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== Definition ==
== Definition ==
-
Osteochondral injury or condition affecting
an articular
surface that involves
separation of a segment of cartilage and
subchondral bone
<
ref name="Robert"
>
Robert C et al., Osteochondritis Dissecans
:
a Current Concept Review. J Bone Joint Surg Am. 1996:78:439-456
. Level of evidence:
A1.
</
ref
>
.
+
Osteochondritis dissecans is
an
idiopathic disease which affects the subchondral bone and its overlying
articular
cartilage due to loss of blood flow. <sup>[12]</sup> This may result in
separation
and instability
of a segment of cartilage and
free movement of these osteochondral fragments within the joint space.
<
sup
>
[11] (Level of evidence
:
1A)</sup> That process can lead to pain, loose body formation and joint effusion
.
<sup>[12] (
Level of evidence:
1A)
</
sup><br
>
== Clinically Relevant Anatomy ==
== Clinically Relevant Anatomy ==
-
The femoral condyles
,
lateral and medial
, form
the rounded
end
of the femur
. The tibial plateau
,
which articulates
with the
femoral condyles, is the upper
side of the tibia. The articular bones are covered by white, shiny and elastic cartilage. The smooth articular surface of the femur roll and slide on the tibia plateau. Synovial fluid nourishes and lubricates the cartilage <
ref name="K"
>
Van Nugteren
,
K. (2008). Examination
and
Treatment of the Knee. Houten: Bohn Stafleu Van Loghum. p.82-87
. Level of evidence:
A1
</
ref
>
.
+
[http://www.physio-pedia.com/Knee The knee] (art.genus) is a synovial joint where 3 bones articulate with each other: femur, tibia and patella. It consists of 2 articulations. The first is located between the femur and tibia (art. femorotibialis).
The femoral condyles
(
lateral and medial
) which are
the
distal
rounded
ends
of the femur,
articulate
with the
proximal
side of the tibia
(tibia plateau)
.
The second joint is one between the femur and the patella. <sup>[21] (Level of evidence: D)</sup><br>
The articular bones are covered by white, shiny and elastic cartilage. The smooth articular surface of the femur roll and slide on the tibia plateau. Synovial fluid nourishes and lubricates the cartilage
.
<
sup
>
[2]</sup><br>In patients with osteochondritis dissecans
,
the subchondral bone with his articular cartilage doesn’t get any blood supply anymore
and
degenerates
.
<sup>[14] (
Level of evidence:
3B)<br>
</
sup><br
>
== Epidemiology /Etiology ==
== Epidemiology /Etiology ==
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== Differential Diagnosis ==
== Differential Diagnosis ==
-
add text here
+
If there is no certain radiological determination of osteochondritis dissecans, there can also be alternative causes of the same symptoms that should be sought. <br> • Inflammatory arthritites: a group of conditions which affect your own immune system.<br> • Osteoarthritis: degradation of joints <br> • Bone cysts: type of cyst in joints <br> • Septic arthritis: purulent invasion of the knee which produces arthritis <br>An x-ray, ct scan or MRI scan can be performed to show necrosis of subschondral bone or formation of loose fragments. This can lead to a better diagnosis.<sup>[20] (Level of evidence: D)</sup><br><br>
== Diagnostic Procedures ==
== Diagnostic Procedures ==
-
add text here related
to
medical diagnostic procedures
+
• Clinical research <br>1 stadium: vague pain at the knee and stiffness after exercising. <br>2 stadium: mechanical problems, a swollen knee and quadriceps muscle atrophy.<br>
+
+
• Technical research<br>radiographic testing.<br>
+
+
• Normally, an immobilization of the knee for a couple of weeks is sufficient in the treatment of growing children. In case immobilization is insufficient, as would normally be the case for adults, a mobilization procedure must be started up. In this procedure, stretching exercises are performed. The range of motion and strengthening ability of the muscles will be gradually increased in the next 3
to
6 months. In the end, in case the knee is not fully recovered, surgery should be necessary.<br><sup>[10] [13] (Level of evidence: C5, F5)</sup><br><br>
== Outcome Measures ==
== Outcome Measures ==
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== Examination ==
== Examination ==
-
*The knee feels warmer than the non-injured knee <
ref name="K"
/>.
+
*The knee feels warmer than the non-injured knee<
sup>[2]<
/
sup
>.
-
*There is swelling palpable <
ref name="K" /><ref name="Robert" /
><
ref name="Hoffman"
/>.
+
*There is
an intermittent
swelling palpable<
sup
>
[2][1][3] [15]
</
sup
>.
-
*Quadriceps muscle atrophy <
ref name="Alvin" /
><
ref name="Matthew"
/>.
+
*Quadriceps muscle atrophy <
sup
>
[6][4]
</
sup
>.
-
*The passive and active extension of the knee is limited <
ref name="Pascual"
>
Cecilia Pascual G. et al., Surgical Treatment Options for Osteochondritis Dissecans of the Knee. American Orthopaedic Society for Sports Medicine. 2009:1-9. Level of evidence: A2.
</
ref
>.
+
*The passive and active extension of the knee is limited <
sup
>
[7]
</
sup
>.
-
*Catching or locking of the knee <
ref name="Robert" /
><
ref name="Matthew"
/>.
+
*
Catching or locking of the knee <
sup
>
[1][4]
</
sup
>.
-
*Tibial external rotation during gait <
ref name="Matthew"
/>.
+
*Tibial external rotation during gait <
sup>[4]<
/
sup
>.
