Abstract

This study aimed to evaluate the clinical outcomes of paediatric patients who underwent a retrograde drilling treatment for their osteochondritis dissecans (OCD) of the talus. The secondary purpose was to identify factors that are predictive of a failure of the treatment.

A retrospective study was done. All patients treated for talar OCD between 2014 and 2017 were reviewed to extract clinical and demographic information (age, sex, BMI, OCD size and stability, number of drilling, etc). Inclusion criteria were: (1) talar OCD treated with retrograde drilling, (2) less than 18 years, (3) at least one available follow up (4) stable lesion. Exclusion criteria was another type of treatment for a the talar OCD. Additionally, all pre-operative and post-operative medical imaging was reviewed. Outcome was classified based on the last follow-up appointment in two ways, first a score was attributed following the Berndt and Harty treatment outcome grading and second according to the necessity of a second surgery which was the failure group. Chi-square and Mann-Whitney tests were used to compared the success and failure group.

Seventeen patients (16 girls and 1 boy, average age: 14.8±2.1 years) were included in our study group. The mean follow up duration was 11.5 (±12) months. Among this population, 4/17 (24%) had a failure of the treatment because they required a second surgery. The treatment result grading according to Berndt and Harty outcome scale identified good results in 8/17 (47%) patients, fair results in 4/17(24%) patients and poor results in 5/17 (29%) patients. The comparisons for various patient variables taken from the medical charts between patients who had a success of the treatment and those who failed did not find any significant differences.

At a mean follow-up duration of 11.5 months, 76% of patients in this study had a successful outcome after talar OCD retrograde drilling. No statistically significant difference was identified between the success and failure group.

Talar OCD in a paediatric population is uncommon, and this study reviewed the outcome of retrograde drilling with the largest sample size of the literature. Retrograde drilling achieved a successful outcome in 76% of the cases and represents a good option for the treatment of stable talar OCD.

1. One hundred patients with osteochondritis dissecans of the knee have been reviewed. Sixty-eight were male. Unilateral lesions were found in seventy-four. The average age at onset of symptoms was eighteen years.

2. The outstanding etiological feature was found to be direct injury to the joint surface (46 percent), repeated injuries sustained in first class athletics and field sports, and mechanical abnormalities of the knee.

3. Osteochondral fracture was found in seven cases.

4. The results of various types of treatment are described and a plan of management outlined.

1. This is a small series and patients have been treated in a variety of ways. Some impressions emerge, however, concerning the importance of initial trauma, the importance of the factor of heredity and the results of treatment.

2. More than 40 per cent of the patients in the series had an injury to the knee before symptoms began, which tends to support the traumatic theory. Twenty of the twenty-three patients who gave a past history of trauma had a lesion on the medial condyle, next to the intercondylar notch, and one patient of the three who had lesions on the lateral femoral condyle suffered from recurrent dislocation of the patella.

3. Although numerous examples have been reported in the literature of osteochondritis dissecans occurring in several members of a family, the family history of only one patient in this series suggested a familial tendency, and this was doubtful. It seems that patients showing a familial tendency are not commonly seen compared with the number of patients presenting with osteochondritis dissecans.

4. It is often stated that osteoarthritic changes will follow if part of the articular surface is lost, as in osteochondritis dissecans, and this belief has led to the school of thought which advocates restoration of the articular surface by reposition of the fragment. While there is no doubt that this method should be used if a large proportion of the weight-bearing surface of a femoral condyle is affected, the argument has less force if a small area is affected. It is interesting to find that of the five patients treated by replacement of a separated fragment four developed osteoarthritis, whereas in the first series only six patients out of the twenty-two developed such changes. Although these former had what appeared to be an accurate reposition of the fragment it is possible that a "step up" on the joint surface was produced, which gave rise to a more rapid deterioration of the articular cartilage. Accurate conclusions cannot be drawn from five patients, but it may be that attempts to reconstruct the articular surface of a femoral condyle can, over a long period of time, give worse results than simple removal of the lesion.

5. The group of patients treated conservatively gave encouraging results, and improved radiographic appearances were seen in most cases. There was also a notable absence of osteoarthritic changes and these results support the view that conservative treatment is indicated in adolescents and children.

Both osteochondritis dissecans and coxa plana are diseases with identical pathological changes, namely avascular necrosis. Although the etiology is not known in either case, it seems likely that when the etiological factors are fully determined they will prove to be applicable to either condition. The relative importance of each etiological factor in the multiple pathogenesis of these two conditions is almost certainly different in each disease process, and probably in each individual case. Present day concepts suggest that there is an underlying constitutional disturbance, which is associated with other factors (of which trauma is almost universally accepted as being one; perhaps the only one), to predispose the individual to these conditions.

