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Osteochondritis Dissecans of the Femoral Head
Abstract
Seven patients with symptomatic osteochondritic lesions of the femoral head are presented. All were male with a mean age of 26 years (16 – 33 years). Two distinct morphologic appearances of the hip joint could be identified. Five patients presented with a coxa valga deformity, four of whom had signs of epiphyseal dysplasia. There were 2 patients whose hips appeared normal apart from the osteochondrontic lesions. In both cases an additional acetabular rim lesion due to a reproducible femoro-acetabular impingement was diagnosed at arthrotomy. This may have acted as the underlying cause of osteochondritis dissecans in these cases.
All 7 patients underwent surgical treatment. An intertrochanteric osteotomy (I.O.) alone was performed in 2 patients. Follow-up of these patients at 6.5 and 8.5 years after surgery revealed that the osteochondritic lesions had not healed and one individual remained symptomatic. In the remaining 5 patients, treatment consisted of femoral head dislocation and screw fixation of the osteochondritic lesion. This was combined with an I.O. in two of these patients for coxa valga and osteoplasty of a broad femoral neck in 2 other patients. All lesions had healed at an average follow-up of 4.3 years (2 – 8.5 years). Three patients were asymptomatic and 2 patients had minor residual pain. No progressive osteoarthritic changes or signs of avascular necrosis of the femoral head were observed.
... Many reports discussed focal lesions with subchondral bone collapse, development of epiphyseal distortion with coxa magna, and subsequent articular loose body formation; these cases did not represent idiopathic presentations of these lesions. [21][22][23][24][25] One of the primary overlapping pathologies reported in the literature is Legg-Calve-Perthes (LCP) disease. 21,22,25 There seems to be both a trend to identify LCP disease as an etiology for the femoral head OCD, and also to report both in the same article as if they represent similar pathologies. ...
... 27 Despite these confounding reports, there do appear to be a few case reports that may actually represent OCD of the hip joint, and they involve both the femoral head and the acetabulum. 23,25,26,[28][29][30][31][32] Acetabulum OCD appears to be the rarest form of this pathology, occurring truly as singular case reports at least 3 times. 28,31,32 Each was confirmed by advanced imaging demonstrating findings most consistent with an OCD, and the treatment for each person was distinct, ranging from expectant observation to surgical dislocation and curettage of the lesion. ...
... This patient was treated with arthroscopic removal of loose body that has, at least temporarily, relieved symptoms of pain at the hip (Fig. 3C). Femoral head OCD appears to be more common than that of the acetabulum, 23,25,26,29,30 although, due to the overlap and associated diagnosis of LCP in the literature, the true incidence is unknown. 23,25,26,29 Limiting the diagnosis of OCD of the femoral head to those cases when the rest of the femoral head appears normal, there are only 9 confirmed cases in the literature. ...
Shoulder and hip osteochondritis dissecans (OCD) are uncommon. Both glenoid and humeral head OCD are commonly associated with a traumatic etiology. Humeral head OCD can be treated with observation or drilling of the sclerotic margin for stable or unstable lesions. Glenoid OCD often presents with delamination of the articular cartilage and requires debridement and fixation of fragments. Hip OCD often involves the femoral head; yet, there are case reports of acetabular involvement. The etiology of femoral OCD is associated with other pathologies, and therefore may represent the sequelae of other disease processes. Hip lesions often require extensive surgical intervention.
... The natural history of femoral head osteochondritis dissecans is typically poor. 1,2,5 Options include, but are not limited to, drilling or excision of the osteochondritic fragments, 3 microfracture, chondroplasty, autologous chondrocyte implantation, autograft 6 or allograft 7 tissue transplantation, intertrochanteric osteotomy, 8 and hip arthroplasty. Recently, screw fixation of femoral head osteochondritis dissecans via open surgical dislocation of the hip has been successful in a small series with clinical improvement and radiographic union of the osteochondritic fragment. ...
... Recently, screw fixation of femoral head osteochondritis dissecans via open surgical dislocation of the hip has been successful in a small series with clinical improvement and radiographic union of the osteochondritic fragment. 8 Historically, hip arthroscopy has had a relatively minor role in the treatment of femoral head osteochondritis dissecans. Arthroscopy may aid in the staging of the condition, assessing the overlying articular cartilage, resecting loose fragments and debris, and treating concomitant chondrolabral pathology. ...
... Of the 7 patients in that series, the 2 patients treated without fragment internal fixation failed to unite, whereas the 5 patients treated with screw fixation demonstrated healing at an average 4.3-year follow-up without osteoarthritic progression. 8 The current case further supports the beneficial effect of fragment fixation. ...
Osteochondritis dessicans of the femoral head is an uncommon problem. Limited literature reports the incidence of osteochondritis dessicans and its treatment. The surgical technique used and outcomes for a 40-year-old man with symptomatic femoral head osteochonditis dissecans who was treated 11 years previously with retrograde drilling and hip arthroscopy are discussed.
Despite temporary symptomatic improvement without subchondral collapse after his index procedure, increasing pain a decade later was thought to be caused by a large apical osteochondritic fragment and chondrolabral dysfunction from femoroacetabular impingement. Acetabuloplasty of acetabular overcoverage permitted arthroscopic internal fixation of the bone fragment by improving screw trajectory. Labral refixation and femoroplasty were subsequently performed. At 18-month follow-up, his nonarthritic hip score improved from 53 to 76 and his osteochondritic lesion had healed radiographically.
Although clinical improvement with radiographic union has been reported following open screw fixation of femoral head osteochondritis dissecans, to the authors’ knowledge this is the first published case with a similar outcome using arthroscopic techniques. Clinical improvement and union of even long-standing osteochondritis dissecans of the femoral head may occur with arthroscopic fragment fixation. Hip arthroscopy may play significant therapeutic and diagnostic roles in the treatment of this condition while offering a less invasive alternative to open osteosynthesis.
... After releasing traction, cam osteochondroplasty was performed using a motorized round burr when indicated. Arthroscopic capsular repair was then performed as previously described [17]. ...
... It is suggested that SIFFH in the context of hip instability may be due to the presence of an acetabular labral tear, which is associated with bone deformities. Both open and arthroscopic fragment stabilization allows bone healing and union and improves symptoms of femoral head OCD [17]. Consistent with those studies, osseous union and significant clinical improvement was obtained in all of our patients that underwent arthroscopy with pin stabilization of unstable lesions in precollapse SIFFH. ...
