Michael Saper, DO, ATC, CSCSAssistant Professor, Orthopedics and Sports Medicine

Knee Osteochondritis Dissecans (OCD) in

the Pediatric and Adolescent Patient

Wall OCD Knee NonOperative 2015

Pediatric Sports Medicine Operative Challenges and Solutions: A Case Based Approach

AAOS 2015 Annual Meeting

Eric J Wall, MD, Cincinnati Children’s

Objectives

! Discuss the indications/contraindications for the non-operative treatment of knee

OCD

! Discuss the clinical and radiographic predictors of success for non-operative

treatment of knee OCD

! Describe the non-operative treatment methods of OCD of the knee

Should I Even Try Non-operative Treatment of Knee OCD?

! Success rates of non-operative treatment for OCD range from 50%-100%

! Will patients tolerate non-operative treatment?

! Should I go straight to surgery?

What Predicts Non-Operative Success?

! Patient Age: Open growth plates

! Lesion Size: Smaller is better

! Lesion Stability on MRI: Only stable lesions amenable for non-op treatment

! Blood Flow: Inconsistent data on vascular vs avascular

! Lesion Location (MFC, LFC, Patella, Trochlear Groove)

! Radiographic Sclerosis: More sclerosis is worse. (Ramirez A 2010)

! More bone in OCD Lesion: Perhaps

! Absence of Mechanical Symptoms: Perhaps

! Cyst Like Lesions: If < 1.3 mm in total length on MRI (Krause M 2013)

Stable MRI Unstable MRI

Predictive Model: Nomogram (Wall EJ 2008)

! Helps to individualize the specific success rate of non-operative treatment for each

patient

! Let’s parents choose non-operative vs operative treatment based on success rate

! How it works

Anatomy

• Cartilage covers the joint surface

at end of a bone.

• When healthy, allows:

• Range of motion

• Shock absorption

• Poor healing ability

What is OCD?

12/19/2017

7

Boundary

Boundary distinct

higher or lower density line separating parent from progeny

TJG

Juvenile OCD - Uniform Nomenclature – Credit ROCK group

Parent Bone

Progeny Bone

Fragmentation Fragmented >/= 2 pieces of bone

• Injury to the bone below the

cartilage

• Due to loss of blood supply from

repetitive trauma

• Risk for instability and disruption of

overlying cartilage

• May result in early arthritis

• Both knees in 25%

Can be a 3-4 procedure

problem

Treatment depends on….

• Stability of OCD lesion

• Fragment salvageable?

• Location

• Size

• Amount of bone

involvement

Cue Ball, Shadow

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12

TJG

Articular Surface Intact

-Not Marginated

-Wide open growth plates

Juvenile OCD

A

Articular Surface Intact

Marginated

B

Not Intact

C

TJG

Arthroscopic Evaluation

ROCK

Stable, Salvageable ProgenyCue Ball

Shadow

Immobile

TJG

Arthroscopic Evaluation

ROCK

Stable, Salvageable Progeny Locked Door mobile

Osteochondritis Dissecans – Locked Door

12/19/2017

12

TJG

Articular Surface Intact

-Not Marginated

-Wide open growth plates

Juvenile OCD

A

Articular Surface Intact

Marginated

B

Not Intact

C

TJG

Arthroscopic Evaluation

ROCK

Stable, Salvageable ProgenyCue Ball

Shadow

Immobile

TJG

Arthroscopic Evaluation

ROCK

Stable, Salvageable Progeny Locked Door mobile

Trap Door

12/19/2017

13

TJG

Unstable, Salvageable progeny:Trap Door

Crater with congruent flap

Crater with incongruent loose flap

That can be made congruent

Juvenile OCD

ROCK

mobile

TJG

Unstable, Unsalvageable progenyCrater with incongruent loose body that can not be made congruent

Crater with fagmented loose body

Crater without loose body

Juvenile OCD

ROCK

TJG

• Phase 1 (4-6 weeks)

– Immobilization – WBAT

• Phase 2 (6 weeks)

– No immobilization – ADL’s – PT

• Phase 3 (Lesion healed - absence of symptoms)

– Gradual/Supervised return to sport

OCD of the Knee

AlgorithmNonoperative Protocol

2010 AAOS Presentation – Unloader > Casting or Restriction

Kocher/Ganley/Micheli et al

Crater

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13

TJG

Unstable, Salvageable progeny:Trap Door

Crater with congruent flap

Crater with incongruent loose flap

That can be made congruent

Juvenile OCD

ROCK

mobile

TJG

Unstable, Unsalvageable progenyCrater with incongruent loose body that can not be made congruent

