ADULT –OCD

DR.V.CHANDAN NOEL
 Introduction
 Idiopathic disorder primarily affecting and
destabilizing the subchondral bone.
 It is most common in the knee ( mfc>lfc>pfj)
 Less commonly affects ( ankle, capitellum, hip
joint).
 Males > females
 Two types – juvenile & adult
 Etiology – no difference
 JUVENILE VS ADULT
 BASED ON THE OSSEOUS AGE OF THE PATIENT AT
ONSET OF SYMPTOMS

 JUVENILE BETTER PROGNOSIS FOR HEALING

JUVENILE OCD’S PREVIOUSLY ASYMPTOMATIC , WHICH

PRESENT AT ADULTHOOD.
PROGNOSIS

Risk of
arthritis
-80%
 EVALUATION &
DECISION MAKING
SIGNS OF INSTABILITY IN MRI
1.) LINE OF HIGH
SIGNAL INTENSITY
IN T 2

2.)SUBCHONDRAL
CYST

3.) OSTEOCHONDRAL
DEFECT

4.) SUB CHONDRAL /

OCD FRACTURING
 ROCK ARTHROSCOPY
CLASSIF``ICATION

IMMOBILE LESIONS - NO OBSERVED MOVEMENT OF

PROGENY FRAGMENT WITH RESPECT TO THE
SURROUNDING PARENT SURFACE UPON PROBING

MOBILE LESIONS -- OBSERVED MOVEMENT OF

PROGENY FRAGMENT WITH RESPECT TO THE
SURROUNDING PARENT SURFACE UPON PROBING
GROSS OCD LESION DESCRIPTION – CUE BALL

0 - No abnormalityImage
Arthroscopic detectable arthroscopically
Illustration
IMMOBILE Lesion

Need image
 1 - CARTILAGE IS INTACT AND DEMARCATED, BUT NOT MOBILE OR
BALLOTABLE WITH PROBING. THIS MAY BE SEEN BEST UNDER
GROSS OCD LESION LOW LIGHT CONDITIONS, OR TANGENTIAL VIEWS.
DESCRIPTION – Shadow
IMMOBILE LESION

Need image

Arthroscopic Image
CARTILAGE IS DEMARCATED WITH A FISSURE, BUCKLE, AND/OR WRINKLE, BUT NOT
MOBILE OR BALLOTABLE WITH PROBING (WRINKLE IN THE RUG)
IMMOBILE LESION
 GROSS OCD LESION DESCRIPTION – Trampoline
3 - CARTILAGE IS INTACT AND DEMARCATED, BUT MOBILE OR BALLOTABLE WITH
PROBING
MOBILE LESION
GROSS OCD LESION DESCRIPTION – Locked Door
4 - CARTILAGE FISSURING AT PERIPHERY, BUT UNABLE TO HINGE
MOBILE LESION
 GROSS OCD LESION DESCRIPTION – Trap Door
5 - CARTILAGE FISSURING AT PERIPHERY, WITH INTACT HINGE
(RED ARROWS)
 GROSS OCD LESION DESCRIPTION – MANHOLE COVER
6 - CIRCUMFERENTIAL FISSURING, (HIGHLIGHTED BY THE RED ARROWS) LESION IN
SITU, BUT CAN BE ENTIRELY DISPLACED WITH A PROBE.
MOBILE LESION

Need image
 GROSS OCD LESION DESCRIPTION – Crater

Need image

1 - Congruent 7 - EXPOSED SUB-CHONDRAL BONE DEFECT

2 - Incongruent CONGRUENT = FRAGMENT FITS INTO CRATER WITHOUT
3 - Fragmented MODIFICATIONS
4 - Absent INCONGRUENT = FRAGMENT FITS INTO CRATER WITH
MODIFICATIONS
Non operative treatment
 CONSERVATIVE GUIDELINES
 No clinical features of locking and catching
 Stable- Adult ocd
 Lesions < 160mm2
 Lesions in atypical locations.
 INCIDENCE OF ARTHROPLASTY

 86 PATIENTS-
TREATED
CONSERVATIVELY

 15% DEVELOPED
ARTHRITIS

 CUMULATIVE
INCIDENCE OF
ARTHROPLASTTY- 8 %
 RISK FACTORS FOR
ARTHRITIS

1. BMI > 25
2. ADULT AT DIAGNOSIS
3. PATELLAR OCD
 AAOS GUIDELINES- UNABLE TO MAKE A
RECOMMENDATION WITH CURRENT EVIDENCE

CURRENT PROTOCOL FOR CONSERVATIVE

• 3 MONTHS IN ADULTS
• LIMITED EVIDENCE FOR IMMOBILIZATION
• 4-6 WEEKS TTWB / RESTRICT FLXN IN PFJ-OCD
• ACTIVITY MODIFICATION- NO RUNNING / SPORTS
• ANTI-INFLAMMATORIES
• OFF LOADING BRACE AFTER 4-6 WEEKS
• MRI AT 12 WEEKS & TAKE A CALL
• A SINGLE HIGH-ENERGY
SHOCKWAVE - 0.35 MJ/MM

• 2500 APPLIED IMPULSES

IN GENERAL ANESTHESIA
 • Significant decrease in vas scores
• 40 % complete healing
• 30 % decreased from gr 2 to gr 1.
• 10 % lesions showed no change

