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Juvenile OCD: Tips offered for proper diagnosis and treatment options
Eric J. Wall, MD, answers 4 Questions about osteochondritis dissecans in the young patient.
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A finding of juvenile osteochondritis dissecans (JOCD) on a knee roentgenogram is an uncommon finding in most orthopedic surgeons’ offices. The presentation can be confusing because the patient may be relatively free of symptoms or complain of knee pain.I have invited Eric J. Wall, MD, to answer this month’s 4 Questions related to evaluating and treating osteochondritis dissecans (OCD) lesions in the young patient. I feel that his approach, which is based on his experiences with these lesions in the skeletally immature knee, to be a good review of this topic for myself and our readers.
Douglas W. Jackson, MD
Chief Medical Editor
Douglas W. Jackson, MD: How do you define a stable JOCD lesion and determine its healing?
Eric J. Wall, MD: A stable JOCD lesion has an intact articular surface on a high resolution (1.5- or 3.0-T) MRI scan. Healing is determined by progressive reossification on plain films. Care must be taken to evaluate AP lateral and tunnel views. Because of a slight difference in projection taken on different visits, I like to see two consecutive X-ray visits spaced about 6 to 8 weeks apart showing reossification of the lesion before I describe the lesion as showing healing.
Jackson: What would be the indications to operate on an OCD lesion?
Wall: I usually recommend surgery for any OCD lesion greater than 10 mm in diameter if the child is within 1 year of skeletal maturity, or has a closed growth plate.
The second indication would be a child with a stable lesion with open growth plates who fails to show any progression toward healing under a nonoperative treatment protocol of 6 months.
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The third indication would be any child who, on initial MRI scans, shows a crack in the articular cartilage – an unstable lesion.
Jackson: What are your speculations on why a stable OCD lesion can be symptomatic?
Wall: Although the etiology of JOCD is unknown, I believe that repetitive stress injury to the subchondral bone is a main component of the pathomechanics of these lesions. I believe it is the underlying injury to the subchondral bone that generates the pain from JOCD, similar to a stress fracture.
Jackson: What are the physical restrictions you follow with your patients during the 6 months of activity modification and/or immobilization?
Wall: Virtually all authors agree that patients need abstinence from sports as initial treatment. I start most children with a weight-bearing cylinder cast for about 6 weeks. This is followed by weight-bearing in a double-hinge unloader-type brace. If X-rays show progressive reossification, I will then allow the patient to be out of their knee brace during everyday activities with brace use for sports. This is then followed by a full return to sports without the brace once reossification of the lesion appears complete on radiographs.
Crutches may be substituted for the cylinder cast, however, young patients may have difficulty in compliance to crutch use and in this case a cylinder cast may be a better option.
For more information:Reference:
- Eric J. Wall, MD, is the Director, Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave. MLC# 2017, Cincinnati, OH 45229; 513-636-4787; e-mail: Eric.Wall@cchmc.org.
- Wall EJ, Vouraveris J, Meyer GD, et al. The healing potential of stable juvenile osteochondritis dissecans knee lesions. J Bone Joint Surg (Am). 2008;90(12):2655-2664.