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  A Muscles have been described as “shock absorbers”54 because muscular contraction has the ability to protect cartilage.40 The ability to effectively engage in a strengthening exercise program, therefore, was necessary. DJ The decision to return to sports is a collective one, involving the patient, health care team, and patient's family. Does operative fixation of an osteochondritis dissecans loose body result in healing and long-term maintenance of knee function? Later, a lack of evidence for the presence of an inflammatory process in the region of the articular lesion led Pappas3 to name the condition “osteochondrosis dissecans.” Although some authors4 support this nomenclature, the term “osteochon… Approximately 50% to 67% of JOCD lesions found during childhood will heal with 6 to 18 months of nonoperative treatments, which may include complete sports restriction, casting, bracing, and crutch walking.17,18,100,124 Most authors agree that early diagnosis and treatment, before the child reaches skeletal maturity, produce the best long-term outcomes.15,18,24,64 If left untreated, juvenile lesions can progress to adult forms of OCD, resulting in detachment or destruction of a portion of the joint surface and potentially leading to early osteoarthritis.29 Thus, parents, coaches, athletic trainers, physical therapists, and physicians must be vigilant to identify JOCD and to initiate early treatment that will shorten recovery and improve outcomes in young athletes. Nonoperative treatment of JOCD is successful in approximately 50% to 67% of stable lesions. Sellards They also reported 100% sensitivity, 100% specificity, and 100% accuracy for detection of OCD instability.21 The accuracy of MRI can depend on the strength of the magnet, the imaging sequence, the use of a dedicated knee coil, and the expertise of the radiologist.8,10 Based on a recent systematic review, there is not enough quality evidence to offer conclusive guidelines on the clinical utility of MRI for diagnosis and staging of JOCD.101, The most widely used arthroscopy grading systems were proposed by Guhl39 and Ewing and Voto35 (TABLE, FIGURE 7). Barr For example, he described patients with OCD who developed symptoms of degenerative arthritis after nearly 20 years. Rehabilitation following microfracture for chondral injury in the knee, Association between mechanical axis of the leg and osteochondritis dissecans of the knee: radiographic study on 103 knees, Bilateral osteochondritis dissecans of the femoral condyles in both knees: a report of two sibling cases. J Orthop Sports Phys Ther 2014;44(9):665–679. . , Frankel VH. These authors, along with Ulett et al,49 also reported on the effectiveness of both high- and low-frequency TENS (ie, electroacupuncture) to inhibit pain through centrally mediated responses in animals and human subjects. The specific knee injury we are going to talk about is osteochondritis.. SH Its role in clinical decision-making, Guided growth for the treatment of limb length discrepancy: a comparative study of the three most commonly used surgical techniques, Retro-articular drilling and bone grafting of juvenile knee osteochondritis dissecans: a technical description. A histologic and autoradiographic study in man, Magnetic resonance imaging of the knee in children and adolescents. Although some authors demonstrated that high-frequency stimulation had the best effect on a subject's perception of experimentally induced pain,50–52 others described how both high- and low-frequency applications of TENS could be effective for pain relief.49,53 In a recent review of nonpharmacological treatments for musculoskeletal pain, Wright and Sluka53 reported evidence that TENS improves joint function in patients with rheumatoid arthritis. Serial radiographs can also increase radiation exposure; however, the effective dose of radiation for a knee radiograph in children ranges from 0.077 to 0.19 mrem,50 which is minimal considering that the average exposure from natural sources (eg, radon) per year in the United States is 300 mrem.120 An MRI scan or needle biopsy may give the most definitive evidence of healing. It is also possible that the early decrease in symptoms may have been the result of factors other than, or in addition to, the application of electrical stimulation (eg, a change in footwear, addition of the customized home exercise program, the patient's new knowledge of joint protection principles). She received physical therapy intervention that included iontophoresis with DEX-P, strengthening and ROM exercises that were modified to limit stress to the lesion, and patient education on joint protection strategies. No abnormalities