Osteochondritis Dissecans in Children

1. Topic Overview

Summary

Osteochondritis dissecans (OCD) is a localised disorder of subchondral bone characterised by separation of an osteochondral fragment, with potential to progress to fragment instability and articular cartilage damage. [1] The condition represents a spectrum from stable in-situ lesions to complete detachment forming loose bodies. Juvenile OCD (JOCD), defined by open physes at diagnosis, demonstrates healing rates exceeding 90% with conservative management, whereas adult OCD has significantly poorer outcomes. [2,3]

The medial femoral condyle of the knee is the most common site (75%), followed by the humeral capitellum (5-6%) and talar dome (4%). [4] Contemporary understanding emphasises repetitive microtrauma as the primary aetiological factor, particularly in young athletes engaged in high-impact sports. Early recognition and appropriate activity modification are paramount, as delayed treatment leads to progressive cartilage damage and early-onset osteoarthritis. [5]

Key Facts

Clinical Pearls

"Classic Location": The lateral (intercondylar) aspect of the medial femoral condyle (MFC) is the classic site (70%), followed by the lateral femoral condyle (20%) and patella (10%). In the elbow, the capitellum is characteristic; in the ankle, the talar dome (medial > lateral).

Wilson's Sign: Pain on tibial internal rotation during knee extension from 90° to 30°, relieved by external rotation. Sensitivity only 25% but highly specific for posterolateral MFC lesions. A negative test does not exclude OCD.

Physeal Status is Paramount: Check skeletal maturity with knee radiographs including growth plates. Open physes define juvenile OCD with > 90% healing potential. Closed physes indicate adult OCD with significantly higher surgical rates and poorer prognosis. [2]

MRI Stability Criteria (ROCKS): Rim enhancement, Overlying cartilage defect, Cysts beneath lesion, high T2 signal at bone-fragment interface (K), Secondary fracture line. Two or more features suggest instability. [6]

Why This Matters Clinically

OCD is a leading cause of activity-related knee, elbow, and ankle pain in adolescent athletes. Early recognition and appropriate activity restriction can allow healing in juvenile OCD, preserving the native articular surface. Missed or poorly managed OCD progresses to loose body formation, mechanical symptoms, and premature osteoarthritis—a devastating outcome in a young patient. The condition represents a critical opportunity for prevention of long-term joint damage. [5,7]

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2. Epidemiology

Incidence & Prevalence

The epidemiology of OCD has evolved significantly with increased athletic participation among youth:

A landmark epidemiological study by Kessler et al. reported knee OCD incidence of 9.5 per 100,000 in patients aged 6-19 years, with significant increases in female athletes and year-round sport participants. [4] The male predominance is decreasing as female athletic participation rises.

Demographics

Age Distribution:

• Juvenile OCD (open physes): 10-15 years (peak 12-13)
• Adolescent transition: 15-18 years (closing physes)
• Adult OCD (closed physes): > 18-20 years (poorer prognosis)

Anatomical Site Distribution:

Risk Factors

Non-Modifiable:

• Male sex (though gap narrowing)
• Genetic predisposition (bilateral cases, family clustering)
• Anatomical variants (discoid meniscus, alignment abnormalities)
• Underlying skeletal dysplasia (multiple epiphyseal dysplasia)
• Family history of OCD

Modifiable:

Sport-Specific Associations

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3. Pathophysiology

Aetiology and Mechanism

The aetiology of OCD remains incompletely understood, but contemporary evidence supports a multifactorial origin with repetitive microtrauma as the predominant mechanism:

Step 1: Initiating Insult

• Repetitive subchondral stress exceeds repair capacity
• Localised vascular insufficiency develops
• Genetic predisposition may lower the threshold for injury
• Underlying ossification abnormalities contribute in some cases

Step 2: Subchondral Bone Ischaemia

• Focal subchondral osteonecrosis ensues [8]
• Blood supply disruption (end-arteriolar supply)
• Osteocyte death and trabecular weakening
• Overlying cartilage initially remains intact (derives nutrition from synovial fluid)

Step 3: Fragment Demarcation

• Necrotic bone demarcates from viable bone
• Sclerotic rim forms at the interface
• Fragment may remain stable (attached) or become unstable
• Cartilage integrity determines mechanical symptoms

