Jeffrey I. Kessler

The Demographics and Epidemiology of Osteochondritis Dissecans of the Knee in Children and Adolescents

Background: Osteochondritis dissecans (OCD) is a disorder of subchondral bone and articular cartilage whose incidence in children is not clearly known. Purpose: The purpose of this study was to assess the demographics and epidemiology of OCD of the knee in children. Study Design: Descriptive epidemiology study. Methods: A retrospective chart review of an integrated health system was performed on patients with OCD of the knee aged 2 to 19 years from 2007 to 2011, with over 1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. The incidence of OCD was determined for the group as a whole and by sex and age group (2-5 years, 6-11 years, and 12-19 years). Patient differences based on age, sex, and ethnicity were analyzed, and using multivariable logistic regression models, associations between age, sex, ethnicity, and diagnosis of OCD of the knee were evaluated. Results: One hundred ninety-two patients with 206 OCD lesions of the knee fit the inclusion criteria. No OCD lesion of the knee was found in 2- to 5-year-old children. One hundred thirty-one (63.6%) lesions were in the medial femoral condyle, 67 (32.5%) were in the lateral femoral condyle, 96 (50.0%) lesions were right sided, 82 (42.7%) were left sided, and 14 (7.3%) were bilateral. The incidence of patients with OCD of the knee aged 6 to 19 years was 9.5 per 100,000 overall and 15.4 and 3.3 per 100,000 for male and female patients, respectively. Those aged 12 to 19 years represented the vast majority of OCD, with an incidence of 11.2 per 100,000 versus 6.8 per 100,000 for those aged 6 to 11 years. For those aged 6 to 11 and 12 to 19 years, female patients had an incidence of 2.3 and 3.9 per 100,000, respectively, while male patients had an incidence of 11.1 and 18.1 per 100,000, respectively. Multivariable logistic regression analysis revealed a 3.3-fold increased risk of OCD of the knee in patients aged 12 to 19 years compared with those aged 6 to 11 years (P < .001; 95% confidence interval [CI], 2.37-4.48), and male patients had 3.8 times a greater risk of OCD of the knee than female patients (P < .001; 95% CI, 2.71-5.41). Based on race and ethnicity, blacks had the highest odds ratio of OCD of the knee compared with all other ethnic groups. Conclusion: In this population-based cohort study of pediatric OCD of the knee, male patients had a much greater incidence of OCD and almost 4 times the risk of OCD compared with female patients. Also, patients aged 12 to 19 years had 3 times the risk of OCD of the knee as compared with 6- to 11-year-old children.

Associations between childhood obesity and upper and lower extremity injuries

Objectives To estimate the overall and age-specific associations between obesity and extremity musculoskeletal injuries and pain in children. Methods This cross-sectional study used information from electronic medical records of 913 178 patients aged 2–19 years enrolled in an integrated health plan in the period 2007–2009. Children were classified as underweight, normal weight, overweight, or moderately/extremely obese and, using multivariable logistic regression methods, the associations between weight class and diagnosis of upper or lower extremity fractures, sprains, dislocations and pain were calculated. Results Overweight (OR 1.18, 95% CI 1.15 to 1.20), moderately obese (OR 1.24, 95% CI 1.20 to 1.27) and extremely obese (OR 1.34, 95% CI 1.30 to 1.39) children had statistically significantly higher odds of lower extremity injuries/pain compared to normal weight, adjusted for sex, age, race/ethnicity and insurance status. Age-stratified analyses yielded similar results. No consistent association was observed between body mass index and injuries/pain of the upper extremities. Conclusions Greater body mass index is associated with increased odds of lower extremity injuries and pain issues. Because the benefits of physical activity may still outweigh the risk of injury, attention should be paid to injury prevention strategies for these children at greater risk for lower extremity injuries.

Use of allografts in Pemberton osteotomies

Twenty patients treated with 26 Pemberton osteotomies with allograft bone wedges were retrospectively evaluated radiographically. Two patients undergoing four osteotomies were excluded because of incomplete records or <1 year of follow-up. Eleven of the remaining 18 patients had other procedures performed. Osteotomies all united radiographically within 3 months. The acetabular index improved from 33° before surgery to 18° after surgery, and the lateral migration index improved from 60% to 26%. This new technique of Pemberton osteotomy with patellar allograft wedges allows good correction of acetabular dysplasia with immediate graft stability. This stability often obviates the need for postoperative spica casting, even for patients undergoing bilateral procedures, thereby allowing more rapid rehabilitation.

Osteochondritis dissecans of the knee: pathoanatomy, epidemiology, and diagnosis.

