Years published: 2023
NORD gratefully acknowledges Kevin McMahon and Gregory Cichon, MD Candidates, Creighton University School of Medicine, for the preparation of this report.
Osteochondritis dissecans is a joint condition that occurs when a piece of cartilage and the thin layer of bone beneath it separate from the underlying bone. It may be asymptomatic during the early stages of the disease. People with symptoms may experience pain, catching and/or decreased range of motion in the affected joint, especially if the cartilage and bone break off into the joint space. Osteochondritis dissecans can affect people of all ages, but it is usually diagnosed in children between the ages of 10 and 15 years. Osteochondritis dissecans mostly affects the knees, elbows or ankles of young patients who are heavily involved in sports at a young age. It mostly affects only one joint and only one side of the body but may be found on both sides of the body, such as in both knees or both elbows. The disease process is characterized by abnormal alteration of bone in joints that may lead to disruption and separation of the overlying cartilage.
Treatment for the condition varies depending on many factors, including the age of the affected person, stage of the lesion and the severity of the symptoms, but may include rest, weight bearing restriction, brace for unloading or immobilization or surgery and/or physical therapy. If improperly treated, osteochondritis dissecans may cause premature osteoarthritis.
In 1840 a scientist named Paré was the first to describe the removal of loose bodies (osteochondral fragments) from a joint. In 1870, another scientist by the name Paget described the disease process as “quiet necrosis” due to formation of loose, dead osteochondral (joint bone and cartilage) fragments on articular (joint) surfaces. In 1888, another scientist named König described a condition that led to loose body formation which he called “arthrophytes” in a patient without known trauma. It was believed that inflammation of bone and cartilage followed by tissue death and separation (of bone and cartilage from the underlying bone) was the underlying mechanism of the disease.
Though this theory has been questioned, it was the basis for the term osteochondritis dissecans which is derived from “osteochondritis” meaning inflammation of the joint surface and “dissec” meaning to separate.
Symptoms of osteochondritis dissecans are often vague and occur on and off especially in early stages of the condition but may increase with activities such as climbing stairs or throwing. As the condition progresses and more loose bits of cartilage and bone are found in the joint, there may be catching (partial inhibition of movement), locking, (total inhibition of movement) or a sense of giving way of the joint and there may also be the sensation of loose fragments within the joint. Additionally, there may be pain and swelling of the affected joint.
When a doctor evaluates a person with osteochondritis dissecans, the findings are often vague. There may be a grating sound or sensation which is produced by friction between bone and cartilage (crepitus), joint swelling (effusion) or tenderness (pain with pressing). Tenderness is often poorly localized early in the condition but has more definite locations later. In the knee and ankle, patients may even take on an abnormal gait (walking motion) to avoid pain or joint dysfunction. In the ankle, there may be crepitus, tenderness, swelling and inflammation like in the knee, but there may also be pain with compression of the ankle (tibiotalar joint). Osteochondritis dissecans of the elbow is associated with pain, swelling, stiffness and limited range of motion. Although most people with this disease have joint pain and swelling, these symptoms are also associated with many other disorders which can make it difficult to narrow a diagnosis.
The origin of osteochondritis dissecans in the knee is unknown, but many causes have been suggested. It is probably due to many factors that could include some or all the following: inflammation, genetics, poor blood flow (ischemia), defective bone formation (ossification) or repetitive trauma.
The trauma causing osteochondritis dissecans is not due to direct trauma like a car accident, but rather indirect trauma such as repetitive joint movements or overuse. This mechanism is similar to that of shin splints (bone injuries) which runners get after running excessively long distances or on hard surfaces. This theory of repetitive trauma is supported by the increasing incidence of osteochondritis dissecans in younger patients with increasing participation in sports at a young age, specialization in a single sport and increasing rates of childhood obesity (which puts more strain on joints). Alternatively, the increased number of cases could be due to greater awareness and greater ability to detect the condition through improved imaging tests (x-ray, CT, MRI). Individual differences in a person’s joint structures (anatomic variations) may increase the risk of developing osteochondritis dissecans from repetitive trauma.
