Osteochondritis

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Osteochondritis dissecans occurs when a fragment of bone in a joint separates from the rest of the bone because its blood supply is faulty, and there is not enough blood to maintain it. It often affects the knee or the elbow.

Sometimes, the separated fragment stays in place or repairs on its own. However, in the later stages, the bone can splinter and fall into the joint space, resulting in pain and dysfunction. These fragments are sometimes called “joint mice.”

The exact prevalence is unknown, but there may be between 15 and 29 cases in every 100,000 people. It is more common in males, especially those between the ages of 10 and 20 years who are physically active.

However, the incidence is increasing in females.

It usually affects teens and young adults, but it can occur in younger children who are active in sports.

Osteochondritis dissecans (os-tee-o-kon-DRY-tis DIS-uh-kanz) is a joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. This bone and cartilage can then break loose, causing pain and possibly hindering joint motion.

Osteochondritis dissecans occurs most often in children and adolescents. It can cause symptoms either after an injury to a joint or after several months of activity, especially high-impact activity such as jumping and running, that affects the joint. The condition occurs most commonly in the knee, but also occurs in elbows, ankles and other joints.

Doctors stage osteochondritis dissecans according to the size of the injury, whether the fragment is partially or completely detached, and whether the fragment stays in place. If the loosened piece of cartilage and bone stays in place, you may have few or no symptoms. For young children whose bones are still developing, the injury might heal by itself.

Surgery might be necessary if the fragment comes loose and gets caught between the moving parts of your joint or if you have persistent pain.

Causes

The exact cause is unknown, but they may include:

Ischemia: a restriction of blood supply starves the bone of essential nutrients. The restricted blood supply is usually caused by some problem with blood vessels, or vascular problems. The bone undergoes avascular necrosis, a deterioration caused by lack of blood supply. Ischemia usually occurs in conjunction with a history of trauma.

Genetic factors: OCD sometimes affects more than one family member. This may indicate an inherited genetic susceptibility.

Repeated stress to the bone or joint: this can significantly increase the risk of developing OCD. Individuals who play competitive sports are more likely to regularly stress their joints.

Other factors may be weak ligaments or meniscal lesions in the knee.

Symptoms

Depending on the joint that’s affected, signs and symptoms of osteochondritis dissecans might include:

• Pain. This most common symptom of osteochondritis dissecans might be triggered by physical activity — walking up stairs, climbing a hill or playing sports.
• Swelling and tenderness. The skin around your joint might be swollen and tender.
• Joint popping or locking. Your joint might pop or stick in one position if a loose fragment gets caught between bones during movement.
• Joint weakness. You might feel as though your joint is “giving way” or weakening.
• Decreased range of motion. You might be unable to straighten the affected limb completely.

When to see a doctor

If you have persistent pain or soreness in your knee, elbow or another joint, see your doctor. Other signs and symptoms that should prompt a call or visit to your doctor include joint swelling or an inability to move a joint through its full range of motion.

Risk factors

Osteochondritis dissecans occurs most commonly in children and adolescents between the ages of 10 and 20 who are highly active in sports.

Complications

Osteochondritis dissecans can increase your risk of eventually developing osteoarthritis in that joint.

Diagnosis

A person who experiences the symptoms of OCD in a joint should seek medical advice. An early diagnosis can mean more effective treatment and a lower risk of complications.

The doctor will carry out a physical examination and ask the patient about their medical history, family history and lifestyle, including sporting activities.

There may be some imaging tests, such as an X-ray, CT, MRI scan, or ultrasound. This may show whether there is any necrosis, or tissue death, or loose fragments. A bone scan may also be recommended.

In the early stages, tests will show that the cartilage is thickening. In the later stages, there will be loose fragments.

The early stages are considered stable, and treatment is more likely to be effective at this point.

Conditions, with similar symptoms need to be ruled out. These include inflammatory arthritis, osteoarthritis, bone cysts and septic arthritis.

Differential Diagnosis

• Meniscus and collateral ligament injuries – physical examination can rule this out.