Although several hypotheses have been described to explain the cause of osteochondritis dissecans, no single hypothesis has been accepted in the orthopedic community. Given its increased incidence among athletes, most in the sports medicine community agree that repetitive microtrauma plays at least some role in its development. Knowledge regarding the epidemiology and pathoanatomy of osteochondritis dissecans has helped the understanding of osteochondritis dissecans; however, much is still to be learned about this condition and its cause. This article reviews the history of osteochondritis as it pertains to the current understanding of its pathoanatomy, epidemiology, and diagnostic features.

Osteochondritis Dissecans of the Ankle in Children and Adolescents Demographics and Epidemiology

Background: Osteochondritis dissecans (OCD) of the ankle is a disorder of the talar or distal tibial subchondral bone and articular cartilage whose incidence in children is not clearly known. Purpose: To assess the demographics and epidemiology of OCD of the ankle in children. Study Design: Descriptive epidemiologic study. Methods: A retrospective chart review of an integrated health system was conducted on patients with ankle OCD aged 2 to 19 years from 2007 to 2011, with >1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. Ankle OCD incidence was determined for the group as a whole and by both sex and age group (divided into age groups of 2-5, 6-11, and 12-19 years). The risk for ankle OCD for age group, sex, and ethnicity was assessed using multivariate logistic regression models. Results: A total of 85 patients fit the inclusion criteria, and 71.8% of lesions found were in the medial talus, 56.5% of lesions were right sided, and none were bilateral. No ankle OCD lesions were found in 2- to 5-year-olds. The incidence of ankle OCD in patients aged 6 to 19 years was 4.6 per 100,000 overall and 3.2 and 6.0 per 100,000 for male and female patients, respectively. Patients aged 12 to 19 years represented the vast majority of those with OCD, with an incidence of 6.8 per 100,000 compared with 1.1 per 100,000 in those 6 to 11 years of age. In those aged 6 to 11 and 12 to 19 years, female patients had a respective incidence of 1.5 and 8.9 per 100,000, whereas male patients had a respective incidence of 0.7 and 4.8 per 100,000. The overall female/male ratio of ankle OCD was 1.6:1. Multivariate logistic regression analysis revealed a 6.9 times increased risk for ankle OCD in patients aged 12 to 19 years compared with those aged 6 to 11 years (95% CI, 3.8-12.5; P < .0001), and female patients had a 1.5 times greater risk for ankle OCD than male patients (95% CI, 1.0-2.3; P = .06). On the basis of race and ethnicity, non-Hispanic whites had the highest relative risk for disease and African Americans the lowest risk. Conclusion: In this population‐based cohort study of pediatric ankle OCD, female patients had a greater incidence of OCD and a 1.5 times greater risk for ankle OCD compared with male patients. Teenagers had nearly 7 times the risk for ankle OCD compared with children 6 to 11 years of age.

The Incidence of Surgery in Osteochondritis Dissecans in Children and Adolescents.

Background: The frequency of osteochondritis dissecans (OCD), a disorder of the subchondral bone and articular cartilage, is not well described. Purpose: To assess the frequency of pediatric OCD lesions that progress to surgery based on sex, joint involvement, and age. Study Design: Descriptive epidemiology study. Methods: A retrospective chart review (2007-2011) was performed on OCD. Inclusion criteria included OCD of any joint and patients aged 2 to 19 years. Exclusion criteria included traumatic osteochondral fractures or coexistence of non-OCD intra-articular lesions. Differences in progression toward surgery were compared between age groups, sex, and joint location. Logistical regression analysis was performed by sex, age, and ethnicity. Results: Overall, 317 patients with a total of 334 OCD lesions were found. The majority of lesions (61.7%) were in the knee, with ankle, elbow, shoulder, and foot lesions representing 25.4%, 12.0%, 0.6%, and 0.3% of all lesions, respectively. The majority of joints needing surgery were in the knee (58.5%), with ankle and elbow lesions representing 22.9% and 18.6% of surgeries performed, respectively. The percentage of all OCD lesions progressing to surgery was 35.3%; surgical progression for knee, ankle, and elbow joints was 33.5%, 31.8%, and 55.0%, respectively. Logistic regression analysis found no statistically significant different risk of progressing to surgery for OCD of the knee, elbow, and ankle between sexes. Patients aged 12 to 19 years had a 7.4-times greater risk of progression to surgery for knee OCD lesions than 6- to 11-year-olds. Patients aged 12 to 19 years were 8.2 times more likely to progress to surgery for all OCD lesions than patients aged 6 to 11 years. Progression to surgery of ankle OCD did not significantly differ based on location. Three of 4 trochlear lesions progressed to surgery, along with 1 of 1 tibial, 1 of 3 patellar, 40.3% of lateral femoral condylar, and 28.2% of medial femoral condylar lesions. Conclusion: In this large cohort study of pediatric OCD patients, 35% progressed to surgery. Progression to surgery did not differ significantly between sexes with OCD of any joint. Progression to surgery for OCD of the knee, elbow, and ankle strongly correlated with patient age at the time of diagnosis. Clinical Relevance: The knowledge of likelihood of progression to surgery of OCD by location, sex, and age is useful in counseling patients and in planning treatment. This study confirms a worse prognosis in the nonoperative treatment of older patients with OCD.

