Eric W. Edmonds

A Review of Knowledge in Osteochondritis Dissecans: 123 Years of Minimal Evolution from König to the ROCK Study Group

BackgroundOsteochondritis dissecans (OCD) was first described to provide an explanation for the nontraumatic development of loose bodies within a joint. Despite many reports on the subject, there remains no clear understanding of the etiology, natural history, or treatment.Questions/purposesThis review was undertaken to delineate (1) the etiology of OCD; (2) the presentation and locations; (3) the most appropriate imaging modalities; and (4) the most effective treatment strategies.MethodsWe reviewed the English literature using a database compiled from a Medline search for “osteochondritis dissecans”. We identified 1716 publications, 1246 of which were in English. After exclusions, we reviewed 748 articles and of these cited 85. The observations of each study were then synthesized into this report.ResultsThere appears to be no consensus concerning the etiology of OCD lesions. The presentations and locations are variable, but the knee, ankle, and elbow are most commonly involved. Although plain film assessment is important in OCD, there appears to be a trend toward the use of MRI, but the preferred sequences are in evolution. We found no consensus on the treatment of these lesions, related in part to the lack of agreement of methods for assessing outcomes.ConclusionsDespite more than a century of study, we have made little advancement in our understanding of OCD. A study group has been formed to address this issue and actively seeks to answer these unknown issues regarding OCD.

Outcomes of Extra-articular, Intra-epiphyseal Drilling for Osteochondritis Dissecans of the Knee

Background When conservative management fails to heal femoral condyle osteochondritis dissecans (OCD) lesions in a child, then drilling of the subchondral plate below the lesion to stimulate healing may be beneficial. This study reviews the outcomes of extra-articular, intraepiphyseal drilling of OCD lesions of the knee with intact articular cartilage. Methods Over an 8-year period, all children, who failed at least 6 months of nonoperative management, underwent arthroscopic knee surgery and extra-articular, intra-epiphyseal drilling for their symptomatic, nondisplaced femoral condyle OCD lesions. The clinical and radiographic outcomes were evaluated by using demographics, preoperative size of the lesion, intraoperative concomitant pathology, complications, postoperative range of motion, return to activities, radiographic progression of healing, and subsequent operative procedures. Results In all 59 children, the mean time to return to activities was 2.8 months (1.3 to 13.1 mo) and the mean percentage of radiographic healing was 98.2% (79% to 100%) at final follow-up. Forty-four (75%) of the OCD lesions were successfully treated to 100% radiographic healing with an average time for healing of 11.9 months (1.3 to 47.3 mo). The large lesions took significantly longer to heal than the small lesions, 15.3 months versus 8.8 months (P=0.032), and the percentage of radiographic healing at final follow-up approached significance with large (>3.2 cm2) lesions attaining a mean of 96.9% (standard deviation 6.4%) versus small lesions (<3.2 cm2) with a mean of 99.4% (standard deviation 2.1%, P=0.083). No operative complications were observed. Conclusions Extra-articular, intraepiphyseal drilling of OCD lesions produced excellent results over the historical controls using intra-articular drilling for those patients who failed initial conservative management. This technique allows for more drill holes to be placed perpendicular to the OCD lesions, especially the posterior lesions that may have limited intra-articular access. Furthermore, this technique avoids intraoperative damage to the overlying intact articular cartilage and promotes osseous healing by fenestration of the sclerotic rim surrounding the OCD lesion. Level of Incidence Prognostic study, Level IV (retrospective study).

