Osteochondritis dissecans OCD or OD ) is a joint disorder in which cracks form in the articular cartilage and underlying subcondral bone. OCD usually causes pain and swelling in affected joints that catch and lock during movement. Physical examination usually shows effusion, tenderness, and crunching sound with joint motion.
OCD is caused by blood deprivation in the subchondral bone. This loss of blood flow causes the subcondral bone to die in a process called avascular necrosis. The bone is then reabsorbed by the body, leaving the articular cartilage backed prone to damage. The result is fragmentation (dissection) of cartilage and bone, and the free movement of these bones and cartilage inside the joint space, causing pain and further damage. OCD can be difficult to diagnose because this symptom is found with other diseases. However, the disease can be confirmed by X-rays, computed tomography (CT) or magnetic resonance imaging (MRI) scans.
Non-surgical treatment is seldom an option because the ability of articular cartilage to heal is limited. As a result, even cases that are in need of surgery. Where possible, non-operative management forms such as reduced or non-heavy protection and immobilization are used. Surgical treatment includes arthroscopic drilling of intact lesions, securing cartilage flap lesions with pins or screws, drilling and replacement of cartilage stoppers, stem cell transplants, and joint replacement. After rehabilitation surgery is usually a two stage process of immobilization and physical therapy. Most rehabilitation programs combine efforts to protect the joints with strengthening and range of muscle motion. During the immobilization period, isometric exercise, such as straight leg lifting, is usually used to restore muscle loss without disturbing the affected joint cartilage. After the immobilization period has ended, physical therapy involves continuous passive movement (CPM) and/or low-impact activities, such as walking or swimming.
OCD occurs in 15 to 30 people per 100,000 in the general population each year. Although rare, this is an important cause of joint pain in physically active adolescents. Because their bones are still growing, teenagers are more likely than adults to recover from OCD; recovery in adolescents can be attributed to the ability of bones to repair damaged or dead bone and cartilage tissue in a process called bone remodeling. Although OCD can affect any joint, the knee tends to be most commonly affected, and constitutes 75% of all cases. Franz KÃÆ'¶nig coined the term osteochondritis dissecans in 1887, describing it as inflammation at the interface of cartilage. Many other conditions have been confused with OCD when trying to describe how diseases affect the joints, including osteochondral fractures, osteonecrosis, accessory ossification centers, osteochondrosis, and hereditary epiphyseal dysplasia. Some authors have used the term osteochondrosis dissecans and osteochondral fragments as synonyms for OCD.
Video Osteochondritis dissecans
Signs and symptoms
In osteochondritis dissecans, fragments of cartilage or bone become loose in the joints, which causes pain and inflammation. These fragments are sometimes referred to as combined rats. OCD is a type of osteochondrosis in which lesions have formed within the lining of the cartilage itself, causing secondary inflammation. OCD most often affects the knee, although it can affect other joints such as the ankle or elbow.
People with OCD reported activity-related pain that gradually developed. Individual complaints usually consist of mechanical symptoms including pain, swelling, arrest, locking, sounds arise, and bending/giving; the main symptoms that appear may be restrictions in the range of movement. Symptoms usually appear in the early weeks of stage I; However, the onset of stage II occurs within a few months and offers little time for diagnosis. The disease progresses rapidly beyond stage II, because the OCD lesion rapidly moves from a stable cyst or gap to an unstable fragment. Non-specific symptoms, caused by similar injuries such as sprains and strains, can delay a definitive diagnosis.
Physical examination usually reveals fluid in joints, tenderness, and crepitations. Tenderness may initially spread, but often return to well-defined focal points as the lesions develop. Just as OCD shares symptoms with common ailments, acute osteochondral fractures have the same presentation with pain in affected joints, but are usually associated with fatty hemarthrosis. Although there are no significant pathological abnormalities or abnormalities characteristic abnormalities associated with OCD, patients may walk with external involved foot rotated in an attempt to avoid tibial spine throwing on the lateral aspect of the medial condyle of the femur.
