Bartley, Debra L

Berard, Roberta A

Jackson, Bradley C

English

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Western University Scholarship@Western Paediatrics Publications Paediatrics Department 3-1-2020 Osteochondritis Dissecans in Pediatric Patients with Juvenile Idiopathic Arthritis. Bradley C Jackson Debra L Bartley Roberta A Berard rberard2@uwo.ca Follow this and additional works at: https://ir.lib.uwo.ca/paedpub  Part of the Pediatrics Commons Citation of this paper: Jackson, Bradley C; Bartley, Debra L; and Berard, Roberta A, "Osteochondritis Dissecans in Pediatric Patients with Juvenile Idiopathic Arthritis." (2020). Paediatrics Publications. 520. https://ir.lib.uwo.ca/paedpub/520 480 The Journal of Rheumatology 2020; 47:3Osteochondritis Dissecans in Pediatric Patients with JuvenileIdiopathic ArthritisTo the Editor: Joint pain and swelling are common symptoms of patients with juvenileidiopathic arthritis (JIA) with active joint inflammation. When patients withJIA have persistent pain or mechanical symptoms despite treatment of theirinflammation, other causes must be considered.      Osteochondritis dissecans (OCD) is a focal alteration of subchondralbone formation that causes softening of the overlying cartilage, which canprogress to instability, eventual osteochondral detachment, and earlyosteoarthritis1. Poorly localized knee pain with activity is common in earlyOCD lesions, and progresses to swelling, catching, or locking as the lesion becomes unstable1. The incidence in the general population is9.5–29/100,000, occurring 2–3.8 times more frequently in males thanfemales1,2,3. The most commonly affected joint is the knee1. Fifty-one to69% of knee lesions affect the medial femoral condyle (MFC), and16.5–33% affect the lateral femoral condyle (LFC)1,2,3. First-linemanagement is conservative, with 33.5% requiring surgical intervention4.Multiple theories regarding the etiology of OCD lesions have been proposed,including repetitive microtrauma, focal ischemia, and genetic predispo-sition1. König initially theorized an inflammatory etiology when coining theterm osteochondritis dissecans5. Despite major advances in the under-standing of OCD, many issues regarding its pathophysiology remainunresolved6.       Our study has received the approval of the Western Research EthicsBoard and Lawson Research Ethics Board (approval number R-19-269).Informed telephone consent was obtained from each patient or his or hersubstitute decision maker.  The Western Research Ethics Board waived therequirement for written consent on the basis that many of the patients attendin-person hospital visits infrequently.      We identified 10 patients between January 2010 and June 2018 with JIAwho were found to have OCD as the cause of knee pain and mechanicalissues. During this period our clinic saw 20–25 new cases of JIA per year.       Table 1 describes the clinical characteristics of patients with concomitantJIA and OCD. Nine of the patients were female. The mean age of patientsat the time of JIA diagnosis was 6.16 ± 3.74 years (mean ± SD). There were2 patients with psoriatic, 3 oligoarticular, 1 extended oligoarticular, 3polyarticular arthritis, and 1 patient with systemic JIA. Eight of 10 patientsreceived methotrexate at some point during their treatment. Four patientsreceived biologics. Of these, 3 initially received a tumor necrosis factor-αinhibitor (adalimumab, infliximab, or etanercept), and the third, withsystemic JIA, initially received anakinra.      Table 2 describes the characteristics of OCD lesions. All patients hadknee radiographs followed by magnetic resonance imaging (MRI).Indications for imaging were persistent or focal pain, catching or locking,or trauma. Six patients had lesions involving the right knee, and 4 hadlesions involving the left knee. Four lesions involved the MFC, 4 involvedthe LFC, and 2 involved the patella.      The mean age of patients at the time of diagnosis with OCD was 10.85± 1.74 years (mean ± SD). The mean interval between JIA and OCDdiagnosis was 4.69 ± 4.50 years (mean ± SD). All patients had JIA-relateddisease activity in the joint affected by OCD. Three patients had an existingOCD lesion at the time of JIA diagnosis. All 7 patients with JIA onset priorto the diagnosis of OCD received intraarticular glucocorticoid injections ofthe joint subsequently affected by OCD. The number of joint injectionsvaried between 1 and 5. Patients 2 and 7 reported previous minor falls ontothe subsequently affected knee, and patient 10 had OCD identified duringimaging following a kick to the flexed knee during a soccer game. Fourpatients without mechanical symptoms underwent nonoperative manage-ment with rest and activity modification, including avoidance of high-impactsports and repetitive load-bearing activities. Six patients with locking orworsening pain underwent arthroscopic examination. Of these, 5 lesionswere debrided, 1 was microfractured, and 1 received transarticular drilling.Outcomes are listed in Table 2.      In patients with JIA who have persistent or focal joint pain, or atypicalsymptoms such as catching or locking, alternative diagnoses such as OCDshould be considered, particularly when these symptoms are present whileinflammatory disease is clinically inactive. Imaging with radiographs andMRI can help clarify the diagnosis. In contrast to previous epidemiologicstudies, this population was mostly female; the distribution of lesions wasatypical (the LFC was affected as often as the MFC, and 2 patellar lesionswere identified); and 50% of the patients required surgical management.The atypical sex and anatomic distributions are in agreement with previousstudies by Kröger, et al7 and Kubo, et al8.      