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Arthroscopy : the Journal of... Jun 2021The purpose of this review was to systematically examine the literature surrounding elbow arthroscopy for pediatric patients and to assess indications, functional... (Review)
Review
PURPOSE
The purpose of this review was to systematically examine the literature surrounding elbow arthroscopy for pediatric patients and to assess indications, functional outcomes, and complication rates.
METHODS
This systematic review was carried out in accordance with PRISMA guidelines. EMBASE, PubMed, and MEDLINE were searched for relevant literature from inception until December 2019, and studies were screened by 2 reviewers independently and in duplicate for those investigating elbow arthroscopy in a pediatric population (<18 years). Editorials, review articles, and case reports were excluded. Demographic data and data on surgical indications, treatment outcomes, and complications were recorded. A methodological quality assessment was performed for all included studies using the Methodological Index for Non-Randomized Studies.
RESULTS
Overall, 19 studies, all of level IV evidence, were identified with a total of 492 patients (513 elbows). The patient population was 22.3% female with a mean age of 14.0 years (range, 4.0-15.7) and a mean follow-up time of 33.0 months (range, 7.4-96 months). Twelve studies (263 patients) exclusively recruited patients with osteochondritis dissecans (OCD), although other indications for elbow arthroscopy included arthrofibrosis (50 patients), elbow fracture (37 patients), medial ulnar collateral ligament injury (31 patients), and posterior impingement (17 patients). All 13 reporting studies showed a significant improvement in the elbow flexion-extension arc, and 4 of 5 that reported a functional outcome score before and after surgery demonstrating a significant improvement. Last, the overall complication rates ranged from 0% to 23.8%, with a total of 8 instances of neurological injury (5 ulnar, 2 radial, 1 unspecified), all being transient and resolving within 3 to 6 months.
CONCLUSION
Although elbow arthroscopy is primarily being performed for OCD in children and adolescents, there is evidence surrounding several other potential indications. Case series published to date have demonstrated significant improvements in functional outcomes and low rates of major complications.
LEVEL OF EVIDENCE
Level IV, systematic review of level IV studies.
Topics: Adolescent; Arthroscopy; Child; Collateral Ligament, Ulnar; Elbow; Elbow Joint; Female; Humans; Infant; Male; Osteochondritis Dissecans; Range of Motion, Articular; Treatment Outcome
PubMed: 33539972
DOI: 10.1016/j.arthro.2021.01.047 -
Knee Surgery, Sports Traumatology,... Sep 2021The current systematic review and meta-analysis aim to pool together the incidence and risk factors of osteoarthritis following osteochondritis dissecans of the knee. (Meta-Analysis)
Meta-Analysis Review
PURPOSE
The current systematic review and meta-analysis aim to pool together the incidence and risk factors of osteoarthritis following osteochondritis dissecans of the knee.
METHODS
The systematic review was conducted according to PRISMA guidelines. A search was conducted using PubMed and Cochrane Library with the keywords being "knee" and "osteochondritis dissecans" or "osteochondral lesion". All original human studies that reported the incidence or risk factors of osteoarthritis following osteochondritis dissecans of the knee were included.
RESULTS
Nine studies with 496 patients were included. The incidence of osteoarthritis following osteochondritis dissecans is 0.39 (95% CI 0.19-0.59). Patients with a body mass index greater than 25 kg/m had a significantly increased risk of osteoarthritis. Fragment excision had an increased relative risk of 1.89 (95% CI 1.19-3.01) of osteoarthritis as compared to fragment preservation. Significant heterogeneity was identified when comparing between juvenile and adult osteochondritis dissecans. The size of the lesions moderated the between-study heterogeneity with regards to the incidence of osteoarthritis, with the relative risk of osteoarthritis in lesions bigger than 4 cm being 2.29 (95% CI 1.24-4.23). No other risk factors, including gender of the patient, location of osteochondritis dissecans, stability of osteochondritis dissecans, and surgical versus non-surgical management were significant risk factors.
CONCLUSION
Significant risk factors for osteoarthritis were increased body mass index and fragment excision. Probable but inconclusive risk factors were the age of the patients and the size of the osteochondritis dissecans. The gender of the patient, location of osteochondritis dissecans, the stability of osteochondritis dissecans, and surgical versus non-surgical management of osteochondritis dissecans when appropriate were not significant risk factors.
