Osteochondritis dissecans (OCD) is a joint disorder that affects the articular cartilage and subchondral bone, most commonly at the knee. OCD of the sacroiliac joint is extremely rare. Management of OCD remains controversial, and surgery is often needed, especially when conservative treatment fails. We present a rare case of OCD involving the left sacroiliac joint successfully treated by percutaneous computed tomography—guided retrograde drilling and debridemen

Anaye, Anass

Becce, Fabio

Letovanec, Igor

Mosimann, Pascal

Mouhsine, Elyazid

Theumann, Nicolas

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CASE REPORTPercutaneous CT-Guided Treatment of Osteochondritis Dissecansof the Sacroiliac JointFabio Becce • Elyazid Mouhsine • Pascal John Mosimann •Anass Anaye • Igor Letovanec • Nicolas TheumannReceived: 2 September 2011 / Accepted: 17 October 2011 / Published online: 1 December 2011 Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2011Abstract Osteochondritis dissecans (OCD) is a jointdisorder that affects the articular cartilage and subchondralbone, most commonly at the knee. OCD of the sacroiliacjoint is extremely rare. Management of OCD remainscontroversial, and surgery is often needed, especially whenconservative treatment fails. We present a rare case ofOCD involving the left sacroiliac joint successfully treatedby percutaneous computed tomography—guided retro-grade drilling and debridement.Keywords CT guidance  Imaging  Osteochondritisdissecans  Percutaneous treatment  Sacroiliac jointIntroductionOsteochondritis dissecans (OCD) is a pathologic processthat affects the articular cartilage and subchondral bone ofjoints, with an incidence of 15–60 per 100,000 in thegeneral population [1, 2]. The knee joint, especially thelateral aspect of the medial femoral condyle, is most fre-quently involved (approximately 75% of cases), followedby the ankle and the elbow [3]. OCD of the sacroiliac (SI)joint is rare; only a few cases have been reported in theliterature [4–6].More than a century after Ko¨nig termed the disorder‘‘osteochondritis dissecans’’ in 1888 [7], its etiology andmanagement are still debated, and surgery is oftenrequired, particularly when conservative treatment fails[1, 8]. Recently, percutaneous image-guided retrograde(extra-articular) drilling techniques have been proven to befeasible, safe, and effective in the treatment of OCD [9, 10].We present an uncommon case of OCD involving theleft SI joint. To our knowledge, this is the first case of OCDof the SI joint successfully treated by percutaneous com-puted tomography (CT)-guided retrograde drilling anddebridement.Case ReportA 42-year-old otherwise healthy man was referred to ourinstitution for the treatment of a left SI joint disorder. Hepresented with a 14 month history of pain in the left but-tock, which occurred after he fell from his height onto hisbuttocks. The pain was located around the left posteriorsuperior iliac spine and radiated into the groin, the pos-terior thigh, and sometimes the posterior calf. It limited thepatient’s walking perimeter, was aggravated by sitting, andpersisted at night. The symptoms had not responded tosteroidal and nonsteroidal anti-inflammatory drugs, rest,and physical therapy.At physical examination, the patient manifested anantalgic gait. Point tenderness was noted on palpation ofthe left SI joint, approximately 5 cm below the posteriorElectronic supplementary material The online version of thisarticle (doi:10.1007/s00270-011-0305-9) contains supplementarymaterial, which is available to authorized users.F. Becce (&)  P. J. Mosimann  A. Anaye  N. TheumannDepartment of Diagnostic and Interventional Radiology,Centre Hospitalier Universitaire Vaudois, Universityof Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerlande-mail: fabio.becce@chuv.chE. MouhsineDepartment of Orthopaedic Surgery, Clinique HirslandenBois-Cerf, 1006 Lausanne, SwitzerlandI. LetovanecUniversity Institute of Pathology, Centre HospitalierUniversitaire Vaudois, 1011 Lausanne, Switzerland123Cardiovasc Intervent Radiol (2012) 35:963–967DOI 10.1007/s00270-011-0305-9superior iliac spine. The Gillet test (a motion palpation testdescribed elsewhere [11]) was positive on the left side.Gaenslen and posterior shear tests (pain provocation testsalso described elsewhere [11]) were both painful. Passiveand active left hip movements were within normal range.Motor and sensory examinations of the left lower limbwere unremarkable.All imaging studies were performed at another institu-tion. An anteroposterior pelvic radiograph (not shown) wasinterpreted as normal. Lumbosacral spine magnetic reso-nance (MR) imaging (not shown) demonstrated an ill-defined bone marrow edema of the anterior portion