Arthroscopic technique for fragment fixation using absorbable pins for osteochondritis dissecans of the humeral capitellum: a report of 4 cases

Osteochondritis Dissecans of the Elbow in Overhead Athletes: A Comprehensive Narrative Review

Osteochondritis dissecans (OCD) of the elbow mainly occurs in overhead athletes (OHAs). This narrative review aimed to comprehensively analyze the epidemiological data, etiological factors, clinical and imaging features, treatment options, and outcomes of OHAs with the diagnosis of elbow OCD. A literature search was performed in PubMed/MEDLINE, Scopus, and Web of Science. Individuals with elbow OCD were usually 10-17 years of age with incidence and prevalence varying between studies, depending on the sport activity of the patients. The etiology of OCD lesions is multifactorial, and the main causes are believed to be repetitive trauma, the biomechanical disproportion of the articular surfaces, poor capitellar vascular supply, and inflammatory and genetic factors. Athletes usually presented with elbow pain and mechanical symptoms. The mainstay for the diagnosis of elbow OCD is MRI. The treatment of elbow OCD lesions should be conservative in cases of stable lesions, while various types of surgical treatment are suggested in unstable lesions, depending mainly on the size and localization of the lesion. The awareness of medical practitioners and the timely diagnosis of OCD lesions in OHAs are key to favorable outcomes.

Surgical approaches to the capitellum: a comparative anatomic study

BACKGROUND

Osteochondritis dissecans (OCD) of the humeral capitellum is an important cause of elbow disability in young athletes. Large and unstable lesions sometimes require joint reconstruction with osteochondral autograft. Several approaches have been described to expose the capitellum for the purpose of treating OCD. The posterior anconeus-splitting approach and the lateral approach with or without release of the lateral ligamentous complex are the most frequently used for this indication. The surface accessible by these approaches has not been widely studied. This study compared the extent of the articular surface of the capitellum that could be exposed with the Kocher approach (without ligament release) vs. the posterior anconeus-splitting approach. A secondary outcome was the measurement of any additional area that could be reached with lateral ulnar collateral ligament release (Wrightington approach).

METHODS

The 3 approaches were performed on 8 adult cadaveric elbows: first, the Kocher approach; then, the anconeus-splitting approach; and finally, the Wrightington approach. The visible articular surface was marked out after completion of each approach.

RESULTS

The mean articular surface of the capitellum was 708 mm2 (range, 573-830 mm2). The mean visible articular surface was 49% (range, 43%-60%) of the total surface with the Kocher approach, 74% (range, 61%-90%) with the posterior anconeus-splitting approach, and 93% (range, 91%-97%) with the Wrightington approach. Although the Kocher approach provided access to the anterior part of the capitellum, the anconeus-splitting approach showed adequate exposure to the posterior three-quarters of the articular surface and overlapped the most posterior part of the Kocher approach. A combination of the 2 lateral ulnar collateral ligament-preserving approaches allowed access to 100% of the joint surface.

CONCLUSION

Most OCD lesions are located in the posterior area of the capitellum and can therefore be reached with the anconeus-splitting approach. When OCD lesions are located anteriorly, the Kocher approach without ligament release is efficient. A combination of these 2 approaches enabled the entirety of the joint surface to be viewed.

Evaluation of Osteochondritis Dissecans Treatment with Bioabsorbable Implants in Children and Adolescents

(1) Background: This is the first systematic review concerning the treatment of osteochondritis dissecans with the use of bioabsorbable implants. The study was done as a comprehensive review to identify important factors affecting the results of OCD treatment in children and adolescents; (2) Methods: We searched electronic bibliographic databases including PubMed, Cochrane Library, Scopus, and Web of Knowledge until May 2022. This systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and PICO (Patients, Interventions, Comparisons, Outcomes) guidelines; (3) Results: We identified 2662 original papers of which 11 were found to be eligible for further analysis. The study group included a total of 164 OCD lesions in 158 patients. In 94.86% of postoperative cases, there was complete healing or local improvement on follow-up CT or MRI scans. The great majority of patients achieved a good clinical effect. Out of 164 OCD lesions, 10 did not heal (6.09%); (4) Conclusions: Surgical treatment of stable and unstable OCD in children with the use of bioabsorbable implants facilitates a high rate of healing and a good clinical outcome; treatment of juvenile OCD is associated with a better outcome compared to adult OCD; the use of bioabsorbable implants for the treatment of humeral capitellum OCD is associated with a more frequent incidence of synovitis (18.2%).

