1
|
Wintges K, Körner M, Henkies D, Rüther H. [Osteochondral fractures in childhood and adolescence]. ORTHOPADIE (HEIDELBERG, GERMANY) 2024; 53:646-650. [PMID: 39031201 DOI: 10.1007/s00132-024-04527-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Osteochondral fractures (OCF) are traumatic shearing injuries to portions of cartilage and bone. The most common cause is patellar dislocation, with the main localisation being the medial patellar facet and the lateral femoral condyle. They can occur in all age groups. DIAGNOSIS Clinically, there is a painful knee joint effusion (haemarthrosis) with a "dancing patella". This is usually accompanied by restricted movement and/or a locking phenomenon. In addition to the standard X‑ray of the knee in three planes (lateral, anterior-posterior and tangential patella), an MRI should be performed promptly in the case of haemarthrosis and suspicious symptoms, as concomitant injuries are present in up to 70% of cases. TREATMENT The aim of treatment is to restore joint congruence in order to prevent the risk of secondary osteoarthritis. Small chondral and stable osteochondral fractures can be treated conservatively. Surgery is indicated for all other OCFs. In addition to refixation with various materials (bioresorbable screws, bone plugs, suture material and Kirschner wires), cartilage regeneration procedures (AMIC, MACI, OAT, etc.) are available for late diagnosed or non-refixable fragments. However, the number of cases is small. CONCLUSION Osteochondral fractures are rare injuries in children and adolescents. Prompt MRI is recommended for diagnosis in cases of suspected OCF. Refixation is the preferred treatment method, with bioresorbable implants showing promising results in reducing the need for additional surgery. The risk of secondary osteoarthritis can be reduced with regular treatment.
Collapse
Affiliation(s)
- Kristofer Wintges
- Klinik und Poliklinik für Kinderchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland.
| | - Merle Körner
- Klinik und Poliklinik für Kinderchirurgie, Universitätsklinikum Hamburg Eppendorf, Martinistraße 52, 20251, Hamburg, Deutschland
| | - Danny Henkies
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
| | - Hauke Rüther
- Klinik für Unfallchirurgie, Orthopädie und Plastische Chirurgie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland.
| |
Collapse
|
2
|
Pechlivanidou E, Zambakides C, Margariti RE. Pediatric osteochondral fractures: clinical insights associate early diagnosis to early rehabilitation via arthroscopy. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1657-1665. [PMID: 38376585 PMCID: PMC10980612 DOI: 10.1007/s00590-024-03852-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
PURPOSE This retrospective observational cohort analysis aims to address diagnostic and therapeutic challenges in managing osteochondral fractures (OCFs) resulting from acute patella dislocation and ankle sprains in children. METHODS The study includes 15 children treated for OCFs between January 2020 and July 2022. Data were obtained from medical records and analyzed using logistic regression. RESULTS The diagnostic and treatment algorithm involves detailed history, clinical examination, and imaging, with MRI guiding therapeutic decisions. Arthroscopic or mini open fixation led to successful rehabilitation, with 93% achieving full mobility at 9 months. Age was identified as a slight risk factor for free fragments in MRI, and arthroscopic management correlated with faster recovery at 3 months. CONCLUSION This study underscores the importance of immediate diagnosis and minimally invasive intervention for OCFs in children. Timely treatment, guided by a diagnostic algorithm, facilitates joint restoration and prevents degenerative consequences, ensuring a return to regular activities within a year postoperatively. LEVEL OF EVIDENCE IV.
Collapse
Affiliation(s)
- Evmorfia Pechlivanidou
- 1st Department of Orthopaedics, P. & A. Kyriakou Children's Hospital, Athens, Greece.
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias, 115 27, Athens, Greece.
| | - Christos Zambakides
- 1st Department of Orthopaedics, P. & A. Kyriakou Children's Hospital, Athens, Greece
| | - Rodanthi E Margariti
- 1st Department of Orthopaedics, P. & A. Kyriakou Children's Hospital, Athens, Greece
| |
Collapse
|
3
|
Lyons JG, Hudson TL, Krishnamurthy AB. Epidemiology of patellar dislocations in the United States from 2001 to 2020: results of a national emergency department database. PHYSICIAN SPORTSMED 2024; 52:26-35. [PMID: 36476163 DOI: 10.1080/00913847.2022.2156765] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Recent studies have shown an increasing incidence of patellar dislocations among children and adolescents. Updated, population-based studies of all patellar dislocations in the United States (US), however, are lacking. This study investigated recent trends in injury rates and demographics among patients sustaining patellar dislocations in the US from 2001 to 2020. METHODS This descriptive epidemiologic study retrospectively analyzed the National Electronic Injury Surveillance System (NEISS) database to identify cases of acute patellar dislocations presenting to US Emergency Departments (EDs) from 2001 to 2020. Annual, overall, and age-adjusted incidence rates (IRs, expressed per 100,000 at-risk person-years) and additional patient/injury characteristics were analyzed. Average annual percent change (AAPC) estimates are presented to indicate the magnitude/direction of trends in annual injury rates. RESULTS An estimated total of 159,529 patellar dislocations occurred over the study period for an overall IR of 2.58 (95% CI = 2.04-3.12). Accounting for population growth, the overall annual incidence increased significantly from 2.61 in 2001 to 3.0 in 2020 (AAPC = 2.8, p < 0.0001). When considering sex and age, statistically significant increases in annual IRs were observed among males aged 10-19 years (AAPC = 3.8, p < 0.0001), females aged 10-19 years (AAPC = 5.3, p < 0.0001), and females aged 20-29 years (AAPC = 3.5, p = 0.0152), while no significant changes were observed in any other age groups. Two-thirds of patellar dislocations involved sports-related injury mechanisms. The annual incidence of both sports-related and non-sports-related injuries increased significantly over the study period (sports-related: AAPC = 2.6, p = 0.0001; non-sports-related: AAPC = 3.4, p = 0.0001). Athletic patellar dislocations occurred most commonly in basketball and dance. CONCLUSION The number of patients sustaining patellar dislocations is increasing in the US. Similar increasing trends were observed in both males and females aged 10-19 years, whereas injury rates increased in the third decade only among females. A large percentage of injuries occur during athletic activity, but both sports- and non-sports-related patellar dislocations are on the rise.
Collapse
Affiliation(s)
- Joseph G Lyons
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio, United States of America
| | - Tanner L Hudson
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio, United States of America
| | - Anil B Krishnamurthy
- Department of Orthopaedic Surgery, Wright State University Boonshoft School of Medicine, Dayton, Ohio, United States of America
| |
Collapse
|
4
|
Jadidi S, Lee AD, Pierko EJ, Choi H, Jones NS. Non-operative Management of Acute Knee Injuries. Curr Rev Musculoskelet Med 2024; 17:1-13. [PMID: 38095838 PMCID: PMC10767052 DOI: 10.1007/s12178-023-09875-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2023] [Indexed: 01/06/2024]
Abstract
PURPOSE OF REVIEW Acute knee injuries are commonly encountered in both the clinical and sideline setting and may be treated operatively or non-operatively. This article describes an evidence-based approach to non-operative acute knee injury. This includes history, physical exam, imaging, and initial management. In addition, the non-operative management of three such injuries-ligament injury, meniscus injury, and patellar dislocation injury-will be discussed via a case-based practical approach. RECENT FINDINGS Aside from grade III ACL tears, most acute knee ligament injuries, especially in the absence of other concurrent injuries, can be treated non-operatively. There is new evidence that acute traumatic meniscus tears in those younger than 40 can be successfully treated non-operatively and can do equally, as well as those that undergo surgery, at 1 year out from injury. Based on the current literature, a short period of knee bracing in extension with progression to weightbearing to tolerance is recommended after initial patellar dislocation. Many of the most common acute knee injuries, including MCL tears, meniscus tears, and patellar dislocations, can be managed non-operatively. A detailed systemic approach to initial evaluation, including pertinent history, physical exam, and appropriate imaging, is essential and complementary to the subsequent non-operative treatment algorithm.
