Chin J Radiol 2009; 34: 153-159

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Imaging Features of Osteochondritis Dissecans

L i ang -K uang C hen1,2,3 Wai Yip -L aW1 h su -Yi C hen1,2 C heng -Tau s u1 Department of Diagnostic Radiology1, Shin Kong Wu Ho-Su Memorial Hospital School of Medicine2, Fu Jen Catholic University Department of Radio Technology, Yuanpei Institute of Science and Technology College3

Osteochondritis dissecans (OCD) is defined as a focal lesion of subarticular bone in which articular cartilage is characterized by fragmentation and possible separation in a joint. The etiology is uncertain, although trauma and ischemia have been implicated. It most commonly affects the knee joint, followed by the elbow and the ankle joints. OCD typically occurs during adolescence or early adulthood, with joint pain and swelling that worsens with activity. From January 2001 to December 2008, 11 patients with OCD were diagnosed using conventional radiographs and magnetic resonance imaging (MRI). There were seven lesions affecting the knee joint, two lesions in the elbow and two lesions in the ankle, respectively. According to MRI results, two cases were classif ied as stage I; two cases were classif ied as stage II; three cases were classified as stage III; and four cases were classified as stage IV. All lesions were confirmed by arthroscopy and pathology.

Osteochondritis dissecans (OCD) is a disorder of ossification involving both bone and cartilage [1]. OCD is the most common cause of loose fragments in the joint space in adolescents and may lead to considerable debility. It most commonly affects the knee joint, followed by the elbow and ankle joints. Very rarely, it affects articulations of the shoulder, hand, wrist, or hip [2]. In the knee joint, about 85% of lesions are on the medial femoral condyle. In the elbow, lesions affect the capitellum of the humerus, and in the ankle the talar dome is most often affected [6, 8, 9]. The etiology of OCD may be multifactorial, including trauma, ischemia, abnormal ossification centers, genetic predisposition, or a combination of these factors [3, 4, 5, 8]. Here we present data on 11 cases of OCD: their clinical course, their radiographic features, and their stages of disease according to archived magnetic resonance images (MRI).

MATeRIAls AnD MeThOD

Magnetic resonance imaging (MRI) records of eleven patients with osteochondritis dissecans of different joints from January 2001 to December 2008 were collected. The age of these patients ranged from 13 yr to 35 yr (mean age: 24 yr). Ten patients were male, and one was female. All patients had received conventional radiographs (anteroposterior and lateral views) and MRIs (Siemens Magnetom Sy mphony, 1.5T) without int ravenous injection of cont rast mediu m. M R Is were conf ig u red on T1-weighted spin-echo (520700/1220; repetition time in sec/echo time in sec) and T2-weighted spin echo (29003200/96108). Conventional radiography images and MRIs were compared.

Reprint requests to: Dr. Wai Yip-Law Department of Diagnostic Radiology, Shin Kong Wu Ho-Su Memorial Hospital. No. 95, Wen Chang Road, Taipei 111, Taiwan, R.O.C.

ResulTs
Among the 11 patients, there were seven lesions in the knee, two in the elbow, and two in the ankle. No patient had multiple lesions in our study. Seven lesions were completely detected and free in the joint

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Osteochondritis dissecans imaging features of osteochondritis dissecans

(five in the knee and two in the ankle). Two lesions were incompletely detected (both in the elbow). Two lesions were in situ (both in the knee). The right knee was affected more often than the left at a ratio of 5 to 2. Six of the lesions occurred on the lateral aspect of the medial femoral condyle. One lesion in the lateral femoral condyle occurred on the weightbearing surface (Fig. 1). The OCDs in the elbow were located at the lateral condyle of distal humerus of the right elbow. Two lesions in the left ankle were located at the medial aspect of talar dome (Table 1). T h e cl i n i c a l s y m p t o m s of t h e s e p a t i e n t s included joint pain or discomfort and swelling and locking that limited the motion of the joint. Radiographic features revealed well-circumscribed areas of sclerotic subchondral bone separated from the remainder of the epiphysis by a radiolucent zone. MRIs can provide information about the size stability, and viability of the subchondral fragments. High signal intensity between the fragment and the subchondral bone on T2-weighted (T2W) images signified separation of osteochondral fragment and host bone by synovial fluid. All lesions were proven to be OCD by arthroscopy or surgery.

