OSTEOCHONDRITIS DISSECANS

Osteochondritis Dissecans (OCD),  occurs when a fragment of bone in a joint separates from the rest of the bone because its blood supply was faulty - it was not getting enough blood to keep it alive. Sometimes, the separated fragment of bone stays in place; if it falls into the joint space, however, there will be pain and the joint may not work properly.

Osteochondritis Dissecans.


Magnetic resonance imaging patient 14 years with detachment portion of the articular cartilage of the femoral condyle of the knee due to osteochondritis dissecans

The joint, usually the knee or elbow becomes inflamed, sore and painful and will 'give way' - it catches and locks during movement.

The average age at presentation is 10-20 years, but osteochondritis dissecans may occur in persons of any age group.
The male-to-female ratio is 2-3:1.
Bilateral involvement is noted in 30-40% of cases.

In 85% of cases, lesions are observed on the medial femoral condyle (MFC) of the knee; 15% of cases are observed on the lateral   femoral condyle. Of the MFC lesions, 70% occur in the posterolateral aspect.
Of patients with OCD, 21-40% have some history of trauma.


Osteochondral fragment due to Osteochondritis Dissecans

Condral injury due to osteochondritis dissecans.

Etiology

The etiology of OCD is controversial and remains unclear. Theories include ischemia, repetitive microtrauma, familial predisposition, endocrine imbalance, epiphyseal abnormalities, accessory centers of ossification, growth disorders, osteochondral fracture, repetitive microtrauma with subsequent interruption of interosseous blood supply to the subchondral area of the epiphysis, anatomic variations in the knee, and congenitally abnormal subchondral bone.

Symptoms

The most common complaint of patients with Osteochondritis dissecans is pain, which usually is difficult to localize and typically is present for several months. Patients also may report swelling or mechanical symptoms such as catching and popping if the lesion is partially or completely separated.

ORTHOPEDIC DEVELOPMENTS: 

STEM CELLS AND ARTICULAR CARTILAGE LESIONS

Treatment with autologous adult stem cells represents a promising new perspective on the rapidly evolving field of regenerative medicine and is currently the best alternative method for tissue regeneration. The stem cells are precursors of all cells of the human body and under suitable conditions can be converted into chondrocytes repairing thereby deficits of articular cartilage from the joint injury or due to a osteochondritis dissecans.

CONSERVATIVE TREATMENT
THERAPY: 

Conservative treatment

The following options are available:
 

  • Reduction of sporting activity,
  • Relief,
  • Physical therapy,
  • Cast immobilization, splints.

The most important measure is probably the reduction of
sporting activity or a sports ban. The risk that the focus
does not heal spontaneously is much greater if sporting
activity is continued than if it is suspended for a certain
period. Other conservative methods, for example
a specific exercise program and relief, may be useful in
the short term.

The objective of temporary immobilization
in a cylinder cast is not so much to facilitate the
reintegration of the fragment as to effectively impose the
sports ban. However, the cast should not be applied for
longer than 4 weeks, as a more prolonged period of
immobilization is harmful for the joint generally. Since
the (radiological) healing usually takes a lot longer than
4–6 weeks, the use of removable splints is useful. A splint
in a near fully-extended position worn throughout the
day avoids rotational movements, relieves the – usually
dorsally located – osteochondrotic focus and prevents
sporting activity.

OPERATIVE TREATMENT
THERAPY: 

SURGICAL TREATMENT

Many new techniques for the treatment of articular cartilage damage exist with very good results.

OSTEOCHONDRAL FRAGMENT STABILIZATION WITH SPECIAL PINS (ABSORBABLE)

The stabilization of osteochondral section shall be posted when the part is not separated completely from the anatomical position.
The procedure is done with arthroscopy of the knee where with the help of special tools placed by pin absorbable material so as to provide maximum stability.

Special absorbable pins for osteochondral fragment stabilization

Special arthroscopically viewfinder for pin placement

The absorbable pin are positioned to provide stabilization of diseased osteochondral section

 

MICROFRACTURE TECHNIQUE

Microfracture is indicated as first-line treatment for focal Outerbridge grade III and IV lesions under 3–4 cm2 in an otherwise nonarthritic knee in a symptomatic, active, and relatively young patient willing to respect the postoperative rehabilitation requirements.

Τhe microfracture techniques during knee arthroscopy. For older and low-demand patients, microfracture may be useful even in lesions larger than 3–4 cm2.

AMIC technique on knee chondral lesion -  animated

Severe chondral patellar lesion in man 28 years old.  AMIC technique

The microfracture is already done.

The blood contain special substance for remake the new cartilage.

 

A case report

16-year-old Basketball athlete, suffers from knee joint pain left during the athletic activities initially but also during everyday activities.Clinical examination of the affected joint reproduce intense pain, especially during tibial torsion tests.


MRI of the left knee.  Osteochondritis Dissecans of the lateral femoral condyle completely detached



The damage of articular cartilage to the knee of the femoral condyle due to osteochondritis is completely detached from the surrounding healthy tissues and is removed.


The buried osteochondral part is removed. The image shows the anatomical area after the part was removed


The necrotic part of the articular cartilage, which reaches a length of 2 cm


Nanofracture technique

The nanofractures (Linvatec Conmed), in the crater of the damage

Apply the autografts to the base of the lession. The autografts come from the patient's pelvis.

