Osteochondritis dissecans of the capitellum: minimum 1-year follow-up after arthroscopic debridement

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.

Update in diagnosis, treatment, and prevention of osteochondritis dissecans of the capitellum

Osteochondritis dissecans of the capitellum is debilitating and is a potentially sports career-ending injury in a young and athletic population. Osteochondritis dissecans typically occurs in patients between the ages of 10 and 24 years, and boys are more commonly affected than girls. Conventional radiographs have low diagnostic accuracy, and magnetic resonance imaging (with or without contrast) or computed tomography may aid in accurate diagnosis. The primary indication for non-operative treatment is the presence of an intact cartilage cap on magnetic resonance imaging, indicating a "stable lesion." However, if operative treatment is necessary, various surgical procedures are available when operative treatment for an osteochondritis dissecans of the capitellum is considered, including open or arthroscopic removal of loose bodies, with or without microfracturing, fragment fixation, osteochondral autograft transplantation, and osteochondral allograft transplantation. The decision-making process for selecting the appropriate treatment considers factors such as the patient's characteristics, functional limitations, and lesion morphology.

Complications of Elbow Arthroscopic Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Elbow arthroscopic surgery has been popularized and has made significant progress during the past 3 decades. The elbow joint is relatively small and is in close proximity to many neurovascular structures. These factors make elbow arthroscopic surgery technically demanding and liable to complications.

PURPOSE

To evaluate the rate of complications after elbow arthroscopic surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to perform this systematic review and meta-analysis. PubMed, Web of Science, and Embase were searched up to July 2021. All clinical studies that reported complications after elbow arthroscopic surgery were included; a total of 1208 articles were initially found. Case reports, reviews, abstracts, imaging studies, technique studies, nonclinical studies, and those not reporting postoperative complications were excluded. Complication rates were pooled across studies and reported as percentages. Complications were expressed as weighted proportions with 95% CIs.

RESULTS

A total of 95 studies (14,289 elbows) were included in the meta-analysis. The overall weighted complication rate was 11.0% (95% CI, 8.8%-13.5%), with postoperative stiffness being the most commonly encountered complication (4.5% [95% CI, 2.1%-7.6%]; 158/8818 procedures). The second most encountered complication was the need for subsequent surgery with a weighted proportion of 4.1% (95% CI, 2.9%-5.6%; 177/8853 procedures) followed by nerve injury with a weighted proportion of 3.4% (95% CI, 2.6%-4.3%; 267/13,725 procedures). The ulnar nerve was the most commonly injured nerve (2.6% [95% CI, 1.9%-3.4%]; 123/6290 procedures).

CONCLUSION

The results of this study showed that elbow arthroscopic surgery is a relatively safe procedure with low complication rates.

Treatment Strategies and Outcomes for Osteochondritis Dissecans of the Capitellum

BACKGROUND

The optimum management of osteochondritis dissecans (OCD) of the capitellum is a widely debated subject.

PURPOSE

To better understand the efficacy of different surgical modalities and nonoperative treatment of OCD as assessed by radiological and clinical outcomes and return to sports.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all treatment studies published between January 1975 and June 2020 was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 76 clinical studies, including 1463 patients, were suitable for inclusion. Aggregate analysis and subgroup analysis of individual patient data were performed to compare the functional and radiographic outcomes between the various nonoperative and surgical treatment options for capitellar OCD. A unified grading system (UGS; grades 1-4) was developed from existing validated classification systems to allow a comparison of patients with similar-grade OCD lesions in different studies according to their treatment. Patient-level data were available for 352 patients. The primary outcome measures of interest were patient-reported functional outcome, range of motion (ROM), and return to sports after treatment. The influences of the capitellar physeal status, location of the lesion, and type of sports participation were also assessed. Each outcome measure was evaluated according to the grade of OCD and treatment method (debridement/microfracture, fragment fixation, osteochondral autograft transplantation [OATS], or nonoperative treatment).

RESULTS

No studies reported elbow scores or ROM for nonoperatively treated patients. All surgical modalities resulted in significantly increased postoperative ROM and elbow scores for stable (UGS grades 1 and 2) and unstable lesions (UGS grades 3 and 4). There was no significant difference in the magnitude of improvement or overall scores according to the type of surgery for stable or unstable lesions. Return to sports was superior with nonoperative treatment for stable lesions, whereas surgical treatment was superior for unstable lesions. Patients with an open capitellar physis had superior ROM for stable and unstable lesions, but there was no correlation with lesion location and the outcomes of OATS versus fragment fixation for high-grade lesions.

CONCLUSION

Nonoperative treatment was similar in outcomes to surgical treatment for low-grade lesions, whereas surgical treatment was superior for higher grade lesions. There is currently insufficient evidence to support complex reconstructive techniques for high-grade lesions compared with microfracture/debridement alone.