Collapse
Affiliation(s)
- Shaheen Jadidi
- Department of Orthopedics, Edward-Elmhurst Health, Naperville, IL, USA
| | - Aaron D Lee
- Department of Orthopedics and Family Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Eliza J Pierko
- Department of Orthopedics and Family Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Haemi Choi
- Department of Orthopedics and Family Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Nathaniel S Jones
- Department of Orthopedics and Family Medicine, Loyola University Medical Center, Maywood, IL, USA.
| |
Collapse
|
5
|
Papp K, Speth BM, Camathias C. Clinical Insights into the Treatment of Patellofemoral Instability with Medial Patellofemoral Ligament Reconstruction: Pearls and Pitfalls-Lessons Learned from 20 Years. J Pers Med 2023; 13:1240. [PMID: 37623490 PMCID: PMC10455723 DOI: 10.3390/jpm13081240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/25/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
Patellofemoral instability is a prevalent cause of pain and disability in young individuals engaged in athletic activities. Adolescents face a particularly notable risk of patellar dislocation, which can be attributed to rapid skeletal growth, changes in q-angle, ligamentous laxity, higher activity levels, and increased exposure to risk. Specific sports activities carry an elevated risk of patellar dislocation. Younger age and trochlear dysplasia present the highest risk factors for recurrent patellar dislocations. International guidelines recommend conservative therapy following a single patellar dislocation without osteochondral lesions but suggest surgical intervention in recurrent cases. In this study, we have compiled current scientific data on therapy recommendations, focusing on MPFL (medial patellofemoral ligament) reconstruction. We discuss patient selection, surgical indications, graft selection, location and choice of fixation, graft tensioning, and postoperative care.
Collapse
Affiliation(s)
- Kata Papp
- Department of Traumatology and Orthopaedic Surgery, Kantonsspital Aarau, CH-5000 Aarau, Switzerland
| | - Bernhard M. Speth
- Department of Traumatology and Orthopaedic Surgery, Kantonsspital Aarau, CH-5000 Aarau, Switzerland
- Department of Orthopaedic Surgery, University Children’s Hospital Basel, CH-4031 Basel, Switzerland
| | - Carlo Camathias
- Orthopädie für Kinder & Jugendliche, Praxis Zeppelin, CH-9016 St. Gallen, Switzerland
- Faculty of Medicine, University of Basel, CH-4031 Basel, Switzerland
| |
Collapse
|
6
|
Stannard JT, Stannard JP. Fractures and Dislocations on the Playing Field: Which Are Emergent and What to Do? Clin Sports Med 2023; 42:515-524. [PMID: 37208062 DOI: 10.1016/j.csm.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
High-energy injuries, including fractures and dislocations, are occurring with increasing frequency in athletic competitions with the increasing size and speed of players. Common fractures and dislocations will be discussed in this article. We will evaluate emergent versus routine injuries and discuss appropriate treatment at the athletic venue. Fractures that can be seen with athletic activities include cervical spine; knee osteochondral fractures; tibia, ankle, and clavicle. Dislocations that will be considered include knee, patella, hip, shoulder, sternoclavicular joint, and proximal interphalangeal joint of the finger. These injuries vary significantly both in severity and in the emergent nature of the injury.
Collapse
Affiliation(s)
- James T Stannard
- Department of Orthopaedic Surgery, University of Missouri, 1100 Virginia Avenue, Columbia, MO 65212, USA
| | - James P Stannard
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, 1100 Virginia Avenue, Columbia, MO 65212, USA.
| |
Collapse
|
7
|
Isacsson A, Olsson O, Englund M, Frobell RB. Incidence and concomitant chondral injuries in a consecutive cohort of primary traumatic patellar dislocations examined with sub-acute MRI. INTERNATIONAL ORTHOPAEDICS 2023; 47:973-981. [PMID: 36749375 PMCID: PMC10014776 DOI: 10.1007/s00264-023-05707-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 01/03/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE To present age- and sex-specific cumulative annual incidences of primary traumatic lateral patellar dislocation (LPD) and to detail patient characteristics and concomitant chondral injuries including osteochondral fractures, as visualized on magnetic resonance imaging (MRI), in a large consecutive cohort of knee-injured individuals. METHODS Data on primary traumatic lateral patellar dislocations were collected from a large consecutive cohort of knee injuries examined with sub-acute MRI in a single centre with a well-defined catchment area. Annual incidences for different age-groups in relation to gender were calculated together with the risk of concomitant chondral and osteochondral injury, during sports and in general. RESULTS A total of 184 primary patellar dislocations were identified in the cohort of 1145 acute knee injuries (n=175) and surgical records (n=9). Knee MRI was performed within a median of six days of injury. Median age of patients with primary LPD was 16 years (interquartile range, 14-21; range, 9-47) and 41% were females. Males were significantly older than females at the time of injury (median age 17 vs. 15, P = 0.021) and sustained their primary LPD during sports more often than females (65 vs. 40%, P < 0.001). Primary LPD occurred most frequently at the age of 13 to 15 years where the annual incidence was 125 (95% CI, 96-160) per 100,000 persons. The overall annual incidence of primary LPD was 14 (95% CI, 12-16) per 100,000 persons, with a predominance of males versus females (17 vs. 11, P = 0.01). Concomitant lesions to joint surfaces were displayed on MRI or during surgery in 75 (43%) knees. Osteochondral fractures were seen in 32 knees (18%). We found no statistically significant difference in the risk of osteochondral fracture between those injured during sports or during leisure activity (14 vs. 24%, P = 0.08). CONCLUSIONS The annual incidence of first-time patellar dislocation was found to be 14 per 100,000 individuals with the highest incidence found among those aged 13-15 years. Primary LPD was more common among males and was sustained during sports activity in 55% of the cases. Associated injuries to the chondral surfaces should be expected in 43% of knees with primary LPD where 18% represent osteochondral fractures.
Collapse
Affiliation(s)
- Anders Isacsson
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden.
- Department of Orthopedics, Helsingborg Hospital, Charlotte Yhléns gata 10, 251 87, Helsingborg, Region Skane, Sweden.
| | - Ola Olsson
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Orthopedics, Helsingborg Hospital, Charlotte Yhléns gata 10, 251 87, Helsingborg, Region Skane, Sweden
| | - Martin Englund
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Faculty of Medicine, Lund University, Lund, Sweden
| | - Richard B Frobell
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| |
Collapse
|
8
|
Felus J, Kowalczyk B, Starmach M, Wyrobek L. Osteochondral Fractures in Acute Patellar Dislocations in Adolescents: Midterm Results of Surgical Treatment. Orthop J Sports Med 2022; 10:23259671221107608. [PMID: 35859644 PMCID: PMC9289920 DOI: 10.1177/23259671221107608] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/22/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Osteochondral fractures (OCFs) are common injuries during acute patellar
dislocation (APD), carrying a high risk of early joint deterioration if left
untreated. The recommended approach is reduction and stable fixation;
however, data on the results of such treatment are limited. Purpose: To evaluate midterm results of fixation of APD-related OCFs in adolescents
and to identify predictive factors for poor outcomes. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective analysis of adolescent patients who underwent
internal fixation of APD-related OCFs between 2004 and 2015 at a single
tertiary pediatric trauma center. The primary outcome variables included
Knee injury and Osteoarthritis Outcome Score (KOOS), patient satisfaction
(0-10 scale), and sports participation compared with preoperative level.