Purpose:
The purposes of this study were to investigate (1) the clinical, radiographic and arthroscopic presentation of patients with subchondral insufficiency fracture of the femoral head (SIFFH) and (2) the outcomes following arthroscopic treatment with internal fixation using hydroxyapatite poly-lactate acid (HA/PLLA) threaded pins and concomitant arthroscopic treatment of associated findings.
Methods:
Nine patients (median age 49.0 years, range 43-65, five female and four male patients) with SIFFH who underwent arthroscopic treatment with labral repair, capsular closure and internal fixation of SIFFH using HA/PLLA pins were retrospectively reviewed. Inclusion criteria were adult patients with precollapse SIFFH with minimum 1-year follow-up (median follow-up 30.0 months, range 12-56).
Results:
Acetabular labral tears were observed in all patients. The median BMI was 24.3 kg/m(2) (range 20.1-31.8). Clinical presentations and radiographic measurements demonstrated mixed type FAI in six patients, borderline developmental dysplasia in two patients and pincer type FAI in one patient. The median MHHS significantly improved from preoperatively (67.1, range 36.3-78.0) to post-operatively (96.8, range 82.5-100; p = 0.001). The median NAHS significantly improved from preoperatively (34.0, range 17-63) to post-operatively (78.0 range 61-80; p = 0.001).
Conclusion:
SIFFH is associated with bony deformities and labral tears. Precollapse SIFFH can be treated with bioabsorbable pin stabilization of unstable lesions and treatment of associated intra-capsular pathology in those with stable lesions as determined by a new arthroscopic classification system with promising early outcomes.
Level of evidence:
IV.
... Na osteocondrite dissecante, as radiografias simples e a TC são suficientes para o esclarecimento diagnóstico ( Figuras 15A e B). (61) Nas lesões osteocondrais, a artro-TC ou, preferivelmente, a RM deve ser realizada para se constatar o defeito ou descontinuidade da cartilagem articular, característica dessas lesões. (62) ...
... . (A): Imagem radiográfica de um paciente com dor em quadril D, em que se observa um fragmento osteocondrítico na porção superior da cabeça femoral que à TC (B): mostra sua localização anterior. (61) (C): Imagem radiográfica em projeção A-P de uma paciente de 20 anos de idade, com dor em quadril direito, praticante de Taekwondo, que mostra vários cistos subcondrais na porção superior da cabeça femoral. (D). ...
... The mechanical forces exerted on the hip joint during weight-bearing activities further contribute to the development of chondral and osteochondral lesions. Over time, the weakened area can undergo further degeneration, leading to the detachment of a fragment of cartilage and bone [31,32]. ...
Chondral and osteochondral lesions encompass several acute or chronic defects of the articular cartilage and/or subchondral bone. These lesions can result from several different diseases and injuries, including osteochondritis dissecans, osteochondral defects, osteochondral fractures, subchondral bone osteonecrosis, and insufficiency fractures. As the cartilage has a low capacity for regeneration and self-repair, these lesions can progress to osteoarthritis. This study provides a comprehensive overview of the subject matter that it covers. PubMed, Scopus and Google Scholar were accessed using the following keywords: "chondral lesions/defects of the femoral head", "chondral/cartilage lesions/defects of the acetabulum", "chondral/cartilage lesions/defects of the hip", "osteochondral lesions of the femoral head", "osteochondral lesions of the acetabulum", "osteochondral lesions of the hip", "osteochondritis dissecans," "early osteoarthritis of the hip," and "early stage avascular necrosis". Hip osteochondral injuries can cause significant damage to the articular surface and diminish the quality of life. It can be difficult to treat such injuries, especially in patients who are young and active. Several methods are used to treat chondral and osteochondral injuries of the hip, such as mesenchymal stem cells and cell-based treatment, surgical repair, and microfractures. Realignment of bony anatomy may also be necessary for optimal outcomes. Despite several treatments being successful, there is a lack of head-to-head comparisons and large sample size studies in the current literature. Additional research will be required to provide appropriate clinical recommendations for treating chondral/osteochondral injuries of the hip joint.
... 11 Siebenrock et al reported a case of OCD in a 16-year-old with coxa valga. 12 Lee et al reported 13 cases of OCD following Legg-Calvé-Perthes disease in children from ages 7-11 years. 13 This report presents a rare case involving a femoral head OCD lesion in an early-adolescent boy with underlying acetabular dysplasia and coxa valga. ...
This case report describes an early-adolescent boy with an osteochondritis dissecans (OCD) lesion of the left femoral head secondary to significant acetabular dysplasia and coxa valga of the proximal femur. Patient underwent left proximal femur varus osteotomy. Follow-up imaging demonstrates healing and resolution of the OCD lesion. Future plan for left hip is periacetabular osteotomy, following triradiate cartilage closure, to correct acetabular dysplasia. The aim of this case report is to support clinicians in the assessment and treatment of this rare condition.
... 3.1.2 Causal relationship between symptoms and physiological factors will be discovered by causal discovery R Ganz (Siebenrock et al., 2010) proposed a surgical plan which can retain the vascular supply of the femoral head, to guarantee the oxygen and nutritional supply to the cells (Kramer et al., 2009). However, excessive vascular supply may be not conducive to recovery. ...
Although intelligent technologies has facilitated the development of precise orthopaedic, simple internal fixation, ligament reconstruction or arthroplasty can only relieve pain of patients in short-term. To achieve the best recover of musculoskeletal injuries, three bottlenecks must be broken through, which includes scientific path planning, bioactive implants and personalized surgical channels building. As scientific surgical path can be planned and built by through AI technology, 4D printing technology can make more bioactive implants be manufactured, and variable structures can establish personalized channels precisely, it is possible to achieve satisfied and effective musculoskeletal injury recovery with the progress of multi-layer intelligent technologies (MLIT).
... The detached bone fragment was not recovered. The localization in the cranial hemisphere of the femoral head is common for OCD in the hip joint (Siebenrock et al., 2010). ...
Objective
This study discusses the challenges and possibilities of establishing a definition for Ancient Rare Diseases (ARD) in a probable case of Legg-Calvé-Perthes Disease (LCPD) from the Bronze Age cemetery Kudachurt 14, situated in the Northern Caucasus.
Materials
We investigated the skeletal remains of a male aged 35–45 years at death. For comparison we examined other males buried at Kudachurt 14 (n = 24) and reviewed 22 LCPD cases from the paleopathological literature.
