Edmonds, Eric W.

Background: Stable osteochondritis dissecans (OCD) lesions are primarily treated nonoperatively. Nonoperative treatment includes several recommendations, including the use of an unloader brace. However, little is known about the clinical effectiveness of unloader bracing and its influence on OCD healing, return to sports, and patient-reported outcomes (PROs). The purpose of this investigation was to evaluate the impact of unloader bracing on patients with stable medial femoral condyle (MFC) OCD lesions treated nonoperatively. Purpose: To investigate the influence of valgus unloader bracing on the success of treating stable MFC OCD with nonoperative treatment strategies. Study Design: Cohort study; Level of evidence, 2. Methods: The authors used a prospective cohort of patients receiving nonoperative care for stable MFC knee OCD lesions. The primary variable of interest was the efficacy of bracing. The primary outcomes were transition from nonoperative care to surgical intervention, return-to-play (RTP) clearance, and PROs. Bivariate testing was used to determine if there were differences between groups. Chi-square testing was used to determine if there were differences in rates of transition to surgery by group. The timing of the transition by each group was assessed using a Wilcoxon rank-sum test, given the nonparametric nature of the data. Kaplan-Meier survival analysis was used to calculate time at risk, incidence rate, and survival times for each group. Results: A total of 185 knees (bracing group: 123 [66.5%] knees; no-bracing group: 62 [33.5%] knees) were analyzed. Overall, 142 (76.8%) knees were successfully treated nonoperatively. Transition to surgery occurred in 43 (23.2%) knees. There were no differences in transition to surgery by groups, with no differences seen by group. Of the knees that did not transition to surgical care, 65 (71.4%) in the bracing group and 38 (74.5%) in the no-bracing group received RTP clearance ( P = .693). PRO scores were similar between the 2 groups at the time of RTP clearance. Conclusion: The inclusion of an unloader brace in the nonoperative treatment for stable MFC OCD lesions did not decrease the likelihood of patients undergoing surgical intervention or improve their PRO scores at the time of RTP clearance. Registration: NCT02771496 (ClinicalTrials.gov identifier).

Background: There are limited evidence-based guidelines to predict which osteochondritis dissecans (OCD) lesions will heal with nonoperative treatment. Purpose: To train a set of classification algorithms to predict nonoperative OCD healing while identifying new clinically meaningful predictors. Study Design: Case-control study; Level of evidence, 3. Methods: Patients with OCD of the knee with open physes undergoing nonoperative management were prospectively queried from the Research on OCD of the Knee (ROCK) cohort ( https://kneeocd.org ) in April 2022. Patients were included if they met the study criteria for nonoperative treatment success or failure. Nonoperative treatment success was defined as complete healing on magnetic resonance imaging (MRI) and total return to sports participation. Failure was defined as the crossover from nonoperative management to surgery at any point at or beyond the 3-month follow-up. If a patient did not meet one of these criteria, they were not included. Normalized lesion size, lesion location, patient characteristics, and symptoms were used as clinically relevant predictors. Results: A total of 64 patients were included, of whom 24 (37.5%) patients successfully healed with nonoperative management. Multivariate logistic regression revealed that a 1% increase in normalized lesion width was associated with an increase in the likelihood of nonoperative failure (odds ratio [OR], 1.41 [95% CI, 1.17-1.81]; P < .01). By contrast, lesions in the posterior sagittal zone (OR, 0.08 [95% CI, 0.009-0.43]; P < .01) or the medial-most coronal zone (for lesions of the medial femoral) and lateral-most coronal zone (for lesions of the lateral femoral condyle) on MRI (OR, 0.05 [95% CI, 0.004-0.44]; P < .01) were associated with a decrease in the likelihood of nonoperative treatment failure. Support vector machines had a cross-validated area under the receiver operating characteristic curve of 0.89 and a classification accuracy of 83.3%. Conclusion: Lesion location in the posterior aspect of the condyle on sagittal MRI and lesion location in the medial-most or lateral-most locations on coronal MRI were identified as statistically significant predictors of increased nonoperative treatment success on multivariate analysis. Machine learning models can predict which OCD lesions will heal with nonoperative management with superior accuracy compared with previously published models.

Background: Osteochondritis dissecans (OCD) of the knee is a focal idiopathic alteration of subchondral bone and/or its precursor with risk for instability and disruption of adjacent cartilage. Treatment options focused on preventing premature osteoarthritis vary depending on multiple patient and lesion characteristics, including lesion mobility. Purpose: To differentiate lesion mobility before arthroscopy using a multivariable model that includes patient demographic characteristics and physical examination findings. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: Demographic, preoperative physical examination, and radiographic data were collected from a multicenter national prospective cohort of patients with OCD of the knee. Inclusion criteria included patients <19 years of age and patients with arthroscopically confirmed mobility status based on the Research on Osteochondritis Dissecans of the Knee arthroscopy classification. Multivariable logistic regression analysis using stepwise model selection was used to determine factors associated with the likelihood of a mobile versus an immobile lesion. A 75% partition of the data was used for model training, and 25% was used as a validation cohort. Quantitative model fit statistics were computed using the holdout data, including sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC), along with the corresponding 95% CI. Results: A total of 407 patients in the prospective cohort met inclusion criteria, and 62% were male. The mean ± SD age was 13.7 ± 2.2 years, height 161.8 ± 5.3 cm, and weight 59.2 ± 42.2 kg. Arthroscopic evaluation yielded 235 immobile and 172 mobile lesions. Multivariable analysis determined that the best model to predict lesion mobility included chronologic age ≥14 years ( P < .001), effusion on physical examination ( P < .001), and any loss of range of motion on physical examination ( P = .07), while controlling for male sex ( P = .38) and weight >54.4 kg ( P = .12). In the 25% holdout validation sample (n = 102), a sensitivity of 83%, a specificity of 82%, and an AUC of 0.89 (95% CI, 0.82-0.95) were achieved with these predictive factors. Conclusion: Age, effusion, and loss of motion can predict knee OCD lesion mobility at the time of arthroscopy. Education about lesion mobility can help with surgical planning and patient and family counseling.