Evaluation and management of elbow injuries in the adolescent overhead athlete

With an increased interest in youth sports, the burden of overhead throwing elbow injuries accompanying early single-sport focus has steadily risen. During the overhead throwing motion, valgus torque can reach and surpass Newton meters (N m) during the late cocking and early acceleration phases, which exceeds the tensile strength (22.7–33 N m) of the ulnar collateral ligament. While the ulnar collateral ligament serves as the primary valgus stabilizer between and degrees of elbow flexion, other structures about the elbow must contribute to stability during throwing. Depending on an athlete’s stage of skeletal maturity, certain patterns of injury are observed with mechanical failures resulting from increased medial laxity, lateral-sided compression, and posterior extension shearing forces. Together, these injury patterns represent a wide range of conditions that arise from valgus extension overload. The purpose of this article is to review common pathologies observed in the adolescent overhead throwing athlete in the context of functional anatomy, osseous development, and throwing mechanics. Operative and non-operative management and their associated outcomes will be discussed for these injuries.

Treatment of osteochondritis dissecans of the humeral capitellum with a fragment fixation method using absorbable pins

Hypothesis

This study aimed to investigate the results, indications, and limitations of absorbable pin fixation for osteochondritis dissecans of the humeral capitellum in the separation stage.

Methods

This study included 35 patients (mean age, 14.0 years). Patients were divided into two groups: Group A included those who obtained complete union within 6 months and Group B included those who did not observe complete union within 6 months. The clinical findings were compared between the groups.

Results

There were 26 and 6 patients in Groups A and B, respectively. Two patients did not obtain complete union. Clinical outcomes improved after the procedure. In univariate analysis, delayed union was associated with larger major diameter (P = .0004) and more depth (P = .03) of the osteochondral fragment measured by computed tomography, the presence of osteosclerosis in the subchondral bed on X-ray imaging (P = .003), and the presence of comminution of subchondral bone on ultrasound imaging (P = .01). In multivariate analysis, there was a significant difference only in the major diameter of the osteochondral fragment (P = .03). Receiver operating characteristic curves analysis shows that if the major diameter of the osteochondral fragment is 11 mm or less, 85% of patients achieve complete union of the osteochondral fragments within 6 months.

Conclusion

Absorbable pin fixation may be considered for the osteochondral fragments with major diameter of 11 mm or less and should not be considered for patients who demonstrate osteosclerosis in the subchondral bed or comminution of subchondral bone.

Long-Term Outcomes of Arthroscopic Debridement With or Without Drilling for Osteochondritis Dissecans of the Capitellum in Adolescent Baseball Players: A ≥10-Year Follow-Up Study

PURPOSE

To evaluate the long-term clinical outcomes of arthroscopic debridement for capitellar osteochondritis dissecans (OCD) in adolescent baseball players.

METHODS

This retrospective study evaluated clinical outcomes of arthroscopic debridement for capitellar OCD in adolescent baseball players seen between 2003 and 2006. Inclusion criteria were at least 10 years of follow-up after surgery. Exclusion criteria were previous elbow surgery and age <12 years or >19 years. Patients were examined for presence of pain, inflammation (effusion), and range of motion. Outcome measures were determined using Timmerman/Andrews scores. Defect severity on preoperative radiographs was classified into 3 grades: small, moderate, and large. Return to baseball, pre- and postoperative range of motion and Timmerman/Andrews elbow score were evaluated according to defect severity.

RESULTS

Twenty-three elbows of 23 baseball players (mean age, 14.7 [range, 13-17] years) underwent arthroscopic debridement for capitellar OCD. Mean follow-up duration was 11.5 (range, 10-13) years. Twenty patients (87%) returned to competitive baseball at their preoperative level; of these, 15 were non-pitchers and returned to the same position but only 1 of 5 pitchers returned to playing pitcher. One patient with a large defect and drilling underwent reoperation 11 years after the initial operation. Mean change in extension was 4.3° and that in flexion was 3.7°. Timmerman/Andrews score improved significantly from 160 (95% confidence interval 146.7-173.3) to 195 (95% confidence interval 185.2-204.8) at the most recent follow-up (P ˂ .0001). Osteochondral defects detected on preoperative radiographs were small in 10 patients, moderate in 7, and large in 6. There was no significant between-group difference in extension, flexion, or Timmerman/Andrews score preoperatively or at the most recent follow-up.

