Natural History


Seigall et al. J Paediatr Orthop 2018

- instability 3% in patients < 13 years

- instability 100% in patients > 17 years

- not predictive 13-17 years


Non Operative Management




1.  Open growth plates  / Juvenile OCD

- > 2 years of growth remaining

- age 12 or less


2.  Stable lesion / cartilage intact / no fluid on MRI


3.  Smaller lesions




No impact sports

Consider unloader brace first 3 months

After 3 months can swim or bike


Tepolt et al. J Pediatr Orthop 2020

- retrospective study of 333 stable JOCD treated nonoperatively

- treatment successful in 57% at 9 months

- unloader bracing did not improve outcomes and was more often associated with need for surgery


Assessment of healing




Signs of reossification




Reduction in size of lesion

Reduction in edema around lesion on T2

Reossification on T1


OCD T2 edema preOCD T2 edema post

MFC OCD on presentation                                T2 image 6 months later


OCD T1 preOCD T1 post

T1 sagittal on presentation                               T1 sagittal six months later






Andriolo et al. Cartilage 2019

- systematic review of 27 studies and 908 knees undergoing nonoperative treatment

- mix of adult and juvenile, stable and unstable OCD

- overall healing rate of 61%

- poorer prognosis was larger lesion size, worse OCD stage, skeletal maturity


Krause et al. Am J Sports Med 2013

- stable JOCD treated nonoperatively in 62 patients

- girls mean age 11 and boys mean age 12

- after 6 months, 67% showed no progression towards healing or signs of instability

- after 12 months, 51% showed no progression towards healing

- larger lesions and the presence of cyst like lesions associated with increased failure rates

- the presence and size of cyst like lesions >1.3mm was most important predictor of failure


Stable OCD no cystsStable lesion with cysts

Stable lesion with no cysts                                   Stable lesion with cysts


Lateral femoral condyle


Nakayama et al. Knee 2016

- 43 knees in 37 patients with stable LFC JOCD undergoing nonoperative treatment

- 33% failed to heal at 6 months

- all those with associated discoid meniscus failed


Takigami et al. J Paediatr Orthop 2022

- 44 knees in 37 patients with stable LFC JOCD (average age 9) undergoing nonoperative treatment

- no difference in healing rates between those with normal lateral meniscus and incomplete discoid meniscus


Operative Management




1. Stable lesions

- stable, no cartilage breach, no fluid behind lesion

- anterograde or retrograde drilling


2. Unstable and salvageable lesions

- fluid behind lesion on MRI

- cartilage breach on arthroscopy

- screw fixation


Unstable OCD MRICartilage breach arthroscopy OCD


Unstable and unsalvageable OCD

- fragment removal

- cartilage restoration procedure +/- realignment if needed


OCD fragmented


Drilling in situ




Failure non operative management > 6 months

Stable on MRI - no fluid behind lesion

Cartilage intact on arthroscopy




Aim to stimulate vascular ingrowth and subchondral healing


Antegrade v retrograde



- easy to do

- damages cartilage



- image intensifier or PCL guide

- more difficult but preserves cartilage




Gunton et al CORR 2013

- SR of JOCD treated with retrograde v antegrade drilling

- 86% radiographic healing with retrograde drilling by 5.6 months

- 91% radiographic healing with anterograde drilling by 4.5 months

- no significant difference


Baghdadi et al. Arthrosc Sports Med Rehab 2022

- 139 knees in 131 patients average age 13

- 16% bilateral

- 91% transarticular

- 96% healing rate




In a stage 1 lesion there is no cartilage breach

- the MFC / LFC looks normal

- use MRI to identify site of lesion

- i.e. usually adjacent to PCL insertion for MFC OCD

- central LFC for LFC OCD


5 - 10 drill holes

- 20 mm deep


OCD Antegrade Drilling

Transarticular drilling of LFC OCD




Crutches and protected weight bearing 4 - 6 weeks

No sports 6 months

MRI 3 and 6 months


Femoral OCD Healing Before DrillingFemoral OCD Healing Post DrillingKnee Healed OCD Post Drilling