Crater with fagmented loose body

Crater without loose body

Juvenile OCD

ROCK

TJG

• Phase 1 (4-6 weeks)

– Immobilization – WBAT

• Phase 2 (6 weeks)

– No immobilization – ADL’s – PT

• Phase 3 (Lesion healed - absence of symptoms)

– Gradual/Supervised return to sport

OCD of the Knee

AlgorithmNonoperative Protocol

2010 AAOS Presentation – Unloader > Casting or Restriction

Kocher/Ganley/Micheli et al

Operative Treatment Options – Stable/Immobile Lesions

• Subchondral Bone Drilling

• ~1mm wire

• Drill into bone to stimulate healing

• ~85-90% healing at 4.5-5.5 months

12/18/2017

3

Isolated Drilling without additional procedures

• Isolated drilling for stable Lesions in those with significant growth remaining

• If closer to maturity, consider drilling + fixation, possible bone grafting

• For more advanced lesions, drilling in isolation is not enough

Stable/Immobile Lesions

Subchondral bone drilling options

Trans-articular drilling Retro-articular drilling

Drilling

• Trans-articular

– Visualize lesion / holes directly

– Ensures adequate coverage

• Retro-articular

– Doesn’t violate articular cartilage

– Fluoroscopy

• ROCK – RCT ongoing!

– Ben Heyworth CHB

– Trans vs retro MFC OCD lesions

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5

Subchondral Bone Drilling For OCD – Hyaline

Cartilage surface is normal

The C-arm is used to identify the OCD lesion. A guide pin is placed in the most inferior region of the lesion, to be used as a marking point for additional drilling

Medial Femoral Condyle

File name – Picture - Start of subchondral bone drilling video -

This 0.045 K-wire defines the Medial and posterior edge of the OCD lesion.This is placed with Guidance from the mini C-arm.

PCL Origin and Fibers

Medial Femoral Condyle

Notch Drilling Technique for OCD

File name – Picture - Notch Drilling Technique for OCD

Video - OCD Notch drilling

Video - OCD Notch drilling with Marker Pin

Operative Treatment Options – Unstable Lesions

• Fixation (open or arthroscopic)

• Salvageable cartilage

• Metal vs Bioabsorbable

• Biologic

• + Drilling

• Salvage

• Chondroplasty/Microfracture (drilling)/abrasion arthroplasty

• OATS

• OCA

• ACI

• + Bone grafting

Salvageable Unstable Lesions - Fixation

• No difference in outcomes

• Bioabsorbable implants (chondral dart, smart nail, biocompression

screw)

• No need to remove

• ? Cyst formation (with older technology)

• Metal screws

• May need removal 6-8 weeks (time varies depending on screw choice)

12/11/2017

4

Dallas, Texas

Treatment-Operative

15 year-old female

Dallas, Texas

Treatment-Operative

15 year-old female

Dallas, Texas

Treatment-Operative [salvage]

Microfracture

• Technically easy.

• Inexpensive.

• Gudas [2009]

– Microfracture vs. OATS

– Prospective, randomized.

– 41% failure in microfx at 4.2

yrs.

– 0% failure for OATS.

Arthroscopic Fixation with BioCompression Screws

(Preferred Technique)

Unsalvageable Lesions - Marrow Stimulation

• Small lesions (< 1-2 cm)

• Contained (cartilage walls all

around)

• Minimal bone loss

• Drill holes in the bone

• Forms a cartilage plug

Marrow Stimulation Plus Biocartilage

• Allograft cartilage

• Add PRP

• Scaffold

• Improves fill of defect

• Increased Type II collagen

• No outcome data

Introduction

Articular cartilage, also called hyaline cartilage,

is the tissue component that covers the joint

surface at the end of a bone. A joint typically

consists of two bones connected together with

the articular cartilage of each bone opposing

the other. When healthy, the cartilage allows our

joints to go through painless range-of-motion and

helps to provide shock absorption when weight-

bearing. When cartilage is damaged, this may

cause patient discomfort along with joint swelling,

which leads to decreased range-of-motion and

stiffness.

How is injured cartilage treated?

The physician will evaluate your symptoms and

perform a physical examination of the joint that

is causing you discomfort. The physician may

also elect to obtain an imaging study to further

evaluate your injury. Depending on the findings,

your physician may determine a surgical procedure

is warranted. When a cartilage lesion is identified,

your surgeon may recommend a microfracture

procedure, also known as bone marrow stimulation

technique. This procedure consists of debriding

the damaged cartilage until a border of healthy

cartilage is found. Small holes are then made in

the base of the defect providing access channels

for the underlying bone marrow cells to enter

and begin laying down reparative tissue.

