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

Osteochondritis dissecans of the elbow: recent evolution of pathogenesis, imaging, and treatment modalities

Background

The etiology and pathogenesis of osteochondritis dissecans (OCDs) lesions remain controversial.

Methods

This review presents the recent evolution about the healing, imaging, pathogenesis, and how to treat OCD of the capitellum in overhead athletes.

Results

Compressive and shear forces to the growing capitellum can cause subchondral separation, leading to OCD, composed of 3 layers: articular fragment, gap, and underlying bone. Subchondral separation can cause ossification arrest (stage IA), followed by cartilage degeneration (stage IB) or delayed ossification (stage IIA), occasionally leading to osteonecrosis (stage IIB) in the articular fragment. Articular cartilage fracture and gap reseparation make the articular fragment unstable. The mean tilting angle of capitellar OCD is 57.6 degrees in throwers. Anteroposterior radiography of the elbow at 45 degrees of flexion (APR45) can increase the diagnostic reliability, showing OCD healing stages, as follows: I) radiolucency, II) delayed ossification, and III) union. Coronal computed tomography and magnetic resonance imaging with an appropriate tilting angle can also increase the reliability. MRI is most useful to show the instability, although it occasionally underestimates. Sonography contributes to detection of early OCD in adolescent throwers on the field. OCD lesions in the central aspect of the capitellum can be more unstable and may not heal. Cast immobilization has a positive effect on healing for stable lesions. Arthroscopic removal provides early return to sports, although a large osteochondral defect is associated with a poor prognosis. Fragment fixation, osteochondral autograft transplantation, and their hybrid technique have provided better results.

Discussion

Further studies are needed to prevent problematic complications of capitellar OCD, such as osteoarthritis and chondrolysis.

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.

Clinical Outcomes and Return-to-Sport Rates following Fragment Fixation Using Hydroxyapatite/Poly-L-Lactate Acid Threaded Pins for Knee Osteochondritis Dissecans: A Case Series

Osteochondritis dissecans (OCD) of the knee is an uncommon injury in young active patients. There is currently a lack of knowledge regarding clinical outcomes and return-to-sport rates after fragment fixation surgery using hydroxy appetite poly-L-lactic acid (HA/PLLA) threaded pins for knee OCD among athletes. Our purpose was to investigate the clinical outcomes and return-to-sport rates following osteochondral fragment fixation using HA/PLLA pins for the treatment of knee OCD lesions among athletes. A total of 45 patients were retrospectively reviewed. In total, 31 patients were excluded, and 14 patients were included. Pre- and postoperative patient-reported outcome scores (PROSs), including the International Knee Documentation Committee (IKDC) score and Knee Injury and Osteoarthritis Outcome Scale (KOOS), were compared. In addition, patients were categorized into four groups according to postoperative sports status: higher, same, lower than preinjury, or unable to return to sports. The mean age was 14.4 years (SD 1.67). All patients were male. All PROSs significantly improved at 6, 12, and 24 months postsurgery compared to presurgery. 50% of the patients returned to sports at the same or higher level after surgery. Fragment fixation using HA/PLLA pins leads to favorable clinical outcome scores and high return-to-sport rates in the treatment of athletes with knee OCD.

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.

Rehabilitation and return to sport criteria following surgical treatment of osteochondritis dissecans of the capitellum: a systematic review

Background

Osteochondritis dissecans (OCD) of the capitellum is a well-described condition that most commonly affects adolescent throwing athletes and gymnasts. There is no gold standard rehabilitation protocol or timing for return to sport (RTS) after surgical management of OCD of the capitellum.

Hypothesis/Purpose

The purpose of the study was to identify in the existing literature any criteria used for RTS following surgical treatment of OCD of the capitellum. The hypothesis was that surgeons would utilize length of time rather than functional criteria or performance benchmarks for RTS.

Methods

Level 1 to 4 studies evaluating athletes who underwent surgery for OCD of the capitellum with a minimum follow-up of 1-year were included. Studies not describing RTS criteria, including less than 1-year follow-up, non-operative management only, and revision procedures were excluded. Each study was analyzed for RTS criteria, RTS rate, RTS timeline, sport played, level of competition, graft source (if utilized), and postoperative rehabilitation parameters. Assessment of bias and methodological quality was performed using the Coleman methodology score and RTS value assessment.

Results

All studies reported a rehabilitation protocol with immobilization followed by bracing with progressive range of motion. RTS rate was 80.9% (233/288). The majority of studies reported using time-based criteria for RTS (11/15). The most commonly reported timeline was 6 months (range: 3-12 months).

Conclusion

The overall RTS rate after surgical treatment of capitellar OCD is high with no consensus on RTS criteria. The two most consistent RTS criteria reported in the literature are return of elbow range of motion and healing demonstrated on postoperative imaging. There is a wide range of time to RTS in the literature, which may be sport dependent. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols.

Wide Range in Complication Rates Following Elbow Arthroscopy in Adult and Pediatric Patients: A Systematic Review

PURPOSE

To perform a systematic review of complications associated with elbow arthroscopy in adults and children.

