Transarticular Versus Retroarticular Drilling of Stable Osteochondritis Dissecans of the Knee: A Prospective Multicenter Randomized Controlled Trial by the ROCK Group.

BACKGROUND: When stable osteochondritis dissecans (OCD) lesions of the femoral condyle in a skeletally immature patient fail to heal with nonoperative methods, the standard of care treatment is condylar OCD drilling. Two primary OCD drilling techniques have been described, but no prospective studies have compared their relative effectiveness. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the healing and function after transarticular drilling (TAD) with that after retroarticular drilling (RAD). It was hypothesized that there would be no difference in rate or time to healing, rate or time to return to sports, patient-reported outcomes (PROs), or secondary OCD-related surgery. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Skeletally immature patients with magnetic resonance imaging-confirmed stable OCD lesions of the medial femoral condyle who did not demonstrate substantial healing after a minimum of 3 months of nonoperative treatment were prospectively enrolled by 1 of 17 surgeon-investigators at 1 of 14 centers. Patients were randomized to the TAD or RAD group. Tourniquet time, fluoroscopy time, and complications were compared between the treatment groups. Postoperatively, serial radiographs were obtained every 6 weeks to assess healing, and PROs were obtained at 6 months, 12 months, and 24 months. RESULTS: A total of 91 patients were included, consisting of 51 patients in the TAD and 40 patients in the RAD group, who were similar in age, sex distribution, and 2-year PRO response rate. Tourniquet time and fluoroscopy time were significantly shorter with TAD (mean, 38.1 minutes and 0.85 minutes, respectively) than RAD (mean, 48.2 minutes and 1.34 minutes respectively) (P = .02; P = .004). In the RAD group, chondral injury from K-wire passage into the intra-articular space was reported in 9 of 40 (22%) patients, but no associated postoperative clinical sequelae were identified in these patients. No significant differences between groups were detected in follow-up Pediatric-International Knee Documentation Committee, Lysholm, Marx Activity Scale, or Knee injury and Osteoarthritis Outcome Score Quality of Life scores. Healing parameters were superior at 6 months and 12 months in the TAD group, compared with the RAD group, and secondary OCD surgery occurred in 4% of patients who underwent TAD and 10% of patients who underwent RAD (P = .40). Patients in the TAD group returned to sports earlier than those in the RAD group (P = .049). CONCLUSION: TAD showed shorter operative time and fluoroscopy time and superior healing parameters at 6 and 12 months, but no differences were seen in 24-month healing parameters or PROs at all follow-up time points, when compared with RAD. REGISTRATION: NCT01754298 (ClinicalTrials.gov identifier).

Descriptive Epidemiology From the Research in Osteochondritis Dissecans of the Knee (ROCK) Prospective Cohort.

BACKGROUND: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. PURPOSE: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. RESULTS: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. CONCLUSION: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.

Gabapentin use in pediatric spinal fusion patients: a randomized, double-blind, controlled trial.

BACKGROUND: Gabapentin has opioid-sparing effects in adult surgical patients, but no reported studies have involved children and adolescents. In a double-blind, randomized, controlled trial, we examined whether gabapentin decreases postoperative opioid consumption for pediatric spinal fusion patients with idiopathic scoliosis. METHODS: Patients, aged 9 to 18 years, received preoperative gabapentin (15 mg/kg, treatment) or placebo. Anesthesia was standardized. After surgery, all patients received standardized patient-controlled analgesia opioid and continued on either gabapentin (5 mg/kg) or placebo 3 times per day for 5 days. Opioid use was calculated in mg/kg/time intervals. Pain scores and opioid side effects were recorded. RESULTS: Data from 59 patients (30 placebo and 29 gabapentin) did not differ in demographics. Total morphine consumption (mg/kg/h +/- SD) was significantly lower in the gabapentin group in the recovery room (0.044 +/- 0.017 vs 0.064 +/- 0.031, P = 0.003), postoperative day 1 (0.046 +/- 0.016 vs 0.055 +/- 0.017, P = 0.051), and postoperative day 2 (0.036 +/- 0.016 vs 0.047 +/- 0.019, P = 0.018). In addition, gabapentin significantly reduced first pain scores in the recovery room (2.5 +/- 2.8 vs 6.0 +/- 2.4, P < 0.001) and the morning after surgery (3.2 +/- 2.6 vs 5.0 +/- 2.2, P < 0.05), but otherwise pain scores were not significantly different. There were no differences in opioid-related side effects over the course of the study. CONCLUSION: Perioperative oral gabapentin reduced the amount of morphine used for postoperative pain after spinal fusion surgery, but not overall opioid-related side effects. Initial pain scores were lower in the treatment group. Perioperative use of gabapentin seems to be an effective adjunct to improve pain control in the early stages of recovery in children and adolescents undergoing spinal fusion.

Osteochondritis Dissecans of the Knee: An Interrater Reliability Study of Magnetic Resonance Imaging Characteristics.

