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Osteochondritis Dissecans (OCD)

Osteochondritis Dissecans (OCD)

In the 19th century, the separation of the articular cartilage and the subchondral bone fragment from a joint's surface was incorrectly named osteochondritis dissecans, as it was believed to be caused by an underlying inflammatory pathology. Although further medical discoveries proved that this was not the case, the name stuck and is still used to this day.

Osteochondritis dissecans, or OCD, is actually caused by a separated fragment in the knee becoming avascular and existing as a loose body within the joint. The condition of having loose bone fragments in the knee has been separated into two main types which are classified by age. Adult form osteochondritis dissecans occurs after the physis has closed, and juvenile osteochondritis dissecans occur when the epiphyseal plate is still open.

A rare disorder

Osteochondritis dissecans is a relatively rare disorder, and although the exact number of cases remains unknown, there are only around 3-6 reported cases per 10,000 people, with males tending to be more affected than females.

The condition generally affects the knee joint, which has led to the term ‘OCD knee’, but it can occur in the elbow, ankle or, very rarely, in the wrist, hand, shoulder or hip. In 20-30% of cases, the disease is prevalent in more than one site on the body and may be bilateral.

Causes

If identified in adulthood, osteochondritis dissecans is often believed to have been an undiagnosed childhood disease that has only been noted when knee joint pain or other physical symptoms start occuring. The exact causes of this illness are still not wholly certain, but it’s believed that a combination of factors including biochemical, genetic predisposition, repetitive trauma, ischaemia, ligamentous laxity and abnormal ossification all contribute. High impact sports such as football, rugby, boxing or running may also be a cause, and can contribute to the condition worsening at a rapid pace.

There are four stages to the disease, and with each stage the severity increases. In the first stage the articular cartilage will thicken, in the second the articular cartilage becomes interrupted and in the third the cartilage is both interrupted and changes occur in the underlying subchondral bone. In the final stage, when the condition is at its most severe, a loose body has formed.

Identifying symptoms

The sooner OCD knee is diagnosed, the quicker it can be treated and the better the chances of long term issues such as osteoarthritis being avoided. The disease often presents itself in the teenage years, and knee joint pain is the most common symptom. Younger children who are very active in sports may also present symptoms of OCD knee, but diagnosis is sometimes difficult because the same symptoms as Osgood Schlatters are in evidence.

If OCD knee is not diagnosed early in life, it may appear later on. Approximately 5% of middle-aged patients who suffer from osteoarthritis can attribute it to untreated osteochondritis dissecans.

In addition to knee joint pain, other symptom may include swelling which is worsened by activity, a painful sensation when extending or flexing the knee, or a 'locking' or 'giving way' sensation.

Diagnosing OCD knee

There are several different ways that osteochondritis dissecans can be diagnosed, and some cases will require more than an X-ray. X-rays will usually show a subchrondial crescent or loose bodies, but in some cases they may not pick up smaller issues.

An ultrasound scan is an excellent alternative and is also far more cost effective than a MRI or CT scan. In some cases, however, a CT scan is required to monitor the size and exact site of the lesion, and an MRI can identify an increased uptake in bone fragments. Scintigraphy may also be used to guide treatment and to identify the exact areas that need attention.

Treatment options

Early diagnosis of any disease is always beneficial, and the same is true of osteochondritis dissecans. If the condition occurs in a juvenile, there is greater potential for the condition to heal quickly. In older patients, however, a more aggressive treatment approach may be required.

Osteochondritis dissecans which is still in the early stages can be treated in a number of conservative ways, and if patients are younger with open epiphyses, the chances of success are far greater. Non-drug measures to aid in the healing of the condition include stopping all sporting activities and limiting walking for up to 8 weeks or more, whilst attending regular physiotherapy sessions.

Gentle physiotherapy can help align joints and manipulate an OCD knee into a position which can aid healing. Exercises to strengthen the muscles around the knee may be suggested to provide added support.

Bracing, immobilisation or protecting the knee from weight bearing are also often used to treat the condition, and a brace may be worn in the future to protect the knee and try to eliminate reoccurrence of the disease.

Painkillers, simple analgesics and non-steroidal anti-inflammatory drugs (also known as NSAIDs) may be used to control knee joint pain, but they can only mask the symptoms and will not alleviate or halt the disease. During treatment, however, it is normal for painkillers to be used in order to ensure the patient experiences minimal discomfort whilst healing.

Surgical options

Surgery is often seen as a last resort and is only undertaken when conservative, non-drug management has failed over an extended period of time. Surgery is also an option in cases where the knee joint pain is incredibly severe, the lesion is unstable, or there are loose bone fragments that require immediate attention.

Keyhole surgery is generally required and here there are several options. Arthroscopic subchondral drilling may be used to promote revascularisation or debridement and fragment stabilisation. Alternatively, arthroscopic excision, drilling and curettage may be required, or in worse case scenarios, open removal of all loose bodies, reconstruction of the lesion crater base and replacement with fixation may be needed.

Bone grafting or autologous chondrocyte transplantation may also be required in extremely severe cases, and pins, plates or screws can be used to secure the joint and provide much needed stability.

Depending on the type of surgery required, recovery can take anywhere between a few days to 6-10 weeks. Arthroscopic surgery typically heals far faster, but a patient should still take care and rest as much as possible, only engaging in sporting activities and physical exercise once they have been given the go-ahead from their doctor or specialist. For patients who have had bone grafts or transplantations, healing time is typically much longer and very gentle physiotherapy will form part of the healing process.

Prognosis

As the exact causes of osteochondritis dissecans cannot be confirmed, it is important for patients to always take heed of any factors that may have contributed to the development of the disease. Prognosis is generally positive but can depend on the patient’s age, the stage of the lesion and the affected joint.

Younger patients have the best chance of making a full recovery and not suffering from reoccurrence, whilst older patients may struggle, as loose fragments can be harder to fix and heal properly. As with any joint or bone ailment, the sooner it is treated, the better the results, and sometimes simply an adjustment in lifestyle such as losing weight or stopping a certain sport can ensure that the condition does not reoccur.

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