CONCLUSIONS

Arthroscopic debridement with or without drilling allowed return to play in adolescent baseball players for positions other than pitchers. Long-term outcomes are likely durable regardless of lesion size.

LEVEL OF EVIDENCE

Level IV, Case series.

Osteochondritis dissecans lesions of the capitellum in overhead athletes: a review of current evidence and proposed treatment algorithm

PURPOSE OF THE REVIEW

To review the most recent literature on osteochondritis dissecans (OCD) lesions of the capitellum in overhead athletes and describe a treatment algorithm based on current best evidence and surgeon experience.

RECENT FINDINGS

Recent research has included larger cohort studies with longer follow-up as well as quality systematic reviews and meta-analyses. These studies have focused on understanding how lesion characteristics such as size, location, and appearance on advanced imaging can predict treatment success. Current literature continues to support nonoperative management for stable lesions. Operative intervention is generally required for unstable lesions and treatment strategies are largely dictated by lesion size and location: debridement or reparative techniques for small lesions while larger lesions or those in high-stress locations are better served by bone and/or cartilage restoration procedures. There has been a rising interest in the use of allograft materials and cell-based therapies. Overhead athletes are uniquely predisposed to capitellar OCD due to the nature of forces applied to the radiocapitellar joint during repeated activity in the overhead position. Despite improvements in operative techniques, successful use of alternative graft materials, and a better understanding of how lesion characteristics influence results, there is still much to learn about this challenging disorder. Future research should focus on comparing operative techniques, refining their indications, and further developing a reliable treatment algorithm that best serves the overhead athlete.

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 (P = .007). A longer symptom duration also correlated with a longer time to return to sport (P = .008) and older age (P < .001). Range of motion limitations as both a chief complaint and a physical examination finding correlated with a longer symptom duration (P = .014 and .001, respectively). Symptom duration did not show a relationship with most postoperative outcomes, including the return-to-sport rate (P = .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 (P = .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.

Location of Osteochondritis Dissecans Lesions of the Capitellum

PURPOSE

The location of capitellar osteochondritis dissecans (OCD) lesions in the sagittal plane guides the surgical approach, and lesion location in the coronal plane influences surgical management. Although most lesions have been reported to occur between 4 o'clock and 4:30 (120° to 135° anterior to the humerus), some lesions are located elsewhere in the capitellum. The primary aim was to define the region of the capitellum affected by OCD lesions using a novel clock-face localization system.

METHODS

We reviewed 104 magnetic resonance imaging examinations diagnosing a nontraumatic capitellar OCD lesion. In the sagittal plane, lesion margins were recorded as degrees on the capitellum and converted into a clock-face format in which 0° corresponds to 12:00 with the forearm facing to the right. The 0° axis (12-o'clock axis) was defined as a line parallel to the anterior humeral line that intersects the capitellum center. The following coronal measurements were recorded: lesion width, capitellar width, and distance between the lateral capitellum and lateral lesion. Two independent observers took measurements.

RESULTS

In the sagittal plane, average lesion location was 92° to 150° (3:04-5:00, clock face) and ranged from 52.1° to 249.5° (1:44-8:19, clock face). Average lesion dimensions were 10.7 mm (mediolateral width) and 5.2 mm (anteroposterior depth). Interrater reliability was high (intraclass correlation coefficient = 0.98).

CONCLUSIONS

Using a magnetic resonance imaging-based clock-face localization system, we found that capitellar OCD lesions affect a broad region of the capitellum in the sagittal plane.

CLINICAL RELEVANCE

The clock-face localization system allows for precise description of capitellar OCD lesion location, which may facilitate intraoperative decision and longitudinal monitoring.

