the knee is flexed over the examination table

  6. Case Presentation: Exam • Right knee (Continued) • Medial joint pain with McMurray’s Testing • Flexing the patient's hip and knee and palpating for a pop or click along the joint line as the tibia is internally and externally rotated, while extending & flexing the knee

  7. Case Presentation: Exam • Right knee (Continued) • Distally NV intact • Left knee • No abnormalities • Gait • No gross stance or swing phase abnormalities

  8. Case Presentation • Differential Diagnosis? • Meniscal injury • Extensor mechanism injury • Cruciate ligament injury • Collateral ligament injury

  9. Case Presentation • What do you want to order / do now? • Plain films? • Ottawa knee rules? • Which views? • MRI? • Bone scan? • Refer to Ortho? • Pray?

  10. Case Presentation: Plain Radiographs • Lateral View • AP View

  11. Case Presentation: Plain Radiographs • Sunrise View • Oblique View • (aka: Merchant View)

  12. Case Presentation: Plain Radiographs • Tunnel View

  13. Case Presentation: Radiographs & MRI • Right Knee Plain Radiographs • OCD involving lateral half of the articular surface of the medial femoral condyle, with associated 1 cm loose body • Right Knee MRI • OCD @ inner edge of medial femoral condyle, 2 cm in diameter, with adjacent bone edema • Mild thinning of tibial ACL insertion • Tiny tear at the undersurface if the posterior horn of the medial meniscus • Joint effusion

  14. Osteochondral Defects of the Knee Garry W. K. Ho, M.D. VCU / Fairfax Family Practice April 11, 2005

  15. Osteochondral Defect: What It Be • A fragment of cartilage and subchondral bone separates from the articular surface • 2 distinct populations of patients • Differentiated by the status of their physes • Juvenile Knee OCD • 5-15 year olds who have open physes • Adult Knee OCD • Older teens & adults with closed physes • Symptoms depend on stage of the lesion • Untreated, may lead to early OA with chronic pain and functional impairment

  16. Osteochondral Defect: Pathophysiology • Cause unclear & debated • Many etiologies proposed • Trauma • Direct (less likely) trauma  transchondral fracture? • Indirect trauma more likely • Predilection for the posterolateral portion of the medial femoral condyle • Repetitive impingement of the tibial spine on the lateral aspect of the medial femoral condyle during internal rotation of the tibia

  17. Osteochondral Defect: Pathophysiology • Ischemia • 1990: Enneking described the vascular supply to the subchondral bone with poor anastomoses to surrounding arterioles, predisposing it to forming sequestra, making it vulnerable to traumatic insult, fracture, and separation • Rogers and Gladstone: found numerous anastomoses to intramedullary cancellous bone in the distal femur • Chiroff and Cooke: found no signs of avascular necrosis in sections of excised osteochondral loose bodies

  18. Osteochondral Defect: Pathophysiology • Other proposed etiologies & predisposing conditions • Skeletal maturation (accessory centers of ossification) • Genetic conditions (e.g., multiple epiphyseal dysplasias) • Metabolic factors • Hereditary factors • Anatomic variation • Currently believed to be multifactorial • Trauma as the starting point in predisposed individual • Single traumatic event or repetitive microtrauma may interrupt the vascular supply • Vascular insufficiency ultimately leads to fragment separation

  19. Osteochondral Defect: Epidemiology in U.S. • OCD of femoral condyles • 6 cases per 10,000 men • 3 cases per 10,000 women • Average age: 10-20 years old, but may occur in any age • Males-to-Female ratio 2-3:1 • Bilateral in 30-40% • 21-40% have some history of trauma

  20. Osteochondral Defect: Epidemiology in U.S. • Medial femoral condyle: 75-85% • 70% occur in the posterolateral aspect • Lateral femoral condyle: 10-25%

  21. Osteochondral Defect: Symptomatology • History of trauma • Vague and poorly localized knee pain, swelling, and stiffness in varying degrees • Especially activity-related swelling • Possible clicking or popping • Symptoms often intermittent & exacerbated by activity or twisting / cutting movements • “Locking” or “catching” may occur • “Giving way” of the knee may occur • Due to quadriceps weakness • Prolonged course leads to progressive degenerative arthritis

  22. Osteochondral Defect: Exam • Joint effusion may be present • Quadriceps atrophy and weakness may be evident • Quad Girth measured @ 10 cm proximal to superior pole of the patella • Palpable loose body, occasionally • Decreased ROM • Especially in knee extension • Joint line tenderness • Gait abnormalities • External rotated tibia on stance phase • Quadriceps disuse atrophy or weakness

  23. Osteochondral Defect : Exam • Meniscal Tests may be positive • Steinman’s Test (Meniscal) • Joint line pain when the tibia is rotated internally and externally while the knee is flexed over the examination table

  24. Osteochondral Defect : Exam • McMurray’s Test (Meniscal) • Flexing the patient's hip and knee and palpating for a pop or click along the joint line as the tibia is internally and externally rotated, while extending & flexing the knee

  25. Osteochondral Defect : Exam • Apley Test (Meniscal) • With patient prone, rotate the tibia on the femur and applying axial compression to reproduce joint line pain

  26. Osteochondral Defect: Exam • Wilson Test (OCD) OUCH!

  27. Osteochondral Defect : Imaging • Plain Radiographs: useful 1st line imaging • AP & lateral views: OCD on the condyles • Sunrise or Merchant View: patellar OCD • Notch or Tunnel AP View: medial femoral condyle OCD • MRI with gadolinium • Technetium bone scan • Occult bilateral OCD • Estimates prognosis with conservative vs. operative treatment • CT scanning: helpful in preop planning when MRI is contraindicated or not available • Sonography: only advantage is cost

