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In situ fixation of a medial osteochondral lesion in stable juvenile osteochondritis dissecans of the knee after arthroscopic retroarticular drilling failed: Case report

Nobuyuki Kumahashi, Yuji Uchio, Masamichi Shimura, Suguru Kuwata
Department of Orthopedics, Shimane University School of Medicine,Japan

Address for Correspondence:
N. Kumahashi
Department of Orthopedics, Shimane University School of Medicine,
89-1 Enya-cho, Izumo-shi, Shimane 693-8501, Japan

Fax    : +81-853-20-2236


We report a successful in situ fixation procedure for the medial condyle in juvenile osteochondritis dissecans (OCD) of the knee after arthroscopic retroarticular drilling failed.  Our patient was a 13-year-old boy who felt right knee pain for six months while playing baseball.  Plain radiographs and computed tomography (CT) showed a 20 mm ´ 25 mm radiolucent zone in his medial condyle and magnetic resonance imaging (MRI) showed abnormal intensity in the same region.  We diagnosed OCD and no separation from cartilage was seen under arthroscopy following retroarticular drilling with K-wire, after conservative treatment for six months had failed.  After transient disappearance of the knee pain, it persisted for eight months after the first drilling.  Plain radiographs and CT showed a discrepancy in a fragment from the subchondral bone.  No separation was identified arthroscopically and an 8.5 mm osteochondral graft was harvested from the center of the lesion and reimplanted in its original position after drilling sclerotic bone marrow.  The patient’s knee pain disappeared in two months and union was attained one year after the second surgery.  This case shows the limitation of retroarticular drilling for large lesions and in situ fixation of stable osteochondral lesions without any other osteochondral harvest as an effective treatment option.

J.Orthopaedics 2009;6(3)e11


Osteochondritis dissecans; Knee, Retroarticular Drilling; in situ fixation



Osteochondritis dissecans (OCD) of the femoral condyle is seen with increased frequency in adolescents and young adult patients.  It may respond to conservative treatment such as immobilization, restriction of weight bearing and sports activity; however, some cases require surgery.  Surgical treatment includes drilling 1,2,3,4, fixation 5, meniscus transplantation 6, osteochondral allogeneic or autologous graft 7, and chondrocyte implantation 8.

Retroarticular drilling without bone grafting for OCD is less invasive and an effective surgical treatment 1. However, it demands skill and may not effect bone union, the exact rate of which remains unknown.  Furthermore, a reliable method for reoperating in cases of non-union has not yet been established.  We present the successful in situ fixation of a medial osteochondral lesion without any other graft harvest in stable juvenile OCD of the knee after retroarticular drilling failed.

Case report:
A 13-year-old boy presented at our outpatient clinic with a six-month history of right knee pain when playing baseball.  He had no swelling; ballottement and tenderness of the medial condyle were recognized.  Range of motion was 120° flexion and 0° extension.  McMurray’s test was negative and Wilson’s test was positive.  Radiography indicated a radiolucent zone in the medial condyle classified as an extended type of Aichroth’s classical site.  CT showed a 20 mm ´ 25 mm ´ 10 mm osteolytic lesion in the medial condyle (Fig. 1a).  MRI showed both a low and isointensity area in T2-weighted images (Fig. 1b).  The lesion was classified as Nelson grade 1.  We diagnosed our patient with OCD of the medial femoral condyle and treated him conservatively, restricting sports activity for six months.  Pain did not respond to conservative treatment and a standard arthroscopy was performed through the medial and lateral infrapatellar approach.  The preoperative Lysholm score was 66 points.  The cartilage of the medial condyle showed a 15 mm ´ 20 mm softened area, which showed 0–30° of weight-bearing area by probing, and was not separated from the subchondral bone.  Four retroarticular drillings to the lesion from the medial epicondylar with 1.5 mm K-wire were performed under arthroscopy using an image intensifier so as not to penetrate the cartilage and open physis (Fig. 1c).  Continuous passive motion was begun one week postoperatively.  Partial weight bearing was allowed at two weeks and full weight bearing at six weeks.  Pain was decreased one month postoperatively and MRI showed communication between the lesion and bone marrow.  However, the patient’s pain had not disappeared completely and was increased during light exercise.  Radiography showed separation from the subchondral bone eight months after surgery.  CT also detected the discrimination from subchondral bone at twenty-two months (Fig. 1d).  MRI indicated the intensity was decreased, but that union had not been attained.  We decided to reoperate.  During the arthroscopy, cartilage of the lesion showed softening in the same area as previously, but with no apparent damage or separation (Fig. 2a).  An arthrotomy was performed using a medial approach and a medial condyle lesion was identified.  Superficial cartilage of the lesion was indicated using a purple marker and only an 8.5 mm width and 10 mm length from center of the lesion was harvested using a mosaic plasty guide without any other graft harvest (Fig. 2b).  Multiple drillings made in the sclerotic bone marrow area with 1.5 mm or 2.0 mm K-wire.  After identifying bleeding from the bone marrow, the harvested osteochondral graft was reimplanted in the same position using the marker line for guidance without any fresh bone grafting.  Arthroscopy showed no step off around the intact cartilage (Fig. 2c).  Continuous passive motion was started one week postoperatively.  Partial weight bearing was allowed at two weeks and full weight bearing at four weeks.  The patient’s knee pain disappeared completely within two months and he returned to full sports activity.  He displayed a full range of motion and no tenderness at final follow-up.  Radiography showed a complete union and MRI indicated almost the same intensity around the intact area one year postoperatively (Fig. 2d).  The Lysholm score was 100 points at one year after the second operation.

