Author(s): Shane Mario Andre Drakes, MD, Anusha Lekshminarayanan, MD, Michael Lew, DO, Xiao Wei Liu, MD
Originally published: December 2, 2013 Last updated: May 18, 2023
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Disease/ Disorder

Definition

Osteochondritis Dissecans (OCD) is osteonecrosis of subchondral bone, with secondary damage to overlying articular cartilage. It is characterized by degrees of osseous resorption, collapse, and fragmentation.1 There are juvenile and adult forms of this condition; the juvenile form occurs in children or adolescents with open growth plates (skeletally immature). While the vast majority of OCD occurs in the knee, the article herein also discusses OCD in the elbow and the ankle.

Etiology and pathophysiology

In 1888, König first described OCD and at the time suggested inflammation as the cause of these lesions.1 The exact pathophysiology is unknown; however, a disruption of blood supply to subchondral bone is thought to be the underlying mechanism for OCD. Proposed causes include localized avascular necrosis, ossification center deficit, chronic microtrauma or acute trauma, joint malalignment (genu varum), and genetic predisposition, among other causes.1–3 Other considerations include systemic vasculopathies, inflammation, endocrine or metabolic factors, and degenerative joint disease. The most commonly accepted cause of osteochondritis dissecans is repetitive trauma.3,4 Another explanation is involvement of the endochondral epiphyseal growth plate, which can be injured either acutely or repetitively over time. While the uninjured region of the endochondral epiphyseal growth plate continues to ossify, the injured region, either temporarily or permanently, ceases ossification, leading to development of OCD5. Epidemiology including risk factors and primary prevention.

OCD affects adolescents at a rate around 10 per 100,000.6 It is more common among males and African American race6. The highest incidence of juvenile OCD is among patients 10 to 15 years old.7 OCDs are significantly more common in the knee (75% or more of cases), followed by the elbow (6% of cases) and ankle (4% of cases).1 The most common location for juvenile OCD of the knee is the lateral portion of the medial femoral condyle (60-70%) followed by the lateral femoral condyle (15-20%).4,6,8 A large percentage of patients with OCD self-identified as athletes (91.4%), and the majority of those patients were multisport athletes; suggesting that increased physical activity may be a risk factor.9Multiple missense ACAN gene variants with autosomal dominant inheritance, affect the C-type lectin repeat of aggrecan (15q gene) and cause a rare form of hereditary osteochondritis dissecans. ACAN missense gene variants are often demonstrate short stature and early osteoarthritis.10

Knee OCD: Recent studies have shown that Vitamin D deficiency was associated with knee osteochondritis dissecans lesions among the young adult population.11,12 Increased BMI is associated with more severe lesions: subchondral edema, anteromedial condylar lesions of the knee.13 Discoid menisci and valgus alignment have been shown to be a risk factor for lateral femoral condyle OCD. 1

Elbow OCD: Overhead throwing and upper limb weightbearing is associated with OCD of the elbow, as seen in baseball pitches, softball pitchers, cheerleaders, cricket bowlers, cheerleaders, female gymnastics.14,15

Talar OCD: Medial talar dome lesions are often the result of vascular disease and chronic ankle instability lesions, lateral talar dome is associated with acute trauma and lateral ankle ligament injury.16

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

The disease course is characterized by lesion location and stability. Stable lesions with open physeal lesions of the knee, elbow and talus generally respond to conservative management (physical therapy, protected weightbearing) and monitoring with repeat X rays. Repeat X ray monitoring will determine whether surgical referral is needed.

On the other hand, unstable lesions with or without loose bodies in the joint require orthopedic intervention followed by therapy. Untreated small lesions could progress and eventually require surgical intervention.17

Most radiographic classifications are used to describe the location of the lesion or healing progress but their use in assessing lesion stability and severity is still considered to be limited.18,19 Arthroscopy is the gold standard when evaluating stability of OCD lesions, however, MRI is the first line evaluation to guide patient management due to its non-invasive nature and its ability to detect the earliest stages of the disease.18,19

Essentials of Assessment

History

History should include a standard assessment of pain and all its associated qualities such as location, intensity, characteristics, quality, duration, mechanism of onset, exacerbating and relieving factors, and associated symptoms and joint instability. Patients often present with activity-related pain that is nonspecific and poorly localized. The duration of pain can be ongoing and mild for several months before sudden worsening, prompting patient presentation to a provider. Lastly, inquiry of personal and family history of rheumatological conditions, surgical history, prior injury, current activity level and of all previous and ongoing sports participation should be considered.