Osteochondritis Dissecans of Smaller Joints: The Elbow

This review presents the current understanding of the etiology, pathogenesis, and how to diagnose and treat osteochondritis dissecans (OCD) at the elbow joint followed by an analysis of particular characteristics and outcomes of the treatment. OCD is seen in patients with open growth plates (juvenile OCD [JOCD] and in adults [AOCD] with closed growth plates [adult OCD). The etiology at smaller joints remains as unclear as for the knee. Mechanical factors (throwing activities [capitulum] seem to play an important role. Clinical symptoms are unspecific. Thus, imaging techniques are most important for the diagnosis. In low-grade and stable lesions, treatment involves rest and different degrees of immobilization until healing. When surgery is necessary, the procedure depends on the OCD stage and on the state of the cartilage. With intact cartilage, retrograde procedures are favorable while with damaged cartilage, several techniques are used. Techniques such as drilling and microfracturing produce a reparative cartilage while other techniques reconstruct the defect with osteochondral grafts or cell-based procedures such as chondrocyte implantation. There is a tendency toward better results when reconstructive procedures for both the bone and cartilage are used. In addition, comorbidities at the joint have to be treated. Severe grades of osteoarthritis are rare.

Both Debridement and Microfracture Produce Excellent Results for Osteochondritis Dissecans Lesions of the Capitellum: A Systematic Review

Purpose

To analyze the available literature pertaining to the indications, outcomes, and complications of both microfracture (MFX) and simple debridement for capitellar osteochondritis dissecans (OCD).

Methods

A comprehensive literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Studies were included if they evaluated OCD of the capitellum that underwent either arthroscopic debridement (AD) or MFX. The risk of bias was assessed using the Methodological Index for Non-randomized Studies (MINORS) scale. Patient demographic characteristics, imaging findings, return-to-sport rates, patient-reported outcomes, range of motion (ROM), complications, failures, and reoperations were recorded.

Results

Eleven studies with 327 patients (332 elbows) met the inclusion criteria. Methodological Index for Non-randomized Studies (MINORS) scores ranged from 63% to 75% and showed considerable heterogeneity. Both AD and MFX showed improvement in patient outcome scores, ROM, and return to play, although the data precluded relative conclusions. Improvement in motion after MFX ranged from 4.9° to 5° of flexion, 5° to 22.6° of extension, 1° to 2° of pronation, and 0.5° to 2° of supination, whereas after AD, it ranged from –4° to 6° of flexion and –0.4° to 14° of extension, with prono-supination noted in only 1 study. The rate of return to play at a similar level of preinjury athletic competition ranged from 55% to 75% after MFX and from 40% to 100% after AD. Lesion location was discussed in only 1 study. Postoperative imaging trended toward early degenerative changes, most commonly of the radial head. Complications were only reported in 1 MFX study; in all cases, the complication was transient ulnar nerve neurapraxia. Reoperation rates ranged from 0% to 10%, and reoperation was most commonly performed to address radial head enlargement. Five studies reported no reoperations.

Conclusions

Both AD and MFX for capitellar OCD appear to yield excellent improvements in pain, ROM, patient outcome scores, and return to sport. Given that comparable mid-term outcomes can be achieved with debridement alone, without the use of MFX, similarly to recent prospective studies in the knee, AD alone may be a reasonable approach to relatively small OCD defects.

Level of Evidence

Level IV, systematic review of studies, all Level IV evidence.

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.

Acellular Cartilage Repair Technique Based on Ultrapurified Alginate Gel Implantation for Advanced Capitellar Osteochondritis Dissecans

Background:

One of the most important limitations of osteochondral autograft transplant is the adverse effect on donor sites in the knee. Ultrapurified alginate (UPAL) gel is a novel biomaterial that enhances hyaline-like cartilage repair for articular defects. To avoid the need for knee cartilage autografting when treating osteochondritis dissecans (OCD) of the capitellum, we developed a surgical procedure involving a bone marrow stimulation technique (BMST) augmented by implantation of UPAL gel.

Hypothesis:

BMST augmented by UPAL gel implantation improves the cartilage repair capacity and provides satisfactory clinical outcomes in OCD of the capitellum.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 5 athletes with advanced capitellar OCD in the dominant elbow underwent BMST augmented by implantation of UPAL gel. The osteochondral defects were filled with UPAL gel after BMST. At a mean follow-up of 97 weeks, all patients were evaluated clinically and radiographically.

Results:

At final follow-up, all 5 patients had returned to competitive-level sports, and 4 patients were free from elbow pain. The mean Timmerman-Andrews score significantly improved from 100 to 194 points. Radiographically, all patients exhibited graft incorporation and a normal contour of the subchondral cortex. Magnetic resonance imaging showed that the preoperative heterogeneity of the lesion had disappeared, and the signal intensity had returned to normal. Arthroscopic examinations consistently exhibited improvement in the International Cartilage Regeneration and Joint Preservation Society (ICRS) grade of lesions from 3 or 4 to 1 or 2 in 4 patients at 85 weeks postoperatively. Histologic analysis of biopsy specimens revealed an average total ICRS Visual Assessment Scale II histologic score of 1060.

Conclusion:

The acellular cartilage repair technique using UPAL gel for advanced capitellar OCD provided satisfactory clinical and radiographic results. The present results suggest that this novel technique is a useful, minimally invasive approach for treating cartilaginous lesions in athletes.

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.

Outcomes of Arthroscopic Surgical Treatment of Osteochondral Lesions of the Elbow in Pediatric and Adolescent Athletes

Background:

Osteochondral injuries of the elbow are limiting and affect the ability of pediatric and adolescent athletes to participate in sports.

Purpose:

To report short- and midterm outcomes on athletes undergoing microfracture or fragment fixation of osteochondral elbow lesions and evaluate the effects thereof on sporting activity.