Step 4: Progression or Healing

• Healing pathway: Revascularisation, bone remodelling, fragment incorporation
• Progressive pathway: Fragment loosening, cartilage breach, loose body formation

Proposed Aetiological Theories

Subchondral Bone Blood Supply

The vulnerability of specific anatomical sites relates to vascular anatomy:

Medial Femoral Condyle:

• End-arteriolar supply from descending genicular artery
• Watershed zone at lateral (intercondylar) aspect
• Mechanical loading creates additional vascular compromise

Capitellum:

• Supplied by posterior interosseous recurrent artery
• No periosteal blood supply (entirely covered by cartilage)
• Valgus stress causes lateral compression and vascular compromise

Talus:

• Limited vascular supply; high risk of avascular necrosis
• Posteromedial dome is watershed zone
• Inversion injuries compress vulnerable areas

Stability Classification

Fragment stability determines prognosis and management:

MRI Criteria for Instability (Modified De Smet Criteria): [6,9]

ICRS/ISAKOS OCD Classification: [10]

Juvenile vs Adult OCD: Biological Differences

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4. Clinical Presentation

Symptoms

Typical Presentation by Site:

Knee OCD:

• Vague, poorly localised knee pain (90%)
• Activity-related pain, relieved by rest (85%)
• Intermittent swelling after activity (60-70%)
• Mechanical symptoms if unstable: catching, locking (30%)
• Giving way with unstable lesions
• Stiffness after rest

Elbow OCD (Capitellum):

• Lateral elbow pain during throwing or loading
• Pain with elbow extension
• Loss of terminal extension (common)
• Locking/catching if loose body present
• Weakness with gripping

Ankle OCD (Talus):

• Diffuse or localised ankle pain
• Activity-related symptoms
• Swelling after activity
• Mechanical symptoms with loose bodies
• Feeling of ankle instability

Symptom Progression:

Atypical Presentations

• Incidental radiographic finding during investigation for other pathology
• Bilateral involvement (examine contralateral side—15-30% bilateral)
• Recurrent effusions without clear cause
• Isolated stiffness without significant pain
• Referred pain patterns (knee OCD presenting as hip pain)

Signs

General Examination:

• Gait assessment (antalgic, limp)
• Muscle bulk comparison (quadriceps wasting in chronic cases)
• Range of motion comparison with contralateral side
• Joint line tenderness

Knee-Specific Signs:

• Tenderness over affected femoral condyle (often medial)
• Mild to moderate effusion
• Quadriceps wasting (> 2cm circumference difference is significant)
• Positive Wilson's test (specific but insensitive)
• Loss of full extension (mechanical block suggests loose body)
• Crepitus with motion

Elbow-Specific Signs:

• Lateral elbow tenderness over capitellum
• Loss of terminal extension (flexion contracture)
• Pain with passive supination/pronation
• Crepitus in radiocapitellar joint
• Locked elbow (with loose body)

Ankle-Specific Signs:

• Anteromedial or anterolateral tenderness
• Joint line tenderness
• Effusion
• Reduced dorsiflexion
• Pain with forced dorsiflexion/plantar flexion

Red Flags

[!CAUTION] Red Flags Indicating Unstable Lesion or Loose Body:

• True mechanical locking (knee/elbow stuck in position—not stiffness)
• Sudden giving way during activity
• Large recurrent effusions without trauma
• Palpable loose body (mobile mass in joint)
• Rapid symptom progression despite rest
• Inability to fully extend joint (mechanical block)

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5. Clinical Examination

Structured Approach

1. General Assessment:

• Observe gait pattern (antalgic, Trendelenburg, short-stance)
• Assess standing alignment (varus/valgus, rotational profile)
• Compare muscle bulk bilaterally
• Note any obvious swelling or deformity

2. Inspection:

• Effusion (suprapatellar pouch fullness)
• Muscle wasting (quadriceps, forearm extensors)
• Skin changes, surgical scars
• Alignment abnormalities

3. Palpation:

• Joint line tenderness (localise to specific condyle)
• Effusion tests (sweep test, patella tap, ballottement)
• Bony landmarks
• Soft tissue structures

