What is the treatment for osteochondritis dissecans?

Treatment of Osteochondritis Dissecans

Symptomatic patients with salvageable unstable or displaced osteochondritis dissecans (OCD) lesions should be offered the option of surgery to prevent progression to osteoarthritis and relieve symptoms. 1

Diagnostic Approach

• Initial evaluation of patients with knee symptoms (pain, swelling, locking, catching, popping, giving way) should include radiographs (AP, lateral, sunrise/Merchant, and tunnel views) 1
• MRI is recommended for patients with a known OCD lesion on radiograph to better characterize the lesion and identify concomitant knee pathology 1
• MRI helps determine lesion stability, which is critical for treatment decisions 1, 2

Treatment Algorithm Based on Patient Characteristics

Skeletally Immature Patients (Open Physes)

1. Asymptomatic Patients

   • No clear evidence supports specific nonsurgical treatments 1
   • Monitoring with follow-up imaging is reasonable 1

2. Symptomatic Patients with Stable Lesions

   • Initial nonsurgical management is appropriate, though no specific approach (casting, bracing, activity restriction) has proven superiority 1
   • For stable lesions that fail to heal after ≥3 months of nonsurgical treatment, there is insufficient evidence to recommend for or against arthroscopic drilling 1

3. Symptomatic Patients with Unstable/Displaced Lesions

   • Surgery should be offered as an option 1
   • The specific surgical technique depends on lesion characteristics:
     • For salvageable fragments: Surgical fixation to restore joint surface 1, 3
     • For unsalvageable fragments: No specific cartilage repair technique has proven superiority 1

Skeletally Mature Patients (Closed Physes)

1. Asymptomatic Patients

   • Insufficient evidence to recommend repeat MRI for monitoring 1
   • For patients with OCD progression on imaging, there is insufficient evidence to guide treatment 1

2. Symptomatic Patients with Unstable/Displaced Lesions

   • Surgery should be offered as an option 1, 3
   • Surgical approach depends on fragment condition:
     • For salvageable fragments: Fixation to restore joint surface 3
     • For unsalvageable fragments: Various cartilage repair techniques (autologous chondrocyte implantation, osteochondral grafting, marrow stimulation) may be considered, though no specific technique has proven superiority 2, 4

Post-Treatment Management

• Patients who remain symptomatic after treatment should undergo history, physical examination, radiographs, and/or MRI to assess healing 1, 4
• Physical therapy:
  • For nonsurgical treatment: Insufficient evidence to recommend for or against specific protocols 1, 5
  • For surgical treatment: Postoperative physical therapy should be offered 1, 5

Important Considerations

• Early intervention is crucial as untreated OCD can lead to osteoarthritis at a young age 3, 4
• Treatment goals include pain relief, restoration of function, and prevention of secondary osteoarthritis 3
• The decision for surgery should involve shared decision-making between patient, family, and physician 1
• Surgical risks include bleeding, infection, nerve/vessel damage, venous thromboembolism, anesthesia complications, and surgical failure 1
• Not performing surgery when indicated carries the risk of irreversible osteoarthritis 1, 6

Special Populations

• Juvenile OCD (open growth plates) generally has better healing potential than adult OCD 4, 6
• Lesion location affects prognosis - lateral femoral condyle lesions generally have better outcomes than medial femoral condyle lesions 4
• Chronic loose fragments have poor healing potential and may require more complex reconstruction procedures 6