Manipulation Under Anesthesia is Safe and Effective for Management of Early Postoperative Knee Arthrofibrosis in Adolescent Patients.

BACKGROUND: Management of postoperative knee arthrofibrosis can be challenging and the preferred time for intervention remains controversial. The purpose of this study is to evaluate the safety and efficacy of early (<3 mo postoperatively) manipulation under anesthesia (MUA) for the treatment of knee arthrofibrosis in adolescent patients. We hypothesized that early MUA could restore normal knee motion with a low complication rate and without the need for more invasive intervention. METHODS: In a retrospective review, 57 patients who underwent MUA for postoperative knee arthrofibrosis were identified. The time between the index surgery and MUA as well as changes in range of motion (ROM) before and after MUA were analyzed. Descriptive statistics with median and interquartile range were used to analyze this non-parametric study cohort. Repeated measures ANOVA was performed to assess improvement in ROM over time. A P value <0.05 denoted statistical significance. RESULTS: The median age of the cohort at time of MUA was 14.5 years [interquartile range (IQR) 12.9 to 17.6)]. 54.4% were male. Median time to MUA was 64 days (IQR 52 to 79) after index surgery. ROM before MUA was 90.0 degrees (IQR 75 to 100), which improved to 130 degrees (120 to 135) after MUA. At final median follow-up of 8.9 months (IQR 5.1 to 16.1), mean ROM was 133 degrees (130 to 140). There were no iatrogenic fractures or physeal separations associated with MUA. 12.3% (n=7/57) failed MUA either due to the need for subsequent repeat MUA (n=2), need for lysis of adhesions (n=3) or need for surgery after MUA (n=2). Those who failed early MUA and required subsequent procedures had ROM >120 degrees at final follow-up. CONCLUSIONS: Postoperative knee arthrofibrosis can be safely and effectively treated with early (<3 mo postoperative) MUA. There were no iatrogenic fractures or physeal separations during MUA. Patients who had recurrence of motion deficits after early MUA and required further intervention, regained satisfactory knee motion at final follow-up. Although further research is warranted to better characterize risk factors for knee arthrofibrosis in adolescent patients, early recognition and MUA is a safe and effective treatment for arthrofibrosis to help patients regain full ROM without invasive intervention. LEVEL OF EVIDENCE: Therapeutic Study - Level IV.

Intrarater and Interrater Reliability of Radiographic Characteristics in Skeletally Immature Patients With Anterior Cruciate Ligament Tears: A PLUTO Study Group Reliability Study.

BACKGROUND: Radiographic measurements of limb alignment in skeletally immature patients with anterior cruciate ligament (ACL) tears are frequently used for surgical decision-making, preoperative planning, and postoperative monitoring of skeletal growth. However, the interrater and intrarater reliability of these radiographic characteristics in this patient population is not well documented. HYPOTHESIS: Excellent reliability across 4 raters will be demonstrated for all digital measures of length, coronal plane joint orientation angles, mechanical axis, and tibial slope in skeletally immature patients with ACL tears. STUDY DESIGN: Cohort study (diagnosis). METHODS: Three fellowship-trained orthopaedic surgeons and 1 medical student performed 2 rounds of radiographic measurements on digital imaging (lateral knee radiographs and long-leg radiographs) of skeletally immature patients with ACL tears. Intrarater and interrater reliability for continuous radiographic measurements was assessed with intraclass correlation coefficients (ICCs) across 4 raters with 95% CIs for affected and unaffected side measurements. Interrater reliability analysis used an ICC (2, 4) structure and intrarater reliability analysis used an ICC (2, 1) structure. A weighted kappa coefficient was calculated for ordinal variables along with 95% CIs for both interrater and intrarater reliability. Agreement statistic interpretations are based on scales described by Fleiss, and Cicchetti and Sparrow: <0.40, poor; 0.40 to 0.59, fair; 0.60 to 0.74, good; and >0.74, excellent. RESULTS: Radiographs from a convenience sample of 43 patients were included. Intrarater reliability was excellent for nearly all measurements and raters. Interrater reliability was also excellent for nearly all reads for all measurements. CONCLUSION: Radiographic reliability of long-leg radiographs and lateral knee x-rays in skeletally immature children with ACL tears is excellent across nearly all measures and raters and can be obtained and interpreted as reliable and reproducible means to measure limb length and alignment. LEVEL OF EVIDENCE: Level III.