Methods
We use macroscopic as well as osteometric examination methods and imaging techniques.
Results
The morphology of the left hip joint corresponds to skeletal characteristics for LCPD. Co-occurring osteochondrosis dissecans, femoral anteversion, and atrophy of the left femoral shaft suggest a complex disease course.
Conclusions
Modern criteria of rare diseases applied on ancient skeletal remains are either non-transferable or require completion. We conclude that rarity is dynamic, etiological uncertainty has to be accepted, and the respective socioeconomic context is crucial. Degree of disability and level of sociomedical investment are not defining criteria for ARD.
Significance
Dating 2200-1650 cal BCE, this study currently presents the earliest case of probable LCPD. This is the first attempt to transform modern characteristics of rare diseases for establishing a paleopathological concept of ARD.
Limitations
As this study is limited to LCPD, our conclusions are not directly applicable to other ARD in question.
Suggestions for further research
More focused paleopathological research on skeletal populations from different cultures and time periods is needed, enabling an evolutionary perspective on the comparability of ancient, modern and future rare diseases.
... As the incidence of osteonecrosis of the femoral head (ONFH) is increasing and the age of onset become younger, [1] [2] [3] [4], how to retain the femoral head and to prevent it from collapsing, avoiding the total hip replacement arthroplasty (THRA) too early, are developing into the trend of early treatment of ONFH [5] [6] [7]. Arthroscopy assisted percutaneous spinal core decompression and the implantation of osteoinductive absorbing material (OAM) which compounded with autologous red bone marrow (ARBM) associated with titanium rod support to treat the state II ONFH were widely accepted by the academic circle. ...
Objective: To assess the curative effect of the stage II femoral head necrosis treated by arthroscopy assisted lesion clearance, bone graft and titanium rod support. Methods: All the patients (including 58 patients 74 hips) were diagnosed as stage II femoral head necrosis according to the ARCO staging system during 2003-2013. In these patients, 15 hips were stage IIA, 34 hips were stage IIB and 25 hips were stage IIC. Located by C-arm and assisted by arthroscopy, minimally-invasive percutaneous pulp core decompression and lesion clearance within the femoral head were accurately performed, and then, the OAM composite of autologous bone marrow was implanted and the femoral head was supported using the titanium rod. Follow-up including the pain score, the Harris hip score and X-ray observation for disease progression were achieved at 6, 12, 24 and 36 months postoperatively, Kaplan-Meier survival curve was used for the survival analysis. Result: The VAS score and the Harris score after operation were better THRAn THRAt of before the surgery, the difference had statistical significance (p < 0.05). As for the X-ray staging, 5 cases (5 hips) progressed from stage IIB to stage IIC, the femoral head of 6 cases (6 hips) staged IIC collapsed at 24 months after the operation and then underwent THRA after 30 months. In this study, the total improvement rate after the surgery was 79.72% (93.33% for IIA, 82.35% for IIB and 68% for IIC). The total survival rate of these patients was 64.2% (95% CI, 64.2% - 90.1%). Conclusion: Arthroscopy assisted lesion clearance, bone graft and titanium rod support to treat the stage II osteonecrosis of the femoral head are effective and can prevent the femoral head from collapsing. But for stage IIC patients who had a history of the use of hormone, this surgery should be chosen carefully because the outcome is always very poor.
... Osteochondritis dissecans of a concave cartilage surface, such as the acetabulum, is exceedingly rare (16). Osteochondritis dissecans of the hip is frequently associated with perifocal bone marrow edema or a history of Legg-Calvé-Perthes disease, traumatic dislocation, or surgery (17)(18)(19)(20)(21)(22)(23)(24). We did not observe bone marrow edema in the area of the SAF, perifocal sclerotic reaction, or a detached fragment or loose bodies in our patients with SAF. ...
... Osteochondritis dissecans of a concave cartilage surface, such as the acetabulum, is exceedingly rare (16). Osteochondritis dissecans of the hip is frequently associated with perifocal bone marrow edema or a history of Legg-Calvé-Perthes disease, traumatic dislocation, or surgery (17)(18)(19)(20)(21)(22)(23)(24). We did not observe bone marrow edema in the area of the SAF, perifocal sclerotic reaction, or a detached fragment or loose bodies in our patients with SAF. ...
To evaluate the frequency of the supraacetabular fossa (SAF) (pseudodefect of acetabular cartilage) at magnetic resonance (MR) arthrography of the hip and to compare the MR findings with those from arthroscopy.
All patients gave written permission for anonymized use of their medical data for scientific purposes before the imaging examination. The study was submitted to the institutional review board, and the need to obtain additional approval was waived. A medical student, a radiology fellow, and two senior radiologists reviewed 1002 consecutive MR arthrograms for the presence of an accessory bony fossa in the roof of the acetabulum, or SAF. SAF was classified into two types: type 1, which was filled with contrast material on MR arthrograms, and type 2, which was filled with cartilage. The width of the SAF was measured on coronal and sagittal MR images. MR arthrograms showing SAF were evaluated for subchondral reactions. Findings at MR arthrography were compared with those from arthroscopy in four hip joints with SAF type 1 and 13 with SAF type 2.
Sixteen of the 1002 hip joints (1.6%; four female and 12 male patients; mean age, 20.1 years) had SAF type 1 (mean width, 5.2 × 4.5 mm). Eighty-nine hip joints (8.9%; 43 female and 46 male patients; mean age, 37.8 years) had SAF type 2 (mean width, 5.1 × 4.7 mm). No subchondral changes were found around the SAF. No cartilage defect was seen at the site of the SAF at arthroscopy.
The high frequency of SAF on MR arthrograms (10.5%), the absence of subchondral reaction, and the absence of cartilage defects at arthroscopy indicate that the SAF of the acetabulum likely represents a variant.
Case
We describe the unique case of a 20-year-old man with a history of Legg-Calve-Perthes disease, hip dysplasia, and osteochondral fragmentation of the medial femoral head. We performed arthroscopic femoroplasty and femoral head allografting, followed by a valgus-producing derotational femoral osteotomy (DFO) and periacetabular osteotomy (PAO). At 1-year follow-up, the patient achieved osseous union and complete femoral head healing with return to his active hobbies.
Conclusion
We describe the successful utilization of arthroscopic allografting for medial femoral head osteochondral fragmentation. To our knowledge, this is the first report on femoral head arthroscopic allografting before DFO and PAO.