-
*It is possible that both capsular and non-capsular movement restrictions can be found during functional assessment, the severity is dependent on a possible herniation of the knee joint and the degree of joint irritation <
ref name="K"
/>.
+
*
Fluid effusion<sup>[15](Level of evidence: F5)</sup>
-
*The sensitive location of the abandoned section of the osteochondral fracture can be felt, when the knee is in 90° of flexion <
ref name="Matthew"
/>.
+
*
It is possible that both capsular and non-capsular movement restrictions can be found during functional assessment, the severity is dependent on a possible herniation of the knee joint and the degree of joint irritation <
sup>[2]<
/
sup
>.
-
*
[[
Wilson's Test
]]
:
when the patient report pain in the
knee
about
30° from full extension
,
the test is positive <
ref name="Alvin" /
>.<br>
+
*
The sensitive location of the abandoned section of the osteochondral fracture can be felt, when the knee is in 90° of flexion <
sup>[4]<
/
sup
>.
+
*
Wilson's Test:
The
knee
is held in 90° to
30° from full extension
while rotating
the
tibia.<sup>[6]</sup>
+
+
-> The
test is positive
when internal rotation is painful and external rotation relieves symptoms
<
sup
>
[12]
.
(Level of evidence: 1A)</sup><br>
<br>
== Medical Management ==
== Medical Management ==
-
By
minor cases rest can prescribed. The patient has to stop activities for three to six months.
+
In
minor cases rest can prescribed. The patient has to stop activities for three to six months
and the lesion will heal spontaneously, especially with young adolescents
.
<sup>[15]</sup><br>Stages three and four are always treated surgically. Surgery is also required when the conservative treatment in stages one and two was inadequate.<sup>[2][7][8]</sup> It’s more recommended to treat surgically when a large part of the femoral condyle has been excavated, because of the risk to develop osteoarthritis.<sup>[15]</sup><br>Many diagnostic imaging methods (eg, radiography, magnetic resonance imaging (MRI), technetium 99m pyrophosphate joint scintigraphy, bone scans), as well as arthroscopic examination, have been used in an attempt to stage or classify osteochondral lesions. The stages (typically 3 or 4 levels) represent a continuum of tissue degeneration leading to complete disruption and instability of the lesion (loose body). Originally, staging was determined based on radiographic findings. Currently, MRI appears to be the preferred choice for detection of this type of chondral injury and for determination of a lesion's stability.<br>A variety of surgical methods exist for the management of articular cartilage lesions at the knee, such as OCD. These include the use of arthroscopic lavage or debridement, radio frequency energy, bone drilling, osteochondral autografts or allografts, internal fixation of bone fragments, and autologous chondrocyte implantation . <sup>[</sup><sup>19](level of evidence: 3B)</sup>
-
Stages three and four are always treated surgically, and also when the conservative treatment in stages one and two was inadequate <ref name="K" /><ref name="Pascual" /><ref name="MAO">M.A. O et al, Osteochondritis dissecans of the knee in children. British Editorial Society of Bone and Joint Surgery. 2002
:
258-262. Level of evidence: B2.</ref>
+
Surgical techniques
:
-
Surgical techniques:
+
* In stages one and two the articular cartilage is still intact, through retrograde operation trying to tap into to the affected bone ‘from behind’ and clear it. The advantage of this surgical technique is that the articular cartilage stays intact <sup>[2][4][7]</sup>.
+
* Not yet dissected fragment will be fixed by means of an operation <sup>[1][6][5]</sup>.
+
* Excision of the fragment and removal of loose bodies <sup>[1][6]</sup>.
+
* Repair of blood supply by drilling arthroscopic through the cartilage and the hearth of osteochondrosis into the healthy bones<sup>[6][4][7]</sup>.
+
* Stabilization of the fragment through pinning or through screw fixation <sup>[6][4][7][5]</sup>.
+
* Osteochondral autograft transplantation (OATS).
+
* Osteochondral allograft transplantation.
+
* Autologous chondrocyte implantation (ACI) <sup>[6][7]</sup>.
-
*In stages one and two the articular cartilage is still intact, through retrograde operation trying to tap into to the affected bone ‘from behind’ and clear it. The advantage of this surgical technique is that the articular cartilage stays intact
<
ref name="K" /
>
<ref name="Matthew" /><ref name="Pascual" />.
+
<
br
><br>
-
*Not yet dissected fragment will be fixed by means of an operation <ref name="Robert" /><ref name="Alvin" /><ref name="KB">K. B et al., Osteochondritis (osteochondrosis) dissecans: a review and new MRI classification. Department of Diagnostic Radiology and Neuroradiology. 1998:8:103-112. Level of evidence: A1</ref>.
+
-
*Excision of the fragment and removal of loose bodies <ref name="Robert" /><ref name="Alvin" />.
+
-
*Repair of blood supply by drilling arthroscopic through the cartilage and the hearth of osteochondrosis into the healthy bones <ref name="Alvin" /><ref name="Matthew" /><ref name="Pascual" />.
+
-
*Stabilization of the fragment through pinning or through screw fixation <ref name="Alvin" /><ref name="Matthew" /><ref name="Pascual" /><ref name="KB" />.
+
-
*Osteochondral autograft transplantation (OATS).
+
-
*Osteochondral allograft transplantation.
+
-
*Autologous chondrocyte implantation (ACI) <ref name="Alvin" /><ref name="Pascual" />.
<br>
+
== Physical Therapy Management <br> ==
== Physical Therapy Management <br> ==