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Young people have the best chance of returning to their usual activity levels, although they might not be able to keep playing sports with repetitive motions, such as pitching in baseball. Adults are more likely to need surgery and are less likely to be completely cured. They may later develop arthritis in the affected joint.

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If a nonsurgical treatment is recommended, you should avoid activities that cause discomfort. You should avoid competitive sports for 6 to 8 weeks. Your doctor may suggest stretching exercises or swimming instead as a means of physical therapy.

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If signs of osteochondritis dissecans are seen on X-rays of one joint, you’ll have X-rays of the other joint to compare them. After this, you may have an MRI (magnetic resonance imaging) or a CT (computerized tomography) done. These tests can show whether the loose piece is still in place or whether it has moved into the joint space. If the loose piece is unstable, you might need surgery to remove it or secure it. If the loose piece is stable you may not need surgery, but you may need other kinds of treatment, such as resting the affected joint, bracing the joint when playing sports and treating pain and inflammation with ibuprofen.

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The symptoms of osteochondritis dissecans include:

* Swelling of the affected joint
* Decreased joint movement, such as not being able to fully extend your arm or your leg
* Pain, especially after activity
* Stiffness after resting
* A joint that “sticks” or “locks”
* A clicking sound when you move the joint

These are all clues that you may have osteochondritis dissecans. Your doctor will check you to be sure the joint is stable and check for extra fluid in the joint. Your doctor will consider the possible causes of joint pain, such as fractures, sprains and osteochondritis dissecans. If osteochondritis dissecans is suspected, your doctor will order X-rays to check all sides of the joint.

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Anyone can get osteochondritis dissecans, but it happens more often in boys and young men 10 to 20 years old who are very active. Osteochondritis dissecans is being diagnosed more often in girls as they become more active in sports. It affects athletes, especially gymnasts and baseball players. The adult form occurs in mature bone, and the juvenile form occurs in growing bone.

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In osteochondritis dissecans, a loose piece of bone and cartilage separates from the end of the bone because of a loss of blood supply. The loose piece may stay in place or fall into the joint space, making the joint unstable. This causes pain and feelings that the joint “sticks” or is “giving way.” These loose pieces are sometimes called “joint mice.” Osteochondritis dissecans usually affects the knees and elbows.

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Osteochondritis dissecans is a condition in which a segment of articular cartilage with its underlying subchondral bone graudually separates from the surrounding osteocartilaginous tissue.

The separation of the fragment may be partial or complete.

The osteochondral segment may remain in situ, it may become partially detached, or it may become completely detached and lodge in the contiguous joint as a loose body. It is important to differentiate the word dissecans from dessicans, the latter being derived from desiccare, “to dry up”.

The disease was first described in 1870 by Sir James Paget and the term osteochondritis dissecans was given in 1887 by Konig.

During the early part of this century various modalities of treatment of osteochondritis dissecans were recommended like

* Simple observation
* Restriction of physical activity
* Non-weight-bearing by crutch protection
* Immobilization
* Surgery

Various surgeries recommended wer drilling, transfixing with pins, bone grafting, and removal of the partially or completely detached osteochondral fragment.

However in osteochondritis dissecans children, the healing is excellent.

The advent of arthroscopic surgery has opened new vistas in management of osteochondritis dissecans.

Various options available are

* Direct visualization of the lesion.
* Drilling of the base of the osteochondral fragment.
* Stabilization of partially separated fragments.
* Atraumatic removal of loose bodies.

Causes of Osteochondritis Dissecans

Etiology

The exact cause of osteochondritis dissecans is not known yet. There are various theories that try to explain the causation. There appears multiple factor that decide this conditionThe etiology is most probably multifactorial.

Predisposition

Multiple joint involvement in the same patient are known in osteochondritis dissecans, indicating a constitutional factor in its etiology. Diseaseslike Legg-Calve-Perthes disease and tibia vara also associated with this condition.