Maps Osteochondritis dissecans
Cause
Despite much research, the cause remains unclear but includes recurrent physical trauma, ischemia (blood flow restriction), hereditary and endocrine factors, avascular necrosis (loss of blood flow), rapid growth, deficiency and imbalance in the calcium to phosphorus ratio, and formation problems bone. Although the name "osteochondritis" implies inflammation, the lack of inflammatory cells in histologic examination suggests non-inflammatory causes. It is thought that repeated microtrauma, which leads to microfractures and sometimes impaired blood supply to subchondral bone, can lead to localized localized blood supply losses or growth changes.
Trauma, rather than avascular necrosis, is thought to cause osteochondritis dissecans in adolescents. In adults, trauma is considered the primary or perhaps the only cause, and may be endogenous, exogenous or both. The incidence of recurrent strain injury in young athletes is on the rise and leads to a large number of visits to primary care; this reinforces the theory that OCD can be associated with increased participation in sports and subsequent trauma. High-impact sports such as gymnastics, soccer, basketball, lacrosse, soccer, tennis, squash, baseball, and heavy lifting can place the participant at higher risk of OCD in depressed joints (knees, ankles and elbows).
Recent case reports show that some people may be genetically predisposed to OCD. Families with OCD may have mutations in the gene aggrekan. Studies on horses have implicated specific genetic defects.
Pathophysiology
Osteochondritis dissecans differ from degenerative arthritis "wear and tear", which is primarily a matter of articular surfaces. In contrast, OCD is a bone problem that underlies cartilage, which can affect secondary articular cartilages. If left untreated, OCD may lead to the development of degenerative arthritis secondary to joint mismatch and abnormal wear patterns.
OCD occurs when a partial (or complete) piece of bone or cartilage is separated from the end of the bone, often due to loss of blood supply (osteonecrosis) and decalcification of trabecular bone matrix. The piece off may remain in place or shift, making the joints stiff and unstable. OCD in humans most often affects the knees, ankles, and elbows but can affect the joints.
In skeletal immature individuals, the blood supply to the epiphyseal bone is good, supporting osteogenesis and chondrogenesis. With impaired epiphyseal plate vessels, varying degrees and depths of necrosis occur, resulting in cessation of both osteocyte and chondrocytes growth. In turn, this pattern leads to irregular cartilage hardening, resulting in subcondral avorak necrosis and consequently OCD.
Four minor stages of OCD have been identified after trauma. These include revascularization and granulation tissue formation (scarring), absorption of necrotic fragments, intertrabecular osteoid deposition, and remodeling of new bone. With delay in the revascularization stage, OCD lesions develop. Lesions may cause abnormalities of the surfaces, which can ultimately lead to progressive arthritis damage.
Diagnosis
To diagnose osteochondritis dissecans, X-rays, CT scans or MRI scans can be performed to show subchondral bone necrosis, the formation of loose fragments, or both. Sometimes nuclear medicine bone scans are used to assess the level of loosening inside the joint.
Physical exam
Physical examination often begins with a patient walk-through examination. In OCD of the knee, one can walk with externally involved legs rotated in an attempt to avoid the tibial spine collision on the lateral aspect of the medial condyle of the femur.
Furthermore, the examining physician may check for quadriceps weakness. This examination may reveal fluid in joints, tenderness, and crepitations. The Wilson test is also useful in finding OCD lesions of the femoral condyle. This test is done by slowly extending the knee from 90 degrees, maintaining internal rotation. Pain at 30 degree flexion and relief with tibial external rotation is an OCD indication.
Physical examination of patients with ankle OCD often restores symptoms of joint effusion, crepitations, and diffuse or localized pain. Examination often reveals symptoms of general joint pain, swelling, and time with limited range of motion. Some with loose body lesions may report arrest, locking, or both. Possible microtrauma emphasizes the need for evaluation of biomechanical strength on the knee in physical examination. Consequently, alignment and rotation of all major joints in the affected extremity are common, such as extrinsic and intrinsic abnormalities of affected joints, including weakness.
Diagnostic imagery
X-rays show lucency front ossification in adolescents. In the elderly, lesions usually appear as areas of osteosclerotic bone with radiolucent lines between the osteocondral defect and epiphysis. The visibility of the lesion depends on its location and on the amount of knee flexion used. Harding describes lateral X-rays as a method for identifying the location of OCD lesions.
