Osteochondritis Dissecans

Osteochondritis dissecans ( OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD)) is an orthopedic disorder characterized by the detachment of a focal segment of subchondral bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones and cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage as a result of focal aseptic necrosis. This can occur at any age, but it is most commonly seen in adolescents who participate in competitive sports. Patients can be asymptomatic or may present with joint pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, stiffness, and swelling that is worse with activity. The diagnosis can be made with imaging. Management depends on the severity, but can include restricted weight-bearing activity, physical therapy, or surgery.

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Overview

Definition

Osteochondritis dissecans ( OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD)) is a disorder characterized by aseptic necrosis of subchondral bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones that results in focal detachment and displacement of bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones and cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage into the joint space. The term osteochondritis is a misnomer, as histologic analysis reveals a lack of inflammatory cells.

Epidemiology

  • Prevalence: 15–29 per 100,000 patients
  • Peak age: 12–19 years
  • Male > female
  • Higher incidence in young athletes

Etiology and Pathophysiology

Etiology

The exact etiology is unknown. Many theories have been proposed, and OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD) is likely multifactorial.

  • Trauma: 
    • Repetitive microtrauma (mechanical stress from competitive sports)
    • Direct trauma (isolated injury)
  • Ischemia
  • Genetic predisposition

Pathophysiology

Pathogenesis of osteochondritis dissecans:

  • Repetitive microtrauma → injury to the subchondral bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones → fragmentation
  • A defect develops between the osteochondral lesion and the underlying bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones.
  • Results in hypovascularity → osteonecrosis of the lesion
  • Involvement of the overlying cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage → instability of the fragment
  • Subchondral bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones and cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage may become partially or totally separated.

Stages of progression in osteochondritis dissecans:

  • Stage I: small area of compression of the subchondral bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones
  • Stage II: partial detachment of an osteochondral fragment
  • Stage III: 
    • Complete detachment of a fragment
    • Remains within the underlying crater bed
  • Stage IV: 
    • Complete detachment of a fragment
    • Displaced from crater bed (loose body)
Osteochondritis dissecans 4 stages

Osteochondritis dissecans progresses through 4 stages. With continued injury, the lesion fragments and becomes separated from the underlying bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones, eventually becoming displaced in the joint space (loose body).

Image by Lecturio.

Clinical Presentation

Symptoms

Some patients may be asymptomatic, with OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD) found incidentally on imaging. However, symptomatic individuals may experience:

  • Chronic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the affected joint: 
    • Increases with activity
    • Alleviated at rest
  • Progressive symptoms, such as:
    • Joint stiffness
    • Intermittent swelling
    • Joint locking or catching (may signal a loose body)
    • Joint instability
  • Most commonly affected joints:
    • Knee (75% of cases)
    • Elbow (6% of cases)
    • Ankle (4% of cases)

Physical examination

  • Localized tenderness to palpation at the site of the lesion, particularly:
    • Medial femoral condyle of the knee
    • Radiocapitellar joint of the elbow
    • Tibiotalar joint of the ankle
  • Painful range of motion
  • Range of motion:
    • Usually normal if the knee is affected
    • Often diminished in an affected elbow
  • Joint effusion
  • Crepitus
  • Wilson’s test: 
    • Pain with knee extension and internal rotation
    • Has been described with OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD), but lacks sensitivity
  • Abnormal gait:
    • May be seen in some patients with knee involvement
    • Affected leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg is externally rotated with ambulation.
Wilson's test

Demonstration of Wilson’s test, which may be positive in patients with osteochondritis dissecans of the knee.

Image by Lecturio.

Diagnosis

A diagnosis of OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD) should be suspected in adolescents with a characteristic presentation of joint pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and involvement in repetitive activities and sports.

X-ray

X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays of the affected joint are usually diagnostic and are the initial testing method of choice. However, these images can be normal in the early disease stages.

Knee:

  • Findings:
    • Subcortical, crescent-shaped lucency is often first detected.
    • Subchondral bony fragment
  • Frequent lesion locations:
    • Medial condyle (77%)
    • Lateral condyle (17%)
    • Patella (7%)
Osteochondritis dissecans knee x-ray

Knee X-ray of a patient with osteochondritis dissecans:
Note the fragmentation of the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Structure of Bones and the radiolucency underneath (arrows).

Image: “Osteochondritis dissecans diagram” by Kristin M Houghton. License: CC BY 2.0

Elbow:

  • Lateral capitellum flattening
  • Subchondral sclerosis
  • Fragmentation of the capitellum
Osteochondritis dissecans elbow x-ray

X-ray images from a 16-year-old athlete with osteochondritis dissecans of the elbow.
Shown is a radiolucent focus of the capitellum over the radial head.