Knee OCD: History of swelling and presence of mechanical symptoms suggestive of loose joint bodies, such as locking, catching, popping, or buckling should be elicited.

Capitellum OCD: History of posterior or lateral elbow pain relieved with rest should be elicited. Associated mechanical symptoms could include clicking and locking. Swelling may be present.

Talar OCD: History of vague anterior ankle pain relieved with rest. Mechanical symptoms including clicking and locking may be less common compared to the other joints due to the talus being covered by the tibial plafond during range of motion.

Physical examination

The examination of the patient should include inspection of the overall alignment of the affected joint, palpation, range of motion, and provocative examination4. Evaluation should be completed on both sides as up to 1/3 of cases have been found to be present bilaterally but 39% of the contralateral lesions may be asymptomatic.6,20 The patient may have an antalgic gait if the lesion is in the lower extremity and may exhibit avoidance of the injured side. Additionally, there may be pain over the peri-articular regions and chronic or intermittent effusion of the joint.

Knee OCD: Range of motion (ROM) is often preserved in knee. Tenderness to the medial femoral condyle may be noted. Diagnosis of OCD in the knee may be assisted with Wilson sign, a provocative maneuver that elicits the tibial eminence to impinge against the lateral aspect of the medial femoral condyle, where 60-70% of the lesions are found. The test has poor diagnostic value with sensitivities reported to be as low as 25% and when positive, has proved to be of greater utility for assessment of clinical improvement.21

Elbow OCD: ROM may be decreased in elbow lesions. Diagnosis of OCD in the elbow is supported by a positive radio capitellar compression test, which is demonstrated by pain with axial compression force during active pronation and supination of the elbow in extension. Data on the validity of these provocative maneuver is limited.

Talus OCD: ROM is preserved. Diagnosis is supported by tenderness to palpation of the ankle with simultaneous plantar flexion of the ankle, a provocative maneuver that exposes the anterior aspect of the articular surface of the talus to the examiner’s hand. Data on the validity of these provocative maneuver is limited.

Functional assessment

There is currently no evidence supported scales specifically for assessment of pain and functional outcomes in Osteochondritis Dissecans patients.

Knee OCD: However, numerous generalized scales that have been validated for other types of knee injury have been used in OCD research to collect uniform data on outcome measures. The most common ones are listed below:

  • International Knee Documentation Committee and Subjective Knee Evaluation (IKDC): Provides a functional score based on subjective assessment of 3 categories: symptoms, sports activity tolerance, and knee function22.
  • Lysholm Knee Score22,23
  • PEDI-IKDC Questionnaire24: Pediatric version of IKDC
  • Knee Injury and Osteoarthritis Outcome Score (KOOS)25: Evaluates short-term and long-term symptoms and function in subjects with knee injury and osteoarthritis
  • Marx Activity Score questionnaire26: Measure of physical activity at healthiest and most active state from time of taking to year prior.
  • Knee, Elbow, Ankle OCD: Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS)27,28: An eight-item scale that measures level of physical activity and fitness.

Laboratory studies

There are no laboratory findings associated with OCD.

Imaging

The diagnosis of OCD is made radiographically. Plain radiographs are often the first choice of investigation and may demonstrate subtle lucency, fragmentation, and loose bodies in the intra-articular space.

Knee OCD: For the knee, the anteroposterior, lateral, tunnel or notch view and sunrise views should be obtained19.

Elbow OCD: For the elbow, the extension anterior-posterior, 45-degree flexion anterior-posterior, and lateral views are recommended.

Ankle OCD: For the ankle, oblique, mortise, and plantarflexed views including with the ankle in 15-degree of internal rotation is suggested to better visualize the superolateral corner of the talus without fibular overlap. Stress X rays with talar tilt can be useful in the setting of ankle sprains.29

Disease stages are described on plain radiographs (tunnel or notch view)19 as follows:

Stage 1: small fragment of compression/flattening of subchondral bone, nondisplaced.
Stage 2: partially detached fragment.
Stage 3: completely detached fragment that remains within the underlying crater bed, nondisplaced.
Stage 4: completely detached and displaced fragment, known as a loose body.