Magnetic resonance imaging (MRI) is useful for staging OCD lesions, evaluating the integrity of joint surfaces, and distinguishing normal variants of bone formation from OCD by showing bone and cartilage edema in areas of disorder. MRI provides information about features of articular cartilage and bone under cartilage, including edema, fractures, fluid interface, articular surface integrity, and fragment displacement. Low T1 and high T2 signals on the fragment interface are seen in active lesions. It shows unstable lesions or microfractures recently. While MRI and Arthroscopy have a close correlation, X-ray films tend to be less inductive of similar MRI results.
Computed tomography (CT) scans and bone scan Technetium-99m is also sometimes used to monitor the development of treatment. Unlike plain radiographs (X-rays), CT scans and MRI scans can show the exact location and lesions. Technetium bone scans can detect regional blood flow and osseous uptake. These two things seem to be closely correlated with the healing potential in the fragment.
Classification
OCD is classified by the progress of the disease gradually. There are two main staging classifications used; one is determined by MRI diagnostic imaging while the other is determined arthroscopically. However, both stagings represent pathological conditions associated with the natural progression of OCD.
While the arthroscopic classification of bone and cartilage lesions is considered standard, the MRI Anderson staging is the main form of staging used in this article. Stages I and II are stable lesions. Stages III and IV illustrate an unstable lesion in which cartilage lesions have allowed synovial fluid between fragments and bones.
Treatment
Treatment options include activities modified with or without weight bearing; immobilization; cryotherapy; anti-inflammatory drugs; subchondral bone drilling; microfracture; removal or reunification of loose bodies; mosaicplasty procedures and osteoarticular transfer system (OATS). The main goals of treatment are:
- Increases subchondral bone healing potential;
- Fix unstable fragments while maintaining shared similarities; and
- Replace damaged bones and cartilages with planted tissue or cells that can grow cartilage.
Articular cartilage capacity for limited repairs: partial thickness defects in articular cartilages do not recover spontaneously, and articular cartilage injuries that fail to penetrate subcondral bone tend to lead to articular surface damage. As a result, surgery is often necessary in even moderate cases where osteochondral fragments have not been detached from bone (Anderson Stage II, III).
Non-surgical
Candidates for nonoperative treatment are limited to immature adolescents with relatively small, intact lesions and the absence of a loose body. Non-operative management may include activity modification, heavily protected bearings (partial or non-heavy bearings), and immobilization. The goal of non-operative intervention is to promote healing in the subcondral bone and prevent the potential of chondral collapse, subsequent fractures, and crater formation.
Once the candidate for treatment has been screened, treatment is continued according to the location of the lesion. For example, those with an OCD on the knee can not move for four to six weeks or even up to six months in extension to remove the shear stress from the area involved; However, they are allowed to walk with a tolerable load. X-rays are usually taken three months after the start of non-operative therapy; if they reveal that the lesions have healed, the return of activity is gradually institutionalized. Those who demonstrate healing with increased radiodensity in the subchondral region, or those whose lesions do not change, are candidates to repeat the three month protocol described above until healing is recorded.
Surgery
The choice of surgical versus non-surgical treatment for osteochondritis dissecans remains controversial. As a result, the type and level of surgery required vary by patient age, lesion severity, and personal bias of the treating surgeon - involves a complete list of suggested treatments. Surgical options exist for treatment of OCD lesions that are symptomatic, intact, partially separated, and completely detached. Postoperative reparative cartilage is lower than healthy hyaline cartilage in glycosaminoglycan, histologic, and immunohistochemical concentrations. As a result, surgery is often avoided if non-operative treatment is possible.
Whole lesions
If non-surgical measures do not work, drilling may be considered to stimulate subchondral bone healing. Arthroscopic drilling can be performed using an antegrade approach (from the front) of the joint space through articular cartilage, or by using a retrograde approach (behind) through the bone outside the joint to avoid the penetration of articular cartilage. This has proven successful with positive outcomes in one year of follow-up with antegrade drilling in nine of eleven adolescents with a form of OCD adolescence, and in 18 of 20 skeletal immature people (follow-up from five years) who had previously failed conservative programs.
