Diagnosis and Treatment of Osteochondritis Dissecans

In a patient with knee symptoms (pain, swelling, locking, catching, popping, giving way) and/or signs (tenderness, effusion, loss of motion, crepitus), x-rays (including AP, lateral, sunrise/Merchant, and tunnel views) are an option.

Patients with an OCD lesion often present with complaints of knee pain and swelling.  In addition, patients may note sensations of locking (motion of the knee is halted), catching (motion is partially inhibited), popping, or giving way.  Physical examination may reveal tenderness, effusion, loss of motion, or crepitus. 

AAOS conducted a systematic review that identified one diagnostic study which evaluated the diagnostic performance of clinical examination with radiographs and of selective MRI in the evaluation of intra-articular knee disorders by comparing these findings with arthroscopic findings.⁴⁰ Clinical diagnosis was made on the basis of history, physical examination, and standard radiographs (AP, lateral, Merchant, and tunnel views). MRI studies were ordered selectively on the basis of clinical discretion.  Arthroscopic evaluation was performed in the subset of patients that required surgery, based on clinical diagnosis and MRI findings if an MRI was performed.  The clinical diagnosis (from the initial visit), MRI diagnosis (from the MRI report), and the arthroscopic diagnosis (from the operative report) were retrospectively reviewed and compared. Since only a subset of all patients that underwent evaluation of intra-articular knee disorders proceeded to arthroscopic evaluation, this diagnostic study does not universally apply the reference standard of arthroscopy.  Consequently, we assessed this retrospective diagnostic study without a universally applied reference standard as a Level II study. Since only a single study is available to support this recommendation, the strength of recommendation is limited.

We are unable to recommend for or against x-rays on the contralateral asymptomatic knee in patients with confirmed OCD of one knee.

We were unable to find quality evidence to support or recommend against obtaining x-rays on the opposite knee for patients with confirmed OCD on one knee.

In a patient with a known OCD lesion on x-ray, an MRI of the knee is an option to characterize the OCD lesion or when concomitant knee pathology is suspected such as meniscal pathology, ACL injury, or articular cartilage injury.

AAOS conducted a systematic review that identified two diagnostic studies^{40, 41} addressing this recommendation. One of these studies evaluated the diagnostic performance of clinical examination with radiographs and of selective MRI in the evaluation of intra-articular knee disorders by comparing these findings with arthroscopic findings.⁴⁰ The clinical diagnosis (from the initial visit), MRI diagnosis (from the MRI report), and the arthroscopic diagnosis (from the operative report) were retrospectively reviewed and compared.  Since only a subset of all patients that underwent evaluation of intra-articular knee disorders proceeded to arthroscopic evaluation, this diagnostic study does not universally apply the reference standard of arthroscopy.  Consequently, this retrospective diagnostic study without a universally applied reference standard was evaluated as a Level II study.

Similarly, the second diagnostic study identified in the systematic review, prospectively evaluated all consecutive patients undergoing knee arthroscopy who had a preoperative MRI.⁴¹ Again, this study only reports on the subset of patients that required surgery; therefore, this diagnostic study does not universally apply the reference standard of arthroscopy.  Consequently, this prospective diagnostic study without a universally applied reference standard is also evaluated as a Level II study.

These Level II studies, when considered together, may have supported a moderate strength of recommendation.  However, these studies found that both x-ray and MRI are good rule in tests and do not address the incremental diagnostic value of an MRI in the setting of known OCD determined by x-ray.  That is, these studies do not compare the diagnostic performance of clinical examination with standard radiographs to clinical examination with standard radiographs and an MRI; therefore we downgraded the strength of this recommendation to limited.

In addition to identifying the presence of OCD lesions and distinguishing OCD lesions from other intra-articular pathology, an MRI may be used as an adjunct to clinical examination with radiographs to provide additional information that will guide therapeutic decision-making.  Of the 5 therapeutic studies^42-46 that were included in the development of this guideline, three studies ^42-44 report the acquisition of an MRI at enrollment and three studies^{42, 44, 45} report the acquisition of an MRI at follow-up evaluation. Further, one prognostic study¹⁹ predicts the healing potential of stable OCD lesions, utilizing a multivariable logistic regression model. Of all of the variables that were considered (including sex, side, location, symptoms, knee dimensions, and lesion dimensions), only knee symptoms as well as normalized length and normalized width of the OCD lesion as measured on MRI were found to be predictive of healing potential.

Of note, three studies^47-49 correlated MRI findings with arthroscopic findings in patients with OCD of the knee. The evidence for assessment of stability of an OCD lesion was inconsistent.

We are unable to recommend for or against non-operative treatment (casting, bracing, splinting, unloader brace, electrical or ultrasound bone stimulators, or activity restriction alone) for asymptomatic skeletally immature patients with OCD.

We were unable to find any evidence to support non-operative treatment for asymptomatic skeletally mature patients with OCD. Therefore, we are unable to recommend for or against treatment in this patient population.

We are unable to recommend for or against a specific non-operative treatment (casting, bracing, splinting, unloader brace, electrical or ultrasound bone stimulators, or activity restriction alone) for symptomatic skeletally immature patients with OCD.

No conclusions can be made regarding the non-operative management of symptomatic skeletally immature patients. The AAOS systematic review found no prospective studies that determined the efficacy of non operative treatment in this patient population.

We are unable to recommend for or against arthroscopic drilling in symptomatic skeletally immature patients with a stable lesion(s) who have failed to heal with non operative treatment for at least three months.

