Diagnosis and Treatment of Osteochondritis Dissecans (2023)

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.

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.

Supporting Evidence

A single study assessed the pre-operative diagnosis of a pediatric orthopaedic surgeon, which included clinical examination, radiographs, and consideration of the MRI findings.⁴¹ This study enrolled 131 patients with various knee lesions, 19 of which were diagnosed as having OCD during arthroscopic examination. Diagnostic performance estimates from this study reflect the value of a pediatric orthopaedic surgeon’s pre- operative diagnosis to correctly identify OCD from several other lesions. Analysis of likelihood ratios (LR) and associated confidence intervals indicates that diagnosis based on exam, x-rays, and MRI findings is a good rule in and a good, moderately good, or weak rule out test for OCD (XTable 7X). However, the use of a single surgeon’s pre- operative diagnosis reduces the generalizability of these results.

Two studies evaluated the ability of MRI to distinguish OCD from several other lesions.^{40, 41} The studies enrolled 256 patients with various knee lesions, 41 of which were diagnosed as having OCD during arthroscopic examination. Likelihood ratios and the associated confidence intervals indicate MRI is a good or moderately good rule in test and a good, moderately good, or weak rule out test for OCD ( able 8).

In the three remaining studies (n = 124), MRI was evaluated for the ability to diagnose instability of the osteochondritis dissecans.^47-49 Instability at MRI was based on similar criteria, including high signal rims/lines, cysts, and focal defects (XTable 9). One study reported the results of skeletally mature patients separately from skeletally immature patients.⁴⁸ Ninety-one percent (91%) of the patients in one study were skeletally immature ⁴⁹ and 81% of the patients skeletally mature in the remaining study.⁴⁷ Thus, we analyzed the likelihood ratios and the associated confidence intervals for skeletally immature patients and skeletally mature patients separately.

The analysis in skeletally immature patients indicates MRI is good, moderately good, weak, or poor as a rule in and rule out test for instability of OCD (Table 10)X   MRI is a good, moderately good, weak, or poor rule in test for OCD instability in skeletally mature patients and a good, moderately good, or weak rule out test for OCD instability in skeletally mature patients ( able 11)     

Symptomatic skeletally immature patients with 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.

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).

Symptomatic skeletally mature patients with 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.

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)

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.

Supporting Evidence

There is no evidence to address this recommendation.

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 the option of 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.

Supporting Evidence

There is no evidence to address this recommendation.