diagnosis, aggressive treatment benefit athletes
Lyle Micheli, MD
Director of Sports Medicine
Kevin Brake is an avid high school soccer and hockey player.
When he began suffering from osteochondritis dissecans (OCD),
a painful fragmentation of cartilage in his knee, his physicians
initially advised him to take up the violin or guitar, because
his sporting days were over.
Not ready to give up, Kevin's family turned to Children's
Hospital Boston. Lyle
Micheli, MD, director of Sports
Medicine and a nationally recognized expert on sports
injuries in children and adolescents, had a different assessment:
with aggressive treatment, Kevin could be back on the field and
in the rink within a few months.
The different prognoses, says Dr. Micheli, owe to the fact that
the condition is rarely seen in most practices. The average
pediatric orthopaedist doesn't see a lot of OCD. Some see
as few as one case per year, so understandably not everyone is
up to speed with the effectiveness of new treatments. Here, we
treat hundreds of OCD patients from all over the country every
OCD occurs when a loose piece of bone and cartilage separates
from the end of the knee or elbow. That piece may stay in place
or fall into the joint space, making the joint unstable. Patients
usually present with pain, which is often poorly localized and
associated with activity. Effusion may be present, and particularly
in a case of an unstable lesion, the patient may describe mechanical
symptoms such as locking or catching. If a loose body or bodies
have developed, mechanical symptoms and episodic locking may predominate.
Localization of symptoms depends to some extent on the location
of the lesion.
Left: Large OCD of medial femoral
in a teenage boy.
Center: Same lesion shortly after
compression screw fixation.
Right: Complete healing eight weeks
While anyone may present with OCD, it occurs most often in males
10 to 20 years of age, while they are still growing. It affects
athletes disproportionately, especially gymnasts and baseball
players, and has been increasingly seen in adolescent girls as
that group has become more active in team sports. While the etiology
of OCD is still debated, its apparent increased prevalence in
the knees of children involved in organized sports suggests repetitive
impact training as a major factor.
According to Dr. Micheli, the key to successful treatment is
early diagnosis. At least half of OCD patients referred
to us have experienced a delay in diagnosis, he says. In
some cases that's because the symptoms are common to other
conditions, such as juvenile arthritis or Lyme disease. In other
cases the patient is told to give it time.'
Dr. Micheli maintains that any sports-active child with unexplained
knee pain should be thoroughly assessed. If there is swelling
or effusion, he adds, that should be a red flag.
Another problem Dr. Micheli sees is that some care providers
aren't aware that in many circumstances OCD can be treated
effectively. Effective treatment of OCD was pioneered at Children's
in 1951 by William Green, MD, who showed that an immobilized
joint could heal properly. Today, Sport Medicine specialists at
Children's have a wide range of treatment options depending
on the age and relative maturity of the patient, the size and
location of the lesion, whether the lesion is open or closed and
whether it is mechanically unstable or involves a loose body.
Cast or brace immobilization is a viable but relatively conservative
strategy, often used initially in younger patients. Active adolescents
such as Kevin Brake, for whom prolonged immobilization and activity
restriction are unacceptable and have a lower rate of success,
benefit from more aggressive approaches, such as transarticular
drilling (which creates channels for revascularization and healing
within the articular cartilage), antegrade debridement with replacement
and fixation, or retrograde grafting and stabilization. Dr. Micheli
estimates that about 70 percent of the OCD patients his department
sees are candidates for aggressive surgical treatment.
In Kevin's case, Dr. Micheli applied transarticular compression
screws to reconnect the articular cartilage to the bone. Just
six months later, Kevin's family sent a letter to Dr. Micheli
reporting that he had finished the soccer season with no symptoms
and had returned to ice hockey. By all opinions, they
wrote, Kevin is again a college prospect in soccer. Based
on all our early consultations
we never thought we'd
see this level of recovery.
As far as Dr. Micheli is concerned, the negative prognosis Kevin
Brake received is all too common for young athletes with OCD.
The bottom line, he says, is that if OCD is
caught early enough and treated aggressively, the devastating
outcomes we've traditionally seen can be avoided.