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Knee Osteochondritis Dissecans: Treatment & Medication
Updated: Jul 28, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Medical Issues/Complications
Important variables affect the choice of treatment. The general rule is the younger the patient, the better the prognosis. Guidelines for treatment are outlined by the following categories:
- Category 1 (ie, girls younger than 11 y, boys younger than 13 y): These patients usually do well with nonoperative treatment.
- Category 2 (girls aged 11-15 y, boys aged 13-17 y): These patients are near skeletal maturity. Treatment depends on the looseness of the lesions.
- Category 3: Physeal closure and skeletal maturity have occurred. Treatment is based on the size and stability of the lesion.
- Grade 1 - Positive radiography findings and an intact articular surface
- Grade 2 - Articular injury noted at arthroscopy
- Grade 3 - Loose lesion (stays within crater)
- Grade 4 - Loose fragment within joint
Surgical Intervention
Arthroscopy versus open treatment
- Arthroscopy is preferred so that arthrotomy can be avoided.
- Drilling of the defect may be performed, with the hope that revascularization will occur.
- Pinning may be performed to stabilize the fragment. Stainless-steel pins usually require removal to avoid additional chondral injury. Resorbable pins can be used to avoid the need for removal; however, they may not be rigid enough or may not last long enough to allow healing.
- Excision of the fragment and removal of loose bodies may be necessary.
- Screw fixation may be performed for fragment stabilization. In this method, usually a specialized screw or Herbert-type screw is used.
- Osteochondral autograft transplantation (OATS) involves harvesting cylindrical osteochondral grafts from other areas of the knee to reconstruct a weight-bearing surface. A maximum 1-cm lesion (crater) depth is allowed for use of this treatment method.
- Osteochondral allograft transplantation is similar to OATS except that a freshly harvested allograft condyle is used. The advantages are that the exact condyle curvature can be reconstructed and no further defect is created during autograft harvest.
- Autologous chondrocyte implantation (ACI), by Carticel, requires a diagnostic arthroscopy, harvesting of a small amount of cartilage cells for cloning, and subsequent arthrotomy for reimplantation. Bone grafting of the OCD crater is often necessary prior to implantation.
Other Treatment
- In children with nondisplaced fragments, initial treatment includes limitation of activity with the use of crutches and restricted range of motion (eg, knee immobilizer, range-of-motion brace).
- Recommend a trial of nonoperative treatment for 3-6 months. If symptoms persist or failure to unite is observed, proceed with surgical treatment
Medication
Treat with pain medication and nonsteroidal anti-inflammatory drugs (NSAIDs) of choice, as indicated, to control pain, inflammation, and swelling.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who experience pain.
Acetaminophen and Codeine (Tylenol #3)
Indicated for the treatment of mild to moderate pain. Use for postoperative pain control.
Adult
30-60 mg/dose based on codeine PO q 3-6 h; not to exceed 12 tabs/24 h
Pediatric
0.5-1 mg/kg/dose based on codeine q4-6h; 10-15 mg/kg/dose based on acetaminophen content PO; not to exceed 2.6 g/d of acetaminophen
Toxicity of codeine increases with CNS depressants, TCAs, MAOIs, neuromuscular blockers, CNS depressants, phenothiazines, and narcotic analgesics; rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity of acetaminophen
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in patients dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction; hepatotoxicity with acetaminophen is possible following various dose levels in persons with chronic alcoholism; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative doses that exceed recommended maximum dose
Hydrocodone and acetaminophen (Vicodin, Lorcet-HD, Norcet)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or TCAs
Documented hypersensitivity; high-altitude cerebral edema or elevated intracranial pressure
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Tab contains metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction
Nonsteroidal anti-inflammatory drug (NSAID)
Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms also may exist, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-800 mg PO tid with food
Pediatric
10 mg/kg PO tid with food
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy
Naproxen (Naprosyn, Anaprox, Naprelan, Aleve)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Ketoprofen (Oruvail, Actron, Orudis)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
More on Knee Osteochondritis Dissecans |
| Overview: Knee Osteochondritis Dissecans |
| Differential Diagnoses & Workup: Knee Osteochondritis Dissecans |
 Treatment & Medication: Knee Osteochondritis Dissecans |
| Follow-up: Knee Osteochondritis Dissecans |
| Multimedia: Knee Osteochondritis Dissecans |
| References |
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References
Andrews JR, Timmerman LA. Diagnostic and Operative Arthroscopy. Philadelphia, Pa: Harcourt Brace & Company; 1997.
Beaty J. Orthopaedic Knowledge Update 6. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1999:506-507.
Browner BD. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Philadelphia, Pa: WB Saunders Co; 1998.
Delee JC. Orthopaedic Sports Medicine, Principles and Practice. Vol 2. Philadelphia, Pa: WB Saunders Co; 1994.
Siliski JM. Traumatic Disorders of the Knee. New York, NY: Springer-Verlag; 1994.
Further Reading
Keywords
intra-articular osteochondrosis, OCD, osteochondral fracture, articular osteochondrosis, intra-articular segmental osteonecrosis, ossification disorder, knee injury, loose body formation, knee loose body, disordered enchondral ossification, subchondral avascular necrosis
