Outcomes of surgical treatment for osteochondritis dissecans of the elbow: evaluation by lesion location

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.

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.

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.

Preoperative Evaluation and Surgical Simulation for Osteochondritis Dissecans of the Elbow Using Three-Dimensional MRI-CT Image Fusion Images

We used our novel three-dimensional magnetic resonance imaging-computed tomography fusion images (3D MRI-CT fusion images; MCFIs) for detailed preoperative lesion evaluation and surgical simulation in osteochondritis dissecans (OCD) of the elbow. Herein, we introduce our procedure and report the findings of the assessment of its utility. We enrolled 16 men (mean age: 14.0 years) and performed preoperative MRI using 7 kg axial traction with a 3-Tesla imager and CT. Three-dimensional-MRI models of the humerus and articular cartilage and a 3D-CT model of the humerus were constructed. We created MCFIs using both models. We validated the findings obtained from the MCFIs and intraoperative findings using the following items: articular cartilage fissures and defects, articular surface deformities, vertical and horizontal lesion diameters, the International Cartilage Repair Society (ICRS) classification, and surgical procedures. The MCFIs accurately reproduced the lesions and correctly matched the ICRS classification in 93.5% of cases. Surgery was performed as simulated in all cases. Preoperatively measured lesion diameters exhibited no significant differences compared to the intraoperative measurements. MCFIs were useful in the evaluation of OCD lesions and detailed preoperative surgical simulation through accurate reproduction of 3D structural details of the lesions.

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.

Radiographic evaluation of osteochondritis dissecans of the humeral capitellum: A systematic review

Background

The purpose of this study was to evaluate radiographic-based classification systems for osteochondritis dissecans (OCD) of the capitellum and determine their agreement with intraoperative findings.

Methods

Using PRISMA guidelines, we analyzed 44 studies utilizing a total of 19 classification systems.

Results

Magnetic resonance imaging (MRI)-based systems showed better predictive value of intraoperative staging, and the Itsubo and Kohyama classifications showed best predictive value for lesion stability.

Conclusions

No classification system effectively correlated with intraoperative findings. A combination of radiograph, MRI, and computed tomography will most accurately determine OCD lesion stability.

Level of evidence

IV, Systematic Review.

Osteochondritis dissecans of the glenoid: an analysis of grades, treatment, and outcomes

Background

Osteochondritis dissecans (OCD) is an idiopathic disorder of subchondral bone that causes focal articular cartilage disruption with the potential long-term consequence of premature osteoarthritis. Glenoid OCD is exceedingly rare. This case series aims to identify the grades of glenoid OCD and report its grade-specific treatment with clinical, radiological, and functional outcomes.

Methods

Prospectively collected data of consecutive patients diagnosed with a symptomatic glenoid OCD, who had a minimum 2-year follow-up, following nonoperative or surgical treatment, was retrospectively analyzed. Osteochondral defects secondary to acute trauma, instability, and primary osteoarthritis were excluded. Pretreatment and posttreatment clinical, radiological, and sports participation data were collected. This included pretreatment MRI for grading of glenoid OCD according to the International Cartilage Research Society (ICRS) OCD staging system, and postoperative MRI for grading of articular cartilage repair using the MOCART (MRI observation of cartilage repair tissue) scoring system.

Results

The study identified 7 competitive overhead athletes with symptomatic unilateral glenoid OCD, with a post-treatment minimum 2-year follow-up. Of 4 patients with ICRS OCD I, 3 healed with nonoperative treatment, whereas 1 progressed to ICRS OCD II. This patient along with another 3 patients with unstable glenoid OCD underwent arthroscopic OCD excision with bone marrow stimulation cartilage repair. All patients improved following treatment and had full passive and active range of shoulder movements, with normal strength and stability at the 2- year follow-up. The mean MOCART score on MRI at 2 years for the 4 patients who underwent surgery was 82.5 (range, 75-90). MRI documented healing in all 3 patients with ICRS OCD I who underwent nonoperative treatment. All patients returned to the same or higher level of sport following treatment, with mean time to return to sports being 8.0 months (range, 6-11 months) for nonoperative treatment, and 6.8 months (range, 5-10 months) for operative treatment. This difference was not statistically significant (P value .55). No patient had recurrence of symptoms till latest follow-up.

