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Ekman E, Nevalainen S, Karjalainen E, Kohonen I, Vuohelainen J, Rissanen T, Itälä A. Increased lesion depth, higher body mass index and older age are risk factors for osteoarthritis during long-term follow-up in patients with osteochondritis dissecans of the knee. Arch Orthop Trauma Surg 2023; 143:3863-3869. [PMID: 36169727 PMCID: PMC10293403 DOI: 10.1007/s00402-022-04638-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/19/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION To report on the long-term prognosis of osteochondritis dissecans (OCD) patients regarding radiological and patient-reported outcomes and to analyze possible risk factors. MATERIALS AND METHODS All patients diagnosed with knee OCD between 2004 and 2014 with radiographic Kellgren-Lawrence (K-L) grades 0-2 at the time of diagnoses, ability to understand the language of the interview, and willingness to participate in the study were retrospectively reviewed. Current knee radiographs and the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire were prospectively collected between May 2020 and March 2021. The extent of osteoarthritis (OA) and KOOS questionnaire results were evaluated. RESULTS 90 patients (103 knees) with a mean age of 21 years (range 6-60) were included. The mean follow-up time was 12 years (range 7-20). 24 knees (23%) were treated conservatively, and 79 knees (77%) operatively. At the time of diagnoses, 90% of the patients had K-L grades of 0-1; during the follow-up period, 45% of the patients showed radiological progression of OA. Patient body mass index (BMI) (p = 0.004; 95% CI 0.25-0.29), age (p = 0.003; 95% CI 0.18-0.30), operative treatment (p = 0.0075; 95% CI 0.41-0.65) and lesion depth (p = 0.0007) were statistically significantly connected to K-L grade change. Patients with no progression in joint space narrowing had statistically significantly better overall KOOS scores (p = 0.03; 95% CI 0.77-0.88) than patients whose K-L grades worsened. CONCLUSIONS During the long-term follow-up of 12 years, patients with knee OCD had good clinical results. Lac of radiological progression of cartilage degeneration was noted in 55% of the patients, regardless of treatment method. Lesion depth, higher BMI and older age were associated with the progression of OA. The progression of OA was related to a worsening of functional scores. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Elina Ekman
- Department of Orthopaedic Surgery, Turku University Hospital, University of Turku, Kiinamyllynkatu 4-8, 20521, Turku, Finland.
| | | | | | - Ia Kohonen
- Medical Imaging Centre of Southwest Finland, Turku University Hospital, Turku, Finland
| | | | - Tiia Rissanen
- Department of Clinical Medicine, Biostatistics, University of Turku, Turku, Finland
| | - Ari Itälä
- Department of Orthopaedics, Pihlajalinna Hospital, Turku, Finland
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2
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Bangert Y, Zarembowicz P, Engelleiter K, Gkarilas E, Schmitt H, Renkawitz T, Jaber A. Long-Term Outcome and Athletic Level following Operative Treatment for Osteochondritis Dissecans of the Knee in Pediatric and Adolescent Patients. J Clin Med 2023; 12:4140. [PMID: 37373833 DOI: 10.3390/jcm12124140] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/05/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Research on the long-term outcomes following surgical therapy for osteochondritis dissecans (OCD) of the knee is scarce. A single-center retrospective cohort study was conducted to investigate surgically treated patients for knee OCD between 1993 and 2007. A total of 37 patients with an average follow-up duration of 14 years (range 8-18) were in the final cohort. IKDC and Lysholm scores were assessed. The duration and types of sport activity were reported. Long-term results were compared with existing midterm data. Knee scores showed a very good outcome with a mean of 91.3 in the IKDC score and 91.7 in the Lysholm score. Compared to midterm outcomes, both IKDC (p = 0.028) and Lysholm scores (p = 0.01) improved on final follow-up. Patients with open physes showed a significantly better Lysholm score compared to patients with closed physes (p = 0.034). Defect localization and size did not influence the outcome, but a defect depth of <0.8 cm2 achieved significantly better scores than ≥0.8 cm2. Of all surgical interventions, refixation achieved the best outcome. Long-term results significantly improved compared to midterm results with a follow-up of 40 months (p = 0.01). Thirty-six out of 37 patients were physically active, with 56% of sports being knee-straining activities. Long-term results following surgically treated OCD fragments show excellent function and a good athletic level. Patients with open physes potentially have better knee outcomes. Midterm results are sustainable and could improve further in the long term.