Topics: Adult; Humans; Incidence; Knee Joint; Osteoarthritis, Knee; Osteochondritis Dissecans; Risk Factors
PubMed: 33211214
DOI: 10.1007/s00167-020-06365-y -
Arthroscopy, Sports Medicine, and... Oct 2020The purpose of this study is to identify and summarize the current utility of intraoperative ultrasound (US) during hip arthroscopy. (Review)
Review
PURPOSE
The purpose of this study is to identify and summarize the current utility of intraoperative ultrasound (US) during hip arthroscopy.
METHODS
A systematic database query of the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, EMBASE, PubMed (1980 to 2019), and Ovid MEDLINE (1980 to 2019) was performed. After article identification, descriptions of the surgical procedure, use of intraoperative US, procedural complications, and conclusions from each article were recorded and summarized.
RESULTS
Five studies met inclusion criteria, all of which were surgical techniques or technical notes. Four of the 5 studies described US used for placement of arthroscopic portals, and 1 described the use of an intraarticular US catheter for the assessment of an osteochondritis dissecans (OCD) lesion. Of the 4 studies using US for portal placement, 3 were performed supine and 1 was performed in the lateral decubitus position. All studies recognized the need for additional US training or the required assistance of a radiologist to incorporate US into a surgical practice.
CONCLUSION
Descriptions of intraoperative US during hip arthroscopy are limited in the literature. However, existing technique reports demonstrate the feasibility of US for both portal placement with superficial probes and limited evaluation of cartilage using intraarticular US catheters.
LEVEL OF EVIDENCE
V, systematic review.
PubMed: 33135007
DOI: 10.1016/j.asmr.2020.06.001 -
Arthroscopy : the Journal of... Jun 2020To systematically evaluate the outcomes and complications of osteochondral autograft transfer (OAT) and osteochondral allograft transplantation (OCA) for the surgical...
PURPOSE
To systematically evaluate the outcomes and complications of osteochondral autograft transfer (OAT) and osteochondral allograft transplantation (OCA) for the surgical treatment of capitellar osteochondritis dissecans (OCD).
METHODS
A literature search was conducted across 3 databases (PubMed, Cochrane, and CINAHL [Cumulative Index to Nursing and Allied Health Literature]) from database inception through December 2019 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Individual study quality was assessed using the Methodological Index for Non-randomized Studies scale. Studies were published between 2005 and 2019.
RESULTS
Eighteen studies consisting of 446 elbow OCD lesions treated with OAT surgery were included. There was a single OCA study eligible for inclusion. Patient ages ranged from 10 to 45 years. Of the OAT studies, 4 used autologous costal grafts whereas the remainder used autografts from the knee. Outcome measures were heterogeneously reported. A significant improvement in Timmerman-Andrews scores from preoperatively to postoperatively was reported in 9 of 10 studies. Return-to-play rates to the preinjury level of competitive play ranged from 62% to 100% across 16 studies. Significant improvement in motion, most often extension, was noted in most studies. Reported complication, reoperation, and failure rates ranged from 0% to 11%, 0% to 26%, and 0% to 20%, respectively. When used, knee autografts resulted in low donor-site morbidity (Lysholm scores, 70-100).
CONCLUSIONS
OAT surgery for large, unstable OCD lesions of the capitellum reliably produced good outcomes, few complications, and a high rate of return to competitive play. Complications are relatively uncommon, and donor-site morbidity is low. Less is known about the performance of OCA given the paucity of available literature.
LEVEL OF EVIDENCE
Level IV, systematic review of Level II to IV studies.
Topics: Autografts; Bone Transplantation; Elbow Joint; Humans; Magnetic Resonance Imaging; Orthopedic Procedures; Osteochondritis Dissecans; Plastic Surgery Procedures
PubMed: 32035172
DOI: 10.1016/j.arthro.2020.01.037 -
Arthroscopy : the Journal of... Aug 2019To report the rate of radiographic union, patient-reported outcomes, complications, and reoperations after internal fixation of unstable osteochondritis dissecans (OCD)... (Meta-Analysis)
Meta-Analysis
PURPOSE
To report the rate of radiographic union, patient-reported outcomes, complications, and reoperations after internal fixation of unstable osteochondritis dissecans (OCD) in the skeletally mature knee.