METHODS

A literature search was performed in the PubMed, EMBASE, and Cochrane databases. Studies reporting complications or reoperations after elbow arthroscopy with at least 5 patients were included. Based on the Nelson classification, the severity of complications was categorized as minor or major. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized clinical trials, and nonrandomized trials were assessed using the Methodological Items for Non-randomized Studies (MINORS) tool.

RESULT

A total of 114 articles were included with 18,892 arthroscopies (16,815 patients). A low risk of bias was seen for the randomized studies and a fair quality for the nonrandomized studies. Complication rates ranged from 0% to 71% (median 3%; 95% confidence interval [CI], 2.8%-3.3%), and reoperation rates from 0% to 59% (median 2%; 95% CI, 1.8%-2.2%). A total of 906 complications were observed, with transient nerve palsies (31%) as the most frequent complication. According to Nelson classification, 735 (81%) complications were minor and 171 (19%) major. Forty-nine studies reported complications in adults and 10 studies in children, showing a complication rate ranging from 0% to 27% (median 0%; 95% CI, 0%-0.4%) and 0% to 57% (median 1%; 95% CI, 0.4%-3.5%), respectively. A total of 125 complications were observed in adults, with transient nerve palsies (23%) as the most frequent complication, and 33 in children, with loose bodies after surgery (45%) as the most frequent complication.

CONCLUSIONS

Predominantly low-level evidence studies demonstrate varying complication rates (median 3%, range 0%-71%) and reoperation rates (median 2%, range 0%-59%) after elbow arthroscopy. Higher complication rates are observed after more complex surgery. The incidence and type of complications can aid surgeons in patient counseling and refining surgical techniques to further reduce the complication rates.

LEVEL OF EVIDENCE

Level IV; systematic review of Level I-IV studies.

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.

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

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

Isolated trochlea osteochondral fracture of the distal humerus in a 6-year-old patient surgically fixed using biodegradable pins: A case study with over 3 years of follow-up

Isolated humeral trochlea fracture, particularly in skeletally immature children, is extremely rare. The exact mechanism of this injury remains unknown because the humeral trochlea is embraced within the olecranon fossa without any muscular or ligamentous attachment. We report the treatment of a 6-year-old boy who sustained an isolated trochlea osteochondral fracture when he fell with his elbow in a flexed position while skateboarding. The patient had a history of lateral condyle fracture of the ipsilateral humerus one year previously. At the diagnosis, computed tomography (CT) revealed a small bony fragment displaced anteromedially from the superior border of the trochlea with lifting of its lateral border. Ultrasonography confirmed instability of the fractured segment. At the time of surgery, the anterior trochlea surface fracture formed a hinged fracture line on its proximal and medial border. The fracture was anatomically reduced and fixed using biodegradable pins.

Postoperatively, the involved elbow showed a sufficient functional recovery to a normal level without complications during 3 years of observation, although the biodegradable pins remained radiographically in place with partial degradation. The laterally opened avulsed fragment on primary CT clearly depicted the mechanism of injury: the impact entered from the lateral side of the elbow and progressed from the longitudinal ridge of the coronoid process onto the sulcus of the trochlea to shear off the anteromedial portion of the trochlea in a medial direction. The use of biodegradable pins for fixing a trochlea fracture in a skeletally immature patient provided favorable fracture healing; however, close observation is necessary until the completion of skeletal growth because of the lack of sufficient information on the long-term prognosis of trochlea fracture, especially when treated using biodegradable implants.

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.

A high rate of children and adolescents return to sport after surgical treatment of osteochondritis dissecans of the elbow: a systematic review and meta-analysis

PURPOSE

The purpose of this systematic review was to determine the return to sport rates following surgical management of ostechondritis dissecans of the elbow.

METHODS

The databases EMBASE, PubMed, and MEDLINE were searched for relevant literature from database inception until August 2020 and studies were screened by two reviewers independently and in duplicate for studies reporting rates of return to sport following surgical management of posterior shoulder instability. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS score.

RESULTS

Overall, 31 studies met inclusion criteria and comprised of 548 patients (553 elbows) with a median age of 14 (range 10-18.5) and a median follow-up of 39 months (range 5-156). Of the 31 studies included, 14 studies (267 patients) had patients who underwent open stabilization, 11 studies (152 patients) had patients who underwent arthroscopic stabilization, and 6 studies (129 patients) had patients who underwent arthroscopic-assisted stabilization. The pooled rate of return to any level of sport was 97.6% (95% CI 94.8-99.5%, I² = 32%). In addition, the pooled rate of return to the preinjury level was 79.1% (95% CI 70-87.1%, I² = 78%). Moreover, the pooled rate of return to sport rate at the competitive level was 86.9% (95% CI 77.3-94.5%, I² = 64.3%), and the return to sport for overhead athletes was 89.4% (95% CI 82.5-95.1%, I² = 59%). The overall return to sport after an arthroscopic procedure was 96.4% (95% CI 91.3-99.6%, I² = 1%) and for an open procedure was 97.8% (95% CI 93.7-99.9%, I² = 46%). All functional outcome scores showed improvement postoperatively and the most common complication was revision surgery for loose body removal (19 patients).

