Dr. Robert Fullick investigated three conservative treatments for juvenile osteochondritis dissecans (OCD) lesions of the knee. He noted that there is little consensus regarding the optimal non-operative treatment of this pathology. Dr. Fullick conducted a retrospective study examining 103 skeletally immature patients (112 knees) who presented with a stable OCD lesion of the knee. Patients were treated conservatively with 1) physical therapy and activity modification, 2) unloader bracing and physical therapy, or 3) casting followed by physical therapy. He found that overall 62.5% (70 lesions) were considered healed after conservative treatment. Healing occurred in twentytwo (59.5%) of thirty-seven lesions treated with physical therapy and activity modification, thirty-two (71%) of forty-five lesions treated with unloader bracing and physical therapy, and sixteen (53%) of thirty lesions treated with casting. Dr. Fullick found no significant difference in healing rates between treatment groups, however bracing plus physical therapy showed a trend towards improved healing rates. Bivariate analysis demonstrated that younger age, smaller lesion size, and shorter duration of symptoms at presentation were significantly predictive of successful conservative treatment. He found that less than two-thirds of stable knee OCD lesions healed when treated conservatively. Dr. Fullick concluded that while there is no significant difference in healing rates between the three types of conservative treatment examined, patients treated with bracing plus physical therapy showed a trend towards improved healing rates. Dr. Kramer commented that this study demonstrates the power of collaboration between Boston and Philadelphia.

Dr. John Kwon described a novel technique for studying injury mechanisms using in-vivo injury videos obtained from Youtube.com and presented the results of a case series using this methodology as it pertains to ankle fractures. His study inclusion criteria included 1) video demonstrating clear visualization of the mechanism of injury including foot position and deforming force, 2) candidates who sustained a fracture or dislocation, and 3) x-rays of adequate quality revealing a fracture of the ankle. Four reviewers classified each video. After the videos and radiographs were independently classified according to the Lauge-Hansen fracture classification, each participant’s video and radiograph was examined together for correlation between mechanism of injury and expected fracture pattern. 15 videos with corresponding radiographs were reviewed. Eight had supination/adduction (SAD) deforming trauma, and seven had pronation/external rotation (PER) deforming trauma as appreciated in the videos. Injuries occurred as the result of skateboarding (n=8), bicycling (n=2), wrestling (n=2), martial arts (n=2) and trampoline injury (n=1). One study participant demonstrated a likely subtalar dislocation with an SAD mechanism of injury but without fracture or dislocation. When assessing ankle fractures, all five fractures judged by video to be SAD injuries resulted in corresponding SAD pattern radiographic ankle fractures. Of the seven fractures judged by video to be PER injuries, only two resulted in PER pattern radiographic ankle fractures. Five PER injuries resulted in supination/ external rotation (SER) ankle fracture patterns. Dr. Kwon concluded that Lauge-Hansen’s mechanistic classification may not consistently produce the radiographic fracture pattern predicted for a given injury mechanism in actual patients sustaining live injuries. He has also developed a flexible and valuable methodology for studying injury mechanisms, one with a wide array of potential future applications. Future direction includes continued recruitment to statistically assess the validity of the Lauge-Hansen classification as applied to in-vivo injuries and use of this methodology to study other injury mechanisms. Dr. Chiodo applauded Dr. Kwon’s hard work and perseverance in overcoming numerous obstacles to introduce a valuable new tool in the study of orthopaedic trauma.

Dr. Babajide Ogunseinde presented a study comparing the functional outcomes of staged and unstaged treatment of pilon fractures managed at a level one trauma center. He noted that high-energy pilon fractures are complex injuries requiring special consideration of soft tissue management and timing of fixation. To study these complex injuries, Dr. Ogunseinde conducted a retrospective cohort analysis of 72 patients treated for pilon fractures between 2004 and 2008 and examined rate of complication, nonunion, infection, and revision surgery. Average follow-up was 22 months (range 12-42 months). Fifty-one (70%) of the seventy-two patients underwent staged treatment with an external fixator. Average healing time for all patients regardless of treatment modality was 5.2 months. Healing time was highest for AO/OTA C3 fractures (6.4 months) and lowest with staged AO/OTA type B2/3 fractures (4.0) months. He found six nonunions in the staged group, three of which were open fractures at presentation. All nonunions required revision surgery with bone grafting, and all subsequently went on to union. Fifteen patients had delayed union, defined as fracture healing greater than six months. The visual analog scale (VAS) score rating pain was similar for both unstaged and staged groups. There was a trend towards higher rate of infection in the unstaged group which did not reach statistical significance. However, when deep infections were isolated, there was a statistically significantly increased rate of deep infections in the unstaged group. There were no differences between groups when comparing satisfaction with treatment. Dr. Ogunseinde concluded that both staged and unstaged treatment of pilon fractures results in good functional outcomes but with a higher rate of deep infection in the unstaged group.