Osteochondritis Dissecans Imaging

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Osteochondritis dissecans (OCD) is a term for osteochondral fracture. An osteochondral fragment may be present in situ, incompletely detached, or completely detached. A completely detached fragment is a loose body (see the images below). ^[1]

OCD is limited to the articular epiphysis. Articular epiphyses fail as a result of compression. Both trauma and ischemia probably are involved in the pathology. Trauma is most likely the primary insult, with ischemia as secondary injury. ^{[2, 3]}

Trauma may be direct, such as impaction fracture, or repetitive microtrauma, such as excessive normal compressive stress. ^{[2, 3]} The pathology of OCD may be described in 3 stages.

In the first stage (acute injury), thickened and edematous intra-articular and periarticular soft tissues are observed. Often, the adjacent metaphysis reveals mild osteoporosis resulting from active hyperemia of the metaphysis.

In the second stage, the epiphysis reveals an irregular contour and a thinning of the subcortical zone of rarefaction. On radiography, the epiphysis may demonstrate fragmentation. Blood vessels within the epiphysis are incompetent because of thrombosis or microfractures of the trabeculae, which results in poor healing.

The third stage is the period of repair in which granulation tissue gradually replaces the necrotic tissue. Necrotic bone may lose its structural support, which results in compression and flattening of the articular surface.

Injury of the articular cartilage allows an influx of synovial fluid into the epiphysis, creating a subchondral cyst (see the images below). The subchondral cyst and increased joint pressure may prevent healing.

In the knee joint, the medial femoral condyle is the most commonly involved site. Potential locations are the lateral aspect of the medial femoral condyle (75%), the weightbearing surface of the medial (10%) and lateral femoral condyles (10%), and the anterior intercondylar groove or patella (5%). Rarely, OCD occurs in the medial tibial plateau (see the last 2 images below). ^{[4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16]}

See the images of OCD of the knee below.

In the elbow joint, the most common site of OCD occurs in the anterolateral aspect of the capitellum. Singer and Roy proposed that repeated valgus stress and a tenuous blood supply within the capitellum explain the frequent occurrence of OCD in this location. ^[17] In a cadaveric study of the articular surfaces of the radiocapitellar joint, Schenck et al demonstrated significant topographic differences in the mechanical properties and thickness of cartilage in the capitellum and radial head. ^[18] Disparity in the mechanical properties of the central radial head and lateral capitellum probably is a factor in the initiation and localization of OCD of the capitellum (see the images below). ^{[19, 20]}

In the ankle joint, OCD occurs more frequently in the talus (see the first 9 images below) than in the tibial plafond (see the final four images below) and is 4-14 times more common. ^{[21, 22]} Disparity in frequency results from the biomechanical topography of the human ankle cartilage, since tibial cartilage is stiffer than talar cartilage. The usual sites of OCD of the talar dome are the posteromedial aspect (56%) and the anterolateral aspect (44%) of the talus. Occasionally, mirror-image osteochondral defects of the talus and distal tibia occur, suggesting trauma as a potential cause of both lesions. ^{[5, 23, 24, 25, 26, 27, 28, 29]}

Occasionally, OCD of the tarsal navicular (see the images below) is seen on ankle radiographs. Osteochondral fracture of the tarsal navicular is not as rare as previously reported in the radiologic literature. Radiographic findings can be subtle and, in some patients, may mimic Mueller-Weiss syndrome or stress fracture of the tarsal navicular. CT or MRI helps confirm the diagnosis. OCD of the tarsal navicular is limited to the proximal articular surface. Tarsal navicular OCD does not demonstrate the classic radiographic appearance of Mueller-Weiss syndrome, which includes comma-shaped deformity of the navicular resulting from collapse of the lateral portion of the bone, bipartite navicular resulting from fracture, or protrusion of portions of the bone or the entire navicular bone, medially or dorsally. In addition, tarsal OCD does not demonstrate either partial or complete sagittal fracture line on CT or MRI. ^[30]

In the hip joint, OCD occurs overwhelmingly in the femoral capital epiphysis. Only case reports exist of patients with OCD of the acetabulum. Many patients with OCD of the femoral capital epiphysis have a prior history of Legg-Calve-Perthes Disease. OCD is observed in approximately 3% of adults who had Legg-Calvé-Perthes disease as children. However, this complication cannot be predicted during the early stages of the Legg-Calvé-Perthes process and may present years later. ^{[25, 31, 32, 33, 34]}