Many Radiographic and Magnetic Resonance Imaging Assessments for Surgical Decision Making in Pediatric Patellofemoral Instability Patients Demonstrate Poor Interrater Reliability.

PURPOSE: To evaluate the interrater reliability of several common radiologic parameters used for patellofemoral instability and to attempt to improve reliability for measurements demonstrating unacceptable interrater reliability through consensus training. METHODS: Fifty patients with patellar instability between the ages of 10 and 19 years were selected from a prospectively enrolled cohort. For measurements demonstrating unacceptable interrater reliability (intraclass correlation coefficient [ICC]: <0.6), raters discussed consensus methods to improve reliability and re-examined a subset of 20 images from the previous set of images. If reliability was still low after the second round of assessment, the measure was considered unreliable. RESULTS: Of the 50 included subjects, 22 (44%) were male and the mean age at the time of imaging was 14 ± 2 years. With 1 or fewer consensus training sessions, the interrater reliability of the following radiograph indices were found to be reliable: trochlea crossing sign (ICC: 0.625), congruence angle (ICC: 0.768), Caton-Deshamps index (ICC: 0.644), lateral patellofemoral angle (ICC: 0.768), and mechanical axis deviation on hip-to-ankle alignment radiographs (ICC: 0.665-0.777). Reliable magnetic resonance imaging (MRI) indices were trochlear depth (ICC: 0.743), trochlear bump (ICC: 0.861), sulcus angle (ICC: 0.684), patellar tilt (ICC: 0.841), tibial tubercle to trochlear groove distance (ICC: 0.706), effusion (ICC: 0.866), and bone marrow edema (ICC: 0.961). CONCLUSIONS: With 1 or fewer consensus training sessions, the interrater reliability of the following patellofemoral indices were found to be reliable for trochlear morphology: trochlea crossing sign and congruence angle on radiograph and trochlear depth, trochlear bump, and sulcus angle on MRI. Reliable patellar position measurements included: Caton-Deshamps index and lateral patellofemoral angle on radiograph and patellar tilt and tibial tubercle to trochlear groove distance on MRI. Additional global measurements (e.g., mechanical axis deviation on standing radiographs) and MRI assessments demonstrated acceptable reliability. LEVEL OF EVIDENCE: II, prospective diagnostic study.

The nonoperative treatment of osteochondritis dissecans of the knee.

PURPOSE OF REVIEW: The purpose of this review is to update the reader on the controversial subject of osteochondritis dissecans (OCD) with a focus on nonoperative treatment indications, methods, and success rate. RECENT FINDINGS: Work by an international multicenter study group ROCK (Research in OsteoChondritis of the Knee) will be reviewed including new classifications systems of healing, arthroscopy, radiographs, and MRI, along with new evidence on off-loading bracing compared to restricted weight bearing. SUMMARY: The paucity of evidence behind OCD treatment of the knee can lead to confusion for doctors, patients, and parents. The present review will bring more clarity to the subject.

What's New in the Management of Pediatric Anterior Cruciate Ligament Tears and Tibial Spine Fractures.

As the number of pediatric and adolescent patients participating in sports continues to increase, so too does the incidence of anterior cruciate ligament (ACL) tears in this population. There is increasing research on pediatric and adolescent ACL tears; hundreds of articles on the topic have been published in the past few years alone. It is important to highlight the most pertinent information in the past decade. In discussing pediatric ACL tears, it is also important to review tibial spine fractures. These injuries are rightfully grouped together because tibial spine fractures often occur with a mechanism of injury similar to that of ACL tears, but typically in a younger age group. Because management is different, understanding the similarities and differences between the two pathologies is important. Recent updates on the epidemiology, diagnosis, management, and outcomes of both pediatric ACL tears and tibial spine fractures need to be reviewed.