  28. Osteochondral Defect : Imaging • MRIs of Knee showing OCD

  29. Osteochondral Defect : Grading Osteochondral Fragment Stability • Grade / Stage 1: Depressed OCD • Small area of compressed subchondral bone • Grade / Stage 2: Partial OCD • Partially detached osteochondral fragment • Sclerotic subchondral bone • Grade / Stage 3: Complete nondisplaced OCD • Completely detached fragment that remains within the underlying crater (nondisplaced) • Most common • Grade / Stage 4: Displaced OCD • Completely detached & displaced fragment • Loose body

  30. Osteochondral Defect : Grading Osteochondral Fragment Stability

  31. Osteochondral Defect : Treatment Categories • Based on physeal status and OCD size & stability • Category 1 • females < 11 y/o, males < 13 y/o, no loose body on X-Ray • Do well with non-operative treatment • Category 2 • females 11-15 y/o, males 13-17 y/o • Near skeletal maturity; treatment depends on location, size, and stability of the lesion • Category 3 • Physeal closure and skeletal maturity have occurred • Treatment based on the location, size, and stability of the lesion

  32. Osteochondral Defect : Treatment • Conservative treatment • Category 1 patients & no loose bodies (Juvenile Type) • Category 2 patients with Grade 1 lesions • Questionable: Category 2 patients with Grade 2 lesions

  33. Osteochondral Defect : Treatment • Referral to orthopaedics for surgical therapy • Lesions > 1 cm in size • Category 3 patients • Loose bodies • Mechanical symptoms (e.g. locking, giving way) • Lateral femoral condyle OCDs • Failure of conservative therapy • No evidence of union after 12 weeks • Children approaching physeal closure within 6 months

  34. Osteochondral Defect : Conservative Treatment • Pain control • Relative rest for 1-2 weeks • Limit activity • Protected weight bearing • Knee immobilizer • Check serial X-Rays Q 3-6 months • Modified activity for 6-12weeks • Low impact activity only • Full activity, quads strengthening if: • No pain, normal exam, and X-Rays show evidence of healing

  35. Osteochondral Defect : Conservative Treatment • If still symptomatic or X-Rays do not show improvement after 12 weeks • Refer to Ortho for surgery • Incidental OCDs in asymptomatic patients • Refer Category 3 patients • Follow with serial X-Rays Q 4-6 months until the lesion has healed or until skeletal maturity achieved • If still asymptomatic at skeletal maturity and the X-Rays have not progressed • Reassure patient • No further treatment is indicated

  36. Osteochondral Defect : Surgical Therapy Arthroscopic views of OCDs

  37. Osteochondral Defect : Surgical Therapy Debridement & Lavage Microfracture

  38. Osteochondral Defect : Surgical Therapy Fixation

  39. Osteochondral Defect : Surgical Therapy Osteochondral Allograft Implantation (OCA)

  40. Osteochondral Defect : Surgical Therapy Osteochondral Autologous Transplantation (OATS)

  41. Case Presentation: J.B. Revisited • J.B. was seen by Dr. Petrone • Arthroscopic OATS performed • Tolerated well • Physical Therapy • Doing well

  42. In Conclusion • When you think of meniscal injuries, consider osteochondral injuries as well • Pain & swelling associated with activity is abnormal & your tip-off for OCDs • While using the Ottawa rules are helpful, don’t be afraid to order X-rays when the Dx isn’t clear • “Extension of the physical exam” • There’s more to knee X-rays than the standard “Knee series” • Order the views you need

  43. Thanks! Questions ?

  44. References • Rogers WM, Gladstone H: Vascular foramina and arterial supply of the distal end of the femur. J Bone Joint Surg Am 1950 Oct; 32 (A:4): 867-74 • Schenck RC, Goodnight JM: Osteochondritis dissecans. J Bone Joint Surg Am 1996 Mar; 78 (3): 439-56 • Ralston BM, Williams JS, Bach BR, Bush-Joseph CA, Knopp WD: Osteochondritis Dissecans of the Knee. Phys Sportsmed 1996 Jun; 24 (6) • Pappas AM: Osteochondrosis dissecans. Clin Orthop 1981; Jul-Aug (158):59-69 • Garrett JC: Osteochondritis dissecans. Clin Sports Med 1991;10 (3):569-593 • Osteochondritis Dissecans of the Knee • Wang TW, Knopp WD, Bush-Joseph CA, Bach BR: Osteochondritis Dissecans of the Knee. Phys Sportsmed 1998 Aug; 26 (8) • Cahill BR, Phillips MR, Navarro R: The results of conservative management of juvenile osteochondritis dissecans using joint scintigraphy. A prospective study. Am J Sports Med 1989 Sep-Oct; 17(5): 601-606

  45. Osteochondral Defects: A Brief History • 1558: Ambrose Pare removed loose bodies from the knee joint • 1870: Paget described quiet necrosis within the knee • 1888: König coined the term "osteochondritis dissecans," proposing this condition was caused by spontanous inflammation (osteochondritis) to necrosis & a separation (dissecans) of the fragment • Advent of X-rays: osteochondrotic conditions in other joints, primarily the hip, were recognized • 1910: Legg, Calve, and Perthes independently identified a condition of the hip joint in children, which is now known as Legg-Calve-Perthes disease. • 1921: Waldenström introduced the term coxa plana (ie, disintegration of capital femoral epiphysis.) • Since the introduction of radiographs, 50 additional anatomic sites within the body where OCD can occur have been identified • Investigators have failed to identify inflammatory cells in histologic sections of excised osteochondral loose bodies. Nevertheless, the name “osteochondritis dissecans” has persisted

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