How Displaced Are “Nondisplaced” Fractures of the Medial Humeral Epicondyle in Children? Results of a Three-Dimensional Computed Tomography Analysis

BACKGROUND The management of fractures of the medial humeral epicondyle is controversial, but the primary issue is the relationship of outcomes to the extent of fracture displacement. This study compares the use of radiographs and three-dimensional computed tomography for determining the amount of displacement in medial humeral epicondylar injuries deemed to be minimally displaced (<5 mm) or nondisplaced. METHODS A retrospective review was performed on the cases of all patients with a fracture of the medial humeral epicondyle that had been diagnosed as minimally displaced or nondisplaced who were seen over a one-year period at our institution. Measurements of medial and anterior displacement on both the radiographs and three-dimensional computed tomography scan were recorded. Measurements of displacement were also recorded on internal oblique radiographs of the elbow, if available. Demographics, treatment, and any additional findings by computed tomography scans were noted. Means and Student t tests were utilized for statistical analysis. RESULTS The eleven patients who met the inclusion criteria had a mean age of 12.2 years (range, 7.3 to 15.4 years). One fracture that involved the medial condyle on the computed tomography scan was excluded from the analysis. Anterior displacement was immeasurable on all but one lateral radiograph and recorded as 0 mm; the mean was 0.9 mm, which was significantly less than the anterior displacement on the three-dimensional computed tomography scan (mean, 8.8 mm; range, 0 to 15 mm) (p ≤ 0.001). Conversely, mean medial displacement on anteroposterior radiographs was 3.5 mm (range, 0 to 8 mm), which was significantly more than that measured on three-dimensional computed tomography scans (mean, 0.3 mm; range, 0 to 1.9 mm) (p ≤ 0.001). Mean displacement on internal oblique radiographs of the elbow was 6.6 mm (range, 0 to 10.5 mm) and matched the anterior displacement measurement on the three-dimensional computed tomography scan in three of the six patients (p = 0.037). Five of the six fractures with >1 cm of displacement by three-dimensional computed tomography scan underwent surgical treatment. CONCLUSIONS Standard radiographs (anteroposterior and lateral views) are not sufficient to measure anterior displacement nor accurate enough to measure medial displacement of medial humeral epicondylar fractures. Internal oblique radiographs of the elbow appear to approximate the true anterior displacement, but three-dimensional computed tomography is the most accurate method to assess true displacement. The results of this study demonstrate that fractures that are found to be minimally displaced or nondisplaced by radiographs may have >1 cm of anterior displacement, for which surgery is usually recommended.

Osteochondritis dissecans: editorial comment.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Immediate intramedullary flexible nailing of open pediatric tibial shaft fractures.

Background: Flexible nailing has become the preferred implant for pediatric patients with tibial shaft fractures that require operative fixation. Immediate definitive fracture fixation with flexible nails in patients with high-energy, open fractures has not been examined. The purpose of our study was to determine if immediate flexible nailing of open pediatric tibial shaft fractures is safe and efficacious from a bone healing, wound, and infectious standpoint. Methods: A retrospective review of 26 tibial shaft fractures consecutively treated with flexible nailing at our institution from 2003 to 2010 was performed. Age, mechanism of injury, associated injuries, presence of compartment syndrome, antibiotic administration, systemic insults, time to union, as well as bone healing (nonunion, delayed union, malunion, leg length discrepancy, growth arrest), wound, and infectious complications were collected. Comparisons were made between patients with open fractures and those with closed fractures. Results: We identified 14 patients with open fractures and a control group of 12 patients with closed injuries who underwent flexible nailing. Patients with open fractures were more likely to have polytraumatic injuries (71.0% vs. 25.0%, P=0.04). There was no difference (P=1.0) in the rates of compartment syndrome (open=14.0%, closed=17.0%) between the 2 groups. Systemic complications (pulmonary compromise and increased intracranial pressure) were noted in 2 patients who underwent immediate nailing of their open fractures; both of whom had closed head injuries. There was no difference (P=1.0) in the rates of wound/infectious complications between the open (7.0%) and closed (4.0%) fractures groups, with no cases of wound breakdown or osteomyelitis. There was an increased rate (P=0.02) of bone healing complications in the open fracture group (21.0% vs. 4.0%); all in patients with Gustilo type 2 or 3 injuries. All patients achieved radiographic union at final follow-up. Conclusions: Immediate flexible nailing of open pediatric tibial shaft fractures can be safely performed with minimal risk of wound or infectious complications. Clinicians should understand that prolonged bone healing (particularly in Gustilo type 2 or 3 injuries) should be expected in patients who undergo immediate flexible nailing of their open fractures. Open tibial shaft fractures are high-energy injuries, and should be seen as surrogate markers of polytrauma in the pediatric population. The risk of compartment syndrome is high regardless of whether a patient has a closed or open tibia fracture, and caution should be used in performing flexible nailing in patients who may have closed head injury due to a risk of systemic complications. Level of Evidence: Level III, therapeutic study, retrospective cohort.