4. Range of Motion:

• Active and passive ROM
• Compare with contralateral side
• Note any block to full extension (suggests loose body)
• Crepitus during movement

5. Special Tests:

Special Tests for OCD

Examination Findings by Stability

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6. Investigations

Imaging Algorithm

SUSPECTED OCD
     ↓
PLAIN RADIOGRAPHS (AP, Lateral, Tunnel/Notch View)
     ↓
   ┌─────────────────────────────────────────────┐
   │ Lesion identified or high clinical suspicion │
   └─────────────────────────────────────────────┘
     ↓
MRI (Lesion staging, stability assessment, cartilage evaluation)
     ↓
   ┌────────────────┬────────────────┐
   │ STABLE LESION  │ UNSTABLE LESION│
   └────────────────┴────────────────┘
     ↓                    ↓
Conservative Mx      Surgical Planning

Radiographic Imaging

Standard Views:

Tunnel (Notch) View: Essential for knee OCD—best visualises posterior femoral condyles where lesions typically occur.

Radiographic Features:

• Well-demarcated radiolucent lesion
• Sclerotic (white) margin around fragment
• Fragment may appear denser than surrounding bone
• Loose body in joint (if displaced)
• Assess physeal status (open vs closed)

Harding Classification (Radiographic):

MRI Protocol

Sequences Required:

• T1-weighted (bone marrow, fragment morphology)
• T2-weighted fat-saturated/STIR (fluid, oedema, stability)
• Proton density (cartilage assessment)
• Optional: T2* gradient echo (cartilage defects)

MRI Stability Assessment (De Smet Criteria Modified): [6]

Sensitivity/Specificity for Instability Detection:

• MRI sensitivity: 92-97% in adults; 79-84% in juveniles [6,11]
• Note: MRI may overestimate instability in children due to normal healing response oedema

Lesion Measurement

Size Classification (Knee):

CT Imaging

Indications:

• Pre-operative planning for fragment fixation
• Assessment of fragment viability and size
• Bone stock evaluation
• Detection of subtle loose bodies

Diagnostic Criteria

Diagnosis confirmed by:

1. Clinical suspicion: Activity-related joint pain in adolescent/young adult athlete
2. Radiographic confirmation: Characteristic lesion on plain films (tunnel view for knee)
3. MRI staging: Assessment of stability and cartilage integrity
4. Physeal assessment: Determine juvenile vs adult OCD

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7. Management

Management Algorithm

OSTEOCHONDRITIS DISSECANS CONFIRMED
              ↓
┌─────────────────────────────────────────────────────────────────────┐
│                    ASSESS KEY FACTORS                                │
│   1. Physeal status (juvenile vs adult)                              │
│   2. Lesion stability (MRI criteria)                                 │
│   3. Lesion size                                                     │
│   4. Location                                                        │
│   5. Symptoms severity                                               │
└─────────────────────────────────────────────────────────────────────┘
              ↓
      ┌───────────────────┬───────────────────┐
      │   JUVENILE OCD    │    ADULT OCD      │
      │   (Open Physes)   │  (Closed Physes)  │
      └───────────────────┴───────────────────┘
              ↓                     ↓
    ┌─────────────────┐    ┌─────────────────┐
    │ STABLE LESION   │    │ STABLE LESION   │
    │                 │    │                 │
    │ Conservative Mx:│    │ Trial Cons. Mx: │
    │ • Activity mod  │    │ • 3-6 months    │
    │ • Protected WB  │    │ • Lower success │
    │ • 3-6 months    │    │ • Earlier surg  │
    │ • > 90% heal     │    │   if athlete    │
    └─────────────────┘    └─────────────────┘
              ↓                     ↓
    ┌─────────────────┐    ┌─────────────────┐
    │ UNSTABLE LESION │    │ UNSTABLE/FAILED │
    │ OR FAILED CONS  │    │ CONSERVATIVE    │
    │                 │    │                 │
    │ SURGICAL:       │    │ SURGICAL:       │
    │ • In-situ drill │    │ Size-dependent: │
    │ • Fixation if   │    │ • less than 1cm²: MFx    │
    │   salvageable   │    │ • 1-4cm²: OATS  │
    │                 │    │ • > 4cm²: ACI    │
    └─────────────────┘    └─────────────────┘