Disease stages are described arthroscopically as follows:

Stage 1: Irregular, softened articular cartilage with no fragment
Stage 2: Breached articular cartilage, with non-displaced, definable fragment.
Stage 3: Breached articular cartilage, with displaced, but attached by overlying cartilage, definable fragment.
Stage 4: Loose foreign body

MRI is the best imaging modality for OCD as it can better characterize the lesion through detailed assessment of the subchondral bone and its surrounding cartilage, in addition to other soft tissue structures. This allows the clinician to stage the lesion and assess for instability, which influences whether conservative or surgical management is advised. MRI should also be obtained if the symptomatic patient has negative radiographs. There are four stages of OCD joint injury, the first two stages indicate lesion stability whereas the last two stages indicate lesion instability and necessity for surgical intervention.30

MRI Staging of Joints with Osteochondritis Dissecans

Stage 1: Injury limited to articular cartilage demonstrated as thickening of articular cartilage and subchondral edema.
Stage 2: Injury of articular cartilage with subchondral fracture, no detachment. In addition to changes seen in previous criteria, low-signal rim can be seen behind fragment.
Stage 3: Detached, non-displaced fragment visualized. On MRI, high-signal changes can be seen behind fragment and at underlying subchondral bone.
Stage 4: Osteochondral fragment displaced.

Imaging findings for lesion instability for both adults and juveniles on MRI are characterized as follows

  • high signal surrounding the lesion,
  • focal defect in the articular cartilage,
  • fracture of the articular cartilage, and
  • presence of subchondral cysts.

However, most lesions with a high T2 signal in the base healed in younger, skeletally immature patients.

For juvenile OCD, having all 4 of these criteria was noted to have 100% sensitivity for instability.

With the addition of the following secondary criteria, the specificity was also 100%:

  • multiple breaks in the subchondral bone plate,
  • outer rim of the T2 signal intensity, and
  • rim of fluid signal intensity.

Musculoskeletal ultrasound can provide further screening and diagnostic value with several studies of the capitellum demonstrating significant predictive value when arthroscopic confirmation of sonographic lesions was performed.31

Early predictions of outcomes

Those with stable lesions are predicted to heal more quickly and with less aggressive measures than those with unstable lesions. In addition, patients with open physis have better outcomes than patients with closed physis. Furthermore, patients with BMI greater than 25 have poorer outcomes.13 Physical activity in the form of overhead throwing sports could predispose children to have elbow OCD lesions.32 The presence of Vitamin D deficiency could impede the healing process of osteochondral lesions.11,12

Outcomes in different types of OCD:

Knee OCD: Males had more successful outcomes with less knee pain compared to females.23 Age, lesion size and cystic lesions larger than 1.3mm size could be predictors of outcomes.33

Elbow OCD: Arthroscopic debridement without microfracture and osteochondral autograft (costal or knee) transfer achieved a good healing response for capitellar OCD including the professional athletic population.34,35 On the other hand, Sayani et al noted that no particular surgical technique was superior (OAT vs fixation vs microfracture).36 No correlation was noted in outcomes based on lesion location36.

Ankle OCD: Lower BMI and younger age (10-14 years) correlated with better outcomes for talar OCD among children.37 Central-medial tibial plafond OCD responded favorably to microfracture of lesions < 150 sq.mm38

Environmental

Special consideration of the child’s non-weight bearing status and available school accommodations should be explored. Additionally, the child’s home environment should be assessed, including the need to climb stairs or hills to reach home.

Social role and social support system

Social history should be obtained from the patient in regards to the types of sports played (if any), level of competition, and hours of activity per week, all of which should be considered when deciding return to play.

Rehabilitation Management and Treatments

Coordination of care

Coordination of care between the physiatrist, physical therapist and orthopedic surgeon can be helpful if non-operative treatment is not successful in reducing pain complaints and/or function.