CONCLUSION

Surgical management of osteochondritis dissecans of the elbow resulted in a high rate of return to sport, including in competitive and overhead athletes. Similar rates of return to sport were noted across both open and arthroscopic procedures.

LEVEL OF EVIDENCE

Level IV.

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.

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

➤

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

➤

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

➤

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

➤

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

➤

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

The Use of Elbow Arthroscopy for Management of the Pediatric Elbow: A Systematic Review of Indications and Outcomes

PURPOSE

The purpose of this review was to systematically examine the literature surrounding elbow arthroscopy for pediatric patients and to assess indications, functional outcomes, and complication rates.

METHODS

This systematic review was carried out in accordance with PRISMA guidelines. EMBASE, PubMed, and MEDLINE were searched for relevant literature from inception until December 2019, and studies were screened by 2 reviewers independently and in duplicate for those investigating elbow arthroscopy in a pediatric population (<18 years). Editorials, review articles, and case reports were excluded. Demographic data and data on surgical indications, treatment outcomes, and complications were recorded. A methodological quality assessment was performed for all included studies using the Methodological Index for Non-Randomized Studies.

RESULTS

Overall, 19 studies, all of level IV evidence, were identified with a total of 492 patients (513 elbows). The patient population was 22.3% female with a mean age of 14.0 years (range, 4.0-15.7) and a mean follow-up time of 33.0 months (range, 7.4-96 months). Twelve studies (263 patients) exclusively recruited patients with osteochondritis dissecans (OCD), although other indications for elbow arthroscopy included arthrofibrosis (50 patients), elbow fracture (37 patients), medial ulnar collateral ligament injury (31 patients), and posterior impingement (17 patients). All 13 reporting studies showed a significant improvement in the elbow flexion-extension arc, and 4 of 5 that reported a functional outcome score before and after surgery demonstrating a significant improvement. Last, the overall complication rates ranged from 0% to 23.8%, with a total of 8 instances of neurological injury (5 ulnar, 2 radial, 1 unspecified), all being transient and resolving within 3 to 6 months.

CONCLUSION

Although elbow arthroscopy is primarily being performed for OCD in children and adolescents, there is evidence surrounding several other potential indications. Case series published to date have demonstrated significant improvements in functional outcomes and low rates of major complications.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

Evaluation and management of elbow injuries in the adolescent overhead athlete

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

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

Hypothesis

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

Methods

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

Results

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

Conclusion

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

Radial head fractures with interposed capitellar cartilage fragment-hindrance to bone healing-a case series

INTRODUCTION

Radial head fractures account for the majority of bony elbow injuries. The individual treatment options have been described in detail. In some cases, however, an unusual concomitant injury occurs, which can significantly impede primary osteosynthesis and healing. This concomitant injury can be an interposing cartilaginous capitellar fragment.

METHODS

This retrospective study describes four cases of trapped cartilage fragments of the capitellum that compromised primary osteosynthesis or primary conservative healing of a radial head fracture. Radiological imaging, function and pain level are presented pre- and postoperatively (mean follow-up 9.25 months).

RESULTS

None of the four cases showed preoperative evidence of an incarcerated cartilage fragment of the capitellum. They all showed limited elbow range of motion. CT examinations were performed in all cases. In each case, the cartilage fragment was first sighted upon surgery, subsequently removed and the fractures treated with ORIF. Mean follow-up was of 9.25 months. All fractures healed, with excellent function and low pain scores.

CONCLUSIONS

This study presents rare cases of a trapped humeral cartilage fragment in radial head fractures. Radiological imaging including CT scans cannot reliably detect this concomitant injury. Therefore, this problem becomes apparent and treatable only during surgery. A high degree of suspicion is necessary especially in patients with minimally displaced fractures associated with limited elbow motion and a gap at the fracture site as treating these injuries conservatively may lead to poor outcome.

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.

Bioabsorbable Unsintered Hydroxyapatite/Poly-l-Lactic Acid Pin Fixation of Osteochondritis Dissecans in Adolescents: Initial Experiences

BACKGROUND

This study sought to retrospectively evaluate the clinical and magnetic resonance imaging (MRI) outcomes of u-HA/PLLA pin (u-HA/PLLA: hydroxyapatite/poly-L-lactic acid) pin fixation of unstable osteochondritis dissecans (OCD) lesions of the knee.

METHODS

Seven adolescent patients (four females and three males) with arthroscopically unstable OCD lesions of the knee were included. The mean age at diagnosis was 13.1 years. Clinical results were evaluated preoperatively and during follow-up using the Ogilvie-Harris score (0 - 15 points). MRI scans were performed preoperatively and during follow-up, with results evaluated using the Dipaola classification (grades 1 - 4). Mean follow-up time was 29 months.

RESULTS

The median Ogilvie-Harris score improved from 13 points (range: 10 - 14 points) to 15 points (range: 13 - 15 points). Separately, the median Dipaola score improved from 3 points (range: 2 - 4 points) to 1 point (range: 1 - 4 points). No complications such as infection, synovitis, or intra-articular adhesion were observed.

CONCLUSIONS

Initial experiences using bioabsorbable u-HA/PLLA pins for the refixation of unstable OCD lesions in adolescents in the knee are promising, and MRI provides excellent monitoring of healing.