When femoral head chondropaties are located medially or parafoveal, they pose a challenge to arthroscopically reach the affected area through commonly used portals. Though surgical hip dislocation remains as the gold standard for treatment of such lesions, many patients reject surgery for its potential complications and postoperative demanding rehabilitation protocol. We aimed to describe the surgical technique for microfracturing osteochondral lesions of the femoral head with a 3.2-mm drill in an arthroscopically assisted manner and to describe the outcome of this procedure. We describe 9 transtrochanteric drillings throughout an otherwise uneventful arthroscopic treatment of femoroacetabular impingement pathology. All of them had a parafoveal osteochondral lesion unapproachable with curved awls through routinely used portals. After debriding the cartilage flap with a chondrotome, the surgical technique consisted of a minimally invasive 3.2-mm drilling through the femoral lateral cortex fluoroscopically guided. Mean follow-up was 55.8 months (range, 43 to 113 mo). Outcome was evaluated with the modified Harris Hip Score (mHHS) and healing was assessed through magnetic resonance imaging findings. Overall, all patients showed better results when comparing preoperative and postoperative mHHS (43.8 vs. 79.5; P=0.0008). No complications were reported due to the surgical technique. Complete healing of the osteochondral lesion was confirmed in 7 of 9 cases, and partially in one. One patient with Tönnis 2 preoperative changes required conversion to total hip arthroplasty at 80-month follow-up. Retrograde drilling was a valid option for treating small-sized medially located osteochondral lesions of the femoral head which are difficult to treat through standard arthroscopic portals.
Background:
Osteochondritis dissecans (OCD) is estimated to occur in 2% to 7% of patients with Legg-Calvé-Perthes disease (LCPD). Unstable osteochondral fragments secondary to LCPD may produce mechanical symptoms requiring surgical intervention. Reattachment of the fragment with open reduction and internal fixation (ORIF) may provide good clinical outcomes. The purpose of this study is to report short-term clinical and radiographic results of ORIF for the treatment of symptomatic osteochondral lesions resulting from LCPD.
Methods:
Clinical data including patient demographics and patient-reported outcome scores were collected prospectively. All patients underwent preoperative radiographs and magnetic resonance imaging confirming an unstable OCD fragment as well as postoperative radiographs at regular intervals. Indications for ORIF of the OCD fragment were hip pain and mechanical symptoms with radiographic evidence of LCPD and a magnetic resonance imaging demonstrating an OCD fragment of the femoral head. Osteochondral fragment instability was confirmed intraoperatively. Preoperative and postoperative physical examination findings were documented. All patients failed a course of nonsurgical treatment (activity modification, anti-inflammatories, and physical therapy).
Results:
From a total of 64 consecutive patients treated with hip preservation surgery for LCPD, 7 patients with symptomatic OCD secondary to LCPD were treated with surgical hip dislocation and ORIF of the femoral head osteochondral fragment. OCD size lesion ranged from 200 to 625 mm. All patients reported marked clinical improvement, with resolution of both pain and mechanical symptoms. Radiographs at final follow-up demonstrated complete osteochondral fragment healing without implant failure. Mean follow-up was 4.6 years (range, 1.1 to 7.4 y). There was a significant postoperative improvement in measured internal rotation in flexion (5.0±5.0 to 16.4±9.8; P=0.02). Modified Harris Hip Score markedly improved from baseline to final follow-up (47.8 to 82.7; [INCREMENT]34.9; minimal clinically important difference, 11; P=0.002), with all patients meeting minimal clinically important difference for modified Harris Hip Score. There were no complications and no progression of osteoarthritis in all patients at final follow-up.
Conclusions:
We have demonstrated both predictable radiographic healing and marked clinical improvement following ORIF of symptomatic post-Perthes OCD lesions. We advocate ORIF for symptomatic osteochondral lesions as a first-line surgical treatment for these patients due to the advantages of native osteochondral tissue preservation, predictable healing, and marked clinical improvement.
Level of evidence:
Level IV-case series.
An ultrasound arthroscopy (UA) technique is a promising tool for the evaluation of the articular cartilage during arthroscopic examination. However, the applicability of UA for the evaluation of the hip joint is unknown. We describe a UA assessment of a patient with osteochondritis dissecans at the femoral head. An ultrasound catheter designed for intravascular imaging was inserted into the hip joint by use of conventional arthroscopic portals, and the cartilage surfaces of the femoral head and acetabulum were investigated with ultrasound. UA provided essential quantitative information on the integrity of the articular cartilage and the condition of the subchondral plate not assessable with conventional arthroscopy. Furthermore, the UA technique provided the possibility to monitor arthroscopy-assisted retrograde drilling and bone transplantation in the hip joint.
Intra-articular loose bodies are known as a cause of pain. Hip arthroscopy is an ideal setting for the removal of loose bodies; it is minimal invasive and with high potency for removal of loose bodies. However, not all loose bodies have to be removed; moreover, not all can be treated successfully arthroscopically.
Free bodies in the hip joint can be loose or attached and can be due to a variety of different etiologies: posttraumatic fractures of the femoral head or acetabulum, synovial chondromatosis, degenerative joint disease, osteochondritis dissecans after Legg-Calve-Perthes disease, unfused secondary ossification center of the acetabulum (a.k.a. os acetabuli) calcium deposit within the labrum, and ossification of the labrum. This chapter details the properties of each source-free body in the hip joint, presents a case, and discusses the treatment.
The authors’ experience is also shared with the reader. Loose bodies were found in 12% of the cases among 728 in hip arthroscopies. The group of patients with loose bodies had higher average age, higher Tonnis arthritic grading, and larger labral tears. Moreover, pain was higher according to the visual analog scale before the surgery, however similar after.
Osteochondritis dissecans (OCD) can progress to loose body formation, resulting in a Grade IV defect. Several procedures for managing this problem have been established.PurposeThe aim of this study is to determine whether the prognosis and patient satisfaction after Herbert screw insertion are satisfactory.Methods
We collected eight cases that had been diagnosed to have OCD and had undergone Herbert screw insertion. The outcomes were determined via the preoperative, and postoperative magnetic resonance imaging and Knee injury and Osteoarthritis Outcome Scores (KOOS). The average follow-up period was 30.1 months.ResultsAt an average of 30.1 months of follow-up (range, 14–68 months), all of the eight patients completed the KOOS. The KOOS subscale scores for pain (mean, 91.25; range, 80–97), other symptoms (mean, 89.88; range, 82–96), activities of daily living (mean, 92.88; range, 80–97), and function in sports and recreation (mean, 88.25; range, 75–96) were not significantly lower than in the published age-matched control group.Conclusion
We believe that surgical intervention of unstable knee OCD with Herbert screw fixation is an effective procedure, and that unstable OCD should be treated as early as possible.