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Affiliation(s)
- Yannic Bangert
- Department of Orthopaedics, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Patrick Zarembowicz
- Department for Orthopaedic and Trauma Surgery, BG Klinik Ludwigshafen, 67071 Ludwigshafen am Rhein, Germany
| | - Karoly Engelleiter
- Department for Orthopaedic and Trauma Surgery, Helios Clinic, 75175 Pforzheim, Germany
| | - Evangelos Gkarilas
- Department for Orthopaedics, Trauma and Spinal Surgery, Neckar-Odenwald Clinics, 74821 Mosbach, Germany
| | - Holger Schmitt
- German Joint Center, ATOS Clinic Heidelberg, 69115 Heidelberg, Germany
| | - Tobias Renkawitz
- Department of Orthopaedics, Heidelberg University Hospital, 69118 Heidelberg, Germany
| | - Ayham Jaber
- Department of Orthopaedics, Heidelberg University Hospital, 69118 Heidelberg, Germany
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3
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Hashim SS, Morgan C, Sarraf KM. Osteochondritis dissecans. Br J Hosp Med (Lond) 2023; 84:1-7. [PMID: 37127418 DOI: 10.12968/hmed.2023.0044] [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: 05/03/2023]
Abstract
Osteochondritis dissecans is a condition characterised by acquired pathological subchondral bone lesions and its incidence is unknown. It has a multifactorial aetiology, with a combination of genetic and acquired risk factors. It commonly presents in adolescents and young adults. Patients have variable presentations, including trauma, insidious onset and pain exacerbated by exercise. The joints primarily affected are the knee, ankle and elbow joint. Early identification is key to treatment and to prevent future osteoarthritis of the joint. This article gives an overview of the presentation, assessment and management of the juvenile form of osteochondritis dissecans.
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Affiliation(s)
- Sophia Sr Hashim
- Department of Trauma and Orthopaedics, Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Catrin Morgan
- Department of Trauma and Orthopaedics, Imperial College Healthcare NHS Foundation Trust, London, UK
| | - Khaled M Sarraf
- Department of Trauma and Orthopaedics, Imperial College Healthcare NHS Foundation Trust, London, UK
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Korthaus A, Meenen NM, Pagenstert G, Krause M. The "hump" a new arthroscopic phenomenon guiding for reliable therapy of osteochondritis dissecans of variable stability status. Arch Orthop Trauma Surg 2023; 143:1513-1521. [PMID: 35366091 DOI: 10.1007/s00402-022-04409-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 02/27/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Despite 150 years of research, there are currently no reliable morphological characteristics that can be used to differentiate between stable and unstable juvenile osteochondritis dissecans (JOCD) lesions in the knee joint. Arthroscopic probing is still the gold standard. In arthroscopic evaluation, a previously undescribed pattern of a cartilaginous convex elevation ("hump") was identified as a new feature and potential sign of JOCD in transition to instability. The aim of the study was to evaluate the clinical outcomes after surgical intervention (drilling) on the "hump". MATERIALS AND METHODS In a retrospective case series of sixteen patients with an arthroscopically detectable "hump", the analysis of clinical function scores (Lysholm, Tegner) and morphological MRI monitoring of radiological healing were performed. The assessment of lesion healing was based on pre- and postoperative MRI examinations. The "hump" was defined as an arthroscopically impressive protrusion of the femoral articular surface with a minimally softened, discolored, but intact cartilage margin that, is not mobile upon in the arthroscopic palpation hook test. The primary therapy of choice was drilling of all "humps". RESULTS The "hump" could be detected arthroscopically in 16 of 59 JOCD lesions. Specific MRI correlations with the "hump" or arthroscopic unstable lesions could not be detected. Not all "humps" showed signs of MRI-based healing after the drilling, and in some a dissection of the osteochondral flap occurred within the first postoperative year. As a result, secondary refixation became necessary. CONCLUSION In the present study, the "hump" was identified as an important differential diagnostic arthroscopic feature of an arthroscopically primarily stable JOCD lesion, potentially placing the lesion at risk of secondary loosening over time. Therefore, drilling alone may not be appropriate in the event of arthroscopic "hump" discovery, but additional fixation may be required to achieve the healing of the lesion. LEVEL OF EVIDENCE III.
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Affiliation(s)
- A Korthaus
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - N M Meenen
- Pediatric Sports Medicine, Sports Traumatology, Asklepios Clinic St. Georg, Lohmühlenstraße 5, 20099, Hamburg, Germany.
| | - G Pagenstert
- CLARAHOF Clinic of Orthopaedic Surgery, University of Basel, Clarahofweg 19a, 4058, Basel, Switzerland
| | - M Krause
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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5
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Tudisco C, Bernardi G, Manisera MT, De Maio F, Gorgolini G, Farsetti P. An update on osteochondritis dissecans of the knee. Orthop Rev (Pavia) 2022; 14:38829. [PMID: 36540072 PMCID: PMC9760694 DOI: 10.52965/001c.38829] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Osteochondritis dissecans of the knee (OCD) is a multifactorial pathology in where repetitive microtrauma plays a central role in the etiopathogenesis. Knee MRI is indicated in young, active patients who have knee pain and/or effusion, to make an early diagnosis and decide about treatment, according essentially to the MRI stability signs. The choice of treatment should be also tailored, based on the patient's skeletal maturity, as well as the size and location of the lesion. Conservative treatment with restricting sports activities is the first line treatment and often sufficient to ensure healing in patients with open physes. Surgical treatment depends on the persistence of symptoms after 6 months of conservative treatment and/or based on the development of signs of instability of the lesion. Stable lesions with intact articular cartilage may be treated by drilling of the subchondral bone aiming to stimulate vascular ingrowth and subchondral bone healing. Every attempt should be made to retain the osteochondral fragment when possible. Instable lesions should be fixed or "replaced" with salvage procedures to prevent the onset of early osteoarthritis in this young population. Furthers studies are needed to improve the knowledge and optimizing non-operative and surgical treatment and to develop noninvasive diagnostic tools to predict with more accuracy the fragment's stability.
