Theodore J. Ganley

Management of Osteochondritis Dissecans of the Knee Current Concepts Review

Osteochondritis dissecans of the knee is being seen with increased frequency in pediatric and young adult athletes and is thought to be, in part, owing to earlier and increasingly competitive sports participation. Despite much speculation, the cause of both juvenile and adult osteochondritis dissecans remains unclear. Early recognition is essential. Whereas adult osteochondritis dissecans lesions have a greater propensity to instability, juvenile osteochondritis dissecans lesions are typically stable, and those with an intact articular surface have a potential to heal with nonoperative treatment through cessation of repetitive impact loading. The value of adjunctive immobilization, protected weightbearing, and unloader bracing has not been established. Skeletally immature patients with stable lesions that have not healed with nonoperative treatment should have consideration given to arthroscopic drilling to promote healing before the lesion progresses and requires more involved treatment with a less optimistic prognosis. Magnetic resonance imaging may allow early prediction of lesion healing potential. The majority of adult osteochondritis dissecans cases as well as those skeletally immature patients with unstable lesions and secondary loose bodies require fixation and possible bone grafting. Many unstable lesions will heal after stabilization, but long-term prognosis is not clear. Chronic loose fragments can be difficult to fix and have poor healing potential. Results of excision of large lesions from weightbearing zones are poor. Chondral resurfacing techniques have limited long-term data for cases of osteochondritis dissecans in skeletally immature patients.

Effect of Graft Choice on the Outcome of Revision Anterior Cruciate Ligament Reconstruction in the Multicenter ACL Revision Study (MARS) Cohort

Background: Most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome; however, graft choice for revision may be limited due to previously used grafts. Hypotheses: Autograft use would result in increased sports function, increased activity level, and decreased osteoarthritis symptoms (as measured by validated patient-reported outcome instruments). Autograft use would result in decreased graft failure and reoperation rate 2 years after revision ACL reconstruction. Study Design: Cohort study; Level of evidence, 2. Methods: Patients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons at 52 sites. Data collected included baseline demographics, surgical technique, pathologic abnormalities, and the results of a series of validated, patient-reported outcome instruments (International Knee Documentation Committee [IKDC], Knee injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating score). Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Incidences of additional surgery and reoperation due to graft failure were also recorded. Multivariate regression models were used to determine the predictors (risk factors) of IKDC, KOOS, WOMAC, Marx scores, graft rerupture, and reoperation rate at 2 years after revision surgery. Results: A total of 1205 patients (697 [58%] males) were enrolled. The median age was 26 years. In 88% of patients, this was their first revision, and 341 patients (28%) were undergoing revision by the surgeon who had performed the previous reconstruction. The median time since last ACL reconstruction was 3.4 years. Revision using an autograft was performed in 583 patients (48%), allograft was used in 590 (49%), and both types were used in 32 (3%). Questionnaire follow-up was obtained for 989 subjects (82%), while telephone follow-up was obtained for 1112 (92%). The IKDC, KOOS, and WOMAC scores (with the exception of the WOMAC stiffness subscale) all significantly improved at 2-year follow-up (P < .001). In contrast, the 2-year Marx activity score demonstrated a significant decrease from the initial score at enrollment (P < .001). Graft choice proved to be a significant predictor of 2-year IKDC scores (P = .017). Specifically, the use of an autograft for revision reconstruction predicted improved score on the IKDC (P = .045; odds ratio [OR] = 1.31; 95% CI, 1.01-1.70). The use of an autograft predicted an improved score on the KOOS sports and recreation subscale (P = .037; OR = 1.33; 95% CI, 1.02-1.73). Use of an autograft also predicted improved scores on the KOOS quality of life subscale (P = .031; OR = 1.33; 95% CI, 1.03-1.73). For the KOOS symptoms and KOOS activities of daily living subscales, graft choice did not predict outcome score. Graft choice was a significant predictor of 2-year Marx activity level scores (P = .012). Graft rerupture was reported in 37 of 1112 patients (3.3%) by their 2-year follow-up: 24 allografts, 12 autografts, and 1 allograft and autograft. Use of an autograft for revision resulted in patients being 2.78 times less likely to sustain a subsequent graft rupture compared with allograft (P = .047; 95% CI, 1.01-7.69). Conclusion: Improved sports function and patient-reported outcome measures are obtained when an autograft is used. Additionally, use of an autograft shows a decreased risk in graft rerupture at 2-year follow-up. No differences were noted in rerupture or patient-reported outcomes between soft tissue and bone–patellar tendon–bone grafts. Surgeon education regarding the findings of this study has the potential to improve the results of revision ACL reconstruction.