of leftSI joint. An associated osteochondral lesion was suspectedbut hard to assess. There was no joint effusion, andthe right SI joint was normal. Multidetector computedtomography (CT) of the pelvis (Fig. 1) confirmed, that anosteochondral fragment had detached from the left iliacbone. This lesion measured 7.5 9 4 mm in the axial planeand 10 mm craniocaudally. It was surrounded by periphe-ral osteosclerosis. There was no bony erosion or periostealreaction. Furthermore, increased tracer uptake in the sacralaspect of the anterior portion of left SI joint was notedon technetium-99 m single-photon emission computedtomography—CT hybrid imaging (Fig. 2). However, therewas no abnormal tracer accumulation in the osteochondralfragment. All these findings were consistent with thediagnosis of left SI joint OCD. The differential diagnosisalso considered an osteoid osteoma or a Brodie abscess, butthese were thought to be far less likely.Because of the patient’s persistent symptoms, and afterdiscussing treatment options in a multidisciplinary meeting,a percutaneous CT-guided treatment (Fig. 3 and Supple-mentary Material) was scheduled after obtaining thepatient’s written informed consent. The intervention wasperformed under general anesthesia, and a single dose (2 g)of intravenous cefazolin was administered 30 min beforethe procedure. With the patient positioned prone on aneight-slice multidetector CT scanner (LightSpeed Ultra; GEHealthcare, Waukesha, WI), the entire procedure wascarried out under CT fluoroscopy (SmartStep; GE Health-care) guidance. First, under strict aseptic conditions, a 3 cmskin incision was made, and access to the lesion of theanterior portion of the left SI joint was gained through adorsolateral approach using a 1.25 mm Kirschner wiremounted on a cordless motorized drill (TRS Modular Dri-ver; Synthes, Bettlach, Switzerland). The wire was drilledthrough the left iliac bone until it reached the osteochondrallesion. Then a previously cannulated 11-mm-diameter lap-aroscopic bladeless trocar (Endopath Xcel; Ethicon Endo-Surgery, Guaynabo, Puerto Rico) was inserted on theKirschner wire and advanced to the contact with the outercortex of left iliac bone, to protect the surrounding softtissues (Fig. 3A). A cannulated drill bit was subsequentlymounted on the Kirschner wire in a coaxial fashion, and theleft iliac bone was bored until contact was obtained with theosteochondral fragment (Fig. 3B). The retrieved materialwas sent for histopathologic examination and was consis-tent with the diagnosis of OCD (Fig. 4). The sacral aspect ofthe anterior portion of left SI joint was then also drilled inorder to promote joint arthrodesis. Because the differentialFig. 1 Axial (A) and coronal-reformatted (B) unenhanced CTimages of the pelvis display a well-circumscribed osteochondrallesion (arrowhead) of the anterior portion of left SI joint. Theosteochondral fragment originates from the left iliac bone andmeasures 7.5 9 4 9 10 mm. It is surrounded by peripheral osteo-sclerosis. No periosteal reaction is seenFig. 2 Axial fused single-photon emission computed tomography—CT image of the pelvis after intravenous administration of 736 MBqof technetium-99 m—dicarboxy-propane-diphosphonate demonstratesincreased tracer uptake in the sacral aspect (arrow) of the anteriorportion of left SI joint. There is no abnormal tracer accumulation in theosteochondral lesion (arrowhead) detached from the left iliac bone964 F. Becce et al.: Percutaneous Treatment OCD SI Joint123diagnosis of osteoid osteoma could not be completelyexcluded before the procedure, radiofrequency (RF) abla-tion was performed after suction of blood and debris. A20 gauge RF cannula bearing a 5 mm curved tip (RFK;Cosman Medical, Burlington, MA) was inserted through thelaparoscopic trocar and connected to the RF generator(RFG-3C; Radionics, Burlington, MA). After controllingthe accurate position of the RF probe tip by CT fluoroscopy(Fig. 3C), the ablation was achieved by gradually increas-ing the tip temperature to 80C and maintaining it for 4 min.Finally, an absorbable hemostatic plug (Tabotamp; Ethicon,Neuchaˆtel, Switzerland) was inserted into the drilled bonecanal (Fig. 3D) to prevent prolonged bleeding. The skinwas then stitched and a dry dressing applied. The wholeprocedure, from skin incision to wound closure, lastedabout 60 min, and the radiation dose was approximately8.8 mSv (dose–length product = 465 mGy cm).Follow-up pelvic CT scans were obtained immediatelyand 6 h after the procedure to control a small hematoma inthe left gluteus medius muscle. The next day, the patient wasallowed to bear full weight on his left lower limb according topain, and he left the hospital. At 3 months, the pain wasgreatly reduced (visual