The etiology of OCD in patients with JIA compared with healthychildren affected with OCD may be different. Persistent synovitis mayincrease the risk of cartilage damage9 and the development of OCD; gluco-corticoid injections may affect the risk of developing OCD through effectson cartilage metabolism10 and mechanical disruption of the articular surface;and altered gait biomechanics related to joint pain may change load distri-bution in joints affected by JIA. Further prospective studies are needed toTable 1. Demographics and clinical characteristics of patients with JIA and OCD.Patient       Sex            Age at JIA   Time from JIA           ILAR                                 DMARD                        Knee   No. Injections                 OCD                                Diagnosis, yrs     to OCD         Classification                                                               Affected    in Knee                  Lesion                                                       Diagnosis, yrs                                                                                            by JIA Affected by JIA                                                                                                                                                                                                                        L                R                    1*                F                   10.9                –0.2                 Psoriatic                                 MTX                              R                     —               1                  R2                  F                    1.0                 10.5              Polyarthritis                MTX, LEF, HCQ, ADA          L and R                 1                2                  R3                  F                    8.4                  4.1               Polyarthritis                               MTX                              L                       1               —                 L4                  F                    7.4                  3.1                  Psoriatic                                 MTX                         L and R                 3                1                  L5                  F                    1.2                  8.4               Polyarthritis                MTX, ETN, ADA, IFX,          L and R                 3                5                  R                                                                                                                         ABA, TCZ, LEF, Pred6*                F                   10.5                –0.1              Oligoarthritis                                —                            L and R                 1                1                  R7                  F                    3.1                  7.5               Oligoarthritis               MTX, LEF, ADA, TCZ           L and R                 0                1                  R8                  F                    3.0                  11.6                 Systemic              MTX, LEF, ANA, TCZ, Pred      L and R                 4                2                  L9                  F                    7.9                  1.9       Oligoarthritis extended                      MTX                         L and R                 3                2                  L10*             M                   8.3                 –0.1              Oligoarthritis                                —                                 R                     —               0                  R* OCD lesion present at the time of JIA diagnosis. JIA: juvenile idiopathic arthritis; OCD: osteochondritis dissecans; ILAR: International League of Associationsfor Rheumatology; DMARD: disease-modifying antirheumatic drugs; MTX: methotrexate; LEF: leflunomide; HCQ: hydroxychloroquine; ADA: adalimumab;IFX: infliximab; ABA: abatacept; TCZ: tocilizumab; ETN: etanercept; Pred: prednisone; ANA: anakinra.Personal non-commercial use only. The Journal of Rheumatology Copyright © 2020. All rights reserved. www.jrheum.orgDownloaded on June 3, 2021 from 481Letterbetter characterize the contribution of these factors to the development ofOCD lesions in patients with JIA.BRADLEY C. JACKSON, MD, MSc; DEBRA L. BARTLEY, MD;ROBERTA A. BERARD, MD, MSc, Department of Paediatrics, Children’sHospital, London Health Sciences Centre, London, Ontario, Canada.Address correspondence to Dr. R.A. Berard, Department of Paediatrics,800 Commissioners Road E, London, Ontario N6A 5W9, Canada. E-mail: Roberta.berard@lhsc.on.caREFERENCES   1.    Bray CC, Watson ST. Current review of juvenile osteochondritisdissecans of the knee. Curr Orthop Pract 2015;26:466-74.    2.    Kessler JI, Nikizad H, Shea KG, Jacobs JC, Bebchuk JD, Weiss JM.The demographics and epidemiology of osteochondritis dissecans ofthe knee in children and adolescents. Am J Sports Med2014;42:320-6.    3.    Lindén B. The incidence of osteochondritis dissecans in thecondyles of the femur. Acta Orthop Scand 1976;47:664-7.    4.    Weiss JM, Nikizad H, Shea KG, Gyurdzhyan S, Jacobs JC,Cannamela PC, et al. The incidence of surgery in osteochondritisdissecans in children and adolescents. Orthop J Sport Med2016;4:2325967116635515.    5.    König F. The classic: on loose bodies in the joint [translated fromGerman]. Clin Orthop Relat Res 2013;471:1107-15.    