METHODS
A literature search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Patients were included if they were skeletally mature and underwent internal fixation of an unstable OCD lesion of the knee. Risk of bias assessment was performed using the Methodological Index for Non-randomized Studies scoring system. Surgical technique, rate of union, patient-reported outcomes, complications, and reoperations were collected.
RESULTS
Thirteen studies resulted in 148 patients (150 knees) for inclusion. Patient age ranged from 14 to 45 years. Numerous fixation procedures were used, including biodegradable devices (rods, pins, nails, and screws), metal screws, Kirschner wire, and autologous bone sticks. Overall, reported outcome measures were heterogeneous in nature. The rate of radiographic healing ranged from 67% to 100% across 6 studies. Improved subjective results and Hughston criteria on final follow-up ranged from 83% to 100% across 4 studies each. Mean postoperative Lysholm scores ranged from 42 to 98 in studies that reported them. Both complication and reoperation rates ranged from 0% to 44%. The most commonly performed reoperations were loose body excision and cartilage resurfacing procedures.
CONCLUSIONS
A variety of surgical techniques are available for treatment of unstable OCD lesions in the skeletally mature knee. In this systematic review, internal fixation of the native fragment showed acceptable rates of radiographic union and improved patient-reported outcomes relative to other techniques.
LEVEL OF EVIDENCE
Level IV, systematic review of level III-IV studies.
Topics: Bone Nails; Cartilage; Humans; Knee Joint; Orthopedic Procedures; Osteochondritis Dissecans; Patient Reported Outcome Measures; Postoperative Period; Second-Look Surgery
PubMed: 31395194
DOI: 10.1016/j.arthro.2019.03.020 -
The American Journal of Sports Medicine Jan 2020Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well...
BACKGROUND
Multiple knee cartilage defect treatments are available in the United States, although the cost-efficacy of these therapies in various clinical scenarios is not well understood.
PURPOSE/HYPOTHESIS
The purpose was to determine cost-efficacy of cartilage therapies in the United States with available mid- or long-term outcomes data. The authors hypothesized that cartilage treatment strategies currently approved for commercial use in the United States will be cost-effective, as defined by a cost <$50,000 per quality-adjusted life-year over 10 years.
STUDY DESIGN
Systematic review.
METHODS
A systematic search was performed for prospective cartilage treatment outcome studies of therapies commercially available in the United States with minimum 5-year follow-up and report of pre- and posttreatment International Knee Documentation Committee subjective scores. Cost-efficacy over 10 years was determined with Markov modeling and consideration of early reoperation or revision surgery for treatment failure.
RESULTS
Twenty-two studies were included, with available outcomes data on microfracture, osteochondral autograft, osteochondral allograft (OCA), autologous chondrocyte implantation (ACI), and matrix-induced ACI. Mean improvement in International Knee Documentation Committee subjective scores at final follow-up ranged from 17.7 for microfracture of defects >3 cm to 36.0 for OCA of bipolar lesions. Failure rates ranged from <5% for osteochondral autograft for defects requiring 1 or 2 plugs to 46% for OCA of bipolar defects. All treatments were cost-effective over 10 years in the baseline model if costs were increased 50% or if failure rates were increased an additional 15%. However, if efficacy was decreased by a minimum clinically important amount, then ACI (periosteal cover) of femoral condylar lesions ($51,379 per quality-adjusted life-year), OCA of bipolar lesions ($66,255) or the patella ($66,975), and microfracture of defects >3 cm ($127,782) became cost-ineffective over 10 years.
CONCLUSION
Currently employed treatments for knee cartilage defects in the United States are cost-effective in most clinically acceptable applications. Microfracture is not a cost-effective initial treatment of defects >3 cm. OCA transplantation of the patella or bipolar lesions is potentially cost-ineffective and should be used judiciously.