OCD rarely occurs in the shoulder joint, where it involves either the humeral head or the glenoid. Only 7 patients with OCD of the humeral head have been reported. All of the patients were men, ranging from age 12-44 years. Five of the patients (71%) demonstrated lesions in the right shoulder, suggesting an association with right-handedness. Locations of involvement were the anterosuperior, posterosuperior, posteromedial, superior, and medio-inferior aspects of the humeral head. ^{[35, 36, 37, 38]}

OCD of the glenoid is best detected on MRI. A developmental defect of the glenoid is a normal variant that may be mistaken for OCD of the glenoid (see the first two images below). Developmental defect of the glenoid is a small focal defect within the center of the glenoid and without associated subchondral bone marrow edema. OCD of the glenoid usually is a much larger and eccentrically located lesion (see the last four images below).

OCD of the wrist joint is rare and primarily occurs in the scaphoid. It may occur in either the distal or proximal pole and in either the distal or proximal articular surface of the scaphoid and may be bilateral. OCD of the scaphoid has been observed in bakers, boxers, pelota players, acrobats, and pneumatic drill workers, all of whom are subjected to repeated minor trauma of the wrist. One report of OCD of the distal radioulnar joint exists. ^{[39, 40, 41, 42]}

Staging classifications of osteochondral lesions have been described best in the talus. Arthroscopic classifications of osteochondral lesions are the criterion standard. Two arthroscopic classifications of osteochondral lesions of the talus are reported. Both surgical classifications are based on the appearance of the overlying articular cartilage as seen on arthroscopy

The Pritsch arthroscopic staging of osteochondral lesions of the talus is as follows ^[43] :

Grade I – Intact, firm, shiny articular cartilage

Grade II – Intact but soft articular cartilage

Grade III – Frayed articular cartilage

The Cheng arthroscopic staging of osteochondral lesions of the talus is as follows ^[44] :

Grade A – Articular cartilage is smooth and intact but may be soft or ballottable

Grade B – Articular cartilage has a rough surface

Grade C – Articular cartilage has fibrillations or fissures

Grade D – Articular cartilage with a flap or exposed bone

Grade E – Loose, nondisplaced osteochondral fragment

Grade F – Displaced osteochondral fragment

Radiographic findings correspond with arthroscopic staging in 56% of patients, because fibrosis may provide stability in osseous separation. MRI correlates best with surgical staging.

Differentials include the following:

On conventional radiographs, osteochondral lesions may appear normal. When detectable, osteochondral lesions appear as lucencies in the articular epiphysis. Osteochondritis dissecans is suggested by a loss of the sharp cortical line of the articular surface (see the images below). ^{[5, 20, 45, 16]}

The Berndt and Harty radiographic classification of osteochondral lesions of the talus is as follows ^[46] :

Stage I – Normal radiograph (subchondral compression fracture of the talus with no ligamentous sprain)

Stage II – Partially detached osteochondral fragment

Stage III – Complete, nondisplaced fracture remaining within the bony crater

Stage IV – Detached, loose osteochondral fragment

In the ankle joint, helical CT has multiplanar capability. CT is obtained in the direct axial and coronal planes at 1.5-mm slice thickness with sagittal reformations (see the images below). Cystic lesion of the talar dome, cortical depression, or a loose bony fragment within the osteochondral defect may be demonstrated.

The Ferkel and Sgaglione CT classification of osteochondral lesions of the talus is as follows ^[25] :

Stage I – Cystic lesion of the talar dome with an intact roof

Stage IIa – Cystic lesion with communication to the talar dome surface

Stage IIb – Open articular surface lesion with an overlying, nondisplaced fragment

Stage III – Nondisplaced lesion with lucency

Stage IV – Displaced osteochondral fragment

MRI detects radiographically occult lesions that also may not be evident on CT (see the images below). A short tau-inversion recovery sequence is the most sensitive. ^{[5, 19, 47, 48, 49]}

The Anderson MRI classification of osteochondral lesions of the talus is as follows ^[50] :

