Optimizing surgical strategies for osteochondritis dissecans: integrating biological and mechanical enhancements across ICRS grades

PURPOSE: To evaluate and compare clinical and radiological outcomes of surgical strategies for osteochondritis dissecans (OCD) lesions across ICRS grades, and to investigate the impact of recipient hole drilling (RHD) as a biological augmentation to osteochondral grafting. METHODS: This retrospective study included 60 knees (ICRS grades 1-4) treated surgically from 2001 to 2022. Stable lesions (grade 1) were managed with either retrograde or antegrade drilling with bioabsorbable pin fixation. For unstable lesions (grades 2-3), in situ osteochondral autograft transfer (OATS) or detach-and-fix techniques were performed. Detached lesions (grade 4) underwent either mosaicplasty or fragment fixation. RHD was introduced in select OATS and mosaicplasty cases to stimulate subchondral bone remodeling. Outcomes were assessed using the Lysholm and Tegner scores and MOCART-based MRI evaluations. Statistical comparisons were performed across groups. RESULTS: Antegrade drilling resulted in significantly higher Lysholm, Tegner, and MOCART scores than retrograde drilling for ICRS grade 1 lesions. In situ OATS for ICRS 2-3 lesions showed superior clinical and radiological outcomes compared to detach-and-fix, with no reoperations. For ICRS 4 lesions, both mosaicplasty and fragment fixation yielded favorable outcomes, though only Tegner scores showed a significant difference. RHD tended to improve cartilage repair quality in OATS and mosaicplasty but did not reach statistical significance. CONCLUSIONS: Antegrade drilling and in situ OATS were superior to retrograde drilling and detach-and-fix, respectively. No statistically significant advantage was found between mosaicplasty and fragment fixation. RHD may enhance subchondral integration and healing, supporting its further evaluation. CLINICAL RELEVANCE: Optimizing OCD treatment requires surgical strategies that achieve both mechanical stability and biological activation. Integrating these principles may enhance repair quality and long-term joint preservation. LEVEL OF EVIDENCE: Level III, retrospective comparative study.