This 14-year-old male football player presented with a three-month history of increasing medial knee pain. The pain is worse with activity and improved with rest. He reported noticing that his knee has been swollen after football.
On examination the player had a loss of knee flexion, a moderate effusion and had localised tenderness over the medial joint line.
This notch X-ray image shows a massive osteochondral injury involving the medial femoral condyle. This lesion is not visualised as well on the standard AP view.
The MRI images demonstrate a huge osteochondral abnormality involving most of the weight-bearing surface of the medial femoral condyle. There is a large osteochondral fragment in situ which has an AP measurement of 3 cm and transverse measurement of 2.3cm. This fragment is partially, but not completely, demarcated from medial femoral condyle by a fluid signal rim. There is also contiguous cystic change and striking marrow oedema. There appears to be a continuous layer of articular cartilage over the surface of the fragment with no clear-cut, transchondral, defect or fluid left to confirm instability.
This player was treated with an arthroscopy. At the time of surgery the osteochondral fragment was found to be in place and was large enough to be reduced and repaired. The player did well post-operatively. After a careful conversation with the player and their parents he was able to return to football at about five months post-surgery. The potential long-term impact on the player’s knee was clearly outlined.
OCD is a condition that affects the subchondral bone and potentially the overlying articular cartilage. The cause of this condition is unknown and is likely the result of a combination of trauma, microvascular compromise and other predisposing factors. The most commonly affected site is the lateral aspect of the medial femoral condyle.
Subchondral bone is first affected. As the condition progresses, there can be a change in the overlying articular cartilage. While the abnormal area may revascularise and heal, it can become increasingly well demarcated from the surrounding bone causing loosening, separation and displacement of the fragment. This can be a major issue causing pain, swelling and mechanical symptoms.
Children and adolescents need specialised orthopaedic treatment. The outcomes are dictated by the location and extent of the osseous and cartilage lesion (fragment size, stability, location, and separation). The age of the patient – and whether the physes are open or closed – are important considerations. It is important to emphasise to the player that returning to change of direction sports (like football) may not be good for the health of the knee in the longer term.
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