Interobserver reliability of the classification of capitellar osteochondritis dissecans using magnetic resonance imaging

AIM

(1) To determine the interobserver reliability of magnetic resonance classifications and lesion instability criteria for capitellar osteochondritis dissecans lesions and (2) to assess differences in reliability between subgroups.

METHODS

Magnetic resonance images of 20 patients with capitellar osteochondritis dissecans were reviewed by 33 observers, 18 orthopaedic surgeons and 15 musculoskeletal radiologists. Observers were asked to classify the osteochondritis dissecans according to classifications developed by Hepple, Dipaola/Nelson, Itsubo, as well as to apply the lesion instability criteria of DeSmet/Kijowski and Satake. Interobserver agreement was calculated using the multirater kappa (k) coefficient.

RESULTS

Interobserver agreement ranged from slight to fair: Hepple (k = 0.23); Dipaola/Nelson (k = 0.19); Itsubo (k = 0.18); DeSmet/Kijowksi (k = 0.16); Satake (k = 0.12). When classifications/instability criteria were dichotomized into either a stable or unstable osteochondritis dissecans, there was more agreement for Hepple (k = 0.52; p = .002), Dipaola/Nelson (k = 0.38; p = .015), DeSmet/Kijowski (k = 0.42; p = .001) and Satake (k = 0.41; p < .001). Overall, agreement was not associated with the number of years in practice or the number of osteochondritis dissecans cases encountered per year (p > .05).

CONCLUSION

One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans. When making treatment decisions, one should rather use relatively simple distinctions (e.g. stable versus unstable osteochondritis dissecans; lateral wall intact versus not intact), as these are more reliable.

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.

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.

Failure of Surgery for Osteochondral Injuries of the Elbow in the Pediatric and Adolescent Population

PURPOSE OF REVIEW

With an increase in single-sport specialization, elbow injuries have become increasingly common in the pediatric and adolescent population. Osteochondritis dissecans (OCD) of the capitellum frequently requires intervention yet can be difficult to treat given high patient activity demands. The purpose of this paper is to review treatment options, understand failure rates, and provide strategies for successful revision surgery.

RECENT FINDINGS

Patients at high risk for the development of this condition are involved in high-demand upper extremity activity such as baseball or gymnastics. Treatment options include non-operative management, drilling, fixation, loose body removal/microfracture, osteochondral autograft, and osteochondral allograft. Cartilage preservation procedures (i.e., osteochondral autograft) have a significant advantage in terms of clinical and radiographic healing compared with fixation or microfracture. Capitellar OCD lesions afflict a large number of adolescent athletes today and will likely continue increasing in number from sports-related injuries. It is critical to recognize and treat these lesions in a timely and appropriate fashion to optimize clinical outcomes. When faced with failure of healing, surgeons must critically analyze reasons for failure including post-operative compliance, return to high-demand sporting activity, fixation of non-viable fragments, utilization of microfracture, alignment, and concomitant pathology.

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.

Closed-Wedge Osteotomy of the Distal Humerus for Treating Osteochondritis Dissecans of the Capitellum in Young Patients

Background

Even in patients with an open capitellar physis, nonsurgical treatment for advanced-stage osteochondritis dissecans (OCD) of the capitellum often yields poor outcomes. However, surgical methods for such patients are controversial. At our institution, we have consistently performed closed-wedge osteotomy of the distal humerus to treat advanced-stage OCD of the capitellum, regardless of the OCD grade or condition of the capitellar physis.

Purpose

To clarify the clinical and radiological results and determine the influence of the capitellar physis on closed-wedge osteotomy for advanced-stage OCD of the capitellum in young patients.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 32 patients with OCD of the humeral capitellum were treated surgically with closed-wedge osteotomy. Of these, 17 patients with more than 2-year follow-up were available for an evaluation. The mean patient age was 11.8 years (range, 11-12 years), and the mean follow-up period was 70.1 months (range, 25-184 months). The clinical assessment included range of motion, elbow pain, and the Japanese Orthopaedic Association (JOA) and Timmerman-Andrews scores. The radiological assessment at the final examination included cross-bridging of the physis, size and fishtail deformity of the distal part of the humerus, size of the radial head, healing of the OCD lesion, and osteoarthritis.

Results

The mean range of motion and JOA and Timmerman-Andrews scores improved significantly after surgery; 13 patients were completely pain free. In 11 patients with an open capitellar physis, metaphyseal-epiphyseal, cross-bridging was observed in 1 patient. A fishtail deformity of the distal part of the humerus was not observed. Healing of the OCD lesion was defined as excellent in 9 patients, good in 3, fair in 3, and poor in 2. In 3 of the 5 patients in whom healing was described as fair or poor, there was a lesion of the lateral widespread type with osteoarthritis before surgery. Moderate osteoarthritic changes were evident in 2 patients.

Conclusion

Closed-wedge osteotomy for the treatment of advanced-stage OCD of the capitellum in young patients can provide satisfactory clinical and radiological results. However, fair and poor outcomes were found in lateral widespread-type cases with osteoarthritis before surgery. We believe that patients in whom osteoarthritic changes have not yet appeared are eligible for closed-wedge osteotomy.