What's New in Osteochondritis Dissecans of the Knee, Elbow, and Ankle.

Osteochondritis dissecans is a condition of the subchondral bone, with secondary effects on the articular cartilage. It most commonly affects the knee, elbow, and ankle and is typically seen in young, active populations. Many osteochondritis dissecans lesions are asymptomatic, but more advanced lesions can cause pain, swelling, and mechanical symptoms. Multiple treatment options have been proposed, including nonsurgical and surgical approaches. It is important to be aware of the epidemiology, presenting symptoms, and indications for nonsurgical and surgical treatment options for osteochondritis dissecans of the knee, elbow, and ankle.

Extensor Tendon Injury Associated With Dorsal Entry Flexible Nailing of Radial Shaft Fractures in Children: A Report of 5 New Cases and Review of the Literature.

BACKGROUND: Extensor pollicis longus (EPL) tendon injury following the dorsal approach to elastic stable intramedullary nailing (ESIN) of the radius has been reported in a growing number of cases in the literature. This study includes 5 new cases from our institution as well as a comprehensive review of previously reported cases from the literature. METHODS: We conducted a retrospective chart review of all patients undergoing ESIN between January 1, 2004 and December 31, 2013 at our institution. Those patients with an EPL injury or rupture were identified and clinical data collected included operative technique, diagnosis, treatment, and outcomes data. In addition, we performed a systematic review of the literature using Pubmed MEDLINE database, the Chochrane database, Scopus, Web of Science, and Embase. A total of 28 cases of EPL injury following ESIN of the radius were identified in the literature and the relevant data were extracted from those studies. RESULTS: All 33 pediatric cases of EPL tendon injury occurred after entry to the radial canal was obtained by the dorsal approach to ESIN. EPL injury was diagnosed an average of 10 weeks following the index procedure. Extensor indicis pollicis to EPL transfer was performed in 13 patients, tendon release/lysis of adhesions in 5, EPL repair in 2, EPL graft reconstruction from palmaris longus tendon in 1, 3 patients refused further intervention, and treatment was unreported in 7 cases. By 12-month follow-up, all operatively treated patients had a good functional outcome with near anatomic extension at the thumb interphalangeal joint, no pain, and no further complication. CONCLUSIONS: EPL tendon injury was found to be a complication unique to the dorsal entry approach for ESIN of the radius. The lateral approach appears to offer a safer alternative with regard to the EPL tendon. We suggest that physicians consider the risk of EPL tendon injury when planning for ESIN of the radius, and make an effort to avoid direct injury when using a dorsal approach. LEVEL OF EVIDENCE: Level III-therapeutic.

Post-operative imaging of anterior cruciate ligament reconstruction techniques across the spectrum of skeletal maturity.

Due to an increased frequency of anterior cruciate ligament (ACL) injuries in young patients and improved outcomes in athletic performance following ACL reconstruction, surgery is increasingly being performed across the spectrum of skeletal maturity. We present a review of the range of reconstruction techniques performed in skeletally immature patients (physeal sparing techniques, which may involve epiphyseal tunnels or the utilization of an iliotibial band autograft), those performed in patients nearing skeletal maturity (transphyseal techniques), and the more conventional ACL reconstruction techniques performed in skeletally mature adolescents. It is important that radiologists be aware of the range of techniques being performed throughout the spectrum of skeletal maturity in order to accurately characterize the expected post-operative appearance as well as to identify complications, including those unique to this younger population.

Juvenile Osteochondritis Dissecans: Correlation Between Histopathology and MRI.