Role of magnetic resonance imaging and clinical criteria in predicting successful nonoperative treatment of osteochondritis dissecans in children.

Magnetic resonance imaging (MRI) offers promise as a noninvasive method to determine the potential of an osteochondritis dissecans (OCD) lesion to heal without surgical intervention. The purpose of this study was to compare the value of MRI, plain radiographs, and clinical findings in predicting the success of nonoperative treatment of juvenile OCD lesions. Twenty-seven lesions in 24 patients (mean age 12.2 y) with OCD of the distal femur diagnosed based on MRI were identified. A radiologist or orthopaedist, blinded to the clinical status of the patients, correlated the MRIs with patient outcome. MRIs were assessed for lesion size, location, and four criteria evaluating signal intensity changes and articular surface defects to determine lesion stability. Older, more skeletally mature patients with at least one sign of instability on MRI were most likely to have nonoperative treatment fail. Nonoperative treatment failed most often in patients with large lesions in weightbearing areas, as seen on lateral radiographs. However, location based on anteroposterior radiographs was not statistically significant for predicting treatment outcome. Although no single factor was uniformly predictive of successful nonoperative treatment, younger, skeletally immature patients with no MRI criteria of instability were most amenable to nonoperative treatment.

The Operative Management of Pediatric Fractures of the Lower Extremity

The vast majority of pediatric fractures of the upper extremity can and should be treated with closed reduction, immobilization, and close follow-up. However, there is an ongoing debate in the orthopaedic community regarding the exact role of surgical management in the treatment of pediatric fractures 1. In the past two decades, operative management of certain fractures (e.g., percutaneous pinning of displaced supracondylar fractures) has provided better results than closed management. Surgical management is clearly indicated for certain injuries, such as those requiring anatomical realignment of the physis or articular surface. Increasingly, however, surgical management is being used to maintain optimal alignment or to allow early motion. In many such cases, both nonoperative and operative methods have yielded good results and have vocal advocates. Certain technical advances, such as flexible intramedullary fixation and bioreabsorbable implants, have further increased enthusiasm for operative management of pediatric fractures. The goal of these lectures is to describe current concepts in the operative management of selected pediatric fractures of the upper extremity. The focus is on specific indications, techniques, and potential complications in managing fractures of the forearm and elbow in children. The full scope of pediatric fracture management is a subject for textbooks. For introductory information and descriptions of techniques of successful nonoperative management, the reader is directed to comprehensive sources 2. Forearm fractures are among the most common orthopaedic injuries in children, accounting for 30% to 50% of all pediatric fractures 3,4. Historically, almost all forearm fractures in skeletally immature patients were treated nonoperatively. Recent information regarding functional outcomes, however, has challenged many of the traditional tenets of forearm fracture care. Furthermore, with the advent of newer technology, instrumentation, and techniques of fracture fixation, the treatment options have expanded 5. ### Distal Radial Fractures Because of their proximity to the distal radial …

Functional outcomes of early arthroscopic bankart repair in adolescents aged 11 to 18 years.

Recurrent shoulder instability can significantly affect a patients quality of life and place them at risk for extensive soft tissue and bony injury with repeated dislocations. Literature on the operative management of recurrent instability in pediatric patients is limited, as most studies include pediatric patients within a larger sample group comprised primarily of adults. The purpose of this paper was to investigate the role of early arthroscopic Bankart repair (ABR) after anterior shoulder dislocation or subluxation in a pure pediatric population. We retrospectively reviewed 32 consecutive ABRs in 30 pediatric patients. Sixteen shoulders failed initial nonoperative therapy before ABR, whereas surgical stabilization was the primary treatment in 16 shoulders after initial evaluation at our institution. There were 17 males and 13 females with an average age of 15.4 years (age range, 11-18 years). The average follow-up was 25.2 months. Functional outcomes were measured using the single assessment numerical evaluation (SANE) score. In the initial nonoperative group, the average SANE score was 92.2. There were 3 shoulder redislocations in 2 patients (18.75%). In the 16 shoulders treated with ABR as initial therapy, the average SANE score was 91.8, and there were 2 shoulder redislocations in 2 patients (12.5%). We conclude that primary ABR is an effective treatment of traumatically induced shoulder instability in pediatric patients. Primary ABR limits multiple recurring shoulder dislocations that hinder a patients quality of life and places them at risk for future negative sequelae.

