Osteochondral defects

Definition
Focal areas of articular damage with cartilage damage and injury of the adjacent subchondral
bone. It is a term that encompasses osteochondritis dissecans and is used synonymously with
osteochondral injury/defect in the pediatric population.
The recognized sites of osteochondral defects are:

femoral condyle (most common)

humeral head

talus

capitellum of the elbow

Pathology
Causes

osteochondritis dissecans
o

thought to be due to repeated microtrauma

avascular necrosis

Macro trauma.

post-surgical (e.g. following ACL repair)

Staging
Osteochondral injuries are graded according to the stability and location of the fragment and
presence of secondary degenerative changes

Radiographic features
Plain radiograph and CT
Both x-rays and CT are able to detect displaced defects with ease. However, they are insensitive
in grading lower stage lesions and are inadequate in predicting stability.
MRI
MRI is the modality of choice, with high sensitivity and specificity for the detection of separation
of the osteochondral fragment (see: osteochondral injury staging and osteochondritis dissecans
surgical staging). This is essential in determining management.

T1
o

signal is variable with intermediate to low signal adjacent to fragment and

variable fragment signal

high signal line (rim sign) demarcating fragment from bone usually indicates an
unstable lesion however false positives can result from oedema

low signal loose bodies, outlined by high signal fluid

donor defect filled with high signal fluid

high signal subchondral cysts

T2

Osteochondral injury staging system

MRI attempts to grade the stability and severity of osteochondral injury and is used to plan
management.

stage I
o

injury limited to articular cartilage

MRI findings: subchondral oedema

x-ray findings: none

stage II
o

cartilage injury with associated subchondral fracture but without detachment

thin sclerotic margin

x-ray findings: usually none; may see fracture as sclerotic or osteopaenic area

two subtypes 2,3

type A: cystic on CT and/or oedema on MRI

type B: non-displaced and incompletely undercut by fluid (MR) or

lucency (CT), with an open connection to the articular cartilage
(essentially 2a without oedema on MRI)

stage III
o

detached, nondisplaced fragment

MRI findings: high signal around osteochondral fracture (rim sign) but not
displaced

x-ray findings: slight lucency between osteochondral fragment and remainder of

the bone

stage IV
o

osteochondral fragment displaced

usually joint effusion present, surrounding fragment and filling donor site

x-ray findings: increased lucency between osteochondral fragment and

remainder of the bone, or loose body with donor site irregularity

stage V
o

subchondral cyst formation

secondary degenerative change

x-ray findings: secondary osteoarthritis

Treatment and prognosis

Treatment depends on the location and size of the defect as well as presence of secondary
degenerative changes. When the latter is present, then joint replacement is often the only
feasible treatment.
At earlier stages (stage 1 to 4), a number of options exist including:

osteochondral autograft (same patient)

osteochondral allografts (cadaveric donor)

subchondral bone drilling

chondral shaving and abrasion