Study Design:

Case series; Level of evidence, 4.

Methods:

This was a retrospective study analyzing patients who underwent surgical treatment via microfracture or fragment fixation for osteochondral elbow lesions. Patients were treated at a single institution by a single surgeon between 2012 and 2019. Diagnosis was confirmed with magnetic resonance imaging, and patients were indicated for surgery after having persistent symptoms despite trialing rest, immobilization, and/or activity restriction for at least 3 months. Demographic data including sports of choice were collected preoperatively. Imaging and intraoperative findings were documented, and any complications were noted. Range of motion (ROM) was compared pre- to postoperatively. Return-to-sport evaluation included the ability to play the preoperative sport of choice.

Results:

In total, 23 patients (25 elbows) were included with a mean follow-up of 23.5 months (range, 6-60.3 months) and a mean age of 13.8 years. Of 25 lesions, 20 (80%) were on the athlete’s dominant side. There was significant improvement from pre- to postoperative ROM, including extension (mean ± SD, 6.4° ± 5.3° to 0.04° ± 0.2°; P < .00001), flexion (129.2° ± 10.6° to 138.6° ± 4.4°; P = .00013), and arc of ROM (122.6° ± 13.2° to 138.6° ± 4.4°; P < .00001). Mean lesion size was 81.9 ± 59.3 mm² (range, 15-225 mm²). All elbows demonstrated radiographic healing postoperatively. Mean time to release to sport was 4.48 ± 1.38 months (range, 2.5-8 months). Six (26.1%) patients changed or stopped their preoperative sporting activity, including 2 of 4 gymnasts and 4 of 11 baseball players.

Conclusion:

Arthroscopic technique with lesion debridement and microfracture or fixation appears safe and results in radiographic healing; however, with these techniques, there remains a high rate of inability to return to sport in patients involved in higher-demand upper extremity activity, such as baseball and gymnastics. Further treatment strategies, including cartilage restoration procedures, may be warranted in this population.

Satisfaction With Elbow Function and Return Status After Autologous Osteochondral Transplant for Capitellar Osteochondritis Dissecans in High School Baseball Players

BACKGROUND

Osteochondral autograft transplant (OAT), a surgical treatment for capitellar osteochondritis dissecans (OCD), has favorable rates of elbow recovery and return to sports in adolescents. However, few reports have investigated how long patients continue to play baseball after OAT and their satisfaction with their treatment outcome.

PURPOSE

To evaluate the rate of boys who played baseball and received OAT for OCD in junior high school or earlier (age <15 years) and continued to play baseball in high school and the players' satisfaction with their elbow function during play.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 32 elbows of boys who played baseball and received OAT at age ≤15 years (mean, 14.1 years) were examined and divided into pitcher (n = 11) and nonpitcher (n = 21) groups according to their player position before surgery. The clinical Timmerman-Andrews score at the end of their high school baseball, participation percentage of players who continued to play baseball, and satisfaction level during play (on a scale of 0-10 during pitching and batting and in a 4-choice format) were compared between the 2 groups.

RESULTS

The Timmerman-Andrews scores significantly improved after surgery in both groups, with no significant difference between the groups. Of the 32 players, 30 (93.8%) continued to play baseball throughout high school, including all players in the pitcher group and 19 (90.5%) of those in the nonpitcher group. The percentage of players who continued to pitch was 55.6% (6/11) in the pitcher group. Satisfaction with elbow joint function at the time of pitching was significantly lower in the pitcher group. Further, 5 players reported being "a little unsatisfied" because of elbow pain during pitching. All of the players indicated satisfaction with elbow function during batting.

CONCLUSION

The percentage of players who received OAT for OCD in junior high school and continued to play baseball in high school was favorable. However, satisfaction with elbow function during throwing was lower in pitchers than in nonpitchers.

CLINICAL RELEVANCE

Before surgery, consent should be obtained from patients who are pitchers after it is explained that satisfaction with elbow joint function during pitching could be decreased after OAT.

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.

Editorial Commentary: Should We Consider Early Retirement for Adolescent Pitchers and Catchers With Osteochonditis Dissecans of the Capitellum?

Repetitive throwing in the adolescent athlete often leads to long-term problems. Strict pitch counts and limitation of pitches (e.g., curve balls) that place extreme stress on the immature elbow must be monitored closely. And until our outcomes for osteochondritis dissecans of the capitellum in adolescent baseball players improve, it may be wise to counsel those pitchers and catchers who are symptomatic to consider switching to another position or sport.

Lower nationwide rates of arthroscopic procedures in 2016 compared with 1997 (634925 total arthroscopic procedures): has the tide turned?

Objectives

To assess the rates and secular trends of different joint arthroscopies—shoulder, elbow, wrist, hip, knee and ankle—in Finland between 1997 and 2016.

Design

Retrospective nationwide registry study.

Participants

All adults in Finland with any arthroscopic intervention procedure code for knee, shoulder, ankle, wrist, elbow or hip arthroscopy between 1 January 1997 and 31 December 2016 were included.

Main outcome measures

Incidence rate of arthroscopic surgery per 100 000 person-years.

Results

The rate of knee and shoulder arthroscopies declined after reaching a peak in 2006 and 2007, respectively. The rates of wrist, elbow and hip joint arthroscopies declined after their 2014 peak. At the same time, the median age of patients who had knee, ankle and hip arthroscopy decreased, whereas the age of patients who had shoulder arthroscopy increased.