OBJECTIVE: The objective of our study was to correlate specimens of juvenile osteochondritis dissecans (OCD) lesions of the knee to MRI examinations to elucidate the histopathologic basis of characteristic imaging features. MATERIALS AND METHODS: Five children (three boys and two girls; age range, 12-13 years old) who underwent transarticular biopsy of juvenile OCD lesions of the knee were retrospectively included in this study. Two radiologists reviewed the MRI examinations and a pathologist reviewed the histopathologic specimens and recorded characteristic features. Digital specimen photographs were calibrated to the size of the respective MR image with the use of a reference scale. Photographs were rendered semitransparent and over-laid onto the MR image with the location chosen on the basis of the site of the prior biopsy. RESULTS: A total of seven biopsy specimens were included. On MRI, all lesions showed cystlike foci in the subchondral bone, bone marrow edema pattern on proton density-or T2-weighted images, and relatively thick unossified epiphyseal cartilage. In four patients, a laminar signal intensity pattern was seen, and two patients had multiple breaks in the subchondral bone plate. Fibrovascular tissue was found at histopathology in all patients. Cleft spaces near the cartilage-bone interface and were seen in all patients while chondrocyte cloning was present in most cases. Focal bone necrosis and inflammation were infrequent MRI findings. Precise correlation of the MRI appearance to the histopathologic overlays consistently was found. CONCLUSION: A direct correlation exists between the histopathologic findings and the MRI features in patients with juvenile OCD. Additional studies are needed to correlate these MRI features with juvenile OCD healing success rates.

Surgical aspects of spinal growth modulation in scoliosis correction.

Spine growth modulation for scoliosis correction is a technique for slowing growth on the convex side of the curve and enhancing growth on the concave side by using the Heuter-Volkmann principle; this results in gradual deformity correction. The theoretic advantages include speedier recovery because of the minimally invasive approach used, as well as motion preservation. Several devices have been used in humans, including vertebral body stapling, with either a flexible titanium clip or a nitinol staple, and anterior spinal tethering. Prerequisites for the use of these devices are a relatively flexible curve and sufficient remaining growth in the patient. Although vertebral body stapling is effective for moderate curves of less than 40°, anterior spinal tethering can be used for curves greater than 40°. The titanium clip and spinal tethers are used exclusively for thoracic scoliosis, whereas nitinol staples can be used for the thoracic spine or the lumbar spine. The thoracoscopic technique is used for thoracic instrumentation, and the mini-open retroperitoneal technique is used for lumbar staple insertion. The insertion of a titanium clip and an anterior spinal tether requires sacrifice and mobilization of the segmental vessels, whereas nitinol staples can be inserted without such sacrifice. Single lung ventilation and CO2 insufflation are used to improve visualization with the thoracoscope. The curve should be instrumented from an end vertebra to an end vertebra. Postoperative immobilization depends on the type of device used. Most complications are approach related, such as atelectasis caused by a mucus plug, pain at the chest tube site, and pneumothorax. Device-related complications are rare. Overcorrection is a concern. In patients with early onset scoliosis, a hybrid construct with vertebral stapling and growing rods or a vertical expandable prosthetic titanium rib has been suggested. A failure of the spinal growth modulation procedure does not preclude spinal fusion. None of the devices for spine growth modulation have been approved by the FDA for human use and are still investigational. Early results are promising, and continued clinical studies are necessary.

Retro-articular drilling and bone grafting of juvenile knee osteochondritis dissecans: a technical description.

The goal of the surgery in stable juvenile osteochondritis dissecans (OCD) is to promote revascularization and reossification of the osteochondral fragment by creating channels, linking the subchondral bone to the OCD lesion. Retro-articular and trans-articular drilling of OCD lesions has up to a 33 % failure rate based on complete radiographic healing. Healing may be improved with the delivery of pluripotent mesenchymal stem cells into the lesion. We describe a technically simple procedure for retro-articular drilling with the addition of percutaneous iliac crest bone graft placement for stable juvenile OCD lesions of the knee. By using a bone marrow biopsy needle, the bone grafting can be performed in a reproducible manner and in shorter time than in previously described techniques. The proposed technique represents a promising adjunct for the management of stable juvenile OCD lesions that fail to heal after 3-6 months of non-operative treatment and for non-displaced, unstable OCD lesions that undergo internal fixation.