What is BioCartilage®?

BioCartilage is developed from allograft articular

cartilage. After going through a number of pro-

prietary processing steps, the result is a cartilage

extracellular matrix scaffold. BioCartilage contains

the extracellular matrix that is native to articular

cartilage, which includes scaffolding proteins and

additional cartilaginous growth factors. The small

particles are mixed with a blood solution that

comes from your own body in order to create

a paste-like consistency that can be applied over

a cartilage defect.

How does BioCartilage work?

BioCartilage functions as a tissue scaffold that

your body’s cells can attach to and produce

new reparative cartilage tissue in the defect site.

Your surgeon will clean the defect area, clearing

out damaged tissue and use this scaffold in

conjunction with microfracture as a way of

providing attachment sites for the bone marrow

cells. These cells will penetrate through the access

channels to aid in the healing process.

Microfracture procedure

BioCartilage Procedure in the Ankle

BioCartilage applied over defect

BioCartilage smoothed over defect

Completion of BioCartilage procedure

Microfracture procedure

BioCartilage Procedure in the Knee

BioCartilage applied over defect

BioCartilage smoothed over defect

Completion of BioCartilage procedure

Unsalvageable Lesions – Osteochondral Allograft

• Osteochondral Allograft

• Replaces bone and cartilage

• 88% good-excellent results at 10

years in adolescents

• Staged procedure ?

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Dallas, Texas

Treatment-Operative

Fresh Osteochondral Allograft• Replaces bone and

cartilage.

• Emmerson [2007]– 72% good-excellent at 7.7

yrs.

– Mean size 7.5 cm2.

– All had prior surgery.

• Murphy, Pennock, Bugbee[2014]– 88% good-excellent at 10

years in adolescents.

Dallas, Texas

Treatment-Operative

Fresh Osteochondral Allograft• Replaces bone and

cartilage.

• Emmerson [2007]– 72% good-excellent at 7.7

yrs.

– Mean size 7.5 cm2.

– All had prior surgery.

• Murphy, Pennock, Bugbee[2014]– 88% good-excellent at 10

years in adolescents.

Dallas, Texas

Summary

• Always assess alignment.

• Microfracture/Marrow Stimulation/Debridement does not

produce durable long-term results.

• Fixation with bone grafting is an option if cartilage is in good

condition and patient has growth remaining.

• Osteochondral allograft and ACI/MACI are good options for

large unsalvagable lesions.

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6

Dallas, Texas

Treatment-Operative

Fresh Osteochondral Allograft• Replaces bone and

cartilage.

• Emmerson [2007]– 72% good-excellent at 7.7

yrs.

– Mean size 7.5 cm2.

– All had prior surgery.

• Murphy, Pennock, Bugbee[2014]– 88% good-excellent at 10

years in adolescents.

Dallas, Texas

Treatment-Operative

Fresh Osteochondral Allograft• Replaces bone and

cartilage.

• Emmerson [2007]– 72% good-excellent at 7.7

yrs.

– Mean size 7.5 cm2.

– All had prior surgery.

• Murphy, Pennock, Bugbee[2014]– 88% good-excellent at 10

years in adolescents.

Dallas, Texas

Summary

• Always assess alignment.

• Microfracture/Marrow Stimulation/Debridement does not

produce durable long-term results.

• Fixation with bone grafting is an option if cartilage is in good

condition and patient has growth remaining.

• Osteochondral allograft and ACI/MACI are good options for

large unsalvagable lesions.

Operative Treatment Options – Unstable Lesions

• Bone grafting

• If significant bone loss or cystic changes at base of lesion

• Cancellous chips, DBM, autogenous local grafting (proximal tibia,

distal femur)

Rehabilitation and Return to Sports

• Weight-bearing depends on procedure

• From NWB to TTWB

• Encourage range-of-motion exercises

• Goal = full ROM by 6 weeks

• Increased loadbearing exercises at 3 months

• Return to sport at 6-9 months depending on sport

Conclusions

• Goals = remove diseased tissue, fill the defect, return to

sports

• Surgery generally results in improved elbow range-of-

motion and outcomes

• Low rate of complications

• Slow, progressive rehabilitation is key

• Return to sports (6-9 months)

Contact:

@DrMichaelSaper