Conclusion

Despite the glenoid being a concave non–weight-bearing articular surface, OCD at this site has pathological grades similar to other convex weight-bearing articular surfaces. Notwithstanding the limited number of cases, it would appear that ICRS OCD I can often be successfully treated with nonoperative treatment, whereas ICRS OCD II, III, IV, warrant operative treatment. Bone marrow stimulation is a safe and predictable option for glenoid OCD cartilage repair and allows athletes a quick and successful return to sports.

Treatment of advanced stage osteochondrosis dissecans in the adolescent elbow using a hyaloronic acid-based scaffold: a case series of 5 patients

INTRODUCTION

Osteochondrosis dissecans (OCD) is considered to be one of the main causes for pain, discomfort and morbidity in the pediatric elbow joint. Few treatment options, such as microfracture or autologous transplantation, of osteochondral bone grafts have been described to address advanced OCD. The aim of this retrospective case series is to present preliminary clinical and radiologic findings following advanced stage OCD repair using a novel combination of a hyaluronic acid-based scaffold with autologous iliac crest bone grafting.

MATERIALS AND METHODS

Five adolescents, who underwent treatment of OCD (grade 3 or 4 according to Nelson) using a combination technique of defect debridement, transplantation of cancellous iliac crest bone and application of a HYALOFAST® membrane (Anika Therapeutics S.r.L., Italy), were re-assessed using clinical and radiologic examinations (defect diameter, depth, sclerosis, congruency, fragmentation, dissection, radiolucency, growth plate status; MRI) after a minimum of 2 years (mean, 34 months; range, 24-45) postoperatively. Dedicated outcome scores (Numeric Rating Scale [NRS], Pediatric Outcome Data Collection Instrument [PODCI], Mayo Elbow Performance Score [MEPS], and Timmerman-Andrews Score [TIMM] were collected.

RESULTS

All patients reported a NRS score of 0. The mean total TIMM, MEPS and PODCI (Global Functioning Scale) scores were 189 (range 165-200), 94 (range, 70-100), and 92 (range 83-98; normative score 47; range 35-55), respectively, indicating good to excellent clinical outcomes. The radiographic analysis showed overall improvements with regard to OCD width and depth reduction (35%, - 27-100%; 52%, 4-100%), but full resolution in only 2 of 5 cases. Elbow motion improved slightly after surgery. No complications were noted.

CONCLUSION

This study showed promising clinical short- to mid-term results in adolescent patients with advanced OCD using a novel surgical treatment combination. Radiographic results showed partial healing; hence, residual changes should be monitored over a longer period.

Capitellar Osteochondritis Dissecans Lesions of the Elbow: A Systematic Review of Osteochondral Graft Reconstruction Options

PURPOSE

To systematically evaluate the outcomes and complications of osteochondral autograft transfer (OAT) and osteochondral allograft transplantation (OCA) for the surgical treatment of capitellar osteochondritis dissecans (OCD).

METHODS

A literature search was conducted across 3 databases (PubMed, Cochrane, and CINAHL [Cumulative Index to Nursing and Allied Health Literature]) from database inception through December 2019 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Individual study quality was assessed using the Methodological Index for Non-randomized Studies scale. Studies were published between 2005 and 2019.

RESULTS

Eighteen studies consisting of 446 elbow OCD lesions treated with OAT surgery were included. There was a single OCA study eligible for inclusion. Patient ages ranged from 10 to 45 years. Of the OAT studies, 4 used autologous costal grafts whereas the remainder used autografts from the knee. Outcome measures were heterogeneously reported. A significant improvement in Timmerman-Andrews scores from preoperatively to postoperatively was reported in 9 of 10 studies. Return-to-play rates to the preinjury level of competitive play ranged from 62% to 100% across 16 studies. Significant improvement in motion, most often extension, was noted in most studies. Reported complication, reoperation, and failure rates ranged from 0% to 11%, 0% to 26%, and 0% to 20%, respectively. When used, knee autografts resulted in low donor-site morbidity (Lysholm scores, 70-100).