Donor Site Evaluation After Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans

BACKGROUND

Osteochondral autograft transplantation (OAT) for capitellar osteochondritis dissecans (OCD) requires harvesting of tissue from the asymptomatic knee joint. However, donor site morbidity (DSM) in such cases remains unclear.

PURPOSE

To evaluate DSM and postoperative radiographic findings in patients undergoing OAT for advanced capitellar OCD.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Eighty-six juvenile athletes underwent OAT for advanced capitellar OCD. The 2000 International Knee Documentation Committee subjective score, rate of return to sports, and symptoms in the donor knee were assessed at a mean follow-up of 86 months (range, 28-185 months). Additionally, 49 of the 86 patients were assessed by radiographic and magnetic resonance imaging (MRI) findings of the knee donor site. DSM was defined according to the usual criterion (persistent symptoms for >1 year or the need for subsequent intervention) and a stricter criterion (the presence of any symptoms, such as effusion, patellofemoral complaints, crepitation, unspecified disturbance, stiffness, pain/instability during activities, and osteoarthritic change). The stricter criterion was also used to allocate patients into a DSM group and a no-DSM group.

RESULTS

Two and 11 patients were determined to have DSM according to the usual and stricter criteria, respectively. All patients returned to the competitive level of their sports. The mean International Knee Documentation Committee score was 99.0. MRI findings showed abnormal signal intensity in 17 patients (35%) and hypertrophic changes in 11 patients (22%) at the donor harvest sites. The MOCART (magnetic resonance observation of cartilage repair tissue) score was higher in the no-DSM group (mean, 68.2) than in the DSM group (mean, 52.9) (P = .027).

CONCLUSION

OAT for juvenile athletes with advanced capitellar OCD provided good clinical outcomes. The DSM rate was relatively low (2.3%) with the usual criterion but high (12.8%) with the stricter criterion. MRI showed an abnormal signal intensity and hypertrophy in some cases.

Comparison of Antiaging Effects on Rat Skin of Cog Thread and Poly-L-Lactic Acid Thread

BACKGROUND

Polydioxanone Cog thread and poly-L-lactic acid (PLLA) thread have been used clinically for lifting and antiaging purposes. However, the histological changes in tissue and the efficacy of these 2 different types of thread have not been compared.

OBJECTIVE

This study used hematoxylin and eosin (H&E) staining, Masson's trichrome staining, and electron microscopy (EM) to compare the results associated with the use of Cog thread and PLLA thread in rat skin.

METHODS

Thirty female rats were divided into 3 groups of 10 rats each: a control group; a Cog group; and a PLLA group. Biopsy specimens obtained at 1, 3, and 6 months were examined using H&E, MT, and EM.

RESULTS

Although significant increases were observed in dermal thickness and the numbers of fibroblasts in the PLLA group compared with the control group within the first month (p: .019), there were no significant differences between the Cog and control groups during this period (p: .245). Dermal thickness (p: .002) and numbers of fibroblasts (p: .001) were similar in samples obtained from the PLLA and Cog groups at 3 and 6 months, and both groups showed significantly improved outcomes compared with the control group.

CONCLUSION

Poly-L-lactic acid and Cog sutures were effective in facial rejuvenation; both increased dermis thickness and stimulated collagen production.

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

PURPOSE OF THE REVIEW

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

RECENT FINDINGS

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

Implantable composite devices of unsintered hydroxyapatite and poly-l-lactide with dispersive marbling morphology to enhance in vivo bioactivity and bioresorbability

A bone fixation device made of unsintered hydroxyapatite (u-HA) particles uniformly dispersed in a poly-l-lactide matrix and reinforced by compressive forging (uniformly dispersed composite; UDC) has been clinically applied in several fields. However, it has reported some foreign body reactions over a long implantation period due to its slow bioresorbability. To further enhance its bioresorbability, we developed devices comprising a fibrous assembly of poly-l-lactide only three-dimensionally intertwined with particulate hydroxyapatite/poly-l-lactide composite. The biological behavior of the proposed material, provisionally referred to as complementarily reinforced composite (CRC), was compared with that of UDC in vivo. Cylindrical rods of UDC and CRC with 3.2-mm diameters were inserted bilaterally into the intramedullary distal femurs of 32 male Japanese white rabbits. Eight rabbits were euthanized at four, eight, 12, and 25 weeks after insertion. There were no significant differences between the mechanical properties of UDC and CRC over time. However, the results from histological analyses, surface characterization, radiological analyses, and push-out mechanical testing substantiated CRC's superior affinity to bone and enhanced bioactivity and bioresorbability in comparison with UDC. These characteristics were attributed to the dispersive marbling morphology produced by the CRC material's successive connectivity of u-HA particles throughout the PLLA matrix, which would accelerate PLLA hydrolysis degradation by H₂O intrusion and enhance the bioactivity of u-HA particles exposed on the interface soon after implantation.