Topics: Cartilage; Cartilage Diseases; Cost-Benefit Analysis; Humans; Knee Joint; Orthopedic Procedures; Patella; Reoperation; Treatment Outcome; United States
PubMed: 31038980
DOI: 10.1177/0363546519834557 -
AJR. American Journal of Roentgenology Jul 2019The purpose of this study is to perform a systematic review and meta-analysis to estimate the clinical value of MRI in assessing the stability of osteochondritis...
The purpose of this study is to perform a systematic review and meta-analysis to estimate the clinical value of MRI in assessing the stability of osteochondritis dissecans (OCD) lesions. A systematic review of the literature published from January 1995 to July 2018 was performed by two independent reviewers using predefined search terms. The reference standard was established as arthroscopy or open surgery. True- and false-positive results as well as true- and false-negative results were counted. The quality of the selected studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooling of diagnostic accuracy, subgroup analysis, and identification of publication bias were included. Sixteen studies were included in the general data pooling. The pooled sensitivity and specificity were 0.92 (95% CI, 0.87-0.95; = 0.55) and 0.85 (95% CI, 0.64-0.95; = 0.88), respectively. The pooled sensitivity and specificity for juvenile OCD lesions were 0.93 (95% CI, 0.82-0.97) and 0.68 (95% CI, 0.41-0.86), respectively. Subgroup analysis showed that the staging system of Dipaola and colleagues and the criteria of De Smet and colleagues had a significant independent association with sensitivity. There was no evidence of publication bias ( = 0.57). The current meta-analysis suggested that MRI has a high diagnostic value for assessing the stability of OCD lesions. However, the MRI criteria applied for adult OCD lesions do not perform well in predicting stability of juvenile OCD lesions. Although some new juvenile OCD-specific MRI criteria yielding a satisfactory outcome have been proposed, further investigations are warranted.
PubMed: 30995094
DOI: 10.2214/AJR.18.20710 -
Orthopaedic Journal of Sports Medicine Feb 2019Osteochondritis dissecans (OCD) of the capitellum is an increasingly recognized disease affecting young athletes. Because lesion progression is common, early... (Review)
Review
Predictive Role of Symptom Duration Before the Initial Clinical Presentation of Adolescents With Capitellar Osteochondritis Dissecans on Preoperative and Postoperative Measures: A Systematic Review.
BACKGROUND
Osteochondritis dissecans (OCD) of the capitellum is an increasingly recognized disease affecting young athletes. Because lesion progression is common, early identification is potentially beneficial for an athlete's treatment and recovery. However, there is currently no analysis available that evaluates the impact of symptom duration on preoperative and postoperative outcomes.
PURPOSE/HYPOTHESIS
The purpose of this study was to perform a systematic review of surgically treated OCD lesions to examine the effect of symptom duration before the initial presentation on preoperative and postoperative outcomes. We hypothesized that a longer symptom duration would correlate with more severe preoperative signs and symptoms and poorer postoperative outcomes.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
Ovid MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects were queried for studies evaluating symptom duration before the clinical presentation of capitellar OCD and surgical outcomes. A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
RESULTS
A total of 23 studies reporting outcomes in 258 patients (mean patient age, 14.4 ± 1.5 years) were analyzed. Locking as a chief complaint predominated in a greater proportion of patients who presented with a longer history of OCD symptoms ( = .007). A longer symptom duration also correlated with a longer time to return to sport ( = .008) and older age ( < .001). Range of motion limitations as both a chief complaint and a physical examination finding correlated with a longer symptom duration ( = .014 and .001, respectively). Symptom duration did not show a relationship with most postoperative outcomes, including the return-to-sport rate ( = .172), which ranged from 70.7% to 91.1% depending on the surgical procedure performed. No significant difference was observed between symptom duration and the surgical procedure performed ( = .376).
CONCLUSION
Advanced OCD lesions were observed in patients with a longer symptom duration. However, treatment specifics rather than symptom duration correlated best with return to sport for patients with advanced OCD lesions requiring surgery. The earlier detection of capitellar OCD may be valuable in reducing the severity of lesions, the time to return to sport, and potential need for surgery in young athletes.