Ischemia

Interruption in the blood supply to an area of subchondral bone has been proposed as the cause

Trauma

Injury plays a principal role in the causation of osteochondritis dissecans. A direct relationship between injury and the development of osteochondritis dissecans has been noted.

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The usual presenting complaints are

* Intermittent pain in the joint on strenuous physical activity
* Stiffness
* Swelling
* Clicking and locking of the joint
* Limp

When the knee joint is involved, “giving way” of the knee is a frequent complaint.

Physical Findings

These depend on the joint involved, the duration of the disease, and whether or not the fragment has become detached.

An important finding is localized tenderness over the lesoinal area.

In knee it iis usually over the lateral surface of the medial femoral condyle and is best elicited by deep pressure over the lesion with the knee acutely flexed.

When the medial femoral condyle is the site of the lesion, the patient will toe out; lateral rotation of the tibia prevents the tibial spine from impinging on the lateral surface of the medial femoral condyle.

Wilson’s sign

With the patient in supine position, the affected knee is flexed to a right angle, the leg is medially rotated fully, and then the knee is gradually extended. At 30 degrees of flexion, the patient will complain of pain over the anterior aspect of the medial femoral condyle. The pain is relieved on lateral rotation of the leg.

Atrophy of the controlling muscles, synovial thickening, hydrarthrosis, and limited joint motion are common. One may be able to palpate the loose body may be palpated.

When ankle is involved, there is intermittent pain on weight-bearing aggravated by strenuous physical activity such as running and sports. Limp is common. At times, the condition is asymptomatic.

Physical findings include localized tenderness which can be detected by markedly plantar-flexing the ankle joint and palpating the medial and lateral corners of the dome of the talus.

Pressure can be exerted on the dome of the talus by rotating the leg inward and outward while the foot remains on the floor in plantar flexion and inversion, then in dorsiflexion and eversion.

Atrophy of the calf is common.

Radiography

The radiograph shows a well-circumscribed fragment of subchondral bone is demarcated from the surrounding femoral condyle or affected bone by a radiolucent saucer or crescent-shaped line. The affected bone may appear denser than the surrounding parent bone.

As the fragment separates, a  depression is seen at the site of separation. However the  detached loose body in the joint continues to grow deriving its nutrition from synovial fluid. Osteochondritic fragment becomes radiopaque is due to subchondral bone with articular cartilage, secondary calcification in degenerating articular cartilage and  new bone formation following revascularization.

Special views may be necessary to visualize the lesion.

Computed Tomography

The CT scan makes possible a definitive diagnosis and determines the precise location and true extent of the lesion. It also reveals whether the fragment is detached completely or partially.

Bone Scanning with Technetium-99m shows localized increased activity at the site of the lesion

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Treatment of  Osteochondritis Dissecans in children under 12 years of age is nonoperative. Arthroscopy is reserved for the cases in which the fragment has become detached.

If the lesion is in a non-weight bearing area or it involved only a portion of the weight-bearing area of a joint it is observed with serial radiograms made every six to eight weeks to determine its natural course.

Protection from weight-bearing is not required unless the lesion begins to separate and symptoms persist.

In case the weight bearing is prohibited, it is resumed gradually with aid of crutches providing partial support. Generally, a period of three months is required for healing of the lesion.

In case of suspected seapration of fragment, bone imaging with technetium-99m and computed tomographic studies should be carried out.

If osteochondritis dissecans in a child fails to respond to nonsurgical management, arthroscopic examination and drilling of the osteochondritic lesion are recommended.

Indications of arthroscopy

Arthroscopy  directly visualizes the involved area and determines its exact location and size, and the degree of articular cartilage separation.

Arthroscopy is indicated in osteochondritis dissecans in patients 12 years of age and older in whom the weight-bearing area is involved with a lesion over 1 cm. in diameter. Arthroscopic examination is also indicated in case of late diagnosis.

In children under 12 years of age arthroscopy should be done when, there is no radiographic or clinical evidence of improvement after a reasonable period of non operative treatment, or if the lesion becomes partially or completely detached.

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