Predicting Outcomes of Talar Osteochondritis Dissecans Lesions in Children

Background: Reports detailing the rates of radiographic healing after treatment of talar osteochondritis dissecans (TOCD) remain scarce. There is also a paucity of data characterizing treatment outcomes and the risk factors associated with poor outcomes in children with TOCD. Purpose: To identify factors associated with healing, assess treatment outcomes, and develop a clinically useful nomogram for predicting healing of TOCD in children. Study Design: Case-control study; Level of evidence, 3. Methods: This was a retrospective review of all patients ≤18 years of age with TOCD from a single pediatric institution over a 12-year period. Surgical treatment was left to the discretion of the treating surgeon based on standard treatment techniques. Medical records and radiographs were reviewed for patient and clinical data, lesion characteristics, and skeletal maturity. Radiographic healing was evaluated at the 1-year follow-up, and patients with complete versus incomplete healing were compared using multivariable logistic regression models to examine the predictive value of the variables. Results: The authors analyzed 92 lesions in 74 patients (mean age, 13.1 ± 2.7 years [range, 7.1-18.0 years]; 61% female). Of these, 58 (63%) lesions were treated surgically (drilling, debridement, microfracture, bone grafting, or loose body removal), and the rest were treated nonoperatively. Complete radiographic healing was seen in 43 (47%) lesions. In bivariate analysis, patients with complete healing were younger ( P = .006), were skeletally immature ( P = .013), and had a lower body mass index (BMI; P < .001) versus those with incomplete healing. In a multivariate regression model, the factors that correlated significantly with the rate of complete healing were age at diagnosis, BMI, and initial surgical treatment. The lesion dimensions were not significantly associated with the likelihood of healing. A nomogram was developed using the independent variables that correlated significantly with the likelihood of complete radiographic healing. Conclusion: Complete radiographic healing of TOCD lesions was more likely in younger patients with a lower BMI. The effect of initial surgical treatment on potential healing rate was greater in older patients with a higher BMI.

Patellofemoral Instability

Recurrent patellofemoral instability is a common cause of knee pain and functional disability in adolescent and young adult patients, resulting in loss of time from work and sports. There are numerous factors that contribute to recurrent patellofemoral instability; these factors include tear of the medial patellofemoral ligament (MPFL), weakening or hypoplasia of the vastus medialis obliquus (VMO), trochlear dysplasia, increased tibial tuberosity-trochlear groove (TT-TG) distance (>20 mm), valgus malalignment, increased Q angle, malrotation secondary to internal femoral or external tibial torsion, patella alta, and generalized ligamentous laxity. A detailed history and a thorough physical examination are crucial to clinch an early, accurate diagnosis. Imaging studies play an important role to confirm the clinical diagnosis and also help to identify concomitant intra-articular pathologies. Initially, nonoperative management (including the use of physical therapy, patellar taping or brace) is offered to patients with acute, first-time patellar dislocations and most patients respond well to this mode of treatment. Surgical treatment is indicated for patients who have post-trauma osteochondral fracture or loose body; predisposing anatomical risk factors; recurrent, symptomatic instability; and who have failed an adequate trial of nonoperative management. Surgical treatments include MPFL reconstruction, proximal or distal realignment procedures, and trochleoplasty. Lateral release is often performed in combination with other procedures and seldom performed as an isolated procedure. An individualized case-by-case approach is recommended based on the underlying anatomical risk factors and radiographic abnormality.

Assessment and Management of Loose Bodies in the Knee Joint and Related Disease: A Narrative Review

Background: Loose bodies are frequently encountered during clinical activity and a common finding during knee arthroscopy. Usually, treatment consists of the removal of the loose bodies, which can be challenging even for experienced surgeons. The excision alone is not always the complete treatment, because loose bodies are generally secondary to other diseases that can cause persistent symptoms with the risk of new loose body formation. The aim of this narrative review is to show the clinical, imaging and arthroscopic evaluation of loose bodies in order to plan optimal treatment. Methods: A comprehensive search of PubMed was conducted to find the most recent and relevant studies investigating the aetiopathogenesis, the assessment tools and the therapeutic strategies for knee loose bodies and their related diseases. Results: When dealing with a loose body, the first issue is the evaluation of the intra-articular fragment (location, size, number, symptoms) and its aetiopathogenesis by identifying the underlying pathology (e.g., osteochondritis dissecans, osteoarthritis, chondral defect, tumour-like lesions, rheumatoid arthritis, etc.). In the case of symptomatic intra-articular loose bodies, treatment consists of fragment removal and the management of related diseases (e.g., lifestyle modification, physiotherapy, pharmacological and surgical treatment). Conclusion: Loose bodies are not separate entities and in addition to their pathological aspect, must be evaluated within the context of the underlying disease. Correct assessment and comprehensive management allow for relief of symptomatology and prevention of loose body formation by removal and treatment of the associated diseases.