Image: “Osteochondritis dissecans of the capitellum in adolescents: report of a case and review of the literature” by Erraji M, Kharraji A, Abbassi N, Najib A, Yacoubi H. License: CC BY 2.0

Ankle:

  • Normal in ⅓ of cases
  • Cup-shaped lesion on the talus
Osteochondritis dissecans ankle x-ray

X-ray images of an ankle showing osteochondritis dissecans of the superomedial talus.
Note the radiolucency and fragmentation (arrows).

Image: “CT and projectional radiography of osteochondritis dissecans – annotated” by Mikael Häggström. License: CC0 1.0, cropped by Lecturio.

MRI

  • Should be considered in symptomatic patients with normal X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays
  • More sensitive in detecting subchondral changes and can be used in staging Staging Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis
  • Gadolinium can be used to evaluate the blood supply to the area.
  • Frequently used in preoperative planning
Osteochondritis dissecans knee mri

MRI of a knee showing an area of osteochondritis dissecans affecting the medial femoral condyle

Image: “The present state of treatments for articular cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage defects in the knee” by Perera JR, Gikas PD, Bentley G. License: CC BY 3.0, cropped by Lecturio.

Management

The main goal of management is to achieve healing of the osteochondral lesion and return the affected joint to full function. Specialty referrals for sports medicine or orthopedic surgery may be needed.

Conservative management

  • Limit weight-bearing and activity:
    • Critically important to prevent progression
    • Return to activity may occur when: 
      • Pain-free
      • Active full range of motion improves
      • Evidence of healing
  • Joint immobilization
  • Physical therapy
  • Indications for conservative management:
    • Skeletally immature patients with open physes and without an intra-articular foreign body
    • Adult patients who have a small, stable, asymptomatic fragment
  • Asymptomatic patients with incidental X-ray findings of osteochondral lesions: 
    • Repeat X-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays every 6 months.
    • Follow the patient until skeletal maturity or until the lesion has healed.

Surgical management

  • Indications:
    • Signs of joint instability
    • Expanding lesion on x-rays
    • Failed nonoperative treatment
    • Intra-articular loose body
  • Techniques:
    • Arthroscopic subchondral drilling 
    • Fixation of unstable lesion
    • Arthroscopic excision, curettage, and drilling
    • Autologous chondral transplantation 
  • Choice depends on skeletal maturity, stage of the disease, and size of the lesion.

Prognosis

  • Most patients with stable lesions will have spontaneous healing with conservative measures.
  • Success rates for unstable lesions varies depending on the severity and surgical technique: 30%–100%
  • Patients have an increased risk of developing osteoarthritis Osteoarthritis Osteoarthritis (OA) is the most common form of arthritis, and is due to cartilage destruction and changes of the subchondral bone. The risk of developing this disorder increases with age, obesity, and repetitive joint use or trauma. Patients develop gradual joint pain, stiffness lasting < 30 minutes, and decreased range of motion. Osteoarthritis of the joint.
  • Factors linked with an improved prognosis:
    • Younger age
    • Intact articular cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage
    • Smaller osteochondral lesions
    • Stable lesions

