Internal fixation of unstable Cahill Type-2C osteochondritis dissecans lesions of the knee in adolescent patients.
ABSTRACT The treatment of osteochondritis dissecans lesions remains controversial. Twelve adolescent patients, with average 6-year follow-up, underwent compression screw fixation of unstable Cahill Type-2C osteochondritis dissecans lesions. Postoperatively, patients were evaluated with several functional tests and scoring systems, including Lysholm, IKDC, and KOOS. All lesions healed, and no clinical or radiographic evidence of degenerative disease was noted. No significant differences in thigh girth, range of motion, stability, or single-leg-hop distance was observed when compared to the unaffected, contralateral extremity. This technique is appropriate and efficacious for the treatment of unstable osteochondritis dissecans lesions.
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ABSTRACT: Osteochondritis dissecans of the knee is identified with increasing frequency in the young adult patient. Left untreated, osteochondritis dissecans can lead to the development of osteoarthritis at an early age, resulting in progressive pain and disability. Treatment of osteochondritis dissecans may include nonoperative or operative intervention. Surgical treatment is indicated mainly by lesion stability, physeal closure, and clinical symptoms. Reestablishing the joint surface, maximizing the osteochondral biologic environment, achieving rigid fixation, and ensuring early motion are paramount to fragment preservation. In cases where the fragment is not amenable to preservation, the treatment may include complex reconstruction procedures, such as marrow stimulation, osteochondral autograft, fresh osteochondral allograft, and autologous chondrocyte implantation. Treatment goals include pain relief, restoration of function, and the prevention of secondary osteoarthritis.Sports Health A Multidisciplinary Approach 07/2009; 1(4):326-34.
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ABSTRACT: Determination of appropriate treatment options for adult osteochondritis dissecans is difficult, as most published papers on surgical osteochondritis dissecans treatment report outcomes in a population consisting of both adult and juvenile patients. This study examines the outcomes of surgical procedures in patients with adult osteochondritis dissecans. Case series; Level of evidence, 4. The cohort included 46 adult patients (48 knees) with adult osteochondritis dissecans of the knee who had undergone surgical treatment (debridement, drilling, loose-body removal, arthroscopic reduction and internal fixation, microfracture, osteochondral allograft, or autologous chondrocyte implantation). The average patient age was 34 +/- 9.5 years (range, 20-49) and patients were followed for 4.0 +/- 1.8 years. The mean defect size was 4.5 +/- 2.7 cm(2). Outcomes were assessed via clinical assessment and established outcome scales, including the Lysholm, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Tegner, Cincinnati, and Short Form-12. Statistically significant improvement (P < .05) was noted in all outcome scales, including Noyes, Tegner, Lysholm, IKDC, KOOS (subdivided into 5 categories including Pain, Symptoms, Activities of Daily Living, Sport, and Quality of Life), Short Form-12 Physical, and Short Form-12 Mental. Seven knees (14%) had clinical failure of the initial treatment and underwent a revision procedure at a mean follow-up of 14 months. Patients treated with arthroscopic reduction and internal fixation and loose-body removal demonstrated a statistically higher postoperative percentage score increase for the KOOS Sport (P = .008) and KOOS Quality of Life (P = .03) categories than those treated with an osteochondral allograft. Patients with adult osteochondritis dissecans of the knee, treated with surgical cartilage procedures, show durable function and symptomatic improvement at a mean 4.0 years of follow-up. Patients treated with arthroscopic reduction and internal fixation and loose-body removal demonstrated a greater improvement in outcome scores than those treated with osteochondral allograft.The American journal of sports medicine 10/2009; 37 Suppl 1:125S-30S. · 3.61 Impact Factor
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ABSTRACT: PURPOSE OF REVIEW: Osteochondritis dissecans (OCD) of the knee is a well-described condition that can cause significant morbidity in children and adolescents; timely diagnosis is key to preventing compromise to the articular cartilage and maximizing opportunity to perform a restorative procedure. Juvenile OCD has a better prognosis than does adult OCD, with higher rates of spontaneous healing with conservative treatment. Still, there are certain indications for surgical restoration procedures. Controversies arise over when to decide surgical procedure and what is the best surgical treatment option in this young population. RECENT FINDINGS: Some authors believe nonoperative management should be the first-line treatment for stable OCD lesions in children. The only consensus in regard to this modality is that, if a patient is truly asymptomatic or experiencing low-level symptoms, then the duration of nonoperative treatment should be at least 3-6 months before opting for operative treatment. In the case of failed nonsurgical management or in the setting of an unstable fragment, surgical intervention should be implemented. Recent published data suggest no difference in clinical or radiographic outcome when comparing different surgical techniques. SUMMARY: OCD of the knee requires a timely diagnosis to maximize opportunity to perform a reparative procedure. Indications for surgical treatment are based on lesion stability, skeletal maturity, and clinical symptoms. Reestablishing the joint surface, improving the blood supply of the fragment, rigid fixation, and early motion are primary goals for osteochondral fragment preservation. When the fragment is not suitable for preservation, careful consideration of defect location and the patient's clinical presentation will determine when cartilage restoration procedures should be utilized.Current opinion in pediatrics 11/2012; · 2.01 Impact Factor
JUNE 2007 | Volume 30 • Number 6 1
■ Brief Report
Internal Fixation of Unstable Cahill
Type-2C Osteochondritis Dissecans
Lesions of the Knee in Teenage
ANDREAS H. GOMOLL, MD; KYLE R. FLIK, MD; JENNIFER K. HAYDEN, MSN; BRIAN J. COLE, MD, MBA;
CHARLES A. BUSH-JOSEPH, MD; BERNARD R. BACH JR., MD
Dr Gomoll is from the Department of Ortho-
pedic Surgery, Brigham and Women’s Hospital,
Boston, Mass; Dr Flik is from the Department of
Sports Medicine, Northeast Orthopaedics, LLP,
Albany, NY; Drs Hayden, Cole, Bush-Joseph, and
Bach are from the Division of Sports Medicine,
Department of Orthopaedic Surgery, Rush Uni-
versity Medical Center, Chicago, Ill.