Interobserver and intraobserver reliability of the modified waldenström classification system for staging of legg-calvé-perthes disease

BACKGROUND The absence of a reliable classification system for Legg-Calvé-Perthes disease has contributed to difficulty in establishing consistent management strategies and in interpreting outcome studies. The purpose of this study was to assess interobserver and intraobserver reliability of the modified Waldenström classification system among a large and diverse group of pediatric orthopaedic surgeons. METHODS Twenty surgeons independently completed the first two rounds of staging: two assessments of forty deidentified radiographs of patients with Legg-Calvé-Perthes disease in various stages. Ten of the twenty surgeons completed another two rounds of staging after the addition of a second pair of radiographs in sequence. Kappa values were calculated within and between each of the rounds. RESULTS Interobserver kappa values for the classification for surveys 1, 2, 3, and 4 were 0.81, 0.82, 0.76, and 0.80, respectively (with 0.61 to 0.80 considered substantial agreement and 0.81 to 1.0, nearly perfect agreement). Intraobserver agreement for the classification was an average of 0.88 (range, 0.77 to 0.96) between surveys 1 and 2 and an average of 0.87 (range, 0.81 to 0.94) between surveys 3 and 4. CONCLUSIONS The modified Waldenström classification system for staging of Legg-Calvé-Perthes disease demonstrated substantial to almost perfect agreement between and within observers across multiple rounds of study. In doing so, the results of this study provide a foundation for future validation studies, in which the classification stage will be associated with clinical outcomes.

The Demographics And Epidemiology Of Osteochondritis Dissecans Of The Ankle, Elbow, Foot, And Shoulder In Children

Objectives: To assess the demographics and epidemiology of osteochondritis dissecans (OCD) of the ankle, elbow, foot, and shoulder in patients age 2-19. Methods: A retrospective chart review was done on OCD between 2007 and 2011. Inclusion criteria included OCD of the ankle, elbow, foot, or shoulder, and patients aged 2-19. Exclusion criteria included the co-existence of any other intra-articular lesions. Joint involvement, laterality, and all patient demographics were recorded. The incidence of OCD in 2010 was determined for the ankle, elbow, and foot. Results: 125 patients with a total of 128 OCD lesions fit the inclusion criteria. 60.2% of lesions were right sided and 39.8% left sided. Males had 53.9% and females 46.1% of all lesions. Lesions of the ankle, elbow, foot, and shoulder represented 66.4%, 31.3%, 0.8%, and 1.6% of all joints, respectively. No OCD lesions were found in the 2-5 year-olds. The incidence of ankle OCD for patients aged 6-19 was 4.7 per 100,000 for all patients, and 3.5, and 6.0 per 100,000 for males and females, respectively. The incidence of elbow OCD was 2.2 per 100,000 for all patients, and 3.8 and 0.6 per 100,000 for males and females, respectively. The incidence of OCD in the foot was 0.15 per 100,000 for all patients. The male/female ratio for elbow OCD was 6.4/1, and 1/1.6 for ankle OCD. In the ankle joint, the vast majority involved the medial talus (71.8%), with most of the rest involving the lateral talus (22.4%). Females had 28.8% of lesions in the lateral talus while males had only 12.1%. Almost all elbow lesions (97.5%) involved the capitellum. In the shoulder, both lesions involved the glenoid, and in the foot, the single lesion involved the metatarsal head. Conclusion: In this population-based cohort study of pediatric OCD in nearly 1 million children, males had a greater incidence of OCD and most were right sided. Females had nearly twice the incidence of ankle OCD, while males had over 6 times the incidence of elbow OCD. To our knowledge, this is the largest epidemiologic/demographic study of pediatric OCD of the ankle, elbow, foot, and shoulder reported.