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Affiliation(s)
- Cosimo Tudisco
- Unicamillus - Saint Camillus International University of Health Sciences, Rome, Italy
| | - Gabriele Bernardi
- Department of Orthopaedics and TraumatologyNuova Itor Clinic, Rome, Italy
| | - Maria Teresa Manisera
- Department of Clinical Science and Translational Medicine, Section of Orthopaedics and TraumatologyUniversity of Rome “Tor Vergata”, Italy
| | - Fernando De Maio
- Department of Clinical Science and Translational Medicine, Section of Orthopaedics and TraumatologyUniversity of Rome “Tor Vergata”, Italy
| | - Giulio Gorgolini
- Department of Clinical Science and Translational Medicine, Section of Orthopaedics and TraumatologyUniversity of Rome “Tor Vergata”, Italy
| | - Pasquale Farsetti
- Department of Clinical Science and Translational Medicine, Section of Orthopaedics and TraumatologyUniversity of Rome “Tor Vergata”, Italy
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Males and Females Exhibit Comparable Outcomes Following Treatment of Osteochondritis Dissecans Lesions of the Knee: A Systematic Review. Arthroscopy 2022; 38:2919-2929. [PMID: 35337959 DOI: 10.1016/j.arthro.2022.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the impact of patient sex on outcomes after treatment of osteochondritis dissecans (OCD) lesions of the knee through a systematic review of current evidence. METHODS This review was conducted according to the PRISMA guidelines using the PubMed, PubMed Central, Embase, Ovid Medline, Cochrane Libraries, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Relevant outcomes included functional (e.g., International Knee Documentation Committee and Subjective Knee Evaluation, Lysholm Knee Score) and clinical outcomes (e.g., symptom/pain resolution, reoperation rates) for males and females after operative or nonoperative treatment of knee OCD lesions. RESULTS Ten articles with a total of 691 (73%) males and 260 (27%) females were included. Mean age ranged from 11.3 ± 2.1 years to 34.5 ± 10.3 years, and follow-up ranged from 6 months to 16.3 years. In four studies reporting functional outcomes, no significant differences were found between males and females in any metric assessed (all P > .05). Seven studies reported clinical outcomes after treatment of knee OCD lesions. One study determined males were more likely to have a successful nonoperative outcome than females (OR: 1.85, 95% CI: 1.00-3.40). Another study found males had a lower risk of developing symptomatic knee pain following operative or nonoperative treatment at a mean 14-year follow-up (HR: 0.24; 95% CI: 0.07-0.81). The remaining 5 studies reported statistically comparable clinical outcomes between males and females (all P > .05). CONCLUSION The present systematic review found mostly comparable clinical and functional outcomes between males and females following treatment of knee OCD lesions. Despite sex-related differences in the prevalence of these lesions and limited evidence of differences in clinical outcomes, these data suggest that sex does not independently predict outcomes after treatment. LEVEL OF EVIDENCE III, systematic review of Level II and III studies.
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Andriolo L, Solaro L, Altamura SA, Carey JL, Zaffagnini S, Filardo G. Classification Systems for Knee Osteochondritis Dissecans: A Systematic Review. Cartilage 2022; 13:19476035221121789. [PMID: 36117427 PMCID: PMC9634996 DOI: 10.1177/19476035221121789] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE Aim of this systematic review was to describe all classification systems for knee osteochondritis dissecans (OCD) lesions, evaluating their accuracy and reliability, as well as their use in the literature on knee OCD. DESIGN A systematic review of the literature was performed in July 2021 on PubMed, WebOfScience, and Cochrane Collaboration (library) to describe all published classification systems for knee OCD lesions and quantify the use of these classifications in the literature. RESULTS Out of 1,664 records, 30 studies on 33 OCD classifications systems were identified, describing 11 radiographic, 13 MRI, and 9 arthroscopic classifications. The search included 193 clinical studies applying at least one OCD classification, for a total of 7,299 knee OCD cases. Radiographic classifications were applied to 35.8%, MRI to 35.2%, and arthroscopic classifications to 64.2% of the included studies. Among these, in the last two decades, the International Cartilage Repair Society's (ICRS) arthroscopic classification was the most described approach in studies on knee OCD. Overall, there is a lack of data on accuracy and reliability of the available systems. CONCLUSIONS Several classifications are available, with ICRS being the most used system over the time period studied. Arthroscopy allows to confirm lesion stability, but noninvasive imaging approaches are the first line to guide patient management. Among these, radiographic classifications are still widely used, despite being partially superseded by MRI, because of its capability to detect the earliest disease stages and to distinguish stable from unstable lesions, and thus to define the most suitable conservative or surgical approach to manage patients affected by knee OCD. LEVEL OF EVIDENCE Systematic review, level IV.
