What is the recommended treatment for a low-grade osteochondral lesion?

Treatment of Low-Grade Osteochondral Lesions

For low-grade osteochondral lesions, intralesional excision (curettage) with or without adjuvant therapy is the recommended treatment for resectable intracompartmental lesions, while wide excision with negative margins is preferred for larger lesions or those with intraarticular or pelvic localization. 1

Diagnosis and Assessment

• Low-grade osteochondral lesions are typically cartilage-based growths that can range from benign to malignant, requiring proper evaluation and grading to determine appropriate treatment 2
• Contrast-enhanced MRI is essential for revealing high-grade areas and guiding biopsy location 1, 2
• Pain at the site of a cartilaginous lesion may indicate malignancy, though many lesions present as painless masses 1, 2
• The differentiation between benign lesions (enchondroma/osteochondroma) and low-grade malignant lesions can be difficult and requires expert assessment 1

Treatment Algorithm Based on Lesion Characteristics

For Low-Grade Lesions:

• Resectable low-grade intracompartmental lesions:

  • Intralesional excision (curettage) with or without adjuvant therapy (e.g., phenol, cement, cryotherapy) 1
  • This approach has a high chance of success for grade I central chondrosarcomas in long bones 1

• Low-grade lesions with larger size or intraarticular/pelvic location:

  • Wide excision with negative margins is preferred 1
  • For peripheral chondrosarcomas (arising from osteochondromas), surgical excision should aim to remove the tumor with a covering of normal tissue 1

• Unresectable low-grade lesions:

  • Radiation therapy is recommended 1
  • Proton-beam radiotherapy has shown excellent local tumor control and long-term survival in patients with low-grade skull base chondrosarcomas 1

For Specific Anatomical Locations:

• Femoral head lesions <2 cm:

  • First-line: Microfracture 1
  • Second-line: Mosaicplasty or osteochondral allograft transplant (single plug) 1

• Femoral head lesions 2-6 cm:

  • Osteochondral allograft is recommended 1

• Acetabular lesions <2 cm or 2-6 cm:

  • Microfracture is the primary treatment 1
  • For delaminated chondral flaps with viable cartilage, suture repair can be considered 1

Post-Treatment Surveillance

• For low-grade lesions, surveillance should include:
  • Physical examination
  • Imaging of the lesion
  • Chest radiograph every 6-12 months for 2 years, then yearly as appropriate 1
  • Functional assessment at every visit 1

Management of Recurrence

• Local recurrence of low-grade lesions should be treated with wide excision if resectable 1
• Radiation therapy should be considered after wide excision with positive surgical margins 1
• Negative surgical margins should be observed 1
• Unresectable recurrences should be treated with radiation therapy 1

Important Considerations and Caveats

• Histologic grade and tumor location are the most important variables in determining primary treatment 1
• Low-grade cartilage tumors are unlikely to metastasize but may recur locally 1
• Chemotherapy is generally not effective for low-grade chondrosarcomas 1
• For osteochondral lesions in young patients (particularly in the humeral capitellum), conservative treatment with discontinuation of heavy use for at least 6 months may be effective in early stages 3
• The goal of all treatment methods is to provide a stable, congruent joint surface, restore function, and prevent the evolution of osteoarthritis in the injured joint 4