Osteochondritis dissecans
| Osteochondritis dissecans | |
|---|---|
| Specialty | Orthopedic surgery  |
Osteochondritis dissecans (typically abbreviated to OCD) is defined as "a [form] of osteochondritis in which articular cartilage and associated bone becomes partially or totally detached to form joint loose bodies."[1]
Presentation
In osteochondritis dissecans, fragments of cartilage or bone have become loose within a joint, leading to pain and inflammation. These fragments are sometimes referred to as "joint mice" due to a squeaking sound sometimes resulting from the joint.[2] Specifically, OCD is a type of osteochondrosis in which a lesion has formed within the cartilage layer itself, giving rise to secondary inflammation.
The primary presenting symptom may be a restriction in the range of movement,[3] however, pain and swelling of the affected joint are also indications of OCD.
Pathophysiology
Osteochondritis dissecans (OCD) is a condition affecting the subchondral bone of joints with secondary effects on articular cartilage that results in pain, effusions, loose-body formation, and mechanical symptoms. Left untreated, OCD can lead to the development of degenerative arthritis secondary to joint incongruity and abnormal wear patterns.[4]
OCD occurs when a loose piece of bone or cartilage partially (or fully) separates from the end of the bone, often because of a loss of blood supply (osteonecrosis) and insufficient amounts of calcium. The loose piece may stay in place or slide around making the joint stiff and unstable. OCD in humans most commonly affects the knees or ankles, but can also affect other joints such as the elbow.
Functional Anatomy
In skeletally immature individuals, the vascularity to the epiphyseal bone (growth plate) is very good, supporting both osteogenesis and chondrogenesis. With disruption of the epiphyseal plate vessels, varying degrees and depth of necrosis occur, resulting in a cessation of growth to both osteocytes and chondrocytes. In turn, this pattern leads to nonspecific changes that produce disordered intracartilaginous ossification, resulting in subchondral (below cartilage) avascular necrosis or OCD.
Four stages of OCD have been identified, including revascularization and formation of granulation (scar) tissue, absorb of necrotic fragments, intertrabecular osteoid deposition, and remodeling of new bone. With delay in the revascularization stage, an OCD lesion develops. OCD lesions may lead to articular-surface irregularities, which can cause degenerative arthritic changes. [5]
Cause
It has a complex etiology, and can be caused by genetic, hormonal, environmental and nutritional factors. Deficiencies and imbalances in the ratio of calcium to phosphorus within the body may also predispose joints to OCD problems as both elements are critical components of bone.[6]
Interestingly, the incidence of overuse injuries in young athletes is on the rise and accounts for a significant number of visits to the primary care office;[7] this reinforces the theory that OCD may be associated with increased participation in sports.[8][9]
Epidemiology
OCD is a relatively rare disorder. It commonly occurs in boys and young men from 10-20 years of age while they are still growing. As girls become more active in sports, it is becoming more common among them as well. Prevalence In knee, 30–60 cases per 100,000 population.[citation needed]
Diagnosis
To determine whether pains are osteochondritis dissecans, an MRI[10] or X-Ray can be performed to show whether the loose piece of bone is still in place. In specific cases if caught early enough, a harmless dye will be injected into the blood stream to show where the calcium will most likely continue to build up. Doing this makes the removal process much easier.
Also see: Joint locking, Wilson test, and crepitus.
Treatment
Treatment options include modified activity with or without weight-bearing; immobilization; cryotherapy; anti-inflammatories; drilling of subchondral bone to improve vascularity; microfracture; reattachment and or removal of loose bodies and OATS procedure (osteochondral allograft transplant).[8] OCD is commonly treated through a form of articular cartilage repair.
Non-Surgical Treatments
The use of braces and drug therapies, such as anti-inflammatories (ex. diclofenac, ibuprofen, and naproxen), COX-2 selective inhibitors, hydrocortisone, glucosamine, and chondroitin sulfate, have been shown to alleviate the pain caused by cartilage deficiency/damage.[citation needed]
Joint Immobilization
In the case of young patients (whose growth plates haven't closed yet), some doctors may suggest immobilization of the knee at a straight-legged position as to have the bone reattach on its own. This procedure is only used if the piece of bone is still partially connected to the joint. This usually takes around eight weeks on crutches to heal, followed by physio therapy. After the first four weeks, another x-ray or MRI is conducted, and should it still be healing based on the results of these, then the treatment continue the same for another four weeks. Should this procedure be deemed not working after eight weeks and two x-rays or MRI's, then surgery is necessary. There is an estimated 50% chance that this treatment will work without surgical intervention.[citation needed]
Surgery
"The choice of surgical or non-surgical treatments for osteochondritis dissecans is... still controversial" according to some doctors. Nonetheless, surgery, such as fragment fixation, has proved effective in patients whose lesion thickness was "less than 9 mm." However, fixation by flexible wire or thread and revascularization by drilling for the fragment were "considered to be insufficient for large lesions with a thickness of 9 mm or more." [11]
"Antegrade curettement, bone grafting and pinning of osteochondritis dissecans in the skeletally mature knee" is considered a reliable and generally successful surgery. However, the results of some studies tend to appear worse in those patients who "had more preoperative degenerative changes, a larger lesion, or a loose fragment. This suggests that intervention before these changes occur may improve results."[12] Reconstruction of the articular surface with use of osteochondral plug grafts, autologous bone grafting and matrix-supported autologous chondrocyte transplantation (ACT) has also proved successful. "For large unstable lesions, fragment fixation or reconstruction of the articular surface leads to better results than simple excision."[13][14]
Veterinary aspects
In animals, OCD is considered a developmental and metabolic disorder related to cartilage growth and endochondral ossification. Osteochondritis itself signifies the disturbance of the usual growth process of cartilage, and OCD is the term used when this affects joint cartilage causing a fragment to become loose.[15] OCD in animals is "well recognized but poorly understood".
