Table of Contents  
CASE REPORT
Year : 2014  |  Volume : 7  |  Issue : 5  |  Page : 635-637  

Osteochondritis dissecans of the knee joint: A diagnosis not to miss


1 Department of Orthopaedics, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India
2 Department of Radiology, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

Date of Web Publication10-Sep-2014

Correspondence Address:
Rahul R Bagul
Department of Orthopaedics, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.140473

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  Abstract 

Osteochondritis dissecans (OCD) is the most common cause of a loose body in the joint space in adolescent patients. Diagnosis requires a high index of suspicion as clinical findings are often subtle. Limited range of motion may be the only notable clinical sign. The diagnosis is made by thorough clinical examination, radiographic examination and magnetic resonance imaging (MRI). Early diagnosis and treatment can change the prognosis of the disease. If not diagnosed early, OCD can lead to the development of osteoarthritis at an early age. Conservative management is the mainstay of treatment for stable lesions. While the majority of patients respond to conservative treatment, those with unstable lesions require arthroscopic management.

Keywords: Knee joint, loose body, OCD


How to cite this article:
Bagul RR, Rajani D, Salgia A, Kharat A. Osteochondritis dissecans of the knee joint: A diagnosis not to miss. Med J DY Patil Univ 2014;7:635-7

How to cite this URL:
Bagul RR, Rajani D, Salgia A, Kharat A. Osteochondritis dissecans of the knee joint: A diagnosis not to miss. Med J DY Patil Univ [serial online] 2014 [cited 2021 Sep 17];7:635-7. Available from: https://www.mjdrdypu.org/text.asp?2014/7/5/635/140473


  Introduction Top


OCD is a pathological condition that results in destruction of subchondral bone with secondary damage to overlying articular cartilage. [1] Factors such as ossification, inflammation, and repetitive trauma contribute to the pathogenesis of OCD. If not diagnosed early, OCD can lead to the development of osteoarthritis at an early age, resulting in progressive pain and disability. [2] This condition is found primarily in the knee, ankle and elbow joints. The knee is the most commonly affected, being involved in nearly 75% of cases. [3],[4] OCD is classified as the adult form, which occurs after the physis closes, and the juvenile form, which occurs in patients with an open epiphyseal plate. [5] Many researchers believe that the adult form is undiagnosed persistent juvenile OCD. [6]


  Case Report Top


A 26-year-old female came with complains of pain, locking and palpable loose body in the right knee joint since last 4 months. She gives history of pain and swelling in right knee joint since 12 months that was worse with weight bearing. There was history of trauma. Patient does not give history of any definitive treatment taken for her complains. There was no history of any other inflammatory or infectious disease. The serologic tests for rheumatoid arthritis and for other seronegative arthritis, tuberculosis were negative. On examination there was synovial effusion, palpable loose body and knee range of movement from 0 to 100 degree. No neurological deficits of her lower limbs were found. Lachman's test, valgus and varus stress tests, and the pivot-shift test were negative. X-ray of the right knee joint antero-posterior and lateral views showed osteoarthritis changes, osteophytes and loose bodies [Figure 1] and [Figure 2]. MRI was done which showed on coronal gradient image loose bodies [Figure 3] and on coronal T1W image osteoarthritic changes in both the medial and lateral compartment, osteophytes and bone defect in subarticular aspect lateral femoral condyle and interspinous area of tibia [Figure 4]. Patient was treated with arthroscopy which showed synovitis, osteoarthritic changes grade 1 in both the medial and lateral compartment, and bone defect in lateral femoral condyle of size 2 cm × 1.5 cm. Arthroscopy assisted loose body of size 1.5 cm × 2 cm was removed [Figure 5]. For bone defect in lateral femoral condyle of size 2 cm × 1.5 cm, unstable cartilage and loose cartilage was removed so that there is a stable edge of cartilage surrounding the defect. Microfracture was then made in the exposed bone about 3 mm to 4 mm apart. Postoperatively rehabilitation in the form of 4 weeks of non-weight bearing with knee range of motion exercises were started. There was relief of symptoms and range of knee movement was increased to 130 degree.
Figure 1: X-ray knee joint AP view

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Figure 2: X-ray knee joint lateral view

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Figure 3: MRI coronal gradient image

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Figure 4: MRI coronal T1W image