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Affiliation(s)
- Luca Andriolo
- Clinica Ortopedica e Traumatologica 2,
IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Luca Solaro
- Clinica Ortopedica e Traumatologica 2,
IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy,Luca Solaro, Clinica Ortopedica e
Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Via Pupilli, 1/10, 40136
Bologna, Italy.
| | | | - James L. Carey
- Penn Center for Advanced Cartilage
Repair and Osteochondritis Dissecans Treatment, Hospital of the University of
Pennsylvania, Philadelphia, PA, USA,Perelman School of Medicine, University
of Pennsylvania, Philadelphia, PA, USA
| | - Stefano Zaffagnini
- Clinica Ortopedica e Traumatologica 2,
IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giuseppe Filardo
- Applied and Translational Research
(ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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8
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Roseti L, Grigolo B. Current concepts and perspectives for articular cartilage regeneration. J Exp Orthop 2022; 9:61. [PMID: 35776217 PMCID: PMC9249961 DOI: 10.1186/s40634-022-00498-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
Articular cartilage injuries are common in the population. The increment in the elderly people and active life results in an increasing demand for new technologies and good outcomes to satisfy longer and healthier life expectancies. However, because of cartilage's low regenerative capacity, finding an efficacious treatment is still challenging for orthopedics. Since the pioneering studies based on autologous cell transplantation, regenerative medicine has opened new approaches for cartilage lesion treatment. Tissue engineering combines cells, biomaterials, and biological factors to regenerate damaged tissues, overcoming conventional therapeutic strategies. Cells synthesize matrix structural components, maintain tissue homeostasis by modulating metabolic, inflammatory, and immunologic pathways. Scaffolds are well acknowledged by clinicians in regenerative applications since they provide the appropriate environment for cells, can be easily implanted, reduce surgical morbidity, allow enhanced cell proliferation, maturation, and an efficient and complete integration with surrounding articular cartilage. Growth factors are molecules that facilitate tissue healing and regeneration by stimulating cell signal pathways. To date, different cell sources and a wide range of natural and synthetic scaffolds have been used both in pre-clinical and clinical studies with the aim to find the suitable solution for recapitulating cartilage microenvironment and inducing the formation of a new tissue with the biochemical and mechanical properties of the native one. Here, we describe the current concepts for articular cartilage regeneration, highlighting the key actors of this process trying to identify the best perspectives.
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Affiliation(s)
- Livia Roseti
- IRCCS Istituto Ortopedico Rizzoli Bologna, Bologna, Italy
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9
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Metz AK, Riederer M, Gagnier J, Crawford EA. Incidence of Subsequent Surgical Intervention at Short-term Follow-up in Previously Healing and Stable Juvenile Osteochondritis Dissecans of the Knee. J Pediatr Orthop 2022; 42:e271-e276. [PMID: 34999630 DOI: 10.1097/bpo.0000000000002041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Juvenile osteochondritis dissecans (OCD) of the knee is a defect of subchondral bone seen primarily in active children and adolescents. Studies have evaluated the incidence of surgery in knee OCD, but the incidence of subsequent surgery in patients with stable, healing lesions cleared to return to activities is unknown. This study sought to determine the incidence of surgery in participants with knee OCD lesions cleared to return to activities and evaluate predictors of subsequent surgery. METHODS A single center, retrospective review was performed of participants aged 7 to 18 with knee OCD. Inclusion criteria were stable lesion, skeletal immaturity, no history of previous knee surgery, release to activity without surgery, and at least 12 months of follow-up. Documentation of subsequent surgery was queried in the electronic health record. Participants with no recorded surgery were contacted through phone. Analysis included bivariate and logistic regression. RESULTS Twenty-five individuals were included in this study, with 7 undergoing surgery after returning to activity. Medial femoral condyle lesions were less likely to undergo surgery (B=-2.6, P=0.038). Average lesion size for the Surgery and No Surgery groups was 1.76±0.65 and 1.32±0.81 cm2, respectively, though not significantly different (P=0.21). The Surgery group returned to activity sooner (3.7 mo, range 1.1 to 6.4) than the No Surgery group (8.1 mo, range 1.8 to 35.4), though not significantly different (P=0.18). Mean follow-up time for the study was 42.7 (range 12.6 to 77.6) months. No participants contacted by phone progressed to surgery or reported symptoms that limited their activities. CONCLUSIONS While the majority of participants with stable, healing, and asymptomatic knee OCD lesions have favorable outcomes with nonoperative management, some lesions may progress to surgery. Lesions on the medial femoral condyle may be predictive of lower likelihood of progression to surgery. Our study provides insight on the outcomes of nonoperative management of OCD lesions. LEVEL OF EVIDENCE Level IV-prognostic study.
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Affiliation(s)
| | - Mark Riederer
- Departments of Pediatrics
- Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
| | - Joel Gagnier
- Orthopaedic Surgery, University of Michigan, Ann Arbor, MI
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10
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Massey PA, McClary KN, McBride HD, Walt J, Mielke CH, Barton RS. Arthroscopic Fixation of Knee Femoral Condyle Osteochondritis Dissecans Fragment With Bone Marrow Aspirate Concentrate. Arthrosc Tech 2021; 10:e2357-e2363. [PMID: 34754745 PMCID: PMC8556664 DOI: 10.1016/j.eats.2021.07.013] [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: 04/22/2021] [Accepted: 07/02/2021] [Indexed: 02/03/2023] Open
Abstract
This article reviews a technique for arthroscopic fixation of an osteochondritis dissecans fragment with bone marrow aspirate concentrate augmentation. This technique involves safe harvest of bone marrow arthroscopically from the intercondylar notch, proper preparation and debridement of the parent bone, reduction of the progeny osteochondritis dissecans fragment, insertion of the bone marrow aspirate concentrate, and placement of multiple headless compression screws for fixation.