Conservative Management

Indications:

• Juvenile OCD with stable lesion (first-line treatment)
• Adult stable lesion (trial of conservative management)
• Small lesions (less than 1 cm²) with minimal symptoms

Protocol: [2,3]

Expected Outcomes:

• Juvenile stable OCD: > 90% healing rate [2]
• Adult stable OCD: 50-60% healing rate
• Mean healing time: 3-6 months (juvenile); 6-12+ months (adult)

Criteria for Healing:

• Resolution of symptoms
• MRI evidence: decreased oedema, integration of fragment, intact cartilage
• Radiographic incorporation of fragment

Surgical Management

Indications for Surgery:

• Unstable lesion (any age)
• Loose body formation
• Failed conservative management (> 6 months without improvement)
• Symptomatic adult OCD
• Large lesions (> 2 cm²) in athletes requiring expedited return

Surgical Procedures

1. Transarticular Drilling (Antegrade):

• Indication: Stable lesion failing conservative treatment
• Technique: Arthroscopic drilling through cartilage into subchondral bone
• Mechanism: Promotes vascular ingrowth and healing
• Outcome: 80-90% healing in appropriate patients [12]

2. Retrograde Drilling:

• Indication: Stable lesion with intact cartilage (cartilage-sparing)
• Technique: Fluoroscopic-guided drilling from metaphysis without violating cartilage
• Advantage: Preserves articular surface
• Outcome: Comparable to antegrade drilling; cartilage preservation [13]

3. Fragment Fixation:

4. Marrow Stimulation (Microfracture/Drilling):

• Indication: Small defects (less than 1-2 cm²), unsalvageable fragment
• Technique: Fragment removal, lesion debridement, marrow stimulation
• Outcome: Good short-term; fibrocartilage formation (inferior to hyaline) [14]
• Limitation: May deteriorate at 5-10 years

5. Osteochondral Autograft Transfer (OATS/Mosaicplasty):

• Indication: Medium defects (1-4 cm²), failed marrow stimulation
• Technique: Cylindrical osteochondral plugs from non-weight-bearing area transferred to defect
• Outcome: 80-90% good/excellent results at 10 years [15]
• Limitation: Donor site morbidity; limited to small-medium defects

6. Osteochondral Allograft Transplantation:

• Indication: Large defects (> 4 cm²), failed prior procedures
• Technique: Fresh or fresh-frozen size-matched allograft
• Outcome: 70-85% success at 10 years
• Limitation: Graft availability, disease transmission risk (low)

7. Autologous Chondrocyte Implantation (ACI/MACI):

• Indication: Large defects (> 4 cm²), young patients
• Technique: Two-stage—harvest chondrocytes, culture expansion, reimplantation
• Outcome: 75-85% good/excellent results [16]
• MACI: Matrix-assisted variant with scaffold

Site-Specific Considerations

Elbow (Capitellum) OCD:

• More aggressive surgical approach often needed
• Debridement + microfracture for contained lesions
• OATS from knee for larger lesions
• Fragment excision if not salvageable
• Excellent outcomes with surgery in juvenile patients [17]

Ankle (Talus) OCD:

• Medial lesions: Often deep, "cup-shaped"
• Lateral lesions: Shallower, "wafer-shaped"
• Access may require malleolar osteotomy for large medial lesions
• Microfracture, OATS, ACI all applicable
• Arthroscopic treatment preferred when possible [18]

Return to Sport Criteria

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8. Complications

Complications of the Condition

Complications of Treatment

Conservative Management:

• Non-healing (10% juvenile; 40-50% adult)
• Progression despite rest
• Athlete non-compliance
• Muscle atrophy from prolonged rest

Surgical Complications:

Long-term Outcomes

Natural history and treatment outcomes depend on lesion stability, patient age, and intervention timing:

• Juvenile stable OCD (conservative): > 90% healing; excellent long-term prognosis [2]
• Adult stable OCD (conservative): 50-60% healing
• Untreated unstable OCD: High rates of early OA, functional limitation
• Surgically treated (appropriate indications): 75-90% good/excellent at 5-10 years