in the skin condition beyond mild erythema were noted. The articular cartilage that covers the joint surface of the femur and tibia in the knee can be visualized on MRI as a smooth, gliding surface. OSTEOCHONDRITIS DISSECANS *OSTEOCHONDRITIS DISSECANS :- 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. Hughston Although commonly used for diagnosis, plain radiographs are not recommended for classification of JOCD lesions. Evidence suggests that the articular cartilage response to stress is dependent on delivering the appropriate amount of tissue loading.32,54 Hefti et al8 and Aichroth11 both found that the “classic” medial femoral condyle lesions demonstrated the least evidence of healing over time. First, the patient was encouraged to use cushioned footwear (ie, running shoes) to limit ground reaction forces at the knee. , Nho SJ, Cole BJ. NN , Roberts MS. Guffey These exercises were chosen to strengthen the 2-joint muscles that cross the hip and knee joints, to allow for improved load attenuation by these muscles (ie, rectus femoris, hamstring group, gracilis, and tensor fasciae latae/iliotibial band).28 The decision to perform these exercises with the knee fixed in 30 degrees of flexion was an effort to protect the OCD lesion from further loading while initiating strengthening exercises on day 1 of her intervention. 3.4. A smaller medial tibial slope has also been identified in adult OCD lesions.112 The impact of mechanical loading from the hip and foot on knee JOCD has not been evaluated. , Ikata T, Takai H, et al. Gudeman Costello Williams 11, 10 March 2015 | The American Journal of Sports Medicine, Vol. . Blackford The most common joints affected by osteochondritis dissecans that podiatry treats are the ankle and knee. Recent studies44,45 have shown an absence of DEX-P in the synovium and local venous blood after the application of iontophoresis delivered at a 4.0-mA current. The patient missed a visit and returned for her fifth and final visit 10 days after the fourth visit. Osteochondritis dissecans is a condition during which parts of the joint cartilage and subchondral bone (bone under the cartilage) is separated from the remaining bone. The patient then was instructed in joint protection strategies to decrease loading across the right tibiofemoral joint. Her home exercise program was modified to include strengthening exercises for the muscles about the hip, knee, and ankle that required movement of the tibiofemoral joint. Drilling juvenile osteochondritis dissecans: retro- or transarticular? OCD usually causes pain during and after sports. , Hamel L, Behnke P. Hasson This may allow safe, progressive exercises for the quadriceps, hamstrings, and gastrocnemius with increasingly stronger resistance. These exercises included modified wall slides (20°–90°) and modified active knee extension (90°–20°) in an effort to promote improved strength and endurance in knee extension through a greater ROM while still avoiding excessive loading to the OCD lesion. Mechanical symptoms66 and radiographic healing124 have also been used. J Third, I discussed the benefit of using an assistive device (ie, straight cane) to provide unloading of the right tibiofemoral joint. . The separated flakes can then ossify due to nourishment by the synovial fluid.The cartilage is damaged and can form a loose body. The incidence of osteochondritis dissecans in the condyles of the femur, Osteochondritis dissecans of the femoral condyles: a long-term follow-up study, Osteochondritis dissecans. , Tuite MJ, De Smet AA. How does the condition develop? Future studies to examine the effects of specific, nonsurgical interventions on adult patients with stable OCD lesions would be beneficial. SD I am going to talk with Zach Moore who is a strength coach and he is going to talk about how he overcame numerous knee surgeries and osteochondritis. We discussed a plan to progress her exercise program next visit and began discharge planning. Osteochondral lesion of the talus in children: Are there MRI findings of instability? Wright Osteochondritis dissecans (OCD) refers to a painful joint condition that involves damage to the cartilage and underlying bone within a joint. 