Hinged Lesions
Pin and screws can be used to secure the flap (sometimes referred to as hinged lesions). Bone pegs, metal pins and screws, and other bioresorbable screws can be used to secure this type of lesion.
Full-thickness lesions
The three most common methods used in treating full-thickness lesions are arthroscopic drilling, abrasion, and microfracturing.
In 1946, Magnusson determined the use of stem cells from the bone marrow with the first surgical debridement of the OCD lesion. These cells usually differentiate into fibrokartilago and rarely form hyaline cartilage. While small lesions may reappear using this form of surgery, repair tissue tends to have a smaller strength than normal hyaline cartilage and should be protected for 6 to 12 months. Results for large lesions tend to decrease over time; this may be associated with decreased endurance and poor wear characteristics of fibrocartilage.
In an effort to overcome the weak structures of reparative fibrocartilage, new techniques have been designed to fill the defects with closer tissues simulating normal hyaline articular cartilage. One such technique is autologous chondrocyte implantation (ACI), which is useful for large femoral defects that are isolated in younger people. In this operation, chondrocytes are arthroscopically extracted from the intercondylar notch from the articular surface. Chondrocytes are planted and injected into the defects under the periosteal patch. ACI Surgery has reported good results until very well to reduce swelling, pain and locking in clinical follow-up. However, some doctors prefer to use undifferentiated pluripotential cells, such as periosteal cells and bone marrow stem cells, compared with chondrocytes. It has also shown the ability to grow the underlying subcondral cartilage and bone.
Similar to OATS, artroscopic articular cartilage paste grafting is a surgical procedure that offers effective and long-lasting results for stage IV lesions. A bone and cartilage paste derived from a crushed plug from a non-weight heavy density can achieve pain relief, repair damaged tissue, and restore function.
Unstable lesions
Some fixation methods for unstable lesions include countersunk compression screw and Herbert screw or pins made of stainless steel or materials that can be absorbed by the body. If corpses are found, they are removed. Although each unique case and treatment is selected individually, ACI is generally performed on large defects in skeletal adults.
Rehabilitation
Continuous passive motion (CPM) has been used to improve the healing of articular surfaces during the postoperative period for people with full-thickness lesions. It has been proven to promote healing of articular cartilage for small (& lt; 3 mm diameter) lesions in rabbits. Similarly, Rodrigo and Steadman reported that CPM for six hours per day for eight weeks resulted in better clinical outcomes in humans.
Rehabilitation programs often involve the protection of compromised articular surfaces and subcondral bone combined with maintenance of strength and range of motion. Postoperative analgesics, which are a mixture of opioids and NSAIDs, are usually required to control pain, inflammation and swelling. Straight leg straightening and other isometric exercises are recommended during the postoperative or immobilization period. Physical therapy programs or physical therapy six to eight weeks are usually instituted after the immobilization period ends, combining range of motion, stretching, progressive strengthening, and special functional or exercise training. During this time, patients are advised to avoid running and jumping, but are allowed to perform low-impact activities, such as walking or swimming. If patients return to activity before the cartilage becomes hard, they will usually complain of pain during maneuvers such as squatting or jumping.
Prognosis
The prognosis after different treatments varies and is based on several factors including the age of the patient, the affected joint, the stage of the lesion and, most importantly, the state of the growth plate. It follows that the two main forms of osteochondritis dissecans are defined by skeletal maturity. The juvenile form of this disease occurs in open growth plates, usually affecting children between the ages of 5 and 15 years. Adult forms generally occur between the ages of 16 and 50, although it is unclear whether adults develop the disease after bone maturity or undiagnosed as children.
Prognosis is good for stable lesions (stage I and II) in adolescents with open growth plates; conservatively treated - usually without surgery - 50% of cases will be cured. Recovery in adolescents can be attributed to the ability of bones to repair damaged or dead bone and cartilage tissue in a process called bone remodeling. Open growth plates are characterized by an increase in the number of undifferentiated chondrocytes (stem cells) that are precursors to bone and cartilage tissue. As a result, the open growth plate allows more stem cells that are needed for repair in affected joints. Unstable, large, full-thickness lesions (stage III and IV) or lesions at each stage found in mature bones are more likely to fail in nonoperative treatments. These lesions offer a worse prognosis and surgery is needed in many cases.
