Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

knee

1st line – conservative management

Back
ACUTE
|
knee
|
stable lesion, without malalignment
1st line – 

conservative management

The goal of conservative non-operative treatment is to promote healing of lesions in situ and prevent lesion displacement.[5] Treatment includes activity modification, protected weight-bearing, short-term immobilisation and pain relief.

Phases of treatment are as follows:

Initial phase includes 4 to 6 weeks' immobilisation with crutch-protected partial weight-bearing

Phase 2 consists of 6 weeks with weight-bearing as tolerated and gentle strengthening programme without immobilisation, but no sport or repetitive impact activities

Phase 3 is a supervised sport readiness programme.

50% of juvenile osteochondritis dissecans lesions will heal within 10 to 18 months in patients who comply with management.[2]

Primary options

ibuprofen: children <12 years of age: up to 30 mg/kg/day orally given in 3-4 divided doses; children >12 years of age and adults: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

or

naproxen: children >2 years of age: 10-20 mg/kg/day orally given in divided doses every 8-12 hours, maximum 1000 mg/day; adults: 250-500 mg orally every 12 hours, maximum 1500 mg/day

-- AND / OR --

paracetamol: children <12 years of age: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; children >12 years of age and adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – transchondral or retroarticular drilling

Back
ACUTE
|
knee
|
stable lesion, without malalignment
Consider – 

transchondral or retroarticular drilling

Additional treatment recommended for SOME patients in selected patient group

Surgical treatment for stable skeletally immature and mature lesions with normal articular cartilage involves drilling the subchondral bone with the intention of stimulating vascular ingrowth and subchondral bone healing.[3]

Success of transchondral and retroarticular drilling is better in skeletally immature patients, but the technique is warranted in all patients with a stable lesion where conservative management has failed.

1st line – conservative management

Back
ACUTE
|
knee
|
stable lesion, with malalignment
1st line – 

conservative management

Conservative non-operative treatment involves a period of activity modification, protected weight-bearing, and immobilisation with a goal of symptom relief and lesion healing.

Phases of treatment are as follows:

Initial phase includes 4 to 6 weeks' immobilisation with crutch-protected partial weight-bearing

Phase 2 consists of 6 weeks with weight-bearing as tolerated and gentle strengthening programme without immobilisation, but no sport or repetitive impact activities

Phase 3 is a supervised sport readiness programme.

Primary options

ibuprofen: children <12 years of age: up to 30 mg/kg/day orally given in 3-4 divided doses; children >12 years of age and adults: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

or

naproxen: children >2 years of age: 10-20 mg/kg/day orally given in divided doses every 8-12 hours, maximum 1000 mg/day; adults: 250-500 mg orally every 12 hours, maximum 1500 mg/day

-- AND / OR --

paracetamol: children <12 years of age: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; children >12 years of age and adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Consider – osteotomy

Back
ACUTE
|
knee
|
stable lesion, with malalignment
Consider – 

osteotomy

Additional treatment recommended for SOME patients in selected patient group

Lower extremity alignment should be assessed with a full-length lower extremity film. If malalignment exists and the weight-bearing line passes through the involved compartment, some orthopaedic surgeons will consider an osteotomy to unload the involved compartment.[3]

1st line – arthroscopy with surgical intervention

Back
ACUTE
|
knee
|
unstable lesion, without full-thickness defects of articular cartilage
1st line – 

arthroscopy with surgical intervention

Non-operative treatment of unstable lesions results in joint incongruity, prolonged pain, and risk of early degenerative joint disease. Simple removal of loose lesions has been shown to have poor results.[43]

The current recommended treatment for a loose fragment that is not macerated or fragmented is arthroscopic assisted internal fixation. A variety of options exist with regard to the method of fixation.[44] The technique used is at the discretion of the treating orthopaedic surgeon.

