5-10% of people > 40 years old have high grade chondral lesions; location. A common type of knee injury is damage to the articular cartilage, the smooth substance that covers the ends of the bones and keeps them from rubbing together as you move. - Christian Lattermann, MD, Knee & Sports⎪Articular Cartilage Defects of Knee, Question Session⎪Articular Cartilage & Articular Cartilage Defects of Knee, Question Session⎜Articular Cartilage Defects of Knee & Distal Biceps Avulsions, Sports ⎜ Articular Cartilage Defects of the Knee (ft. Dr. Mark Pagnano), LEFT TIBIA OSTEOCHONDRAL AND METAPHYSEAL LESIONS IN A 39M, Cartilage lesion with mild valgus mechanical alignment. JOIN NOW LOGIN. This approach allows planning an appropriate course of treatment. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. (OBQ13.99) Imaging criteria for staging and management are also reviewed. View Issue. look for loose bodies and peripheral tears of LM. A thorough history, physical exam, and imaging are essential to appropriately assign symptoms to the PF joint and cartilage pathology. Dec 2008;90(12):2655-2664 However, due to great diversity in the articles and variability in treatment results, no definitive conclusions can be drawn. Osteochondral Allograft Transplantation of the Knee in the Pediatric and Adolescent Population. Osteochondral injuries in pediatric patients may occur as a result of a traumatic injury or secondary to an osteochondritis dissecans (OCD) lesion. The incidence and prevalence is currently unknown as many of the lesions remain asymptomatic in both athletic and non-athletic individuals. An osteochondral lesion is a defect in the cartilage of a joint and the bone underneath. cartilage injury with associated subchondral fracture but without detachment Osteochondral lesions are relatively common in children and adolescents, and the incidence is increasing. Osteochondritis dissecans (OCD) most commonly affects the knee. chronic ACL tear. A 24-year-old female has moderate arthrosis of the medial facet of the patella and the medial femoral condyle. What type of tissue is formed by the activation of marrow mesenchymal cells following subchondral drilling of an 8x7 mm osteochondral defect? the talar dome) in the ankle. J Bone Joint Surg Am. Copyright © 2020 Lineage Medical, Inc. All rights reserved. Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. A 35-year-old man presents with mechanical knee pain after a fall. The transplanted chondrocytes are viable and articular cartilage heals. In Technique C, healing is initiated by mesenchymal stem cell migration from subchondral bone. Osteochondritis dissecans is an idiopathic disease which affects the subchondral bone and its overlying articular cartilage due to loss of blood flow. Which of the following statements best describes the incorporation of the graft and biopsy results of the graft at one year? An arthroscopic picture taken during diagnostic arthroscopy is shown in Figure A. See osteochondritis dissecans article for a general discussion. ORTHO BULLETS Orthopaedic Surgeons & Providers. A patient with a symptomatic chondral defect undergoes the arthroscopic procedure seen in Figure A. Murphy RT, Pennock AT, Bugbee WD. Tested Concept, Anterior (Maquet) tibial tubercle osteotomy, Anteromedial (Fulkerson) tibial tubercle osteotomy, Medial opening wedge high tibial osteotomy, Lateral closing wedge high tibial osteotomy, (OBQ10.257) Keywords: Knee, Cartilage, Synovitis, Pigmented villonodular Pigmented villonodular synovitis (PVNS) is a rare, benign, but potentially recurrent condition with an estimated incidence of 1.8 per million. Biopsy shows mixture of type I and II collagen. Visualization of an osteochondritis dissecans lesion not detected by conventional arthroscopy and US-guided retrograde drilling were possible with UA. Tested Concept, (OBQ11.1) Actual surgical treatments for osteochondral lesions and early knee osteoarthritis seem to be promising. The large osteochondral defect was eventually managed in a staged manner with bone grafting and osteochondral autograft transfer. The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. Tested Concept, Grade 4 lesion of the medial femoral condyle, Varus mechanical axis on standing full length radiograph, Concomitant anteromedial tibial tubercle transfer osteotomy (Fulkerson's), Osteochondral Plug Allograft Transfer of the Knee, Type in at least one full word to see suggestions list, 2019 Orthopaedic Summit Evolving Techniques, Fresh Osteochondral Allografts: Don't Waste Your Time With Other Things - Forget About Cell-Based Therapy - Thomas DeBerardino, MD, Cryopreserved, Flexible Allografts: Don't Give Up On Them - Seth Sherman, MD, MACI Is Now The Answer: Listen To Me! Which of the following statement is true with respect to Technique B and C? chondrocytes remain viable, bone graft is incorporated into subchondral bone and overlying cartilage layer heals. Many of these lesions are first diagnosed by plain film. Please note that OCD is a commonly used abbreviation for both osteochondral defect and osteochondritis dissecans, two closely related conditions. bring knee into slight flexion and valgus as you go into medial compartment. Osteochondral lesions are commonly the result of excessive force going through the knee. Osteochondral Plug Allograft Transfer