Variation in Surgical Treatment of Knee Osteochondritis Dissecans (OCD) Among High-Volume OCD Surgeons

OBJECTIVES: Clinical practice guidelines (CPG) for osteochondritis dissecans (OCD) of the knee have demonstrated lower levels of evidence for treatment of this condition. Elucidating variation in treatment is a national priority within healthcare, due to evidence demonstrating that reduction of unnecessary variation can improve outcomes, lower costs, and increase value. The purpose of this study was to assess surgical treatment variation for OCD amongst 20 surgeon-investigator members of an international multi-center OCD study group. METHODS: Using a validated arthroscopy classification system, surgeons were queried as to which, amongst 5 different surgical treatment ‘principles’ should be applied for each of 6 different arthroscopic OCD presentations in both skeletally immature and mature patients. The process was repeated with an expanded set of 12 different surgical ‘techniques’ for each of the arthroscopy categories. Intra-class correlation coefficients (ICC) were calculated across all surgeons amongst 5 ‘principles’ and amongst 12 ‘techniques’, as well as for each individual arthroscopic presentation. RESULTS: When assessing the most prevalent treatment ‘principles’ overall, agreement between surgeons was excellent (ICC = 0.79, 95% CI 0.58-0.96) for skeletally immature knees and good (ICC = 0.74, 0.51-0.95) for skeletally mature knees. Agreement of selected treatment ‘principles’ for each individual arthroscopic presentation ranged from excellent to poor, with more advanced-stage lesion presentations yielding poorer agreement. For selection of specific surgical ‘techniques’, agreement was poor for both for skeletally immature knees (ICC = 0.27, 0.09-0.71) and skeletally mature knees (ICC = 0.0, 0.0-0.95), and fair to poor for the individual arthroscopic presentations. CONCLUSION: High volume OCD surgeons demonstrated good to excellent agreement on the optimal treatment ‘principles’ to apply for the various arthroscopic presentations of knee OCD, but agreement worsens as lesion stage becomes more advanced. Agreement on application of specific surgical ‘techniques’ is consistently poor, suggesting high variation in surgical approaches, even amongst high volume surgeons.Substantiating agreement for surgical ‘principles’ of knee OCD with higher levels of evidence is important, given what the CPG has revealed about literature on OCD. More importantly, the lack of agreement regarding surgical techniques makes multi-center investigations into outcomes following different techniques a critical research initiative in the future. Higher quality prospective research may reduce variation and improve outcomes in surgical techniques for OCD.