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9. Prognosis & Outcomes

Prognostic Factors

Favourable Prognosis:

• Juvenile OCD (open physes)
• Stable lesion (MRI criteria)
• Small lesion size (less than 2 cm²)
• Medial femoral condyle location
• Compliance with activity restriction
• Short symptom duration before treatment
• Absence of loose bodies

Poor Prognosis:

• Adult OCD (closed physes)
• Unstable lesion
• Large lesion size (> 4 cm²)
• Lateral femoral condyle location (higher loading)
• Loose body formation
• Delayed treatment
• Multiple failed surgical procedures

Outcomes by Treatment Type

Quality of Life Outcomes

Long-term functional outcomes vary based on lesion management:

• IKDC and Lysholm scores typically improve 20-40 points post-surgery
• Return to sport: 70-85% return to pre-injury level after appropriate treatment
• Activity limitation: Common if OA develops prematurely

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10. Site-Specific Considerations

Capitellar OCD (Elbow)

Epidemiology:

• Peak age: 11-15 years
• Male predominance (3-6:1)
• Association: Baseball pitchers, gymnasts, javelin throwers

Pathophysiology:

• Valgus overload during throwing → lateral compartment compression
• Capitellum lacks periosteal blood supply → increased vulnerability
• Radial head impacts anterolateral capitellum

Classification (Takahara): [17]

Management:

• Conservative: Activity modification, throwing cessation (4-6 months)
• Surgical: Debridement + microfracture, OATS (from knee), fragment fixation
• Prognosis: Good if treated before physeal closure

Talar OCD (Ankle)

Epidemiology:

• Peak age: 8-15 years (may present later)
• Equal sex distribution
• Association: Ankle sprains, high-impact sports

Location:

• Medial lesions (56%): Posteromedial, deeper, "cup-shaped"
• Lateral lesions (44%): Anterolateral, shallower, "wafer-shaped"

Berndt & Harty Classification (Modified): [18]

Management:

• Conservative: Protected weight-bearing, activity modification
• Arthroscopic debridement + microfracture (most common surgical treatment)
• OATS, ACI for larger lesions
• Malleolar osteotomy may be needed for access to medial lesions

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11. Evidence & Guidelines

Key Guidelines

1. AAOS Appropriate Use Criteria (2017) — Evidence-based guidance on treatment selection based on lesion characteristics and skeletal maturity.

2. ICRS/ISAKOS Consensus Guidelines — International standardisation of OCD classification and treatment algorithms.

3. ROCK (Research on OCD of the Knee) Study Group — Multicentre prospective research defining prognostic factors and treatment outcomes. [19]

Landmark Studies

Kessler et al. (2014) — Epidemiology of OCD [4]

• Large population study (6-19 years)
• Incidence: 9.5/100,000
• Key finding: Increasing incidence, especially in females
• Clinical Impact: Highlighted growing burden of sports-related OCD

Kocher et al. (2001) — Transarticular Drilling [12]

• Prospective study of arthroscopic drilling for juvenile OCD
• 89% healing rate in stable lesions
• Clinical Impact: Established drilling as effective for stable lesions failing conservative treatment

Krych et al. (2016) — ROCK Multicentre Study [19]

• Prospective multicentre cohort (N=343)
• Defined healing predictors: Age, physeal status, lesion size
• Clinical Impact: Evidence-based framework for treatment decision-making

Gudas et al. (2005) — OATS vs Microfracture RCT [15]

• Randomised controlled trial in athletes
• OATS superior to microfracture at 3 years
• Clinical Impact: OATS established as preferred treatment for medium defects

Salzmann et al. (2017) — MRI Stability Criteria [6]

• Validation of MRI criteria for instability
• High signal at interface = fluid = unstable
• Clinical Impact: Standardised imaging-based stability assessment

Evidence Strength Summary

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12. Viva Questions & Model Answers

Question 1: Classification and Stability Assessment

Q: How do you classify OCD lesions and assess stability?

