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8/8/2017 1 OCD
Geoffrey S. Van Thiel, MD/MBA
OrthoIllinois
Associate Professor – Rush University Medical Center Associate Professor – University of Illinois Team Physician – US National Soccer Team Team Physician – Chicago Blackhawks Medical Network – Ice Hogs
www.VanThielMD.com : VanThielMD@orthoillinois.com
Disclosures
Please visit the AAOS website for a complete list of disclosures
OCD
Osteochondritis Dissecans - ROCK Study Group A focal, idiopathic alteration of subchondral bone with risk for instability and disruption of adjacent articular cartilage that may result in premature osteoarthritis.
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Cause of OCD
Incompletely understood Dysvascular - necrosis Repetitive microtrauma Genetic Most cases represent a multifactorial contribution of pathomechanical and biomolecular features that remain incompletely understood
Characterization of OCDs
First, understand the patient and their goals then break the defect into groups.
- 1. Stable and skeletally immature
- 2. Unstable and skeletally immature
1. Fragmented 2. Whole
- 3. Stable and skeletally mature
- 4. Unstable and skeletally mature
1. Fragmented 2. Whole
Classification
63% in the medial femoral condyle 32.5% occurred in the lateral femoral condyle
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Classification Treatment Alogrithm
What happens to these long term? How do I counsel patients? Possible Osteoarthritis
Treatment Alogrithm
What happens to these long term? Counsel patients? However……. You can always make people worse Listen to them
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Treatment Algorithm
Stable and skeletally immature Nonoperative treatment - well- established primary approach
Foot flat weightbearing – crutches PT for ROM and strength Unloader brace – 3 months Activity Modification 6 weeks – then return based on symptoms
Stable and Skeletally Immature
Stable and skeletally immature Failed conservative treatment Drill It Two principal techniques – Antegrade and Retrograde Establish channels between healthy cancellous bone and unhealthy subchondral bone
Stable - Mature
Louisia et al. demonstrated poorer with chondral fissures and closed physes Understand Patient Goals Always a role for conservative care………..
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Case Example
Natural Hx of OCD
14 y.o. orthopedic surgeon “wanna-be”
Case Example Natural Hx of OCD
42 y.o. orthopedic surgeon
Stable - Mature
Failure of Conservative Management If OK with possible two stage procedure – Drill If not OK or has had long standing symptoms Osteochondral Allograft
Great Option with long term results Limited revision options
MACI with possible sandwich technique
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Unstable - Immature
Principle Restoration of the articular surface, use of rigid fixation, enhancement of the blood supply of the osseous interface, and initiation of early postoperative range of motion across the joint surface.
Unstable - Immature
Whole Located Fix
Screw fixation – solid, variable angle, bio
Displaced With Bone – Fix With minimal bone - ????
Unstable - Immature
Fragmented Remove fragments – 1st stage Cartilage Procedure
Osteochondral allograft MACI with possible bone grafting
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Unstable - Mature
Remove fragment – 1st Stage Monitor symptoms Cartilage Procedure
Osteochondral Allograft MACI with bone grafting
www.orthoguidelines.org/auc
Thank You
Geoffrey S. Van Thiel, MD/MBA
VanThielMD@OrthoIllinois.com www.VanThielMD.com