Musculoskeletal complaints account for about 20% to 30% of all primary care office visits; of these visits, discomfort in the knee, shoulder, and back are the most prevalent musculoskeletal symptoms. Having pain or dysfunction in the front part of the knee is a common presentation and reason for a patient to see a health care provider. There are a number of pathophysiological etiologies to anterior knee pain. This article describes some of the common and less common causes, and includes sections on diagnosis and treatment for each condition as well as key points.
For the athlete with a newly diagnosed osteochondritis dissecans of the knee, the first step in formulating a treatment plan is determining the stability of the lesion. When the lesion is found to be unstable but salvageable, several methods for fixation are available. Fixation of osteochondritis dissecans in the athletic population has been described and each has its own advantages and disadvantages. Determining the most appropriate method for fixation depends on several variables and should include the athlete's level of play, sport, and overall goals.
Osteochondritis dissecans is a potentially devastating cause of knee pain in adolescents and adults. Prognosis and treatment depends on the stability of the lesion and the age of the patient. Skeletally immature patients with stable lesions are amenable for nonoperative treatment. Nonoperative treatment is less predictable in skeletally mature patients and patients with unstable lesions. Lesion size, location, stability along with symptomatology should all be considered before initiating treatment. Modalities of nonoperative treatment can range from activity modification to complete immobilization. Close follow-up is recommended to monitor healing progression and symptom resolution.
La osteocondritis disecante de los cóndilos femorales es una afección poco común cuya causa exacta se desconoce. Sin duda alguna responde a muchos factores; entre ellos, los factores mecánicos y vasculares se encuentran en primer plano. Es una afección artrógena cuando aún no se ha logrado la cicatrización. Existe una forma juvenil, con capacidad de cicatrización, y una forma del adulto que a menudo requiere cirugía. El objetivo de la cirugía es alcanzar la cicatrización de la lesión osteocondral gracias a un injerto óseo y a una osteosíntesis. Cuando el fragmento está despegado, o es imposible fijarlo, se puede optar entre dejar el defecto osteocartilaginoso tal como se encuentra o tratar de rellenarlo. Las técnicas posibles son numerosas: injertos en mosaico, injertos de condrocitos o aloinjertos, que aún no han dado pruebas respecto a su longevidad.
Osteochondritis dissecans is a disease that originates in the subchondral bone that affects the articular cartilage. It generally presents gradually and is associated with non-specific symptoms. The true etiology is unknown but likely related to genetic, vascular or trauma. Multiple modes for diagnosis and classification exist. Conservative management often fails in adults unless the lesion is stable. Different surgical techniques have shown improvement over baseline, but there are no randomized controlled trials that demonstrate superiority of one technique over another.
A 45-year-old man developed avascular necrosis of the first metatarsal head of the left foot. He was a heavy smoker and suffered from vascular claudication. Investigations showed severe bilateral atherosclerosis in the lower limbs. He was referred to the department of vascular surgery where bypass surgery of his lower limbs was performed. No additional surgery was performed on his foot. At 1-year follow-up, his foot pain has settled down and a good clinical and functional result was noted.
Osteochondritis dissecans (OCD) rarely involves the femoral condyle and affects especially the athletes. Etiology of OCD remains enigmatic. This retrospective study analyzed 32 cases (28 children) stemming from a paediatric series. All the concerned children exercised a sports activity. OCD can be grave on the functional plan and burden the sports future of the child. The clinical symptomatology was poor. The circumstances of discovery were essentially represented by an atypical pain of the knee. The diagnosis was confirmed by a standard radiography revealing a specific hurt of variable aspect, being able to go of a simple suspect line to a big loss of substance at the level of the femoral condyles. The used classifications were the ones of Bedouelle, Cahill, as well as Harding one. Mostly, the pathology was diagnosed at a premature stage I and II of Bedouelle. The examinations of imaging (Magnetic Resonance Imaging [MRI], CT scan) were individually decided to explore the lesion or for a choice of the therapeutics. The stake in simple discharge with a strict stop of the sport gave satisfactory results so clinical as radiological in our study. The surgery was exceptional. The forecast is usually good at the child's subject to an adapted coverage by not allowing passing the hour of the surgery. The sport practised in an excessive, intense way (competitive sport) is recognized as a major risk factor.
Background: Osteochondritis dissecans is a localized condition or injury affecting an articular surface that involves separation of a segment of cartilage and subchondral bone. Methods: This article discusses the etiology, anatomy, evaluation, classification and treatment of osteochondritis dissecans lesions in the knee joint. Results: Osteochondritis dissecans is primarily found in the knee, ankle and elbow joints. Various theories about its etiology have been proposed, but none has been accepted universally or has adequately explained its occurrence. It is believed that repetitive microtrauma may interrupt the tenuous epiphyseal blood supply in the growing child and contribute to the development of osteochondritis dissecans lesions. Patients typically present with vague complaints and a gradual onset of symptoms. The treatment of osteochondritis dissecans is dependent upon age at presentation, fragment size, fragment location and fragment stability. The vast majority of stable lesions in the skeletally immature patient can be successfully treated with nonoperative management. Unstable lesions or those that have failed conservative management may require surgical treatment primarily in the form of drilling with or without mechanical stabilization. Treatment has further evolved with the use of osteochondral autogenous grafts and autologous chondrocyte transplantation. Conclusions: Well-designed prospective studies with long-term follow up are necessary to determine the adequacy of these techniques in preventing the development of degenerative arthritis.
Magnetic resonance imaging (MRI) is a common clinical tool used to diagnose and monitor the progression and/or healing of osteochondritis dissecans of the knee. The purpose of this study was to systematically review the literature relative to the following questions: (1) Is MRI a valid, sensitive, specific, accurate, and reliable imaging modality to identify knee osteochondritis dissecans compared with arthroscopy? (2) Is MRI a sensitive tool that can be utilized to characterize lesion severity and stability of osteochondritis dissecans fragments in the knee?
A systematic search was performed in December 2010 with use of PubMed MEDLINE (from 1966), CINAHL (from 1982), SPORTDiscus (from 1985), Scopus (from 1996), and EMBASE (from 1974) databases.