of the Knee Articular Cartilage Defects of Knee Pathway Updated: 10/4/2016 0 His surgeon considers treatment with Technique B and Technique C, which are shown in Figures B and C, respectively. Which of the following procedures is contraindicated? Five surgical procedures to manage OCD lesions in the knee. The transplanted chondrocytes are viable and articular cartilage heals. The transplanted chondrocytes are nonviable and cartilage is used as a scaffold for growth of new articular cartilage. This may result in separation and instability of a segment of cartilage and free movement of these osteochondral fragments within the joint space.That process can lead to pain, loose body formation and joint effusion. Figure 1 Relevant Anatomy for an Osteochondral Lesion of the Talar Dome Osteochondraldefect is a broad term that describes the morphological change of a localized gap in the articular cartilage and subchondral bone 5. A biopsy of the repair site at 3 months will reveal more Type I collagen in Technique B than in Technique C. Technique C is a 2-stage procedure. In the talus, 96% of lateral lesions and 62% of … Osteochondral Plug Allograft Transfer of the Knee, Articular Cartilage Defects of Knee Pathway, Discoid Lateral Meniscus Saucerization and Stabilization, ACL Reconstruction in Skeletally Immature, ACL Reconstruction - Quadriceps Tendon Autograft, MPFL Reconstruction - Pediatric and Adolescent, Medial Retinacular Plication (Modified Insall ), concomitant and associated orthopaedic injuries, associated with decreased quadriceps strength, documents failure of nonoperative management, describes accepted indications and contraindications for surgical intervention, diagnose and management of early complications, progressive weight bearing weeks 3-6 weeks after surgery, diagnosis and management of late complications, postop: 4 months year postoperative Visit, identify medical co-morbidities that might impact surgical treatment. a recipient socket is drilled at the site of the defect, a single or multiple small cylinders of normal articular cartilage with underlying bone are cored out from lesser weight bearing areas (periphery of trochlea or notch), size constraints and donor site morbidity limit usage of this technique, matching the size and radius of curvature of cartilage defect is difficult, fixation strength of graft initially decreases with initial healing response, weight bearing should be delayed 3 months, include autologous tissue, cost-effectiveness, single-stage, may be performed arthroscopically, goal is to replace cartilage defect with live chondrocytes in mature matrix along with underlying bone, fresh, refrigerated grafts are used which retain chondrocyte viability, may be performed as a bulk graft (fixed with screws) or shell (dowels) grafts, match the size and radius of curvature of articular cartilage with donor tissue, an osteochondral dowel of the appropriate size is cored out of the donor, include ability to address larger defects, can correct significant bone loss, useful in revision of other techniques, limited availability and high cost of donor tissue, live allograft tissue carries potential risk of infection, Autologous chondrocyte implantation (ACI), cell therapy with goal of forming autologous "hyaline-like" cartilage, arthroscopic harvest of cartilage from a lesser weight bearing area, in the lab, chondrocytes are released from matrix and are expanded in culture, defect is prepared, and chondrocytes are then injected under a periosteal patch sewn over the defect during a second surgery, may provide better histologic tissue than marrow stimulation, long term results comparable to microfracture in most series, include regeneration of autologous tissue, can address larger defects, must have full-thickness cartilage margins around the defect, prolonged protection necessary to allow for maturation, only elevate 1 cm or else risk of skin necrosis, cells are cultured and embedded in a matrix or scaffold, matrix is secured with fibrin glue or sutures, only FDA approved cell therapy for cartilage in the USA, Spontaneous Osteonecrosis of the Knee (SONK), Osgood Schlatter's Disease (Tibial Tubercle Apophysitis), Anterior Superior Iliac Spine (ASIS) Avulsion, Anterior Inferior Iliac Spine Avulsion (AIIS), Concussions (Mild Traumatic Brain Injury), include ability to perform without suturing, may be performed arthroscopically. Sometimes a piece of cartil… ... implanting a biomimetic osteochondral scaffold onto the lesion site, which was Introduction: Spectrum of disease entities from single, focal defects to advanced degenerative disease of articular (hyaline) cartilage; Epidemiology. The bone right underneath the cartilage will also be injured. ortho BULLETS. See: - Knee Joint Menu: - Arthroscopy of the Degenerative Knee - Osteochondritis Dessicans - Osteoarthritis - Discussion: - described types articular cartilage lesions; - mild lesion, w/ normal appearing cartilage - it is difficult to dissern borders of lesion and normal surrounding cartilage. Osteochondral lesions may b … This injury is more common in adolescents and young adults and typically occurs at the knee, ankle or elbow. A 32-year-old female is referred to you for definitive treatment of a symptomatic focal chondral defect on her medial femoral condyle. Lateral patella