Regarding the possibility of poor blood flow, some scientists have suggested that poor blood flow may make certain areas of the cartilage and bone in joints more susceptible to separation from the underlying bone. The underlying mechanism is that this area of bone and cartilage gets injured, does not heal well and accumulates injuries over time. Eventually, the bone is damaged and some of the overlying bone and cartilage separate and may fall into the joint space as a flap or as loose bodies.
The theory about abnormal bone formation (ossification) in younger patients suggests that bones may fail to properly harden, leading to separation under stress. This separation may initially be partial but after a cycle of repeated trauma, partial reattachment and accumulation of damage, the layers may fully separate.
Researchers have studied genetic causes of osteochondritis dissecans but have found only small effects from family history and genetic predispositions.
Ankle & Elbow
Osteochondritis dissecans of the ankle and elbow are even more strongly related to trauma than osteochondritis of the knee. In the ankle, osteochondritis dissecans lesions that are more lateral (towards the outside edge) are strongly associated with trauma while those that are more medial (towards the centerline) are less associated with trauma. In the elbow, osteochondritis dissecans is highly associated with repetitive trauma and has a relatively high rate in throwing activities such as baseball or racquet sports.
Osteochondritis dissecans is estimated to be 2-3x more common in males and more common in people aged 10-15 (average = 11.3-13.4 years). It affects fewer than 30 people per 100,000. It is rarer for patients older than 50 or younger than 10 to develop this condition. While OCD most commonly affects the knees, boys tend to have a higher risk of developing osteochondritis dissecans in the knees or elbows whereas girls have a higher risk of developing it in the ankles.
There are two main populations to consider when discussing those affected by osteochondritis dissecans. Younger patients (age 5-15) with open growth plates and older patients with closed growth plates. Younger patients with open growth plates have the “juvenile” form of osteochondritis dissecans and are most commonly young male athletes. Older patients with closed growth plates have the “adult” form of osteochondritis dissecans. Osteochondritis dissecans is rarely seen in patients <10 or >50 years. Adults with a new diagnosis likely had it for years without symptoms.
Juvenile osteochondritis dissecans of the knee is generally diagnosed in early adolescent or teen years. Diagnosis in adults is more variable and may occur at any age but is generally before age 40.
Most people with osteochondritis dissecans of the ankle are diagnosed in early adulthood. Osteochondritis dissecans of the lateral ankle is associated with trauma and may have more persistent symptoms. Osteochondritis dissecans of the medial ankle is often not associated with trauma and is frequently asymptomatic.
Patients with osteochondritis dissecans of the elbow are often adolescents who participate in throwing sports like baseball.
As mentioned above, the physical exam findings in a person with osteochondritis dissecans are often not specific enough to confirm a diagnosis. Therefore, diagnosis is mostly reliant on imaging. Initial imaging of the joint is usually conducted with x-rays that may show transparency of subchondral bone, separation of bone fragments from underlying bone, evidenced by a dark (radiolucent) line, or loose osseous bodies. On further imaging such as an magnetic resonance imaging (MRI), physicians may be able to better characterize the state of the bone and cartilage, determine the degree of displacement of those pieces and monitor treatment progress or restoration of vascular supply. Studies have shown that MRI and arthroscopy (surgical visualization of the inside of the joint with a camera) are the best tools to determine disease diagnosis and progression.
In addition to identification of disease, MRI and arthroscopy may help determine the stage of the disease. Ultrasound may also be used but tends to be less reliable. An imaging technique called scintigraphy was once used in diagnosis and evaluation of treatment response but has been increasingly phased out due to increased use of MRI.
Treatment for osteochondritis dissecans has evolved over the past 150 years. The original treatment was either non-operative treatment or simple open removal of loose fragments (arthrotomy), but modern therapy is a combination of both non-surgical and more advanced surgical treatments. Though definitive treatment guidelines have not firmly been established, there are well-established trends, recommendations and indications for both surgical and non-surgical treatments. Conservative, nonoperative treatment is preferred in early stages of the disease or in young patients with open growth plates. In later stages or in older patients, improved imaging techniques like MRI, treatment options (arthroscopy) and understanding of joint bone-cartilage healing allow for more accurate assessment of disease stage, progression and treatment response.