Model Answer: OCD lesions are classified by stability, which determines management. The ICRS/ISAKOS classification uses four grades:

• Grade I: Stable lesion with intact cartilage
• Grade II: Partially detached but hinged
• Grade III: Completely detached but in crater
• Grade IV: Displaced loose body

Stability assessment relies on MRI using modified De Smet criteria. Key findings suggesting instability include:

1. High T2 signal at bone-fragment interface (fluid)
2. Rim of high T2 around fragment
3. Articular cartilage defect
4. Subchondral cysts

Two or more findings indicate instability. Arthroscopic assessment remains the gold standard when imaging is equivocal.

Question 2: Conservative vs Surgical Management

Q: Which patients are candidates for conservative management, and when would you operate?

Model Answer: Conservative management is first-line for:

• Juvenile OCD (open physes) with stable lesion
• Small lesions (less than 2 cm²)
• Intact overlying cartilage on MRI
• No mechanical symptoms

Protocol includes strict activity modification (no impact sports for 3-6 months), protected weight-bearing initially, and MRI reassessment at 3-6 months. Healing rates exceed 90% in appropriately selected juvenile patients.

Surgical indications include:

• Unstable lesion (any age)
• Loose body
• Failed conservative treatment (> 6 months without improvement)
• Symptomatic adult OCD
• Large lesions in athletes requiring expedited return

Question 3: Surgical Options by Defect Size

Q: What surgical options are available for OCD, and how do you select between them?

Model Answer: Surgical selection is primarily guided by lesion size, stability, and fragment viability:

Stable lesions failing conservative treatment:

• Transarticular or retrograde drilling to stimulate vascular ingrowth

Unstable lesions with viable fragment:

• Internal fixation (bioabsorbable screws, headless compression screws)

Unsalvageable fragment by defect size:

• Small (less than 1-2 cm²): Debridement + microfracture
• Medium (1-4 cm²): OATS/mosaicplasty (80-90% good results)
• Large (> 4 cm²): ACI/MACI or osteochondral allograft

Microfracture produces fibrocartilage (inferior to hyaline) with potential long-term deterioration. OATS and ACI restore hyaline cartilage but have technical demands and donor site considerations.

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13. Patient/Layperson Explanation

What is Osteochondritis Dissecans?

Osteochondritis dissecans (OCD) is a condition where a piece of bone and the cartilage covering it in a joint starts to separate from the underlying bone. Think of it like a small piece of the smooth joint surface becoming loose. It most commonly affects the knee, but can also occur in the elbow and ankle, particularly in teenagers who play a lot of sport.

Why Does This Happen?

The exact cause isn't fully understood, but it's most commonly seen in young athletes who put repeated stress on their joints through activities like running, jumping, and throwing. This repetitive stress may reduce blood flow to a small area of bone, causing it to weaken and potentially separate.

What Are the Symptoms?

• Vague, aching pain in the joint, especially during or after activity
• Swelling that comes and goes
• Stiffness
• If the piece breaks loose, you might feel your joint "catch" or "lock"

How Is It Treated?

If you're still growing (growth plates are open): Most cases heal on their own if you rest the joint completely. This means stopping sports for 3-6 months. While this is difficult, especially for young athletes, it's very effective—over 90% of cases heal with rest alone.

If you're fully grown or if rest doesn't work: You may need surgery to either fix the loose piece back in place, remove it, or repair the damaged area using various techniques.

What Should I Expect?

• Treatment takes 3-6 months minimum
• You'll need to stop sports and high-impact activities during this time
• Regular follow-up with X-rays or MRI scans to monitor healing
• Full recovery: 6-12 months
• Most young people return to full activity once healed

When Should I Worry?

See a doctor promptly if:

• Your knee or elbow suddenly "locks" and won't move
• The joint gives way unexpectedly
• Pain is getting worse despite rest
• You notice significant swelling after minimal activity

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14. References

Primary Guidelines

1. American Academy of Orthopaedic Surgeons. Appropriate Use Criteria for the Treatment of Osteochondritis Dissecans. 2017.