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Figure 5: Loose body

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  Discussion Top


OCD is the most common cause of a loose body in the joint space in adolescents and may lead to considerable debility. [7] The prevalence of OCD is estimated at 15 to 21 per 100000. [8] OCD is characterized by a focal area of subchondral bone that undergoes necrosis. The overlying cartilage remains intact to variable degrees, receiving nourishment from the synovial fluid. As the necrotic bone is resorbed, the cartilage loses its supporting structure. [9] Subsequently, the bony fragment may be displaced into the joint space. In OCD clinical findings may be subtle, so often diagnosis may be missed by clinicians. Early diagnosis and appropriate management may prevent long-term sequelae. In our case patient presented to us with knee pain, swelling, locking, loose body and osteoarthritic changes in the knee joint on X-rays and MRI. Patient took initial treatment elsewhere in the form of analgesics, massage and manipulation. Had the patients diagnosed and treated early the prognosis would have changed. Patients with OCD presents with vague knee discomfort and restriction in the range of motion. Approximately 21% of patients relate onset of symptoms to injury and most have pain related to activity. [8] On examination, effusions, crepitus and joint line tenderness may be present. Patients with OCD of the knee may walk with an external tibial rotation, and Wilson's sign may be positive. [7] Wilsons sign is elicited by flexing the knee to 90 degrees, internally rotating the tibia and extending the knee slowly, watching for a painful response. [5] When OCD of the knee is suspected, it is confirmed by X-ray of the knee joint, antero-posterior, lateral and intercondylar notch views, MRI, bone scan and arthroscopy for knowing the grading of OCD to plan for treatment. Guhl developed a 4-stage classification system for OCD based on the degree of fragment separation observed during arthroscopic examination. Grade 1 lesions are intact and stable to probing, grade 2 lesions show early signs of separation with intact cartilage, grade 3 lesions are partially detached, and grade 4 lesions are loose bodies with a crater defect. [10] Had the patients diagnosed and treated early the prognosis would have changed. Conservative management is the mainstay of treatment for stable lesions. While the majority of patients respond to conservative treatment, [11] those with unstable lesions require arthroscopic management. Many treatments have been tried for OCD, including the removal of the fragment, [12] drilling [13],[14],[15] and curettage of the crater, microfracture, replacement of the native fragment with internal fixation, allograft replacement, autograft replacement and autologous chondrocyte transplantation. [16] We treated with removal of the fragment, debridement of the crater and microfracture. Postoperatively rehabilitation in the form of 4 weeks of non-weight bearing with knee range of motion exercises were started. There was relief of symptoms and range of knee movement was increased to 130 degree.


  Conclusion Top


OCD is a rare pathological condition and the most common cause of a loose body in the joint space in adolescents. Diagnosis may be missed because the clinical findings may be subtle. The diagnosis is made by thorough clinical examination, radiographic examination, and MRI. Early diagnosis and treatment can change the prognosis of the disease.

 
  References Top

1.Cahill BR. Osteochondritis dissecans of the knee: Treatment of juvenile and adult forms. J Am Acad Orthop Surg 1995;3:237-47.  Back to cited text no. 1
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2.Detterline AJ, Goldstein JL, Rue JP, Bach BR Jr. Evaluation and treatment of osteochondritis dissecans lesions of the knee. J Knee Surg 2008;21:106-15.  Back to cited text no. 2
    
3.O′Connor MA, Palaniappan M, Khan N, Bruce CE. Osteochondritis dissecans of the knee in children. A comparison of MRI and arthroscopic finding. J Bone Joint Surg Br 2002;84:258-62.  Back to cited text no. 3
    
4.Schenck RC Jr, Goodnight JM. Osteochondritis dissecans. J Bone Joint Surg Am 1996;78:439-56.  Back to cited text no. 4
    
5.Clanton TO, DeLee JC. Osteochondritis dissecans: History, pathophysiology and current treatment concepts. Clin Orthop Relat Res 1982;167:50-64.  Back to cited text no. 5
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6.Schenck RC Jr, Goodnight JM. Osteochondritis dissecans. J Bone Joint Surg Am. 1996;78:439-56.   Back to cited text no. 6
    
7.Obedian RS, Grelsamer RP. Osteochondritis dissecans of the distal femur and patella. Clin Sports Med 1997;16:157-74.  Back to cited text no. 7
    
8.Hughston JC, Hergenroeder PT, Courtenay BG. Osteochondritis dissecans of the femoral condyles. J Bone Joint Surg Am 1984;66:1340-8.  Back to cited text no. 8
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9.Williamson LR, Albright JP. Bilateral osteochondritis dissecans of the elbow in a female pitcher. J Fam Pract 1996;43:489-93.  Back to cited text no. 9
    
10.Guhl JF. Arthroscopic treatment of osteochondritis dissecans. Clin Orthop Relat Res 1982;167:65-74.  Back to cited text no. 10
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11.Cahill BR. Current concepts review: Osteochondritis dissecans. J Bone Joint Surg Am 1997;79:471-2.  Back to cited text no. 11
[PUBMED]    
12.Aglietti P, Ciardullo A, Giron F, Ponteggia F. Results of arthroscopic excision of the fragment in the treatment of osteochondritis dissecans of the knee. Arthroscopy 2001;17:741-6.   Back to cited text no. 12
    
13.Aglietti P, Buzzi R, Bassi PB, Fioriti M. Arthroscopic drilling in juvenile osteochondritis dissecans of the medial femoral condyle. Arthroscopy 1994;10:286-91.  Back to cited text no. 13
    
14.Kocher MS, Micheli LJ, Yaniv M, Zurakowski D, Ames A, Adrignolo AA. Functional and radiographic outcomes of juvenile osteochondritis dissecans the knee treated with transarticular arthroscopic drilling. Am J Sports Med 2001;29:562-6.  Back to cited text no. 14
    
15.Boughanem J, Riaz R, Patel RM, Sarwark JF. Functional and radiographic outcomes of juvenile osteochondritis dissecans of the knee treated with extra-articular retrograde drilling. Am J Sports Med 2011;39:2212-7.  Back to cited text no. 15
    
16.Peterson L, Minas T, Brittberg M, Lindahl A. Treatment of osteochondritis dissecans of the knee with autologous chondrocyte implantation: Results at two to ten years. J Bone Joint Surg Am 2003;85-A Suppl 2:17-24.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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