If a large defect of subchondral bone exists, bone grafting may be necessary to fill the void and restore the articular congruency when the osteochondritis dissecans lesion is fixed.[5]

1st line – arthroscopy and salvage techniques

Back
ACUTE
|
knee
|
unstable lesion, with full-thickness defects of articular cartilage
1st line – 

arthroscopy and salvage techniques

Several techniques for salvage of full-thickness defects exist, including microfracture, autologous chondrocyte implantation, mosaicplasty, and osteochondral allograft. Each of these techniques has advantages and disadvantages. There is no superior standard treatment at this point, and the technique used is largely at the discretion of the treating orthopaedic surgeon.[45][46][47][48]

elbow

1st line – conservative management

Back
ACUTE
|
elbow
|
stable lesion at presentation, with intact articular cartilage and in-situ subchondral fragments
1st line – 

conservative management

Initial treatment should be conservative management, which can include non-steroidal anti-inflammatory drugs (NSAIDs). Athletes should be instructed to avoid sport and other aggravating activities for 3 to 6 weeks until symptoms subside. Some consultants recommend a hinged elbow brace for protection. Physiotherapy begins once symptoms have abated. Unrestricted sport activity may begin 3 to 6 months after treatment is initiated.

Conservative management has shown favourable results when the lesion is detected early.[38]

Primary options

ibuprofen: children <12 years of age: up to 30 mg/kg/day orally given in 3-4 divided doses; children >12 years of age and adults: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

or

naproxen: children >2 years of age: 10-20 mg/kg/day orally given in divided doses every 8-12 hours, maximum 1000 mg/day; adults: 250-500 mg orally every 12 hours, maximum 1500 mg/day

-- AND / OR --

paracetamol: children <12 years of age: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; children >12 years of age and adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

2nd line – arthroscopy and surgical intervention

Back
ACUTE
|
elbow
|
stable lesion at presentation, with intact articular cartilage and in-situ subchondral fragments
2nd line – 

arthroscopy and surgical intervention

For patients with persistent or worsening symptoms despite 6 weeks of conservative care, loose bodies, or evidence of instability including violation of intact cartilage or detachment, the only universally accepted treatment regimen is the removal of intra-articular loose bodies.[8][39][49][50][51][52]

At this time there is insufficient evidence supporting the use of either osteochondral allograft or autologous chondrocyte implantation for osteochondritis dissecans lesions in the elbow.

ankle (talus)

1st line – conservative management

Back
ACUTE
|
ankle (talus)
|
asymptomatic lesions, low-symptomatic lesions, stable lesions with intact articular surface
1st line – 

conservative management

Initial treatment for these lesions should include rest, temporarily protected weight-bearing, and, in the case of giving way, short-term immobilisation with an orthosis. NSAIDs are used for symptomatic pain relief.

Evidence for successful treatment for talar juvenile osteochondritis dissecans using conservative management is not encouraging. One series reported that 77% of patients treated with 6 months of conservative therapy continued to have symptoms and persistent lesions on radiograph.[40] An additional 6 months of conservative management for those patients with persistent lesions resulted in 42% eventually having surgery for unhealed lesions and pain.

Primary options

ibuprofen: children <12 years of age: up to 30 mg/kg/day orally given in 3-4 divided doses; children >12 years of age and adults: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

or

naproxen: children >2 years of age: 10-20 mg/kg/day orally given in divided doses every 8-12 hours, maximum 1000 mg/day; adults: 250-500 mg orally every 12 hours, maximum 1500 mg/day

-- AND / OR --

paracetamol: children <12 years of age: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; children >12 years of age and adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

1st line – surgical intervention

Back
ACUTE
|
ankle (talus)
|
failure of conservative treatment, intra-articular loose bodies, or lesion becomes unstable
1st line – 

surgical intervention

The best current available treatment for primary osteochondral ankle defects that are too small for fixation is excision, debridement, and drilling.[42]

With lesions >15 mm, fixation with lag screws is preferred. Large talar cystic lesions can be treated with retrograde drilling and filling the gap with bone graft.

In cases of failed primary treatment, an osteochondral transplant or cultured chondrocyte transplant can be considered.[41] Each of these techniques has advantages and disadvantages. Studies have yet to show which salvage technique provides the best outcome.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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