Conclusions

Numerous randomised controlled trials point to lack of efficacy of the most common knee and shoulder arthroscopic procedures. It should not be assumed that this has contributed to decreased rates of arthroscopic surgery. The concurrent decrease in most of the other joint arthroscopic procedures was unexpected.

Encouraging mid-term outcomes for arthroscopic autologous osteochondral transplant (OAT) in capitellum osteochondritis dissecans (OCD)

PURPOSE

The primary outcomes are the evaluation and quantification of pain relief and improvement in range of motion after OAT in OCD. The secondary outcomes are: resuming of sport activities, evaluation of the ADL recovery rate and subjective evaluation of the quality of life improvement.

METHODS

Nine patients, affected by an unstable and non-acute OCD lesion of the capitulum humeri, have been treated by the same surgeon. The patient mean age was 22.4 (16-45 years). All subjects were treated with the same surgical technique (arthroscopic OAT from the same side knee, a single cylinder of 6.5-9 mm in diameter) and underwent the same rehabilitation. The mean follow-up was 48 months (30-52 months). The authors documented the clinical assessment of each patient and carried out a questionnaire which included the VAS scale, MEPS Score and Quick DASH score. Patients were asked for MRI and radiographs pre- and post-operatively at follow-up.

RESULTS

The mean range of motion improvement was 17.9° in extension (range 13°-27°) and 10.6° in flexion (range 0°-20°) The VAS mean improvement was 7.1 (range 6-8) and the mean post-op value 0.6 (range 0-3). The MEPS score mean post-operative value was 98.3 (range 85-100). The Quick-DASH mean post-operative value was 2.5 (range 0-9.1) with a mean improvement of 41.4 points (range 36.4-47.7 points). All patients resumed sports in 6 months post-operatively.

CONCLUSIONS

The autologous transplant of an osteochondral plug is a safe and promising procedure. Despite being more demanding, the arthroscopic approach is a valuable tool if the surgeon aims to reduce the invasiveness of the procedure, with all the consequent advantages.

LEVEL OF EVIDENCE IV

Retrospective case series, therapeutic study.

Demographics and Epidemiology of Osteochondritis Dissecans of the Elbow Among Children and Adolescents

Background

Osteochondritis dissecans (OCD) of the elbow is a disorder of subchondral bone and articular cartilage, of which the incidence among children is not clearly known.

Purpose

To assess the demographics and epidemiology of OCD of the elbow among children.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A retrospective chart review of an integrated health system for the years 2007 through 2011 was performed for patients with elbow OCD aged 2 to 19 years. Lesion location, laterality, and all patient demographics were recorded. OCD incidence was determined for the group as a whole as well as by sex and age group (2-5, 6-11, 12-19 years). Patient differences based on age, sex, and ethnicity were analyzed, and multivariable logistic regression models were used to assess the risk of elbow OCD by group.

Results

A total of 37 patients with 40 OCD lesions fit the inclusion criteria. No lesion was found among 2- to 5-year-olds. A majority of lesions (n = 39, 97.5%) were in the capitellum, and 1 (2.5%) was in the trochlea. Twenty-five patients (67.6%) had right-sided lesions; 9 (24.3%), left-sided; and 3 (8.1%), bilateral. The incidence of elbow OCD for patients aged 6 to 19 years was 2.2 per 100,000 overall and 3.8 and 0.6 per 100,000 for males and females, respectively. The majority of OCD cases were seen in those aged 12 to 19 years, with an incidence of 3.4 per 100,000 versus 0.38 among 6- to 11-year-olds. Multivariable logistic regression analysis revealed a 21.7-times increased odds ratio of elbow OCD among patients aged 12 to 19 years versus 6 to 11 years, and males had a 6.8-times greater odds ratio of elbow OCD than females (P < .0001 for both). Based on race and ethnicity, non-Hispanic whites had the highest incidence of elbow OCD as compared with all other ethnic groups.

Conclusion

In this population-based cohort study of pediatric elbow OCD, males had almost 7 times the risk of elbow OCD as compared with females, and 12- to 19-year-olds had nearly 22 times the risk of elbow OCD versus 6- to 11-year-olds. In keeping with many prior studies, the majority of patients had right-sided lesions.

Autologous Osteochondral Mosaicplasty for Centrally and Laterally Located, Advanced Capitellar Osteochondritis Dissecans in Teenage Athletes: Clinical Outcomes, Radiography, and Magnetic Resonance Imaging Findings

BACKGROUND

Autologous osteochondral mosaicplasty (ie, mosaicplasty) results in satisfactory clinical outcomes and reliable return to play for patients with large or unstable lesions due to osteochondritis dissecans (OCD) of the humeral capitellum. However, the association between the healing of the reconstructed cartilage and clinical outcomes remains unclear.

PURPOSE

To evaluate the efficacy of mosaicplasty in teenage athletes through use of clinical scores and imaging. The secondary purpose was to compare the clinical outcomes with images of centrally and laterally located lesions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study analyzed 22 elbows (all male patients; mean age, 13.5 ± 1.2 years) with capitellar OCD managed with mosaicplasty. Patients were divided into 2 groups according to the location of the lesions: central (10 patients) and lateral (12 patients). Evaluation was performed through use of the clinical rating system of Timmerman and Andrews, plain radiographs, and magnetic resonance imaging (MRI; the cartilage repair monitoring system of Roberts). The mean follow-up period was 27.5 months (range, 24-48 months).

