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Determining Healing of Juvenile Osteochondritis Dissecans of the Talus
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Posted on: 10/11/2007
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Osteochondritis dissecans, a disorder that keeps blood from reaching a part of bone beneath a joint, usually affects teens and young adults; because it rarely affects children who are still growing, there is not much information on the best way to treat it. As well, because children who do have OCDT begin to feel better before healing is actually complete, many do not show up for follow-up appointments, so it is difficult to tell when the problem has healed.
The authors of this study reviewed the healing rate of juvenile osteochondritis dissecans of the talus; the talus is the ankle bone. Also called JOCDT, this type is treated very differently from the adult type.
After reviewing records of children diagnosed with OCDT, the researchers found 32 patients (20 boys) who met the requirements for JOCDT and had completed at least 6 months of follow up. Thirty one of the patients were treated without surgery. The researchers noted information including patient age, race, sex, history of the injury, pain, swelling, limp, range of motion of the ankle, and how long the pain lasted. They then classified the injury, or lesion, according to where it was located and the size.
The researchers also used magnetic resonance imaging, or MRI, to confirm the diagnosis. They used a classification scale (the Berndt and Harty); if the lesions were classified as stage 1, 2, or 3, the patients were treated without surgery. Weight-bearing (walking) casts were applied and kept on for 6 to 8 weeks, followed by a removable brace and activity restrictions for a total of 6 months treatment. They were to return for follow-up at that point. On follow-up, the lesion was checked for new bone formation. If this didn't appear to happen, MRIs were repeated.
In many children, the pain and symptoms of JOCDT disappear before the healing is complete. If this was found (evidence of no healing by MRI, but no reports of pain), it is recommended that surgery be done to graft bone or remove dead bone. However, surgery could be held off for up to a year if the patient agreed to continued restriction to activities.
For those patients with stage 4 lesions, surgery is likely required, followed by casting and non-weight bearing until given the go-ahead by the treating physician.
Among the 31 patients who did not have surgery, 2 patients (6 percent) complained of severe pain and they underwent surgery after the casts were removed, 5 patients (16 percent) were found to have healed both clinically (symptomatically) and on x-ray, and 24 patients (77 percent) still had signs of lesions on the x-rays. Ten had surgery, 11 felt no symptoms - 4 had successful healing after another 6 months of non-surgical treatment, 7 did not but did not go on for any more treatment - and 3 patients were lost to follow-up.
The authors write that the cause of OCD isn't yet understood, with many doctors suggesting that it is caused by trauma. During treatment, pain seems to decrease before the lesion is healed, so clinical (symptomatic) results have always had a better rate than x-ray results, after treatment. They point out that 24 of the patients continued to have signs of lesions seen on x-ray, even after 6 months of treatment, and 7 continued after another 6 months. This gives a failure rate from treatment of 54 percent.
The study subjects were all patients who did not have adult bones, something that has not yet been noted in the medical literature. The authors conclude that many patients with JOCDT do not respond to conservative treatment within 6 months and that parents and children should be warned that the treatment could take longer. However, if the pain continues, despite the treatment, surgery should be considered.
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References:
Venkat Perumal, MD, Eric Wall, MD, and Nadir Babekir, MBBS. Juvenile Osteochondritis Dessecans of the Talus. In Journal of Pediatric Orthopedics. October/November 2007. Volume 27. No. 7. Pp. 821-825.
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