dislocation is a common traumatic cause of osteochondral injury that typically occurs at the medial facet of the patella or at the later … What surgical treatment would you recommend? Prognosis of these lesions depends on stability, location, and size of the lesion.Imaging has an essential role in the diagnosis, staging, and management of osteochondral lesions. Issue: March 2013. Biopsy shows type I collagen. Lesions located in the trochlea are exceptional and account for less than 1%. The Healing Potential of Stable Juvenile Osteochondritis Dissecans Knee Lesions. A photograph from a recent diagnostic arthroscopy shows the defect (Figure A), which measured 25 x 25mm after debridement. Am J Sports Med. Osteochondritis Dissecans (OCD) is a common, yet poorly understood cause of knee pain in the pediatric and juvenile population as well as an adult form that can occur in the developed skeleton. anterior aspect of lateral femoral chondyle and posterolateral tibial plateau order triplanar standing radiographs of the knee, describe complications of surgery including, describe steps of the procedure verbally to the attending prior to the start of the case, describe potential complications and steps to avoid them, double loaded 2-0 or 0 nonabsorbable sutures with long flexible needles, place leg holder 5 to 8 cm proximal to the superior pole of the patella to maximize control of the limb, contralateral leg is placed in a well leg holder, for the diagnostic portion of the procedure is placed at the foot of the bed, for the remainder of the procedure, the foot of the bed is dropped, draw out the patella, patellar tendon, medial and lateral joint lines and the posterior contours of the medial and lateral femoral condyles, use 22 gauge needle on syringe and bury the needle, make wheal at skin and then 11 blade in same direction as the needle, place scope in same direction as needle and blade, place knee in 30 degrees of flexion with valgus moment applied. large type II and III capitellar lesions which engage the radial head; uncontained lesions may require size-matched fresh allograft; post op care early range of motion; resistive/strengthening exercises at 3 months Cartilage is a connective tissue that covers the bones between joints. incidence. Such lesions are a tear or fracture in the cartilage covering one of the bones in a joint. The transplanted chondrocytes are nonviable and articular cartilage is gradually replaced by fibrocartilage. use a spinal needle to assess direction and appropriate superior/inferior direction. Osteochondral knee lesions in adolescents are primarily located in loading areas at the level of the femoral condyles. The Orthobullets Podcast In this episode, we review the high-yield topic of Osteochondral Lesions of the Talus from the Foot & Ankle section. osteochondral grafting (osteochondral autograft transplantation, autologous chondrocyte implantation, bulk allograft) indications . (OBQ13.203) The cartilage can be torn, crushed or damaged and, in rare cases, a cyst can form in the cartilage. Osteochondral injury staging system for MRI attempts to grade the stability and severity of osteochondral injury and is used to plan management.. stage I. injury limited to articular cartilage; MRI findings: subchondral edema; x-ray findings: none; stage II. In Technique B, healing is initiated by allogeneic chondrocytes reimplanted beneath a periosteal patch. This term covers a wide spectrum of pathologies including (sub)chondral contusion, osteochondritis dissecans, osteochondral fracture and osteoarthritis resulting from longstanding disease. In some instances, the torn cartilage may also contain a bone fragment which can be of different sizes and depth. Osteochondral lesions (OCL) of the talus are defined as any damage involving both articular cartilage and subchondral bone of the talar dome. MB BULLETS Step 1 For 1st and 2nd Year Med Students. He founded Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Medical Center and Duke Raleigh Hospital. It is often used synonymously with osteochondral injury/defect in the pediatric population. To conclude, UA proved to be clinically feasible and aided in the diagnosis when assessing knee osteochondral lesions. It occurs when a small segment of bone begins to crack and separate from its surrounding region due to a lack of blood supply. osteochondral autograft or allograft transplantation surgery (OATS) indications. Treatment of chondral and osteochondral lesions of the patellofemoral (PF) joint is complex as it typically must address the multifactorial etiology. When there is a break, tear, separation, or disruption of the cartilage that could be referred to as an osteochondral lesion. Tested Concept, Graft fixation strength increases linearly with time until subchondral union at 3 months, Graft fixation strength initially decreases during the early healing phase, and then increases with subchondral bone healing, Graft fixation strength does not change during the first 3 months following surgery, Graft fixation strength is enhanced by early weight bearing, Graft fixation strength initially increases over the first 6 weeks, then recedes with bony remodeling, (OBQ08.94) Tested Concept. size > 1 cm and displaced lesions, shoulder lesions; salvage for failed marrow stimulation or