Juvenile OCD of the Knee: Transarticular Drilling
Abstract & Commentary
Synopsis: This retrospective study shows reliable clinical and radiographic outcome with transarticular drilling for the isolated, stable, juvenile OCD lesion of the medial femoral condyle.
Source: Kocher MS, et al. Functional and radiographic outcome of juvenile osteochondritis dissecans of the knee treated with transarticular arthroscopic drilling. Am J Sports Med. 2001;29(5):562-566.
This study by Kocher and colleagues from Boston Children’s Hospital retrospectively evaluated a simple and straightforward arthroscopic treatment approach to juvenile osteochondritis dissecans (OCD). Kocher et al describe their technique of transarticular drilling with remarkable results, including improvement both clinically and radiographically. Twenty-three patients created the database for this study with 30 knees diagnosed as having a stable, juvenile OCD lesion. All patients had failed 6 months of nonoperative treatment including activity modification and periods of protected weight bearing. Average age was 12.3 years with follow-up ranging from 2 to 7.2 years (average follow-up, 3.9 years). The mean Lysholm scale improved from 58 to 93, with a significant decrease in mean lesion size (4.5 mm average decrease on AP radiographs and 8.4 mm average decrease on lateral radiographs). Radiographic healing was achieved in all patients on average at 4.4 months (range, 1-11 months). The younger the age of the patient, the better the improvement noted.
Comment by Robert C. Schenck, Jr., MD
OCD of the knee is a confusing and difficult clinical topic. Multiple definitions, treatments, and limited follow-up have made consensus treatment of this entity nonuniform. Kocher et al are to be commended for the useful information available from using a single treatment method for the stable, juvenile OCD lesion in patients having failed conservative management for 6 months. The reader should note the significant difference in clinical course between adult and juvenile (growth plates open at presentation) OCD. As discussed elsewhere,1 dissecans means "to separate" and most commonly involves injury to the osteochondral layer of the lateral aspect of the medial femoral condyle (~ 85% of the time) vs. occurring in the lateral femoral condyle (~15% of the time). In the discussion of juvenile OCD, initial management involves conservative care, which has involved relative rest, immobilization, and as Kacher et al note, "watchful waiting" for up to 6 to 18 months. Once conservative management has failed, surgical options include antegrade or retrograde drilling, internal fixation, grafting, OATS internal fixation, autologous or allogenic grafting, and autologous chondrocyte implantation (ACI, Carticel®).
Kocher et al provide substantial evidence in the treatment of a stable, juvenile OCD lesion failing conservative treatment to simply drill antegrade through the soft cartilage lesion with 6 to 10 perforations using a 1.6 mm Kirshner wire. Kocher et al note that the alternative, "retrograde drilling avoids violation of the articular surface; however, in our experience it may be associated with technical difficulty, inaccuracy, and inadequate depth of penetration." I have found this to occur as well with retrograde drilling, and it is reassuring to see documented improvement despite violation of the articular surface with antegrade drilling. Lastly, Kocher et al show that the younger the patient, the better the overall improvement. It behooves the clinician, in my opinion, to watch these patients carefully and not overextend conservative care. I suspect earlier surgical management will become more commonplace instead of the long held belief of conservative treatment up to 18 months.
Reference
1. Schenck RC, Goodnight JM. Osteochondritis dissecans. A current concepts review. J Bone Joint Surg Am. 1996;78(3):439-456.
Dr. Schenk, Deputy Chairman, Department of Orthopaedics, University of Texas Health Science Center, San Antonio, is Associate Editor of Sports Medicine Reports.
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