Osteochondritis Dissecans of the Lateral Femoral Condyle

Following Total Resection of the Discoid Lateral Meniscus

Hiroshi Mizuta, M.D., Eiichi Nakamura, M.D., Yutaka Otsuka, M.D.,

Satoshi Kudo, M.D., and Katsumasa Takagi, M.D.

Purpose: The purpose of this study was to describe the clinical presentation of 6 athletically active
children with symptomatic osteochondritis dissecans (OCD) of the lateral femoral condyle following
total resection for a torn discoid lateral meniscus and to discuss its cause. Type of Study: Case series.
Methods: Six patients in whom OCD affecting the lateral femoral condyle developed after total
resection of the discoid lateral meniscus participated in a detailed clinical, radiologic, and arthro-
scopic review. The average age at the time of meniscectomy was 9 years (range, 6 to 12 years). At
a mean of 50 months (range, 36 to 65 months) after surgery they developed recurrent pain in the
treated knee; all had radiologic abnormalities at the lateral femoral condyle consistent with OCD.
Before the recurrence of pain, all patients had been continuously engaged in sports activity.
Radiologic and arthroscopic findings of the OCD lesions were assessed. Clinical outcomes of surgical
treatment for OCD were also documented. Results: The radiographic evaluation showed all lesions
to be in the central portion of the lateral femoral condyle on the anteroposterior views and posteriorly
next to a line extending distally from the posterior femoral cortex on the lateral views. Arthroscopic
evaluation revealed softening in 2 knees, a separated fragment in 2 knees, and a completely loose
fragment in 2 knees. All lesions were treated surgically, including 2 drillings of the lesion, 2 fixations
of separated fragment, and 2 excisions of loose bodies with drilling. At an average follow-up period
of 51 months (range, 22 to 77 months), all patients but 1 were asymptomatic. Conclusions: Repeated
impaction in sports activities on the immature osteochondral structures under altered mechanical
force transmission after total resection of the discoid meniscus might be a predisposing factor in the
development of OCD in the lateral femoral condyle. Key Words: Osteochondritis dissecans—
Lateral femoral condyle—Discoid lateral meniscus—Total meniscectomy.

O steochondritis dissecans (OCD) in the femoral

condyle is characterized by partial or complete
separation of a segment of articular cartilage together
with subchondral bone from the underlying bone, usu-
ally seen in children through young adults.1 This con-
dition is well documented in the orthopaedic litera-
ture, but its incidence is relatively infrequent. Lindén2
From the Department of Orthopaedic Surgery, Kumamoto Uni-
versity School of Medicine; and Inoue Hospital (Y.O.), Kumamoto,
Japan.
Address correspondence and reprint requests to Hiroshi Mizuta,
M.D., Department of Orthopaedic Surgery, Kumamoto University
School of Medicine, 1-1-1 Honjo, Kumamoto-city 860-8556, Ja-
pan. E-mail: mizuta@kaiju.medic.kumamoto-u.ac.jp
© 2001 by the Arthroscopy Association of North America
0749-8063/01/1706-2575$35.00/0
doi:10.1053/jars.2001.19979
reported it to be 15 to 21 per 100,000 in his study of
a closed, stable population in Sweden. OCD affects
the medial femoral condyle more frequently than the
lateral femoral condyle, which is involved in approx-
imately 15% to 18% of reported cases.1,3
A discoid lateral meniscus is a congenital meniscal
anomaly that can produce knee symptoms such as
pain, limping, and snapping. Previous studies have
shown a significantly higher prevalence of discoid
meniscus in east Asian countries, including Japan.4,5
Ikeuchi et al.4 found it in 16.6% of the knees examined
arthroscopically. In Japan, knee disorders caused by a
discoid lateral meniscus is relatively common among
children and adolescents.
In this article we describe a series of 6 children who
underwent total resection for discoid lateral meniscus
tear with no preoperative evidence of OCD. They all

