Option of Surgery for Skeletally Mature Patients with Salvageable Unstable OCD Lesions

Skeletally mature patients with OCD lesions who have a history of not healing and/or have signs of loosening (usually detected by MRI) are unlikely to heal without treatment. Further, these skeletally 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 minimal symptoms. Accordingly, the work group makes no recommendations about surgery or physical therapy for such patients.

Supporting Evidence

One Level IV study⁴³ (See Table 46) (n = 15) reported the Tegner activity, Lysholm, Knee Outcome and Osteoarthritis Symptom and Sport (KOOS) and the SF-12 Mental and Physical scores of patients treated with arthroscopic reduction and internal fixation (ARIF). At 48 months, patients treated with ARIF had statistically significantly improvements from baseline measured by the Lysholm, International Knee Documentation Committee, Short form-12 (SF-12) Physical, and Knee injury and Osteoarthritis Outcome (KOOS) scores (See XTable 47X-XTable 51X). The authors reported no statistically significant improvements measured by the Tegner activity and the SF-12 mental outcome scores at 48 months (See XTable 51X). Twenty percent of patients treated with arthroscopic internal fixation required secondary surgical procedures (See Table 52X ).

PROGNOSTIC EVIDENCE

Two Level IV studies^{43, 57}, (n = 59) reported the results of skeletally mature patients with OCD lesions treated by internal fixation or allograft and any associations between the patient’s age, lesion severity and size with final clinical outcome results. One study ⁴⁷ included only male patients that were actively involved in the military. These patients had either stable (Guhl: I and II) or unstable (Guhl: III and IV) OCD lesions and were treated with either bioabsorbable pins or nails. The second study ⁴⁶ enrolled patients with unstable OCD lesions and compared the results of patients treated with fixation with plates and screws to patients treated with allograft. One study ⁴⁷ reported a statistically significant positive association between the lesion size and the appearance of sclerosis (See XTable 55X). Both studies reported no other statistically significant associations between the remaining factors analyzed with the final outcomes (See XTable 55)