In this article, we will discuss a case of multiple OCDs.
OCD (Osteochondritis Dissecans) is a condition that is difficult to imagine occurring simultaneously.
Since OCD itself is a common clinical condition, I will introduce some of the more rare cases.
What is Discrete Osteochondritis?
Discrete osteochondritis (OCD) is a disorder that affects the subchondral bone and can cause separation of cartilage and bone fragments as it progresses.
The exact etiology of the disease is unknown, although it is known to occur more frequently in men than in women.
Several theories have been proposed, including trauma, genetics, inflammation, nutritional imbalance, and vascular abnormalities.
Cases
A 15-year-old boy.
He was referred to the author's hospital after failing conservative treatment for an OCD lesion of the left knee.
He came to the orthopedic department 3 months ago and complained of pain in his left knee during sports activities such as baseball.
At the time of her first visit, her height was 150 cm, which was below the -2 standard deviation of the Japanese average for the same age, and her body mass index was 22. The patient's father was also short (153 cm, -3.1 SD), had a history of OCD in both knees, and was surgically treated as an adult.
There is no other family history.
There is no swelling or tenderness in the boy's knee joints.
Furthermore, physical examination did not reveal any abnormalities in range of motion or joint laxity and stability.
The boy was pain free during normal daily activities, including physical education (PE) at school.
According to Brueckl, OCD of the medial femoral condyle (MFC) was detected radiographically and classified as stage III.The lesion was confirmed by magnetic resonance imaging of the left knee, which was classified as stage II according to Nelson's classification.
Despite 3 months of incidental treatment, the radiographic findings of the lesion progressed to stage IV according to Brückl's classification.
Since the patient was asymptomatic at the time of referral, she was treated conservatively for another 3 months, but there was no improvement in the radiographic findings.
Therefore, we decided to perform surgical treatment.
Surgical treatment consisted of arthroscopic examination and probing identified the lesion as there was a tear in the margin of the lesion.The cartilage was slightly elevated, but not completely separated from the subchondral bone.
The size of the lesion was 10 mm wide and 24 mm long.
Arthroscopic drilling with 1.6 mm Kirschner steel wire was performed from the surface of the MFC lesion to create 10 penetrating holes deep enough to reach the subchondral bone beneath the lesion with the goal of inducing bleeding from the bone marrow to promote healing.
The lesion was confirmed by radiographs to have achieved bony union three months after the surgery, and sports activities were permitted.
Her postoperative course was good until she fell and hit her left anterior knee one year and four months after surgery.
X-rays taken immediately after this injury did not show any abnormal findings.
As the patient began to feel pain on running and developed locking of the knee joint, another X-ray was taken one month after the injury, which showed no abnormal findings, and conservative treatment was given.
Four months after the injury, the knee locked more frequently, knee pain due to flexion and swelling of the knee joint became evident and another X-ray was performed.
An MRI scan confirmed the lesion, as radiography detected a defect on the lateral aspect of the femoral pulley that had been normal on the previous MRI.
The lesion was diagnosed as OCD in the femoral pulley (radiographs showed Brückl's classification stage V, MRI showed Nelson's classification stage IV) and no kissing lesion was identified in the patella.
The osteochondral fragment was treated surgically by fixation to the bed with four biodegradable pins.
The fragment was stabilized by computed tomography and MRI scans, and the patient was able to return to sports activities four months after surgery.
One month after his return to sports (5 months after the fragment fixation surgery), the patient returned to the hospital complaining of pain in the contralateral knee during sports activities, but without any obvious history of injury.
X-rays and MRI scan were performed on his right knee, which revealed an OCD lesion on the lateral aspect of the glenoid with Brückl's classification stage II and Nelson's classification stage I OCD.
The lesion was carefully monitored and remained stable without further restriction of physical activity.
However, the lesion became unstable 17 months after its initial detection, and the patient underwent open revision and internal fixation surgery under spinal subarachnoid anesthesia.
The fragments were found to have united by 3 months after surgery.
Takeda T, Akagi R, Sato Y, et al. Multiple Osteochondritis Dissecans in Multiple Joints. Case Rep Orthop. 2021;2021:8828687. Published 2021 Jan 28. doi: Published 2021 Jan 28. doi: 10.1155/2021/8828687
Conclusion
This was a case of OCD that was treated for a long time.
The lesion was not detected in the early stages and was treated surgically, but the OCD recurred later due to trauma.In my clinical experience, it was difficult to detect OCD, so I tried to consider the possibility based on tender points and range of motion tests.
I have seen only three cases of OCD, but unlike this case, they have resolved with conservative treatment.
From this case, I learned that if there is a family history of short stature, it is necessary to perform MRI of the joints.