6.    Accadbled F, Vial J, Sales de Gauzy J. Osteochondritis dissecans ofthe knee. Orthop Traumatol Surg Res 2018;104:S97-105.    7.    Kröger L, Piippo-Savolainen E, Tyrväinen E, Penttilä P, Kröger H.Osteochondral lesions in children with juvenile idiopathic arthritis.Pediatr Rheumatol Online J 2013;11:18.    8.    Kubo H, Oommen PT, Hufeland M, Heusch P, Laws HJ, Krauspe R,et al. Osteochondritis dissecans shows a severe course and pooroutcome in patients with juvenile idiopathic arthritis: a matched pairstudy of 22 cases. Rheumatol Int 2018;38:1705-12.    9.    Prakken B, Albani S, Martini A. Juvenile idiopathic arthritis. Lancet2011;377:2138-49.  10.    Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articularcorticosteroids on articular cartilage: a systematic review. Orthop JSport Med 2015;3:2325967115581163. First Release January 15 2020; J Rheumatol 2020;47:3;doi:10.3899/jrheum.190731Table 2. Characteristics of OCD lesions in patients with JIA.Patient                        Age at OCD                     OCD Lesion                Previous Injury                        Surgery                                     Outcome                                 Diagnosis, yrs                       Location                   of Affected Joint1*                                      10.7                                 R LFC                               No                      R knee debridement and              Ongoing mechanical                                                                                                                                                        transarticular drilling                  symptoms and pain2                                        11.5                                 R LFC                 Fall on R knee while          R knee debridement              Resolution of mechanical                                                                                                         playing as a hockey goalie      and microfracturing                  symptoms and pain3                                        12.5                                 L MFC                               No                      L knee arthroscopy only           Resolution of mechanical                                                                                                                                                                                                             symptoms and pain4                                        10.5                                 L LFC                                No                                     None                             Gradual resolution of                                                                                                                                                                                                      symptoms and MRI findings5                                         9.6                                 R MFC                               No                         R knee debridement              Resolution of mechanical                                                                                                                                                                                                             symptoms and pain6*                                      10.4                                R MFC                               No                                     None                          No symptom progression7                                        10.6                         R medial inferior             Fall on R knee               R knee debridement              Resolution of mechanical                                                                                 patella                       while skating                                                               symptoms, ongoing pain8                                        14.6                          L central patella                        No                         L knee debridement              Resolution of mechanical                                                                                                                                                                                                             symptoms and pain9                                         9.8                                  L MFC                               No                                     None                             Ongoing L knee pain10*                                     8.2                                  R LFC                  Fall and kick to the                        None                          No symptom progression                                                                                                             R knee during soccer                                             * OCD lesion present at the time of JIA diagnosis. OCD: osteochondritis dissecans; JIA: juvenile idiopathic arthritis; L: left; LFC: lateral femoral condyle;MFC: medial femoral condyle; R: right; MRI: magnetic resonance imaging.Personal non-commercial use only. The Journal of Rheumatology Copyright © 2020. All rights reserved. www.jrheum.orgDownloaded on June 3, 2021 from 

Osteochondritis Dissecans in Pediatric Patients with Juvenile Idiopathic Arthritis.

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Osteochondritis Dissecans in Pediatric Patients with Juvenile Idiopathic Arthritis.

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