Progression of reossification over 6 months following drilling


Screw fixation




Unstable lesion



OCD unstable 1OCD unstable 2




Open or arthroscopic


Cannulated headless variable pitch compression screws

- metal or bioabsorble


Consider bone graft


Yellin et al. J Paediatr Orthop 2017

- survey of 129 members of the Pediatric Orthopedic Society of North America

- majority use a metal or bioabsorble screw with no bone graft


Arthroscopic Screw Fixation in situ


Femoral OCD in situ Femoral OCD K wireFemoral OCD Screw InsertionFemoral OCD Pinned in Situ


Arthroscopic bone graft and screw fixation


Adult OCD LargeAdult OCD Burr Base


Open bone graft and screw fixation


Open OCD 1Knee OCD Hinged open & Base drilled


OCD Open 3OCD open final


Arthroscopic Mosaicplasty / OATS


Lateral femoral OCDMosaicplasty plugsMosaicplasty plugs in OCD




Miura et al Am J Sports Med 2007

- 12 unstable OCD treated with mosaicplasty plugs

- complete union on MRI in all cases

- 8 excellent and 3 good outcomes

- no donor site morbidity


Miniaci et al. Arthroscopy 2007

- 20 patients with unstable OCD treated with mosaicplasty

- MRI demonstrated bony healing in all patients at 6 months

- cartilage healing by 9 months


Assessing Union




OCD preopOCD post op

Some reossification and evidence of union




MRI OCD HealingMRI OCD Healing 2

Reossification and evidence of bony bridging




OCD Healing CT 1CT healing OCD 2

Evidence of bony union on CT




Wu et al. AJSM 2018

- 87 patients undergoing screw fixation for unstable OCD

- 76% union rate at 2 years

- no difference between open or closed growth plates

- increased nonunion for LFC OCD


Komnos et al. Cartilage 2021

- retrograde drilling and bioabsorble pins in 40 patients mean age 13

- 84% union stage 3


Barrett et al. Cartilage 2016

- metal compression screws in 22 patients mean age 22

- union seen in 82%


Risk factors for non union


Fragmentation of piece

Thin bony fragment


Unsalvageable OCD / failed OCD fixation


OCD Failed FixationDisplaced ocdOCD fragmentedDetached OCD

Failure of fixation                                Chronic displaced fragment              Fragmented OCD                   Fully detached OCD




Important to address osteochondral defect


Sanders et al. AJSM 2017

- OCD fixation:         OA 7% at 10 years,   25% at 20 years, 50% at 30 years

- fragment excision:  OA 17% at 10 years, 40% at 20 years, 70% at 30 years






Usually inappropriate for osteochondral defects


Mosaicplasty +/- osteotomy


Defect often too large for 4.5 mosaicplasty plugs

Number required to fill defect often results in donor site morbidity


LFC chondral defectChondral defect mosaciplasty


Autologous chondrocyte implantation (ACI) +/- osteotomy


Carey et al. AJSM 2020

- 55 patients with 61 unsalvageable OCD treated with ACI

- average 19 year follow up

- 61% reached pre-injury level function

- 85% 15 year survival


Autologous Matrix Induced Chondrogenesis (AMIC) +/- osteotomy


Microfracture base +/- bone graft

Application of collagen patch - secured with sutures or Tisseal fibrin glue


AMIC collagen patchAMIC kneeAMIC HTO


Bertho et al. Orthop Traumatol Surg Res 2018

- 13 patients with large osteochondral defects treated with AMIC and bone grafting
- 11/13 had satisfactory outcomes


Osteochondral Allograft +/- osteotomy


OCA knee 1OCA knee 2Osteochondral Allograft APOsteochondral Allograft Lateral


Sadr et al. AJSM 2016

- 135 patients with 149 knees

- osteochondral allograft for unsalvageable OCD

- 93% 10 year survival (based on revision allograft, or arthroplasty)