If there is no certain radiological determination of osteochondritis dissecans, there can also be alternative causes of the same symptoms that should be sought for e.g.:

• Inflammatory arthritites: a group of conditions which affect your own immune system.
• Osteoarthritis: degradation of joints
• Bone cysts: type of cyst in joints
• Septic arthritis: purulent invasion of the knee which produces arthritis
• Ideopathic osteonecrosis
• Chondral seperations
• Osteochondral fractures

An x-ray, ct scan or MRI scan can be performed to show necrosis of subschondral bone or formation of loose fragments. This can lead to a better diagnosis. 

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Examination

• The knee feels warmer than the non-injured knee.
• There is an intermittent swelling palpable.
• Quadriceps muscle atrophy
• The passive and active extension of the knee is limited .
• Catching or locking of the knee .
• Tibial external rotation during gait.
• Fluid effusion
• It is possible that both capsular and non-capsular movement restrictions can be found during functional assessment, the severity is dependent on a possible herniation of the knee joint and the degree of joint irritation .
• The sensitive location of the abandoned section of the osteochondral fracture can be felt, when the knee is in 90° of flexion .
• Wilson’s Test: The knee is held in 90° to 30° from full extension while rotating the tibia.  The test is positive when internal rotation is painful and external rotation relieves symptoms

Prevention

Adolescents participating in organized sports might benefit from education on the risks to their joints associated with overuse. Learning the proper mechanics and techniques of their sport, using the proper protective gear, and participating in strength training and stability training exercises can help reduce the chance of injury.

Diagnosis

A person who experiences the symptoms of OCD in a joint should seek medical advice. An early diagnosis can mean more effective treatment and a lower risk of complications.

The doctor will carry out a physical examination and ask the patient about their medical history, family history and lifestyle, including sporting activities.

There may be some imaging tests, such as an X-ray, CT, MRI scan, or ultrasound. This may show whether there is any necrosis, or tissue death, or loose fragments. A bone scan may also be recommended.

In the early stages, tests will show that the cartilage is thickening. In the later stages, there will be loose fragments.

The early stages are considered stable, and treatment is more likely to be effective at this point.

Conditions, with similar symptoms need to be ruled out. These include inflammatory arthritis, osteoarthritis, bone cysts and septic arthritis.

Treatment

Conservative measures include changes of activity or rest. This can give the bone time to heal and to prevent future fracture, crater formation, or chondral (cartilage) collapse. Rest and the use of crutches may help.

If the patient has been involved in sports, they may need to stop for a while.

The doctor may immobilize the joint with a medical device, such as a splint or a brace. Crutches may be necessary.

A non-steroidal anti-inflammatory medication (NSAID) can help with pain. A physical therapist may offer guidance with stretching and specific exercises.

Children can normally return to sports after 2 to 4 months. In young children, OCD normally heals with rest, as the bones are still growing.

In older children and adults, the effects can be more severe.

Surgery

Surgery aims to:

• restore normal bloodflow
• get the joint to work normally again

It may be recommended if conservative measures have not worked, if a lesion has become detached and is moving around inside the joint, or if the lesion is over 1 centimeter in diameter.

Drilling into the lesion can create pathways for new blood vessels to form in. This allows blood to flow, and encourages the bone to heal.

The surgeon makes a small incision. Using some long, thin instruments, they either remove or reattach the loose fragments of bone. If the cartilage is still attached to the bone, pins or screws can be used to secure it.

Osteochondral autograft transfer (OATS) uses healthy cartilage to replace damaged cartilage on the surface of the joint that receives weight-bearing stress. It is like a cartilage transplant, but the recipient and donor is the same person.

After surgery the patient will undergo a rehabilitation program. After an initial period of immobilization, physical therapy can help regain joint strength and stability.

According to the American Academy of Orthopedic Surgeons (AAOS), the patient will probably need:

• crutches for about 6 weeks after surgery
• physical therapy for 2 to 4 months, to recover strength and motion

After 4 to 5 months, a gradual return to sports may be possible.

Minimally invasive arthroscopic surgery is less painful, the recovery time is faster, and the risk of complications is lower.

Medical Management

In minor cases rest can be prescribed. The patient has to stop activities for three to six months and the lesion will heal spontaneously, especially with young adolescents.