Elbow Injuries in the Adolescent Thrower

PURPOSE OF REVIEW

With an increasing rate of adolescent elbow injuries, especially in throwing athletes, the purpose of this review is to investigate the current literature regarding the diagnosis, treatment, and non-operative and operative outcomes of medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures.

RECENT FINDINGS

Acceptable outcomes with both non-operative and operative treatments of medial epicondyle fractures have been reported, with surgical indications continuing to evolve. Unstable osteochondritis dissecans lesions, especially in patients with closed growth plates, require operative fixation, and emerging open and arthroscopic techniques including lesion debridement, marrow stimulation, autograft transfer, and allograft transplantation are described with good outcomes. Ulnar collateral repair has emerged as an exciting treatment option for an avulsion of either end of the ligament in young throwing athletes, with faster rehabilitation times than traditional ulnar collateral ligament reconstruction. Olecranon stress fractures are increasing in prevalence, and when a non-operative treatment course is unsuccessful, athletes have a high return-to-play rate after percutaneous cannulated screw placement. With proper indications, non-operative and operative treatment modalities are reported with a high return-to-play and acceptable clinical outcomes for common elbow injuries, including medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures, in adolescent throwing athletes. Further research is needed to better define treatment algorithms, surgical indications, and outcomes.

Early Results of Drilling and/or Microfracture for Grade IV Osteochondritis Dissecans of the Capitellum

BACKGROUND

Surgical treatment is recommended for patients with unstable osteochondritis dissecans (OCD) of the elbow. However, little information is available comparing the anticipated results from the host of techniques. In this investigation, clinical and radiographic resolution as well as return to sports rates were assessed in adolescent patients following loose body (LB) removal and drilling/microfracture of grade IV lesions.

METHODS

We reviewed 21 adolescents treated with LB removal and drilling/microfracture for grade IV elbow OCD. Patients with additional elbow pathology, prior elbow surgery, or <1 year follow-up were excluded. Clinical resolution was defined as resolution of tenderness and radiographic resolution as resolution of edema on magnetic resonance imaging (MRI). Return to sport rates and Timmerman scores were assessed. Mean clinical and MRI follow-up times were 2.2±1.19 and 2.4±1.54 years, respectively. Clinical and radiographic parameters associated with clinical and/or radiographic resolution or return to sports were determined using penalized likelihood logistic regression. Wilcoxon signed-rank tests were used to evaluate the change in range of motion and in Timmerman scores.

RESULTS

Fifteen (71.4%) patients had either clinical or radiographic resolution at most recent follow-up. Nine (50%) had complete resolution on MRI, whereas 13 (61.9%) were nontender at their follow-up. Four patients with recurrent LBs underwent revision surgery. There were no complications in the 21 index procedures. Eighteen (85.7%) patients returned to any sport, whereas 14 (66. 7%) returned to their primary sport. Elbow flexion and extension improved by medians of 12 and 21 degrees, respectively (P=0.002, 0.01). Timmerman scores improved by a median of 30 (P=0.001). Shorter duration of symptoms correlated with smaller OCD lesions (P=0.03) and with improved clinical or radiographic resolution and return to sport rates.

CONCLUSIONS

The majority of patients with grade IV elbow OCD achieves clinical and/or radiographic resolution and return to sports 2 years after LB removal and drilling/microfracture. Recurrence may be seen, however, and further investigation is needed to assess the efficacy of this technique compared with other treatment strategies.

LEVEL OF EVIDENCE

Level IV.

Results of Bone Peg Grafting for Capitellar Osteochondritis Dissecans in Adolescent Baseball Players

BACKGROUND

Bone peg grafting (BPG) has been advocated for early-stage humeral capitellar osteochondritis dissecans (COCD). However, the clinical and radiological results of BPG, along with its indications, have not been described in detail.

HYPOTHESIS

COCD classified as International Cartilage Repair Society (ICRS) osteochondritis dissecans (OCD) I or II in adolescent baseball players can be treated successfully by BPG.

STUDY DESIGN

Case series; Level of evidence, 4 METHODS: Eleven male baseball players (age range at surgery, 13-16 years) who underwent BPG for COCD were enrolled in this study. No improvement had been seen in any patient after 6 months of preoperative nonthrowing observation. During surgery, 2 to 5 bone pegs were inserted into the COCD lesion after confirmation of lesion stability to the bony floor. All patients were directly evaluated at 12 and 24 months after surgery by physical findings, radiological prognosis, and magnetic resonance imaging (MRI).