Decreased Defect Size and Partial Restoration of Subchondral Bone on Computed Tomography After Arthroscopic Debridement and Microfracture for Osteochondritis Dissecans of the Capitellum

BACKGROUND

Arthroscopic debridement and microfracture are considered the primary surgical treatment for capitellar osteochondritis dissecans (OCD). Healing of the subchondral bone plays an essential role in cartilage repair, while lack of healing is related to the development of osteoarthritis. To date, it is unknown to what extent healing of the subchondral bone occurs after this technique in the elbow.

PURPOSE

To analyze defect size changes and subchondral bone healing with computed tomography (CT) after arthroscopic debridement and microfracture for advanced capitellar OCD.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2009 and 2016, 67 patients underwent arthroscopic debridement and microfracture for advanced capitellar OCD. Fifty-four patients (81% follow-up rate) with CT scans were included (mean ± SD: preoperative, 4.0 ± 1.7 months; postoperative, 29 ± 9.0 months). OCD defect size was assessed by measuring the largest diameter in 3 directions: medial-lateral direction (coronal plane) and anterior-posterior direction and depth (both in sagittal plane). Healing of the OCD was divided into 3 categories: good-complete osseous union or ossification; fair-incomplete osseous union or ossification but improved; poor-no changes between pre- and postoperative scans. Postoperative clinical outcome was assessed with the Oxford Elbow Score (OES) at the same time as the postoperative CT scan.

RESULTS

There were 30 female and 24 male patients (age, 15.7 ± 3.2 years). Defect size decreased ( P < .001) in all 3 directions (medial-lateral × anterior-posterior × depth) at 29 ± 9.0 months: preoperatively, 7.9 ± 2.8 × 8.0 ± 3.2 × 4.1 ± 1.5 mm; postoperatively, 3.5 ± 3.3 × 4.0 ± 3.5 × 1.6 ± 1.4 mm. Healing of the subchondral bone was graded as good in 19 defects (35%), fair in 27 (50%), and poor in 8 (15%). The mean postoperative OES score was 40 ± 8.4. Neither postoperative defect size nor healing grade correlated with the OES ( P > .05).

CONCLUSION

Arthroscopic debridement and microfracture for advanced capitellar OCD result in improved (ie, decreased) defect size at a mean follow-up of 29 months, both in width and in depth. Healing of the subchondral bone was either good or fair in 85%. Interestingly, CT findings did not correlate with clinical outcomes.

A matched quantitative computed tomography analysis of 3 surgical approaches for osteochondral reconstruction of the capitellum

BACKGROUND

The location of capitellar osteochondritis dissecans (OCD) lesions in the sagittal plane guides the surgical approach used for autologous osteochondral transplantation. We sought to compare the capitellar region accessible for orthogonal graft placement through 3 approaches: (1) posterior anconeus-split approach; (2) lateral approach with lateral collateral ligament (LCL) preservation (LCL-preserving lateral approach); and (3) lateral approach with LCL release (LCL-sacrificing lateral approach).

METHODS

The 3 approaches were sequentially performed on 9 cadaveric elbows: posterior anconeus-split approach, LCL-preserving lateral approach, and LCL-releasing lateral approach. The extent of perpendicular access was delineated with Kirschner wires. Each specimen underwent computed tomography. The accessible region was quantified as degrees on the capitellum and converted into time on a clock, where 0° corresponds to the 12-o'clock position. Generalized estimating equation modeling was used to investigate for significant within-specimen, between-approach differences.

RESULTS

The LCL-preserving and LCL-sacrificing lateral approaches provided more anterior perpendicular access than the posterior anconeus-split approach (mean, 0° vs 83°; P < .001). The posterior anconeus-split approach provided more posterior perpendicular access (mean, 215.0°; P < .001) than the LCL-preserving (mean, 117°; P < .001) and LCL-sacrificing (mean, 145°; P < .001) lateral approaches. The LCL-sacrificing lateral approach provided more posterior exposure than the LCL-preserving lateral approach (mean, 145° vs 117°; P < .001). The mean arc of visualization was greater for the LCL-sacrificing lateral approach than for the LCL-preserving lateral approach (145° vs 117°, P < .001).

CONCLUSIONS

A capitellar OCD lesion can be perpendicularly accessed from a posterior anconeus-split approach if it is posterior to 83° (2:46 clock-face position). A laterally based approach may be required for lesions anterior to this threshold. These data inform clinical decisions regarding the appropriate surgical approach for any OCD lesion.

Arthroscopic Management for Acetabular Rim Stress Fracture and Osteochondritis Dissecans in the Athlete With Hip Dysplasia

Intra-articular lesions are common in patients with acetabular hip dysplasia. Rim stress fractures (RSFs) have also been described in patients with acetabular hip dysplasia. This lesion is believed to be a result of an unfused secondary ossification center or a stress fracture that could be caused by repetitive impingement of an abnormal-shaped femoral head-neck junction. In addition, osteochondritis dissecans of the acetabulum is a rare condition that can also result from impingement and has been described in patients with hip dysplasia. Here, we describe an arthroscopic technique for internal fixation of osteochondritis dissecans of the acetabulum and concomitant RSF associated with hip dysplasia in a rhythmic gymnast.

Elbow Injuries in the Adolescent Thrower

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

What's New in Pediatric Upper Extremity Sports Injuries?