AAOS conducted a systematic review examining arthroscopic drilling for stable symptomatic OCD lesions in skeletally immature patients. We were unable to find any quality evidence to support arthroscopic drilling for symptomatic skeletally mature patients with OCD. Therefore, we are unable to recommend for or against drilling in this patient population.

AAOS conducted a systematic review examining arthroscopic drilling for stable symptomatic OCD lesions in skeletally immature patients and the data were inconclusive.

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.

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.

We are unable to recommend for or against a specific cartilage repair technique in symptomatic skeletally immature patients with unsalvageable fragment.

The AAOS conducted a systematic review of the literature and found one quality study to address this recommendation.  Because there was only one Level II study and many applicable outcomes and techniques were not addressed, the results of this single study were evaluated as inconclusive.

We are unable to recommend for or against repeat MRI for asymptomatic skeletally mature patients.

We were unable to find quality evidence to support repeat MRI for asymptomatic skeletally mature patients with OCD. Therefore, we are unable to recommend for or against repeat MRI in this patient population.

We are unable to recommend for or against treating asymptomatic skeletally mature patients with OCD progression (as identified by X-ray or MRI) like symptomatic patients.

We were unable to find any evidence to support treating asymptomatic skeletally mature patients with progression of OCD on x-ray and/or MRI as symptomatic skeletally mature patients. Therefore, we are unable to recommend for or against a treatment in this patient population.

In the absence of reliable evidence, it is the opinion of the work group that symptomatic skeletally mature patients with salvageable unstable or displaced OCD lesions be offered the option of surgery.

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.

We are unable to recommend for or against a specific cartilage repair technique in symptomatic skeletally mature patients with an unsalvageable OCD lesions.

There are many different cartilage repair techniques including autologous chondrocyte implantation, osteochondral transplantation using allograft or autograft, and marrow stimulation techniques such as abrasion arthroplasty and microfracture. There were four Level IV studies that addressed cartilage repair techniques for an unsalvageable OCD lesion. Since each of these Level IV articles utilized different techniques, different outcome measures and differing lengths of follow-up, the work group deemed that the evidence for any specific technique was inconclusive. 

In the absence of reliable evidence, it is the opinion of the work group that patients who remain symptomatic after treatment for OCD have a history and physical examination, x-rays and/or MRI to assess healing.

We suspect that patients with OCD have risk of developing severe osteoarthritis (osteoarthrosis) at a young age. The treatment options for these young patients with osteoarthritis (osteoarthrosis) are limited and therefore, their quality of life is significantly impacted. Based on this premise, the work group issued a consensus recommendation despite the lack of evidence to support or refute the use of ongoing evaluation in patients with a diagnosis of OCD.

In patients with OCD that remain symptomatic despite previous treatment, ongoing evaluation with a goal to preserve the patient’s knee function and native cartilage is a priority.  The evaluation is based upon the patient’s symptoms, signs, and imaging to detect possible deterioration.  Recognition and intervention allowing treatment of lesions at early stages may improve outcomes and prevent sequelae (e.g. severe osteoarthritis (osteoarthrosis)) associated with later stages of disease. Although lesion stability may not be assessed with a high level of confidence on imaging studies, the progression or worsening of the condition can be evaluated by comparing sequential imaging studies. The work group acknowledges that radiographic studies expose the patient to radiation. We are also aware of the increased costs of imaging studies. We believe that the practice of ongoing history, physical, and imaging studies is consistent with the current practice of most orthopaedic surgeons.

We are unable to recommend for or against physical therapy for patients with OCD treated non-operatively.

Some skeletally immature patients with OCD of the knee and intact articular cartilage have the potential to heal non-operatively. A systematic review of the literature did not identify any studies that addressed specific physical therapy protocols for patients with OCD treated non-operatively. A period of restricted activity to reduce impact loading on the lesion and physical therapy to address impairments such as loss of motion, strength deficits, residual effusion and altered movement patterns are reported in the medical literature for patients with other conditions such as osteoarthritis (osteoarthrosis) (Please see AAOS Clinical Guideline on the Treatment of Osteoarthritis of the Knee⁵⁸).

We were unable to find any studies that addressed these impairments or specific physical therapy protocols in patients with OCD lesions of the knee.

In the absence of reliable evidence, it is the opinion of the work group that patients who have received surgical treatment of OCD be offered post-operative physical therapy.

Patients who receive surgical interventions for OCD of the knee may experience impairments such as loss of motion, strength deficits, altered movement patterns, and post-operative effusion. Although we could not locate any rigorously collected evidence about how common these impairments are, or their degree of severity, the work group deemed that it was imprudent to ignore them.

In making this consensus recommendation, the work group is issuing a recommendation consistent with current practice. However, the work group also acknowledges the paucity of evidence on the effectiveness of physical therapy, including its effects on either the duration or severity of these impairments (none of the eight studies included in this guideline that reported that their patients received post-operative physical therapy.^{42, 44-46, 51, 52, 56, 57} evaluated the effects of that therapy), or whether supervised therapy and unsupervised therapy yield different outcomes. Accordingly, it is not possible to determine whether patients should be offered supervised or unsupervised therapy.

The work group also notes that there are minimal risks associated with physical therapy, which, given its potential benefits, also argues for offering it to patients. These patients should be offered sufficient information to allow them to choose between supervised and unsupervised therapy, given their own, unique circumstances.

We are unable to recommend for or against counseling patients about whether activity modification and weight control prevents onset and progression of OCD to osteoarthritis (osteoarthrosis).

AAOS conducted a systematic review and found no evidence to support or refute this recommendation. Therefore, we are unable to recommend for or against counseling patients about whether activity modification and weight control prevents onset and progression of OCD to osteoarthritis (osteoarthrosis).