Surgical management of osteochondritis dissecans of the knee

Abstract

Osteochondritis dissecans of the knee primarily affects subchondral bone, with a secondary effect on the overlying articular cartilage. This process can lead to pain, effusions, and loose body formation. While stable juvenile lesions often respond well to nonoperative management, unstable juvenile lesions, as well as symptomatic adult lesions, often require operative intervention. Short-term goals focus on symptomatic relief, while long-term expectations include the hope of preventing early-onset arthritis. Surgical options include debridement, loose body removal, microfracture, arthroscopic reduction and internal fixation, subchondral drilling, osteochondral autograft or allograft transplantation, and autologous chondrocyte implantation. Newer single-stage cell-based procedures have also been developed, utilizing mesenchymal stem cells and matrix augmentation. Proper treatment requires evaluation of both lesional (size, depth, stability) and patient (age, athletic level) characteristics.

Fig. 1

a Coronal T2-weighted magnetic resonance image (MRI) shows a high signal intensity line (arrowheads) beneath the lesion [81]. b OCD of lateral femoral condyle with two signs of instability: Sagittal T2-weighted MRI shows a high signal intensity line (straight arrow; criterion 1) and a cystic area (curved arrow; criterion 2) beneath fragment [39]. c Unstable osteochondritis dissecans of the medial femoral condyle: This T2-weighted sagittal MRI image shows a large focal defect (arrow) in the weight-bearing portion of the articular surface [39]. d This sagittal T2-weighted MRI image shows a posterior cartilage fracture (arrow) [81]

Fig. 2

Algorithm for treating knee osteochondritis dissecans. Left: Decision tree for stable lesions with no loose body present. Right: Framework for unstable/displaced lesions

Fig. 3

Arthroscopic view of osteochondritis dissecans fragment with awl between fragment and underlying bone

Fig. 4

Arthroscopic view of final product of an arthroscopic reduction and internal fixation using 3 Accutrack screws to secure an osteochondritis dissecans fragment in place

Fig. 5

Arthroscopic view of osteochondritis dissecans lesion undergoing microfracture

Fig. 6

a Intraoperative clinical photograph of an osteochondritis dissecans lesion of the medial femoral condyle. b Intraoperative clinical photograph after lesional preparation. c Intraoperative clinical photograph after placement of an osteochondral allograft restoring continuity of the articular cartilage