Osteochondritis Dissecans: Gabe's Story
Eighteen-year-old Gabe Keeton has always been an active kid, playing baseball, tennis, weightlifting and running cross country. But at about 15 years old, Gabe began having knee pain, something he considered unusual for someone so young.
“I noticed it when I was doing any movement that involved my right knee,” Gabe said. “I hadn’t injured my knee, so I thought that was odd. At first, the pain was manageable.”
But Gabe remembers when the pain started to get worse. “We were on a family vacation and I went for a swim in the pool. When I got out of the pool, my knee was really hurting. It would lock up and it made a clicking sound. That’s when I decided I needed to get it checked out,” he said.
A congenital condition?
At first, Gabe consulted an orthopedic surgeon who cares for adults, but that physician felt he needed to see someone who specializes in adolescents, referring him to Kevin Latz, MD, pediatric orthopedic surgeon and Chief, Sports Medicine at Children’s Mercy Kansas City.
Dr. Latz diagnosed Gabe with an articular cartilage defect called osteochondritis dissecans, or OCD. Cartilage is the fine, rubbery tissue that acts as a cushion between the bones and joints. OCD is a condition in which the bone that supports the cartilage inside a joint undergoes softening. This softening is caused by an interruption in blood flow to that portion of bone.
“Healthy cartilage allows bones to glide over each other and flex freely, like when a car drives over a smoothly surfaced road,” Dr. Latz explained. “But in Gabe’s case, the defect created a ‘pothole’ in the cartilage that prevented the joint from functioning smoothly, causing the pain he was experiencing.”
Though no one knows exactly what caused Gabe’s cartilage defect, Dr. Latz suspects he may have been born with it. In fact, the Children’s Mercy orthopedic surgeons are investigating the theory that OCD is congenital, participating in Genomic Answers for Kids, a flagship initiative of the Children’s Mercy Research Institute and the Genomic Medicine Center.
This research program is building a first-of-its-kind pediatric data repository to facilitate the search for answers and novel treatments. Genomic Answers for Kids collects and stores genomic information and biological samples from children and their biological family members who are searching for diagnoses and are suspected to have rare genetic conditions.
In the case of OCD, tissue samples from more than 500 patients will be sequenced to determine if there is a possible genetic connection that may one day identify the defect and better inform treatment options.
In the meantime, Dr. Latz recommended surgery to repair Gabe’s damaged cartilage, but he also carefully explained the risks.
“Our preference is always to get the patient’s own cartilage to heal,” Dr. Latz said. “There are several different options available, but this is an unpredictable surgery, and I always tell families it may take more than one surgery to repair the problem.”
“Dr. Latz said from the start that this surgery might not work, and that I might need another one, but I decided to give it a try,” Gabe said.
In February 2019 during a minimally invasive outpatient procedure called an arthroscopy, Dr. Latz repaired Gabe’s knee, pinning the damaged cartilage to the bone using tiny bioabsorbable pegs.
Initially, Gabe’s knee surgery and recovery went as planned. He walked on crutches and wore a knee brace the first few weeks after leaving the hospital, participated in physical therapy for five months at Children’s Mercy College Boulevard, and sat out of sports.
After spending several months getting his right knee back to full strength, Gabe was released from rehab that summer. Though his knee felt fine at first, soon it began hurting again.
When Gabe returned to see Dr. Latz, he discovered that the cartilage repair had failed. “Even though we all wanted this surgery to heal my knee, Dr. Latz was clear from the start it might not work,” Gabe said.
Using Gabe’s own cells to do the repairs
But there was another, newer surgical option that Dr. Latz told Gabe about called articular chondrocyte implantation, or MACI®.
MACI uses the patient’s own cells to create a durable repair for damaged knee cartilage. It’s been used successfully for several years in adults, but it requires special approval for patients under 18, and is only performed at a handful of pediatric hospitals in the nation, most of them participants in the Research in OsteoChondritis of the Knee collaborative.
Dr. Latz explained that this surgery was the best chance to restore function to Gabe’s knee, and to help him return to an active lifestyle.
“I wanted a definitive answer and to be healed,” Gabe said. “I did some research on my own, and decided I wanted to try the MACI repair. I had 100% faith that this surgery would heal my knee.”
With Gabe committed to the process, Dr. Latz performed a second arthroscopy, collecting two to three patches of healthy knee cartilage, each about the size of a Tic Tac®. After removing the cells, they were sent to a lab in Cambridge, Mass., where they were embedded onto a special sponge-like material.
Gabe’s cells were treated to help them expand and multiply. A few weeks later during an outpatient arthroscopy, Dr. Latz matched the size and shape of the cartilage repair material to the defect. After being implanted back into his knee, the cartilage cells began regenerating, forming a tissue repair that filled the “pothole,” or the damaged area of the knee cartilage.
“This procedure was a similar experience to the others, but to recover, I did a lot of physical therapy at Children’s Mercy College Boulevard with Nathan Apple, PT, physical therapist,” Gabe said. “I had worked with Nathan before, but this time, the therapy was much more intense, and I had to do a lot of extra work at home on my own.”
After spending most of his junior year in high school on crutches, Gabe was released from therapy in April 2020.
Now midway through Gabe’s senior year, his knee is standing up to the test. “My knee feels very, very good,” he said. “I’m completely recovered.” But Gabe is also careful which activities he participates in.
“No more high-impact sports for me,” he said. “I do weightlifting, but other than that, I’ve given sports up. I’ve found other things I enjoy, like fishing, volunteering and school.
“I had my second surgery when I was going for my driver’s license,” Gabe said. “That was a bit of a setback, but this whole experience has made me slow down and be more laid back.”
It’s also influenced Gabe’s plans for college and beyond. “I’ll graduate from Grain Valley High School in May 2021 and plan to go to the University of Missouri-Columbia to study biology,” he said. “After that, I’d like to attend medical school and maybe pursue a career in research.”
Gabe’s Children’s Mercy Team
Though Gabe had three knee surgeries and put a lot of effort into his recovery, he recognizes that it took a dedicated team to help him get healthy and back on his feet.
“Dr. Latz has an amazing bedside manner,” he said. “He understood that I wanted to be as active as I could be, and he really talked with me, explaining everything. I felt very well informed every step of the way.”
Angie Vanderpool, RN, advanced practice nurse, also received high marks from the teen for her outstanding follow-up and caring attitude. “Angie was always checking up on me. I felt very cared for.”
And his physical therapist, Nathan, made sure Gabe followed Dr. Latz’s prescription for rehab to the letter. “I was the first MACI patient Nathan had worked with, so this was a new challenge for us all. It was a really great experience. I felt like it was a partnership.”
Gabe’s mom, Brenda Keeton, agreed. “I think as a parent, I really appreciated how everyone, from Dr. Latz to Angie to anesthesia to Nathan, would talk with Gabe. They didn’t treat him like a kid. The communication between all of us was really good. They included Gabe in each conversation. I felt we were all working toward getting Gabe back up and moving. They had his best interests at heart. Always.”
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Chief, Section of Sports Medicine; Pediatric & Adolescent Orthopaedic Surgery; Associate Professor of Orthopaedic Surgery, University of Missouri-Kansas City School of Medicine; Clinical Assistant Professor of Orthopaedic Surgery, University of Kansas School of Medicine