Normally, immobilization of the knee for a couple of weeks is sufficient in the treatment of growing children. In case immobilization is insufficient, as would normally be the case for adults, a mobilization procedure must be started up. In this procedure, stretching exercises are performed. The range of motion and strengthening ability of the muscles will be gradually increased in the next 3 to 6 months. In the end, in case the knee is not fully recovered, surgery should be necessary. (Level of evidence: C5, F5)

Stages three and four are always treated surgically. Surgery is also required when the conservative treatment in stages one and two was inadequate. It is recommended to treat surgically when a large part of the femoral condyle has been excavated, because of the risk to develop osteoarthritis.

A variety of surgical methods exist for the management of articular cartilage lesions at the knee, such as OCD. These include the use of arthroscopic lavage or debridement, radio frequency energy, bone drilling, osteochondral autografts or allografts, internal fixation of bone fragments, and autologous chondrocyte implantation . ^{(level of evidence: 3B)}

Surgical techniques:

• In stages one and two the articular cartilage is still intact, through retrograde operation trying to tap into to the affected bone ‘from behind’ and clear it. The advantage of this surgical technique is that the articular cartilage stays intact .
• Not yet dissected fragment will be fixed by means of an operation Excision of the fragment and removal of loose bodies.
• Repair of blood supply by drilling arthroscopic through the cartilage and the hearth of osteochondrosis into the healthy bones
• Stabilization of the fragment through pinning or through screw fixation
• Osteochondral autograft transplantation (OATS).
• Osteochondral allograft transplantation.
• Autologous chondrocyte implantation (ACI).
  

Physical Therapy Management

In stages one and two the condition is localized in the subchondral bone, the cartilage is still intact and gets its nourishment from synovial fluid. In these two stages conservative therapy can be applied. The goals of conservative therapy are: pain reduction, promote the repair of the cartilage and prevent degeneration of the surface of the knee joint.  There is no standard treatment.

Immobilisation

Adaption of the strain is needed so that the bone can heal. 2 weeks of immobilization and partial support is recommended when having an acute injury. With children whose bones will still grow, the bone defect may heal by resting the joint. Long-term immobilization has to be prevented, because joint motion is necessary for the nutrition and strengthening of the cartilage. Sport activities should be stopped temporally.

Physical Therapy

• Stretching to improve range of motion
• Strengthening exercises for the muscles
• First exercises: closed chain exercises, low impact activities like cycle and swim. Using exercises as straight leg raises and ankle band exercises, strength can be maintained.
• Coactivation or setting of the quadriceps and hamstring can be performed while in an immobilizer or cast.
• Using neuromuscular electrical stimulation to the quadriceps and hamstrings for coactivation contractions can further augment the strength maintenance program.
• Following immobilization, range of motion exercises, as well as progressive quadriceps and hamstring strengthening should be performed.
• Weight-bearing progression throughout rehabilitation should be to patient tolerance.
• In facilitating the return to full-weight-bearing status is aquatic therapy very beneficial.
• To adress any gait deviations that developed during the immobilization and decreased weight-bearing phases of rehabilitation gait training techniques may be used, such as manual facilitation and visual feedback tot the patient via a full length mirror.
• Additional exercises to restore ankle joint and normal knee proprioception, such as biomechanical ankle platform systems (BAPS board) exercises or unilateral stance, are also beneficial to the athlete planning to return to competition.
• After this period the sport activities can be partly restart.
• Next criteria should be managed: the patient is pain free, has a full joint mobility, no swelling, no pressure sensitivity and there’s radiological prove of recovery.

Post-operative Physical Therapy

An operative treatment is indicated if, after a treatment of three to six months and no recovery has occurred, or when the loose fragment is to big. The surgery goals would be to remove loose fragments or to reattach fragments.

Immobilization is not necessary before surgery. Immediately after the intervention the knee get scontinuous passive motion for 48 hours. After this therapy is recommend, including 8 weeks of rehabilitation exercises for limb function and recruitment. Between week 6 and 8 weight-bearing is gradually introduced to full weight bearing.

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