Stage I – Bone marrow edema (subchondral trabecular compression; radiograph results are negative with positive bone-scan findings)

Stage IIa – Subchondral cyst

Stage IIb – Incomplete separation of the osteochondral fragment

Stage III – Fluid around an undetached, undisplaced osteochondral fragment

Stage IV – Displaced osteochondral fragment

Kijowski et al retrospectively compared the sensitivity and specificity of previously described MRI criteria for the detection of instability in patients with juvenile or adult osteochondritis dissecans of the knee, with arthroscopic findings as the reference standard. The authors concluded from their findings that previously described MR imaging criteria for OCD instability have high specificity for adult but not juvenile lesions of the knee. ^[51]

Separately, previously described MRI criteria for detection of OCD instability were 0-88% sensitive and 21-100% specific for juvenile OCD lesions and 27-54% sensitive and 100% specific for adult OCD lesions. When used together, the criteria were 100% sensitive and 11% specific for instability in juvenile OCD lesions and 100% sensitive and 100% specific for instability in adult OCD lesions. ^[51]

Griffith MRI classification of osteochondral lesions of the talus, showing the grade description of osteochondral lesions, is as follows ^[52] :

Grade 1a – Bone marrow change (edema, cystic change) with no collapse of subchondral bone area and no osteochondral junction separation and intact cartilage

Grade 1b – Similar to grade 1a, although with cartilage fracture

Grade 2a – Variable collapse of subchondral bone area with osteochondral separation through intact cartilage

Grade 2b – Similar to grade 2a, although with cartilage fracture

Grade 3a – Variable collapse of subchondral bone area with no osteochondral separation with or without variable cartilage hypertrophy

Grade 3b – Similar to grade 3a, although with cartilage fracture

Grade 4a – Separation within or at edge of bone component, with intact overlying cartilage

Grade 4b – Similar to grade 4a, although with cartilage fracture; unstable lesion, with level of instability related to extent of cartilage fracture

Grade 5 – Complete detachment of osteochondral lesion; unstable lesion

Grades 2b, 4b, and 5 are classified as unstable lesions of variable severity.

Sonography has been used to evaluate osteochondritis dissecans of the knee and humeral capitellum (see the images below). The advantage of sonography is dynamic scanning with motion of the evaluated joint. In one study, sonographic assessment of OCD of the humeral capitellum agreed with radiographic assessment in 23 of 27 patients (85%), MRI assessment in 9 of 10 (90%), and surgical findings in 14 of 15 (93%).’

The sonographic appearance of OCD of the capitellum is as follows:

Stable – Localized, subchondral bony flattening and normal articular surface

Stable – Lesion with nondisplaced osteochondral fragment

Unstable – Capitellar osteochondral defect with loose intra-articular fragment

Unstable – Lesion with slightly displaced osteochondral fragment

Scintigraphic findings are nonspecific, demonstrating a mild-to-marked increase in focal uptake in the involved bone, depending on the age of the osteochondritis dissecans. Dynamic bone scintigraphy is twice as sensitive as static scintigraphy in the detection of OCD of the femoral condyles. The scintigraphic appearance is probably a result of the slow repair process around an OCD, involving only the bone tissue surrounding the lesion, and is not a result of the OCD itself. ^{[7, 53]}

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[Guideline] Griffith JF, Lau DT, Yeung DK, Wong MW. High-resolution MR imaging of talar osteochondral lesions with new classification. Skeletal Radiol. 2012 Apr. 41(4):387-99. [Medline].

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Liem T Bui-Mansfield, MD Adjunct Professor, Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Consulting Physician, Department of Radiology, Brooke Army Medical Center

Liem T Bui-Mansfield, MD is a member of the following medical societies: American Roentgen Ray Society, International Skeletal Society, Radiological Society of North America, Society of Skeletal Radiology

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Javier Beltran, MD Chair, Department of Radiology, Maimonides Medical Center

Disclosure: Nothing to disclose.

Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine

Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America

Disclosure: Nothing to disclose.

Leon Lenchik, MD Program Director and Associate Professor of Radiologic Sciences-Radiology, Wake Forest University Baptist Medical Center

Leon Lenchik, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America

Disclosure: Nothing to disclose.

Osteochondritis Dissecans Imaging

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