(From the January 2014 Issue of PediatricsOnline)
Conservative management of multifocal juvenile osteochondritis dissecans, a type of knee injury that often affects adolescents, may not offer the best chance of healing, according to a new study from a team at Nationwide Children’s Hospital. The findings, published in a recent issue of the Journal of Pediatric Orthopedics, suggest that in most cases, surgery increases the rate of recovery and that, contrary to conventional wisdom, a patient’s age has no effect on healing.
Osteochondritis dissecans occurs when a loss of blood supply causes a small piece of bone and cartilage to separate from the end of a bone. Although it can affect any joint, it is most commonly seen in the knees. The point of injury is called a lesion, and it can be either stable (if the piece of cartilage stays in place) or unstable (if it slips into a joint space). The cause is unknown, but some studies point to a link between the disorder and repetitive minor trauma, such as the bumps and knocks that often accompany football, hockey, soccer and other sports.
New cases of juvenile osteochondritis dissecans (JOCD) are on the rise, possibly due to increased participation in competitive athletics, says Kevin E. Klingele, MD, chief of orthopaedics at Nationwide Children’s and senior author of this new study. The exact prevalence of JOCD is unknown, with reports of between 15 and 29 cases per 100,000 people.
Dr. Klingele and his colleagues were particularly interested in multifocal JOCD, which occurs when a patient has more than one lesion in the same knee or lesions in both knees. To determine whether one treatment strategy was more effective than another, the team examined 28 patients with multifocal JOCD. The patients had a total of 59 lesions, the majority of which were located on the medial femoral condyle (MFC), found at the base of the femur, or on the lateral femoral condyle (LFC), on the outer side of the lower extremity of the femur.
The team found that MFC lesions were more likely to be stable and also more likely to heal. LFC lesions, which are less common, were more likely to be unstable, which may have contributed to their lower rate of healing.
“The study verified what I had thought from treating these kids clinically, that children who had more than one lesion or lesions in atypical areas don’t tend to do as well,” Dr. Klingele says. “We usually treat these patients more aggressively, and these findings suggest that is, indeed, the best course of action.”
The study did yield one surprising finding about the rate of healing and patients’ ages, Dr. Klingele notes.
“We always felt that the younger patients were more likely to heal quickly with or without surgery, but surprisingly, our study found no significant effect of age on the healing process,” he says. “This could mean that there is some form of etiology behind these injuries that we don’t yet understand.”
Dr. Klingele’s team plans to study this question and other issues in JOCD, with the goal of creating a clearer picture of the disorder and its treatments.
“We hope the work increases awareness of a very common problem and that you will seek treatment quickly if you have a child who has chronic or intermittent pain that is activity-limiting or who has occasional swelling of the knee,” Dr. Klingele says. “Hopefully, we will start catching these kids a little earlier.”
Backes JR, Durbin TC, Bentley JC, Klingele KE. Multifocal juvenile osteochondritis dissecans of the knee: A case series. Journal of Pediatric Orthopedics. 2013 Nov 16. [Epub ahead of print]