RESULTS

Of the 11 patients, 10 could return to comparable baseball ability levels within 12 months. The Timmerman-Andrews score improved significantly from a mean ± SD of 171.8 ± 12.1 preoperatively to 192.3 ± 6.5 at the final observation. Radiological healing of the lesions was determined as complete in 8 patients and partial in 3. Patients possessing a centrally positioned lesion or a lesion <75% of the size of the capitellum tended most strongly to achieve complete radiological healing, while growth plate status appeared unrelated to outcome. The mean Henderson MRI score improved from 6.3 ± 1.5 to 4.8 ± 1.6 at 12 and 24 months after BPG, respectively. MRI findings also suggested that remodeling of COCD lesions had continued to up to 24 months postoperatively.

CONCLUSION

BPG enabled 91% of COCD patients with ICRS OCD I or II to return to preoperative baseball abilities within 12 months. Integration of the grafted site may continue until at least 24 months postoperatively. An ICRS OCD I or II lesion with central positioning and/or occupying <75% of the size of the capitellum in the coronal plane is a good indication for BPG.

Internal Fixation of Unstable In Situ Osteochondritis Dissecans Lesions of the Capitellum

BACKGROUND

Limited data exist regarding the indications and expected outcomes of internal fixation of unstable in situ osteochondritis dissecans (OCD) lesions of the capitellum. The objective of this investigation was to characterize healing rates, clinical results, and functional outcomes of internal fixation of unstable in situ OCD lesions in adolescents.

METHODS

Retrospective analysis was performed of 26 elbows in 24 patients who underwent internal fixation for unstable in situ OCD. Mean age at surgery was 14.1 years; 7 patients had open physes. Mean lesion width and thickness were 12.0 and 5.4 mm, respectively. Demographic, clinical, and radiographic variables of patients who went on to healing versus revision procedures were compared with univariate analysis. Classification and regression tree analysis identified optimal threshold values associated with healing. Functional outcomes were assessed with the Mayo Elbow Performance Score, Timmerman, and Pediatric Outcomes Data Collection Instrument scores. Mean clinical follow-up was 39 months (range, 12 to 96 mo).

RESULTS

Twenty of 26 elbows healed. Patients who healed were younger (P=0.01) and had smaller sagittal plane lesion widths (P=0.03) than patients who underwent revision. Classification and regression tree analysis identified 15.3 years and 13 mm as the threshold values distinguishing patients who did and did not heal. Overall, mean arc of elbow motion improved from 109 degrees preoperatively to 127 degrees at last follow-up (P=0.001). Mean Mayo Elbow Performance Score improved from 68 to 92 (P<0.001). Of 18 questionnaire respondents, two thirds reported full return to their prior level of sports participation without elbow complaint; 9 had excellent final Timmerman scores, 5 good, and 4 fair. Mean Pediatric Outcomes Data Collection Instrument upper extremity and sports scores were 98 and 93, respectively.

CONCLUSIONS

Healing, return to sports, and good to excellent functional outcomes may be expected in the majority of patients undergoing internal fixation of unstable in situ OCD lesions of the capitellum, particularly in younger patients with lesions <13 mm in sagittal width. Higher levels of evidence must further differentiate the optimal surgical treatments of unstable OCD.

LEVEL OF EVIDENCE

Level IV.

Short-term clinical results of arthroscopic osteochondral fixation for elbow osteochondritis dissecans in teenaged baseball players

BACKGROUND

Reports regarding arthroscopic fixation of the osteochondral fragments for elbow osteochondritis dissecans (OCD) are few. This study assessed the clinical outcomes of arthroscopic fixation of unstable osteochondral fragments by using absorbable pins over a postoperative period of at least 1 year.

METHODS

The patients were 13 adolescent baseball players with a mean age of 14 years (range, 12-16 years) who underwent OCD of primary lesions at International Cartilage Repair Society grades III and IV. The patients were evaluated by using validated outcome measures at a mean follow-up period of 24 months (range, 12-50 months).