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Affiliation(s)
- Patrick A. Massey
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A.,Address correspondence to Patrick A. Massey, M.D., Department of Orthopaedic Surgery, Louisiana State University, 1501 Kings Hwy, Shreveport, LA 71103, U.S.A.
| | - Kaylan N. McClary
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - Hayden D. McBride
- School of Medicine, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - Jennifer Walt
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
| | - Cary H. Mielke
- Department of Orthopaedic Surgery, Shriners Hospitals for Children, Shreveport, Louisiana, U.S.A
| | - R. Shane Barton
- Department of Orthopaedic Surgery, Louisiana State University, Shreveport, Louisiana, U.S.A
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Di Martino A, Perdisa F, Filardo G, Busacca M, Kon E, Marcacci M, Zaffagnini S. Cell-Free Biomimetic Osteochondral Scaffold for the Treatment of Knee Lesions: Clinical and Imaging Results at 10-Year Follow-up. Am J Sports Med 2021; 49:2645-2650. [PMID: 34283948 DOI: 10.1177/03635465211029292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Cell-free devices have been introduced to restore osteochondral defects, avoiding the limitations of cell-based procedures. Among these, an osteochondral scaffold made of type I collagen and hydroxyapatite has been investigated with promising results up to medium-term follow-up. However, the clinical and imaging results over time still need to be documented. PURPOSE To evaluate the clinical outcome and tissue maturation at long-term follow-up after the implantation of the osteochondral scaffold. STUDY DESIGN Case series; Level of evidence, 4. METHODS A total of 24 patients (7 women, 17 men; age, 36 ± 9.5 years) underwent surgical implantation of the osteochondral scaffold and were prospectively evaluated before surgery, at 2-, 5-, and 10-year follow-up. The mean defect size was 2.9 ± 1.4 cm2. Patients were evaluated using the International Knee Documentation Committee (IKDC) subjective and objective scores, and the activity level was documented with the Tegner score. Magnetic resonance imaging (MRI) evaluation involved the use of the magnetic resonance observation of cartilage repair tissue score combined with 5 more variables focused on the bone layer. RESULTS A statistically significant improvement of all clinical scores was documented from the baseline to the final evaluation. The IKDC subjective score improved from the preoperative level to 2 years (41 ± 13.2 and 77.1 ± 14.6, respectively) (P < .0005), with stable results up to 10 years (77.4 ± 19.4). The IKDC objective score changed from 52% of normal and nearly normal knees before the treatment to 84% at 10 years (P < .0005). Tegner sports activity at the final evaluation (3.8 ± 1.7) was higher compared with the preoperative level (1.6 ± 1.1; P < .05), but it remained significantly lower compared with the preinjury level (5.5 ± 2.6; P < .05). Treatment failed in 1 patient. Persisting graft alterations were observed on MRI scans, although without correlating with the clinical outcome. CONCLUSION The regenerative potential of this scaffold is limited, as demonstrated by the signal alterations persisting over time on MRI scans. On the other hand, the clinical improvement was significant and stable over time both in terms of subjective and objective outcomes, including activity level, with overall good results.
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Affiliation(s)
| | - Francesco Perdisa
- SC Chirurgia Protesica e dei Reimpianti di Anca e di Ginocchio; IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Maurizio Busacca
- SC Radiologia diagnostica ed interventistica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Elizaveta Kon
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Maurilio Marcacci
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center, IRCCS, Rozzano, Milan, Italy
| | - Stefano Zaffagnini
- SC II Clinica Ortopedica, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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12
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Cost-Effectiveness Analysis of Nonoperative Management Versus Early Drilling for Stable Osteochondritis Dissecans Lesions of the Knee in Skeletally Immature Patients. Arthroscopy 2021; 37:624-634.e2. [PMID: 33271176 DOI: 10.1016/j.arthro.2020.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 09/09/2020] [Accepted: 09/10/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate the cost-effectiveness of a trial of nonoperative management versus early drilling in the treatment of skeletally immature patients with stable osteochondritis dissecans (OCD) of the knee. METHODS A decision tree model was used to compare the cost-effectiveness of a trial of nonoperative management versus early drilling (within 6 weeks of the first office visit) from payer and societal perspectives over a 3-year time horizon. Relevant transition probabilities, costs (in 2019 US dollars based on Medicare reimbursement), health state utilities, and times to healing were derived from the literature. The principal outcome measure was the incremental cost-effectiveness ratio (ICER). One- and 2-way sensitivity analyses were performed on pertinent model parameters to validate the robustness of the base-case results using a conservative willingness-to-pay (WTP) threshold of $50,000 per quality-adjusted life-year (QALY). The Consolidated Health Economic Evaluation Reporting Standards checklist for reporting economic evaluations was used. RESULTS In the base-case analysis from a payer perspective, early drilling was more effective (2.51 versus 2.27 QALYs), more costly ($4,655 versus $3,212), and overall more cost-effective (ICER $5,839/QALY) relative to nonoperative management. In the base-case analysis from a societal perspective, early drilling dominated nonoperative management owing to its increased effectiveness (2.51 versus 2.27 QALYs) and decreased cost ($13,098 versus $18,149). These results were stable across broad ranges on sensitivity analysis. Based on 1-way threshold analyses from a payer perspective, early drilling remained cost-effective as long it cost less than $19,840, the disutility of surgery was greater than -0.40, or the probability of successful early drilling was greater than 0.62. CONCLUSIONS Although the traditional approach to stable OCD lesions of the knee in skeletally immature patients has been a trial of nonoperative management, our data suggest that early drilling may be cost-effective from both payer and societal perspectives. LEVEL OF EVIDENCE III, economic and decision analysis.