608 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 17, No 6 (July-August), 2001: pp 608 – 612
 OCD AFTER RESECTION OF DISCOID MENISCUS
developed recurrent pain of the involved knee at a
mean of 50 months after surgery, and all showed
radiologic abnormalities of OCD affecting the lateral
femoral condyle. Before the recurrence of pain, all 6
patients had participated in sports activities. We sug-
gest that total resection of the discoid meniscus might
be a predisposing factor of OCD of the lateral femoral
condyle in athletically active children.
METHODS
Between July 1988 and September 1997, 6 patients
(5 boys and 1 girl) with symptomatic OCD of the
lateral femoral condyle following total resection of the
discoid lateral meniscus presented at our department.
The left knee was involved in 5 patients and the right
knee in 1 patient.
Initial resection of the lateral discoid meniscus was
performed at our department and at affiliated hospi-
tals. Medical records of these patients, including pre-
operative history, physical examination, radiographs,
arthrograms, operative summaries, and videotapes of
their arthroscopic procedures were retrospectively re-
viewed. The primary complaint before surgery was
pain on the lateral side of the knee with limping,
locking, and/or snapping. Their ages at the time of
operation ranged from 6 to 12 years, with a mean of 9
years. After confirmation as the complete type of
discoid lateral meniscus by arthroscopy, total menis-
cectomy was undertaken by arthroscopic techniques in
3 knees and by open arthrotomy in 3. A tear was
identified in all menisci: longitudinal tears in 4 and
horizontal cleavage in 2. No evidence of OCD was
found in preoperative radiographs or arthrograms, and
there were no lesions of the chondral surface in the
lateral femoral condyle at the time of surgery.
Meniscectomy was successful, and all patients re-
sumed unrestricted activity without any symptoms
within 4 months. At a mean of 50 months after surgery
(range, 36 to 65 months), however, they developed
pain in the involved knee. All patients had been con-
tinuously engaged in sports activity (2 in judo, 2 in
baseball, 1 in soccer, and 1 in volleyball) for more
than 2 years before recurrence of pain and none had
any obvious history of trauma. The average age at
presentation was 13 years (range, 10 to 16 years). The
average duration of the symptoms at presentation was
8 months (range, 2 to 26 months). Two of 6 patients
complained of knee pain during sports participation.
The remaining 4 patients reported knee pain even
during activities of daily living and 2 of them had
occasional episodes of catching sensation. Physical
609
examination showed that all the patients had tender-
ness on the lateral joint space or the lateral femoral
condyle. Swelling was noted in 2 knees, and 2 knees
had limited motion. Plain radiographs revealed abnor-
malities at the lateral femoral condyle consistent with
OCD in every patient. The epiphyses were closed in 3
patients. Based on anteroposterior and lateral radio-
graphs, the anatomic location of the lesion was clas-
sified by the criteria of Cahill and Berg.6 The size of
the lesion was also measured. The stage of the lesion
was assessed according to the radiologic classification
of Brückl et al.7: stage 1, dawn stage; stage 2, obvious
translucency; stage 3, demarcation by sclerosis; stage
4, pronounced demarcation, lesion is sclerotic and
loosened; and stage 5, loose body.
Arthroscopic examination was performed in all 6
patients. The average duration of symptoms before
arthroscopic examination was 13 months (range, 5 to
40 months). Arthroscopic findings of the lesion were
graded according to the classification system de-
scribed by Johnson et al.8: grade 1, intact articular
cartilage, with the lesion being either stable or mobile;
grade 2, unstable, separated fragment; and grade 3,
completely loose fragment.
RESULTS
Details of the 6 patients are listed in Table 1.
Anteroposterior radiographs showed all OCD lesions
to be in the central portion of the lateral femoral
condyle, classified as Cahill and Berg’s location 4-5
(Fig 1A). The average medial lateral width of the
lesion was 1.7 cm (range, 1.5 to 2.0 cm), and the width
compared with that of the lateral femoral condyle
averaged 58% (range, 50% to 77%). On the lateral
radiographs, all lesions were located posteriorly next
to a line extending distally from the posterior femoral
cortex, corresponding to Cahill and Berg’s location C
(Fig 1B). The average anteroposterior length was 2.0
cm (range, 1.2 to 2.8 cm). According to Brückl’s
criteria of the radiologic staging, 2 knees were classi-
fied as stage 3, 2 as stage 4, and 2 as stage 5. At the
time of arthroscopic evaluation, OCD lesions were
confirmed in all patients and classified as grade 1 in 2
knees, grade 2 in 2, and grade 3 in 2. In 2 knees of
grade 1, the lesion showed softening on probing with
no disruption of the overlying articular cartilage.
On the basis of the arthroscopic grading, treat-
ment was performed as follows: In grade 1, the
lesions were treated with arthroscopic multiple dril-
ling guided by an image intensifier; in grade 2,
curettage of the base of the crater followed by screw
610 H. MIZUTA ET AL.

