Option of Surgery for Skeletally Immature Patients with Salvageable Unstable OCD lesions
In the absence of reliable evidence, it is the opinion of the work group that symptomatic skeletally immature patients with salvageable unstable or displaced OCD lesions be offered the option of surgery.

Rationale
Children who are skeletally immature (i.e., those with open physes) who exhibit continued or progressing symptoms and signs of loosening (usually detected by MRI) are unlikely to heal without treatment. This is also true of skeletally mature patients with OCD lesions who have a history of not healing and/or there are already signs of loosening. Further, these skeletally immature and mature patients, because of loss of bone and cartilage, may be at higher risk of developing severe osteoarthritis (osteoarthrosis) at an early age. Although the exact degree of risk is not known, the work group deemed that it was imprudent to ignore it. 

In issuing this consensus recommendation, the work group is issuing a recommendation consistent with current medical practice. However, the work group also acknowledges the paucity of evidence on the effectiveness of fixation of unstable OCD lesions, and that surgery entails risks. These risks include, but are not limited to, bleeding, infection, damage to nerves and blood vessels, venous thromboembolic events, anesthesia complications, and surgical failure. Again, however, not performing surgery also carries a risk, irreversible osteoarthritis/osteoarthrosis. This latter risk is of particular concern since effective treatments for young patients with severe osteoarthritis (osteoarthrosis) are limited. It is, therefore, the opinion of the work group that symptomatic patients with salvageable unstable or displaced OCD lesions (the work group defines “salvageable, unstable or displaced OCD lesions”, either unstable but in situ or displaced, as those that may be restored, using the patient’s native tissue from the osteochondritis region) be given the option of balancing the risks of performing or not performing surgery against the benefits of performing or not performing it. One potential benefit of surgery is the prevention or delay of severe osteoarthritis (osteoarthrosis). Another potential benefit is that these patients will be relieved of their existing symptoms.

The work group stresses that the choice to proceed with surgery is part of a shared decision making process between the patient, family, and physician. Offering patients the option of surgery is not a mandate that they have it. Patients can, and sometimes do, decline surgery.

Offering patients surgery requires informed consent. Failure to inform patients concerning the possible risks of surgical treatment is unethical and precludes them from surgery. Informed consent should provide patients with enough information about surgery to make a sound judgment about whether they wish to proceed to surgery given their individual situation.

The present recommendation does not apply to all patients with OCD. In many skeletal immature children (i.e., those with open physes), these lesions heal without treatment. This is particularly true in children who have incidentally discovered lesions and have minimal symptoms. Accordingly, the work group makes no recommendations about surgery or physical therapy for such patients.

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