Differential Diagnosis

  • Meniscal tear: an acute injury often seen in younger patients: The presentation may include a tearing or popping sensation during the injury, knee pain Knee Pain Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. Knee Pain, decreased range of motion, locking or catching, and joint effusion. The diagnosis is based on the physical examination and imaging. Management includes conservative measures and surgery for severe injury.
  • Plica syndrome: irritation and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the medial synovial component of the knee, which can occur with repetitive trauma: Patients may experience knee pain Knee Pain Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. Knee Pain, often of the medial aspect of the joint, with a catching or popping sensation. A definitive diagnosis is provided by arthroscopy. Management consists of conservative measures, physical therapy, intra-articular steroid injections, and arthroscopic surgery for refractory cases.
  • Patellofemoral syndrome: most common cause of anterior knee pain Knee Pain Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. Knee Pain, which may result from malalignment of the leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg, muscular imbalance, overactivity, or trauma: Patellofemoral syndrome produces dull and generalized anterior knee pain Knee Pain Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. Knee Pain that is exacerbated by activity or prolonged sitting. Patellofemoral syndrome is a diagnosis of exclusion, and other intra-articular etiologies should be ruled out. Conservative measures and physical therapy are used in management.
  • Little League elbow: overuse injury that results in apophysitis of the medial epicondyle of the elbow: This condition is often associated with repetitive throwing, commonly in preadolescent and adolescent baseball pitchers. Patients develop elbow pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, particularly of the medial epicondyle. The diagnosis is clinical, and management includes conservative measures and physical therapy.
  • Panner disease: osteochondrosis of the humeral capitellum epiphysis consisting of atypical ossification, necrosis, and regeneration: In contrast to OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD), this disorder is seen at younger ages and does not progress to a loose body. Patients present with elbow pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, stiffness, and limited range of motion. The diagnosis is made with imaging, and management includes conservative measures.
  • Medial epicondylitis: also known as “golfer’s elbow”: This disorder is caused by valgus force on the elbow resulting in inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the wrist flexor group tendon at its insertion on the medial epicondyle. Patients will have medial elbow pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and tenderness. Pain will be provoked by flexion of the wrist and pronation against resistance. The diagnosis is clinical, and management involves conservative measures and physical therapy.
  • Lateral epicondylitis: also known as “tennis elbow”: This condition results from inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the extensor tendons of the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm at their insertion on the lateral epicondyle. Patients will have lateral elbow pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain that can radiate to the forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm. Pain will be provoked by wrist extension with resistance. The diagnosis is clinical, and management involves conservative measures and physical therapy.
  • Ankle sprain: injury of the ankle, most often from inversion of the foot: Patients will have pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, tenderness, and swelling of the anterolateral ankle (most common location). The diagnosis is clinical. Imaging may be done to exclude other causes of ankle pain Ankle pain Ankle pain accounts for up to 20% of cases of musculoskeletal complaints in outpatient clinics. The most common etiologies of foot and ankle pain can be categorized into arthritis, trauma, sprains, and systemic causes. Ankle and Foot Pain. Management includes conservative measures and physical therapy.

References

  1. Pallin, D. J. (2018). Knee and lower leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg. In Walls, R. M., et al. (Eds.). Rosen’s emergency medicine: Concepts and clinical practice. pp. 614‒633.e2. Retrieved March 15, 2021, from https://www.clinicalkey.es/#!/content/3-s2.0-B9780323354790000507
  2. O’Keefe, K. P. (2020). Hip and knee pain Knee Pain Knee pain is a common presentation to primary care physicians. The diagnosis can be challenging as the pain may arise from the joint, surrounding tissues, or referred to the joint from distant structures. The differential diagnosis of knee pain is broad and categorizing the various diagnoses related to the timing (acute or chronic) is useful. Knee Pain. In Tintinalli, J. E., et al. (Eds.). Tintinalli’s emergency medicine: A comprehensive study guide. New York, NY: McGraw-Hill Education. https://accessmedicine.mhmedical.com/content.aspx?aid=1167030636
  3. Ferri, F., Ferri, F. (2020). Ferri’s clinical advisor 2020: 5 books in 1. Philadelphia: Elsevier.
  4. Park, N.H., Kim, H.S., Yi, S.Y., Min, B.C. (2013). Multiple osteochondritis dissecans of knee joint Knee joint The knee joint is made up of the articulations between the femur, tibia, and patella bones, and is one of the largest and most complex joints of the human body. The knee is classified as a synovial hinge joint, which primarily allows for flexion and extension with a more limited degree of translation and rotation. Knee Joint in a patient with Wilson disease, focusing on magnetic resonance findings. Knee Surg Relat Res 25(4):225‒229. https://doi.org/10.5792/ksrr.2013.25.4.225
  5. Cooper, G., Warren, R. (2018). Osteochondritis dissecans. In DeBerardino, T.M. (Ed.). Medscape. Retrieved March 15, 2021, from https://emedicine.medscape.com/article/1253074-overview
  6. Wood, D., Davis, D.D., Carter, K.R. (2021). Osteochondritis dissecans. StatPearls. Retrieved March 15, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK526091/
  7. Hergenroeder, A.C., Harvey, B.S. (2019). Osteochondritis dissecans ( OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD)): Clinical manifestations and diagnosis. In Wiley, J.F. (Ed.). UpToDate. Retrieved March 15, 2021, from https://www.uptodate.com/contents/osteochondritis-dissecans-ocd-clinical-manifestations-and-diagnosis
  8. Hergenroeder, A.C., Harvey, B.S. (2019). Management of osteochondritis dissecans ( OCD OCD Obsessive-compulsive disorder (OCD) is a condition characterized by obsessions (recurring and intrusive thoughts, urges, or images) and/or compulsions (repetitive actions the person is compelled to perform) that are time-consuming and associated with functional impairment. Obsessive-compulsive Disorder (OCD)). In Wiley, J.F. (Ed.). UpToDate. Retrieved March 15, 2021, from https://www.uptodate.com/contents/management-of-osteochondritis-dissecans-ocd

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