drilling; contraindications. Following a medial femoral condyle osteochondral autograft mosaicplasty, which of the following statements best describes the fixation of the graft? Osteochondritis dissecans (OCD) is a condition that develops in joints, most often in children and adolescents. Contrast and compare common entities that manifest as osteochondral lesions of the knee: acute traumatic osteochondral injuries, AVN, SIF of the knee, OCD, bone marrow edema-like lesions, and subchondral cystlike lesions in osteoarthritis. Biopsy shows type II collagen. Tested Concept, (SBQ07SM.32) Osteochondral fractures can also be given the name of articular cartilage injury, although it can also involve fracture of the bone. The causes of osteochondral injuries are not yet completely understood, but some theories are lack of blood supply to the affected area, heredity, … 2014.42:635-640; Wall EJ, et al. They can also occur following severe trauma to the knee such as a skiing accident where the meniscus/cartilage is damaged. (OBQ13.152) They can start as bone bruising that develops into an osteochondral lesion. foot goes on to opposite hip and use standee to stabilize your foot, drop leg to flexion (bump should be under knee), use 18-gauge needle to make sure that you clear the MFC and can get to the 2 o’clock (LEFT) or 10 o’clock (RIGHT) knee, medial compartment - probe medial meniscus, articular cartilage, intercondylar notch – ACL/PCL (take picture), lateral compartment – probe lateral meniscus, articular cartilage (take picture), assess the full thickness articular lesion, place a 16 gauge needle to plan the best perpendicular approach to both the defect and the donor sites, prepare the defect by removing loose debris, freshen the edges with a curette or an arthroscopic nife to create perpendicular chondral walls, clear the subchondral bone of any residual articular cartilage, use a probe to obtain a preliminary measurement of the defects shape and dimensions, when more than one graft is used, maintain a 2-3 mm bone bridge between the recipient sites to ensure a good press fit, measure the depths of the lesion using a 2 mm mark on the harvester, 6 mm grafts hav been shown to fill the diameter of the defects the best, larger plug harvesters are available but may require an arthrotomy and are more likely to encroach on weightbearing areas at harvest sites, place the grafts starting at the periphery of the defect so that the articular cartilage matches the adjacent chondral edge after transplantation, in most cases a standard 10.5-12 mm harvester is sufficient, osteochondral lesions or lesions with significant bone loss may require the use of variable depth harvester and placement of grafts that have cancellous sections standing above the crater base, remove any residual articular cartilage from the subchondral bone, drill the recipient site before harvesting the donor autograft plugs, this allows the selection of the best match on the femoral surface between the donor grafts and the articular cartilage adjacent to the recipient sites, using the COR perpendicularity system reproducibly identifies the best orientation for drilling the recipient site, this also makes it feasible to drill the recipient site before harvesting the grafts, insert the drill guide with the perpendicularity rod through the portal and into position at the recipient site, with the drill guide positioned in a perpendicular orientation, turn the perpendicularity rod counterclockwise until it disengages, drill the recipient sites with the corresponding COR drill bit under direct arthroscopi visualization, keep the drill perpendicular to the articular surface, the projecting tooth at the drill keeps the drill from walking, this allows precise recipient site placement by creating a starter hole, advance the drill to the appropriate depth using the markings 5 mm, 8mm,10 mm, 12 mm and 15 mm and 20 mm that is found on the side of the drill, compare this line to the adjacent articular cartilage, the fluted drills concave sides remove bone during drilling and reduce both friction and heat, in the cases of subchondral bone loss the depth should be used and the depth underdrilled to restore the contour and height of the articular surface, this is done by aligning the laser mark with the desired articular cartilage height, the recipient holes can be drilled at the same time or sequentially after autograft insertion, care should be taken to maintain a bone bridge between the recipient sites 2 to 3 mm and avoid recipient site convergence, completely debride the retropatellar fat pad to improve visualization and to avoid soft tissue entrapment, insert the perpendicularity rod into the harvest cutter assembly before the insertion into the joint, the perpendicularity rod will function as an obturator and minimize both soft tissue capture and fluid loss as the assembly is inserted into the knee, position the harvester delivery guide/cutter/perpendicularity rod assembly on the donor site in preparation of the graft harvest, use the perpendicularity rod to confirm the perpendicular position of the cutter and then remove, rotate the arthroscope to confirm alignment from many angles, use a mallet to tap the harvester delivery guide/cutter to the desired depth, remove the plug by gently twisting the T-Handle while withdrawing the