Absence of radiographic abnormalities in nursemaid's elbows.

BACKGROUND: Disagreement exists between physicians on the usefulness of a prereduction radiograph for diagnosis and treatment of nursemaid's elbows in children. Some evidence suggests that nursemaid's elbows have identifying features on radiographs. This study compares the radiographs of nursemaid's elbows to normal, control elbows in children and hypothesizes that differentiating features do not exist on radiograph. METHODS: For this retrospective case-control study, hospital billing records were searched to identify all patients under age 6 treated with closed reduction for a nursemaid's elbow between November 2005 and October 2009. Twenty-seven nursemaid's elbows were age-matched and sex-matched to 27 normal "comparison view," control elbows. Radiocapitellar line offset, proximal radial length, anterior fat pad angle, and visibility of the posterior fat pad were measured on the radiographs by 2 raters. Their interrater reliability was assessed with intraclass correlations, and the nursemaid's and control elbow measures were compared using Wilcoxon tests. RESULTS: Nursemaid's elbows and healthy control elbows did not differ significantly in offset of the radiocapitellar line from the capitellum center on anteroposterior (P=0.49) or lateral views (P=0.67), in proximal radial length (P=0.95), anterior fat pad angle (P=0.49), or posterior fat pad visibility (P=1.00) on lateral views. CONCLUSIONS: Nursemaid's elbows are indistinguishable from healthy elbows on radiograph. Thus, the term "radial head subluxation" appears to be a misnomer, and prereduction radiographs should only be used to eliminate the possibility of fracture. From a radiologic perspective, nursemaid's elbows remain a diagnosis of exclusion. LEVEL OF EVIDENCE: Therapeutic Level III-retrospective comparative study.

Direct beam radiation exposure to surgeons during pinning of supracondylar humerus fractures: does C-arm position and the attending surgeon matter?

BACKGROUND: Direct beam radiation exposure to the surgeon, especially to their hands, is extremely common during supracondylar humerus fracture pinnings and results in exposure to significantly greater doses of ionizing radiation when compared with scatter radiation. The purpose of this study was to determine how often surgeons are exposed to direct beam radiation during this surgery and whether the C-arm position and the surgeon's experience influence radiation exposure. METHODS: In this double blind study, we collected 3842 fluoroscopic still images from 78 closed reduction and percutaneous pinning surgeries for supracondylar humerus fractures performed or supervised by 6 attending surgeons. The percentage of images containing a surgeon's body was calculated as an indicator of direct beam radiation exposure. Total fluoroscopy time, C-arm position (standard or inverted), and whether the primary surgeon was an attending, resident, or both were recorded. Nonparametric statistical analyses were performed. RESULTS: Fluoroscopy lasted for a median of 34 seconds, and the surgeon was exposed to direct beam radiation in a median of 13% of fluoroscopy films, with exposure ranging from 0% to 97% per surgery. Fluoroscopy was significantly longer when the C-arm position was inverted when compared with the standard position (43 vs. 26 s, P=0.034). Surgeons' exposure to direct beam radiation was also slightly greater when the C-arm position was inverted (16% vs. 10%, P=0.087). The duration of fluoroscopy exposure and the percentage of films with the body exposed to radiation did not differ based on whether the surgery was performed by an attending, a resident, or both (P=0.53 and 0.28, respectively). However, the percentage of films with bodily radiation exposure did significantly differ between the attending physicians (P=0.029). CONCLUSIONS: Direct beam radiation exposure varied widely between surgeries and surgeons, ranging from none to nearly constant exposure. Surgical time also significantly increased with the C-arm in the inverted position compared with the standard position. Given the significant variation in exposure between attending physicians, it is likely that exposure to direct beam radiation can be avoided with improved awareness about the risk of direct beam radiation exposure and cautious surgical technique. LEVEL OF EVIDENCE: Not applicable.