CONCLUSIONS

OAT surgery for large, unstable OCD lesions of the capitellum reliably produced good outcomes, few complications, and a high rate of return to competitive play. Complications are relatively uncommon, and donor-site morbidity is low. Less is known about the performance of OCA given the paucity of available literature.

LEVEL OF EVIDENCE

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

Osteochondritis Dissecans of the Capitellum :Review of the Literature

Osteochondritis dissecans (OCD) of the capitellum is a leading cause of elbow disability in adolescent baseball players. Previous studies have not found an association of player position with capitellar OCD. Elbow pain and a longer playing history might be related to progression of capitellar OCD but do not in themselves increase the risk of development of the condition. The cause of capitellar OCD is likely to include a combination of repetitive microtrauma and internal factors, such as ischemia and genetic predisposition. A combination of radiography, computed tomography, magnetic resonance imaging, and ultrasonography have aided our understanding of the pathology of capitellar OCD. Screening using ultrasonography enables early detection and provides an opportunity for successful conservative treatment. Treatment has conventionally included both operative and nonoperative measures based on the stage and size of the lesion, skeletal maturity, subjective symptoms, and structural integrity of the cartilage. Early-stage lesions respond better to nonoperative treatment than those in more advanced stages. Operative indications include persistent symptoms despite nonoperative treatment, symptomatic loose bodies, and displacement or detachment of fragments. J. Med. Invest. 67 : 217-221, August, 2020.

Editorial Commentary: "Elbow-to-Elbow" Capitellar Osteochondral Autologous Transplantation for Osteochondritis Dissecans-Are We Closer to the Holy Grail of Osteochondral Graft?

The knee or rib has been used routinely as a donor site for capitellar osteochondral autologous transplantation (osteoarticular transplantation) procedures with promising results. However, donor-site morbidity is a bitter truth that has led surgeons to pursue alternatives to the ipsilateral elbow. The non-articulating radial head and the lateral olecranon tip show acceptable topography and histology. However, size limitations require additional and clinical study.

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.

Early Clinical Results of Arthroscopically Assisted Drilling via the Radius in a Distal-to-Proximal Direction for Osteochondritis Dissecans of the Elbow

Background:

We have previously reported the technique of arthroscopically assisted drilling of osteochondritis dissecans (OCD) lesions of the elbow via the radius in a distal-to-proximal direction. With this technique, the entire OCD lesion can be drilled vertically under arthroscopic guidance with pronation and supination of the forearm and flexion and extension of the elbow joint.

Purpose:

To retrospectively evaluate return to sport, range of motion, and the Japanese Orthopaedic Association–Japan Elbow Society Elbow Function Score (JOA-JES score) after treatment of an elbow OCD lesion by drilling through the radius.

Study Design:

Case series; Level of evidence, 4.

Methods:

From November 2003 to January 2006, a total of 7 male adolescent baseball players with OCD lesions of the elbow were treated through use of arthroscopically assisted drilling via the radius. The stage of the OCD lesion was evaluated based on preoperative plain radiographs. Patients were observed for a minimum of 36 months, and clinical analysis included time for return to sport, elbow range of motion, and the JOA-JES score before intervention and at final follow-up.

Results:

We evaluated all 7 patients at a mean follow-up time of 36.1 months (range, 24-68 months). The stage of the OCD lesion on plain radiography was “translucent” in 1 patient, “sclerotic” in 5 patients, and “loosening” in 1 patient. The mean range of motion before surgery was 131.2° and –4.7° in flexion and extension, respectively, and this improved to 138.6° and 1.1° at final follow-up. The improvement in extension was statistically significant (P = .04). The mean JOA-JES score of 83.0 before surgery significantly improved to 94.0 at final follow-up (P < .001). One patient required excision of a free body at 51 months postoperatively, but all patients returned to sports early and without pain at an average of 4.6 months postoperatively. No feature of osteoarthrosis was noted on radiography on the final examination in any patient.

Conclusion:

The findings of this study demonstrate that arthroscopically assisted drilling of an elbow OCD lesion through the radial head allows for early return to sporting activities as well as improved motion and functional scores.