BACKGROUND: Imaging characteristics of osteochondritis dissecans (OCD) lesions quantified by magnetic resonance imaging (MRI) are often used to inform treatment and prognosis. However, the interrater reliability of clinician-driven MRI-based assessment of OCD lesions is not well documented. PURPOSE: To determine the interrater reliability of several historical and novel MRI-derived characteristics of OCD of the knee in children. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: A total of 42 OCD lesions were evaluated by 10 fellowship-trained orthopaedic surgeons using 31 different MRI characteristics, characterizing lesion size and location, condylar size, cartilage status, the interface between parent and progeny bone, and features of both the parent and the progeny bone. Interrater reliability was determined via intraclass correlation coefficients (ICCs) with 2-way random modeling, Fleiss kappa, or Krippendorff alpha as appropriate for each variable. RESULTS: Raters were reliable when the lesion was measured in the coronal plane (ICC, 0.77). Almost perfect agreement was achieved for condylar size (ICC, 0.93), substantial agreement for physeal patency (ICC, 0.79), and moderate agreement for joint effusion (ICC, 0.56) and cartilage status (ICC, 0.50). Overall, raters showed significant variability regarding interface characteristics (ICC, 0.25), progeny (ICC range, 0.03 to 0.62), and parent bone measurements and qualities (ICC range, -0.02 to 0.65), with reliability being moderate at best for these measurements. CONCLUSION: This multicenter study determined the interrater reliability of MRI characteristics of OCD lesions in children. Although several measurements provided acceptable reliability, many MRI features of OCD that inform treatment decisions were unreliable. Further work will be needed to refine the unreliable characteristics and to assess the ability of those reliable characteristics to predict clinical lesion instability and prognosis.

The Reliability of Assessing Radiographic Healing of Osteochondritis Dissecans of the Knee.

BACKGROUND: The reliability of assessing healing on plain radiographs has not been well-established for knee osteochondritis dissecans (OCD). PURPOSE: To determine the inter- and intrarater reliability of specific radiographic criteria in judging healing of femoral condyle OCD. STUDY DESIGN: Cohort study (Diagnosis); Level of evidence, 3. METHODS: Ten orthopedic sports surgeons rated the radiographic healing of 30 knee OCD lesions at 2 time points, a minimum of 1 month apart. First, raters compared pretreatment and 2-year follow-up radiographs on "overall healing" and on 5 subfeatures of healing, including OCD boundary, sclerosis, size, shape, and ossification using a continuous slider scale. "Overall healing" was also rated using a 7-tier ordinal scale. Raters then compared the same 30 pretreatment knee radiographs in a stepwise progression to the 2-, 4-, 7-, 12-, and 24-month follow-up radiographs on "overall healing" using a continuous slider scale. Interrater and intrarater reliability were assessed using intraclass correlations (ICC) derived from a 2-way mixed effects analysis of variance for absolute agreement. RESULTS: Overall healing of the OCD lesions from pretreatment to 2-year follow-up radiographs was rated with excellent interrater reliability (ICC = 0.94) and intrarater reliability (ICC = 0.84) when using a continuous scale. The reliability of the 5 subfeatures of healing was also excellent (interrater ICCs of 0.87-0.89; intrarater ICCs of 0.74-0.84). The 7-tier ordinal scale rating of overall healing had lower interrater (ICC = 0.61) and intrarater (ICC = 0.68) reliability. The overall healing of OCD lesions at the 5 time points up to 24 months had interrater ICCs of 0.81-0.88 and intrarater ICCs of 0.65-0.70. CONCLUSION: Interrater reliability was excellent when judging the overall healing of OCD femoral condyle lesions on radiographs as well as on 5 specific features of healing on 2-year follow-up radiographs. Continuous scale rating of OCD radiographic healing yielded higher reliability than the ordinal scale rating. Raters showed substantial to excellent agreement of OCD overall radiographic healing measured on a continuous scale at 2, 4, 7, 12, and 24 months after starting treatment.

Novel Arthroscopic Classification of Osteochondritis Dissecans of the Knee: A Multicenter Reliability Study.

BACKGROUND: Several systems have been proposed for classifying osteochondritis dissecans (OCD) of the knee during surgical evaluation. No single classification includes mutually exclusive categories that capture all of the salient features of stability, chondral fissuring, and fragment detachment. Furthermore, no study has assessed the reliability of these classification systems. PURPOSE: To determine the intra- and interobserver reliability of a novel, comprehensive arthroscopic classification system with mutually exclusive OCD lesion types. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: The Research in OsteoChondritis of the Knee (ROCK) study group developed a classification system for arthroscopic evaluation of OCD of the knee that includes 6 arthroscopic categories-3 immobile types and 3 mobile types. To optimize comprehensibility and applicability, each was developed with a memorable name, a brief description, a line diagram corresponding to the archetypal arthroscopic appearance, and an arthroscopic photograph depicting this archetype. Thirty representative arthroscopic videos were evaluated by 10 orthopaedic surgeon raters, who classified each lesion. After 4 weeks, the raters again classified the OCD lesions depicted in the 30 videos in a new, randomly selected order. Reliability was assessed via the intraclass correlation coefficient (ICC). RESULTS: The interobserver reliability of this novel arthroscopy classification was estimated by an ICC of 0.94 (95% CI, 0.91-0.97) for the first round and 0.95 (95% CI, 0.93-0.98) for the second round. According to the standards for the magnitude of the reliability coefficient of Altman, these ICCs indicate that interobserver reliability was very good. The intraobserver reliability was estimated by an ICC of 0.96 (95% CI, 0.95-0.97), which indicates that the intraobserver reliability was similarly very good. CONCLUSION: The ROCK OCD knee arthroscopy classification system demonstrated excellent intra- and interobserver reliability. In light of this reliability, this classification system may be used clinically and to facilitate future research, including multicenter studies for OCD.