BACKGROUND

Sports injuries are common in pediatric and adolescent patients and the evaluation and treatment of these injuries continues to evolve. The purpose of this review is to provide a comprehensive appraisal of the most recent literature, highlighting updates on sports-related upper extremity injuries in pediatric patients.

METHODS

An electronic search of the PubMed, EMBASE, and Google Scholar databases was performed for keywords related to pediatric overhead athletes, osteochondritis dissecans (OCD) of the capitellum, medial epicondyle fractures, shoulder instability, and clavicle fractures. Search results were filtered by publication date to yield articles published electronically or in print on or after January 1, 2013 to May 30, 2017. Papers were selected based on expert opinion and consensus by the authors and included if deemed to have contributed important findings to the above topics.

RESULTS

A total of 51 articles were deemed to have contributed significant findings to the literature: 11 overhead athlete, 9 OCD of the capitellum, 6 medial epicondyle fractures, 17 shoulder instability, and 8 clavicle fractures. The level of evidence for most studies was either Level III or IV.

CONCLUSIONS

Overuse and traumatic conditions of the pediatric elbow including UCL tear, capitellar OCD, and medial epicondyle fractures represent a significant portion of injuries in the overhead athlete. Research in the prevention and treatment of primary and recurrent shoulder instability in young athletes continues to evolve. The operative treatment of clavicle fractures in adolescents has been increasing without a commensurate increase in the level of evidence supporting such treatment. Advances have been made in the treatment of sports-related upper extremity injuries in pediatric patients, however, high-level, comparative outcomes research in many areas is lacking and this review may help inform topics for future study.

LEVEL OF EVIDENCE

Level IV-Literature review.

Hip arthroscopy enables classification and treatment of precollapse subchondral insufficiency fracture of the femoral head associated intra-articular pathology

PURPOSE

The purposes of this study were to investigate (1) the clinical, radiographic and arthroscopic presentation of patients with subchondral insufficiency fracture of the femoral head (SIFFH) and (2) the outcomes following arthroscopic treatment with internal fixation using hydroxyapatite poly-lactate acid (HA/PLLA) threaded pins and concomitant arthroscopic treatment of associated findings.

METHODS

Nine patients (median age 49.0 years, range 43-65, five female and four male patients) with SIFFH who underwent arthroscopic treatment with labral repair, capsular closure and internal fixation of SIFFH using HA/PLLA pins were retrospectively reviewed. Inclusion criteria were adult patients with precollapse SIFFH with minimum 1-year follow-up (median follow-up 30.0 months, range 12-56).

RESULTS

Acetabular labral tears were observed in all patients. The median BMI was 24.3 kg/m² (range 20.1-31.8). Clinical presentations and radiographic measurements demonstrated mixed type FAI in six patients, borderline developmental dysplasia in two patients and pincer type FAI in one patient. The median MHHS significantly improved from preoperatively (67.1, range 36.3-78.0) to post-operatively (96.8, range 82.5-100; p = 0.001). The median NAHS significantly improved from preoperatively (34.0, range 17-63) to post-operatively (78.0 range 61-80; p = 0.001).

CONCLUSION

SIFFH is associated with bony deformities and labral tears. Precollapse SIFFH can be treated with bioabsorbable pin stabilization of unstable lesions and treatment of associated intra-capsular pathology in those with stable lesions as determined by a new arthroscopic classification system with promising early outcomes.

LEVEL OF EVIDENCE

IV.

Comparison of Clinical and Radiographic Outcomes Between Central and Lateral Lesions After Osteochondral Autograft Transplantation for Osteochondritis Dissecans of the Humeral Capitellum

BACKGROUND

Clinical studies have reported satisfactory results after osteochondral autograft transplantation (OAT) for central lesions of unstable osteochondritis dissecans (OCD) of the elbow. However, the outcomes after OAT for lateral lesions remain unclear.

HYPOTHESIS

The clinical outcomes of OAT would be better for central lesions than for lateral lesions.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors retrospectively evaluated 103 juvenile athletes (mean age, 13.2 years; range, 11-16 years) who underwent OAT for symptomatic OCD of the humeral capitellum from 2003 to 2014. Sixteen patients were excluded because they did not fit the inclusion criteria. The final cohort of 87 patients was divided by lesion type into central lesion (n = 43) and lateral lesion (n = 44) groups. When possible, a single large plug was created for grafting and trimmed to reconstruct the rounded joint surface. The clinical, radiographic, and magnetic resonance imaging outcomes were evaluated for each group at a mean follow-up of 43 months (range, 24-100 months).

RESULTS

There were no significant differences in the age, sex, height, weight, duration of symptoms, follow-up time, preoperative range of motion, or Timmerman and Andrews score between the 2 groups. The preoperative osteoarthritic changes (0 of 43 for central vs 5 of 44 cases for lateral; P = .023), mean lesion size (12.2 ± 2.9 vs 18.2 ± 7.0 mm; P < .001), and graft number (1.6 vs 2.8; P < .001) were significantly greater in the lateral group versus the central group. The mean range of extension (2.3° ± 5.4° vs -3.2° ± 8.7°; P < .001) and Timmerman and Andrews score (194 vs 185; P = .006) at the final follow-up were significantly better for patients in the central group. More patients in the lateral group had postoperative radial head subluxation (0 of 43 vs 6 of 44; P = .012) and osteoarthritic changes (1 of 43 vs 9 of 44; P = .008). The mean MOCART score showed no significant differences between the groups (78.0 ± 15.7 vs 72.6 ± 20.9; P = .181). The rate of return to sports at the previous level was 100% in the central group and 86% in the lateral group ( P = .012).

