What is an OCD lesion of the knee? What treatment options exist for a young athlete? When is surgery for osteochondritis dissecans necessary? I address these concerns in my latest Ask Dr. Geier column.
Victor in Portugal asks:
Good day . I am writing from Portugal and I am a concerned parent seeking the best medical solution for my son. Nothing guarantees your answers to my questions, but had to try, anyway thanks. My son and practicing football and now has 13. At about 1.5 years and after complaints in his left knee, did tests and found that one had osteochondritis dissecans “in situ” ie without fragment displacement. There was a conservative treatment, without sports and rest for 6 months. At the end of this period, gradually resumed practicing sports, playing sports without being limited to about one year. Throughout this period there were no complaints, pain, or inflammation of the knee. At about 15 days and during a game, making a rotation and held the foot felt a snap in the knee followed by mild inflammation and pain. The next day did MRI scans and X-rays and there was the release of free bone fragment in the knee joint and with apparent origin in the former osteochondral lesion. At this point the doctors in Portugal suggest surgery to fraguemento extraction and treatment of osteochondral lesion of about 12mm in size with the microfracture process. There is also the possibility to associate the treatment with growth factors. My question is: For a young man with 13, with the condition that the correct option and including microfracture. Treatment with growth factors and safe for this age. There is scientific evidence that treatment with these factors is a benefit in the regeneration of tissues. (Bone and cartilage) Given the age of 13 years where the possibility of a good recovery and that the possibility of returning to active sports. The make is the type of surgical treatment which the average recovery time for the beginning of the sport. There is now an alternative to surgical technique or clinical situation worldwide. My thanks for your help.
What is osteochondritis dissecans?
Osteochondritis dissecans is a condition that affects young athletes, usually between 9 and 15. It mainly occurs in the knee, but it can occur in other joints, like the capitellum of the elbow. The bone under the articular cartilage in part of the knee dies. Early in the process, the overlying articular cartilage remains intact, but if it fractures or fragments, the piece of bone and cartilage can break off and become a mechanical block to knee motion and function. In general, treatment can be difficult, and selecting the appropriate treatment depends on a number of factors.
Non-surgical treatment of an OCD lesion
When an osteochondritis dissecans fragment is not displaced, especially if the articular cartilage is intact, nonoperative treatment can be tried. Healing of the lesion by limiting weight bearing on the lower extremity actually has good success rates in kids who have not stopped growing. If x-rays and MRIs show that these nondisplaced lesions are still not healing, then early surgery is often performed. In these cases, drilling small holes in the bone to try to allow blood to get to the bone often helps the lesion heal.
If the lesion doesn’t heal, and the fragment of bone and cartilage breaks off, treatment options and surgery for osteochondritis dissecans become much more difficult. If the surgeon discovers the problem quickly, it is occasionally possible to put the lesion back in place and hold it with pins or screws. Fixation of the lesion is ideal if it works because it is the patient’s own bone and cartilage and has the correct geometry. Unfortunately it is often unsuccessful.
Fragment excision alone to keep this lesion from damaging the rest of the knee does not have good results. I often compare it to a pothole in a road. Removing the loose body prevents it from catching on other structures in the knee, but the pothole is still there, so to speak. It is essential to fill in the lesion with bone and cartilage somehow to create smooth surfaces for the knee to be able to withstand impact from sports and other activities going forward.
Surgery for osteochondritis dissecans
Microfracture, which is essentially using a fancy pick to make 2-3mm holes in the bone throughout the lesion, is an option for pure cartilage injuries. While many surgeons might disagree, I don’t think it has much of a role in the treatment of osteochondritis dissecans because the underlying bone is dead. Microfracture does not fill in bony defects. If it is successful in creating fibrocartilage, it will do so at the base of the lesion and not in a smooth contour where the cartilage needs to be.
Options to fill in the bone and cartilage typically involve transferring one or more cylinders of bone and cartilage from either the patient’s knee or from a donor. If it is a small lesion (less than 10mm ideally, but it can be done in lesions up to 20mm in diameter), one or more small cylinders can be harvested from nonweightbearing areas in the knee. These cylinders of bone and cartilage can then be implanted in the defect. If it is larger, then the surgeon can obtain part of a femur from a donor that matches the size of the patient. He or she can then take a cylinder of bone and cartilage from the corresponding area and place it in the patient’s knee.
As for growth factors to augment healing, it is hard to comment. If the surgeon means platelet-rich plasma, that could be an option. I don’t know of many studies that have looked at PRP to augment healing in mosiacplasty, osteochondral allografts, or even microfracture surgery, but it might not be an unreasonable addition. The theory behind PRP is that taking blood from the patient and reinjecting the plasma and platelets with their growth factors will help stimulate an inflammatory response and help tissue heal. While media attention and patient interest in PRP has grown in recent years, especially with many high-profile athletes undergoing it for a number of problems, some recent studies have suggested that it might not be terribly effective.
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