RESULTS

The mean (standard deviation) score in the disability/symptom section of the Disabilities of the Arm, Shoulder, and Hand improved from 12.4 (6.0) before the surgery to 0.5 (1.2) after the surgery, and the sports section improved from 74.5 (25.4) to 1.4 (5.2). The mean (standard deviation) extension improved from -11° (10.8) to -2° (3.9; P < .001). The mean (SD) flexion improved from 129° (11.6) to 137° (5.6; P = .040). All patients were able to resume playing baseball, and 9 (69%) resumed playing at the same position as before their injuries.

CONCLUSIONS

The clinical results of arthroscopic osteochondral fragment fixation in the teenaged baseball players with elbow OCD, albeit obtained over only a short period, were favorable. This arthroscopic treatment enables repair of lesions and is considered appropriate for unstable OCD during the adolescent growth spurt.

Outcomes of arthroscopic treatment of osteochondritis dissecans of the capitellum and description of the technique

HYPOTHESIS

We hypothesize that a technique for all-arthroscopic fixation of capitellum osteochondritis dissecans (OCD) lesions using suture fixation and autogenous iliac crest bone grafting offers a successful alternative to open internal fixation techniques as shown by 2-year validated patient-reported outcomes.

METHODS

Our technique uses arthroscopic all-inside suture fixation with iliac crest autogenous bone grafting. The procedure was performed on 4 elite-level, adolescent athletes presenting with 5 unstable capitellum OCD lesions resulting in elbow pain, limited range of motion, and decreased ability to play. Magnetic resonance imaging showed an unstable OCD lesion, which was correlated with arthroscopy. Postoperatively, patients were evaluated by the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire; Oxford Elbow and Mayo Elbow scores; visual analog scale; postoperative range of motion; and return to play.

RESULTS

Three female patients and one male patient aged 13 to 15 years underwent the procedure. The mean final follow-up period was 2.8 years. Union was achieved in all patients, as seen on magnetic resonance imaging at a mean of 3 months. At follow-up, the mean loss of extension was 2°. Mean flexion was 153°. There was no loss of supination or pronation. The mean score on the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire was 11. The mean Mayo Elbow score was 88. The mean Oxford Elbow score was 42. The mean visual analog scale score was 2. The mean time to return to play was 4 months. All patients continued to compete at an elite level. There were no infections or cases of fixation failure, and no patients required conversion to open surgery or needed revision surgery.

CONCLUSION

Arthroscopic all-inside fixation of unstable OCD lesions is a successful technique, facilitating athletes to return to an elite level of play.

Arthroscopic fragment fixation using hydroxyapatite/poly-L-lactate Acid thread pins for treating elbow osteochondritis dissecans

BACKGROUND

Various procedures, such as arthroscopic debridement, osteochondral transplantation, and bone plug fixation, have been described for the treatment of osteochondritis dissecans (OCD) of the humeral capitellum. However, the use of hydroxyapatite/poly-L-lactate acid (HA/PLLA) thread pins to fix the osteochondral fragment in an OCD lesion is a recent development.

HYPOTHESIS

Adolescent throwing athletes would return to preinjury levels of function after arthroscopic osteochondral fragment fixation using HA/PLLA thread pins.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Enrolled in this prospective cohort study were 18 adolescent baseball players (mean age, 14.2 years; range 12-16, years) with elbow OCD who underwent arthroscopic fragment fixation with HA/PLLA thread pins between 2006 and 2009. All patients were affected on their dominant side. Plain radiographs taken before surgery showed an open physis in 13 patients (72%) and a closed physis in 5 patients (28%). During surgery, the condition of the OCD lesion was evaluated by use of the International Cartilage Research Society (ICRS) classification system; there were 5 grade II, 11 grade III, and 2 grade IV cases. Outcomes were assessed after 3 years (mean, 39 months; range, 36-50 months). Elbow function was measured using the Timmerman and Andrews score and the Mayo Elbow Performance Index. Return to sports activity was assessed as higher than preinjury, same level, lower level, or no return to sports.