MRI helps determine the best treatment choice by detecting the degree of disease progression, growth plate closure and stability of the OCD lesion.
Young patients with open growth plates, minimal symptoms, intact joint surfaces and those with less unstable joints often can be treated with simple weight bearing restrictions and physical therapy as osteochondritis dissecans will frequently heal without surgery. Weight bearing restrictions may involve the use of off-loading braces or crutches to prevent further joint damage and allow for proper healing. Often patients will have these activity limitations until they are symptom free, or a series of MRIs shows significant healing. If after 3 months of conservative treatment, patients remain symptomatic or imaging shows little healing, surgery may be needed.
In contrast, patients with closed growth plates, severe or persistent symptoms or unstable joints often require surgery due to the low chance of healing without surgical treatment. Improper treatment carries the risk of joint disease progression to premature and potentially irreversible osteoarthritis. Regardless of type, patient symptoms may be best managed with acetaminophen (Tylenol).
The nonoperative treatments for the knee are highly variable among institutions, but may generally be broken down into 3 phases.
Phase 1 includes 4-6 weeks of knee immobilization with crutch-assisted partial weight bearing gait.
Phase 2 includes 6-8 weeks of weight bearing without immobilization plus initiation of a rehabilitation program focused on knee range of motion and low impact strengthening of the quadriceps and hamstring muscles. Patients should continue to avoid sports or repetitive-impact activities during this phase.
Phase 3 consists of supervised jumping, running and cutting (quick directions changing) sport activities. A gradual increase in activity intensity and return to sports is permitted if the patient remains pain free. At this stage an MRI should be repeated to assess for healing. If images show recurrence of lesions or patients again become symptomatic, repeated non-surgical treatment may be advised.
Surgical treatment of osteochondritis dissecans is indicated in patients with any of the following: symptomatic loose bodies, disease progression or persistence during conservative/non-surgical treatment, and detection of a displaced or completely separated fragment in the joint. Most adults with osteochondritis dissecans are treated surgically due to a high rate of joint instability and low rate of spontaneous healing.
The goals of surgery include restoring the continuity (smoothness) of joint surfaces, enhancement/restoration of blood supply to fragments, rigid fixation of salvageable fragments and removal of loose fragments that cannot be restored to their proper location (approximated). After surgery patients should begin to use a walker or crutches as permitted by their doctor to help maintain range of motion and strength. Surgeons use minimally invasive techniques such as arthroscopy to restore the joint surface, promote blood vessel growth and smooth out any rough bone or cartilage. Simply removing all the bone fragments or trying to put them all back in place is not recommended due to the risk of creating an irregular joint surface. Thus, replacement of larger fragments to their proper location and removal of smaller ones that cannot be properly replaced is key to helping reconstruct a smooth joint surface. The larger fragments are then fixed in place with pins, wires, screws or pegs that may be biodegradable. If the joint surface is unsalvageable, the surgeon may need to take some bone or cartilage from a different, non-weight bearing joint surface or from a cadaver donor to reconstruct the deformed joint. If patients are older and have significant joint disease, they may be referred for treatment with more significant surgeries such as a total or partial knee replacement.
In the ankle, early-stage lesions are treated conservatively without surgery, while late-stage lesions are treated with surgery. All very late-stage lesions, regardless of location, are treated with minimally invasive arthroscopic surgery as listed above.
In the elbow, like in other joints, treatment can be either non-surgical or surgical based on the disease stage, size of the lesion, patient skeletal maturity, patient symptoms or imaging findings. Surgical treatment may consist of only removing loose fragments with drilling to help stimulate blood vessel growth in bone, but the preference is to salvage the fragment with fixation. Transplanting a plug of cartilage and subchondral bone from a different part of the body or from a cadaver donor is another treatment option. Loss of elbow motion is one of the most common complications after surgery.
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