Secondary outcome variables included relationship between final results and
OCF location (patellofemoral vs tibiofemoral), surgical delay (>6 weeks),
and patellar instability after OCF fixation. OCF healing was evaluated using
magnetic resonance imaging (MRI). Results: Included were 40 patients (19 female, 21 male) with 42 OCFs (29 patellar
OCFs, 13 lateral femoral condyle OCFs). The median patient age at surgery
was 14.5 years (interquartile range [IQR], 13-15.5 years), and median
follow-up was 76 months (IQR, 52.5-95 months). Recurrence of patellar
instability occurred in 27.5% of patients. Median overall KOOS was 93.8
(IQR, 90.8-97.6); KOOS–Symptoms, 92.9 (IQR, 85.7-96.4); KOOS–Pain, 97.2
(IQR, 91.7-100); KOOS–Activities of Daily Living, 100 (IQR, 97.1-100);
KOOS–Sports, 90 (IQR, 80-100); and KOOS–Quality of Life, 78.1 (IQR,
56.2-87.5). Median satisfaction score was 8 (IQR, 8-9), and 16 patients
(40%) returned to sports participation at their preinjury level. MRI scans
revealed a 100% rate of bone healing. Abnormalities exceeding the fracture
area were evident on MRI scans in 86.5% of patients. Recurrence of patellar
instability (even after surgical fixation) and unstable patella at final
follow-up were independent predictors of worse results after OCF
fixation. Conclusion: In the current study, reduction and internal fixation for APD-related OCF in
adolescents yielded favorable midterm outcomes. Recurrence of dislocation
and persistent patellar instability jeopardized clinical results.
Collapse
Affiliation(s)
- Jaroslaw Felus
- Pediatric Orthopedics and Trauma Surgery Department, University Children's Hospital, Krakow, Poland
| | - Bart Kowalczyk
- Pediatric Orthopedics and Trauma Surgery Department, University Children's Hospital, Krakow, Poland
| | - Michal Starmach
- Pediatric Orthopedics and Trauma Surgery Department, University Children's Hospital, Krakow, Poland
| | - Lukasz Wyrobek
- Pediatric Orthopedics and Trauma Surgery Department, University Children's Hospital, Krakow, Poland
| |
Collapse
|
9
|
Ackermann J, Waltenspül M, Merkely G, Germann C, Villefort C, Aufdenblatten C, Fucentese SF. Association of Subchondral Changes With Age and Clinical Outcome in Patients With Osteochondral Fractures in the Knee: MRI Analysis at 1 to 10 Years Postoperatively. Orthop J Sports Med 2022; 10:23259671221113234. [PMID: 35912386 PMCID: PMC9326836 DOI: 10.1177/23259671221113234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 05/12/2022] [Indexed: 11/15/2022] Open
Abstract
Background: Predictive factors influencing outcomes after surgical fixation of osteochondral fractures (OCFs) in the knee, particularly time between injury and surgery, have not been determined. Purpose: To report imaging and clinical outcomes after OCF fixation and to assess the association between clinical scores and patient characteristics, lesion morphology, and appearance on magnetic resonance imaging (MRI) scans. Study Design: Case series; Level of evidence, 4. Methods: We assessed the clinical and imaging outcomes of 19 patients after screw fixation for OCFs in the knee at a minimum follow-up of 1 year. Patient characteristics, lesion morphology, and time from trauma to surgery were reviewed for each patient. At final follow-up, patients completed a 100-point visual analog scale (VAS) for pain, Tegner activity scale, Knee injury and Osteoarthritis Outcome Score (KOOS), and patient satisfaction survey. Postoperative MRI scans were assessed using the MOCART (magnetic resonance observation of cartilage repair tissue), Osteochondral Allograft MRI Scoring System, and bone marrow edema (BME) size. Results: The mean patient age at surgery was 21.3 ± 11.4 years, and the median time from trauma to surgery was 10 days (range, 0-143 days). The refixed OCF fragment failed in 1 (5.3%) patient on the lateral condyle at 15 months postoperatively. The mean follow-up for the remaining 18 patients was 4.7 ± 3.2 years, and postoperative outcomes were as follows: VAS pain score, 9.5 ± 17.9; Tegner score, 4.8 ± 2.3; KOOS–Pain, 85.9 ± 17.6, KOOS-Symptoms, 76.4 ± 16.1; KOOS–Activities of Daily Living, 90.3 ± 19.0; KOOS–Sport, 74.4 ± 25.4; and KOOS–Quality of Life, 55.9 ± 24.7. Overall, 84.2% were satisfied or very satisfied with outcomes. Patient age was significantly associated with KOOS subscale scores and subchondral imaging parameters including BME and presence of subchondral cysts, which in turn were the only imaging variables linked to clinical outcomes (P < .05). Time from injury to surgery was not correlated with clinical or imaging outcomes. Conclusion: Fixation of OCFs yielded acceptable clinical and imaging outcomes at a mean 5-year follow-up with seemingly little influence of delayed surgical treatment. Postoperative subchondral changes were significantly associated with clinical outcomes and were linked to patient age at surgery.
Collapse
Affiliation(s)
- Jakob Ackermann
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Clinic for Orthopaedics and Traumatology, Department of Surgery, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Manuel Waltenspül
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Gergo Merkely
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Germann
- Department of Radiology, University Hospital Balgrist, University of Zurich, Zurich, Switzerland
| | - Christina Villefort
- Department of Pediatric Surgery, Division of Trauma and Orthopedic Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Christoph Aufdenblatten
- Department of Pediatric Surgery, Division of Trauma and Orthopedic Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| |
Collapse
|
10
|
Fletcher C, Strickland S. Hybrid Treatment of Osteochondral Fracture of the Patella With Particulated Juvenile Cartilage and Fragment Fixation. Arthrosc Tech 2022; 11:e1189-e1193. [PMID: 35936839 PMCID: PMC9353158 DOI: 10.1016/j.eats.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/16/2022] [Indexed: 02/03/2023] Open
Abstract
Acute patellar dislocation can result in osteochondral fracture of the patella, resulting in multiple osteochondral fragments, with only one fragment able to be fixated into the defect effectively. In these cases, we propose a hybrid procedure to repair the defect using the fixation of one of the osteochondral fragments and particulated juvenile articulate cartilage to fill the remaining defect in the patella. This technique maximizes the amount of native articular surface that we can preserve on the patella. The use of fragment fixation in combination with particulated juvenile articulate cartilage will help prevent further articular damage to the patella and reduce the risk of developing osteoarthritis in patients suffering from an osteochondral fracture as a result of acute patellar dislocation.
