Sixteen studies were deemed acceptable in quality and design to be included in a systematic review of osteochondritis dissecans (OCD) of the knee. The review was conducted by a panel of pediatric orthopedic surgeons from all over the United States.
Out of these 16 studies comes 16 recommendations called clinical practice guidelines (CPGs) for the treatment of osteochondritis of the knee in children.
Osteochondritis dissecans (OCD) is a problem in the cartilage of the knee that affects the end of the femur (big bone of the thigh). The problem occurs where the cartilage of the knee attaches to the bone underneath.
The area of bone just under the cartilage surface is injured, leading to damage to the blood vessels of the bone. Without blood flow, the area of damaged bone actually dies. A joint surface damaged by OCD doesn't heal naturally.
Even with surgery, OCD usually leads to future joint problems, including degenerative arthritis and osteoarthritis. That's why proper treatment (based on evidence of what works and what doesn't) is so important.
But as this report shows, what we don't know about the treatment of OCD far outweighs what we do know. Most of the recommendations made by this group were graded as inconclusive -- meaning there's not enough evidence to say for sure. Based on clinical experience combined with data from the studies collected, the panel was able to agree (consensus) on four recommendations.
We'll start with those four consensus recommendations and then fill you in on what the group had to say about future directions in research. The way the authors reported their consensus recommendations was to say, "In the absence of reliable evidence, it is the opinion of the work group that..."
Surgery should be offered to children with unstable or displaced osteochondritis dissecans (OCD) lesions that can be salvaged (saved).
Likewise, the same treatment recommendation can be made for those patients who have the same condition (unstable or displaced OCD) but who have reached skeletal maturity (bone is no longer growing).
For those patients who do receive treatment for OCD but who don't get better (pain persists), follow-up is recommended. The surgeon should complete a history, physical examination, and order imaging studies (X-rays, MRIs) to see what kind of healing response is present.
Physiotherapy is advised after surgery for OCD.
Some of the advice routinely given patients with OCD will probably still be included in patient education -- at least until more conclusive evidence is found to support or negate these recommendations. For example, patients are advised to modify their activities and lose weight if they are overweight. The idea behind these guidelines is to help prevent osteoarthritis.
As to the specific type of cartilage repair to perform for unstable or displaced but still salvageable OCD lesions...well, that's an area of great debate and controversy. There are many different surgical techniques currently available but no consensus as to which one works best.
Likewise, when it comes to nonsurgical treatment of OCD, there simply isn't enough evidence to support one approach over another. Splinting, bracing, electrical stimulation of the bone, and activity restriction may be prescribed but the effectiveness of any of these techniques is unknown. This is true for both those individuals who are still growing (skeletally immature) and those who have reached full bone maturity.
With so many unknowns and so few really evidence-based clinical practice guidelines, where do we go from here? The authors' strongest recommendations are for future studies to help clear up some of the confusion.
First of all, we need studies that use different surgical techniques but measure the same things (outcomes) in the same way over the same period of time (follow-up). There is a need to find reliable predictive factors.
These are patient characteristics that help predict when treatment will be successful (or fail). These types of predictive values are needed for four groups: patients who are skeletally mature, patients who are skeletally immature, patients treated conservatively (without surgery), and patients who are treated with surgery.
When you add the fact that there are many different types of cartilage repair procedures and then look at all the ways these various factors can be combined, you see how complex the problem is of finding conclusive evidence. And that doesn't begin to evaluate post-operative care.
The authors conclude by suggesting that the best way to continue future research is to conduct multicenter studies. Surgeons at a number of different children's hospitals should work together to combine patient data to form larger sample sizes. If everyone gathers the same information then it is more likely that reliable results can be obtained.
Reference: Henry G. Chambers, MD, et al. Diagnosis and Treatment of Osteochondritis Dissecans. In Journal of the American Orthopaedic Surgeons. May 2011. Vol. 19. No. 5. Pp. 297-305.