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
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
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
Case Presentation: Exam
Right knee (Continued)
Valgus stress testing
No ligamentous laxity
Increased pain
Varus stress testing
No laxity or increased pain
Lachmans, anterior drawer, and posterior
drawer testing all without laxity
Equivocal pivot shift
Case Presentation: Exam
Right knee (Continued)
Positive Steinmans test
medially
Joint line pain when the tibia
is rotated internally and
externally while the knee is
flexed over the examination
table
Case Presentation: Exam
Right knee (Continued)
Medial joint pain with
McMurrays 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
Case Presentation: Exam
Right knee (Continued)
Distally NV intact

Left knee
No abnormalities

Gait
No gross stance or swing phase abnormalities
Case Presentation
Differential Diagnosis?
Meniscal injury
Extensor mechanism injury
Cruciate ligament injury
Collateral ligament injury


Case Presentation
What do you want to order / do now?
Plain films?
Ottawa knee rules?
Which views?
MRI?
Bone scan?
Refer to Ortho?
Pray?
Case Presentation: Plain
Radiographs
AP View
Lateral View
Case Presentation: Plain
Radiographs
Oblique View
Sunrise View
(aka: Merchant View)
Case Presentation: Plain
Radiographs
Tunnel View
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
Osteochondral Defects of the Knee
Garry W. K. Ho, M.D.
VCU / Fairfax Family Practice
April 11, 2005
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
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
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
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
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
Osteochondral Defect:
Epidemiology in U.S.
Medial femoral condyle: 75-85%
70% occur in the posterolateral aspect
Lateral femoral condyle: 10-25%
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
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
Osteochondral Defect : Exam
Meniscal Tests may be
positive

Steinmans Test (Meniscal)
Joint line pain when the tibia
is rotated internally and
externally while the knee is
flexed over the examination
table
Osteochondral Defect : Exam
McMurrays 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
Osteochondral Defect : Exam
Apley Test (Meniscal)
With patient prone, rotate the tibia on
the femur and applying axial
compression to reproduce joint line
pain
Osteochondral Defect: Exam
Wilson Test (OCD)
OUCH!
Osteochondral Defect : Imaging
Plain Radiographs: useful 1
st
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
Osteochondral Defect : Imaging
MRIs of Knee showing OCD
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
Osteochondral Defect : Grading
Osteochondral Fragment Stability

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

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
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
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
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
Osteochondral Defect :
Surgical Therapy
Arthroscopic views of OCDs
Osteochondral Defect :
Surgical Therapy
Microfracture Debridement & Lavage
Osteochondral Defect :
Surgical Therapy
Fixation
Osteochondral Defect :
Surgical Therapy
Osteochondral Allograft Implantation (OCA)
Osteochondral Defect :
Surgical Therapy
Osteochondral
Autologous
Transplantation
(OATS)
Case Presentation: J.B. Revisited
J.B. was seen by Dr. Petrone

Arthroscopic OATS performed
Tolerated well

Physical Therapy

Doing well
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, dont be
afraid to order X-rays when the Dx isnt clear
Extension of the physical exam

Theres more to knee X-rays than the standard
Knee series
Order the views you need
Thanks!
Questions ?
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
Osteochondral Defects: A Brief
History
1558: Ambrose Pare removed loose bodies from the knee joint
1870: Paget described quiet necrosis within the knee
1888: Knig 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: Waldenstrm 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