RESULTS

Lateral lesions were significantly larger than central lesions (147.1 ± 51.9 mm² vs 95.5 ± 27.4 mm², P = .01). No other significant differences were found between central and lateral lesions. Timmerman and Andrews scores for both central and lateral lesions improved significantly from 125.0 ± 30.1 points and 138.3 ± 34.5 points preoperatively to 193.5 ± 11.3 points and 186.7 ± 18.1 points, respectively, at final follow-up ( P < .0001, P < .0001). Radiography identified complete graft incorporation in all cases and the absence of severe osteoarthritic changes or displaced osteochondral fragments. In the lateral group, the radial head ratio at final follow-up (1.83 ± 0.23) was significantly larger than the preoperative findings (1.75 ± 0.14, P = .049). The quality of joint surface reconstruction was found to be acceptable for central and lateral lesions on MRI evaluation.

CONCLUSION

Mosaicplasty resulted in satisfactory clinical outcomes and smooth cartilage surface integrity in teenage athletes with OCD on their return to competition-level sports activities irrespective of lesion location.

Variation in stress distribution patterns across the radial head fovea in osteochondritis dissecans: predictive factors in radiographic findings

BACKGROUND

Predictive factors for the development of osteoarthritis in adolescent osteochondritis dissecans (OCD) of the humeral capitellum remain unclear. The objectives of this study were to assess subchondral bone density in the radial head fovea of patients with OCD and to evaluate stress distribution in the radiocapitellar joint. The relationship between radiologic classification and stress distribution, according to multivariate ordinal regression analysis, was also investigated.

METHODS

Computed tomography (CT) imaging data from 54 male patients with OCD (mean age, 13.1 years) were collected. Stress in the radial head fovea was measured using CT osteoabsorptiometry. A stress map was constructed and divided into 4 sections, and percentages of high-density regions in each section were quantitatively analyzed. Multivariate ordinal regression analyses were performed of bone density, incorporating the stage, location, and size of the OCD lesion and the presence of medial elbow disturbance in the radiographic images.

RESULTS

The percentage of high-density area in the anteromedial, posteromedial, and the anterolateral sections of the radial head fovea were significantly increased compared with the posterolateral section. Multivariate ordinal regression analysis revealed that the location and size of the lesion and a history of excessive valgus stress were associated with imbalances in the radial head fovea.

CONCLUSIONS

When the OCD lesion is large and located laterally and a medial epicondyle disturbance is apparent on radiographs, the risk for developing advanced radiocapitellar osteoarthritis should be considered. These findings can be useful in the decision-making process for treating OCD.

Grade I Osteochondritis Dissecans in a Young Professional Athlete

BACKGROUND

Osteochondritis dissecans (OCD) is a disorder primarily affecting subchondral bone, with secondary effects on the overlying articular cartilage. Knee joint (75%) and radiocapitellar joint (6%) are the most common sites for OCD lesions. The presence of an open growth plate differentiates juvenile osteochondritis dissecans from adult form of osteochondritis. Early diagnosis and treatment produce best long term results. The objective of this study is to determine the best mode of management of a Grade I osteochondritis lesion in a young athlete.

MATERIALS AND METHODS

A PubMed search was made using the keywords "OCD" and "athlete". Articles that were based on participants between the ages of 6-24 years (children, adolescent and young adult) and early stages of OCD were included in this study. A total of 25 articles were thus included for the review.

RESULTS

The healing potential is based on the age of the patient, status of physis, and stage of the lesion. Most authors have observed good to excellent results of drilling of early OCD in skeletally mature patients. Similarly, most authors also reported equally successful outcomes of nonoperative treatment for early OCD in skeletally immature patients.

CONCLUSIONS

We recommend initial nonoperative line of management in patients with open physis. In case of progression of the lesion or failure of conservative treatment a reparative, restorative or palliative surgical intervention can be done. For Stage I OCD lesions in patients with closed physis, we advocate reparative surgery either by means of retro- or trans-articular drilling.

Arthroscopic Fragment Resection for Capitellar Osteochondritis Dissecans in Adolescent Athletes: 5- to 12-Year Follow-up

Background

Capitellar osteochondritis dissecans (OCD) in skeletally immature athletes has often been seen in baseball players and gymnasts. The choice of surgical procedure for unstable lesions in skeletally immature athletes remains controversial.

Purpose

To investigate functional outcomes and radiographic changes in the midterm to long-term postoperative period after arthroscopic (AS) resection for small to large capitellar OCD lesions in skeletally immature athletes.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 38 elbows in 38 patients (33 boys, 5 girls; mean age, 14 years [range, 13-15 years]) with skeletally immature elbows underwent AS resection for capitellar OCD. Patients were observed for at least 5 years (mean, 8 years [range, 5-12 years]). Elbows with a lesion width that did not exceed one-half of the radial head diameter were assigned to group 1 (n = 17 elbows), and larger lesions were assigned to group 2 (n = 21 elbows). Functional scores, patient satisfaction, range of motion (ROM), and osteoarthritis (OA) grades were evaluated between the groups.