PubMed: 30800689
DOI: 10.1177/2325967118825059 -
The Journal of Knee Surgery Nov 2019We sought to evaluate the effectiveness of autologous chondrocyte implantation (ACI) for the treatment of adult osteochondritis dissecans (OCD) lesions according to...
We sought to evaluate the effectiveness of autologous chondrocyte implantation (ACI) for the treatment of adult osteochondritis dissecans (OCD) lesions according to patient-reported outcomes, complication rates, and failure rates. A search of MEDLINE, Scopus, and Cochrane Library was performed to identify clinical studies (levels I-IV) reporting outcomes after ACI treatment for OCD in adult knees. Our inclusion criteria included the following: (1) published between January 2000 and April 2017, (2) stable and unstable OCD lesions of the knee, (3) use of ACI in at least one group, (4) subjects ≥18 years old or skeletally mature, (5) inclusion of at least one patient-reported clinical outcome measure, and (6) written in English. A total of nine studies (179 patients), mean age of 27.6 years (range: 18-49 years), were included. There were 227 OCD lesions with an average size of 4.1 cm (range: 1.2-9.4 cm). The average follow-up was 61.3 months (range: 6.5-120 months). In general, there was significant improvement in symptoms, but better results occurred among active male patients with smaller lesions as well as younger patients. Statistically significant improvement in patient-reported outcomes was reported in all studies. There were 23 complications reported (15.6%), including 12 failures (8.2%). Significant improvement in clinical outcome measures demonstrates clinical efficacy of autologous cartilage therapies for the treatment of OCD in adult patients. Better outcomes are often observed with males, active patients, smaller lesion sizes, and younger age at the time of surgery.
Topics: Adolescent; Adult; Cartilage; Female; Humans; Knee Joint; Male; Middle Aged; Orthopedic Procedures; Osteochondritis Dissecans; Patient Reported Outcome Measures; Transplantation, Autologous; Treatment Outcome; Young Adult
PubMed: 30396204
DOI: 10.1055/s-0038-1675568 -
Cartilage Jul 2020The purpose of this manuscript is to analyze the evidence regarding etiopathogenesis of knee osteochondritis dissecans (OCD) lesions through a systematic review, so to...
OBJECTIVE
The purpose of this manuscript is to analyze the evidence regarding etiopathogenesis of knee osteochondritis dissecans (OCD) lesions through a systematic review, so to summate the current understanding of the origin and progression of this pathologic articular processes.
DESIGN
A systematic review of the literature was performed on the PubMed and Cochrane databases on October 2017 by 2 independent authors and included all levels of evidence. This included all English language literature, pertaining specifically to etiopathology of knee OCD with exclusions for review articles and expert opinion. Of 965 identified records, 154 full-text articles were assessed for eligibility and 86 studies met the inclusion criteria.
RESULTS
According to these studies, the etiology of OCD can be of a biological or mechanical origin: 40 articles proposed a biological hypothesis, including genetic causes (27), ossification center deficit (12), and endocrine disorders (9); conversely, 52 articles supported a mechanical hypothesis, including injury/overuse (18), tibial spine impingement (5), discoid meniscus (16), and biomechanical alterations (20) as the cause of the onset of OCD. The pathogenic processes were investigated by 36 of these articles, with a focus on subchondral bone fracture and ischemia as the ultimate events leading to OCD.
CONCLUSIONS
Biological and mechanical factors are found to result in subchondral bone remodeling alterations, acting independently or more likely synergically in the progression of knee OCD. The former includes genetic causes, deficit of ossification centers and endocrine disorders; the latter, tibial spine impingement, discoid meniscus, and biomechanical alterations, together with injuries and overuse. The resultant subchondral bone ischemia and/or fracturing appears to determine the onset and progression of OCD.
LEVEL OF EVIDENCE
Systematic review of level II-IV studies, level IV.
Topics: Adolescent; Biomechanical Phenomena; Bone Remodeling; Cartilage, Articular; Causality; Child; Cumulative Trauma Disorders; Female; Humans; Knee; Knee Injuries; Knee Joint; Male; Menisci, Tibial; Osteochondritis Dissecans; Tibia; Young Adult
PubMed: 29998741
DOI: 10.1177/1947603518786557