Functional outcome analysis of triplane and tillaux fractures after closed reduction and percutaneous fixation.

BACKGROUND: There are limited data regarding the outcomes of triplane and tillaux fractures. The purpose of our study was to provide a long-term follow-up analysis of the functional outcomes as they relate to articular displacement using validated outcome tools. METHODS: A retrospective chart and radiographic review was performed to identify the age, the sex, the treatment method, complications, the fracture type, and articular displacement. Most patients underwent closed reduction with percutaneous fixation. We used 2 validated outcome measures, namely the Foot and Ankle Outcomes Score and the Marx Activity Scale, to assess functional results at a minimum of 2 years from the time of injury. RESULTS: We identified 78 patients between 2000 and 2009 who underwent computed tomographic scan evaluation of either a triplane (n=58) or a tillaux fracture (n=20). Triplane fractures occurred at a significantly younger age than tillaux fractures for both men and women (P=0.01). Women were found to suffer transitional fractures at a younger age than men (P<0.001). Patients with residual articular displacement of up to 2.4 mm after definitive treatment did not have worse functional outcomes compared with those who had an anatomic reduction on any of the Foot and Ankle Outcomes Score subscales and the Marx Activity Scale. Similarly, there was no correlation between the magnitude of residual gap or step-off with functional outcome when the gap and step-off are <2.5 mm. Patients with longer-term follow-up (>4 y) did not have deterioration of function compared with those with a follow-up of 2 to 4 years. CONCLUSIONS: Tillaux and triplane fractures have good medium-term outcomes after reduction and fixation. Using primarily closed reduction and percutaneous fixation techniques, patients with a residual displacement of <2.5 mm after treatment have a uniformly good result. Functional results do not deteriorate at longer-term follow-up (4 to 10 y) as long as adequate reduction has been achieved. Percutaneous fixation yielded uniformly good results on all scales. LEVEL OF EVIDENCE: Therapeutic level III.

Trochlear groove osteochondritis dissecans of the knee patellofemoral joint.

BACKGROUND: The trochlear groove is the rarest location for osteochondritis dissecans (OCD) of the knee, with only about 50 previously reported cases, most of which were treated before the advent of magnetic resonance imaging (MRI) and modern techniques of cartilage fixation or osteochondral transplantation. The purpose of this multicenter study was to assess the patient presentation and clinical, radiographic, and functional results of treatment for trochlear groove OCD lesions. METHODS: Hospital records from 5 institutions of the Research in Osteochondritis of the Knee (ROCK) study group were retrospectively reviewed for cases of trochlear groove OCD. Demographics, clinical presentation, diagnosis, treatment, time to pain resolution, and return to sports were recorded. Lesion appearance, size, stability, and time to radiographic healing were evaluated on plain x-rays and MRIs. RESULTS: Trochlear groove OCD lesions were evaluated in 24 knees in 21 adolescents (17 male, 4 female), with an average age of 14 years (range, 10 to 18 y). Fifty-four percent (13/24) of the lesions were identifiable on radiographs, and all were identifiable on MRI, 38% of which (9/24) was unstable. One fourth (6/24) of knees had coexistent femoral condyle OCD lesions. Treatment outcomes were evaluated in patients with a minimum of 1-year follow-up (average: 3 y; range: 1 to 12 y) or healing before 1 year. Half of the knees (2/4) treated nonoperatively and two thirds (8/12) treated operatively showed radiographic signs of healing with patients returning to full activity without pain. Operative treatment success rates were as follows: drilling (3/3), fixation (3/3), microfracture (1/2), drilling with subsequent delayed microfracture (1/1), and drilling with fixation (0/3). CONCLUSIONS: MRI aids in the diagnosis and staging of trochlear groove OCD lesions, as almost one half may not be identifiable on radiographs, and one quarter are associated with OCD lesions in other locations of the same knee. Multiple operative treatments can be used to achieve healing or resolution of symptoms in stable and unstable lesions; however, a larger comparative study is needed to make specific recommendations. LEVEL OF EVIDENCE: Therapeutic Level IV.