Background/Objective: To share technical pearls of a basic knee arthroscopy in a pediatric patient by presenting tips and tricks used by experienced pediatric arthroscopists. Indications: Knee arthroscopy is a common procedure performed by most orthopedic surgeons. However, technical considerations and equipment should be considered before performing this procedure in a pediatric patient. This video provides information on indications, equipment, and patient positioning, as well as outlining a systematic approach to diagnostic arthroscopy and pertinent pediatric anatomy. Discussion/Conclusion: This video provides an excellent overview as well as specific pathology-dependent considerations for the inexperienced orthopedic surgeon, or the orthopedic surgeon who rarely performs knee arthroscopy. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Background: Osteochondritis dissecans (OCD) occurs most commonly in the knees of young individuals. This condition is known to cause pain and discomfort in the knee and can lead to disability and early knee osteoarthritis. The cause is not well understood, and treatment plans are not well delineated. The Research in Osteochondritis Dissecans of the Knee (ROCK) group established a multicenter, prospective cohort to better understand this disease. Purpose: To provide a baseline report of the ROCK multicenter prospective cohort and present a descriptive analysis of baseline data for patient characteristics, lesion characteristics, and clinical findings of the first 1000 cases enrolled into the prospective cohort. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Patients were recruited from centers throughout the United States. Baseline data were obtained for patient characteristics, sports participation, patient-reported measures of functional capabilities and limitations, physical examination, diagnostic imaging results, and initial treatment plan. Descriptive statistics were completed for all outcomes of interest. Results: As of November 2020, a total of 27 orthopaedic surgeons from 17 institutions had enrolled 1004 knees with OCD, representing 903 patients (68.9% males; median age, 13.1 years; range, 6.3-25.4 years), into the prospective cohort. Lesions were located on the medial femoral condyle (66.2%), lateral femoral condyle (18.1%), trochlea (9.5%), patella (6.0%), and tibial plateau (0.2%). Most cases involved multisport athletes (68.1%), with the most common primary sport being basketball for males (27.3% of cases) and soccer for females (27.6% of cases). The median Pediatric International Knee Documentation Committee (Pedi-IKCD) score was 59.9 (IQR, 45.6-73.9), and the median Pediatric Functional Activity Brief Scale (Pedi-FABS) score was 21.0 (IQR, 5.0-28.0). Initial treatments were surgical intervention (55.4%) and activity restriction (44.0%). When surgery was performed, surgeons deemed the lesion to be stable at intraoperative assessment in 48.1% of cases. Conclusion: The multicenter ROCK group has been able to enroll the largest knee OCD cohort to date. This information is being used to further understand the pathology of OCD, including its cause, associated comorbidities, and initial presentation and symptoms. The cohort having been established is now being followed longitudinally to better define and elucidate the best treatment algorithms based on these presenting signs and symptoms.

Background Shoulder arthroscopy is not common in the pediatric and adolescent population, but the frequency may be on the rise. The purpose of the study was to determine the incidence of acute complications of arthroscopic shoulder surgery in children and adolescents. Methods A retrospective, cross-sectional review was performed identifying patients aged 18 years or less who underwent an arthroscopic shoulder procedure from 1997 to 2009 at Institution 1 and 2007 to 2010 at Institution 2. Exclusion criteria included open procedures and missing records. Demographic and surgical data were collected, including intra-operative and post-operative complications during the first 6 months. The complications were divided into minor (no secondary treatment) and major (secondary treatment rendered). Results Two hundred children, mean age 15.9 years, met criteria and 73 % were boys. All procedures were performed under general anesthesia, but 51 % included inter-scalene regional anesthesia. There were 16 (8.0 %) total complications recorded. Major complications occurred in five (2.5 %) patients, including two tendinitis/bursitis requiring injections, one broken pain pump catheter requiring an accessory incision to retrieve, one pain control readmission, and one laceration of the cephalic vein requiring ligation. Minor complications occurred in 11 (5.5 %) patients, including allergic reactions, transient dysesthesias, headaches, bronchitis, syncope, transient hypotension, and uvula swelling. Conclusion Although we found no seriously deleterious outcomes, it is important to recognize that an additional service was rendered for 2.5 % of children undergoing shoulder arthroscopy. The events that did occur may be preventable and this study should serve as a baseline to improve quality and safety of shoulder arthroscopy in the pediatric population.