Correspondence should be addressed to:
Bernard R. Bach, Jr., MD, The Claude N. Lam-
bert, MD–Helen S. Thomson Professor, Director,
Division of Sports Medicine, Dept of Orthopedic
Surgery, Rush University Medical Center, 1725 W
Harrison St, Ste 1063, Chicago, IL 60612.
The treatment of osteochondritis dissecans (OCD) lesions remains contro-
versial. We present a case series of 12 teenage patients with average 6 year
follow-up after compression screw fi xation of unstable Cahill Type-2C OCD
lesions. Postoperatively, patients were evaluated with several functional
tests and scoring systems, including Lysholm, IKDC, and KOOS. All lesions
healed, and no clinical or radiographic evidence of degenerative disease
was noted. No signifi cant differences in thigh girth, range of motion, stability,
or single-leg-hop distance was observed when compared to the unaffected,
contralateral extremity. We conclude that this technique is appropriate and
effi cacious for the treatment of unstable OCD lesions.
thought to be an infl ammatory phenom-
enon, various investigations point to vas-
cular insuffi ciency,11 repetitive microtrau-
ma,10 and genetic factors9 as playing a role
in the etiology of this disease. Prognosis
and treatment recommendations are pri-
marily determined by the patient’s bone
age, and secondarily by characteristics of
the lesion (ie, location, fragmentation and
stability).4 Osteochondritis dissecans le-
sions of the knee have an incidence that is
estimated between 0.02% and 1.2%,1,7 are
more common in boy than girls by a fac-
tor of 2, and typically manifest between
he specifi c pathophysiology of
osteochondritis dissecans (OCD)
remains controversial. Originally
10 and 15 years of age. Both knees should
be routinely imaged as bilateral presenta-
tion occurs in 15%-30% of cases.5
A large, controlled trials has not been
conducted to investigate different treat-
ment modalities for OCD lesions. There-
fore, treatment recommendations often
are based on smaller case series and per-
sonal experiences of treating physicians.
However, there appears to be a consen-
sus that nondisplaced, smaller lesions
(?2 cm), in the classic location on the
lateral aspect of the medial femoral con-
dyle have a better prognosis—especially
in children with open growth plates.5
Conversely, unstable or displaced lesions
after physeal closure have little poten-
tial for healing and should therefore be
treated surgically, preferably by fi xation
of the fragment in its original bed.2 Sev-
eral authors have reported on their expe-
rience with compression screw fi xation
of unstable OCD lesions.6,8,12 These re-
ports mostly consisted of small case se-
ries with comparatively short follow-up,
but reported ?80% good and excellent
results with this technique.
We present a case series of 12 teenage
patients that were treated with internal fi x-
ation of unstable OCD lesions of the knee.
Patients were observed with clinical and
radiographic examination for ?2 years.
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■ Brief Report
MATERIALS AND METHODS
Through a retrospective, IRB-approved
review of the surgical logs of three senior
surgeons at our institution (B.R.B., C.A.B-
J., B.J.C.) for the years 1990-2002, 22
teenage patients were identifi ed as meeting
the following inclusion criteria: unstable
OCD lesion; classic location; treated with
internal fi xation; minimum 2-year follow-
up. Even though patients were identifi ed
retrospectively, data collection had been
performed in a prospective manner with
regular radiographic and functional evalu-
ation. Of 22 patients, 9 patients could not
be located, and 1 patient was unwilling to
return for a follow-up examination, leav-
ing 12 patients for inclusion into the study.