Seven studies, four Level-II and three Level-III investigations, met the specified inclusion criteria. No randomized controlled studies were identified. Because of inconsistencies between imaging techniques and methodological shortcomings of many of the studies, a meta-analysis was not performed.
The limited available evidence, methodological inconsistencies in imaging techniques, and lack of standardized grading criteria used in current studies prevent clear conclusions regarding the diagnostic and specific staging equivalency of MRI with arthroscopy. However, available evidence supports the use of MRI to detect the stability or instability of the lesion. Given the benefits of the use of MRI as a noninvasive tool to diagnose, predict lesion progression, and assess clinical outcomes of treatment, there is a pressing need for high-level, systematic, sound, and thorough studies related to the clinical utility of MRI for assessing osteochondritis dissecans of the knee.
Magnetic resonance imaging (MRI) is a widely available, powerful imaging modality in the United States that has rapidly become a mainstay for evaluation of the musculoskeletal system, largely because of its unparalleled depiction of most osseous and soft-tissue pathology. The application of MRI to detect cartilage injuries has evolved to the point where it is possible to noninvasively diagnose cartilage lesions that previously required an invasive examination, eg, arthrography or arthroscopy. However, successful cartilage imaging requires knowledge of the unique technical considerations and limitations of MRI. In this chapter we review current state-of-the-art knee MRI for three groups of chondral disorders: acute osteochondral fractures, osteochondritis dissecans, and degenerative lesions. The role of MRI in osteochondral fractures includes the demonstration of purely chondral intra-articular fragments and the identification of associated injuries, especially previously unrecognized subchondral bruises. MRI may also play a role in surveillance for osteochondral sequelae after injury. For osteochondritis dissecans, MRI can provide evidence supporting the diagnosis of a loose fragment and may aid in the evaluation of cartilage overlying osteochondral defects. Current MRI techniques can show moderate and severe lesions of chondromalacia and chondrosis. Newer techniques show potential for diagnosing these degenerative conditions at earlier stages when the changes are mild. We review these issues and provide examples showing the MRI appearance of common articular injuries.
Osteochondritis dissecans is a relatively common cause of knee pain. The aim of this study was to describe the outcomes of five different surgical techniques in a series of sixty patients with osteochondritis dissecans.
Sixty patients (age 22.4 ± 7.4 years, sixty-two knees) with osteochondritis dissecans of a femoral condyle (forty-five medial and seventeen lateral) were treated with osteochondral autologous transplantation, autologous chondrocyte implantation with bone graft, biomimetic nanostructured osteochondral scaffold (MaioRegen) implantation, bone-cartilage paste graft, or a "one-step" bone-marrow-derived cell transplantation technique. Preoperative and follow-up evaluation included the International Knee Documentation Committee (IKDC) score, the EuroQol visual analog scale (EQ-VAS) score, radiographs, and magnetic resonance imaging.
The global mean IKDC score improved from 40.1 ± 14.3 preoperatively to 77.2 ± 21.3 (p < 0.0005) at 5.3 ± 4.7 years of follow-up, and the EQ-VAS improved from 51.7 ± 17.0 to 83.5 ± 18.3 (p < 0.0005). No influence of age, lesion size, duration of follow-up, or previous surgical procedures on the result was found. The only difference among the results of the surgical procedures was a trend toward better results following autologous chondrocyte implantation (p = 0.06).
All of the techniques were effective in achieving good clinical and radiographic results in patients with osteochondritis dissecans, and the effectiveness of autologous chondrocyte implantation was confirmed at a mean follow-up of five years. Newer techniques such as MaioRegen implantation and the "one-step" transplantation technique are based on different rationales; the first relies on the characteristics of the scaffold and the second on the regenerative potential of mesenchymal cells. Both of these newer procedures have the advantage of being minimally invasive and requiring a single operation.
Young adults with osteochondral lesions of the femoral head are at risk of rapid progression to symptomatic arthritis of the hip joint. Between January 2008 and July 2009, 10 patients were treated for femoral cartilage damage by a osteochondral mosaicplasty of the femoral head through a trochanteric flap with dislocation of the hip. The consecutive series had the following exclusion criteria: acetabular chondropathy age above 25 years, and femoral head osteonecrosis. Patients were followed up after surgery using the Oxford-12 score, Harris hip score and the Merle d'Aubigné score, and activity assessed by the UCLA and Devane scores. Radiological evaluation by computed tomographic (CT) arthrography was undertaken in all patients at 6 months and plain radiographs.
Mean follow-up was 29.2 months (20–39 months). The Postel Merle d'Aubigné score improved from the pre-operative period to the latest follow-up, from 10.5 points (8–13) to 15.5 points (12–17). Global range of motion increased from 175.4° (140–215) to 210.7° (175–240). All radiological investigations at latest follow-up showed that the autograft plugs were well-incorporated at the site of osteochondroplasty in the femoral head with intact cartilage over them and smooth interfaces between articulating bony surfaces. Osteochondral autograft transplantation may be a new alternative option for osteochondral lesions of the femoral head, but this has to be confirmed with longer follow-up and in a larger number of patients. The results of similar surgery in the knee have been mixed, and in the hip the technique is demanding, requiring familiarity with surgical hip dislocation.
This article defines the characteristic features of osteochondritis dissecans of the trochlea of the femur, and indicates that important differences distinguish it from the more familiar femoral condylar form. The clinical features in 16 knees included: gradual onset of symptoms, pain with running and jumping, no significant history of injury; inconstant tenderness of the trochlea, and pain with resisted extension at 20 to 45 degrees. Diagnosis was usually difficult, and was often delayed because of subtle radiographic changes. Treatment depended on the stage of presentation. Nonsurgical treatment failed in four of seven knees. Drilling the lesions failed in two of the three cases. Fixation with small screws produced two good results; two others healed, but with short follow-up. Removal of the loose bodies from six knees produced one poor result and five good results. This process differs in presentation from femoral condylar osteochondritis dissecans. Although the results (average follow-up more than 5 years) were generally good, the mild symptoms probably represent incongruity of the patellofemoral joint, and probably foretell osteoarthritis.