Collagen membrane - AMIC technique above the grafts with special biologic glue

Taking bone marrow from the patient's pelvis (iliac bone). Advanced processing and isolation of autologous stem cell

Applying the stem cells to the surface of the collagen insert and stabilizing them with a bioadhesive agent

The space created by removal of the necrotic portion in the femoral condyle is covered by autologous grafts, collagen insert and stem cells

OSTEOCHONDRAL AUTOGRAFT TRANSPLANTATION

Osteochondral autograft transplantation is a well-established technique in the treatment of chondral and osteochondral defect. Cylindrical osteochondral plug are harvested from areas of the articular surface with a lesser weight – bearing role and transferred to areas of osteochondral damage.

Using a press fit- technique, the plugs are inserted to replace damage or missing articular cartilage and to supply the chondral lesion with island of viable and immediately functional hyaline cartilage. The presence of focal unipolar cartilage defects in the knee measuring 1-4 sq.cm is a current indication for osteochondral autograft transplantation.

  

Donor site upper left, osteochondral press-fit right.  (Operative technique Sports Knee Surgery, Saunders Publication)

The plugs are inserted to replace damage articular cartilage.

Osteochondral imlantation. (3 cylinders).  (Μaster Techniques in Orthopeaedic Surgery.  Knee reconstruction 3rd edition).

Intraoperative view.

contraindication

The procedure is not indicated for the condition as:

Generalized arthritis, rheumatoid and/or degenerative type
Lack of appropriate donor area
Infectious or tumor defects
Age greater than 50 years
Osteochondral defects deeper than 10 mm

 

AUTOLOGOUS CHONDROCYTE IMPLANTATION

Injuries to joint surfaces can result from acute high-impact or repetitive shear and torsional loads to the superficial zone of the articular cartilage architecture. The use of autologous chondrocyte implantation is promising and is associated with several potential long-term benefit.

Autologous chondrocyte implantation is ideally suited for symptomatic deep chondral lesion along the femoral condyle or trochlear region. High-demand patient between 15-55 years of age with excellent motivation and potential for compliance are the best candidates.

However autologous chondrocyte implantation is a viable option for a symptomatic patient with a lesion of >2 sq.cm but <12 sq.cm. and for a patient who continues to have pain after mosaicplasty or microfracture procedure. Bone involvement is not contraindication, but staged or concomitant autologous bone grafting should be undertaken when the bone involvement is deeper than 6-8 mm.

Autologous chondrocyte transplantation is not a treatment for osteoarthritis (general joint disease), gout, and rheumatoid arthritis or other systemic joint diseases.

femoral condyle chondral lesion.  Arthroscopic evaluation.

Chondral lesion mesuring during arthroscopy.

Autologous chondrocyte are arthroscopicaly harvested from a less weight-bearing area, commercially extracted from the harvested cartilage (200-500mg), and multiplied in vitro (labor cell culture).


Chondrocyte cultivation in Bioengineer Lab

Elective reinplantation is performed 4-6 weeks after cartilage harnesting by debridement of the defect to an intact margin, carelully avoiding osseous bleeding from the bed of the defect.

Clear the lesion area with curette.


The lesion area is already clear and ready to receveive the autologous chondrocyte.


Chondrocyte culture.


The surgeon cut the chondrocyte film like the shape of the chondral defect.


The autologous chondrocyte is ready to implant.


The autologous chondrocyte is transplanted.  The chondral defect is covered.


Chondral defect due to trauma.


The autologous chondlal cell filling the defect. 

The chondral defect covered by autologous chondrocyte atrhoscopically.

The arthroscopy procedure is finished.  The knee movement is without any problem.

REHABILITATION: 

MICROFRACTURE TECHNIQUE

Cold therapy is typically used for 1 to 7 days postoperatively.
Crutch-assisted touchdown weight-bearing ambulation (10% of body weight initially) is prescribed for 6 to 8 weeks, depending on the size of the lesion. For most patients, 6 to 8 weeks is adequate time to limit weight bearing. However, for patients with small lesions (<1 cm diameter), weight bearing may be initiated earlier.

Patients with lesions on the femoral condyles or tibial plateaus rarely use a brace during the initial postoperative period. However, we may prescribe an unloading type brace when the patient becomes more active and the postoperative swelling has resolved.

 

OSTEOCHONDRAL AUTOGRAFT TRANSPLANTATION

Postoperatively, patients are placed in a hinged knee brace set at 0º to 90º. Therapy is initiated the next day and stresses range of motion exercises and isometric quadriceps strengthening. An emphasis is placed on regaining range of motion and reducing postoperative effusion. The brace is unlocked after 1 weeks and is discontinued when the patient is able to perform a straight leg raise without an extension lag.

Patients are permitted only touch-down weight bearing for the first 6 weeks. At 6 week postoperative evaluation, the patient progresses to weight bearing as tolerated. The brace is discontinued.
After 12th week advanced strengthening with minimal restriction. Return to vigorous activities is discouraged for at least 12 months.

 

ΑUTOLOGOUS CHONDROCYTE IMPLANTATION

Postoperatively protected weight-bearing are restricted for 6 weeks. The crutches is necessary for walking.
The physical therapy program started 2nd post-op day with passive movement (physical therapist or CPM machine) until 4th week. Therapy concentrates on quadriceps activation and isometric straight leg raises. After the 6th week the patient can walk without aid devices with full weight-bearing. Full weight bearing and full range of motion are achieved. Closed-chain exercises and functional training are started.

After 12th week Strengthening and functional training are progressed. Return to full activities is delayed for at least 8 months to protect the lesion as it matures.
Return to participation in pivoting sports is usually allowed by 12 months.