Results

All patients returned to sports activity. Functional scores at the final follow-up were not significantly different between the groups. Patient satisfaction scores were significantly higher in group 1 than in group 2. There was significant improvement in flexion ROM at the final follow-up compared with preoperative values in group 1 (P = .017), and there was a significant between-group difference (group 1: 141°; group 2: 133°; P = .002). Extension ROM showed significant improvement in both groups (group 1: from -8° to 3°; group 2: from -17° to -1°; P < .001 for both). Group 1 tended to have better extension than group 2, but the difference was not significant. There were no elbows with severe OA in either group, but the OA grade progressed in 5 elbows (29%) in group 1 and 9 elbows (43%) in group 2, and this rate of OA progression was statistically significant between groups (P = .005).

Conclusion

Both functional outcomes and radiological findings after AS fragment resection were excellent in elbows with small lesions. Although overall outcomes were acceptable in elbows with larger lesions, flexion ROM and patient satisfaction scores were significantly inferior to those in elbows with smaller lesions.

Clinical Outcome After Arthroscopic Debridement and Microfracture for Osteochondritis Dissecans of the Capitellum

BACKGROUND

Various surgical treatment techniques have been developed to treat capitellar osteochondritis dissecans; however, the optimal technique remains the subject of ongoing debate.

PURPOSE

To evaluate clinical outcomes after arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2008 and 2015, the authors followed 77 consecutive patients (81 elbows) who underwent arthroscopic debridement and microfracture, and loose body removal if needed, for advanced capitellar osteochondritis dissecans. Seventy-one patients (75 elbows) with a minimum follow-up of 1 year were included. The mean age was 16 years (SD, ±3.3 years; range, 11-26 years) and the mean follow-up length was 3.5 years (SD, ±1.9 years; range, 1-8.2 years). Based on CT and/or MRI results, 71 lesions were classified as unstable and 4 as stable. Clinical elbow outcome (pain, function, and social-psychological effect) was assessed using the Oxford Elbow Score (OES) at final follow-up (OES range, 0-48). Range of motion and return to sports were recorded. Multivariable linear regression analysis was performed to determine predictors of postoperative OES.

RESULTS

Intraoperatively, there were 3 grade 1 lesions, 2 grade 2 lesions, 10 grade 3 lesions, 1 grade 4 lesion, and 59 grade 5 lesions. The mean postoperative OES was 40.8 (SD, ±8.0). An open capitellar physis was a predictor of better elbow outcome (5.8-point increase; P = .025), as well as loose body removal/grade 4-5 lesions (6.9-point increase; P = .0020) and shorter duration of preoperative symptoms (1.4-point increase per year; P = .029). Flexion slightly improved from 134° to 139° ( P < .001); extension deficit slightly improved from 8° to 3° ( P < .001). Pronation ( P = .47) and supination did not improve ( P = .065). Thirty-seven patients (55%) returned to their primary sport at the same level, and 5 patients (7%) returned to a lower level. Seventeen patients (25%) did not return to sport due to elbow-related symptoms, and 10 patients (13%) did not return due to non-elbow-related reasons. No complications were recorded.

CONCLUSION

Arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans provide good clinical results, especially in patients with open growth plate, loose body removal, and shorter duration of symptoms. However, only 62% of patients in this study returned to sports.

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis

PURPOSE

To determine the rate of donor-site morbidity after osteochondral autologous transplantation (OATS) for capitellar osteochondritis dissecans.

METHODS

A literature search was performed in PubMed/MEDLINE, Embase, and Cochrane Library to identify studies up to November 6, 2016. Criteria for inclusion were OATS for capitellar osteochondritis dissecans, reported outcomes related to donor sites, ≥10 patients, ≥1 year follow-up, and written in English. Donor-site morbidity was defined as persistent symptoms (≥1 year) or cases that required subsequent intervention. Patient and harvest characteristics were described, as well as the rate of donor-site morbidity. A random effects model was used to calculate and compare weighted group proportions.

RESULTS

Eleven studies including 190 patients were included. In eight studies, grafts were harvested from the femoral condyle, in three studies, from either the 5th or 6th costal-osteochondral junction. The average number of grafts was 2 (1-5); graft diameter ranged from 2.6 to 11 mm. In the knee-to-elbow group, donor-site morbidity was reported in 10 of 128 patients (7.8%), knee pain during activity (7.0%) and locking sensations (0.8%). In the rib-to-elbow group, one of 62 cases (1.6%) was complicated, a pneumothorax. The proportion in the knee-to-elbow group was 0.04 (95% CI 0.0-0.15), and the proportion in the rib-to-elbow group was 0.01 (95% CI 0.00-0.06). There were no significant differences between both harvest techniques (n.s.).

CONCLUSIONS

Donor-site morbidity after OATS for capitellar osteochondritis dissecans was reported in a considerable group of patients.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

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.

Arthroscopic Autologous Chondrocyte Transplantation for Osteochondritis Dissecans of the Elbow

Osteochondritis dissecans of the humeral capitellum is characterized by separation of a circumscript area of the articular surface and the subchondral bone in juvenile patients. In advanced lesions, arthroscopic fragment refixation or fragment removal with microfracturing or drilling can be successful. The purpose of this technical note is to describe an all-arthroscopic surgical technique for 3-dimensional purely autologous chondrocyte transplantation for osteochondral lesions of the humeral capitellum.