Diagnostic tests:

X-ray is the initial diagnostic test.39

After diagnosis of OCD, the lesion should be categorized utilizing MRI as either stable or unstable. In known cases of OCD, MRI provides information on lesion characteristics, concomitant knee pathology and healing.39,40

Treatment plan40

Juvenile OCD (Open physes) with stable lesions:

Initial treatment choice is conservative management with protective weightbearing of the joint for a duration of 6 weeks. A recent systematic review on non-operative management of OCD of the knee found that strict restriction of sport/activity was the only significant positive prognostic factor.41

Physical therapy can be utilized to correct any malalignment/strength deficits after restricted weight bearing with strengthening and stretching around the joint and improving abnormal movement patterns.41

X-rays are taken at 4-6 weeks to evaluate for healing. If healing is not noted on X-ray, gentle non-weight bearing range of motion followed by re-casting for a total of 3 months is done. After 3 months of casting, or after X-ray evidence of healing is noted, the child is provided with a brace. MRI could be considered at 3- months to evaluate the healing process. Restriction of painful and impactful activities (running, jumping, sports) is recommended.

X-rays are repeated at the 6 to 8-week mark to monitor for healing. With continued healing, activity restrictions and bracing can be progressively decreased for 6 months or until pain-free. If healing is not noted, surgery referral is recommended. Repeat MRI at 6 months and if the lesion is worsening, surgery referral is warranted. Vitamin D deficiency should be treated, if present.11,12

Knee OCD: Weight bearing precautions can be implemented by using assistive devices (cane, walker, crutches), casting or bracing (non-unloader brace42). Malalignment should be addressed. Studies showed around 60% healing at 10 months.42

Elbow OCD: No throwing (pitchers, fielders, bowlers), tumbling (cheerleaders, gymnasts), weight bearing for 3 months with gradual return to activity. Successful outcomes have been reported to occur with non-operative treatment in 50% to 94% of cases43 and should be trialed for a period of 3 to 6 months before considering surgical options.

Talus OCD: Cam walker boots with crutches could be used to offload weight for 2-3 weeks followed by non-impact activities including swimming, walking and cycling in order to preserve ROM.

Salvageable unstable lesions or loose bodies among skeletally mature and immature population:

Orthopedic surgery referral is indicated. Surgery should be followed by post-operative rehabilitative physical therapy. Surgical approaches include drilling of intact OCD lesion (retro-articular or trans-articular), fixation with or without bone grafting, fragment excision and isolated debridement, fragment excision and marrow stimulation, osteochondral autograft transfer, osteochondral allograft transplantation and autologous chondrocyte implantation (with or without bone grafting).

Surgery for stable lesions:  

Surgery to stimulate growth, restoration, or repair can be considered in patients with stable lesions whose symptoms have failed to improve despite a course of conservative management. These restorative techniques include drilling, microfracture, and OAT. Drilling of the subchondral bone is thought to stimulate growth and restoration via neovascularization and re-ossification. This procedure is often considered for stable lesions with intact articular cartilage. Microfracture involves operative fracture of the subchondral bone to promote cartilage healing via release of growth factors and stem cells from the underlying cancellous bone. OAT is a technique that replaces hyaline cartilage in the lesion by transplantation of osteochondral plugs from non-weight bearing surfaces of the femur. Salvage procedures, such as osteochondral allografts, should not be attempted as a first line procedure, but may be helpful in larger and deeper OCD lesions.

Surgery for unstable lesions:

Surgical options include arthroscopic reduction and internal fixation with bioabsorbable/ metal screws, microfracture, bone grafting, and fixation with autograft osteochondral plugs or autologous cultured chondrocytes on porcine collagen membrane.1,44A systematic review noted that resorbable magnesium screws achieved good healing.34

Patient & family education

The patient and family should be educated on the fact that many stable lesions do not require any operative treatments. Additionally, they should be educated about the fact that many patients do not have any long-term risk or complications from having a history of OCD.

Prolonged symptom duration and older age may lead to delayed return to sport.45 There is evidence to suggest that those with fragmented lesions or large amounts of bone/cartilage loss are at an increased risk for degenerative changes in the joint later in life especially patients with BMI greater than 25, lesions greater than 4 sq.cm and after undergoing fragment excision.46 Occasionally, transient ulnar neurapraxia and radial head enlargement (capitellar OCD) can occur.35 Depending on the donor-site, OAT can result in complications including pneumothorax (costal) and mechanical symptoms (knee).47

The child may need help with carrying their books or going up/downstairs if there is no available elevator. This should be discussed with the parent and the school to make appropriate accommodations.