analog scale score decreased from 7to 2), but slight discomfort persisted in the left groin. Thesesymptoms completely disappeared within the next fewweeks. At 6 months, the patient was asymptomatic, andfollow-up pelvic MR imaging revealed minimal residualbone marrow edema and arthrodesis of the anterior portion ofleft SI joint (Fig. 5). More than a year after the intervention,the patient is still free of symptoms.Fig. 3 Periprocedural axialunenhanced pelvic CTfluoroscopy images. A First, aKirschner wire is drilledthrough the left iliac bone with adorsolateral approach untilreaching the osteochondrallesion. A laparoscopic bladelesstrocar is then inserted on thewire and advanced to thecontact with the outer cortex ofleft iliac bone, in order toprotect the surrounding softtissues. B A cannulated drill bitis subsequently mounted on theKirschner wire in coaxialfashion, and the left iliac bone isbored until contact is achievedwith the osteochondralfragment. C A RF ablationcannula is then inserted throughthe laparoscopic trocar, and theprobe tip is positioned in theregion of the formerosteochondral lesion. D Finally,an absorbable hemostatic plug isplaced through the laparoscopictrocar into the drilled bone canalto prevent prolonged bleedingFig. 4 Photomicrograph of the retrieved osteochondral specimenreveals avascular hyaline cartilage (dagger) and necrotic subchondralbony trabeculae (asterisk). No osteoid matrix or anastomosing bonytrabeculae with osteoblastic rimming are observed. There are noinflammatory cells. Hematoxylin and eosin; original magnification,950F. Becce et al.: Percutaneous Treatment OCD SI Joint 965123DiscussionOCD (also called osteochondrosis) is a pathologic processthat primarily affects the subchondral bone of joints, andmay secondarily involve the articular cartilage. More than150 years after Pare´ described the first case of loose bodiesretrieval and Ko¨nig coined the controversial term ‘‘osteo-chondritis dissecans’’ [7], its etiology remains unclear [1, 8,12]. Trauma in specific and susceptible locations plays amajor role, and about 40% of patients with OCD of the kneehave a history of trauma [1, 8]. However, the pathogenesisseems multifactorial and ischemic; accessory centers ofossification as well as genetic theories have been proposed[1, 8, 12]. The overall incidence of OCD varies between 15and 60 cases per 100,000 in the general population [1, 2]. Amale predominance exists, with a male–female ratio of 2:1to 4:1 [1, 8]. The juvenile form of the disease affects chil-dren (with open physes) between 5 and 15 years, whereasthe adult form involves patients (with closed physes) from16 to 50 years [8]. The knee is the most frequently affectedjoint (approximately 75% of cases), with the lateral aspectof the medial femoral condyle being involved in about 80%of cases [3]. The ankle (particularly the talar dome) and theelbow (specifically the humeral capitellum) are also com-monly affected [12]. Bilateral lesions may be found in 5 to30% of cases [3, 8, 12].Cases of OCD of the hip (mainly the femoral head butalso the acetabular roof) [12, 13], the shoulder (the humeralhead and glenoid fossa) [12, 13], and the wrist [12, 14]joints have less often been reported in the literature. To ourknowledge, OCD of the SI joint is extremely rare, and onlya few cases have been published so far, in German andFrench [4–6].The diagnosis of OCD is challenging because symptomsare often vague and nonspecific, and depend on the stage ofthe disease [1, 8, 12]. Patients may present with variablepain, swelling, and catching and/or locking of joints, andthe physical findings tend to be inconclusive. At the SIjoint, the diagnosis is even more difficult and may beconsidered as one of exclusion [4, 5]. Indeed, inflammatoryor infectious disorders must be first excluded [4, 5, 11].OCD is rather a radiological diagnosis. Conventionalradiographs typically display a well-circumscribed area ofsclerotic subchondral bone separated from the epiphysis bya radiolucent line [3]. CT is helpful to precisely delineatethe osteochondral lesions [3]. Bone scintigraphy and MRimaging have been used to evaluate the healing potential ofthe defects [3, 15]. Furthermore, MR imaging has proven tobe useful to differentiate between stable and unstablelesions and to direct clinical management [1, 3, 15].The treatment of OCD is still debated and depends onthe patient’s age, the affected joint and its degree ofinvolvement, and the experience of the orthopedic surgeon[1, 8, 15]. Conservative treatment should be emphasized inyoung patients with open physes, while a more aggressiveapproach is recommended in older symptomatic patientsbecause 30 to 50% of stable OCD lesions fail to progresstoward healing [8, 