Eric W Edmonds, MD Jay Albright, MD Scott J Mubarak, MD Tracey Bastrom, MA Henry G Chambers, MD

1. Outcomes of extra-articular,intra-epiphyseal drilling for OCD lesions of the knee with intact articular cartilage Eric W Edmonds, MD Jay Albright, MDScott J Mubarak, MDTracey Bastrom, MAHenry G Chambers, MD

2. Introduction • Juvenile Osteochondritis dissecans (JOCD) • Subchondral lesion with degrees of osseous resorption, collapse, and sequestrum formation, possible delamination of articular cartilage in the skeletally immature

3. Guhl Classification

4. Management • Non-operative management: • Activity modification, PT, casting • 50% heal in 10 to 18 months (Cahill, 1989) • Operative techniques: • Intra-articular drilling • Four outcome studies: 82% to 95% successful union

5. Outcomes of Intra-articular Drilling • Multiple perforations in the previously intact cartilage.

6. Outcomes of Intra-articular Drilling • Less perpendicular perforations in the sclerotic rim of the lesion.

7. Purpose • Evaluate: • Extra-articular, intra-epiphyseal drilling • Does not damage intact articular cartilage • Increased fenestration of sclerotic rim

8. Methods • Retrospective review • Years 1997 to 2005 • 68 children, 75 knees (76 OCD lesions) • Inclusion criteria • Open growth plates, failed six months conservative management, arthroscopically confirmed intact articular cartilage • Exclusion criteria • Arthroscopic drilling through cartilage, detached cartilage, or closed growth plates.

9. Technique • Diagnostic arthroscopy to confirm Guhl grade • A 0.062 inch K-wire, percutaneous, intra-epiphyseal to center of lesion

10. Technique • This center-center “guide” wire is then preserved as a guide for further wire placement.

11. Technique • A parallel wire guide is used to direct a subsequent “drilling” K-wire • 15 to 20 holes are drilled through the sclerotic rim

12. Outcome Determination • Radiographic outcomes • Success: complete resolution of OCD lesion • Clincial outcomes • Failure: further intervention

13. Results • 59 lesions with complete data • 17 lateral condyles and 42 medial condyles • Mean age 13.4 years (8 to 18.6) • 15 girls and 36 boys

14. Results Pre-drilling • 52 lesions with successful healing (87%) • 7 lesions requiring further intervention (13%) Post-drilling

15. Results • Mean duration to healing: • 11.8 months (1.3 to 47.3) • Mean follow-up: • 23.7 months (1.3 to 72) Duration to Complete Healing Time (months) 12 6 3 Each Lesion in Study

16. Failures • 2nd operation, mean 18 months after index operation: • 4 required repeat drillings • 2 required repeat drilling with bone graft • 1 required trans-articular drilling with osteochondral tack

17. Failures • 3rd operation: requiring matchstick bone graft and chondroplasty • 39 months after the index procedure (15 months after the second procedure of repeat drilling)

18. Complications • No other complications resulted from this procedure

19. Comparing Our Results • Our rate of 87% complete radiographic healing represents comparable outcomes to previous intra-articular drilling reports of 82% to 95% successful union

20. Discussion • Extra-articular, intra-epiphyseal drilling of OCD lesions • Similar rate of healing compared to intra-articular drilling • Improved fenestration of subchondral rim • Nullifies damage to the overlying articular cartilage

21. Conclusion • Less iatrogenic damage • A safe and effective technique

22. Thank You