Return to Sport After Operative Management of Osteochondritis Dissecans of the Capitellum: A Systematic Review and Meta-analysis

BACKGROUND

Capitellar osteochondritis dissecans (OCD) is commonly managed surgically in symptomatic adolesent throwers and gymnasts. Little is known about the impact that surgical technique has on return to sport.

PURPOSE

To evaluate the clinical outcomes and return-to-sport rates after operative management of OCD lesions in adolescent athletes.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The PubMed, CINAHL, EMBASE, SPORTDiscus (EBSCO), and Cochrane Central Register of Controlled Trials databases were queried for studies evaluating outcomes and return to sport after surgical management of OCD of the capitellum. Two independent reviewers conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting patient outcomes with return-to-sport data and minimum 6-month follow-up were included in the review.

RESULTS

After review, 24 studies reporting outcomes in 492 patients (mean age ± SD, 14.3 ± 0.9 years) were analyzed. The overall return-to-sport rate was 86% at a mean 5.6 months. Return to the highest preoperative level of sport was most common after osteochondral autograft procedures (94%) compared with debridement and marrow stimulation procedures (71%) or OCD fixation surgery (64%). Elbow range of motion improved by 15.9° after surgery. The Timmerman-Andrews subjective and objective scores significantly improved after surgery. Complications were low (<5%), with 2 cases of donor site morbidity after osteoarticular autograft transfer (OAT) autograft harvest. The most common indications for reoperation were repeat debridement/loose body removal.

CONCLUSION

A high rate of return to sport was observed after operative management of capitellar OCD. Patients were more likely to return to their highest level of preoperative sport after OAT autograft compared with debridement or fixation. Significant improvements in elbow range of motion and patient outcomes are seen with low complication rates after OCD surgery.

Arthroscopic Microfracture for Osteochondritis Dissecans Lesions of the Capitellum

Capitellar osteochondritis dissecans (OCD) is one of the most common causes of elbow pain and dysfunction in adolescent athletes. It typically occurs in gymnasts and overhead throwers and presents along a wide spectrum of severity. Stable lesions can typically be treated with conservative therapy; however, those presenting with instability, fragmentation, or loose bodies generally require surgical intervention. Although there are a number of described surgical options used to treat capitellar OCD lesions, microfracture is one of the most commonly performed and well studied. Patients who are candidates for microfracture generally have favorable outcomes with high rates of return to athletic activity after postoperative rehabilitation. In this work, we present our preferred arthroscopic technique for microfracture of OCD lesions of the capitellum. This technique is most suitable for patients with unstable or fragmented OCD lesions that are less than 1 cm in diameter and do not violate the lateral-most articular margin of the capitellum.

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.

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.

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.

Magnetic resonance imaging after arthroscopic microfracture of capitellar osteochondritis dissecans

BACKGROUND

Osteochondritis dissecans (OCD) of the capitellum affects young athletes involved in elbow load-bearing activities. Unstable lesions are best managed surgically, although debate remains regarding the optimal method. Arthroscopic treatment allows rapid recovery, but the effect on the articular surface is undetermined.

HYPOTHESIS

The clinical outcome after arthroscopic microfracture of stage III/IV capitellum OCD would be successful in terms of return to sport and restoration of function, and there would be some evidence of articular restoration or repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We reviewed records of 10 consecutive adolescent patients (age ≤18 years) with stage III or IV OCD lesions of the capitellum managed with arthroscopic microfracture. The mean age at the time of surgery was 13.9 years (range, 10.8-18.5 years); 7 patients were skeletally immature and 3 were skeletally mature. Pre- and postoperative functional assessment included active range of motion, Mayo Elbow Performance Score (MEPS), and Timmerman/Andrews elbow score. All patients underwent plain radiographic and magnetic resonance imaging (MRI) evaluation at a minimum of 12 months (mean, 27 months; range, 12-49 months) and clinical evaluation at a minimum of 24 months (mean, 42 months; range, 27-54 months) after surgery.

RESULTS

The mean range of motion improved in both flexion (135.8°→140.7°, P = .112) and extension (20.4°→-2.2°, P = .005). The mean MEPS (70.5→97, P = .007) and Timmerman/Andrews elbow scores (116.4→193.0, P = .008) improved significantly. magnetic resonance imaging (MRI) evaluation demonstrated an improvement in overall joint congruence and the formation of a reparative articular surface in 8 of 10 (80%) patients. No reoperations or major complications were encountered. Six of 8 patients involved in competitive athletics returned to the same level of participation at an average of 5.1 months.

CONCLUSION

Arthroscopic OCD fragment excision and capitellar microfracture demonstrates good to excellent functional results in short-term follow-up. Follow-up MRI suggests potential for a reparative fibrocartilaginous articular surface. Longer term follow-up is necessary to determine durability of the technique.

Surgical treatment for osteochondritis dissecans of the capitellum

Context:

Osteochondritis dissecans (OCD) of the capitellum is most often seen in adolescents who participate in sports that involve repetitive loading of the elbow. Unstable defects typically require surgical intervention that involves fragment fixation, debridement, or reconstruction with an osteochondral autograft transfer. Optimum surgical management of unstable defects remains controversial.

Type of Study:

Clinical review.