ONCE AGAIN THE EVEIDENCE

IS LIMITED FOR THIS
MODALITY ALSO………..!!!!!!!
OPERATIVE
TREATMENT
 OPTIONS
 DRILLING (RETRO & ANTEGRADE)

 FRAGMENT SALVAGEABLE AND UNDISPLACED-

REFIXATION

 FRAGMENT UNSALVAGEABLE –
MICROFRACTURE
OATS ( AUTO/ALLO)
ACI
 DRILLING PERFORATE THE SUBCHONDRAL SCLEROSIS OR TO PROMOTE
BLOOD SUPPLY TO THE SUBCHONDRAL NECROTIC AREA

o STABLE ADULT VS JOCD PATIENT

o HEALING AT 2 YRS 100% IN JOCD VS 25 % IN AOCD
o RECOMMENDED TO MICROFRACTURE THE SCLEROSIS AND FIX
IT
o EXCISE THE SCLEROTIC PART AND CANCELLOUS GRAFT + RE-
FIXATION.
 22 skeletally mature knees
 Metal headless cannulated
screws
 Follow-up 9 years
 Fragment union in 82% ( 18
knees)
 18 KNEES – (STAGE II-USED
DEVICES 8 , STAGE III- 9,
STAGE IV- 1) HYBRID
6%
SCREWS
6%

 FRAGMENTDART
UNION
11%
OCCURRED ONLY IN
67%,
 33% - REMOVAL OF LOOSE FRAGMENT
PIN NAIL
17% 61%
 OUT OF 11 TREATED WITH NAILS – 2
REQUIRED REOPERATION DUE TO NAIL
BACK OUT.
NAIL-75%
PIN – 35%
 USING AN OAT PLUG TO
FIX THE UNSTABLE OCD
FRAGMENT.
 9 OF THE 20 CASES WERE
AOCD
 AVERAGE 4 GRAFTS PLUGS
REQUIRED PER LESION

16

1
 7/12 – AOCD
 GRADE IV OCD
 ORIF – METAL SCREW
 AVERAGE LESION SIZE -3.5 CM FOLLOW UP -10 YRS
UNSALVAGEABLE
 LEVEL 1 RCT
 OATS VS MICROFRACTURE @ 10 YEAR FOLLOW UP
 60 ATHELETES ( MEAN AGE – 24.5YRS)
 OAT’S- 75 % RETURN TO SPORT + MAINTAINANCE
 MF- 25 % RETURN TO SPORT + MAINTAINANCE
QUESTIONED THE ROLE OF MFX IN OCD AS THE PRIMARY
REQUISITE FOR mfx WAS AN INTACT SUBCHONDRAL PLATE.

IN CONTRAST TO OCD’S WHERE PATHOLOGY IS IN THE SUB

CHONDRAL BONE.
 MEGA OATS IN 16 PATIENTS WITH
OCD’S
 FOLLOW-UP 5 YEARS
 GOOD RESULTS IN 93.8% (15 PATIENTS)
 NO DONOR SITE MORBIDITY
 DETECTED NEWLY FORMED TISSUE
AT DONOR SITE.
OATS LESION SIZE < 6CM2
 AOCD- 33 AND JOCD-35
 LESION SIZE- 5.7CM2,
DEPTH -8MM.
 >1CM SANDWICH ACI
 >90 % HAD GOOD OR
EXCELLENT OUTCOMES
 4 FAILURES
• Follow up 2 years
Recommended forofdefect
8
patients
depths larger than 8mm
 Bone grafting of the bed
• 80 good results with no
 Suturing two layers of
complications/ stiffness
periosteum with cambial
players
• How everfacing
scopyeach
and other
 histology showuse
Alternatively moreof
fibrous
collagenand lessinhyaline
I/III bilayer
repair
fashion
PROTOCOL FOR MANAGEMENT OF OCD IN ADULTS
 KAI MITHOEFFER
AJSM-2009

RETURN TO SPORTS

MFX-66% ACI-67% OATS-91%

 TIME OF RETURN TO SPORTS

MFX-8 MO’S ACI-18 MO’S OATS-7 MO’S

 PRE-INJURY LEVEL OF SPORTS

Mfx-68% Aci-71% Oats-70%

 CONTINUED SPORTS PARTICIPATION

MFX-52% ACI-96% OATS-52%

 CONCLUSION
 OCD IN ADULTS – PREVIOUSLY ASSYMPOTMATIC LESIONS IN JUVENILES
 POOR PROGNOSIS – RISK OF OSTEOARTHROSIS- 80 %
 MORE AGGRESSIVE APPROACH TO FIXATION
 NO RELIABLE CONSERVATIVE OPTIONS
 MFX HAS NO ROLE IN THIS- AMIC ( DEBATABLE )
 ORIF AS EARLY AS POSSIBLE ( DON WAIT FOR THE LESION TO WORSEN)
 SCREWS & NAILS OFFER BETTER FRAGMENT- ROTATIONAL STABILITY THAN PINS
 BIOLOGICAL OPTIONS OF I.F – OAT PLUGS
 LESIONS UP TO 6 CM2 GO FOR OATS – MOSAICPLASTY
 LESIONS MORE THAN 6 CM2 - ACI
 DEPTH >8 MM GO FOR SANDWICH
 ATHELETES – IN SEASON (OATS- OFFERS FASTER RETURN TO PLAY) – DURABILITY
QUESTIONABLE