Collapse
Affiliation(s)
- Connor Fletcher
- Hospital for Special Surgery, Sports Medicine Institute, New York, New York, U.S.A.,Address correspondence to Connor Fletcher, Hospital for Special Surgery, Sports Medicine and Shoulder Service, 535 East 70th St., New York, NY 10021.
| | - Sabrina Strickland
- Hospital for Special Surgery, Sports Medicine Institute, New York, New York, U.S.A
| |
Collapse
|
11
|
Duporté L, Toanen C, Pujol N. Good medium-term functional results in reconstruction of lateral femoral condyle osteochondral lesions. Orthop Traumatol Surg Res 2022; 108:103051. [PMID: 34530131 DOI: 10.1016/j.otsr.2021.103051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 02/14/2021] [Accepted: 02/25/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Results of autologous osteochondral graft (mosaicplasty) are well-reported for the medial femoral condyle but much less for the lateral femoral condyle. The main aim of the present study was to assess results specifically for lateral condyle reconstruction. The secondary objective was to compare results according to the two main etiologies: osteochondritis dissecans (OCD) and osteochondral fracture (OCF). HYPOTHESIS The study hypothesis was that medium-term functional and radiological results of lateral femoral condyle autologous osteochondral graft are good. MATERIAL AND METHODS A single-center retrospective continuous study included 24 patients with symptomatic focal lateral femoral condyle osteochondral lesion treated by osteochondral autograft, at a minimum 24 months' follow-up. Mosaicplasty was performed for lesions <200 mm2, with associated fixation for lesions >200 mm2 with viable osteochondral fragments. IKDC, Lysholm and KOOS functional scores and pain on visual analog scale (VAS) were collected at last follow-up. Progression toward osteoarthritis was assessed on comparative X-ray. RESULTS Twenty patients were analyzed (11 OCD, 9 OCF) at a mean of 66.4±44 months. Mean pain on VAS was 1.8±2 out of 10. Mean subjective IKDC, Lysholm and global KOOS scores were respectively 68.1±26, 76.5±22 and 73.9±21. Two patients showed Ahlbäck grade 2 lateral femorotibial osteoarthritis. Functional results were comparable between OCD and OCF. CONCLUSION Reconstruction of lateral femoral condyle osteochondral lesion by osteochondral autograft gave good medium-term functional results, whatever the etiology. Longer-term studies are needed to assess progression toward osteoarthritis and functional deterioration over time. LEVEL OF EVIDENCE IV; retrospective study.
Collapse
Affiliation(s)
- Léonard Duporté
- Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalier de Versailles, 177, rue des Versailles, 78150 Le Chesnay, France
| | - Cécile Toanen
- Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalier de Versailles, 177, rue des Versailles, 78150 Le Chesnay, France.
| | - Nicolas Pujol
- Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalier de Versailles, 177, rue des Versailles, 78150 Le Chesnay, France
| |
Collapse
|
12
|
Medina Pérez G, Barrow B, Krueger V, Cruz AI. Treatment of Osteochondral Fractures After Acute Patellofemoral Instability: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202204000-00004. [PMID: 35394969 DOI: 10.2106/jbjs.rvw.21.00242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» An osteochondral fracture (OCF) of the patella or the femur is a frequent sequela after an episode of acute patellofemoral instability. » Patients commonly present with anterior knee pain after direct trauma to the patella or a noncontact twisting injury. » Radiographs and magnetic resonance imaging (MRI) are the most common imaging modalities that are used to diagnose OCFs. » Arthroscopy may be indicated in cases of displaced OCFs, and the decision regarding osteochondral fragment fixation or loose body removal depends on fragment size, location, and extent of injury. » Most of the current literature suggests worse outcomes for patients with OCFs who undergo nonoperative treatment, no significant differences in outcomes for patients sustaining an acute patellar dislocation with or without an OCF, and inconclusive results concerning outcomes for patients treated with loose body removal compared with fixation. » Current outcome data are limited by studies with low levels of evidence; therefore, well-designed randomized controlled trials are needed.
Collapse
Affiliation(s)
- Giancarlo Medina Pérez
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | | | | | | |
Collapse
|
13
|
Khan SA, Baghdadi S, Carey JL, Moores TS, Sheth NP, Ganley T. Osteochondral Fractures After Patellar Dislocation: Current Concepts. J Am Acad Orthop Surg Glob Res Rev 2021; 5:01979360-202112000-00001. [PMID: 34860734 DOI: 10.5435/jaaosglobal-d-21-00155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 07/08/2021] [Indexed: 06/13/2023]
Abstract
Osteochondral fractures of the knee occur frequently after acute patellar subluxation or dislocation. They can be challenging to manage because of the difficulty in diagnosing and treating these injuries in a timely fashion, in addition to choosing the optimum fixation method. This review presents the background, considerations for patient evaluation, and the best treatment options available for osteochondral fractures.
Collapse
Affiliation(s)
- Shehzaad A Khan
- From the Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK (Mr. Khan); Children's Hospital of Philadelphia (CHOP), Philadelphia, PA (Dr. Baghdadi and Dr. Ganley); Hospital of the University of Pennsylvania, Philadelphia, PA (Dr. Carey and Dr. Sheth); and Walsall Manor Hospital, Moat Road, Walsall, UK (Mr. Moores)
| | | | | | | | | | | |
Collapse
|
14
|
Gesslein M, Merkl C, Bail HJ, Krutsch V, Biber R, Schuster P. Refixation of Large Osteochondral Fractures After Patella Dislocation Shows Better Mid- to Long-Term Outcome Compared With Debridement. Cartilage 2021; 13:966S-973S. [PMID: 31718260 PMCID: PMC8808872 DOI: 10.1177/1947603519886637] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE The purpose of this study was to compare results of osteochondral fractures (OCF) after first-time lateral patella dislocation, when either refixation or debridement was performed in a mid- to long-term follow-up and to analyze redislocation and reintervention rates. DESIGN Fifty-three consecutive patients with OCF were included in this retrospective comparative study. Indication for refixation was presence of subchondral bone at the fragment. Thirty-six OCF were located at the patellar surface, and 17 at the lateral condyle of the distal femur. Refixation was performed in 28 patients while 25 patients underwent removal and debridement. Mean follow-up was 8.9 years (±4.4, range 2.0-16.7 years). For assessment of clinical outcome, the International Knee Documentation Committee (IKDC) Score, Knee Injury and Osteoarthritis Outcome Score (KOOS), and Lysholm score were used. Redislocation rate and further surgical interventions within follow-up were evaluated. RESULTS All clinical scores in the refixation group yielded significantly better results at mid- to long term follow-up (IKDC P < 0.001, KOOS P = 0.006, Lysholm P = 0.001). Significantly more surgical reinterventions were necessary after debridement (48% vs. 7.1%, P = 0.001). The overall redislocation rate in cases with medial reefing as single stabilizing procedure was 43.3%. CONCLUSIONS Refixation of OCF after lateral patella dislocation shows improved clinical outcome at mid- to long-term follow-up compared with debridement. Therefore, effort to try fragment refixation is recommended. Redislocation rate is high without proper restoration of patellofemoral instability.
Collapse
Affiliation(s)
- Markus Gesslein
- Department of Orthopedics and
Traumatology Klinikum Nuremberg, Paracelsus Private Medical University Nuremberg,
Nuremberg, Germany,Markus Gesslein, Paracelsus Private Medical
University Nuremberg, Breslauer Strasse 201, Nuremberg, 90471, Germany.
| | - Carolin Merkl
- Department of Orthopedics and
Traumatology Klinikum Nuremberg, Paracelsus Private Medical University Nuremberg,
Nuremberg, Germany
| | - Hermann Josef Bail
- Department of Orthopedics and
Traumatology Klinikum Nuremberg, Paracelsus Private Medical University Nuremberg,
Nuremberg, Germany
| | - Volker Krutsch
- Department of Otorhinolaryngology
Klinikum Nuremberg, Paracelsus Medical University Nuremberg, Nuremberg,
Germany
| | - Roland Biber
- Department of Traumatology, Klinken Dr.