A Rare Case of Bilobed Giant Peritoneal Loose Body

A 50-year-old male patient was referred to Department of Radiodiagnosis for evaluation of a longstanding intermittent abdominal pain associated with a palpable mass migrating in different quadrants of the abdomen and had gradually increased in size over last few years. The initial ultrasonographic (USG) evaluation revealed a well circumscribed bilobed hypoechoic pelvic solid space occupying lesion (SOL) with central calcific foci. Subsequent contrast enhanced computed tomography (CECT) imaging showed a 10.1 x 7.5 x 5.8 cm, bilobed non-enhancing pelvic mass with central dense calcific foci and concentric soft tissue layers of different attenuation. The mass was diagnosed to be a giant peritoneal loose body (gPLB) and confirmed by surgical exploration.

Management of Neglected Peroneal Tendon Dislocation of Iatrogenic Etiology: A Case Report

Introduction:Neglected peroneal tendon dislocation with iatrogenic etiology has been rarely reported in the literature and its management has not been fully understood to date. Case Report:We present a case of a 25-year-old male who presented with pain over the posterolateral aspect of his left ankle which was diagnosed to be a case of neglected peroneal tendon dislocation of iatrogenic etiology. Peroneal groove deepening with superior retinaculum repair was done in the patient along with loose body removal and osteophyte excision. Subsequent fibrosis augmented with the deepening of the groove maintained peroneal tendon position in the retromalleolar groove. On post-operative follow-up, the patient was completely satisfied with relief of pain and no complications. He also regained full range of motion and could walk without support. Conclusion:Surgical intervention of fibular groove deepening with superior peroneal retinaculum reconstruction results in an excellent outcome for neglected peroneal tendon dislocation Keywords:Peroneal tendon, Superior peroneal retinaculum, Fibular groove.

Spatial distribution characteristics of loose bodies in Huaishu River levee and their influence on seepage field

At present, many levees contain a large number of loose bodies as a result of poor-quality construction, biological damage, and other factors. In this context, loose bodies refer to soil with a relative density less than a specified value. Taking the Huaishu River levee in China as an example, this paper studies the distribution characteristics of loose bodies in the levee using statistical methods. First, ground-penetrating radar and other geophysical exploration methods are used to investigate loose bodies in the levee. The frequency distribution and Shapiro–Wilk method are then employed to study the distribution characteristics of the area and depth of loose bodies. The influence of loose bodies on the seepage field of the levee is then examined considering the spatial distribution of the loose bodies. It was found that the areas of loose bodies in the western and eastern upstream slope obey a logarithmic normal distribution. In the shallow layer (depth between 0–1 m), loose bodies appear relatively frequently, and the frequency initially increases with depth before decreasing. The maximum hydraulic gradient of the levee initially increases and then decreases as the depth of the loose body increases.

Current practice trends in the surgical management of patellofemoral instability: a survey of the Paediatric Research in Sports Medicine (PRiSM) Society

Purpose Patellofemoral instability (PFI) in young athletes presents both diagnostic and management dilemmas for which consensus often does not exist. The purpose of this study was to identify trends in management of PFI in children and adolescents in the United States and nationwide. Methods A 27-question multiple choice survey was distributed in 2018 to the members of the Pediatric Research in Sports Medicine (PRiSM) Society regarding treatment of PFI in paediatric and adolescent patients. Results In all, 56 of the respondents who were orthopaedic surgeons that manage patellar instability in children and adolescents and had performed PFI surgery more than five times in the past year completed the entire survey. A total of 41% of respondents reported that surgery for fragment refixation or loose body removal was indicated when a loose body or osteochondral fragment was evident, regardless of fragment size. Overall, 74% reported that if surgery was performed for an osteochondral loose body, primary repair (36%) or reconstruction (38%) of medial patellofemoral ligament (MPFL) was also completed. A total of 89% of members reported MPFL reconstruction in the absence of alignment or rotational abnormalities, tibial tubercle lateralization or trochlear dysplasia in skeletally immature patients; 59% reported performing the MPFL reconstruction with hamstring allograft, while 30% prefer autograft (hamstring, quadriceps). For patients with significant trochlear dysplasia, 87% reported no surgical management of trochlea in first-time or in revision surgery. Conclusion There is a lack of consensus regarding optimal diagnostic and treatment algorithms in the management of PFI, however, consistent trends have emerged among paediatric sports medicine surgeons. Level of Evidence Level V – survey of expert opinion and experience