Ultrasound imaging of the humeral capitellum: a cadaveric study

Understanding Osteochondritis Dissecans: A Narrative Review of the Disease Commonly Affecting Children and Adolescents

BACKGROUND

Osteochondritis dissecans (OCD) is a joint disorder predominantly affecting the knee, elbow, and ankle of children and adolescents. This comprehensive review delves into the epidemiology, etiology, clinical manifestations, diagnostic approaches, and treatment of OCD.

RESULTS

The most common cause of OCD is repetitive microtrauma, typically associated with sports activities, alongside other significant factors such as genetic predisposition, ischemia, and obesity. In early stages or when lesions are small, OCD often presents as non-specific, vaguely localized pain during physical activity. As the condition progresses, patients may experience an escalation in symptoms, including increased stiffness and occasional swelling, either during or following activity. These symptom patterns are crucial for early recognition and timely intervention. Diagnosis in most cases is based on radiographic imaging and magnetic resonance imaging. Nonsurgical treatment of OCD in young patients with open growth plates and mild symptoms involves activity restriction, immobilization methods, and muscle strengthening exercises, with a return to sports only after symptoms are fully resolved and at least six months have passed. Surgical treatment of OCD includes subchondral drilling in mild cases. Unstable lesions involve methods like restoring the joint surface, stabilizing fractures, and enhancing blood flow, using techniques such as screws, anchors, and pins, along with the removal of fibrous tissue and creation of vascular channels. The specifics of OCD treatment largely depend on the affected site.

CONCLUSIONS

This synthesis of current research and clinical practices provides a nuanced understanding of OCD, guiding future research directions and enhancing therapeutic strategies.

Advantages of CT Versus MRI for Preoperative Assessment of Osteochondritis Dissecans of the Capitellum

BACKGROUND

Magnetic resonance imaging (MRI) is considered to be the gold standard for imaging of osteochondritis dissecans (OCD).

PURPOSE/HYPOTHESIS

The purpose was to determine the additional value of a preoperative computed tomography (CT) scan in adolescent patients with capitellar OCD of the elbow. Consistent with the fact that OCD is a lesion involving the subchondral bone, the hypothesis was that CT would be superior to MRI for imaging OCD of the capitellum.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

All patients being treated surgically for an OCD of the capitellum between 2006 and 2016 at one institution were reviewed for preoperative imaging. A total of 28 patients met the inclusion criteria. Corresponding MRI and CT scans were compared retrospectively. Multiple parameters were recorded, with special emphasis on OCD lesion size, fragmentation, and tilt as well as joint surface integrity, loose bodies, and osteophytes.

RESULTS

The OCD lesions were best seen on CT scans, whereas MRI T1-weighted images overestimated and T2-weighted images underestimated the size of defects. A subchondral fracture nonunion was found on CT scans in 18 patients, whereas this was seen on MRI T1-weighted images in only 2 patients (P < .001) and MRI T2-weighted images in 4 patients (P < .001). Fragmentation of the OCD fragment was found on CT scans in 17 patients but on MRI scans in only 9 patients (P = .05). Osteophytes as a sign of secondary degenerative changes were seen on CT scans in 24 patients and were seen on MRI scans in 15 patients (P = .02). Altogether, only 51 of 89 secondary changes including loose bodies, effects on the radial head and ulnohumeral joint, and osteophytes that were seen on CT scans were also seen on MRI scans (P = .002).

CONCLUSION

OCD fragmentation and secondary changes were more often diagnosed on CT. These factors indicate OCD instability or advanced OCD stages, which are indications for surgery. In an adolescent who is considered at risk for OCD (baseball, gymnastics, weightlifting, tennis) and who has lateral elbow joint pain with axial or valgus load bearing, CT is our imaging modality of choice for diagnosing and staging OCD of the capitellum.

Osteochondritis Dissecans: Current Understanding of Epidemiology, Etiology, Management, and Outcomes

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Osteochondritis dissecans occurs most frequently in the active pediatric and young adult populations, commonly affecting the knee, elbow, or ankle, and may lead to premature osteoarthritis.

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While generally considered an idiopathic phenomenon, various etiopathogenetic theories are being investigated, including local ischemia, aberrant endochondral ossification of the secondary subarticular physis, repetitive microtrauma, and genetic predisposition.

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Diagnosis is based on the history, physical examination, radiography, and advanced imaging, with elbow ultrasonography and novel magnetic resonance imaging protocols potentially enabling early detection and in-depth staging.

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Treatment largely depends on skeletal maturity and lesion stability, defined by the presence or absence of articular cartilage fracture and subchondral bone separation, as determined by imaging and arthroscopy, and is typically nonoperative for stable lesions in skeletally immature patients and operative for those who have had failure of conservative management or have unstable lesions.

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Clinical practice guidelines have been limited by a paucity of high-level evidence, but a multicenter effort is ongoing to develop accurate and reliable classification systems and multimodal decision-making algorithms with prognostic value.

Comparison of sonography and MRI in the evaluation of stability of capitellar osteochondritis dissecans

PURPOSE

To compare the diagnostic accuracies of ultrasonography (US) and magnetic resonance imaging (MRI) with intraoperative capitellar osteochondritis dissecans (COCD) fragment stability findings.

METHODS

Patients whose International Cartilage Repair Society (ICRS) osteochondritis dissecans (OCD) classifications were I/II (stable) or III (unstable) were included. Patients underwent preoperative US and MRI. On US, lesions were evaluated as unstable when irregular contours of the chondral surface were observed. On MRI, lesions were evaluated as unstable when articular bone irregularity, a T2 high signal intensity interface, or a high signal intensity line through the articular cartilage was observed. Using the surgical assessment as the gold standard, accuracies of fragment stability diagnoses were calculated for US and MRI.

RESULTS

Thirty-four patients with OCD classifications of I/II (stable) or III (unstable) were included. Twenty-four patients (stable: 12, unstable: 12) underwent preoperative US; 22 (stable: 11, unstable: 11) underwent preoperative MRI. Preoperative US and MRI stability assessments correctly matched intraoperative fragment findings in 23 of 24 patients and 16 of 22 patients, respectively. US criteria in this study achieved superior accuracy compared with MRI criteria (96% vs. 73%; P < .05).

CONCLUSION

US was a useful tool for evaluating fragment instability in COCD.

Osteochondritis dissecans of the capitellum in adolescents

Osteochondritis dissecans (OCD) is a disorder of articular cartilage and subchondral bone. In the elbow, an OCD is localized most commonly at the humeral capitellum. Teenagers engaged in sports that involve repetitive stress on the elbow are at risk. A high index of suspicion is warranted to prevent delay in the diagnosis. Plain radiographs may disclose the lesion but computed tomography and magnetic resonance imaging are more accurate in the detection of OCD. To determine the best treatment option it is important to differentiate between stable and unstable OCD lesions. Stable lesions can be initially treated nonoperatively with elbow rest or activity modification and physical therapy. Unstable lesions and stable lesions not responding to conservative therapy require a surgical approach. Arthroscopic debridement and microfracturing has become the standard initial procedure for treatment of capitellar OCD. Numerous other surgical options have been reported, including internal fixation of large fragments and osteochondral autograft transfer. The aim of this article is to provide a current concepts review of the etiology, clinical presentation, diagnosis, treatment, and outcomes of elbow OCD.