Epidemiology
OCD is a relatively rare disorder, with an estimated incidence of 15 to 30 cases per 100,000 people per year. Widuchowski W et al. found OCD to be the cause of articular cartilage defects in 2% of cases in a study of 25,124 knee arthroscopy. Although rare, OCD is noted as an important cause of joint pain in active adolescents. The adolescent form of this disease occurs in children with open growth plates, usually between the ages of 5 and 15 years and occurs more frequently in men than women, with a ratio between 2: 1 and 3: 1. However, OCD has become more common among adolescent women as they become more active in sports. Adult forms, which occur in those who have reached bone maturity, are most commonly found in people aged 16 to 50 years.
While OCD may affect any joint, the knee - especially the medial femoral condyle in 75-85% of the knee cases - tends to be most commonly affected, and constitutes 75% of all cases. Elbow (especially humerus capitulum) is the second most affected joint with 6% of cases; ankle talar dome represents 4% of cases. Less frequent sites include patella, vertebra, femoral head, and glenoid scapula.
History
This condition was originally described by Alexander Monro (primus) in 1738. In 1870, James Paget described the disease process for the first time, but it was not until 1887 that Franz KÃÆ'¶nig published a paper on the cause of the sagging body in common. In his paper, KÃÆ'¶nig concludes that:
- Trauma must be very severe to decide part of the joint surface.
- Less severe trauma can cause bone to cause a possible necrosis area later.
- In some cases, the absence of significant trauma makes it possible that there are several causes of spontaneous expansion.
KÃÆ'¶nig calls the disease "osteochondritis dissecans", describing it as a subcondral inflammation of the knee, resulting in a loose fragment of cartilage of the femoral condyle. In 1922, Kappis described this process in the ankle joint. In a review of all the literature explaining transchondral fractures of the talus, Berndt and Harty developed a classification system for staging osteochondral talous lesions (OLTs). The term osteochondritis dissecans has survived, and has since been expanded to describe similar processes occurring in many other joints, including knee joints, hips, elbows, and metatarsophalangeal.
Famous cases
- Michael Russell, American player
- Kristina Vaculik, a Canadian Artist Gymist
- Jonathan Vilma, an American football linebacker
Aspects of Veterinary Medicine
OCD is also found in animals, and is of particular concern to horses, since there may be a hereditary component in some horse breeds. Eating for forced growth and selective breeding for increased size is also a factor. OCD has also been studied in other animals - especially dogs, especially German Shepherd - where it is the main cause of primate dysplasia in medium-to-large breeds.
In animals, OCD is considered a developmental disorder and metabolism associated with cartilage growth and endocondral ossification. Osteochondritis itself signifies a disruption of the usual cartilage growth process, and OCD is the term used when it affects joint cartilage causing the fragment to become loose.
According to the Columbia Animal Hospital, the frequencies of infected animals are dogs, humans, pigs, horses, cows, poultry and turkeys, and the most commonly exposed breed breeds including German Shepherd, Golden and Labrador Retriever, Rottweiler, Great Dane, Bernese Mountain Dog, and Saint Bernard. Although each joint may be affected, those who are usually exposed to OCD in dogs are: shoulder (often bilateral), elbows, knees and tarsus.
The problem develops in puppies although often subclinical, and there may be pain or stiffness, inconvenience to the extension, or other compensatory characteristics. Diagnosis generally depends on X-rays, arthroscopy, or MRI scans. While the OCD case from stopping was undetectable and healed spontaneously, others were exhibited in acute vaginal discharge. Surgery is recommended after the animal is considered paralyzed.
Osteochondritis dissecans is difficult to diagnose clinically because animals show only an unusual gait. As a result, OCD can be disguised by, or misdiagnosed as, bone and other joint conditions such as hip dysplasia.
References
External links
- MR Radiology and CT OCD
Source of the article : Wikipedia
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