Twenty-four knees with osteochondritis dissecans of the femoral condyles failed a conservative program and were treated with antegrade drilling. To our knowledge, this represents the largest reported series using this technique. The average age at the time of surgery was 13 years 6 months. Seventeen patients had open physes, and four were skeletally mature. Nineteen lesions involved the medial femoral condyle, and five involved the lateral femoral condyle. The average follow-up was 5 years. Postoperative evaluation included rating by the International Knee Documentation Committee (IKDC) form and the Hughston Rating Scale for osteochondritis dissecans. Twenty of the 24 lesions healed after antegrade drilling, and the average time of healing was 4 months. According to the criteria on the IKDC grading form, 14 were normal, 6 nearly normal, three abnormal, and one severely abnormal. The results of the Hughston Rating Scale were similar: 15 were excellent, seven good, one fair, and one poor. Only two of the four skeletally mature patients healed after antegrade drilling. Antegrade drilling is an effective method of treatment for osteochondritis dissecans of the knee that occurs in adolescents with open physes. This operation is not as likely to result in a successful outcome in patients with closed physes; consequently, other methods should be considered in skeletally mature patients.
Osteochondritis dissecans (OCD) and loose body formation are rare following Perthes' disease. We have reviewed the literature about clinical presentation, treatment and outcome and added a further three cases of the condition. Cases mentioned in the literature were poorly documented. We feel that a thorough documentation should be carried out as soon as the diagnosis is made. Conservative treatment should be given when the disability is moderate. The loose body should only be removed surgically when it is mobile, when it bulges into the joint space or when there are signs of early arthritis.
This study aimed to show the results of osteochondritis dissecans fragment excision. We reviewed 85 patients (98 knees) with osteochondritis dissecans in a retrospective study of the results of merely excising the osteochondral lesion. Thirty-one knees were treated by only the removal of the fragment. Of these, it was possible to contact and examine 14 patients (14 knees); the average follow-up periods were 8.3 years (range 4.5-32 years). Knee function was evaluated according to the criteria of the International Knee Documentation Committee (IKDC), 12 knees in the 14 patients had no further symptoms and the 2 others had mild pain when going up- and downstairs. Roentgenograms at follow-up showed slight osteoarthritic changes. The preoperative femoro-tibial angle measured at surgery showed no marked change compared with that at follow-up. The study suggests that clinical and radiological results are good following removal of the osteochondral loose fragments are excised.
In situ fixation of unstable lesions of osteochondral dissecans of the knees with cylindrical osteochondral autograft transplantation has been reported to provide excellent results with healing of the osteochondral dissecans fragment.
To evaluate the clinical results and magnetic resonance imaging findings of the osteochondral dissecans of knees treated with in situ fixation of the osteochondral fragments with osteochondral autograft transplantation.
Case series; Level of evidence, 4.
Twelve knees (12 patients; mean age, 16.0 years) with osteochondral dissecans lesions were treated with in situ fixation with autogenous osteochondral plugs. The mean lesion size was 2.4 cm(2) (range, 1.0-4.9 cm(2)). The osteochondral dissecans lesions were located on the medial femoral condyle in 10 patients and on the lateral femoral condyle in 2 patients. Seven lesions were located in the weightbearing area. The International Cartilage Repair Society classification in arthroscopic findings was grade II in 1 patient, grade III in 8 patients, and grade IV in 3 patients. All patients were evaluated with the Hughston Rating Scale form with the mean follow-up at 4.5 years (range, 2.8-5.9 years). The interface between the osteochondral fragment and subchondral bone and changes in donor site of the osteochondral graft were evaluated with T2-weighted magnetic resonance image up to 12 months postoperatively.
The Hughston Rating Scale scored 8 knees as excellent, 3 as good, and 1 as fair. The interface between the osteochondral fragment and subchondral bone had disappeared on magnetic resonance image by 3 months postoperatively in all cases. No complications arising from the donor site area were observed. Signal intensity of donor site changed from high signal preoperatively to homogeneous surrounding cancellous bone by 1 year postoperatively.
Biological fixation of the osteochondral dissecans lesion with cylindrical osteochondral autograft provided healing of the osteochondral fragments.
We reviewed 32 knees in 26 patients who had previously undergone arthroscopic debridement for symptomatic osteochondritis dissecans (OCD) of the knee. The patients were followed up at a minimum of 11 years following surgery and were evaluated clinically using the American Knee Society Clinical Rating Score. Additional evaluation was performed using the Hughston Scale to include radiographic assessment. The mean American Knee Society Score was 179 (out of 200), indicating good clinical function. Radiographically, however, only 29% scored excellent or good on the Hughston Scale. Younger patients with a small, stable (and therefore preserved), medial femoral condyle lesion had the best prognosis. Whilst more novel and complex options such as chondrocyte implantation are being assessed for the treatment of OCD, it is clear that within this study group careful debridement with removal of loose tissue can achieve good clinical results in the long term. There was however radiographic evidence of early degenerative joint disease in 17/24 (71%) of patients reviewed. Patients undergoing excision of OCD fragments did worse than those in whom the fragment was preserved, however the risk of further surgery is raised if a fragment is left in situ at initial surgery.
In a longitudinal study, we performed a second follow-up examination on patients suffering from osteochondritis dissecans at the femoral condyles 10 years after a first follow-up, which had been performed 10 years after surgical treatment. Results (clinical score; radiological signs of OA) were analysed depending on the stage of the epiphyseal plate at the time of surgery, the used surgical procedure was divided into retrograde and anterograde procedures, and removal of loose bodies depending on the stage of the lesion. The analysis clearly exhibited that JOCD patients demonstrated better results than AOCD patients. The clinical score obtained after 10 years improved significantly with time, particularly for JOCD patients. Overall, when a retrograde procedure had been used in cases with an intact cartilage layer clinical results were better than those obtained in patients in whom an anterograde procedure with restoration of the joint surface or simple removal of the loose fragments had been performed. After a mean follow-up of 20 years the mean OA-stage was 0.27 in JOCD patients, whereas in AOCD patients a mean OA-stage of 1.55 was detected. Worst OA-changes were detected in patients in whom acrylic glue had been used for refixation of the loose bodies.
Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a 'trochanteric flip' osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage.
Surgical dislocation of the hip is rarely undertaken. The potential danger to the vascularity of the femoral head has been emphasised, but there is little information as to how this danger can be avoided. We describe a technique for operative dislocation of the hip, based on detailed anatomical studies of the blood supply. It combines aspects of approaches which have been reported previously and consists of an anterior dislocation through a posterior approach with a 'trochanteric flip' osteotomy. The external rotator muscles are not divided and the medial femoral circumflex artery is protected by the intact obturator externus. We report our experience using this approach in 213 hips over a period of seven years and include 19 patients who underwent simultaneous intertrochanteric osteotomy. The perfusion of the femoral head was verified intraoperatively and, to date, none has subsequently developed avascular necrosis. There is little morbidity associated with the technique and it allows the treatment of a variety of conditions, which may not respond well to other methods including arthroscopy. Surgical dislocation gives new insight into the pathogenesis of some hip disorders and the possibility of preserving the hip with techniques such as transplantation of cartilage.