Childhood Obesity as a Risk Factor for Lateral Condyle Fractures Over Supracondylar Humerus Fractures

BackgroundObese children reportedly have an increased risk of sustaining musculoskeletal injuries compared with their normal-weight peers. Obese children are at greater risk for sustaining fractures of the forearm, particularly from low-energy mechanisms. Furthermore, obesity is a risk factor for sustaining an extremity fracture requiring surgery. However, it is unclear what role obesity plays in fractures about the distal humerus.Questions/purposesWe therefore asked whether (1) children who sustain lateral condyle (LC) fractures have a higher body mass index (BMI) as compared with those with supracondylar (SC) humerus fractures; and (2) children with a higher BMI sustain more severe fractures regardless of fracture pattern.MethodsWe retrospectively reviewed 992 patients: 230 with LC injuries and 762 with SC fractures. We determined BMI and BMI-for-age percentiles. Fracture types were classified by the systems proposed by Weiss et al. (LC fractures) and Wilkins (SC fractures).ResultsThe LC group had both a higher mean BMI and BMI-for-age percentile than the SC group as well as had more obese patients (37% versus 19%). Within the LC group, children with Type 3 fractures had a higher BMI that those with Type 1 fractures (19 versus 17). There was a higher percentage of obese patients with Type 3 LC fractures compared with Type 1 and 2 fractures (44% versus 27% and 26%). Among patients with SC fractures, there was no difference among the BMI, BMI-for-age percentiles, or percentage of obese children when analyzed by fracture subtype.ConclusionsObesity places a child at greater risk for sustaining a LC fracture and when these fractures occur, they are often more severe injuries compared with those in nonobese children.Level of EvidenceLevel II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Tibial Tubercle Fractures: Complications, Classification, and the Need for Intra-articular Assessment

Background: Adolescent tibial tubercle fractures are uncommon, complex, high-energy injuries. The use of lateral radiographs in isolation to diagnose and treat these injuries is the standard of practice. However, with a single 2-dimensional (2D) view, there may be a risk that the degree of injury can be underestimated. This study was performed to report on the outcomes of tibial tubercle fractures operatively treated, determine the utility of a single lateral x-ray to accurately document injury severity and pattern, delineate the role of advanced imaging and intraoperative arthroscopy/arthrotomy in injury treatment, and propose a new classification system of tibial tubercle fractures that accounts for the complex 3D nature of proximal tibial physeal closure, and recognizes the importance of intra-articular extension, providing guidance for intervention. Methods: A retrospective review of operatively treated tibial tubercle fractures at our institution from 2003 to 2010 was performed. Child age, weight, mechanism of injury, Ogden classification (x-ray), advanced imaging results [computed tomography (CT)/magnetic resonance imaging (MRI)] including intra-articular fracture patterns, surgical techniques, intraoperative articular findings, and postoperative complications were collected. In addition, we classified all of our patients into a new classification system (type A—tubercle youth, type B—physeal, type C—intra-articular, type D—tubercle teen) based on a combination of plain radiograph (anteroposterior and lateral), advanced imaging (CT/MRI), and intraoperative arthrotomy/arthroscopy findings. Results: We found 41 tibial tubercle fractures in 40 children (all of whom were male) with a mean age of 15.0±1.1 years, and mean weight of 80.3±23.4 kg. Injuries mostly occurred during jumping activities. At initial presentation, compartment syndrome or vascular compromise was seen in nearly 10% of patients, all of whom had type B—physeal injuries under our new classification system. Fifty percent of injuries were underestimated and/or not appreciated by lateral x-ray alone. In patients with intra-articular involvement, consistent 3D fracture patterns were seen on CT including anterior fragments (sagittal plane), lateral fragments (coronal plane), and anterolateral fragments (axial plane). Our new 4 part classification system was able to classify all fractures: type A (2 patients, mean age, 12.7±0.2 y), type B (13 patients, mean age, 14.8±0.7 y), type C (22 patients, mean age, 15.3±1.1 y), and type D (2 patients, mean age, 15.5±0.1 y). All fractures achieved radiographic union with 2 patients (type A—tubercle youth and type B—physeal) requiring additional procedures due to premature physeal closure. Conclusions: Tibial tubercle fractures represent high-energy injuries with potentially devastating complications such as compartment syndrome and/or vascular compromise. Intra-articular involvement is often missed with the use of plain x-ray and drastically underestimates injury severity. The use of preoperative CT scan or MRI should be utilized as adjunct to plain lateral radiograph. If intra-articular involvement is recognized preoperatively, arthroscopy or open arthrotomy should be utilized at the time of surgery. Our new classification system is rooted in the development of the proximal tibia, accounts for intra-articular involvement, and provides guidance for treatment. Level of Evidence: Level III—diagnostic study.

