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This is an example of one of my favorite cases: intra-epiphyseal, extra-articular drilling of a stable OCD
12 y.o. boy with 6 months of symptoms. Outside doc treated for 4 mos of rest. No improvement on PE or x-ray. 2nd opinion.
No effusion. Pain with deep palpation, only.
12 y.o. boy with 6 months of symptoms. Outside doc treated for 4 mos of rest. No improvement on PE or x-ray. 2nd opinion.
No effusion. Pain with deep palpation, only.
MRI shows a Grade II lesion. There is a clear rim with peripheral edema. The cartilage shows no signs of disruption.
Options?
More rest
Immobilization
Surgery (which type?)
Rest can work, but results are not guaranteed and require 100% compliance (family was worried about psychological impact of more rest, given that 4 months showed no improvement). Immobilization does not improve results.
More rest
Immobilization
Surgery (which type?)
Rest can work, but results are not guaranteed and require 100% compliance (family was worried about psychological impact of more rest, given that 4 months showed no improvement). Immobilization does not improve results.
So, surgery. On stable lesions, I prefer the intra-epiphyseal, extra-articular drilling described by Hank Chambers. There is no violation of the cartilage.
I rarely scope these anymore, unless the cartilage on MRI concerns me.
No fixation for Grade II, unless older patient*.
I rarely scope these anymore, unless the cartilage on MRI concerns me.
No fixation for Grade II, unless older patient*.
The surgical setup is with a thigh post and a speed bump for the foot. Too much knee flexion can make it hard to visualize on the AP.
I stand to drill medially, and C-arm comes in from the lateral.
The only instruments are a 0.062” K-wire and a driver.
I stand to drill medially, and C-arm comes in from the lateral.
The only instruments are a 0.062” K-wire and a driver.
A single pin hole is used, and the K-wire is advanced to the lesion. I aim for the far side of the lesion and once I feel a “hard stop,” I get biplanar fluoro to confirm position. On AP, I move lateral to medial, by both feel and fluoro. Try to keep the same sagittal plane.
Similar rules on the lateral view.
When I have made a sufficient amount of holes (this one got 10), and I cannot find any more rim to break through, I stop. Pin comes out, and the dressing is a band aid.
When I have made a sufficient amount of holes (this one got 10), and I cannot find any more rim to break through, I stop. Pin comes out, and the dressing is a band aid.
Post op care is NWB for 6 weeks (NO BRACE!!!), and then an exam/x-ray at 6 weeks.
If pain free, and improved x-ray, advance to WBAT with RTS after additional 4 - 6 weeks.
These are the pre-op and 6 week x-rays; if you look closely, you can see the pin pathways.
If pain free, and improved x-ray, advance to WBAT with RTS after additional 4 - 6 weeks.
These are the pre-op and 6 week x-rays; if you look closely, you can see the pin pathways.
I have always been fascinated by bone biology, and this case is a great example of how dynamic bone is. All I had to do was make the bone bleed on the far side of the lesion, and the body took over.
As in many things peds ortho, a 0.062" K-wire is king.
As in many things peds ortho, a 0.062" K-wire is king.