Erler, Nuremberg, Germany
| | - Philipp Schuster
- Centre for Sports Orthopedics and
Special Joint Surgery, Orthopedic Hospital Markgroeningen, Markgroeningen,
Germany
| |
Collapse
|
15
|
Kuwabara A, Kraus E, Fredericson M. Narrative Review - Knee Pain in the Pediatric Athlete. Curr Rev Musculoskelet Med 2021; 14:239-245. [PMID: 33818701 PMCID: PMC8137791 DOI: 10.1007/s12178-021-09708-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW This review article seeks to highlight common youth athlete knee conditions due to overuse or trauma and elucidate differences from the adult populations. RECENT FINDINGS Overuse conditions presented include apophysitis, osteochondritis dissecans plica syndrome, and discoid meniscus. Traumatic conditions presented include patellar instability, patellar sleeve fracture, and patellofemoral osteochondral fractures. Knee injuries affect a significant proportion of youth athletes. These injuries place athletes at higher risk of chronic pain and potentially osteoarthritis. We have reviewed common overuse and traumatic knee injuries and differentiating factors between the adult population to improve and expedite the diagnosis, treatment, and prognosis for youth athletes with knee injuries.
Collapse
Affiliation(s)
- Anne Kuwabara
- Department of Physical Medicine and Rehabilitation, Stanford University, 500 Jefferson Avenue #823, Redwood City, CA 94063 USA
| | - Emily Kraus
- Department of Physical Medicine and Rehabilitation, Stanford University, 500 Jefferson Avenue #823, Redwood City, CA 94063 USA
| | - Michael Fredericson
- Department of Physical Medicine and Rehabilitation, Stanford University, 500 Jefferson Avenue #823, Redwood City, CA 94063 USA
| |
Collapse
|
16
|
Gudeman A, Wischmeier D, Farr J. Surgical Fixation of Chondral-Only Fragments of the Knee: A Case Series With a Mean 4-Year Follow-up. Orthop J Sports Med 2021; 9:2325967120961391. [PMID: 33521156 PMCID: PMC7818004 DOI: 10.1177/2325967120961391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/11/2020] [Indexed: 11/26/2022] Open
Abstract
Background: Chondral-only fragments of the knee have traditionally been treated with
excision, with or without cartilage restoration procedures. This is because
of the historical assumption that cartilage has limited ability to heal to
cancellous or subchondral bone. There is now a growing body of evidence
supporting surgical fixation of these fragments. Hypothesis: We hypothesized that surgical fixation of chondral fragments would result in
acceptable rates of healing with improvement in clinical outcome scores. Study Design: Case series; Level of evidence, 4. Methods: Data were collected on 15 surgically fixed chondral-only fragments in 14
patients. We retrospectively collected participant demographic information,
lesion characteristics, primary mechanism (osteochondritis dissecans vs
traumatic shear injury), fixation methods, reoperation information,
second-look arthroscopic information, and clinical outcome scores. The mean
clinical follow-up was 3.96 years, with a minimum of 1-year follow-up. All
patients underwent follow-up magnetic resonance imaging at a mean of 2 years
after the index procedure. Results: The mean age of our cohort was 17.7 years. We found an 80% survival rate for
fixation of the fragments at a mean 4-year follow-up. There were
statistically significant improvements in postoperative Knee injury and
Osteoarthritis Outcome Score and Tegner scores compared with preoperative
scores. Follow-up magnetic resonance imaging scans showed complete healing
in 10 knees, partial healing in 2 knees, and loss of fixation in 3 knees.
Second-look arthroscopic surgery of 3 knees for reasons other than fragment
symptoms showed healing of the fragment, while arthroscopic surgery of 3
symptomatic knees showed loss of fixation. Conclusion: Surgical fixation of chondral-only lesions showed an 80% success rate with
improvements in the KOOS and Tegner scores.
Collapse
Affiliation(s)
- Andrew Gudeman
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dillen Wischmeier
- Knee Preservation and Cartilage Restoration Center, OrthoIndy, Indianapolis, Indiana, USA
| | - Jack Farr
- Knee Preservation and Cartilage Restoration Center, OrthoIndy, Indianapolis, Indiana, USA
| |
Collapse
|
17
|
Hinckel BB, Baumann CA, Ejnisman L, Cavinatto LM, Martusiewicz A, Tanaka MJ, Tompkins M, Sherman SL, Chahla JA, Frank R, Yamamoto GL, Bicos J, Arendt L, Fithian D, Farr J. Evidence-based Risk Stratification for Sport Medicine Procedures During the COVID-19 Pandemic. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e20.00083. [PMID: 33986224 PMCID: PMC7537824 DOI: 10.5435/jaaosglobal-d-20-00083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023]
Abstract
Orthopaedic practices have been markedly affected by the emergence of the COVID-19 pandemic. Despite the ban on elective procedures, it is impossible to define the medical urgency of a case solely on whether a case is on an elective surgery schedule. Orthopaedic surgical procedures should consider COVID-19-associated risks and an assimilation of all available disease dependent, disease independent, and logistical information that is tailored to each patient, institution, and region. Using an evidence-based risk stratification of clinical urgency, we provide a framework for prioritization of orthopaedic sport medicine procedures that encompasses such factors. This can be used to facilitate the risk-benefit assessment of the timing and setting of a procedure during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Betina B Hinckel
- From the Oakland University, Rochester (Dr. Hinckel, and Dr. Cavinatto); Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak (Dr. Hinckel, Dr. Cavinatto), MI; the University of Missouri-School of Medicine, Columbia, MO (Mr. Baumann); the Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, SP, BR (Dr. Ejnisman); the Shoulder and Elbow Surgery, Beaumont Orthopaedic Associates, Beaumont Health (Dr. Martusiewicz); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Dr. Tanaka); the Department of Orthopedic Surgery, TRIA Orthopedic Center, University of Minnesota, Gillette Children's Specialty Healthcare, MN (Dr. Tompkins); the Department of Orthopedic Surgery, Stanford University, CA (Dr. Sherman); the Rush University Medical Center, Chicago, IL (Dr. Chahla); the Division of Sports Medicine and Shoulder Surgery, Department of Orthopedics, Aurora, CO (Dr. Frank); the Department of Orthopaedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr. Yamamoto); CEGH-CEL, Instituto de Biociências, Universidade de São Paulo (Dr. Yamamoto); DASA Laboratories, Sao Paulo, Brazil (Dr. Yamamoto); the Michigan Orthopedic Surgeons, Fellowship Director William Beaumont Sports Medicine Fellowship, Assistant Professor Oakland University William Beaumont School of Medicine, MI (Dr. Bicos); the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN (Dr. Arendt); the Southern California Permanente Medical Group and Torrey Pines Orthopaedic Medical Group, San Diego, CA (Dr. Fithian); and the Knee Preservation, Cartilage Regeneration and OrthoBiologics, Department of Orthopedic Surgery, Indiana University School of Medicine, OrthoIndy and OrthoIndy Hospital, Greenwood and Indianapolis, IN (Dr. Farr)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Beckert MW, Klitzman RG. Large chondral fragment of the lateral femoral condyle treated with arthroscopic internal fixation in an elite young athlete - A case report. SICOT J 2020; 6:1. [PMID: 31916531 PMCID: PMC6951029 DOI: 10.1051/sicotj/2019041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/20/2019] [Indexed: 11/14/2022] Open
Abstract
Focal chondral lesions in the adolescent population create a particular challenge for orthopedic surgeons, and currently there exists no consensus on proper treatment. Numerous techniques for addressing focal chondral defects are employed in both pediatrics and adults, including fragment excision, debridement and fixation, bone marrow stimulation and microfracture techniques, cell-based options, as well as chondral and osteochondral grafts. Although historical evidence is mixed, recent reports of primary fixation of displaced cartilage fragments have shown favorable results. We present a case of reduction and fixation of a large displaced cartilage lesion in an elite young tennis player. Our results, in addition to other reports mentioned in this manuscript, highlight the importance of considering primary fixation of large chondral lesions when amenable to repair.
