Articular Cartilage Injury and Adult OCD : Treatment Options and Decision Making

Osteochondritis dissecans (OCD) is a pathologic process in which the subchondral bone and the overlying articular cartilage detach from the underlying bony surface. The disease results in subchondral bone loss and destabilization of the overlying articular cartilage, leading to separation and increased susceptibility to stress and shear. Fragmentation of both cartilage and bone leads to early degenerative changes and loss of function in the affected compartment. The true cause is unknown but is likely related to repetitive microtrauma, an acute traumatic incident, ischemia, an ossification abnormality, or endocrine or genetic predisposition. The prevalence of OCD is estimated at 15 to 30 cases per 100,000, most frequently occurring in the knee, with medial femoral condyle involvement in 80% of cases, lateral femoral condyle in 15%, and patellofemoral in 5%. The lateral aspect of the medial femoral condyle is the classic site of the OCD lesion. In addition to the knee, OCD has the propensity of occurring in the elbow, wrist, and ankle. Osteochondritis dissecans is divided into juvenile (JOCD) and adult (AOCD) forms. The distinction between JOCD (open growth plates) and AOCD (closed growth plates) may be important in treatment and prognosis. JOCD often resolves with nonoperative management and has a much better prognosis compared with adult OCD, which, once symptomatic, can follow a progressive, unremitting course. Nonoperative treatments for symptomatic AOCD are rarely an option because of the inherent poor regenerative capacity of articular cartilage. Thus, cases of AOCD usually require surgical intervention, such as loose body removal, drilling, internal fixation, marrow stimulation, autologous chondrocyte implantation, or osteochondral autograft/ allograft transplantation, to replace the damaged cartilage. In advanced cases, joint replacement may be the only feasible solution.