My latest question through Ask Dr. Hacker:
Dear Dr. Hacker:
My son has OCD lesions in both of his knees (lateral condyles) but it isn’t so bad to where the articular cartilage has sustained major damage; no loose bodies or tears, just a bit spongy as the articular cartilage has de-laminated from the bone. The orthopedist addressed the necrosis by drilling small holes into the lesion through the articular cartilage and told us that it should allow the bone to heal as the bone will accept the blood, bone marrow and stem cells and begin to harden or re-grow the bone. I have only seen cases where the articular cartilage has been torn or has broken off. I understand that the articular cartilage isn’t easily regenerated and that the fibrocartilage that re grows isn’t as strong as the hyaline cartilage that we are born with. Since his articular cartilage hasn’t sustained that type of damage am I to assume that he should have a better outlook moving forward? His growth plates are still open, but just barely. I understand how difficult it can be when the articular cartilage is torn or has been ripped completely off but I don’t know much about a case like the one my son has. Any help is appreciated.
(Published with permission)
Management of cartilage and bone lesions
What is an OCD lesion?
OCD stands for ‘osteochondritis desiccans’. This is a condition where a portion of the joint surface and some of the bone beneath it of a joint is missing. You can read more about this condition here.
Damage to the joint surface of the knee is a problem often seen in the adolescent years. Most patients come to the office complaining of pain, popping or clicking in the knee and often an x-ray is all that is needed to see an area of damage. An MRI study always shows this best.
Treatments for osteochondritis dessicans lesions
The treatments suggested are usually based on severity of the damage. For cartilage lesions that are intact, the options mentioned above include drilling through the cartilage to try to bring new healing tissue in behind it. This is not a sure thing. Results are mixed. I am not a fan of removing this cartilage unless it has already started to delaminate, or tear away.
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There are many treatment options available for OCD lesions once the cartilage surface itself has become damaged. In this case, it no longer provides a nice smooth surface and should either be repaired or removed. If the surface is generally stable, there are small ‘darts’ that can be placed to try to encourage the cartilage to heal. I haven’t seen these be extremely successful. The next option is to replace this area of cartilage.
Replacing damaged cartilage with new tissue is challenging. Encouraging the body to grow new cartilage is difficult, and fibrocartilage often results. This is not made up of the same type of collagen found in joint cartilage. As a result, it is not as mechanically strong and durable.
My frequent method of choice with displaced or loose cartilage lesions is to replace large areas of damaged cartilage with an allograft. This is performed by using a donor and harvesting cartilage from the donor that essentially matches the same curvature as the damaged area in the patient. This fits snugly in with the normal surrounding cartilage and provides normal cartilage structure and mechanical properties. This is important for the cartilage to work correctly.
The next best option is to utilize cartilage from the patient’s own knee and transplant it from an area where it is not as important into the defect. We call this a mosaic plasty as it often takes multiple small plugs to fill in a damaged surface.
Another option is to perform a micro fracture. This procedure creates small punctate holes into the deeper bone marrow and encourage formation of a cartilage-like scar. Again, this grows fibrocartilage, which may be enough to relieve symptoms of pain.
New methods are evolving. There are cartilage pastes that can be injected into an OCD lesion, bone marrow transplants that can be placed in a defect, and new FDA trials are underway for cartilage patches using one’s own cells. There is hope that stem cell methods may be utilized in the future.
For the question sent to my above I would love to know more about the patient’s symptoms. If the symptoms are minimal, it maybe best left alone. It would be nice to do something proactive and prevent further issues, however this may or may not be possible. No two OCD lesions are the same, no two patients are the same, and treatments are individualized. There is also no guarantee that an area of softened cartilage will become further damaged. Always treat the patient, not the X-ray or MRI finding.
If you or a family member has a chondral or osteochondral injury, I am happy to review your options with you in detail.
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