15]. Treatment options include intra- orextra-articular drilling, mosaicplasty, fixation, autologouschondrocyte transplantation, or debridement [10, 15]. Atthe knee, treatment should promote revascularization ofsubchondral bone and restoration of articular surfacescongruity by fragment replacement, with or without bonegrafting [12]. Lesions of the ankle and elbow are usuallytreated with debridement and subchondral curettage ordrilling [12]. Recently, image-guided extra-articular dril-ling techniques proved to be clinically effective in selectedpatients [10]. The main advantages of minimally invasiveprocedures are decrease in total rehabilitation time,decrease in length and cost of hospitalization, and avoid-ance of open surgery with its associated risk of infection[9, 10, 16].In our case, failure of conservative treatment promptedintervention. Because of the complex anatomy of the SIjoint and its close relationship to vital soft tissues,arthroscopy or open arthrotomy could not be safely andeffectively performed [17, 18]. Thus, a percutaneous CT-guided procedure was planned. Given the current relativelack of instrumentation for MR- guided interventions [10],CT guidance was preferred. Moreover, CT-guided inter-ventions on the SI joints have already been shown to betechnically feasible, safe, and effective in the treatment ofsacral disruptions and nonunions [16, 17]. CT is also farmore accessible in clinical practice, and metal artifacts area minor issue, even with low-dose CT imaging [16].Finally, although radiation dose may be a concern inchildren, this is a minor one with CT fluoroscopy guidancein adults.Fig. 5 Follow-up axial gadolinium-enhanced fat-suppressed T1-weighted (TR/TE = 425/9) turbo spin echo MR image of the pelvisshows fusion (arrowhead) of the anterior portion of left SI joint.Minimal residual bone marrow edema is noted in the sacral aspect ofthe SI joint. The drilled left iliac bone canal is still visible966 F. Becce et al.: Percutaneous Treatment OCD SI Joint123In conclusion, a high index of suspicion is needed forthe diagnosis of OCD of the SI joint in patients with long-lasting SI joint pain of unknown origin. The case presentedhere demonstrates that percutaneous CT-guided treatmentof OCD of the SI joint may be technically feasible, safe,and effective. However, further studies with large numbersof patients are needed to consider this technique as a validalternative when conservative treatment fails.Acknowledgment The authors thank Dr. Emilie Uldry for her helpin providing the surgical equipment, and Dr. Vincent Mino for filmingand editing the electronic supplementary material.Conflict of interest The authors declare that they have no conflictof interest.References1. Federico DJ, Lynch JK, Jokl P (1990) Osteochondritis dissecansof the knee: a historical review of etiology and treatment.Arthroscopy 6:190–1972. Obedian RS, Grelsamer RP (1997) Osteochondritis dissecans ofthe distal femur and patella. Clin Sports Med 16:157–1743. Bohndorf K (1998) Osteochondritis (osteochondrosis) dissecans:a review and new MRI classification. Eur Radiol 8:103–1124. Robert M, Moulies D, Alain JL (1984) Sacroiliac osteochondritis.Chir Pediatr 25:338–3405. Delbart P, Delcambre B, D’eshougues JR (1976) Sacro-iliacosteochondritis. 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Clin J Pain 21:446–45512. Schenck RC Jr, Goodnight JM (1996) Osteochondritis dissecans.J Bone Jt Surg Am 78:439–45613. Berthelot JM, Huguet D, Bertrand-Vasseur A et al (2000)Chondritis dissecans of concave articular surfaces (acetabulumand glenoid fossa). Two case reports. Jt Bone Spine 67:238–24114. Aghasi M, Rzetelni V, Axer A (1981) Osteochondritis dissecansof the carpal scaphoid. J Hand Surg Am 6:351–35215. Cahill BR (1995) Osteochondritis dissecans of the knee: treat-ment of juvenile and adult forms. J Am Acad Orthop Surg3:237–24716. Huegli RW, Messmer P, Jacob AL et al (2003) Delayed union ofa sacral fracture: percutaneous navigated autologous cancellousbone grafting and screw fixation. Cardiovasc Intervent Radiol26:502–50517. Amoretti N, Hovorka I, Marcy PY et al (2009) Computed axialtomography-guided fixation of sacroiliac joint disruption: safety,outcomes, and results at 3-year follow-up. Cardiovasc InterventRadiol 32:1227–123418. Borra V, Serra MJ, Rubel IF (2006) Trans-iliac removal of bulletfragments from the sacroiliac joint. J Orthop Trauma 20:52–55F. Becce et al.: Percutaneous Treatment OCD SI Joint 967123

Percutaneous CT-Guided Treatment of Osteochondritis Dissecans of the Sacroiliac Joint

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Percutaneous CT-Guided Treatment of Osteochondritis Dissecans of the Sacroiliac Joint

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