These patients were evaluated by a singe
surgeon (K.F.) who was uninvolved in the
patients’ prior surgical care in an attempt
to minimize surgeon’s bias.
All patients had undergone pre-op-
erative evaluation with conventional ra-
diographs (Figure 1) as well as magnetic
resonance imaging (MRI) to classify the
lesion (Figure 2). Based on the system
described by Cahill and Berg,3 all defects
were described as 2C lesions located in
the classic, eccentric position in the lat-
eral aspect of the medial femoral condyle.
Magnetic resonance imaging demonstrat-
ed a high signal consistent with fl uid be-
hind the fragment (Figure 2B)—a fi nding
characteristic for unstable OCD lesions.
However, lesions were not displaced out
of their bed.
Patients presenting to our facility with
a symptomatic, nondisplaced OCD lesion
undergo an initial nonoperative treatment
course aimed at decreasing joint infl am-
mation and achieving union of the le-
sion. The program consists of short-term
immobilization, followed by a period of
?6 weeks of nonweight bearing. Subse-
quently, patients are asked to modify their
activities to avoid impact-loading of the
lesion. Persistent pain for ?3-5 months
and apparent nonunion on radiographs
and/or MRI are indications to consider
surgical fi xation. All patients in this study
participated in this protocol, and elected
for surgical intervention due to failure of
conservative management. One patient
with a concomitant anterior cruciate liga-
ment tear was treated acutely.
No patients had undergone prior surgi-
cal procedures for this, or any other patho-
logic entity of the ipsilateral knee.
All patients underwent arthroscopic or
mini-open internal fi xation of the OCD le-
sion with a compression screw. Initially, the
lesions were localized through a standard
diagnostic arthroscopy of all three com-
partments of the knee. If found to be not
amenable to arthroscopic fi xation, a mini-
arthrotomy was performed to expose the
defect. The lesions were then opened to ex-
pose the often sclerotic bed. This was per-
formed by superfi cially releasing fi bers of
the posterior cruciate ligament insertion to
expose the lateral margin of the lesion (Fig-
ure 3) which was then hinged open slightly
on a medial cartilage bridge. Thereafter,
the bony bed was prepared with a curette
and microfracture awl as needed to remove
Figure 1: AP (A) and lateral (B) radiographs of an OCD lesion in the medial femoral condyle. Figure 2: Coronal (A) and sagittal (B) MRI cuts depicting an OCD lesion
in the femoral condyle. Note the sclerotic appearance of the defect bed, and presence of a bright fl uid signal behind the fragment. Figure 3: The fragment is carefully
mobilized, often requiring a release of superfi cial fi bers of the PCL. Figure 4: Compression screw fi xation: a guide wire is drilled through the fragment into the femoral
condyle (A); the guide wire is overdrilled (B); the screw is placed, compressing the fragment into the bed (C); at the end of the procedure, the knee is taken through
a range of motion to ensure that the screw head is seated under the articular surface and does not abrade against the opposing surface (D).
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INTERNAL FIXATION OF OSTEOCHONDRITIS DISSECANS LESIONS | GOMOLL ET AL
or perforate the sclerotic surface. The le-
sion was reduced back into its bed, and
fi xated with either one or two conventional
3.5-mm AO compression screws, or stan-
dard Acutrak headless screws (Acumed,
Beaverton, Ore), based on surgeon’s pref-
erence (Figure 4).
Patients were kept nonweight bear-
ing on crutches for 6-8 weeks. Physical
therapy with range of motion (ROM) ex-
ercises as tolerated and straight-leg-rais-
ing–quad-strengthening was instituted on
postoperative day 1. Patients returned for
follow-up after 7-10 days for suture re-
moval. Radiographs were obtained at this
visit (Figure 5), as well as after 6 weeks.
Based on surgeon’s preference, screws
were removed between 8 and 10 weeks,
either arthroscopically or through a mini-
arthrotomy. Postoperatively, patients were
rapidly advanced to full-weight bearing,
but were restricted from impact activities
for 4 to 5 months. They were observed
clinically and radiographically every 3
months for 1 year.
At follow-up, patients were assessed
with several well-established and vali-
dated scoring systems. In addition, the fol-
lowing parameters were recorded in both
legs: thigh girth, alignment, knee ROM,
presence of effusion, and single-leg-hop
distance. Standard anteroposterior, fl exion
posteroanterior, and fl exion lateral weight-
bearing radiographs were obtained at fi nal
follow-up (Figure 6).
Findings in the operated extremity
were compared to the uninvolved, con-
tralateral extremity with the use of the
Student’s t test. The level of signifi cance
was set at 0.05.