Evidence Acquisition:

Relevant articles published after 1992 were identified using MEDLINE, the EMBASE database, and the Cochrane Library.

Results:

Both debridement and osteochondral autograft transfer for treatment of capitellar OCD lesions result in good short- and midterm outcomes with a high rate of return to sports. Larger defects involving more than 50% of the articular surface or involving the lateral margin of the capitellum may have worse outcomes after debridement and may be better treated with fragment fixation or osteochondral autograft transfer.

Conclusions:

High-level evidence is lacking to determine the superiority of debridement or osteochondral autograft transfer for the treatment of capitellar OCD lesions. A prospective longitudinal multicenter study, using validated outcome measures, that enrolls a large number of patients is needed to establish optimal treatment for unstable capitellar OCD lesions.

Short-term results of arthroscopic treatment of osteochondritis dissecans in skeletally immature patients

BACKGROUND

Osteochondritis dissecans (OCD) of the capitellum occurs in skeletally immature athletes, and most likely results from repetitive trauma during overhead activities. Treatment may consist of activity modifications, internal fixation, abrasion chondroplasty, microfracture, antegrade drilling, retrograde drilling, osteochondral autograft or allograft implantation, chondrocyte implantation, and rib autograft through arthroscopy or arthrotomy. One treatment modality has not been proven to be clearly more effective than the others. This study was undertaken to evaluate our treatment regimen that utilized arthroscopic-assisted treatments of capitellar OCD, including removal of loose bodies, antegrade or retrograde drilling, and chondroplasty in the pediatric population.

METHODS

All patients treated arthroscopically for a diagnosis of capitellar OCD over a 5-year period, were retrospectively reviewed. All were asked to return for follow-up questionnaire and radiographs. Exclusion criteria included those lost to follow-up. Demographics were recorded and range of motion was evaluated preoperatively and at most recent follow-up for flexion, extension, supination, and pronation. Preoperative and the most recent anterior/posterior and lateral radiographs of the elbow were reviewed. A 200-point elbow rating scale was used to assess patient outcomes. The arthroscopic appearance of the lesion was graded. Changes in preoperative to postoperative range of motion and size of lesion were compared using repeated measures analysis of variation.

RESULTS

There were 13 elbows in 12 patients; only 3 of the injuries occurred acutely. Mean age at the time of surgery was 13.1±1.07 (range, 10.8 to 14.6 y). Mean follow-up was 23.4±16.7 months (range, 2 to 60 mo). There were 3 grade I lesions, 2 grade II lesions, 1 grade IV lesion, and 7 grade V lesions. Seven of the lesions underwent transhumeral drilling, 2 transarticular drilling, 3 loose body removals, and 2 had only debridement. There were no postoperative infections or neurovascular injuries. Three of the elbows (20%) required eventual arthrotomy at a mean of 27.9 months after the index procedure. At final follow-up, 67% reported no pain and 33% reported occasional pain. No patients reported any swelling. Eighty-three percent reported no locking or catching and 17% reported occasional locking or catching. No patients reported any activity restrictions. The mean subjective score was 96±6 of 100 and the mean objective score was 100 of 100. Mean extension improved significantly from -17 to -7 degrees (P<0.001).

CONCLUSIONS

Treatment of children with OCD lesions of the capitellum with arthroscopic-assisted debridement and fenestration of the sclerotic rim (trans-humeral if overlaying cartilage is intact), plus fixation of the overlaying cartilage if not securely attached to the subchondral bone permits the return to physical activity, but may not allow return to the injury-inducing sport. Our short-term outcomes obtained using this regimen found this technique to be safe and reliable, but other interventions may be required if continued disability persists.

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.

Arthroscopic debridement of the humeral capitellum for osteochondritis dissecans: radiographic and clinical outcomes

PURPOSE

Although arthroscopic debridement of the humeral capitellum is an accepted procedure for osteochondritis dissecans, some patients develop radial head enlargement or osteoarthritic lesions after the procedure. The aim of this study was to investigate the radiographic and clinical outcomes of arthroscopic debridement and consider its indications.

METHODS

We retrospectively evaluated 106 patients who had arthroscopic debridement between 1997 and 2007. Surgery was performed after closure of the capitellar physis. We categorized the patients into 4 groups by lesion size and by whether the proximal radial physis was open or closed. The average patient age at surgery was 15 years (range, 12-18 y), and the average follow-up period was 13 months (range, 8-46 mo).

RESULTS

In patients with large lesions and open proximal radial physes, radiographic and clinical outcomes were poor. Three of 4 patients developed early osteoarthritic lesions of the radiohumeral joint, secondary to radial head enlargement. Radial head resection was required in 2 of 3 patients. Conversely, osteoarthritic lesions did not occur, and we observed noteworthy improvement in elbow pain routinely after the procedure in the other 3 groups. For range of motion, clinically important changes were not observed. Overall, postoperative elbow pain was absent in 89 patients. Mild pain was present in 15 patients and moderate or severe pain in 2 patients. A total of 90 patients returned to sports at pre-injury levels. Time of return to sports varied from 1 month to 5 months (mean, 2.4 mo).

CONCLUSIONS

Arthroscopic debridement of the capitellum can provide excellent short-term results for the treatment of osteochondritis dissecans. However, it is contraindicated in cases with large lesions when the proximal radial physis remains open.