DIsCussIOn
The incidence of OCD in the general population is estimated to be 15 to 30 cases per 100,000 persons. Although rare, it is recognized as an important cause of joint pain in active adolescents [2]. The clinical condition known as osteochondritis

Figure 1. Anteroposterior and lateral view of right knee demonstrates osteochondritis dissecans lucency (arrows) of the femoral lateral condyle (arrow).

2a

2b

Figure 2. a. T1 weighted sagittal image shows a low signal intensity lesion (arrow) of the medial femoral condyle. b. T2-weighted sagittal image shows subchondral bone marrow edema (arrow) in the medial femoral condyle.

Osteochondritis dissecans imaging features of osteochondritis dissecans Table 1. eleven cases of OCD recorded between January 2001 and December 2008.

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Case Med history

Clinical symptoms

X-ray Sclerotic subchondral bone separated from the epiphysis by a radiolucent line

MRI

Treatment surgical findings

Follow-up

Motor cycle Acute #1 right knee 33 yr accident 6 tenderness for mo prior M 2 weeks

Unstable OCD of the lateral Operation femoral condyle with high SI line and cystic area beneath the fragment noted in sagittal T2WI. The lesion was demarcated from underlying subchondral bone with apparent separation of the articular surface. (Stage III) Subchondral defect with high SI noted in coronal T2WI. Intact articular mantle was noted. Depressed osteochondral fracture. (Stage I) A focal defect in the cartilage and subchondral bone region of the medial femoral condyle of the right knee. Markedly joint effusion was found. (Stage IV) Cast

One year: A 1-cm defect of the lateral femoral Recovery condyle. Free bone fragment in the joint space. Joint effusion. Subtle subchondral fracture. N/A 3 mo: Recovery

Trauma #2 15 yr (knee) during M playing basketball 1 yr prior Runner #3 16 yr with trauma history ~2 yr M prior

Right knee No significant pain for 2 mo finding

Right knee swelling and rigidity for 3 mo

Sclerotic subchondral bone separated from the epiphysis by a radiolucent line

Operation

A 1.5-cm defect of None (The the medial femoral patient went condyle. Free abroad.) bone fragment in the joint space. Subchondral fracture. PCL partial tear. N/A 4 mo: Recovery

No #4 13 yr significant trauma M history

No significant Right knee tenderness for finding 1 mo

Subchondral defect with high SI noted in coronal T2WI. Intact articular mantle was noted. Depressed osteochondral fracture. (Stage I)

Cast

Right knee Traffic #5 20 yr accident 3 yr painful prior M swelling for 6 mo. Range of motion was limited. Soccer #6 Left knee 22 yr player. ACL swelling, M stiffness for 1 Injury 2 yr prior (treated mo with cast)

Sclerotic subchondral bone separated from the epiphysis by a radiolucent line Sclerotic subchondral bone separated from the epiphysis by a radiolucent line Sclerotic subchondral bone separated from the epiphysis by a radiolucent line Radiolucency of the lateral portion of capitellum

T2WI sagittal view shows large Operation focal defect in the weight-bearing portion of the articular surface of the right knee. (Stage IV)

2 yr: A 1-cm defect Recovery noted at the medial femoral condyle. Free bony fragment in the joint. Joint effusion A 0.6-cm free bone 1 yr: fragment in the Recovery joint space. Joint effusion. Medial collateral ligament tear, partial. A 1.2-cm bony fragment freely in the joint space. Bony defect noted at the medial femoral condyle. Joint effusion. 2 yr: Recovery