Twelve patients (10 males, 2 females)
were evaluated at an average of 6 years
(range: 24-184 months) after surgical
fi xation of an unstable OCD lesion. The
average age at the time of surgery was 16
years (range: 12-19 years) (Table 1). At
Epidemiologic Characteristics of Study Population
Gender 10 males, 2 females
Average Age (years)16 (range: 12-19)
Affected side 8 left, 4 right knees
Average lesion size (cm2)4.85 (range: 1.8–7.5)
Fixation techniqueAcutrek screw (8); 3.5-mm AO screw(4)
Average time from symptoms to surgical
fi xation (months)
17 (range: 0.5–84)
Average follow-up (months)72 (range: 24–184)
Noyes Activity Scale86.714.955100
Tegner Activity Score8.2 2.1410
IKDC82.8 15.358 100
Pain89.9 10.4 75100
Symptoms87.5 10.7 71 100
ADL96.8 3.788 100
Sports participation 80.416.2 50100
QoL79.7 17.1 50100
PCS 44.72.6 4150
Abbreviations: IKDC?Internation Knee Documention Committee, KOOS?Knee and
Osteoarthritis Outcome Score, ADL?activities of daily living, QoL?quality of life,
Figure 5: Postoperative radiographs showing fragment fi xation with two compressive screws in AP (A)
and lateral (B) views. Figure 6: AP (A) and lateral (B) radiographs 6 years after OCD fi xation and subse-
quent screw removal showing a well-healed lesion and no degenerative changes.
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■ Brief Report
the time of secondlook arthroscopy for
hardware removal, all lesions appeared
to be stable to probing. No surgical or
postsurgical complications occurred. One
patient had a subsequent chondroplasty 6
years after the index procedure. The frag-
ment was found to be stable, but had de-
veloped a small chondral defect where it
bordered on surrounding cartilage.
On physical examination at the most
recent follow-up, all patients demonstrat-
ed normal gait; one patient had a small ef-
fusion. No statistical difference was noted
in ROM, thigh girth, ligamentous stability,
or tenderness to palpation when compared
to the contralateral extremity. Functional
evaluation with a single-leg-hop test dem-
onstrated no statistically signifi cant dif-
ferences with an average distance of 133
cm on the affected, and 136 cm on the
unaffected side. All patients reported be-
ing satisfi ed with the outcome, and would
undergo the same procedure again. Table
2 reports the results of patient assessment
through a variety of scoring systems.
Radiographic evaluation at the time
of fi nal follow-up demonstrated normal
alignment, healed lesions, and no arthritic
changes in all patients.
Our results demonstrate that internal
fi xation of unstable OCD lesions of the
knee provides a stable and functional
knee, even in the active teenage popula-
tion. Our patients reported excellent satis-
faction with their functional outcomes and
an overall low morbidity at a minimum of
2 years after fi xation; all patients reported
that they would undergo surgical fi xation
again. These fi ndings are in agreement
with prior studies that have demonstrated
good to excellent results in ?80% of pa-
tients6,8,12; the classic articles of Johnson6
and Thomson12 describing compression
screw fi xation of OCD lesions found good
or excellent outcomes reported by 88%
and 80% of patients, respectively; Maki-
no’s8 more recent article from 2005 found
healing in 14 of 15 lesions treated with
Herbert screw fi xation.
Further analysis of our data showed no
signifi cant differences in outcomes based
on size of the lesion. Even though not
statistically signifi cant, a trend was noted
towards worse outcome with longer delay
Our study shares the limitations of prior
publications, such as a comparatively small
patient population. We were able to locate
only 12 of 22 patients for follow-up, an
issue commonly encountered in a young
and geographically mobile group. Also,
the age span at the time of operation was
7 years (12-19 years), thus including both
skeletally mature and immature patients.
Even though outcomes of OCD treatment
are known to vary in these two groups, this
holds mainly true for conservative manage-
ment of stable lesions. Unstable fragments,
such as seen in our patient population, have
a low chance of healing in either age group,
and we feel that our results are therefore
not excessively infl uenced by this factor.
Arthroscopic or mini-open fi xation of
unstable Cahill Type-2C OCD lesions in a
teenage population has demonstrated excel-
lent patient satisfaction with low morbidity
at an average of 6 years after surgery.
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What is already known on this topic
■ Osteochondritis dissecans lesions of the knee have an incidence that is estimated
between 0.02% and 1.2%, are more common in boy than girls by a factor of 2, and
typically manifest between 10 and 15 years of age.
■ Smaller lesions (?2 cm), in the classic location on the lateral aspect of the medial
femoral condyle have a better prognosis—especially in children with open growth plates.
■ Treatment of unstable OCD lesions in an active, teenage population by compres-
sion screw fi xation led to predictable healing in all cases.
■ Patients reported high satisfaction and a virtually normal knee function.
What this article adds
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