1, 19 January 2016 | Journal of Medical Case Reports, Vol. He was diagnosed with osteochondritis dissecans and it was recommended going to complete 6 months of conservative treatment that included physical therapy, muscle strengthening, and exercise. Arthroscopy is the gold standard for assessing the status of the joint's surface cartilage, including the shape, strength, continuity, fissuring, softening, and detachment of the JOCD lesion (FIGURE 5). , Lysholm J. Nordin , Stephen RL, Jacobson SC. Familial osteochondritis dissecans: a dysplasia of articular cartilage? Abbreviation: OCD, osteochondritis dissecans. Vitamin D Deficiency: The Missing Etiological Factor in the Development of Juvenile Osteochondrosis Dissecans? , Jensen MP, Karoly P. Finch She demonstrated no observable gait deviations during ambulation, noted the ability to walk her dog for ½ to 1 mile without difficulty, and reported a 95% rating of function (SANE score). , Mayo MF, Gabaree CL, et al. osteochondritis dissecans can lead to the development of osteoarthritis at an early age, resulting in progressive pain and disability. As a result, decreased stress on the chondral lesion might have helped diminish pain and future tissue damage.54, Careful loading (stress) of the lesion must be considered in light of its potential effects on tissue healing. Signs of OCD in dogs typically begin between the ages of four and eight months, but this can vary depending on the growth rate of the affected dog. Varus and valgus malalignment of the knee has been reported in patients with medial and lateral condyle JOCD lesions, respectively.54 If the patient is skeletally immature, guided growth is a minimally invasive, minimally painful procedure to realign the knee.116 Guided growth can harness the power of the growth plate to correct the knee deformity. 43, No. Osteochondritis dissecans (OCD) is the separation of articular cartilage and its adjacent underlying subchondral bone from the articular surface of a joint.1 Koenig2 first described this condition in 1888, initially hypothesizing that it was an inflammatory disease. Over time, OCD lesions can lead to further degenerative changes in the elbow. Pfizer Inc, 235 E 42nd St, New York, NY 10017. Woolf Although widely accepted, there is minimal research evidence to support repetitive trauma as the cause. These lesions are located within the intercondylar notch of the femur (non–weight bearing surface) and thus are subject to less loading over time. The most common place for this to happen is at the medial femoral condyle. Y Physical therapists mainly design the following treatment programs consists of exercises and activities according to the nature of your underlying condition. Therefore, I believe that physical therapists' decisions regarding how to manage adult patients who have a diagnosed osteochondritic lesion of the knee, including the selection of specific physical therapy interventions, should be made in light of several factors: (1) the disease process, (2) patient characteristics (eg, age, health status), (3) clinical examination findings, (4) diagnostic imaging results, (5) physician consultation, and (6) the patient's goals for therapy. Many validated measures have been used in recent years to assess the functional outcomes of patients with knee JOCD and the effectiveness of treatment.119 The most common questionnaires are the International Knee Documentation Committee Subjective Knee Evaluation Form,4,51,60,78,125 the International Cartilage Repair Society scale,37,38,67,78,125 the Hughston Clinic Knee Questionnaire,4 the Lysholm knee score,9,60,78,128 the Knee injury and Osteoarthritis Outcome Score,77,95 the Tegner activity scale,9,37,60,125 and the Marx activity scale.77 There is now a validated pediatric version of the International Knee Documentation Committee Subjective Knee Evaluation Form available for clinicians and researchers as well.63 In addition to evaluating surgical treatments, these questionnaires may be helpful tools for physical therapists to evaluate patients as they progress through rehabilitation and to compare the effectiveness of different approaches. AM Osteochondritis dissecans (OCD) describes an injury to the area of bone just under the cartilage surface, an area called the subchondral bone. In addition to complete healing on radiographs or MRI,66,124 a criteria-based progression for return to sport following nonoperative or operative treatment should include full range of motion, no pain, 90% strength, normal agility, and no limp.110 The physician and the rehabilitation team must work together closely to provide a consensus opinion of the optimal, evidence-based time frame for returning to sports. The healing process for JOCD can be frustratingly slow for all parties involved; however, premature return to activity can be devastating. If the patient has completed growth, then the bone can be cut and realigned with a metal plate or an external fixator, which is a much more invasive procedure than guided growth in the growing patient.82, There are few evidence-based recommendations in the literature for postoperative rehabilitation following surgical interventions for JOCD lesions of the knee. The dosage was consistent with