Midterm Outcomes of Isolated Medial Patellofemoral Ligament Reconstruction for Patellar Instability in Ehlers-Danlos Syndrome.

Background: Patellar instability is frequently encountered in patients with Ehlers-Danlos syndrome (EDS). The clinical outcomes of isolated medial patellofemoral ligament reconstruction (MPFLR) for patellar instability in patients with EDS are unknown. Purpose: To evaluate midterm clinical outcomes of isolated MPFLR for patellar instability in patients with EDS and factors affecting these outcomes. Study Design: Case series; Level of evidence, 4. Methods: In a retrospective study, 31 patients (n = 47 knees) with EDS and patellar instability who underwent isolated MPFLR for recurrent patellar instability between 2008 and 2017 and had a minimum 2-year follow-up were identified. Preoperative radiographic images were measured for anatomic risk factors. Clinical outcomes-including postoperative complications-were evaluated. Factors associated with MPFLR failure were identified. Postoperative patient-reported outcomes (PROs)-including the pediatric version of the International Knee Documentation Committee, the Kujala score, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale, the Banff Patellofemoral Instability Instrument 2.0, and the Knee injury and Osteoarthritis Outcome Score-were collected, and factors affecting PRO scores were analyzed. Results: The mean age of the cohort was 14.9 ± 2 years. At a mean follow-up of 7.2 years, 18 of 47 (38.3%) knees required reoperations, of which 9 of 47 (19.1%) knees required revision stabilization for recurrent patellar instability. Also, 7 of 31 knees (22.6%) with autografts failed compared with 2 of 16 (12.5%) with allografts (P = .69). For autografts, 6 of 17 (35.3%) failures occurred with gracilis, but 0 of 13 (0%) occurred with semitendinosus (P = .02). Compared with patients without failures, patients with failed primary MPFLR were significantly younger (P = .0005) and were able to touch the palm to the floor with their knees extended (P = .03). For radiographic parameters, the patellar height and tilt were significantly higher in the failure group. The postoperative PROs were suboptimal at a mean follow-up of 5.2 years. All but 1 patient were satisfied with the final outcome. Conclusion: At the midterm follow-up, 38.3% of patients with EDS required further surgery after isolated MPFLR for patellar instability; half of these revisions (19.1%) were to address recurrent instability. Recurrent instability after isolated MPFLR was more likely in younger patients and those who could touch the palm to the floor with their knees extended. Postoperative PROs were inferior; nonetheless, patient satisfaction was high.

MPFL Reconstruction and Implant-Mediated Guided Growth in Skeletally Immature Patients With Patellar Instability and Genu Valgum.