Collapse
Affiliation(s)
| | - Robert G Klitzman
- Department of Orthopaedics, Indiana University, Indianapolis, IN, USA
| |
Collapse
|
19
|
Churchill JL, Krych AJ, Lemos MJ, Redd M, Bonner KF. A Case Series of Successful Repair of Articular Cartilage Fragments in the Knee. Am J Sports Med 2019; 47:2589-2595. [PMID: 31479328 DOI: 10.1177/0363546519865497] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND It is unclear whether chondral fragments without bone have the potential to heal after fixation. Controversy exists and opinions differ regarding the optimal treatment of chondral defects after pure chondral fracture. PURPOSE To determine clinical and radiographic outcomes after internal fixation of traumatic chondral fragments repaired to bone in the knee. STUDY DESIGN Case series; Level of evidence, 4. METHODS A retrospective clinical and radiographic evaluation of 10 male patients with a mean age of 14.6 years (range, 10-25 years) at the time of surgery was performed. Eight of 10 patients were skeletally immature. Patients were selected by operating surgeons per the presence of a large displaced pure chondral fragment on magnetic resonance imaging and confirmed on intraoperative inspection. All patients had a diagnosed traumatic displaced pure chondral fracture of the knee (without bone) and underwent internal fixation with minimum 1-year follow-up. Validated patient-reported and surgeon-measured outcomes were collected pre- and postoperatively. All patients were evaluated at a mean 56 months postoperatively. RESULTS At surgery, the mean defect size that was primarily repaired with the displaced chondral fragment was 1.9 × 2.0 cm. With minimum 1-year follow-up, there were no clinical failures. All 8 patients who had subsequent magnetic resonance imaging follow-up had radiographic evidence of complete healing of the chondral fragment back to bone. At a mean follow-up of 56 months (range, 13-171 months; median, 36 months), patients had a mean International Knee Documentation Committee score of 94.74 (range, 87.4-100), a mean Marx Activity Scale score of 14.4 (range, 8-16), and a mean Tegner Activity Scale score of 7 (range, 5-9). At final follow-up, all patients except 1 returned to sports. CONCLUSION The treatment of large traumatic chondral fragments is controversial. In this select series of 10 young patients who underwent primary repair with internal fixation, there were no failures clinically. Patients demonstrated excellent short-term clinical and radiographic results after fixation of these relatively large chondral fragments in the knee.
Collapse
Affiliation(s)
| | - Aaron J Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J Lemos
- Department of Orthopaedic Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts, USA
| | - Morganne Redd
- Department of Orthopedic Surgery and Sports Medicine, Jordan-Young Institute, Virginia Beach, Virginia, USA
| | - Kevin F Bonner
- Department of Orthopedic Surgery and Sports Medicine, Jordan-Young Institute, Virginia Beach, Virginia, USA
| |
Collapse
|
20
|
Gruskay JA, Strickland SM, Casey E, Chiaia TA, Green DW, Gomoll AH. Team Approach: Patellofemoral Instability in the Skeletally Immature. JBJS Rev 2019; 7:e10. [PMID: 31365447 DOI: 10.2106/jbjs.rvw.18.00159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Jordan A Gruskay
- Departments of Orthopedics (J.A.G., S.M.S., D.W.G., and A.H.G.), Physiatry (E.C.), and Sports Rehabilitation (T.A.C.), Hospital for Special Surgery, New York, NY
| | | | | | | | | | | |
Collapse
|
21
|
Iwame T, Matsuura T, Iwase J, Takao S, Egawa H, Sairyo K. Two Years of Follow-up Magnetic Resonance Imaging for Osteochondral Injury of the Lateral Femoral Condyle in an Adolescent Basketball Player. THE JOURNAL OF MEDICAL INVESTIGATION 2019; 66:213-217. [PMID: 31064946 DOI: 10.2152/jmi.66.213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Chondral and osteochondral injuries of the femoral condyle are rare, and relatively few cases have been reported. Therefore, the mechanism, treatment, and findings on follow-up of these injuries are not well described. Here, we report the case of an adolescent basketball player who sustained a sports-related traumatic osteochondral injury of the lateral femoral condyle. He was treated with open reduction and internal fixation with the pull-out suture technique. Two years later, he was able to resume sporting activities at his pre-injury level with no symptoms. Magnetic resonance imaging (MRI) confirmed survival of the fixed osteochondral fragment and restoration of the congruity of the articular cartilage with no sign of delamination. This report describes the clinical outcome of this osteochondral injury of the lateral femoral condyle as seen on MRI at the 2-year follow-up and discuss the mechanism and treatment of this injury. J. Med. Invest. 66 : 213-217, February, 2019.
Collapse
Affiliation(s)
- Toshiyuki Iwame
- Department of Orthopedic Surgery, Tokushima Prefectural Central Hospital, Tokushima, Japan, 1-10-3 Kuramoto, Tokushima, Japan
| | - Tetsuya Matsuura
- Department of Orthopedic Surgery, Tokushima Prefectural Central Hospital, Tokushima, Japan, 1-10-3 Kuramoto, Tokushima, Japan
| | - Joji Iwase
- Department of Orthopedic Surgery, Tokushima Prefectural Central Hospital, Tokushima, Japan, 1-10-3 Kuramoto, Tokushima, Japan
| | - Shoichiro Takao
- Department of Diagnostic Radiology, Tokushima University Graduate School, Institute of Health Sciences, 3-18-15 Kuramoto, Tokushima, Japan
| | - Hiroshi Egawa
- Department of Orthopedic Surgery, Tokushima Prefectural Central Hospital, Tokushima, Japan, 1-10-3 Kuramoto, Tokushima, Japan
| | - Koichi Sairyo
- Department of Orthopedic Surgery, Tokushima Prefectural Central Hospital, Tokushima, Japan, 1-10-3 Kuramoto, Tokushima, Japan
| |
Collapse
|
22
|
Abstract
Compared with skeletally mature patients, skeletally immature patients are at a higher risk of acute traumatic patellar dislocation. Surgical treatment is the standard of care for patients with recurrent instability and requires important and technically challenging physeal considerations. Physeal-sparing medial patellofemoral ligament reconstruction is the treatment of choice for these patients, replacing older nonanatomic extensor mechanism realignment techniques. Implant-mediated guided growth is an important adjunct to correct genu valgum angular deformities that contribute to patellar instability. Patient-specific surgical techniques and proper surgical indications are crucial for successful outcomes.