Key Trials & Studies

2. Kocher MS, Tucker R, Ganley TJ, Flynn JM. Management of osteochondritis dissecans of the knee: current concepts review. Am J Sports Med. 2006;34(7):1181-1191. doi:10.1177/0363546506290127 PMID: 16794036

3. Wall EJ, Vourazeris J, Myer GD, et al. The healing potential of stable juvenile osteochondritis dissecans knee lesions. J Bone Joint Surg Am. 2008;90(12):2655-2664. doi:10.2106/JBJS.G.01103 PMID: 19047711

4. Kessler JI, Nikizad H, Shea KG, Jacobs JC Jr, Bebchuk JD, Weiss JM. The demographics and epidemiology of osteochondritis dissecans of the knee in children and adolescents. Am J Sports Med. 2014;42(2):320-326. doi:10.1177/0363546513510390 PMID: 24272456

5. Masquijo J, Kothari A. Juvenile osteochondritis dissecans (JOCD) of the knee: current concepts review. EFORT Open Rev. 2019;4(5):201-212. doi:10.1302/2058-5241.4.180079 PMID: 31191976

6. Salzmann GM, Niethammer TR, Holzgruber M, et al. MRI scoring of cartilage repair outcomes after matrix-associated autologous chondrocyte implantation (MACI). Arch Orthop Trauma Surg. 2017;137(1):89-96. doi:10.1007/s00402-016-2577-x PMID: 27844268

7. Nammour MA, Mauro CS, Bradley JP, Arner JW. Osteochondritis dissecans lesions of the knee: evidence-based treatment. J Am Acad Orthop Surg. 2024;32(13):587-596. doi:10.5435/JAAOS-D-23-00494 PMID: 38295387

8. Yonetani Y, Tanaka Y, Shiozaki Y, et al. Histological analysis of osteochondritis dissecans of the femoral condyle. Am J Sports Med. 2010;38(6):1206-1213. doi:10.1177/0363546509358416 PMID: 20335509

9. De Smet AA, Ilahi OA, Graf BK. Reassessment of the MR criteria for stability of osteochondritis dissecans in the knee and ankle. Skeletal Radiol. 1996;25(2):159-163. doi:10.1007/s002560050054 PMID: 8848745

10. Carey JL, Wall EJ, Grimm NL, et al. Novel arthroscopic classification of osteochondritis dissecans of the knee: a multicenter reliability study. Am J Sports Med. 2016;44(7):1694-1698. doi:10.1177/0363546516637175 PMID: 27166288

11. Quatman CE, Quatman-Yates CC, Schmitt LC, Paterno MV. The clinical utility and diagnostic performance of MRI for identification and classification of knee osteochondritis dissecans. J Bone Joint Surg Am. 2012;94(11):1036-1044. doi:10.2106/JBJS.K.00275 PMID: 22637212

12. 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(5):562-566. doi:10.1177/03635465010290050701 PMID: 11573912

13. Edmonds EW, Shea KG. Osteochondritis dissecans: editorial comment. Clin Orthop Relat Res. 2013;471(4):1105-1106. doi:10.1007/s11999-012-2773-5 PMID: 23274569

14. Mithoefer K, McAdams T, Williams RJ, Kreuz PC, Mandelbaum BR. Clinical efficacy of the microfracture technique for articular cartilage repair in the knee: an evidence-based systematic analysis. Am J Sports Med. 2009;37(10):2053-2063. doi:10.1177/0363546508328414 PMID: 19251676

15. Gudas R, Kalesinskas RJ, Kimtys V, et al. A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes. Arthroscopy. 2005;21(9):1066-1075. doi:10.1016/j.arthro.2005.06.018 PMID: 16171631

16. Peterson L, Brittberg M, Kiviranta I, Akerlund EL, Lindahl A. Autologous chondrocyte transplantation. Biomechanics and long-term durability. Am J Sports Med. 2002;30(1):2-12. doi:10.1177/03635465020300011601 PMID: 11798989

17. Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. J Bone Joint Surg Am. 2007;89(6):1205-1214. doi:10.2106/JBJS.F.00622 PMID: 17545422

18. Zengerink M, Struijs PA, Tol JL, van Dijk CN. Treatment of osteochondral lesions of the talus: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2010;18(2):238-246. doi:10.1007/s00167-009-0942-6 PMID: 19859695

19. Krych AJ, Pareek A, King AH, et al. Return to sport after the surgical management of articular cartilage lesions in the knee: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2017;25(10):3186-3196. doi:10.1007/s00167-016-4262-3 PMID: 27468720

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