that recommended by Costello and Jeske.39 Upon completion of the iontophoresis, the skin under the active and dispersive electrodes was examined for any abnormal reactions to the direct current stimulation. A full re-examination was performed and a decision for discharge was made in agreement with the patient. Although conservative management of OCD at the knee typically consists of limited weight bearing for 6 to 8 weeks and often is not even recommended for adult patients (>20 years), my decision to treat this patient was based on the “favorable” conditions8 of her OCD lesion and the specific goals she had for physical therapy. The patient, however, was reluctant to use an assistive device and decided instead to initiate the first 2 strategies. M JC We suggest the use of safe zones as a means of protection for the healing tissue. He can walk okay but he has problems on steps, stairs, hills, and inclines. This condition occurs when a piece of the bone partially or fully separates from the end of the bone that forms a joint. The transarticular technique penetrates the articular cartilage through small drill holes. She reported minor “fatigue” in the right lower extremity at the end of her 8-hour workday. Aichroth The active electrode was then resecured with tape and the patient was instructed to leave it in place for 8 to 12 hours as tolerated. Surgical treatment is indicated mainly by lesion stability, physeal closure, and clinical symptoms. Therefore, it appears that careful and controlled loading of the articular lesion must be considered given its potential to contribute to healing during conservative management.32,54. Report of a kindred, Role of magnetic resonance imaging and clinical criteria in predicting successful nonoperative treatment of osteochondritis dissecans in children, The clinical utility and diagnostic performance of MRI for identification and classification of knee osteochondritis dissecans, Juvenile osteochondritis dissecans of the knee: perifocal sclerotic rim as a prognostic factor of healing, Subsequent injury patterns in girls' high school sports, Current concepts in the rehabilitation following articular cartilage repair procedures in the knee, Effects of cryotherapy on arthrogenic muscle inhibition using an experimental model of knee swelling, Matching osteochondritis dissecans lesions in identical twin brothers, Vascular foramina and arterial supply of the distal end of the femur, Indications for surgical management of osteochondritis dissecans of the knee in the pediatric population: a systematic review, Juvenile osteochondritis dissecans of the knee: predictors of lesion stability, Osteochondritis dissecans knee histology studies have variable findings and theories of etiology, A predictive factor in osteochondritis dissecans: a radiographic analysis, Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament. Kendall Ulett S OCD is defined as “a fragment of articular cartilage together with subchondral bone that has become separated partly or completely from a joint surface”. Therefore, clinical diagnosis currently relies on plain radiographs and MRI.123, Radiographs are useful to visualize subchondral involvement of a JOCD lesion in the femoral condyle; however, the sensitivity and specificity of radiographs for diagnosis have never been evaluated. Thank you for submitting a comment on this article. This may result in separation and instability of a segment of cartilage and free movement of these osteochondral fragments within the joint space.That process can lead to pain, loose body formation and joint effusion. . Magnetic resonance imaging also enhances the visibility of bone cysts, subarticular high-signal lines, and articular cartilage fissures that may affect prognosis and treatment.30 For identifying JOCD knee lesions, MRI has been found to have a sensitivity ranging from 78% to 100%, a specificity ranging from 95% to 100%, and an accuracy of 100%.61,73 These findings for MRI are similar to those for radiographs and physical examination combined.61 Typically, all 3 methods are used for diagnosis and to make treatment decisions. This nomogram was found to be 80% sensitive and 57% specific.66 Another nomogram has been developed that identified younger age, narrower normalized lesion width, and smaller cyst-like lesion size as predictors of healing after 6 months of nonoperative treatment.66 This nomogram was 60% sensitive and 84% specific.66 Although lesion stability typically dictates whether a patient will be treated operatively versus nonoperatively, little evidence is available to support this convention.19,20, Juvenile osteochondritis dissecans lesions are typically managed with an initial trial of nonoperative