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Li T, Chen S, Pei M. Contribution of neural crest-derived stem cells and nasal chondrocytes to articular cartilage regeneration. Cell Mol Life Sci 2020; 77:4847-4859. [PMID: 32504256 PMCID: PMC9150440 DOI: 10.1007/s00018-020-03567-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/06/2020] [Accepted: 05/27/2020] [Indexed: 12/12/2022]
Abstract
Due to poor self-regenerative potential of articular cartilage, stem cell-based regeneration becomes a hopeful approach for the treatment of articular cartilage defects. Recent studies indicate that neural crest-derived cells (NCDCs) have the potential for repairing articular cartilage with even greater chondrogenic capacity than mesoderm-derived cells (MDCs): a conventional stem cell source for cartilage regeneration. Given that NCDCs originate from a different germ layer in the early embryo compared with MDCs that give rise to articular cartilage, a mystery remains regarding their capacity for articular cartilage regeneration. In this review, we summarize the similarities and differences between MDCs and NCDCs including articular and nasal chondrocytes in cell origin, anatomy, and chondrogenic differentiation and propose that NCDCs might be promising cell origins for articular cartilage regeneration.
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Affiliation(s)
- Tianyou Li
- Stem Cell and Tissue Engineering Laboratory, Department of Orthopaedics, West Virginia University, 64 Medical Center Drive, PO Box 9196, Morgantown, WV, 26506-9196, USA
- Department of Pediatric Orthopaedics, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, China
| | - Song Chen
- Department of Orthopaedics, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan, China
| | - Ming Pei
- Stem Cell and Tissue Engineering Laboratory, Department of Orthopaedics, West Virginia University, 64 Medical Center Drive, PO Box 9196, Morgantown, WV, 26506-9196, USA.
- WVU Cancer Institute, Robert C. Byrd Health Sciences Center, West Virginia University, Morgantown, WV, USA.
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Chernchujit B, Artha A. Osteochondritis Dissecans of the Knee: Arthroscopic Suture Anchor Fixation. Arthrosc Tech 2020; 9:e1203-e1209. [PMID: 32874902 PMCID: PMC7451442 DOI: 10.1016/j.eats.2020.04.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/26/2020] [Indexed: 02/03/2023] Open
Abstract
Osteochondritis dissecans (OCD) is a subchondral bone abnormality, in which subchondral bone and the overlying articular cartilage detach from the bony bed. Multiple techniques for OCD fixation have been described, including metallic, bioabsorbable implants and biological fixation. We describe a surgical technique for OCD lesions including bony bed preparation with curettage and microfracture, anatomic reduction, and fixation using a suture anchor to provide stability and healing of the lesion.
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Affiliation(s)
| | - Arrisna Artha
- Address correspondence to Arrisna Artha, M.D., Department of Orthopaedics, Faculty of Medicine, Thammasat University Hospital, Bangkok, Thailand.
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Andelman SM, Mandelbaum BR, Fitzsimmons KP, Pace JL. Retroarticular Core Decompression with Biologic Augmentation for Juvenile Osteochondritis Dissecans of the Knee. Arthrosc Tech 2020; 9:e1003-e1009. [PMID: 32714811 PMCID: PMC7372571 DOI: 10.1016/j.eats.2020.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/29/2020] [Indexed: 02/03/2023] Open
Abstract
Juvenile osteochondritis dissecans (OCD) of the knee is a rare condition of subchondral bone that has secondary effects on articular cartilage as the condition advances. Traditional treatment for early-stage OCD involves different types of drilling procedures that work to stimulate healthy bone formation via creeping substitution. This article describes a technique that involves a complete removal, or decompression of an early-stage OCD, while preserving the overlying articular cartilage that is augmented with bone grafting and bone marrow aspirate concentrate. This allows for quicker and more reliable healing of early-stage OCD and can minimize the chance for reoperation.
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Affiliation(s)
- Steven M. Andelman
- Department of Orthopedics, State University of New York Downstate Medical Center, New York, New York, U.S.A
| | | | - Kevin P. Fitzsimmons
- Elite Sports Medicine, Connecticut Children’s Medical Center, Farmington, Connecticut, U.S.A.,Department of Orthopedic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, U.S.A
| | - J. Lee Pace
- Department of Orthopedic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut, U.S.A.,Address correspondence to J. Lee Pace, M.D., Elite Sports Medicine, Connecticut Children's Medical Center, 399 Farmington Avenue, Farmington, CT 06032, U.S.A.