Knee OCD: Juvenile OCD with stable lesions managed non-operatively could mean that 2/3rd of the kids could return to playing (track and field, weightlifting) by around 10 months.42 In order to keep kids active and to preserve ROM, non-weightbearing exercises like biking could be encouraged.

Elbow OCD: Strict non-weightbearing precautions are recommended for gymnasts and cheerleaders (bilateral limb use), pitchers (dominant upper limb). Around 3 months, decision could be made based on MRI findings regarding surgical referral if lesion has not healed. In order to preserve ROM and encourage exercise, non-weightbearing exercises like swimming could be encouraged.15

Ankle OCD: 3 months of non-impact activities (walking, cycling, swimming) could be encouraged while MRI could provide guidance regarding surgical referral for stable lesions.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

Consider X-ray imaging and immobilization of involved limb for a child presenting with knee/elbow/ankle joint pain:

  • of insidious onset or after a traumatic event
  • chronic joint-related/intra-articular pain
  • evidence of intra-articular injury (traumatic effusion)
  • with or without mechanical symptoms (buckling, clicking, locking).

If X-ray is suggestive of possible OCD lesion, MRI is pursued to characterize and stage the lesion.

If X-ray is not suggestive of OCD and the pain is extra-articular without mechanical symptoms, consider other injuries should be excluded:

Knee:

  • Tibial tubercle apophysitis (Osgood-Schlatter)
  • Patellar apophysitis (Sinding-Larsen-Johansson)

Elbow:

Panner’s disease is seen among kids aged 4-12 years without loose bodies15

Ankle:

Osteochondral lesions of the talus are noted among adults aged 30-50 years and should not be mistaken for OCD lesions.

Cutting Edge/ Emerging and Unique Concepts and Practice

Joints of patients having unstable OCD lesions, despite surgical treatment, have been observed over time, often to progress to early osteoarthritis. A number of recent interventions have shown promise in reducing risk of progressive joint degeneration for patients with unstable OCD lesions that have failed surgical fixation. Cartilage reconstruction or unstable fragment (OCD knee) removal have been helpful in these cases44. Bone marrow aspirate concentrate resulted in significant improvement in functional outcomes in knee and ankle OCD after 1 year.48,49

Another emerging treatment option for OCD lesions is extracorporeal shock wave therapy (ESWT), utilizing high amplitude, abrupt pulses of mechanical energy applied locally to the affected area. ESWT has been shown to have a chondroprotective effect and to improve cartilage and subchondral bone healing as shown by a case report of a volleyball player and an arthroscopy-based study.50

Gaps in the Evidence-Based Knowledge

There are still several gaps in knowledge pertaining to OCD. The exact etiology of acquiring OCD is unknown. While MRI is a helpful tool in staging the injury and determining stability, there are no known imaging findings that correlate with information on prognosis or length to recovery. CT-SPECT and PET-scans can be used in characterizing and provide prognostic information, but its use comes with exposure to high doses of radiation. Finally, the natural history and progression for OCD lesions is still unclear. Most recommend non-operative treatment in skeletally immature patients for the first 3 to 6 months in stable lesions. However, the type of non-operative treatment and length of time for healing is less clear.

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American Academy of Orthopedic Surgeons. Appropriate Use Criteria: Diagnosis and Treatment of Osteochondritis Dissecans. Available at: http://www.aaos.org/auc

Original Version of the Topic

Farah Hameed, MD. Osteochondritis Dissecans. 12/02/2013

Previous Revision(s) of the Topic

Thomas Chai, MD, Larry Driver, MD. Osteochondritis Dissecans. 2/12/2018

Author Disclosure

Shane Mario Andre Drakes, MD
Nothing to Disclose

Anusha Lekshminarayanan, MD
Nothing to Disclose

Michael Lew, DO
Nothing to Disclose

Xiao Wei Liu, MD
Nothing to Disclose