Collapse
|
23
|
Kohli S, Gillani S, Chatoo M. A successful technique to repair an osteochondral patellar fracture composed of largely primary articular cartilage. TRAUMA-ENGLAND 2018. [DOI: 10.1177/1460408616672244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 15-year-old girl presented with knee pain, inability to extend and weight bear after a twisting injury to the knee leading to dislocation and spontaneous reduction of the patella. An osteochondral defect was identified over the medial facet of patella with a loose osteochondral fragment with very little bone attached to the large cartilaginous part. This unusual fracture was fixed using four biocomposite suture anchors and a bioabsorbable pin. Three months after the surgery, she was mobilising fully, weight bearing and had a full range of motion with satisfactory outcome. MRI six months postop suggested complete healing of the fragment. Usually such fractures occur due to an impaction injury of the medial patellar facet over the lateral femoral condyle during the relocation phase of an injury. In this case, the patella was dislocated and then reduced spontaneously. There are very few case reports in the literature with successful repair of this type of patellar fracture and a good patient outcome.
Collapse
Affiliation(s)
- Suraj Kohli
- Trauma and Orthopaedics Department, Lister Hospital, Stevenage, UK
| | - Syed Gillani
- Trauma and Orthopaedics Department, Lister Hospital, Stevenage, UK
| | - Minhal Chatoo
- Trauma and Orthopaedics Department, Lister Hospital, Stevenage, UK
| |
Collapse
|
24
|
Fabricant PD, Yen YM, Kramer DE, Kocher MS, Micheli LJ, Lawrence JTR, Ganley TJ, Heyworth BE. Fixation of Traumatic Chondral-Only Fragments of the Knee in Pediatric and Adolescent Athletes: A Retrospective Multicenter Report. Orthop J Sports Med 2018; 6:2325967117753140. [PMID: 29450207 PMCID: PMC5808975 DOI: 10.1177/2325967117753140] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: While traditional biological principles have suggested that fragments consisting of cartilage alone cannot be reaffixed to bone with expectable long-term healing, case reports of successful healing after fixation in younger patients indicate that this concept remains incompletely explored. Purpose: To evaluate the presenting features, techniques, healing rates, and clinical and radiological results in a cohort of pediatric and adolescent athletes who underwent fixation of traumatic chondral-only fragments in the knee. Study Design: Case series; Level of evidence, 4. Methods: Patient registries at 2 tertiary care children’s hospitals were reviewed to identify patients ≤18 years old who underwent fixation of a “chondral-only” fragment in the knee, defined as the inability to visualize the fragment on injury radiographs or discern bone on the articular portion of a fragment intraoperatively. The mechanism of injury, fragment features, fixation technique, and postoperative clinical course, including timing of sports clearance, healing on postoperative magnetic resonance imaging (MRI), and any complications or reoperations, were assessed. Results: Fifteen patients with a median age at surgery of 12.7 years (interquartile range [IQR], 11.7-14.2 years) and median follow-up of 12.0 months (IQR, 6.0-19.2 months) were analyzed. All patients sustained an acute knee injury before surgery. The injured sites, as assessed on MRI, were the patella (n = 6), trochlea (n = 5), and lateral femoral condyle (n = 4). The median fragment surface area was 492.0 mm2 (IQR, 400.0-787.5 mm2). Fixation with bioabsorbable implants was performed in all patients at a median of 1.6 weeks (IQR, 1.0-2.6 weeks) after the injury. One patient (7%) sustained a fall 8 weeks postoperatively, requiring secondary surgery for excision of a dislodged fragment, and 1 patient (7%) underwent unrelated patellar stabilization surgery 3.4 years postoperatively, at which time the fragment was found to be stable. MRI was performed in 9 of 14 patients with retained fragments (median, 12.0 months postoperatively), with 5 patients (56%) showing restoration of the cartilage contour and the resolution of subchondral edema; 2 patients showed thinning but intact cartilage, 1 had cartilage thickening, and 1 had subchondral edema, fissuring, and cystic changes. The median time to return to sports for all 15 patients was 26.0 weeks (IQR, 22.8-40.9 weeks), including 2 patients who required second surgery and returned to sports at 26.1 and 191.1 weeks. Conclusion: Fixation of traumatic chondral-only fragments using bioabsorbable implants may result in successful short-term healing in the majority of pediatric and adolescent athletes.
Collapse
Affiliation(s)
- Peter D Fabricant
- Pediatric Orthopedic Surgery Service, Hospital for Special Surgery, New York, New York, USA
| | - Yi-Meng Yen
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dennis E Kramer
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Mininder S Kocher
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lyle J Micheli
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - J Todd R Lawrence
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Theodore J Ganley
- Division of Orthopaedics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Benton E Heyworth
- Sports Medicine Division, Department of Orthopedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
25
|
Sanders TL, Pareek A, Hewett TE, Stuart MJ, Dahm DL, Krych AJ. Incidence of First-Time Lateral Patellar Dislocation: A 21-Year Population-Based Study. Sports Health 2017; 10:146-151. [PMID: 28795924 PMCID: PMC5857724 DOI: 10.1177/1941738117725055] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: First-time lateral patellar dislocation is a common orthopaedic injury. The purposes of this study were to (1) evaluate the incidence of first-time lateral patellar dislocation in a geographically-determined population, (2) report trends over time in the incidence of dislocation, and (3) describe the rate of surgical treatment. Hypothesis: The rate of patellar dislocation is highest among adolescent patients. Study Design: Cohort study. Level of Evidence: Level 3. Methods: The study population included 609 individuals identified through a multidisciplinary geographic cohort county database who were diagnosed with first-episode lateral patellar dislocation between 1990 and 2010. The complete medical records were reviewed to confirm the diagnosis and to evaluate details of injury and treatment. Age- and sex-specific incidence rates were calculated and adjusted to the 2010 US population. Poisson regression analyses were performed to examine incidence trends by age, sex, and calendar period. Results: The overall age- and sex-adjusted annual incidence of patellar dislocation was 23.2 (95% CI, 21.2-24.9) per 100,000 person-years. The annual incidence was similar between male and female patients and highest among adolescents aged 14 to 18 years (147.7/100,000 person-years). The mean age at dislocation was 21.4 ± 9.9 years, and 331 patients (54.4%) were female. During the study period, there was a significant decline in the incidence of patellar dislocation among men aged 19 to 25 years (P = 0.002) and girls aged 14 to 18 years (P = 0.025). Eighty patients received surgical treatment during the study period, including 66 patients (10.8%) for recurrent instability and 14 patients (2.3%) for acute osteochondral injury. Conclusion: With an annual incidence of 23.2 per 100,000 person-years, lateral patellar dislocation is a frequently encountered orthopaedic injury. The incidence of dislocation among adolescent patients in this cohort is higher than previously reported. Despite a decrease in the annual incidence of dislocation in adolescent girls, the overall incidence of patellar dislocation remained relatively constant over a 21-year observation period. Clinical Relevance: This study demonstrates that the incidence of patellar dislocation in adolescents is greater than previously reported.
Collapse
Affiliation(s)
- Thomas L Sanders
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ayoosh Pareek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Timothy E Hewett
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Michael J Stuart
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Diane L Dahm
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Aaron J Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
26
|
Crossing Suture Technique for the Osteochondral Fractures Repair of Patella. Arthrosc Tech 2017; 6:e1035-e1039. [PMID: 28970989 PMCID: PMC5621615 DOI: 10.1016/j.eats.2017.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/14/2017] [Indexed: 02/03/2023] Open
Abstract
Osteochondral fracture of the patella is a common concomitant injury of the knee, especially in lateral patellar instability, and the importance of early stable fixation with minimal complication and early mobilization should be emphasized. Screws and Kirschner wires both absorbable and nonabsorbable have been the common mode of fixation of these fractures. Nevertheless, these fixation techniques require larger osteochondral fragments and are associated with cartilage abrasion, hardware prominence, synovitis, and foreign body reaction. In contrast, suture fixation can adequately stabilize smaller osteochondral fragments without comminution and prevent some of the possible complications of other techniques of fixation. We created 4 holes in a rectangular pattern on the patella oriented perpendicular to its anteroposterior surface. We used readily available, and affordable, no. 2 Ultrabraid sutures inserted into the holes and looped around the osteochondral fragment, compressing it to the patella. The technique is very simple and is relatively easy to learn. It provides secure fixation and allows early mobilization. And it spares the knee from subsequent surgical procedure for removal of metallic implants.