CONCLUSION

The clinical and radiographic outcomes after OAT associated with unstable OCD of the humeral capitellum were better for central lesions than for lateral lesions. However, satisfactory outcomes and a high rate of return to sports were obtained for unstable lateral lesions after OAT.

Osteochondritis dissecans of the capitellum: lesion size and pattern analysis using quantitative 3-dimensional computed tomography and mapping technique

BACKGROUND

The goals of this study were to evaluate the reliability of a quantitative 3-dimensional computed tomography (Q3DCT) technique for measurement of the capitellar osteochondritis dissecans (OCD) surface area, to analyze OCD distribution using a mapping technique, and to investigate associations between Q3DCT lesion quantification and demographic characteristics and/or clinical examination findings.

METHODS

We identified patients with capitellar OCD who presented to our orthopedic sports medicine practice between January 2001 and January 2016 and who had undergone a preoperative computed tomography scan (slice thickness ≤1.25 mm). A total of 17 patients with a median age of 15 years (range, 12-23 years) were included in this study. Three-dimensional polygon models were reconstructed after osseous structures were marked in 3 planes. Surface areas of the OCD lesion as well as the capitellum were measured. Observer agreement was assessed with the intraclass correlation coefficient (ICC). Heat maps were created to visualize OCD distribution.

RESULTS

Measurements of the OCD surface area showed almost perfect intraobserver agreement (ICC, 0.99; confidence interval [CI], 0.98-0.99) and interobserver agreement (ICC, 0.93; CI, 0.86-0.97). Measurements of the capitellar surface area also showed almost perfect intraobserver agreement (ICC, 0.97;CI, 0.91-0.99) and interobserver agreement (ICC, 0.86; CI, 0.46-0.96). The median OCD surface area was 101 mm² (range, 49-217 mm²). On the basis of OCD heat mapping, the posterolateral zone of the capitellum was most frequently affected. OCDs in which the lateral wall was involved were associated with larger lesion size (P = .041), longer duration of symptoms (P = .030), and worse elbow extension (P = .013).

CONCLUSIONS

The ability to quantify the capitellar OCD surface area and lesion location in a reliable manner using Q3DCT and a mapping technique should be considered when detailed knowledge of lesion size and location is desired.

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.

Visualization of the Capitellum During Elbow Arthroscopy: A Comparison of 3 Portal Techniques

Background:

Capitellar osteochondritis dissecans (OCD) is a debilitating condition of unknown etiology for which various arthroscopic treatments are available. Prior data suggest that greater than 75% of the capitellum can be visualized arthroscopically through a dual lateral portal approach. However, there is no literature assessing arthroscopic visualization of the capitellum via alternative portals.

Purpose:

To determine the percentage of capitellum visualized using the dual lateral, distal ulnar and soft spot, and posterolateral and soft spot portal configurations in a cadaver model.

Study Design:

Descriptive laboratory study.

Methods:

Arthroscopy was performed on 12 fresh-frozen cadaver elbows, 4 for each of the following approaches: dual lateral, distal ulna, and posterolateral. Electrocautery was used to mark the most anterior, posterior, medial, and lateral points seen on the capitellum. The radiocapitellar joint was subsequently exposed through an extensile posterior dissection, and the surface anatomy was reconstructed using the Microscribe 3D digitizing system. Using Rhinoceros software, the percentage of capitellum surface area visualized by each approach was determined.

Results:

The mean percentage of capitellum visualized for the dual lateral, distal ulna, and posterolateral approaches was approximately 68.8%, 66.3%, and 63.5%, respectively. There was no significant difference between the percentage of capitellum seen among approaches (P = .68). On average, 66.5% of the capitellum was visible through these 3 arthroscopic approaches to the elbow.

Conclusion:

Approximately 66.5% of the capitellum is visualized through the popularized posterior arthroscopic portals, with no significant differences found between the 3 investigated approaches.

Clinical Relevance:

As determined in this cadaveric model investigation, each portal technique provides equivalent visualization for capitellar OCD pathology.

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.

Osteochondritis dissecans of the elbow

Capitellar osteochondritis dissecans (OCD) can be a significant problem in adolescent overhead athletes. The cause is likely multifactorial secondary to repetitive stresses, biomechanical mismatch, and a tenuous vascular supply of the capitellum. Recent literature reveals that the prevalence is likely higher than previously thought. This, in conjunction with increased levels of athletic competition in children at younger ages, has fed the recent interest in this topic. The literature continues to show that non-operative treatment is still successful for stable lesions. Unstable lesions, therefore, have been the focus of the new literature regarding operative management and outcomes. The aim of this paper is to provide a summary of current literature and an up-to-date approach to the diagnosis, evaluation, and treatment of osteochondritis dissecans of the 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.

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.