It is hoped that further studies along these lines will not only help to provide a better understanding of the two conditions mentioned above, but will also be of value in the appreciation of the pathogenesis and etiology of a large number of disturbances including such varied conditions as dysplasia epiphysialis multiplex congenita, cretinoid dysgenesis of the capital femoral epiphysis, adolescent coxa vara, transient synovitis of the hip, and the recently discussed (Merle d'Aubigné 1964) idiopathic avascular necrosis of the femoral head in adults.

That there is an etiological relationship between osteochondritis dissecans and coxa plana seems clear, but much more work is required before we will have at hand the patho-physiological evidence that will permit an accurate correlation of these two conditions.

Osteochondritis dissecans occurring bilaterally in either the knees or the elbows is recorded in four members of one family. The suggestion is supported that the underlying pathology may be developmental, resulting in a form of localised osteochondrodystrophy.

1. The pathological anatomy of osteochondritis dissecans of the hip is described, and its causation is discussed.

2. Eight new cases are reported.

3. The problems of treatment are considered.

1. The record is presented of an attempt to treat osteochondritis dissecans on idealistic lines.

2. The operative technique to be adopted in the various circumstances likely to be encountered in the knee joint is described. Two cases affecting the talus are recorded.

3. The radiological appearance has become virtually normal in twenty-seven cases (the remaining four are recent); healing has been observed directly in seven cases in which a second operation to remove the means of internal fixation was necessary; and the patients' complaints have been eliminated, but the long term results of treatment are unknown.

4. Suggestions are made for possible developments in the technique of operation.

1. A family, in which ten members of the second and third generations had osteochondritis dissecans, is described.

2. It is probable that the disease also occurred in the first and fourth generations.

Nine cases of osteochondritis dissecans of the elbow and knee in three generations of the same family are described. There was clear evidence of a dominant inherited factor.

1. Three patients suffering from osteochondritis dissecans in several joints, and all below average height, are described.

2. There was evidence of a constitutional upset in each case.

3. It is suggested that there was an underlying endocrine imbalance at puberty.

Autologous chondrocyte transplantation has become a possible solution for the treatment of chondral knee lesions. Recently an autologous tissue engineered cartilage (Hyalograft C), using biodegradable scaffolds for cell proliferation, was successfully developed. In osteochondritis dissecans (OCD) the lesion also involves subchondral bone. For this reason we began to use a two-step technique: arthroscopic autologous bone grafting followed by autologouos condrocyte Hyalograft C transplantation after 4–6 months. We treated five patients affected by OCD.

All the patients were clinically evaluated and analysed according to the International Repair Cartilage Society score at 12 and 24 months. The ICRS score showed highly satisfactory clinical results in all treated patients at 12 and 24 months; CT and MRI evaluation had demonstrated a good articular surface reconstruction with complete bone defect restoration at a short 12-month follow-up period. The autologous chondrocyte transplantation provides highly satisfactory clinical results.

This second-generation autologous tissue-engineered cartilage transplantation avoids the use of periosteal flap, simplifies the surgical procedure and permits use of an arthroscopic approach. In association with autologous bone grafting, bone loss can also be restored in order to recreate a perfect articular surface. The preliminary clinical and histological results are encouraging but longer follow-up is required to better evaluate this technique.

Background: Seven cases of osteochondritis dissecans (OCD) of the tarsal navicular bone have been described mainly radiologically.

Aims: We report our experience with additional 6 patients which represent the largest series described, and conclude about the treatment modalities in this unique type of OCD.

Methods: All patients who had OCD of the tarsal navicular bone during the years 1993 and 1998 were evaluated. The parameters which were examined were the age and sex of the patients, the location of pain, duration of symptoms, and any trigger mechanism if this was noted. The various treatments used for these patients as well as their outcome were recorded.

Results: Six patients were treated by us between 1993 and 1998 (follow up 3–7 years). There were 4 males and 2 females aged between 14 and 35 years (mean 21 years). All patients had pain in the dorsal aspect of the midfoot, and painful limitation in midfoot movements. Duration of symptoms varied between 4 months and 1 year. In 3 patients basic training in army service and in one running short distances triggered the pain. In 3 patients an accompanying stress fracture of the navicular bone was developed. Three patients were managed conservatively. Two patients underwent excision, curettage and drilling, and one patient underwent excision and fusion. All patients, whether treated conservatively or surgically, still suffer form pain in activities and painful limitation of midfoot motion.