RESULTS

The mean Timmerman and Andrews score improved significantly from 126.6±6.5 to 197.5±1.5, and the mean Mayo Elbow Performance Index improved significantly from 68.0±2.1 to 98.06±0.9 (P=.0001 for both). Mean elbow extension improved significantly from -10°±10.4° to -0.8°±5.2° (P=.006), and mean flexion improved significantly from 123.1°±17.9° to 138.6°±6.1° (P=.001). Three patients had a loss of extension greater than 5°. Five patients returned to a higher level of sports activity, 10 patients returned to the same level, and 2 patients returned to a lower level. A remaining patient did not return to baseball. In one patient, the lesion did not heal, resulting in fragmentation at 1 year after surgery. This patient consequently underwent revision arthroscopy to remove the lesion, and he eventually returned to sports at the same level of activity.

CONCLUSION

Arthroscopic fragment fixation using HA/PLLA thread pins provides a beneficial clinical outcome to adolescent baseball players with humeral capitellar OCD.

Costal osteochondral autograft for reconstruction of advanced-stage osteochondritis dissecans of the capitellum

BACKGROUND

Advanced-stage osteochondritis dissecans of the capitellum affecting the lateral wall may result in osteoarthritis, and suitable treatment is needed to avoid permanent deformation and impaired function. We aimed to assess postoperative outcomes of costal osteochondral autograft for treatment of this condition.

METHODS

We included 22 young overhead athletes (mean age, 13.9 years) with advanced osteochondritis dissecans of the humeral capitellum who underwent costal osteochondral autograft. All patients had elbow pain and wide-range articular cartilage lesions. We evaluated clinical and radiographic outcomes at a mean follow-up of 27 months (range, 12-77 months).

RESULTS

All patients achieved rapid functional improvement and returned to their former sports activity levels. The baseball players were able to play catch within 62 to 164 days (mean, 107 days) and returned to full pitching activity within 123 to 339 days (mean, 226 days). We assessed mean elbow function by the clinical rating system of Timmerman and Andrews and the Japanese Orthopaedic Association sports score; the scores improved from 121.5 and 53.7 points preoperatively to 169.2 points and 86.1 points, respectively, at the time of follow-up. Four patients required additional minor surgical procedures, including screw removal, loose body removal, and shaving off of spur formation. No patient showed obvious radiographic changes of osteoarthritis. All patients were satisfied with the final outcomes and had good functional recovery.

CONCLUSION

Costal osteochondral autograft gave satisfactory results for advanced osteochondritis dissecans of the humeral capitellum with extensive lesions affecting the lateral wall.

Osteochondritis Dissecans of the Humeral Capitellum: The Significance of Lesion Location

Background:

There is a paucity of information regarding the effect of lesion location on surgical outcomes in the treatment of osteochondritis dissecans (OCD) of the humeral capitellum.

Purpose:

To survey the literature for conclusions that can be drawn regarding the effect of lesion location on treatment of capitellar OCD lesion. The hypothesis was that lesion severity and the need for more aggressive surgical interventions are increased for lesions that are located laterally on the capitellum.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

All studies from the past 20 years were determined using a literature search of PubMed, Scopus, and Cochrane databases. Included studies were clinical studies that specifically commented on the location of the OCD defect on the capitellum. Excluded studies were case reports, review articles, and those that did not include information regarding the location of the OCD lesion on the capitellum.

Results:

Six studies met the inclusion criteria. Autograft reconstruction was found to yield reliable outcomes regardless of lesion location, as 87% (26/30) of lateral lesions had excellent or good outcomes using the Timmerman and Andrews score, while 91% (21/23) of central lesions had excellent or good outcomes. There was a trend toward improved outcomes with more aggressive surgical management of lateral lesions, specifically those involving the lateral cartilage margin. The failure rate for nonreconstructive operative management for lateral lesions was noted to be significant, as failure rates for peg fixation of lateral lesions was seen to be as high as 44% (4/9) in one of the studies.

Conclusion:

Studies regarding capitellar OCD lesion location, as it relates to symptom severity and surgical outcome, are limited. The literature suggests that lesions located on the lateral capitellum—particularly those involving the lateral cartilage margin—require more aggressive surgical management than those located medially. A refinement of the Takahara classification is proposed, which includes lesion location as a factor influencing surgical decision making.

Cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans

BACKGROUND

There is a need to clarify the usefulness of and problems associated with cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans.