Lateral elbow ecchymosis as a clinical sign of lateral humeral condylar fractures.

Given the appropriate clinical history and mechanism of injury, the presence of localized lateral elbow ecchymosis in a young child is usually the sign of lateral condyle fracture of the humerus. Recognition of this clinical sign helps in directing the diagnostic studies and empiric treatment toward a lateral condyle fracture of the humerus not apparent on initial radiographs.

Effects of trunk position on back surface-contour measured by raster stereophotography.

A study of the contour of the surface of the back was conducted using the Quantec spinal image system (QSIS; raster stereophotography) and the Vicon 3-dimensional (3-D) motion analysis system with a plaster model of the scoliotic spine. With postural changes in 3 dimensions came alterations in the surface shape of the back. Most changes in QSIS parameters occurred in the coronal plane. The study showed that model 1, with 9 degrees of Q angle (similar to Cobb angle in the coronal plane) in right thoracolumbar scoliosis, altered 3-D metrics less than model 2 did, with 54 degrees of Q angle in scoliosis. The change in the position of the trunk in the transverse plane had a more significant impact on the QSIS parameters. Raster stereophotography has been used clinically to monitor curve progression. Changes in transverse rotation of the trunk correlate significantly with variations in Q angle and axial rotation. Clinicians using a raster stereophotograph system to assess scoliotic deformity need to control postural sway, as doing so results in more stable and reproducible measurements that can be used for clinical follow-up.

Development of a 3-Dimensional Back Contour Imaging System for Monitoring Scoliosis Progression in Children.

STUDY DESIGN: Control study. OBJECTIVES: To present a new surface topography system capable of taking 3-dimensional (3D) spine measurements, to establish baseline values for the measured parameters in a typically developing population, and to determine the intra-rater and inter-rater reproducibility of these parameters. SUMMARY OF BACKGROUND DATA: Cumulative exposure to radiation from diagnostic radiographs increases patient risk for cancer development. There is a need for noninvasive and non-radiographic tools to accurately and reproducibly measure spine deformity and track scoliosis progression. METHODS: We measured 10 typically developing subjects with the new Milwaukee Topography System, which is composed of 2 electromagnetic markers, an electronic processing unit, a handheld laser scanner, a software package, and a desktop computer. Two investigators separately scanned the same subjects multiple times, yielding a total of 4 scans per subject per investigator. We measured 17 3D back parameters in each scan. We performed a multivariate analysis of variances to test the hypothesis of no difference for all variables, measured intra-rater and inter-investigator reliability with intra-class correlation (ICC) coefficients, and calculated mean values. RESULTS: There were highly reproducible ICC values between investigators for 6 parameters (ICC > 0.75), moderate ICC values for 8 parameters (0.75 > ICC > 0.4), and poor ICC values for 3 parameters (ICC < 0.4), all at p < .05. Intra-investigator ICCs were moderate to excellent for almost all parameters. CONCLUSIONS: The Milwaukee Topography System can be used to monitor and measure 3D back contours in children. The 3D back parameters values measured in the typically developing population can be considered baseline values that can be compared with parameters measured in children with idiopathic scoliosis.

Reliability of a functional classification system in the monitoring of patients with idiopathic scoliosis.

STUDY DESIGN: Patients with scoliosis from 1999 to 2001 were monitored using radiographs and the Quantec Spinal Imaging System (Quantec) to validate the Functional Classification System (FCS) developed at Children's Hospital of Wisconsin (CHW). OBJECTIVE: To determine the accuracy of the FCS. SUMMARY OF BACKGROUND DATA: The authors evaluated different noninvasive ways of evaluating the scoliotic spine. The FCS was developed as a means to predict the degree of scoliotic curve. METHODS: Consecutive scoliosis visits (543) seen at CHW between 1999 and 2001 for initial or follow-up examination were investigated; of them, 157 had an radiograph within 6 months of Quantec. Subjects were placed into groups based on Cobb Angles. FCS classifications were compared to Cobb angle groupings and calculated sensitivity and specificity. Pearson's correlation coefficient was calculated for 39 subjects. RESULTS: Sensitivity of the FCS for single curve groups ranged from 0.50 to 0.63 and specificity from 0.64 to 0.86. For double curve, both sensitivity and specificity ranged from 0.48 to 0.81. Pearson's correlation was statistically significant (r = 0.45, P < 0.05). CONCLUSIONS: Sensitivity, specificity, and Pearson's correlation coefficient reflect the reliability of the Quantec method. Therefore, the FCS can be considered as a reliable tool for monitoring the progression of scoliosis with reduced need of radiographs.