Conclusions: OCD of tarsal navicular bone affects mainly young patients. Physical efforts are the trigger mechanism for the symptoms. The clinical presentation includes painful limitation in midfoot motion. The outcome is reserved both for conservative or operative treatment.

1 . Two cases of osteochondritis dissecans after Legg-Calvé-Perthes' disease observed for thirty years are described.

2. Osteochondritis dissecans of the hip can remain in an apparently unchanged state for many years and in these two patients is associated with excellent function, not requiring surgery.

A case of osteochondritis dissecans complicating Legg-Calvé-Perthes' disease is reported. Despite four years of conservative treatment in an ischial-bearing caliper a part of the fragmented femoral head failed to unite with the rest of the epiphysis and has persisted as an intra-articular loose body.

Freehafer (1960) listed the indications for surgical removal of this fragment in such cases: 1) persisting symptoms; 2) dislocation of the loose fragment into the joint with secondary arthritic changes inevitable; 3) a mechanical block to movement of the hip.

Since our patient had a relatively symptomless hip with a full range of movement, surgical removal of the loose body was not advised. The prognosis for this hip is nevertheless guarded, and surgery can be reserved for the above indications or for reconstructive procedures should they be required in the future.

One of the most important factors influencing therapeutical decisions in orthopaedic surgery are long-term results. Although, osteochondritis dissecans (o.c.d.) of the femoral condyles is the most often occurring location little is known about long-term results. Furthermore, it is of interest to see the time course of such patients regarding the development of secondary osteoarthritis. Thus, it was the aim of our study to re-analyse patients suffering from o.c.d. of the femoral condyle which had been operated have been followed up after a medium time-intervall.

Material & methods: 97 of 147 with o.c.d. of the femoral condyles which were operated using different surgical techniques depending on the stage were followed-up clinically (Lysholm-Score) & radiologically (Arcq- classification/Tapper- & Hoover-score for OA). Results were analysed depending on the age, stage and surgical technique. In 2nd follow-up ten years after the first follow-up patients were reexamined with the same clinical and radiological scores.

Results: At 1st follow-up we found a median Lysholm-Score of 83.7 (21–100, SD 19.6) pts.. Regarding the OA-changes in 56.3% no changes, in 21.9 % 1°-changes, in 3.1% 3°-changes, in 6.3 % 3°-changes & in 12.5 % 4° changes. The mean stage postop. was 0.97 SD 1.4. Ten years later similar results were found: in 56.3% no osteoarthritic changes were seen. 1°-changes were found in 21.9%, 2°-changes in 3.1% and 3°-changes in 6.3% and severe OA 4°-changes were found in 12.5%. In comparison to the 1st follow-up at the 2nd follow-up no individual changes could be detected in 73 %, a slight impairment in 11.5 % & a slight improvement in 15.4%. In most of the patients osteoarthritic changes were slight & did not show a severe impairment after a mean of 20.3 years.

Depending on the age (the stage of the growth plate open vs. closed) adolescents exhibited no or slight oa-changes in 83.3% & moderate changes in 16.7%. Severe oa-changes were not detectable. Adults exhibited a distinct higher incidence of oa (no o.-a.: 37.5%/1°: 25%/2°: 12.5% 3°:/12.5%/4°:12.5%). Regarding the surgical technique retrograde technique leaving the cartilage layer intact resulted in distinct better results than those perforating the cartilage layer.

Conclusion: Best long-term results with a low incidence of OA are to obtain in cases with o.c.d. with intact cartilage layer not necessitating cartilage damage. Worst results are seen in adult patients with 4°-lesions.

1. A case of osteochondritis dissecans of the hip in a young girl who at the age of one and a half years underwent open reduction of congenital dislocation of the hip, is reported.

2. The possible relationship between this condition and the osteochondritic changes which followed the reduction is discussed.

1. In sixty mature rabbits osteochondral fractures of various types were made in the medial femoral condyle.

2. The fractures or fragments which remained stable united but those in which movement occurred progressed to non-union.

3. An ununited osteochondral fragment resembled osteochondritis dissecans in the human both radiologically and histologically.

4. Experiments in the cadaveric knee show that the patella articulates with the classical site on the intercondylar aspect of the medial femoral condyle in full flexion of the joint and here an osteochondral fracture could be sustained.

5. It is concluded that the fragment in osteochondritis dissecans follows an osteochondral fracture which remains ununited.