Collapse
|
27
|
Nguyen JC, Sheehan SE, Davis KW, Gill KG. Sports and the Growing Musculoskeletal System: Sports Imaging Series. Radiology 2017. [DOI: 10.1148/radiol.2017161175] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Jie C. Nguyen
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, E1/313, Madison, WI 53792-3252
| | - Scott E. Sheehan
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, E1/313, Madison, WI 53792-3252
| | - Kirkland W. Davis
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, E1/313, Madison, WI 53792-3252
| | - Kara G. Gill
- From the Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, E1/313, Madison, WI 53792-3252
| |
Collapse
|
28
|
Abstract
Acute patellar dislocation affects approximately 1:1000 healthy children 9-15 years of age, and up to 50% are at risk for recurrent dislocations. In adults the condition is associated with long-term complications, such as osteoarthritis and impairment of knee function. However, literature describing the outcome in a pediatric population is sparse. The present review article evaluates the long-term effects on knee function and cartilage quality after traumatic patellar dislocation in childhood, and also to evaluate the reliability of two clinical tests of medio-lateral knee position, in healthy children.
Collapse
Affiliation(s)
- Baobiao Gao
- Department of Orthopedics, The Affiliated Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Yingchun Shi
- Department of Orthopedics, The Affiliated Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China -
| | - Fengfei Zhang
- Department of Orthopedics, The Affiliated Xuzhou Children's Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| |
Collapse
|
29
|
Sinikumpu JJ, Serlo W. Biodegradable poly-L-lactide-co-glycolide copolymer pin fixation of a traumatic patellar osteochondral fragment in an 11-year-old child: A novel surgical approach. Exp Ther Med 2017; 13:242-246. [PMID: 28123496 DOI: 10.3892/etm.2016.3934] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 07/21/2016] [Indexed: 11/06/2022] Open
Abstract
Treating displaced patellar bone fractures in growing children remains a challenge for orthopedic surgeons. Removal of loose bone fragments may prolong healing time and result in early onset osteoarthrosis. Therefore, primary fixation of osteochondral fragments is preferred. Metallic pin and screw implants are typically used for fixation, as there is little evidence available regarding the use of modern biodegradable implants in traumatic patellar fractures of a premature skeleton. The present report describes a novel operative technique using headless poly-L-lactide-co-glycolide (PLGA) pins in treating an 11-year-old girl with a patellar fracture from a cycling injury. The surgical technique of this procedure is described in detail in the current report. Excellent subjective outcomes were achieved from this surgery, with superb bone healing according to follow-up radiographic and computerized tomography scans. In conclusion, the results of this case indicate that, similarly to osteochondritis, intra-articular osteochondral fractures in children may be fixed using biodegradable PLGA pins. Randomized clinical trials should be performed to confirm this finding and evaluate the use of PLGA pins as a treatment for adolescent osteochondral fractures.
Collapse
Affiliation(s)
- Juha-Jaakko Sinikumpu
- Department of Pediatric Surgery and Orthopedics, Oulu University Hospital, Oulu, 90029 OYS, Finland
| | - Willy Serlo
- Department of Pediatric Surgery and Orthopedics, Oulu University Hospital, Oulu, 90029 OYS, Finland
| |
Collapse
|
30
|
Abstract
Adolescents are predisposed to chondral injuries of the knee; however, the incidence of traumatic chondral and osteochondral fractures and their role in the development of joint degeneration are not fully elucidated. Several methods are described for the treatment of chondral or osteochondral fractures of the knee. In our literature review, we could not find any report on the management of chondral fractures with autologous bone pegs or headless screws. We report three cases of traumatic cartilage fractures of the lateral femoral condyle in adolescents who were treated with three different methods. We also present their follow-up outcomes.
Collapse
|
31
|
Chawla A, Twycross-Lewis R, Maffulli N. Microfracture produces inferior outcomes to other cartilage repair techniques in chondral injuries in the paediatric knee. Br Med Bull 2015; 116:93-103. [PMID: 26491082 DOI: 10.1093/bmb/ldv040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2015] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Chondral injuries are becoming increasingly common in the paediatric knee. First line surgical therapy is usually microfracture (MF), but the emergence of alternative techniques raises the question of what is the optimal treatment in paediatric patients. SOURCES OF DATA A comprehensive search of PubMed, OVID, Web of Science, SportDiscus and Cochrane databases was performed using the key words 'autologous chondrocyte implantation, MF, mosaicplasty, juvenile, paediatric'. AREAS OF AGREEMENT Each technique demonstrated a significant post-surgical improvement in clinical outcome scores. However, MF demonstrated poorer outcomes in larger lesions (>3 cm(2)) and shorter durability. AREA OF CONTROVERSY The quality of the available literature is poor, and there is a lack of comparative trials. GROWING POINTS The impact of defect characteristics, mechanism of injury and concomitant surgeries should be investigated. AREAS TIMELY FOR DEVELOPING RESEARCH Appropriately powered randomized controlled trials with suitably long follow up and condition-specific outcome measures should compare different techniques against each other and placebo.
Collapse
Affiliation(s)
- Amit Chawla
- Imperial College School of Medicine, Imperial College London, London, UK
| | - Richard Twycross-Lewis
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Nicola Maffulli
- Centre for Sports and Exercise Medicine, William Harvey Research Institute, Bart's and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK Department of Musculoskeletal Disorders, University of Salerno School of Medicine and Dentistry, Salerno, Italy Queen Mary University of London, London, UK Barts and The London School of Medicine and Dentistry, London, UK Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK
| |
Collapse
|
32
|
Albuquerque RPE, Félix dos Santos Neto J, Albuquerque MIPE, Giordano V, Pecegueiro do Amaral N. Fixation of an osteochondral fragment after acute patellar dislocation in an immature skeleton. Rev Bras Ortop 2014; 49:202-5. [PMID: 26229800 PMCID: PMC4511747 DOI: 10.1016/j.rboe.2014.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 07/12/2013] [Indexed: 11/29/2022] Open
Abstract
Fixation of an osteochondral fracture after acute patellar dislocation is an infrequent form of treatment. Likewise, the location of this fragment in the lateral region of the lateral femoral condyle, functioning as a free body, is uncommon. The aim of this study was to present a case of osteochondral fracture of the patella at an unusual site, along with the therapy used and the clinical follow-up.
Collapse
Affiliation(s)
| | | | | | - Vincenzo Giordano
- Orthopedics Service, Hospital Municipal Miguel Couto, Rio de Janeiro, RJ, Brazil
| | | |
Collapse
|
33
|
Albuquerque RPE, Félix dos Santos Neto J, Albuquerque MIPE, Giordano V, Pecegueiro do Amaral N. Fixação do fragmento osteocondral após luxação aguda da patela no esqueleto imaturo. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2014.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
|