1. The pathological anatomy of osteochondritis dissecans of the hip is described, and its causation is discussed.
2. Eight new cases are reported.
3. The problems of treatment are considered.
Es wird ber 13 Flle von O. d. der Hfte berichtet. An Hand dieser Flle wird gezeigt, da einerseits mechanische Faktoren, andererseits eine konstitutionelle Minderwertigkeit der Gelenkkrper bei der Entstehung der O. d. von Bedeutung sind.Report on 13 cases of Osteochondrosis dissecans of the hip. Mechanical factors on the one hand, inferior constitution of the joint articulations on the other are shown as the cause of origin of the disease.A propos de 13 cas d'ostochondrite disscante de la hanche. Selon ces cas sont dmontrs les facteurs mcaniques aussi que la constitution infrieure des corps d'articulation comme cause d'origine de l'ostochondrite disscante.
Two examples of familial osteochondritis dissecans are described, one affecting a mother and daughter and the other a father and son. The mother and daughter both have genu valgum and are short statured. This combination of features has not been reported previously. Radiographs of lesions affecting knee, elbow, hip and ankle joints demonstrate the wide spectrum of radiological abnormality that can occur in this condition. © 1989 The Royal College of Radiologists, 38 Portland Place, London W1N 3DG, UK. All rights reserved.
Osteochondritis dissecans is seen after skeletal maturity is reached in approximately 3% of adults who have had Legg-Calvé-Perthes disease as children. This diagnosis should be considered in the patient with hip pain, locking or catching, or early degenerative joint disease. In a series of 465 patients treated for Perthes' disease, 14 later developed osteochondritis dissecans. In asymptomatic hips, no treatment is indicated. In symptomatic patients, arthroscopic surgery of the hip has been employed to remove the loose osteocartilaginous fragment and to diagnose degenerative joint disease. Although removal of the osteocartilaginous fragment may not be indicated in patients with severe degenerative arthritis, an osteotomy to redirect the femoral head (valgus extension osteotomy) may be beneficial.
Two patients with osteochondritis dissecans of the hip were operated on and their case histories are presented. The relatively large foci were situated on the weight-bearing surface of the joint and the fragments were fixed using transplants of cortical bone. In both cases the focus healed, and the symptoms were relieved. At follow-up six and nine years later respectively, the clinical results were good and no signs of osteoarthritis had as yet developed.
In 36 patients treated for osteochondritis dissecans (OCD) of the elbow, ankle and hip during a period of 20 years in the same hospital, trauma seems to have been the main etiologic factor in about half of the patients. The first symptoms of the lesions occurred when the patients were between 15 and 20 years of age. Osteochondritis dissecans of the elbow was seen in 19 men. Osteochondritis dissecans in the ankle occurred in 6 men and 5 women. Osteochondritis dissecans in the hip appeared in 5 men and one woman. The first symptoms were pain and restriction of joint movement. Conservative treatment was satisfactory for about one-half of the patients. When operative treatment was indicated, extirpation of loose bodies or loosening fragments was the treatment of choice in OCD of the elbow and ankle. Fixation of the fragment gave satistfactory results in some cases of OCD of the hip. Late results were excellent in only about one-half of the patients. Osteoarthritic changes appeared in the hip, elbow, ankle, in order of decreasing frequency.
Osteochondritis dissecans of the femoral capital epiphysis is uncommon and is usually reported as a case report or in association with other diseases. This study reports 17 cases with the primary underlying diagnosis of Legg-Calvé-Perthes disease in seven, idiopathic in six, avascular necrosis following trauma in three, and avascular necrosis with previous infection in one. Twelve cases had long-term follow-up. Two cases in which no surgery was performed were followed for an average of 12.5 years; 10 cases in which surgery was performed were followed for an average of 16.1 years. Excision of the osteochondritis fragment was performed in six cases. It was necessary only to dislocate the hip to excise the lesion in five cases. No morbidity resulted from temporary surgical dislocation. Excision of the osteochondritis dissecans fragment allowed these six patients to return to fairly normal living during the time of follow-up.
The treatment of osteochondritis dissecans has remained controversial since it was initially described more than a century ago. The etiology is still unclear, but it seems to be multifactorial and related to trauma in specific and susceptible locations. Two different populations of patients, children and adults, are affected, and the result of treatment is largely determined by the status of the physes. Children who have a lesion of the knee usually do well irrespective of the method of treatment, and those who have a persistently symptomatic lesion generally respond well to operative arthroscopy if limitation of activity and protected weight-bearing have failed. A lesion of the knee in an older patient is unlikely to heal with non-operative treatment; therefore, treatment should include techniques that promote revascularization of the subchondral bone and restoration of the congruity of the articular surfaces by replacement of the fragment with or without bone-grafting. An advanced lesion of the knee with associated degenerative joint disease in a young patient continues to be a difficult challenge, but osteotomy or the use of osteochondral autogenous grafts may be helpful. Total joint arthroplasty may be the only alternative for a refractory lesion in an older patient. Osteochondritis dissecans of the ankle is unique in that there are two different sites of presentation, posteromedial and anterolateral. Anterolateral lesions of the ankle are true osteochondral fractures that result from trauma. Lesions of the elbow are the result of overuse injuries and most commonly involve the capitellum. Lesions of both the ankle and the elbow are usually treated with debridement and subchondral curettage or drilling.
The causes of hip pain in adults can vary greatly. We present the case of a 44-year-old woman with recurrent hip pain over a period of years. Medical history and clinical examination did not provide any decisive information. The X-rays revealed a loose body in the cavity of the hip joint. The MRI scan made the following differential diagnosis plausible: osteochondrosis dissecans coxae, osteochondroma and chondromatosis. The final diagnosis of osteochondrosis dissecans coxae was confirmed by surgical dislocation of the hip as modified by Ganz and histological examination of the loose body. This case supports the importance of including rare lesions in the differential diagnostic work-up of joint pain. The advantages of the offset operation as modified by Ganz versus arthroscopy of the hip are outlined.
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