| الوصف: |
The two recognized types of osteochondritis, juvenile osteochondritis dissecans (JOCD), and adult osteochondritis dissecans (OCD), differ in several ways. A painful malady found most frequently in the femoral condyles of children, JOCD occurs before the closure of the distal femoral physis, whereas OCD is seen when the physis is closed. The prognosis for healing is much worse for OCD than for JOCD. The pathologic tissue of JOCD resides in the subchondral bone of the afflicted femoral condyles of children, especially active young athletes. If the condition is allowed to continue, the lesion usually will detach. Surgical attempts to repair these detachments seldom restore the articular surface to opticity. This results in early onset of gonarthrosis. On the other hand, when JOCD is diagnosed early, conservative treatment can often result in healing of the lesions. If healing occurs, the child can expect a normal adult knee. There is also a recognized subtype of JOCD, once called asymptomatic JOCD. After joint scintigraphy of a symptomatic JOCD knee, there is often an abnormal scintigram in the opposite, asymptomatic, knee. This JOCD subtype is discussed further in the section on OCD classification. Possibly the first recorded evidence of JOCD was in 1840, when Ambrose Pare reported his finding of a “stone” in the human knee. 11 The stone also might have been a product of degenerative joint disease, and not JOCD or OCD at all. It was not until 1887, in Konig's paper on OCD, that factual information was published that these were not all joint mice or stones. 8 This speculation forced Konig to give this newly described phenomenon a proper christening, thus, he may not have pondered this task for long. The eponym Konig selected was osteochondritis dissecans , literally “dry inflamed bone.” Konig believed that these lesions were the result of inflammation. Subsequent re-examination of these lesions by other surgeons and Konig himself revealed that, in reality, there was no visible sign of inflammation. Ironically, a definitive cause is still not agreed on. The current literature on JOCD is limited largely to the surgical aspects, especially internal fixation of these pernicious lesions. Although there is literature that discusses conservative treatment, there currently is none available focusing on the important role of compliance in successful outcomes, or the interdependent roles of the parents, patient, and the physician—a group we will refer to as the “compliance triad.” The incidence of JOCD has increased during the past 40 to 50 years. 6 This escalation is thought to be related to the increasing exercise dose to which young athletes are subjected. Given the increased incidence of JOCD-related presentations and the explosive growth of intensive, year-round sports for children of both sexes, we believe that it is critical for any physician working with children to be knowledgeable about this condition. Because of the minimal information available on conservative treatment, and the complete lack of articles on the complex roles of the individuals involved in the compliance triad, we believe a need exists to address these issues. This article describes the essence of conservative JOCD treatment, including how to develop compliance in the triad, the importance of early diagnosis, and the results of conservative treatment. This article refers to the knee as the affected joint, because most JOCD cases occur there, and presents only the authors' experience with JOCD. |