AAOS American Academy of Orthopaedic Surgeons

Before these appropriate use criteria are consulted, it is assumed that:
1. The clinician knows the contraindication to the utilization of certain medications and the anesthetic or important surgical contraindications to operative interventions.
2. The patient is healthy enough to undergo surgery if indicated.
3. The patient has a diagnosis of OCD of the knee (not including irregular epiphyseal ossification or epiphyseal dysplasia).
4. The patient has an OCD lesion that may lead to loss of function or arthritis OR is symptomatic including pain, instability, stiffness, and mechanical symptoms.
5. The patient’s symptoms are consistent with the history, physical exam, and imaging findings.
6. The imaging findings are consistent with osteochondritis dissecans of the knee (evidence of OCD lesion, with associated sub-chondral bone changes, in locations including medial femoral condyle and/or lateral femoral condyle
7. AP and/or PA-flexion weight-bearing (notch views), lateral, and patellar view radiographs are obtained. If malalignment is suspected, long leg films.
8. Addressing malalignment, as is appropriate, is recommended.
9. Imaging Definition of Instability:
a. Plain Radiograph definition of instability: Fragment is partially or totally displaced. 
b. If an MRI is obtained, findings of instability are suggested by the following:
 
In patients with closed physes:

• A high T2 signal rim surrounding the OCD lesion.
• The presence of subchondral cyst-like lesions.
• Disruption of articular cartilage signal.

In patients with open physes:

• High T2 signal rim indicates instability only if it is the same signal intensity as the joint fluid and the lesion is surrounded by a second, low T2 signal rim.
• The lesion demonstrates multiple breaks in the subchondral bone plate.
• Cyst-like lesions suggest instability only if they are large (>5mm) or multiple.
   

10. The physical examination, history, and imaging studies have excluded the following potential causes of knee pain:

• Referred pain from the spine
• Ipsilateral hip disorder, including DDH, SCFE, etc.
• Ankle/foot deformity
• Non-articular causes of knee pain including soft-tissue disorders
• Neoplasm
• Neuropathy
• Infection
• Acute knee injury
• Stress fractures, insufficiency fracture, osteonecrosis, or symptomatic metabolic bone disease
• Proximal tibiofibular pain

11. The physician has an informed discussion with the patient about the treatment options and that the optimum treatment options may change over time for the patient. Before operative intervention is recommended, the appropriateness and potential efficacy of non-operative intervention has been considered. 
 
12. All patients with defined OCD lesions should receive surveillance and follow up.
13. In patients with open physes, contralateral x-rays may be considered. If symptoms or findings are bilateral, contralateral x-rays should be obtained.
14. The patient has no contralateral lower extremity disease (including OCD) that would preclude appropriate treatment for the OCD lesion in question. 
15. Idiopathic familial OCD is not excluded from this AUC.
16. Physical Therapy addresses impaired strength, mobility, and function and can assist with progression back to ADLs sports, work, and functional activities.  
17. The location of all lesions in this AUC are assumed to be in the medial or lateral femoral condyle.  Although medial and lateral femoral condyle lesions are distinct, the appropriateness of treatment recommendations is the same.
18. If the patient has a change in status regarding pain, swelling, or mechanical symptoms, that patient should be reassessed and treatment modified accordingly.
 
 

Conditions Not Covered by this AUC

• Irregular epiphyseal ossification (developmental irregularity/accessory ossification centers). Normal variant in child that mimics juvenile osteochondritis dissecans. May be asymptomatic and often bilateral (bilateral radiographs are often indicated). Follow-up may be indicated to distinguish resolving from progressing ossification variants.
• Epiphyseal dysplasias that may include dwarfing syndrome, multiple epiphyseal dysplasia, metaphyseal dysplasias, and genetic syndromes that may mimic OCD.
• Osteonecrosis mimicking OCD.
• Patella, femoral trochlea, and tibial plateau OCD lesions.

Disclaimer: 

Volunteer physicians from multiple medical specialties created and categorized these Appropriate Use Criteria. These Appropriate Use Criteria are not intended to be comprehensive or a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. These Appropriate Use Criteria represent patients and situations that clinicians treating or diagnosing musculoskeletal conditions are most likely to encounter. The clinician’s independent medical judgment, given the individual patient’s clinical circumstances, should always determine patient care and treatment.