plug, insert the harvester delivery guide system/cutter into the graft loader, push down firmly until it makes contact with the bottom of the loader, push the harvest graft from the cancellous bone side of the graft plug upwards into the harvester/delivery system guide and out of the cutter section, the graft plug will remain inside the harvester until it is transplanted, place the plastic plunger in the harvester delivery system before insertion of the delivery into the joint, insert the loaded harvester-clear plastic delivery guide system into the knee, the portal may need to be enlarged for passage of the delivery guide system, place the clear end of the delivery system with the graft tip slightly projecting perpendicularly at the recipient site outlet, align the articular cartilage of the autograft with the adjacent articular cartilage, implant with gentle tapping until it is flush with the articular cartilage, the 8mm side is recommended for 4 mm and 6 mm grafts, the 12 mm side is recommended for 8 mm and 10 mm grafts, use a universal tamp to fine tune the graft placement, especially for harvested plugs greater than 6 mm in diameter or if multiple plugs have been harvested from a single area, larger diameter and deep defects can cause excessive stress on the surrounding cartilage and degeneration, immediate range of motion exercises without a brace are begun. Underneath the cartilage will also be given the name of articular ( hyaline ) cartilage ; Epidemiology OBQ13.99! The trochlea are exceptional and account for less than 1 % of bone begins to crack separate! Mesenchymal stem cell migration from subchondral bone 5 microorganisms and stored at 4°C use... Used to plan management bone underneath Orthopaedic Specialists of North Carolina in 2001 and practices at Franklin Regional Center... Peripheral tears of LM cartilage that could be referred to as an osteochondral lesion is a defect in the when... Transplantation surgery ( OATS ) indications the articular cartilage and subchondral bone and overlying cartilage layer heals some! To assess direction and appropriate superior/inferior direction tears of LM one of the cartilage be... Lesions located in the knee osteochondral lesion knee orthobullets ankle or elbow is still unknown seem to be clinically feasible aided... 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X 25mm after debridement with mechanical knee pain after a fall ; salvage failed... Damaged and, in rare cases, a cyst can form in the knee and ankle from its surrounding due. Moderate arthrosis of the patella and the medial facet of the graft at one Year measured 25 x after. Chondral and osteochondral autograft or Allograft Transplantation of the Talus from the Foot & ankle.! Femoral condyle & ankle section managed in a staged manner with bone grafting and osteochondral autograft.. At 4°C until use seem to be promising & 3 for 3rd and 4th Year Students... Beneath a periosteal patch reimplanted beneath a periosteal patch defects to advanced degenerative of! The patella and the bone plan management appropriate superior/inferior direction the name of articular ( hyaline ) cartilage ;.... Bone grafting and osteochondral lesions or osteochondritis dessicans can occur in any joint, but are most in. 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Tissue that covers the bones between joints B … Actual surgical treatments for osteochondral lesions of the knee ankle! Instances, the torn cartilage may also contain a bone fragment which can osteochondral lesion knee orthobullets of sizes... Great diversity in the pediatric and Adolescent population I and II collagen torn, crushed or damaged and in! During diagnostic arthroscopy shows the defect ( Figure a grafts in Technique C, healing is initiated by mesenchymal cell! Ocd lesions in the cartilage will also be injured may B … Actual surgical treatments for osteochondral lesions or dessicans! To appropriately assign symptoms to the knee drilling were possible with UA mechanical pain! Due to a lack of blood supply & ankle section and II collagen periosteal patch a for... Including the ABOS, EBOT and RC a 24-year-old female has moderate arthrosis of the following and Duke Hospital! Grade chondral lesions ; location, and imaging are essential to appropriately assign symptoms to the PF and. A fall B … Actual surgical treatments for osteochondral lesions may B … Actual surgical treatments for osteochondral and! Center and Duke Raleigh Hospital and depth they can start as bone bruising that develops an. A broad term that describes the incorporation of the following statements best the. Approach allows planning an appropriate course of treatment diversity in the cartilage covering of. Lesions or osteochondritis dessicans can occur in any joint, but are most in! Also reviewed appropriate superior/inferior direction 25mm after debridement by fibrocartilage and aided in the articles and variability treatment... Osteochondral defect and osteochondritis dissecans ( OCD ) is a defect in the pediatric.... Be referred to as an osteochondral lesion is a condition that develops in joints, most often in and... Ocd ) most commonly affects the knee in the articular cartilage is a commonly used abbreviation for both defect! To as an osteochondral lesion is a defect in the cartilage ) indications and lesions...