Combined Anterior Cruciate Ligament and Medial Collateral Ligament Injuries in Adolescents

Abstract: Although literature supports bracing of most medial collateral ligament (MCL) injuries followed by arthroscopic repair of anterior cruciate ligament (ACL) tears in adults with combined ACL-MCL injuries, little is published regarding the treatment of these injuries in the pediatric population. The purpose of this study was to present our outcomes after treatment of combined ACL-MCL injuries in a series of adolescents. All 180 patients who underwent ACL reconstruction at our childrens hospital from January 1997 to January 2003 were reviewed to identify those patients with concomitant grade II or III MCL injuries. Clinical data were obtained from chart review. All patients were treated with a hinged brace for their MCL injury followed by delayed arthroscopic reconstruction of their ACL using a transphyseal technique with Achilles tendon soft tissue allograft. Patients were contacted by phone to complete Lysholm knee questionnaires and assess return to athletic competition. Data were compared with a control cohort of patients who underwent isolated ACL reconstruction using the same technique. Twelve (6.7%) of 180 patients had combined ACL-MCL injuries. There were 6 boys and 6 girls; the mean age was 15.6 years (range, 14-17 years). Follow-up averaged 5.3 years (range, 2.6-8.2 years), and no patients were lost to follow-up. At last examination, all patients had a stable knee on both Lachman and valgus stress tests; the mean Lysholm knee score was 96 (range, 94-100). All patients were able to return to their preinjury level of athletics. One patient required manipulation for arthrofibrosis. When compared with the control group of 19 isolated ACL reconstructions, there was no significant difference with regards to Lysholm scores or return to athletics. Bracing of grade 2 or 3 MCL injuries followed by ACL reconstruction was an effective means of treating combined ACL-MCL injuries in this small series of adolescent patients.

Arthroscopic Management of Osteochondritis Dissecans of the Capitellum: Mid-term Results in Adolescent Athletes

Background The optimal treatment of osteochondritis dissecans (OCD) of the capitellum in adolescent athletes remains challenging. The purpose of this study was to investigate the mid-term results of arthroscopic treatment of OCD of the capitellum in a series of adolescents. Methods We identified 25 consecutive patients at our institution that underwent arthroscopic treatment for OCD of the capitellum since 1999. Ten elbows were treated by arthroscopic debridement and drilling alone, whereas 12 elbows required additional mini-arthrotomies for bone grafting or the removal of large loose bodies after arthroscopy. The clinical charts and operative reports of these patients were retrospectively reviewed for relevant clinical information including age, sport, character of symptoms, preoperative and postoperative range of motion, return to sport, and postoperative complications. Twenty-one patients (22 elbows) were reached to determine their current elbow function and athletic activity using the Single Assessment Numerical Evaluation score. Results The average age of the patients in our series was 13.1 years. All patients participated in organized athletics that involved the upper extremity and had undergone an average of 10.2 months of nonoperative treatment before surgery. At a mean follow-up of 48 months, the patients gained an average of 17 degrees of extension and 10 degrees of flexion after surgery. Both the improvement in flexion and extension were statistically significant compared with the preoperative range of motions (P=0.001, P=0.01). When patients were asked to rate their elbow function from 0% to 100% using the Single Assessment Numerical Evaluation score, the average rating was 87%. Eighteen of 21 patients (86%) returned to participate in their sport at their preinjury level. Conclusion Arthroscopic management of capitellar OCD in adolescent athletes results in significantly improved range of motion and a high rate of return to athletics. Accompanying arthrotomy may be required for large loose body removal or bone grafting. Level of Evidence Level IV (case series).

Tibial eminence fractures in children: earlier posttreatment mobilization results in improved outcomes.