BACKGROUND: There is a higher rate of failure of isolated MPFL reconstruction in skeletally immature patients with patellar instability compared to skeletally mature patients. Genu valgum is a known risk factor for patellar instability. There is potential for concomitant surgical correction of genu valgum to achieve better clinical outcomes and to decrease failure rates of MPFL reconstruction. PURPOSE: To evaluate outcomes of combined medial patellofemoral ligament (MPFL) reconstruction and implant-mediated guided growth (IMGG) in skeletally immature patients with patellar instability and genu valgum. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: In a multicenter study, all skeletally immature patients with recurrent patellar instability and genu valgum who underwent MPFL reconstruction using hamstring graft and IMGG using a transphyseal screw or tension band plate for the distal femur and/or proximal tibia were included. The knee valgus angle and mechanical axis were measured on full-length radiographs and anatomic risk factors were measured on MRI. Patients were followed until correction of their lower limb alignment and implant removal or until skeletal maturity. Clinical outcomes, including complications, were analyzed. RESULTS: A total of 31 patients (37 knees) were included in the study. The mean age and skeletal age of the cohort were 12.4 and 12.9 years, respectively. Simultaneous MPFL reconstruction and IMGG were performed in 26 of 37 knees; 11 underwent staged procedures. Twenty knees had transphyseal screws and 17 knees had tension band plates for IMGG. The knee valgus corrected from a mean of 12.4° to 5.1° in 12.1 months. Implants were removed from 22 of 37 knees once genu valgum was corrected. There was no significant difference (P = .65) in the correction rate between plates (0.7 deg/month) and screws (0.6 deg/month). Ten complications occurred in 4 patients (7 knees) and included 5 patellar redislocations, 2 rebound valgus, 1 varus overcorrection, 1 knee arthrofibrosis, and 1 implant loosening. For children <10 years of age, 3 of 6 (50%) knees had patellar redislocations and 5 of 6 knees had a complication. This was statistically significant (P = .003) compared with patients >10 years of age. Similarly, for patients with bilateral knee involvement, 5 of 12 (42%) knees had patellar redislocations and a total of 8 complications occurred in this subset. This was statistically significant (P < .001) compared with patients with unilateral involvement. CONCLUSION: IMGG with plates or screws in the setting of combined MPFL reconstruction improves genu valgum. Children <10 years of age and those with bilateral instability with genu valgum remain difficult subsets to treat with higher complication rates.

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).

Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis?

OBJECTIVE: The primary physis is responsible for longitudinal bone growth. Similarly, epiphysial growth relies on endochondral ossification from the circumferential secondary physeal [corrected]. injury can result in disruption of normal ossification. The cause of juvenile osteochondritis dissecans (OCD) remains elusive. We hypothesized that juvenile OCD results from an insult affecting endochondral ossification from the secondary physis. The purpose of our study was to evaluate the MRI appearance of the distal femoral epiphysis-particularly the secondary physis-of children with juvenile OCD and to compare these findings with the MRI findings of unaffected children. MATERIALS AND METHODS: Knee MRI examinations of 30 children (age range, 8 years 8 months to 13 years 4 months) with OCD and 30 matched control patients were evaluated for skeletal maturity; location of the OCD lesion, if present; secondary physeal [corrected] continuity; overlying chondroepiphysial integrity, contour, and width; signal intensity of subchondral bone; and secondary physeal [corrected] conspicuity. Variables were compared using chi-square tests. RESULTS: All children were skeletally immature. Condylar lesions were medial in 24 knees and lateral in six knees. All were in the middle one third, posterior one third, or middle and posterior thirds in the sagittal plane. The majority of lesions spanned the intercondylar and middle one third of the femoral condyle in the coronal plane (73%). There was a significant difference between secondary physeal [corrected] disruption in juvenile OCD condyles compared with unaffected condyles (p < 0.001) and control condyles (p < 0.001). Compared with unaffected and control condyles, the OCD group showed chondroepiphysial widening (p < 0.001) and subchondral bone edema (p < 0.001) on MRI. Neither chondroepiphysial integrity nor chondroepiphysial contour was significantly different between groups (p = 0.21, p = 0.31, respectively). CONCLUSION: MRI of children with OCD consistently showed secondary physis disruption, overlying chondroepiphysial widening, and subchondral bone edema. We suggest that disruption of normal endochondral ossification may be associated with juvenile OCD.

Growth plate fractures of the distal femur.

Growth plate fractures of the distal femur are challenging to treat, with complications that require a secondary surgery 40% to 60% of the time. These fractures often necessitate operative intervention, even in the youngest patients and even with minimal apparent displacement. Treatment varies with the Salter-Harris (SH) classification and with the extent of initial displacement, ranging from simple casting for nondisplaced SH I fractures to open reduction and internal fixation for almost all SH III and IV fractures. Poor outcomes have been associated with pediatric fracture care of SH III and IV in 29% to 32% of cases. There are many pitfalls that have to be avoided in the treatment of these fractures to prevent malunion, growth arrest, and posttraumatic arthritis.