Operation T2WI sagittal view shows high SI lines at the articular surface r/ o articular fracture. Ill-defined line of high SI beneath the OCD lesion. Loose body noted in the joint space on T2WI. (Stage IV) Operation Large focal defect over the articular surface and subchondral region noted by T2WI with coronal and sagittal view. Loose body noted in the joint space on T2WI (Stage IV) T2WI coronal MR image shows transchondral fracture of the capitellum. No evidence of osteochondral fragment displacement is present. Partial detachment of the fragment seen on T2WI. (Stage II)

No known #7 15 yr trauma history M

Left knee rigidity for 3 mo

Injury #8 18 yr playing basketball 2 M yr prior

Right elbow swelling on and off for 2 yr

N/A Cast. Limitation of extension

Partial recovery; loss of follow-up after 6 mo

156 Table 1. Continued.

Osteochondritis dissecans imaging features of osteochondritis dissecans

Case Med history Injury #9 14 yr history 2 yr prior during M bicycle ride

Clinical symptoms Left ankle rigidity, reddish, and heat sensation for 3 weeks

X-ray Area of sclerotic subchondral bone separated from the remainder of the epiphysis by a radiolucent line

MRI

Treatment surgical findings

Follow-up

T2WI coronal image shows an Operation ill-defined line of high SI beneath the osteochondral lesion noted over the medial talar dome. No evidence of displacement of the fragment is present. Unstable osteochondritis dissecans of medial talar dome is considered. Irregular signal zone at the interface between the fragment and talus on T2WI. (Stage III) Prominent focal defect in the Operation subchondral bone region with high SI fluid surrounded noted over the medial talar dome found on T2WI coronal image. Irregular signal zone at the interface between the fragment and talus and surrounded by fluid on T2WI. (Stage III) T2WI coronal MR image shows transchondral fracture of the capitellum. Apparent interruption of the cortex and with osteochondral defect was also noted. Partial detachment of the fragment seen on T2WI. (Stage II) Cast, limitation of extension

Partial detachment 9 mo: Recovery of the bony fragment from the talar dome.

#10 Climber 35 yr and had the trauma M history 2 yr prior

No special symptom

Loose fragment with complete displacement from the crater

A small, bony fragment free in the joint space. Talar dome defect with subtle subchondral fracture.

1 yr: Recovery

#11 No trauma 13 yr history F

Right elbow Radiolucency tenderness for of the central portion of 2 mo capitellum

N/A

None: Lost to follow-up at OPD

dissecans connotes the development of an osteochond ral f rag ment of a n a r t icula r ca r t ilage on the underlying bone at the superf icial surface of a diar throdial joint [3, 4, 5]. The osteochondral fragment may be in situ, incompletely detached, or completely detached and free within the joint. In our study, seven lesions were completely detached and f loated free within the joint. The affected patients were most frequently males in the second decade of life. The most commonly affected joint was the knee joint; however, other less common sites included the capitellum of the elbow and the talar dome of the ankle. Although lesions in the shoulder, hand, wrist, and hip joints have also been reported, such lesions are rare [2, 6, 7, 8]. Within the knee, OCD lesions occur at the medial femoral condyle (8085% of cases), the lateral femoral condyle (10 15% of cases), and the patella (5% of cases) [5, 8]. Within the medial femoral condyle, the lesion is most commonly observed on the lateral, nonweight-bearing surface.

In our st udy, six of the lesions occur red on the lateral aspect of the medial femoral condyle, one in the lateral femoral condyle on the weight-bearing surface. In the elbow joint, the commonly affected area is the anterolateral aspect of the capitellum. Singer and Roy proposed that repeated valgus stress and a tenuous blood supply within the capitellum explain the f requent occur rence of OCD in this location [9]. In the ankle joint, OCD occurs more frequently in the talus followed by the tibial plafond at a ratio of 4 to 44. The usual sites of OCD of the talar dome occur in the posteromedial aspect (56% of cases) and the anterolateral aspect (44% of cases) of the talus. Occasionally, opposing osteochondral defects in the t alus and dist al tibia may occu r, suggesti ng t rau ma as a potential cause of both lesions. There are many etiologic theories or associated factors regarding OCD. Genetic predisposition, ischemia, repetitive trauma, and abnormal ossification