TABLE 1. Patient Data

Time to Age at OCD Lesion
Age at Recurrence Diagnosis
Meniscectomy of Pain of OCD Size (ML width ⫻ Radiological Arthroscopic
Patient Gender Side (yr) (mo)* (yr) Location† AP length, cm) Stage‡ Grade§

1 M L 8 46 12 4-5 C 2.0 ⫻ 2.2 3 1

2 M L 12 38 15 4-5 C 1.8 ⫻ 2.2 5 3
3 M R 9 55 15 4-5 C 1.8 ⫻ 2.8 4 2
4 M L 11 60 16 4-5 C 1.5 ⫻ 1.8 4 2
5 M L 6 36 10 4-5 C 1.5 ⫻ 1.2 3 1
6 F L 6 65 12 4-5 C 1.6 ⫻ 1.8 5 3

*Interval between meniscectomy and date knee pain recurred.

†Classification of Cahill and Berg.4
‡Classification of Brückl et al.5
§Classification of Johnson et al.6

fixation of the separated fragment with bone graft-
ing was performed through a medial arthrotomy; in
grade 3, excision of loose bodies and multiple dril-
ling of the base of the crater was undertaken arthro-
scopically. At the time of the latest follow-up with
an average period of 51 months (range, 22 to 77
months) after surgical treatment for OCD, 4 patients
were participating in competitive or recreational
sports. Three of these 4 patients (cases 1, 4, and 5)
were asymptomatic, and the other (case 3) had
occasional mild pain after vigorous sports activities.
The remaining 2 patients who underwent removal
of loose bodies and drilling (cases 2 and 6) had
discontinued sports activities on our advice, and
they had no symptoms at all. Radiographically, all
OCD lesions except 1 (case 6) improved, but 3
patients (cases 2, 3, and 4) showed mild articular
irregularity in the area of the lesions. Two patients
(cases 3 and 4) had sclerosis and osteophyte forma-
tion of the lateral tibial plateau, and 1 patient (case

