An obvious advantage of fixation is the anatomical fit of the fragment. But loosening is part of the disease and bone as well as cartilage has biologically changed. Although the successful fixation is recommended and described it might be better to remove the fragment and treat by bone grafting possibly in combination with cartilage repair procedures.
Dear Hagen
The internal fixation of loose osteochondritic fragments depends. In my opinion, is rarely indicated because the cartilage has the biology changed and the best solution is the loose fragment resection or cartilage repair (chondrocytes culture). In some cases when the fragment is big sufficient and is situated in bearing area (hip, knee) the internal fixation it will be possible but we must in mind the possibility of bad results : loosening of implants (mini screws, bioresorbable material etc) and necrosis.
Dear Nelson, thanks for your answer. I agree that the decision depends on location, size and quality of the fragment.
Dear Hagen
The answer for your question is very difficult. The stem cells may be a way.Thank you for your attention.
It depends on the time elapsed from injury (sometimes the correct diagnosis is delayed and the fragment is no more vital enough) and also on the size of the fragment. If the fragment is large enough and vital it should be fixed back to its place. The stem cells is a method which is still not supported by evidence-based clinical studies. The so-called "mosaic" chondroplasty and similar cartilage defect replacements give controversial results. I think they should be preserved for "the second line" of defence.
Thanks for your answer. In case of osteochondral flake fractures fixation is definitely recommended, but time is always questionable in OCD patients. How do you tell whether a piece is vital or not? Best regards, Hagen.
Thank you for this question, Hagen. I must admit it is a difficult one. Anyway, it is presumed that the availability of appropriate imaging diagnostics and correct clinical orientation this type of fragments should be diagnosed soon after the trauma. Unfortunately, sometimes this diagnosis is made late. If this is the case, the joint should be opened and an ad oculo assessment of the defect place and the fragment itself should done. Some macroscopic signs of subchondral necrosis and chondrolytic changes of the above lying cartilage should be looked for. The place of defect should be inspected too. If some reparative signs are present then they should be juxtaposed to the changes of the fragment. If this inspection gives reliable data for inveterate injury then the protocol of the second line of the defence should be followed.
Refixation of an osteochondral fragment in casews of OCD-lesions can only be successfull when the loose body contains an osseous layer and the so-called mouse bed has enough vital bone and blood supply.
Very interesting topic,.Decision to excise or fix the loose body is still controversial in Osteochondritis dissecans, specially into the grade IV defect. But long term results are in the favor of stable fixation in comparation with excision.
Dear Cen, it is surely not enough just to remove the fragments. The alternative would be bone grafting possibly in combination with ACI (http://www.ncbi.nlm.nih.gov/pubmed/21193592). But do you have any published reference supporting your statement? Hagen.
Juvenile OD dissecats should be debrided and refixed. Smart nails and chondral darts could be used. My experience with biocompression screw is not successful, every case the implant broke. My interpretation: there is too much instability during healing process. OD is a pseudarthrosis under vitamin D3 deficiency.
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