Figure 1. (a) Preoperative CT, saggital view.  Black arrows indicate the lesion. (b) Preoperative MRI, saggital view (T2-weighted image).  Black arrows indicate the lesion. (c) Screen display as seen intraoperatively during drilling showing four extraarticular drillings with 1.5 mm K-wire so as not to damage either the cartilage or epiphysis. (d) Postoperative CT, saggital view.  Discrimination of the fragment is clear.

Figure 2. (a) Arthroscopic findings of the 15 mm ´ 20 mm softening lesion with 0–30° partial weighting area. (b) Harvested 8.5 mm osteochondral graft with purple marking.  Black arrows indicate the purple marking. (c) Arthroscopic findings of osteochondral graft implantation in bone marrow following the purple line.  Black arrows indicate the purple marking.  No step off is seen after reimplantation of the osteochondral graft. (d) Postoperative MRI, saggital view (T2-weighted image).

Surgical treatment for OCD has been reported 1,2,3,4,5,6,7,8.  In particular, the effect of arthroscopic drilling for OCD remains controversial.  Antegrade 2,4 or retrograde drilling 1,3 are effective ways to stabilize juvenile OCD.  Antegrade drilling for juvenile OCD is easy and specific to the lesion; however, it can cause cartilage damage.  Once cartilage damage has occurred, it is weakened by shearing stress, and degenerative osteoarthritis may follow.  Extraarticular drilling for OCD was reported by Kawasaki and all 16 lesions were perfectly joined at a mean of 4 postoperative months as determined radiographically 3.  Adachi reported the outcome of stable juvenile OCD of the knee with retroarticular drilling without bone grafting, 16 of which were performed from the epicondyle area 1.  The unhealed rate was 5% (1/20) in that study.  This method is technically demanding to avoid penetration of the cartilage layer and open epiphysis.  In particular, the direction from the cartilage layer to epiphyseal line is limited when drilling the lesion and delayed or non-union may occur.

In contrast, Jürgensen concluded that the rates of remission and progression were not significantly effective between conservative and arthroscopic treatment as evaluated by MRI 9.  We treated our 13-year-old patient with stable OCD by retroarticular drilling; however, a union was not attained.  Two reasons why union was not attained in our patient were considered.  One was the size of the lesion. Anderson reported four cases of non-union in twenty-four cases after antegrade drilling 2.  Two were cases in which the epiphyseal line was not closed and in which the lesions were 2 cm ´ 3 cm and 2.5 cm, respectively.  The lesion size in our patient was 2 cm ´ 2.5 cm ´ 1 cm and this may have been a limitation for extraarticular drilling.  The other cause is the timing of the closure of the epiphyseal line.  On the first drilling, the epiphyseal line was not closed; however, it might have been closed by the second operation.  The gap between the first and second operations was almost two years and the biological healing capacity could have been reduced gradually during this time.

In cases where a large area is affected as in this case, it is not clear what diameter of in situ osteochondral graft is appropriate to unite bone.  The lager the graft selected, the wider the remaining lesion.  The dimension of the 8.5 mm graft was one-sixth of that of the entire lesion in this case and only this size could be used to attain union.  Further study is needed to determine the appropriate graft size for lesions to attain union in the OCD.  This finding is interesting in terms of OCD etiology.

This case is an example of the limitations of retroarticular drilling and the use of osteochondral in situ fixation without any other graft harvest as an option in case of retrograde drilling failure.  This method might be a useful alternative in cases of stable OCD in which the size of the lesion is large and there is closure of the epiphyseal line.

Reference :

  1. Adachi N, Deie M, Nakamae A et al. Functional and radiographic outcome of stable juvenile osteochondritis dissecans of the knee treated with retroarticular drilling without bone grafting. Arthroscopy 2009;52:145–152.

  2. Anderson AF, Richards DB, Pagnani MJ et al. Antegrade drilling for osteochondritis dissecans Arthroscopy 1997;13:319–324.

  3. Kawasaki K, Uchio Y, Adachi N et al. Drilling from the intercondylar area for the treatment of osteochondritis dissecans of the knee. Knee 2003;10:257–263.

  4. Kocher MS, Micheli LJ, Yaniv M et al. Functional and radiographic outcome of juvenile osteochondritis dissecans of the knee treated with transarticular arthroscopic drilling Am J Sports Med 2001;29:562–566.

  5. Victoroff BN, Marcus RE, Deutsch A. Arthroscopic bone peg fixation in the treatment of osteochondritis dissecans in the knee. Arthroscopy 1996;12:506–509.

  6. Deie M, Sumen Y, Adachi N et al. The long-term results of meniscus transplantation for articular cartilage defects in the knee joint. Knee Surg Sports Traumatol Arthrosc 2007;15:61–66.

  7. Emmerson BC, Görtz S, Jamali AA et al. Fresh osteochondral allografting in the treatment of osteochondritis dissecans of the femoral condyle. Am J Sports Med 2007;35:907–914.

  8. Ochi M, Uchio Y, Kawasaki K et al. Transplantation of cartilage-like tissue made by tissue engineering in the treatment of cartilage defects of the knee. J Bone Joint Surg [Br] 2002;84:571–578.

  9. Jürgensen I, Bachmann G, Schleicher J et al. Arthroscopic versus conservative treatment of osteochondritis dissecans of the knee: value of magnetic resonance imaging in therapy planning and follow-up. Arthroscopy 2002;18:378–386.


This is a peer reviewed paper 

Please cite as: N. Kumahashi: In situ fixation of a medial osteochondral lesion in stable juvenile osteochondritis dissecans of the knee after arthroscopic retroarticular drilling failed: Case report

J.Orthopaedics 2009;6(3)e11





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