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have all been proposed as causes of OCD [3, 6, 8, 10]. W hile the etiology remains unclear, it is commonly believed the cause might be multifactorial, with repetitive shear and compressive forces playing primary roles. While trauma may be the star ting point for the development of OCD, it is likely that vascular insufficiency ultimately leads to OCD. In rapidly growing bone, the blood supply

Figure 3. Anteroposterior and lateral views of right ankle radiographs show osteochondritis dissecans lesions (arrows) in the medial talar dome (arrows).

in the epiphysis and secondary ossification center can be tenuous [1,6], and a single traumatic event or repetitive microtrauma may interrupt the vascular supply. Symptoms typically present with poorly localized, aching pain and swelling starting after the injur y. Symptoms of locking or giving way in a joint may develop as the disease progresses. Extension disability of the extremity may be the most important clinical sign. On physical examination, joint effusion, crepitus, and joint-line tenderness may be present. Patients with OCD in the knee may walk with external tibial rotation, and Wilsons sign may be positive. The latter is elicited by flexing the knee to 90, internal rotation of the tibia, and extending the knee, thus provoking pain [2]. Radiographically, OCD often has an associated characteristic roentgenographic appearance. Typically, the lesion consists of a round, well-defined radiolucency in subarticular bone (Fig. 1a, 2a). OCD in the posterior aspect of the medial femoral condyle may be missing on the anteroposterior film alone [2]. It is necessary to obtain at least three views anteroposterior, lateral, and tangentialto localize the defect and to assess the size of the involved area. The older the patient and the longer the duration of the symptoms, the higher the likelihood that

4a

4b

Figure 4. a. T1 weighted sagittal image shows a hypointense OCD in the dome of talus (arrow). b. MRI scan sagittal image shows hyperintense signal in the dome of talus (arrow) consistent with osteochondritis dissecans.

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Osteochondritis dissecans imaging features of osteochondritis dissecans

the roentgenographic changes may progress to the occurrence of an osteodense zone in the base of the defect with irregularity or separation of the fragment with an irregular articular surface. MRI is an effective imaging modality for evaluating the lesions because of its multiplanar capability and because it is an accurate method for staging the lesions (Fig. 1a, 2a). In our study, two lesions were staged; in situ lesions were not diagnosed by plain radiographic film. MRI is able to delineate the fragment, the overlying cartilage, and the interface between the fragment and the parent bone. Unstable fragments visible using MRI may include one or more of the following findings on T2W or on short T1 inversion recovery (STIR) images: (1) linear, high sig nal intensit y surrounding the fragment, (2) 5-mm or larger cystic changes between the fragment and the host bone, (3) a high signal intensity linear defect in the overlying cartilage, or (4) a focal, 5-mm or larger, cartilage defect. MRI has been demonstrated to be helpful in preparative planning, to be useful as a prognostic indicator, and to have 97% percent sensitivity in detecting unstable lesions [11]. The T2W sequence is a sensitive method for evaluating the stability of an OCD [11]. Osteochondritis dissecans should be distinguished from acute chondral fracture and subchondral injury. All cases of OCD should be staged for stability with radiography and MRI; stages I and II represent stable lesions, while stage III and I V represent unstable lesions where in cartilage is breached and synovial fluid separates the fragment and the underlying bone. In our study, management of OCD included conservative treatment for stable lesions and surgical removal of fragment and mosaicplasty in unstable lesions. Arthroscopy is generally accepted for initial

surgical management both as a diagnostic and/or a therapeutic means. In this study, we correlated the radiographic and clinical findings of 11 cases of OCD and found that imaging modalities facilitated accurate diagnosis of OCD. The combination of the imaging modalities is helpful in both preoperative assessment and postoperative follow-up.

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