The Demographics, Epidemiology, and Incidence of Progression to Surgery of Osteochondritis Dissecans of the Knee in Children and Adolescents

Objectives: To assess the demographics and epidemiology of osteochondritis dissecans (OCD) of the knee in patients age 2-19 and the frequency with which these lesions progress to surgery. Methods: A retrospective EMR chart review of an integrated health system was done on OCD between 2007 and 2011. Inclusion criteria included OCD of the knee and patients aged 2-19, with approximately 1 million patients in this cohort. Lesion location, laterality, and all patient demographics were recorded. OCD incidence was determined for the group as a whole and by age group (divided into age 2-5, group A=6-11, group B=12-19). Differences in progression toward surgery were compared between age groups, gender, and joint location. Results: 192 patients with a total of 206 OCD lesions fit the inclusion criteria. No OCD lesions were found in 2-5 year olds. 53.4% of lesions were right-sided, 46.6% left-sided. The medial femoral condyle was the most commonly affected location with 63.6% of the knee OCD lesions, followed by the lateral femoral condyle with 32.5%. Lesions of the femoral trochlea, patella, and lateral tibial plateau represented less than 4% of the total combined. No OCD lesions were found in the 2-5 year-olds. The incidence of knee OCD for patients aged 6-19 was 9.6 per 100,000 for all patients, and 15.7 and 3.3 per 100,000 for males and females, respectively. Group B represented the vast majority of OCD, with an incidence of 21.8 per 100,000 in 12-19 year olds versus 8.7 in group A. Females in group A and B had an incidence of 4.6 and 13.3 per 100,00, respectively, while males had an incidence of 12.5 and 30.1 per 100,00 for group A and B, respectively. The overall male/female ratio for knee OCD was 3.7/1. 33.8% of all lesions progressed to surgery. Lesion location did correlate with progression to surgery, with rare trochlear lesions and tibial lesions more likely to undergo surgery (100%, 100%) than lateral and medial femoral condyle lesions (40.3% and 28.7%) and patellar lesions (33.3%). Conclusion: In this population-based cohort study of pediatric OCD in nearly 1 million children, males had a much greater incidence of OCD and the majority were right sided lesions. Teenagers had nearly 3 times the incidence of OCD as compared to the 6-11 year old group. Although most OCD lesions were located on the medial femoral condyle, lateral femoral condyle lesions were also common. The incidence of OCD in this study was similar to a smaller Swedish study by Linden et al 40 years previously. The knowledge of likelihood of progression to surgery of OCD by location, sex, and age is useful in counseling patients and in planning treatment. To our knowledge, this is the largest study of the demographics, epidemiology, and incidence of progression to surgery of OCD of the knee in children ever reported.

Incidence of Osteochondritis Dissecans in Adults

Background: Osteochondritis dissecans (OCD) has frequently been described in children and adolescents, but cases of OCD in adults are certainly encountered. Little has been published on the epidemiology of OCD in adult patients. Purpose: To assess the frequency of OCD lesions in adults and assess the risk by age, sex, and ethnicity. Study Design: Descriptive epidemiology study. Methods: The authors assessed all patients aged 20 to 45 years from the entire database of patients enrolled as members of Kaiser Permanente Southern California from January 2011 until December 2013. Kaiser Southern California is an integrated health care system serving a racially, ethnically, and socioeconomically diverse population of >3.5 million patients. A retrospective chart review was done on OCD during this period. Inclusion criteria included OCD of any joint. Exclusion criteria included traumatic osteochondral fractures and coexistence of intra-articular lesions other than OCD. Joint involvement/location, laterality, and all patient demographics were recorded. Results: Among 122 patients, a total of 124 OCD lesions were found. The majority of lesions were in the ankle (n = 76) and knee (n = 43), with 3 foot lesions and 2 elbow lesions identified. OCD lesions were identified in 75 men (62%) and 47 women (38%). Overall incidence rates per 100,000 person-years were 3.42 for all OCD, 2.08 for ankle OCD, and 1.21 for knee OCD. The relative risk of adult OCD for men was twice that of women. The relative risk of adult OCD for white patients was 2.3 that of Asians and 1.7 that of Hispanics. Risk of knee OCD was 3.6 times higher for men than women. As compared with women, men had a higher risk for lateral femoral condyle OCD lesions versus the medial femoral condyle (P = .05; odds ratio [OR], 5.19). Conclusion: This large cohort study of Southern California adults with OCD demonstrated an increased OR for men (vs women) of OCD in all joints. The majority of symptomatic lesions were present in the ankle rather than the knee, as previously found in children. White and black patients had the highest OR of OCD; men had a significantly greater OR of lateral femoral condyle knee lesions as compared with women.