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I can't seem to get a straight answer about my son's knee problem. He has osteochondritis dissecans. We've taken him to three different "experts." They all say the same thing: there isn't enough 'evidence' to say for sure this way or that way is the best treatment. As a parent, I find that extremely frustrating. I need some answers. What can you tell me?
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There is a recent summary of current treatment recommendations put out by members of the American Academy of Orthopaedic Surgeons. The summary provides a 16-point clinical practice guideline for the treatment of osteochondritis dissecans (OCD). Although OCD can affect several areas of the body (ankle, elbow, knee), this review is strictly limited to the diagnosis and treatment of the knee.
The guidelines are meant to inform physicians and surgeons of the best practice recommended for this condition. The idea is to present what the evidence shows from studies so far that can aid them in helping patients obtain the best results possible. The problem is that so much of the evidence is weak or inconclusive. Where there is agreement (called consensus), it is usually based on expert opinion not necessarily hard evidence.
We can give you a brief summary of the current treatment guidelines. You can read the full, detailed summary (with explanations) at: http://www.aaos.org/research/guidelines/OCD_guideline.pdf. The committee was unable to recommend for or against nonoperative care for children with OCD that does not cause pain or other symptoms. Likewise, the committee was unable to recommend for or against surgical drilling in patients with symptoms after nonoperative care but with a stable lesion.
Other areas where the research remains inconclusive include: 1) whether or not to take X-rays of the other knee once OCD has been discovered, 2) which type of cartilage repair works best when surgery is needed, 3) whether to treat patient with or without symptoms who are fully grown (skeletally mature) in a similar fashion, and 4) whether or not patients should have repeat or follow-up MRIs when they are skeletally mature without symptoms.
There are some areas where the committee could offer guidelines based on agreement (referred to as consensus). Consensus means the committee agrees on the recommendation even though there isn't enough reliable evidence to prove the guideline is accurate. For example, most experts agree that skeletally immature patients should be offered surgical correction when the lesion is unstable or shifted but still salvageable.
Likewise, the committee agreed that symptomatic patients who are skeletally mature should be offered surgery when the lesion is unstable or displaced. After surgery, all patients should be provided with physical therapy. X-rays and/or MRIs should be taken to assess healing after treatment, especially for those who are still experiencing painful symptoms.
The lack of strong, conclusive evidence shows us the need for better designed (and more) studies in this area of medicine. Even with the current evidence and recommendations, each patient must be evaluated and treated on an individual basis. Decisions made about management and treatment techniques to use are determined by the patient in consultation with the physician.
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