Osteochondritis dissecans of the knee is being seen with increased frequency in pediatric and young adult athletes and is thought to be, in part, owing to earlier and increasingly competitive sports participation. Despite much speculation, the cause of both juvenile and adult osteochondritis dissecans remains unclear. Early recognition is essential. Whereas adult osteochondritis dissecans lesions have a greater propensity to instability, juvenile osteochondritis dissecans lesions are typically stable, and those with an intact articular surface have a potential to heal with nonoperative treatment through cessation of repetitive impact loading. The value of adjunctive immobilization, protected weightbearing, and unloader bracing has not been established. Skeletally immature patients with stable lesions that have not healed with nonoperative treatment should have consideration given to arthroscopic drilling to promote healing before the lesion progresses and requires more involved treatment with a less optimistic prognosis. Magnetic resonance imaging may allow early prediction of lesion healing potential. The majority of adult osteochondritis dissecans cases as well as those skeletally immature patients with unstable lesions and secondary loose bodies require fixation and possible bone grafting. Many unstable lesions will heal after stabilization, but long-term prognosis is not clear. Chronic loose fragments can be difficult to fix and have poor healing potential. Results of excision of large lesions from weightbearing zones are poor. Chondral resurfacing techniques have limited long-term data for cases of osteochondritis dissecans in skeletally immature patients.

Titanium elastic nailing is used instead of traction and casting in many European centers, but limited availability has prevented widespread use in North America. Before a planned general release in America, titanium elastic nails (TENs) were trialed at several major pediatric trauma centers. This multicenter study is a critical analysis of early results and complications of the initial experience. Overall, TENs allowed rapid mobilization with few complications. The results were excellent or satisfactory in 57 of the 58 cases. No child lost rotational alignment in the postoperative period. Irritation of the soft tissue near the knee by the nail tip occurred in four patients, leading to a deeper infection in two cases. As indications, implantation technique, and aftercare are refined, TENs may prove to be the ideal implant to stabilize many pediatric femur fractures, avoiding the prolonged immobilization and complications of traction and spica casting.

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Level III, Retrospective Comparative Study.

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Between 1996 and 2003 six institutions in the United States and France contributed a consecutive series of 234 fractures of the femur in 229 children which were treated by titanium elastic nailing. Minor or major complications occurred in 80 fractures. Full information was available concerning 230 fractures, of which the outcome was excellent in 150 (65%), satisfactory in 57 (25%), and poor in 23 (10%). Poor outcomes were due to leg-length discrepancy in five fractures, unacceptable angulation in 17, and failure of fixation in one. There was a statistically significant relationship (p = 0.003) between age and outcome, and the odds ratio for poor outcome was 3.86 for children aged 11 years and older compared with those below this age. The difference between the weight of children with a poor outcome and those with an excellent or satisfactory outcome was statistically significant (54 kg vs 39 kg; p = 0.003). A poor outcome was five times more likely in children who weighed more than 49 kg.

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This study underscores the advantage of monitoring the spinal cord motor tracts directly by recording transcranial electric motor evoked potentials in addition to somatosensory evoked potentials. Transcranial electric motor evoked potentials are exquisitely sensitive to altered spinal cord blood flow due to either hypotension or a vascular insult. Moreover, changes in transcranial electric motor evoked potentials are detected earlier than are changes in somatosensory evoked potentials, thereby facilitating more rapid identification of impending spinal cord injury.