Nonoperative treatment for first-time patellofemoral dislocation resulted in a 62% success rate. However, skeletally immature patients with trochlear dysplasia had only a 31% success rate with nonoperative management. Nearly half of patients with recurrent instability required surgical intervention to gain stability.

Patellofemoral instability is a complex problem, which can be difficult to manage. The purpose of this study was to describe the demographics of patients with a first-time patellofemoral dislocation, and identify risk factors for recurrent instability. This was a single institution, institutional review board-approved, retrospective review of >2,000 patients with a patellar dislocation between 1998 and 2010. Inclusion criteria are as follows: (1) no prior history of patellofemoral subluxation or dislocation of the affected knee; (2) X-rays within 4 weeks of the initial instability episode; and (3) a dislocated patella requiring reduction, or history/findings suggestive of acute patellar dislocation (effusion/hemarthrosis, tenderness along the medial parapatellar structures, and apprehension with lateral patellar translation). Clinical records and radiographs were reviewed. The Caton-Deschamps and Insall-Salvati indices were used to evaluate patella alta. Trochlear dysplasia was assessed using the Dejour classification system. Skeletal maturity was graded based on the distal femoral and proximal tibial physes, using one of the following categories: open, closing, or closed. Three hundred twenty-six knees (312 patients) met the aforementioned criteria. There were 145 females (46.5%) and 167 males (53.5%), with an average age of 19.6 years (range, 9-62 years). Thirty-five patients (10.7%) were treated with surgery after the initial dislocation. All others were initially managed nonoperatively. Of the 291 patients managed nonoperatively, 89 (30.6%) had recurrent instability, 44 (49.4%) of which eventually required surgery. Several risk factors for recurrent instability were identified, including younger age (p < 0.01), immature physes (p < 0.01), sports-related injuries (p < 0.01), patella alta (p = 0.02), and trochlear dysplasia (p < 0.01). Sixty-nine percent of patients with a first-time patellofemoral dislocation will stabilize with conservative treatment. However, patients younger than 25 years with trochlear dysplasia have a 60 to 70% risk of recurrence by 5 years. This information is helpful when counseling patients on their risk for recurrent instability and determining the most appropriate treatment plan. The clinical tool shown in Fig. 4 may be especially useful.

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Juvenile osteochondritis dissecans (OCD) lesions of the knee are a common cause of knee pain in skeletally immature patients.The authors sought to determine lesion healing rates, the risk factors associated with failure to heal, and the clinical outcomes for patients who underwent internal fixation for unstable OCD lesions. A retrospective review was conducted of all patients who underwent internal fixation of OCD lesions from 1999 to 2009. Using validated scoring systems, clinical outcome and functional activity were evaluated at the follow-up. The study group comprised 19 patients (20 knees). Mean patient age was 14.5 years (range, 12-17 years). Mean clinical follow-up was 7 years (range, 2-13 years). Mean radiographic follow-up was 2.5 years (range, 0.5-9 years). Fourteen (70%) lesions were grade 3 and 6 (30%) were grade 4. Eleven knees had lateral condyle lesions and 9 had medial lesions. Bioabsorbable fixation was used in 13 knees, metal fixation was used in 5 knees, and 2 knees were fixed with a combination of methods. Osseous integration was evident in 15 (75%) of 20 knees at final follow-up. The 5 unhealed lesions were lateral condylar lesions. Mean Tegner activity scores improved from 3.3 preoperatively to 5.6 at final follow-up. Mean Lysholm and International Knee Documentation Committee scores were 86.8 and 88.7, respectively, at final follow-up. Further operative intervention was required in 11 knees, with 50% of patients undergoing removal of hardware and 15% requiring subsequent osteochondral allograft transplantation. The authors recommend bioabsorbable fixation for symptomatic stable lesions and metal compression screws with staged removal for unstable lesions.

BackgroundAneurysmal bone cysts (ABCs) are a benign aggressive tumor that occurs rarely in the pelvis in the pediatric population. Pelvic ABCs may involve the triradiate cartilage and/or the acetabulum, which increases the technical difficulty of surgical treatment and has potential implications on the growth and development of the hip joint. This study examines the clinical presentation, rate of surgical complications, and recurrence rate, as well as, long-term clinical and functional outcomes of children with pelvic ABCs treated at a single institution by a single treatment modality.MethodsBetween 1988 and 2008, 142 children with histologically confirmed ABCs were treated at our institution. Seventeen (12 %) tumors were located in the pelvis. A total of 13 pelvic ABCs (5 ilium-periacetabular, 4 pubic, 3 ilium-iliac wing, and 1 ischium) were included in this study. There were eight male and five female patients with a mean age of 12.9 years (range 4.1–17.5 years) at the time of surgery. The Toronto Extremity Salvage Score (TESS), the Musculoskeletal Tumor Society 1993 (MSTS’93) score, and the Short Form Health Survey Sf-36 were obtained at a minimum 5-year follow-up in all patients (mean follow-up 11.5 years, range 5.5–19.8 years). The mean age at follow-up was 24.3 years (range 14.6–32.6 years).ResultsAll patients were treated surgically with intralesional curettage extended with a high-speed burr and bone grafting. Eight patients received adjunctive therapy with phenol. Five patients had preoperative selective arterial embolization. Of the 13 patients, 1 had a local recurrence diagnosed at 6 months after surgery. The only complication in the cohort was a superficial wound infection. At the latest follow-up, all patients were free of disease. The mean TESS score was 95 and the mean MSTS’93 score was 93 %. The mean self-rated general health score, according to the SF-36 was 87 % of total points possible.ConclusionsExtended curettage and bone grafting of pelvic ABCs in the pediatric population can yield high clinical and functional scores at an average of 11 years follow-up with a low rate of complications and recurrence.Level of evidenceIV, case series.