Background: Arthrofibrosis and decreased range of motion (ROM) are well-described sequelae of tibial eminence fractures. We sought to evaluate the effects of timing of ROM rehabilitation and postsurgical immobilization on clinical outcomes in children with fractures of the tibial eminence. Methods: We retrospectively reviewed the records of all children diagnosed with closed tibial eminence fractures between 2000 and 2010. Patients were treated by experienced surgeons with uniform requirements for return to full activity. Results: Fourteen females and 26 males (40 knees) of mean age 12 years (range, 5 to 17 y) started ROM therapy for a mean of 23 days after treatment (range, 4 to 47 d). Seven patients required additional surgeries for arthrofibrosis at a mean of 3 months after initial fracture treatment (range, 1.5 to 5.5 mo). Compared with patients who started ROM rehabilitation within 4 weeks of treatment, those who started later than 4 weeks required more days to return to full activity (215 vs. 103 d; P=0.011) and were 12 times more likely to develop arthrofibrosis (P=0.029). Even when accounting for other factors in multivariate regression, earlier initiation of ROM therapy was associated with earlier return to full activity (P<0.001). Surgical patients who were immobilized postoperatively required more days to return to full activity (217.5 vs. 103 d; P=0.015) and had a higher rate of arthrofibrosis (36% vs. 0%; P=0.043) than those who were not. Age, sex, fracture classification, and operative versus nonoperative treatment did not have a statistically significant effect on our multivariate model. Conclusions: After definitive treatment, early implementation of ROM rehabilitation results in a more rapid return to full activity. ROM therapy within 4 weeks of treatment results in sooner return to full activity and decreases the likelihood of eventual arthrofibrosis. In surgical patients, postoperative immobilization results in a longer delay until return to full activity and a higher rate of arthrofibrosis. Level of Evidence: Therapeutic study, level III.

Osteoarthritis classification scales: Interobserver reliability and arthroscopic correlation

BACKGROUND Osteoarthritis of the knee is commonly diagnosed and monitored with radiography. However, the reliability of radiographic classification systems for osteoarthritis and the correlation of these classifications with the actual degree of confirmed degeneration of the articular cartilage of the tibiofemoral joint have not been adequately studied. METHODS As the Multicenter ACL (anterior cruciate ligament) Revision Study (MARS) Group, we conducted a multicenter, prospective longitudinal cohort study of patients undergoing revision surgery after anterior cruciate ligament reconstruction. We followed 632 patients who underwent radiographic evaluation of the knee (an anteroposterior weight-bearing radiograph, a posteroanterior weight-bearing radiograph made with the knee in 45° of flexion [Rosenberg radiograph], or both) and arthroscopic evaluation of the articular surfaces. Three blinded examiners independently graded radiographic findings according to six commonly used systems-the Kellgren-Lawrence, International Knee Documentation Committee, Fairbank, Brandt et al., Ahlbäck, and Jäger-Wirth classifications. Interobserver reliability was assessed with use of the intraclass correlation coefficient. The association between radiographic classification and arthroscopic findings of tibiofemoral chondral disease was assessed with use of the Spearman correlation coefficient. RESULTS Overall, 45° posteroanterior flexion weight-bearing radiographs had higher interobserver reliability (intraclass correlation coefficient = 0.63; 95% confidence interval, 0.61 to 0.65) compared with anteroposterior radiographs (intraclass correlation coefficient = 0.55; 95% confidence interval, 0.53 to 0.56). Similarly, the 45° posteroanterior flexion weight-bearing radiographs had higher correlation with arthroscopic findings of chondral disease (Spearman rho = 0.36; 95% confidence interval, 0.32 to 0.39) compared with anteroposterior radiographs (Spearman rho = 0.29; 95% confidence interval, 0.26 to 0.32). With respect to standards for the magnitude of the reliability coefficient and correlation coefficient (Spearman rho), the International Knee Documentation Committee classification demonstrated the best combination of good interobserver reliability and medium correlation with arthroscopic findings. CONCLUSIONS The overall estimates with the six radiographic classification systems demonstrated moderate (anteroposterior radiographs) to good (45° posteroanterior flexion weight-bearing radiographs) interobserver reliability and medium correlation with arthroscopic findings. The International Knee Documentation Committee classification assessed with use of 45° posteroanterior flexion weight-bearing radiographs had the most favorable combination of reliability and correlation. LEVEL OF EVIDENCE Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Prevention of sports injuries in children.

As children around the world become involved in increasingly competitive and more organized sports activities, the frequency and severity of both acute and overuse injuries continues to rise. Over the past year, several important studies have contributed to our knowledge in the prevention of sports injuries in children. Safety guidelines and protective equipment are crucial to minimizing pediatric recreational injuries. Protective headgear, mouth guards, and wrist and shin guards have all been shown to be effective in preventing injuries. Nutrition and nutritional supplements (eg, creatine) for the pediatric athlete have also received greater attention recently. Combined with appropriate physical activity programs, nutrition is essential in battling the increasing epidemic of childhood obesity. Increased attention has also been directed toward specific injuries and injury rates in the female athlete. Specific training for the female pediatric athlete may have a preventive effect in halting the rising injury rates.