According to Lowchens of Australia:[16]
- "Medium and large breeds are most commonly affected including the Rottweiler, Labrador Retriever, Golden Retriever, German Shepherd, Bernese Mountain Dog, Newfoundland, St. Bernard and Great Dane. OCD has also been reported in the cat. Joints commonly affected by OCD include the shoulder, elbow, stifle, and hock. Joints are often affected bilaterally."
The problem develops in puppyhood although often subclinically, and there may be pain or stiffness, discomfort on extension, or other compensating characteristics. Diagnosis is via scans such as X-ray, arthroscopy, or MRI, and treatment is often surgical although the best method remains open to debate.
Because an animal may compensate for painful forelegs by misuse of rear legs, there is a possibility that this condition can be masked by other skeletal and joint conditions such as hip dysplasia.
See also
External links
- . GPnotebook https://www.gpnotebook.co.uk/simplepage.cfm?ID=-731185141.
{{cite web}}: Missing or empty|title=(help) - American Academy of Family Physicians
- Animal
References
- ^ "Definition osteochondritis dissecans from Online Medical Dictionary". Retrieved 2008-09-04.
- ^ "What Should I Know About Osteochondritis Dissecans? - January 1, 2000 - American Academy of Family Physicians".
- ^ Hixon AL, Gibbs LM (2000). "Osteochondritis dissecans: a diagnosis not to miss". Am Fam Physician. 61 (1): 151–6, 158. PMID 10643956.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ Detterline AJ, Goldstein JL, Rue JP, Bach BR Jr (2008). "Evaluation and treatment of osteochondritis dissecans lesions of the knee". J Knee Surg. 21 (2): 106–15. PMID 18500061.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Jacobs, Brian, MD. "Knee Osteochondritis Dissecans".
Osteochondritis dissecans... [is] characterized by sequential degeneration or aseptic necrosis and recalcification.
{{cite web}}: Unknown parameter|accessmonthday=ignored (help); Unknown parameter|accessyear=ignored (|access-date=suggested) (help); Unknown parameter|coauthors=ignored (|author=suggested) (help)CS1 maint: multiple names: authors list (link) - ^ Kobluk, C. N. (1995). The horse disease and clinical management vol. 2. W. B. Saunders Company.
{{cite book}}: Unknown parameter|coauthors=ignored (|author=suggested) (help); Unknown parameter|month=ignored (help) - ^ Powers R (2007). "An ice hockey player with an unusual elbow injury. Osteochondritis dissecans". Adolesc Med State Art Rev. 18 (1): 95–120. PMID 18556892.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ a b Kocher MS, Tucker R, Ganley TJ, Flynn JM (2006). "Management of osteochondritis dissecans of the knee: current concepts review". Am J Sports Med. 34 (7): 1181–91. doi:10.1177/0363546506290127. PMID 16794036.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) Cite error: The named reference "pmid16794036" was defined multiple times with different content (see the help page). - ^ Powers R (2008). "An ice hockey player with an unusual elbow injury. Osteochondritis dissecans". JAAPA. 21 (5): 62–3. PMID 18556892.
{{cite journal}}: Unknown parameter|month=ignored (help) - ^ Boutin RD, Januario JA, Newberg AH, Gundry CR, Newman JS (2003). "MR imaging features of osteochondritis dissecans of the femoral sulcus". AJR Am J Roentgenol. 180 (3): 641–5. PMID 12591666.
{{cite journal}}: Unknown parameter|month=ignored (help)CS1 maint: multiple names: authors list (link) - ^ Nobuta S, Ogawa K, Sato K, Nakagawa T, Hatori M, Itoi E (2008). "Clinical outcome of fragment fixation for osteochondritis dissecans of the elbow". Ups. J. Med. Sci. 113 (2): 201–8. PMID 18509814.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Anderson AF, Lipscomb AB, Coulam C. (1990). "Antegrade curettement, bone grafting and pinning of osteochondritis dissecans in the skeletally mature knee". Am J Sports Med. 18 (3): 254–61. PMID 2372074.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Takahara M, Mura N, Sasaki J, Harada M, Ogino T (2008). "Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. Surgical technique". J Bone Joint Surg Am. 90 (2): 47–62. PMID 18310686.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Maus U, Schneider U, Gravius S, Müller-Rath R, Mumme T, Miltner O, Bauer D, Niedhart C, Andereya S (2008). "[Clinical results after three years use of matrix-associated ACT for the treatment of osteochondral defects of the knee]". Z Orthop Unfall. 146 (1): 31–7. PMID 18324579.
{{cite journal}}: Check|url=value (help)CS1 maint: multiple names: authors list (link) - ^ Berzon JL (1979). "Osteochondritis dissecans in the dog: diagnosis and therapy". J. Am. Vet. Med. Assoc. 175 (8): 796–9. PMID 393676.
- ^ "OSTEOCHONDRITIS DISSECANS (OCD) in Dogs - Chinaroad Lowchens of Australia". Retrieved 2007-07-06.