treatment involving restriction of physical activity and/or weight bearing.15,25,28,46,124 Patients are instructed to stop activities that cause repetitive stress to the affected joint, including all contact sports, running, jumping, excessive squatting, long periods of standing, and compressive stress to the joint (eg, skiing, skateboarding). When this damage occurs, what happens is that a fragment of the cartilage comes loose from the bone. Byl Damage to the secondary growth plate could then disrupt new bone production. Osteochondritis dissecans (OCD) of the elbow doesn't occur in immature throwing athletes very often so there isn't a lot of information about it to help guide treatment. Li , White DJ. Early work by Singh and Roberts,46 using salicylic acid with rats, suggested that increased cutaneous blood flow aided clearance of the solute from the skin. Wall, Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229. Children as young as nine or ten can develop this condition. Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis. B . OCD most commonly occurs in individuals between the ages of 10 and 20, typically affecting males more than females. Osteochondritis dissecans affects joints, most frequently the knee, in children and adolescents. Osteochondritis dissecans causes pain in the affected joint. Linden On radiographs, most JOCD lesions appear as a dark, bone-deficient area just beneath the cartilage surface.16,44 Due to their frequent posterior location, many JOCD lesions can only be visualized on a tunnel or notch-view radiograph. Magnetic resonance imaging (FIGURE 4) is the diagnostic method of choice for assessing the supporting bone and cartilage quality of a JOCD lesion, which may appear normal on plain radiographs and arthroscopy. The authors of this article recommend that a “safe zone,” defined as the arc of motion in which the tibia does not contact the femur JOCD lesion, be determined from the preoperative MRI scan. Osteochondritis dissecans (OCD) is a problem that affects the knee, mostly at the end of the big bone of the thigh (the femur). Therapy, level 5. Wilson's sign, which measures the pain produced from extending the knee while internally rotating the tibia, is no longer considered a reliable or specific test for JOCD.24,25 Unfortunately, an effective clinical exam for JOCD has yet to be identified and validated. Anderson et al43 also hypothesized that increased cutaneous blood flow, resulting from high-current iontophoresis (1.5–4.0 mA), may aid clearance of DEX-P, resulting in lower penetration of the drug into subcutaneous tissues. During the physical exam, your doctor will press on the affected joint, checking for areas of swelling or tenderness. JD Long-term results of excision of the fragment, Familial osteochondritis dissecans and dwarfism, Biochemical changes in articular cartilage after joint immobilization by casting or external fixation, Transchondral fractures (osteochondritis dissecans) of the talus, Osteochondritis (osteochondrosis) dissecans: a review and new MRI classification, Functional and radiographic outcomes of juvenile osteochondritis dissecans of the knee treated with extra-articular retrograde drilling, Results of drilling osteochondritis dissecans before skeletal maturity, Articular cartilage: injuries and potential for healing, Osteochondral repair of primate knee femoral and patellar articular surfaces: implications for preventing post-traumatic osteoarthritis, Treatment of juvenile osteochondritis dissecans and osteochondritis dissecans of the knee, Osteochondritis dissecans of the knee: treatment of juvenile and adult forms, The three critical components in the conservative treatment of juvenile osteochondritis dissecans (JOCD). Juvenile Osteochondritis Dissecans. Several validated outcome questionnaires exist for children with knee conditions and may be useful tools for health care professionals to evaluate, compare, and advance the different treatment and rehabilitation approaches to JOCD. Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis? It was my responsibility to provide the patient with information that may help to limit further future injury to her knee. The fourth visit, he described patients with stable OCD lesions can lead to subsequent How! Cs, Harth M. Saggini R, et al fatigue ” in the adolescent athlete that involves damage to area! Active teens between the ages of 10 and 20, typically after a twisting injury of the bone partially fully... Is different from various other types of joint pain that commonly have an effect the... M. De Smet AA knee is an obtained, reversible, idiopathic condition of the ankle may help limit! 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