Osteochondritis Dissecans of the Capitellum of the Elbow: Improved Outcomes in Surgically Treated Versus Nonoperatively Treated Patients at Long-Term Follow-up

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.

Management of Capitellar Osteochondritis Dissecans: A Critical Analysis Review

» Osteochondritis dissecans of the capitellum is a localized compromise of bone that may lead to subchondral collapse with articular cartilage damage and loose body formation.» The etiology is multifactorial; proposed mechanisms include repetitive microtrauma, vascular insufficiency, and genetic predisposition.» Diagnosis is based on patient presentation, clinical examination, diagnostic imaging, and intraoperative findings.» Management is dependent on lesion characteristics, with stable lesions amenable to nonoperative treatment and unstable lesions managed with surgical intervention.» Adolescent athletes can expect a return to their preinjury level of activity or competition following indicated surgical intervention.

Early Arthroscopic Debridement May Be More Cost-Effective Than Nonoperative Management for Symptomatic Osteochondritis Dissecans Lesions of the Capitellum

Purpose

To compare the cost-effectiveness of an initial trial of nonoperative treatment to that of early arthroscopic debridement for stable osteochondritis dissecans (OCD) lesions of the capitellum.

Methods

A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 simulated patients undergoing nonoperative management versus early arthroscopic debridement for stable OCD lesions of the capitellum. Health utility values, treatment success rates, and transition probabilities were derived from the published literature. Costs were determined on the basis of the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER).

Results

Mean total costs resulting from nonoperative management and early arthroscopic debridement were $5,330 and $21,672, respectively. On average, early arthroscopic debridement produced an additional 0.64 QALYS, resulting in an ICER of $25,245/QALY, which falls well below the widely accepted $50,000 willingness-to-pay (WTP) threshold. Overall, early arthroscopic debridement was determined to be the preferred cost-effective strategy in 69% of patients included in the microsimulation model.

Conclusion

Results of the Monte Carlo microsimulation and probabilistic sensitivity analysis demonstrated early arthroscopic debridement to be a cost-effective treatment strategy for the majority of stable OCD lesions of the capitellum. Although early arthroscopic debridement was associated with higher total costs, the increase in QALYS that resulted from early surgery was enough to justify the cost difference based on an ICER substantially below the $50,000 WTP threshold.

Level of Evidence

Level III, economic computer simulation model.