METHODS

Twenty-six patients with advanced osteochondritis dissecans of the humeral capitellum were treated with use of cylindrical costal osteochondral autograft. All were males with elbow pain and full-thickness articular cartilage lesions of ≥15 mm in diameter. Clinical, radiographic, and magnetic resonance imaging outcomes were evaluated at a mean follow-up of thirty-six months (range, twenty-four to fifty-one months).

RESULTS

All patients had rapid functional improvement after treatment with costal osteochondral autograft and returned to their former activities, including sports. Five patients needed additional minor surgical procedures, including screw removal, loose body removal, and shaving of protruded articular cartilage. Mean elbow function, assessed with use of the clinical rating system of Timmerman and Andrews, was 111 points preoperatively and improved to 180 points at the time of follow-up and to 190 points after the five patients underwent the additional operations. Mean elbow motion was 126° of flexion with 16° of extension loss preoperatively and improved to 133° of flexion with 3° of extension loss at the time of follow-up. Osseous union of the graft on radiographs was obtained within three months in all patients. Revascularization of the graft depicted on T1-weighted magnetic resonance imaging and congruity of the reconstructed articular surface depicted on T2-weighted or short tau inversion recovery imaging were assessed at twelve and twenty-four months postoperatively. Functional recovery was good, and all patients were satisfied with the final outcomes.

CONCLUSIONS

Cylindrical costal osteochondral autograft was useful for the treatment of advanced osteochondritis dissecans of the humeral capitellum. Functional recovery was rapid after surgery. Additional operations were performed for five of the twenty-six patients, whereas the remaining patients showed essentially full recovery within a year. All patients were satisfied with the results at the time of short-term follow-up.

Osteochondritis dissecans of the elbow: excellent results in teenage athletes treated by arthroscopic debridement and microfracture

Aim

To extend the microfracture procedure, which has been proven successful on osteochondritis dissecans (OCD) lesions in the knee and ankle, to OCD lesions in the elbow.

Methods

Nine young patients were treated by arthroscopic debridement and microfracture by a single surgeon. The average age at operation was 15.0 years (median 15; range 12-19). The average length of the follow-up was 5.3 years (median 5; range 2-9). The follow-up included physical examination and patient interview with elbow function scoring. Success of treatment was determined according to pre-operative and follow-up Mayo Elbow Performance Index scores and the patients’ return to sports.

Results

Eight patients scored excellent results on the follow-up and 1 scored a good result. Four out of 9 patients were able to increase their training intensity, 2 returned to the same level of activity, 2 changed sports (due to reasons unrelated to the health of their elbow), and 1 left professional sports and started training only recreationally. No patients stopped participating in sports altogether.

Conclusions

We advocate arthroscopic microfracturing, followed by a strict rehabilitation regime, as a highly effective treatment for OCD of the humeral capitellum.

Evidence-based indications for elbow arthroscopy

PURPOSE

The purpose was to review the literature on the outcomes of elbow arthroscopy and to make evidence-based recommendations for or against elbow arthroscopy for the treatment of various conditions. Our hypothesis was that the evidence would support the use of elbow arthroscopy in the management of common elbow conditions.

METHODS

A literature search was performed by use of the PubMed database in October 2010. All therapeutic studies investigating the results of treatment with elbow arthroscopy were analyzed for outcomes and complications. The literature specific to common elbow arthroscopy indications was summarized and was assigned a grade of recommendation based on the available evidence.

RESULTS

There is fair-quality evidence for elbow arthroscopy in the treatment of rheumatoid arthritis of the elbow and lateral epicondylitis (grade B recommendation). There is poor-quality evidence for, rather than against, the arthroscopic treatment of degenerative arthritis, osteochondritis dissecans, radial head resection, loose bodies, post-traumatic arthrofibrosis, posteromedial impingement, excision of a plica, and fractures of the capitellum, coronoid process, and radial head (grade C(f) recommendation). There is insufficient evidence to give a recommendation for or against the arthroscopic treatment of posterolateral rotatory instability and septic arthritis (grade I recommendation).

CONCLUSIONS

The available evidence supports the use of elbow arthroscopy in the management of the majority of conditions where it is currently used. The quality of the evidence, however, is generally fair to poor.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.