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Ogura T, Merkely G, Bryant T, Winalski CS, Minas T. Autologous Chondrocyte Implantation "Segmental-Sandwich" Technique for Deep Osteochondral Defects in the Knee: Clinical Outcomes and Correlation With Magnetic Resonance Imaging Findings. Orthop J Sports Med 2019; 7:2325967119847173. [PMID: 31192269 PMCID: PMC6540512 DOI: 10.1177/2325967119847173] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Symptomatic osteochondral defects are difficult to manage, especially in patients with deep (>8-10 mm) empty defects. The restoration of articular congruence is crucial to avoid the progression to osteoarthritis (OA). Purpose To describe the autologous chondrocyte implantation (ACI) "segmental-sandwich" technique for restoration of the osteochondral unit and to evaluate midterm outcomes in patients treated with this procedure. Correlations between magnetic resonance imaging (MRI) and radiographic findings with outcomes were assessed. Study Design Case series; Level of evidence, 4. Methods Outcomes were evaluated for a consecutive cohort of 15 patients with symptomatic deep (>8 mm) osteochondral lesions who underwent autologous bone grafting plus the ACI segmental-sandwich technique performed by a single surgeon between 2003 and 2011. Patients with a minimum 2-year follow-up were included. All patients completed validated clinical outcome scales and a patient satisfaction survey. The Kellgren-Lawrence (K-L) grade was assessed for the progression to OA. The repair site was evaluated with the MOCART (magnetic resonance observation of cartilage repair tissue) score. Filling and tissue characteristics of the bone defect were analyzed with MRI. Results All patients (mean age at surgery, 31.0 ± 9.1 years) were available for follow-up (mean follow-up, 7.8 ± 3.0 years; range, 2-15 years). The mean chondral lesion size was 6.0 ± 3.5 cm2 (range, 1.5-13.5 cm2), with a mean bone defect area of 1.7 cm2 (27%-40% of overall surface area treated by ACI) and depth of 1.0 cm. All patients had successful clinical outcomes, and all functional scores improved significantly (P < .05). Patients reported a very high satisfaction rate (93%). The K-L grade demonstrated no significant progression to OA over a mean follow-up of 4.7 years. For 12 patients with MRI results available, the mean MOCART score at a mean of 3.3 years was 64.2 ± 19.9, with complete or near-complete (≥75% of defect volume) chondral defect filling (83%) and complete integration to adjacent cartilage (83%). Bone defects were completely filled in 83% of patients. Conclusion The ACI segmental-sandwich technique provides significant functional improvements at midterm follow-up and excellent survival rates. This unique treatment allows for the resurfacing of cartilage defects and the repair of underlying segmental bone lesions.
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Affiliation(s)
- Takahiro Ogura
- Sports Medicine Center, Funabashi Orthopaedic Hospital, Funabashi, Japan.,Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gergo Merkely
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Traumatology, Semmelweis University, Budapest, Hungary
| | - Tim Bryant
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Tom Minas
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Cartilage Repair Center, Paley Orthopedic & Spine Institute, St Mary's Medical Center, West Palm Beach, Florida, USA
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Minas T, Ogura T, Headrick J, Bryant T. Autologous Chondrocyte Implantation "Sandwich" Technique Compared With Autologous Bone Grafting for Deep Osteochondral Lesions in the Knee. Am J Sports Med 2018; 46:322-332. [PMID: 29125919 DOI: 10.1177/0363546517738000] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treating symptomatic osteochondral defects is challenging, especially in young adults with deep (>8-10 mm) empty defects after osteochondritis dissecans (OCD) or collapsed condyles secondary to avascular necrosis (AVN). For this population, osteoarthritis (OA) is inevitable if articular congruence is not restored. PURPOSE To describe the autologous chondrocyte implantation (ACI) "sandwich" technique with autologous bone grafting (ABG) and compare it with ABG alone for restoration of the osteochondral unit. The midterm to long-term outcomes in patients after the treatment for OCD and AVN will be reported and compared. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS The outcomes for a consecutive cohort of 24 patients who underwent combined ABG with the ACI sandwich technique between 2001 and 2013 (ACI sandwich group) was compared with a historical control group of 17 consecutive patients who underwent ABG alone between 1995 and 2002 (ABG group) by a single surgeon for symptomatic deep (>8 mm) osteochondral lesions. Patients who were followed up with a minimum of 2 years were included in this study. The modified Cincinnati Knee Rating System, the Western Ontario and McMaster Universities Osteoarthritis Index, a visual analog scale (VAS), the Short Form-36, and a patient satisfaction survey were used to evaluate clinical outcomes. Survival analysis was performed using the Kaplan-Meier method, with no clinical improvement, graft failure, or conversion to prosthetic arthroplasty as the endpoint (failure). Kellgren-Lawrence (K-L) grading to assess OA progression was also performed. RESULTS In the ABG group, 13 of 17 patients (76%) were available with a mean follow-up of 15.7 years postoperatively (range, 5-21 years). In the ACI sandwich group, all 24 patients were available with a mean follow-up of 7.8 years postoperatively (range, 2-15 years). No significant differences were observed between the groups in terms of age, sex, side of the operated knee, body mass index, lesion type, lesion size, lesion depth, lesion location, or the need for realignment osteotomy. Eight patients (62%) were considered failures in the ABG group, while 3 patients (13%) were considered failures in the ACI sandwich group. The survival rate was significantly better in the ACI sandwich group than the ABG group (87% vs 54% at 5 years, respectively; P = .0025). All functional scores in patients with retained grafts significantly improved in the ACI sandwich group, whereas only the VAS score showed significant improvement in the ABG group. The patient satisfaction survey showed a very high satisfaction rate in the ACI sandwich group, with over 90% of patients reporting their knees as good or excellent and being satisfied with the procedure. In the ACI sandwich group, K-L grading demonstrated no significant OA progression from preoperatively to a mean 5.1 years postoperatively. CONCLUSION Our study showed that the ACI sandwich technique provided excellent and superior survival rates compared to ABG alone and significant improvements over midterm to long-term follow-up. This unique treatment offers native joint preservation for conditions that naturally will progress to OA and eventually require prosthetic arthroplasty.