Does swaddling influence developmental dysplasia of the hip?: An experimental study of the traditional straight-leg swaddling model in neonatal rats.

BACKGROUND The overall effect of swaddling has been controversial for centuries. Its positive effect on the psychological development of the infant has popularized it in European and North American countries, but its negative effect on the development of the hip is of great concern. In our experiment, the influence of straight-leg swaddling in an animal model was observed radiographically and histologically. METHODS One hundred and twelve neonatal rats were divided into a control group and three experimental groups that were swaddled with use of surgical tape in a manner simulating the human practice for the first five days of life (early swaddling), the second five days (late swaddling), and the first ten days (prolonged swaddling). Hip dislocation and subluxation were evaluated on anteroposterior pelvic radiographs, and histological studies were performed to further observe the morphology of the hips. RESULTS Rats in the prolonged swaddling group had the highest prevalence of hip dysplasia (thirty-six of forty-four), followed by the early swaddling group (twenty-one of forty-four). Most of the dysplastic hips in the prolonged swaddling group were dislocated, whereas subluxation dominated in the late swaddling group. Differences between the sexes were significant only in the early swaddling group, and differences between sides were not significant in any group. Appositional growth of the acetabular cartilage and deformity of the triradiate cartilage complex were observed in the dislocated and subluxated hips. CONCLUSIONS Straight-leg swaddling was demonstrated to increase the prevalence of developmental dysplasia of the hip in this animal model, especially if the swaddling was early or prolonged. The severity of hip impairment varied, with early and prolonged swaddling both leading to more dislocations than subluxations. Sex differences also existed but a side preference was not observed. Appositional growth of acetabular cartilage and a deformed triradiate cartilage complex were the pathological basis of the hip dysplasia in this animal model.

Novel Radiographic Feature Classification of Knee Osteochondritis Dissecans A Multicenter Reliability Study

