Medial femoral condyle OCD (osteochondritis dissecans): correlation between imaging and arthroscopy.

Osteochondritis dissecans (OCD) describes a pathologic condition centered at the osteochondral junction that may result in an unstable subchondral fragment (progeny), disruption of the overlying cartilage, which may separate from the underlying parent bone. It is one of the causes of chronic knee pain in children and young adults. The current literature on OCD lesions focuses primarily on the medial femoral condyle (MFC), but inconsistent use of terminology, particularly in the distinction of OCD lesions between skeletally immature and mature patients has created uncertainty regarding imaging workup, treatment, and long-term prognosis. This article reviews the pathophysiology of MFC OCD lesions, highlighting the role of endochondral ossification at the secondary growth plate of the immature femoral condyles, the rationale behind the imaging work-up, and key imaging findings that can distinguish between stable lesions, unstable lesions, and physiologic variants. This overview also provides a case-based review to introduce imaging correlates with the ROCK (Research in Osteochondritis of the Knee) arthroscopic classification.

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.

Poorly Controlled Pediatric Fracture Pain Requiring Unplanned Medical Assistance or Advice.

OBJECTIVES: This study aimed to define the proportion of children who seek assistance for poorly controlled fracture pain, identify factors associated with requesting help, and explore caregivers' opioid preferences. METHODS: We enrolled 251 children and their caregivers in the orthopedic surgery clinic of a tertiary care children's hospital. Children 5 to 17 years old presenting within 10 days of injury for follow-up for a single-extremity, nonoperative long bone fracture(s) were eligible. The primary outcome was seeking unscheduled evaluation or advice for poorly controlled pain before the first routine follow-up appointment by telephone call, medical visit, or rescheduling to an earlier appointment. Factors associated with the outcome were assessed using bivariable analysis. RESULTS: Overall, 7.3% (95% confidence interval, 4.1%-10.6%) of participants sought unscheduled evaluation or advice for poorly controlled pain. The 2 most common reasons were to obtain over-the-counter analgesic dosage information (64.7%) and a stronger analgesic (29.4%). These children were more likely to have a leg fracture, have an overriding or translated fracture, or require manual reduction under procedural sedation. These children had higher Patient-Reported Outcomes Measurement Information System Pain Behavior and Pain Interference scores and more anxious caregivers. One-third of caregivers expressed hesitancy or refusal to use opioids to treat severe pain, and 45.7% reported potential addiction or abuse as the rationale. CONCLUSIONS: A notable proportion of children seek assistance for poorly controlled fracture-related pain. Medical providers should target discharge instructions to the identified risk factors and engage caregivers in shared decision making if opioids are recommended.

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.

Association between early-childhood antibiotic exposure and subsequent asthma in the US Medicaid population.

BACKGROUND: Although socioeconomically disadvantaged children have an increased risk of asthma, the association between early-childhood antibiotics and the incidence of asthma among such children has had limited study. OBJECTIVE: To examine the association between antibiotic fills in the first 2 years of life and risk of developing asthma among children enrolled in Medicaid plans. METHODS: This retrospective cohort study of children with continuous medical and pharmacy coverage from birth to 2.5 years of age was performed from July 1, 2012, to November 31, 2018. We excluded children with a diagnosis of asthma before 2.5 years of age. Hazard ratios (HRs) and 95% CIs were estimated from Cox proportional hazards regression models. Covariates included sex, preterm birth, cesarean delivery, and mother's asthma status. RESULTS: There were 79,582 children in the study cohort of whom 29,931 (37.6%) had 0 antibiotic prescriptions filled, 27,403 (34.4%) had 1 or 2 prescriptions filled, and 22,248 (28.0%) had 3 or more prescriptions filled. A total of 2381 new cases of asthma were observed in 89,545 person-years of follow-up. After adjustment, receipt of 1 or 2 antibiotics was associated with an increased risk of developing asthma, relative to 0 antibiotics (HR, 1.34; 95% CI, 1.21-1.49), and receipt of 3 or more antibiotics was associated with greater increased risk relative to 0 antibiotics (HR, 1.71; 95% CI, 1.54-1.90). After adjustment, the absolute risk of developing asthma by age 4.0 years increased from 2.7% (0 antibiotics) to 3.6% (1-2 antibiotics) and 4.5% (≥3 antibiotics). CONCLUSION: Antibiotic prescriptions filled in the first 2 years of life were associated with an increased risk of asthma diagnosis from 2.5 to 5 years of age in a Medicaid population.

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.

Obstructive lung disease in children with idiopathic scoliosis.

OBJECTIVE: To measure the prevalence of obstructive lung disease (OLD) among patients undergoing preoperative pulmonary assessment for idiopathic scoliosis. STUDY DESIGN: This was a retrospective, descriptive review from clinical data in a tertiary care pediatric hospital in the US. Patients (n = 176) with idiopathic scoliosis with Cobb angles of ≥ 40 degrees who performed acceptable and repeatable preoperative pulmonary function testing were included. The primary outcome measure was the forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) ratio. RESULTS: The prevalence of OLD (low FEV1/FVC ratio) was 39% (68/176 patients). In multivariate modeling, radiographic measures were poor predictors of pulmonary function outcomes of FVC (r(2) 0.06), FEV1 (r(2) 0.05), FEV1/FVC ratio (r(2) 0.08), and total lung capacity (r(2) 0.06). CONCLUSIONS: OLD is common in patients with idiopathic scoliosis. We recommend preoperative pulmonary function testing for patients with idiopathic scoliosis under consideration for spinal fusion surgery.

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.