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Affiliation(s)
- Tom Minas
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Takahiro Ogura
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Sports Medicine Center, Funabashi Orthopaedic Hospital, Funabashi, Japan
| | | | - Tim Bryant
- Cartilage Repair Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Pareek A, Sanders TL, Wu IT, Larson DR, Saris DBF, Krych AJ. Incidence of symptomatic osteochondritis dissecans lesions of the knee: a population-based study in Olmsted County. Osteoarthritis Cartilage 2017; 25:1663-1671. [PMID: 28711583 PMCID: PMC5798004 DOI: 10.1016/j.joca.2017.07.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 07/03/2017] [Accepted: 07/05/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To (1) define population-based incidence of knee Osteochondritis dissecans (OCD) lesions using the population of Olmsted County, (2) examine trends over time, and (3) evaluate rate of surgical management over time. METHOD Study population included 302 individuals who were diagnosed with knee OCD lesions between January 1, 1976 and December 31, 2014. Complete medical records were reviewed to extract injury and treatment details. Age- and gender-specific incidence rates were calculated and adjusted to the 2010 US population. Poisson regression analyses were performed to examine incidence and surgery trends by age, gender, and calendar period. RESULTS Overall age- and gender-adjusted incidence annual incidence of knee OCD lesions was 6.09 per 100,000 person-years. The incidence was significantly higher (P < 0.001) in males (8.82, 95% CI 7.63 to 10.00 per 100,000) compared to females (3.32, 95% CI 2.61 to 4.04 per 100,000). Age- and gender-specific incidence was highest in both males and females in the 11-15 years old at 39.06 and 16.15 per 100,000, respectively. In males aged 11-15 years, OCD incidence increased significantly over the study period from 20.68 in 1976-1985 to 48.16 in 2006-2014 (per 100,000). CONCLUSIONS Overall age- and gender-adjusted annual incidence of knee OCD lesions in the Olmsted Country Population was 6.09 per 100,000 person-years with a significantly higher incidence in males compared to females. The highest incidence for both males and females occurred between the ages 11-15 years. Trends indicate increasing OCD incidence in younger males and decreasing surgical management in females over the last decade.
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Affiliation(s)
- Ayoosh Pareek
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Thomas L. Sanders
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Isabella T. Wu
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Dirk R. Larson
- Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel BF Saris
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA,University of Twente, Enschede, The Netherlands,Department of Orthopaedics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Aaron J. Krych
- Department of Orthopedic Surgery and Sports Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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van den Broek M, Oussedik S. Paediatric fractures around the knee. Br J Hosp Med (Lond) 2017; 78:453-458. [PMID: 28783395 DOI: 10.12968/hmed.2017.78.8.453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Paediatric fractures around the knee are not common but their incidence seems to be increasing as a result of the increasing number of children participating in sports. Given the characteristics of the growing skeleton, specific fractures only occur in children. Diagnosis is mainly based on history, clinical examination and plain radiographs. Advanced imaging may be required in special fracture types. Although many of these injuries can be managed non-operatively, early referral to a specialist team is necessary to avoid delays in surgical management and to reduce the risk of acute or late complications.
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Affiliation(s)
- M van den Broek
- Specialist Registrar in Trauma and Orthopaedics, Department of Orthopaedics, University College Hospital, London NW1 2BU
| | - S Oussedik
- Consultant in Trauma and Orthopaedics, Department of Orthopaedics, University College Hospital, London
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Haddad FS. Raising the bar. Bone Joint J 2017; 99-B:417-418. [PMID: 28385927 DOI: 10.1302/0301-620x.99b4.bjj-2017-0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 03/13/2017] [Indexed: 11/05/2022]
Affiliation(s)
- F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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Haddad FS. In the same vein: looking forward to 2017. Bone Joint J 2017; 99-B:1-2. [PMID: 28053248 DOI: 10.1302/0301-620x.99b1.38084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 12/02/2016] [Indexed: 11/05/2022]
Affiliation(s)
- F S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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