Background: Osteochondritis dissecans (OCD) is a vexing condition for patients, parents, and physicians because of the frequent slow healing and nonhealing that leads to prolonged treatment. Several features on plain radiographs have been identified as predictors of healing, but the reliability of their measurement has not been established. Purpose: To determine the inter- and intrarater reliability of several radiographic features used in the diagnosis, treatment, and prognosis of OCD femoral condyle lesions. Study Design: Cohort study (Diagnosis); Level of evidence, 3. Methods: Pretreatment anteroposterior, lateral, and notch radiographs of 45 knees containing OCD lesions of the medial or lateral femoral condyle were reviewed in blinded fashion by 7 orthopaedic physician raters from different institutions over a secure web portal at 2 time points over a month apart. Classification variables included lesion location, growth plate maturity, parent bone radiodensity, progeny bone fragmentation, progeny bone displacement, progeny bone contour, lesion boundary, and radiodensity of the lesion center and rim. Condylar width and lesion size were measured on all views. Interrater reliability was assessed using free-marginal kappa and intraclass correlations. Intrarater reliability was assessed using the Cohen kappa, linear-weighted kappa, and intraclass correlations based on measurement type. Results: Raters had excellent reliability for differentiating medial and lateral lesions and growth plate maturity and for measuring condylar width and lesion size. In the subset of knees with visible bone in the lesion, the fragmentation, displacement, boundary, central radiodensity, and contour (concave/nonconcave) of the lesion bone were classified with moderate to substantial reliability. The radiodensity of the lesion rim and surrounding epiphyseal bone were classified with poor to fair reliability. Conclusion: Many diagnostic features of femoral condyle OCD lesions can be reliably classified on plain radiographs, supporting their future testing in multifactorial classification systems and multicenter research to develop prognostic algorithms. Other radiographic features should be excluded, however, because of poor reliability.

Short-term results of arthroscopic treatment of osteochondritis dissecans in skeletally immature patients.

Background: Osteochondritis dissecans (OCD) of the capitellum occurs in skeletally immature athletes, and most likely results from repetitive trauma during overhead activities. Treatment may consist of activity modifications, internal fixation, abrasion chondroplasty, microfracture, antegrade drilling, retrograde drilling, osteochondral autograft or allograft implantation, chondrocyte implantation, and rib autograft through arthroscopy or arthrotomy. One treatment modality has not been proven to be clearly more effective than the others. This study was undertaken to evaluate our treatment regimen that utilized arthroscopic-assisted treatments of capitellar OCD, including removal of loose bodies, antegrade or retrograde drilling, and chondroplasty in the pediatric population. Methods: All patients treated arthroscopically for a diagnosis of capitellar OCD over a 5-year period, were retrospectively reviewed. All were asked to return for follow-up questionnaire and radiographs. Exclusion criteria included those lost to follow-up. Demographics were recorded and range of motion was evaluated preoperatively and at most recent follow-up for flexion, extension, supination, and pronation. Preoperative and the most recent anterior/posterior and lateral radiographs of the elbow were reviewed. A 200-point elbow rating scale was used to assess patient outcomes. The arthroscopic appearance of the lesion was graded. Changes in preoperative to postoperative range of motion and size of lesion were compared using repeated measures analysis of variation. Results: There were 13 elbows in 12 patients; only 3 of the injuries occurred acutely. Mean age at the time of surgery was 13.1±1.07 (range, 10.8 to 14.6 y). Mean follow-up was 23.4±16.7 months (range, 2 to 60 mo). There were 3 grade I lesions, 2 grade II lesions, 1 grade IV lesion, and 7 grade V lesions. Seven of the lesions underwent transhumeral drilling, 2 transarticular drilling, 3 loose body removals, and 2 had only debridement. There were no postoperative infections or neurovascular injuries. Three of the elbows (20%) required eventual arthrotomy at a mean of 27.9 months after the index procedure. At final follow-up, 67% reported no pain and 33% reported occasional pain. No patients reported any swelling. Eighty-three percent reported no locking or catching and 17% reported occasional locking or catching. No patients reported any activity restrictions. The mean subjective score was 96±6 of 100 and the mean objective score was 100 of 100. Mean extension improved significantly from −17 to −7 degrees (P<0.001). Conclusions: Treatment of children with OCD lesions of the capitellum with arthroscopic-assisted debridement and fenestration of the sclerotic rim (trans-humeral if overlaying cartilage is intact), plus fixation of the overlaying cartilage if not securely attached to the subchondral bone permits the return to physical activity, but may not allow return to the injury-inducing sport. Our short-term outcomes obtained using this regimen found this technique to be safe and reliable, but other interventions may be required if continued disability persists.