FIGURE 1. Preoperative radiographs of case 3: OCD lesion was shown in (A) the central portion of the lateral femoral condyle and (B)
posteriorly next to a line extending distally from the posterior femoral cortex.
 OCD AFTER RESECTION OF DISCOID MENISCUS
2) showed a 2-mm narrowing of the lateral joint
space and flattening of the femoral condyle.
DISCUSSION
The precise cause of OCD lesions in the knee re-
mains unclear. Many investigators1,9-11 have sug-
gested trauma as the possible etiological factor, but
other factors have also been proposed. These include
ischemia,12 abnormality of ossification,13 and genetic
predisposition.14
The association of OCD in the lateral femoral con-
dyle with a torn discoid lateral meniscus in childhood
was first described by Irani et al.15 Since then,
Aichroth et al.16 found 7 knees with OCD affecting the
lateral femoral condyle in 62 knees with lateral dis-
coid meniscus injury in 52 children under 18 years of
age. Mitsuoka et al.17 studied clinical features of OCD
affecting the lateral femoral condyles and noted that
all patients in their series were in the growing period
and had a damaged lateral discoid meniscus. There-
fore, they suggested that repetitive abnormal stress on
weaker osteochondral structures in the growing period
by a damaged discoid meniscus was a cause of OCD
of the lateral femoral condyle.
Unlike the above-mentioned cases, all the patients
in our series had no evidence of OCD on preoperative
radiographic evaluation or operative findings at the
time of initial meniscectomy. Our patients had devel-
oped recurrent pain in the treated knee within 36 to 65
months after meniscectomy. On presentation, plain
radiographs first showed abnormalities consistent with
OCD, which was confirmed by subsequent arthro-
scopic evaluation. Late-onset of OCD after meniscec-
tomy suggests that the damaged lateral discoid menis-
cus itself may be an unlikely predisposing factor of
OCD in patients like ours. A few similar cases can be
found reported in the literature. Fujikawa18 and his
colleagues Nomoto et al.19 observed an OCD-like
change on radiographs in 9 knees in which total or
subtotal removal of the discoid lateral meniscus had
been performed in childhood, although 4 of them were
asymptomatic. Räber et al.20 reported that OCD in the
lateral femoral condyle developed in 2 of the 17
treated knees of children, 9 and 20 years after total
resection of the discoid meniscus.
Several experimental studies21,22 have shown that
chondral injury in early childhood develops patho-
logic features resembling OCD. Therefore, chondral
lesion concomitant with meniscal tear or iatrogenic
damage to the articular cartilage during arthroscopic
evaluation and meniscectomy may be considered a
611
triggering factor in the development of OCD. In our
patients, however, it was confirmed through a review
of videotapes of arthroscopic procedures and opera-
tive summaries at the time of meniscectomy that no
obvious lesion of the articular cartilage on the lateral
femoral condyle was seen either before or after me-
niscectomy.
Another possible explanation for the development
of OCD in our patients is that OCD may be a sequela
of the removal of the discoid meniscus. It has been
well established that a large proportion of the load in
the knee is carried by the menisci, and meniscectomy
causes a marked decrease in the contact area and a
significant increase in the load per unit area. Maquet et
al.23 found that the contact area ranged from 20 cm2 at
full extension to 11 cm2 at 90° of flexion in normal
knees, whereas these areas decreased to only 12 cm2
and 6 cm2, respectively, after removal of the menisci.
Baratz et al.24 reported that total meniscectomy caused
a decrease of approximately 75% in contact areas and
an increase of approximately 235% in the peak local
contact stress. Our patients had the following clinical
features in common: (1) Total resection of the discoid
meniscus in preadolescence; (2) engagement in sports
activities before the onset of OCD; and (3) location of
the OCD lesions in the lateral femoral condyle in the
weight-bearing area posteriorly next to a line drawn as
an extension of the posterior femoral cortex, which
was in contact with the tibia when the knee was in
mild flexion. Taking these observations into consider-
ation, we speculate that the repeated impaction in
sports activities on the immature osteochondral struc-
tures under altered mechanical force transmission af-
ter total resection of the discoid meniscus may have
been a contributing factor in the development of OCD
in our patients. Three of our 6 patients underwent the
initial meniscectomy at our department between 1984
and 1992, but OCD has not developed in 31 knees of
other children under 15 years of age who also under-
went total resection of the lateral discoid meniscus in
the same time period. Therefore, other intrinsic factors
may also be implicated in the development of OCD.18
The clinical outcome for total versus partial menis-
cectomy for discoid lateral meniscus is controversial.
Ikeuchi4 and Hayashi et al.25 reported better clinical
results in patients treated with total meniscectomy,
whereas Pellacci et al.26 stated that patients treated
with partial meniscectomy did better. Currently, par-
tial meniscectomy is preferred because it preserves the
biomechanical function of the meniscus.16,20,27,28 In
all of our patients and in those described by Räber et
al.,20 OCD developed after total resection of the dis-
612 H. MIZUTA ET AL.
coid lateral meniscus. In the series studied by Nomoto
et al.,19 7 knees had also undergone total meniscec-
tomy, and the remaining 2 had subtotal meniscectomy.
To our knowledge, no similar cases have been re-
ported after partial meniscectomy. This suggests the
possible contribution of the remnant meniscus to the
transmission of load in knees that have undergone
partial meniscectomy.24 We believe that total menis-
cectomy should be avoided whenever possible.
We have presented data on 6 patients in whom OCD
affecting the lateral femoral condyle developed after
total resection of the discoid lateral meniscus. The
relationship between total meniscectomy and OCD
remains speculative, and further investigation is
needed. However, this study shows that OCD should
be recognized as a possible cause of recurrent knee
pain after total resection of the discoid meniscus. The
symptoms of OCD are frequently vague and poorly
characterized in the earlier stages of the disease.29,30
Hence, for early detection of this condition, periodic
follow-up with plain radiographs is recommended af-
ter total resection of the discoid meniscus in the grow-
ing period, especially in athletically active children.
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