Predictors of Failure of Return to Play in Youth Baseball Players After Capitellar Osteochondritis Dissecans: Focus on Elbow Valgus Laxity and Radiocapitellar Congruity

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.

Current concepts: pathology in the overhead athlete's lateral elbow

The lateral elbow is subjected to increasing compressive force in response to repetitive valgus stress. Alterations or deficiencies in overhead mechanics and the kinetic chain may predispose an athlete to injury. Evaluation includes a focused elbow physical examination and imaging, supplemented by a robust screening of core strength, balance, and mechanics of the kinetic chain. Treatment of osteochondritis dissecans, a common lateral elbow pathology, varies based on stability of the lesion, with variable, but often positive outcomes. Proper pitching mechanics, kinetic chain integrity, and workload management provide potential opportunities for prevention.

Return to Sport and Clinical Outcomes Following Osteochondral Autograft Transplantation in Baseball Players and Gymnasts With Unstable Osteochondritis Dissecans: A Critically Appraised Topic

CLINICAL SCENARIO

Osteochondritis dissecans (OCD) of the capitellum is a condition occurring at the elbow and often seen in both baseball players and gymnasts due to the repetitive loading of the radiocapitellar joint. Treatment options for OCD vary and are dependent on lesion presentation, elbow motion, and growth plate maturity. OCD lesions categorized as unstable can be treated with an osteochondral autograft transplantation surgery (OATS).

FOCUSED CLINICAL QUESTION

In an adolescent population, what are the return to sport rates and clinical outcomes following OATS in baseball players and gymnasts with unstable OCD lesions?

SUMMARY OF KEY FINDINGS

Three articles met the inclusion criteria for this appraisal, and all indicate an OATS procedure should be considered in the management of unstable OCD lesions. Return to play outcomes were favorable for both baseball players and gymnasts. Self-reported patient function and elbow extension all improved following an OATS.

CLINICAL BOTTOM LINE

An OATS procedure is a favorable option for the management of OCD lesions of the elbow in baseball players and gymnasts.

STRENGTH OF RECOMMENDATION

There is level B evidence to support return to sport and clinical outcomes in baseball players and gymnasts following an OATS procedure. This score is directly related to the quality of evidence that currently exists on the topic.

Outcomes following arthroscopic posteromedial osteophyte resection and risk of future ulnar collateral ligament reconstruction

BACKGROUND AND HYPOTHESIS

Despite successful return-to-sport (RTS) outcomes after posteromedial osteophyte resection, one possible consequence of osteophyte removal is increased stress on the ulnar collateral ligament (UCL), leading to a UCL injury. It is currently unknown how often overhead athletes who undergo isolated posteromedial osteophyte resection subsequently require UCL reconstruction (UCLR). Therefore, the purpose of this study was to report outcomes following arthroscopic resection of posteromedial osteophytes in overhead athletes and determine whether overhead athletes who underwent arthroscopic posteromedial osteophyte resection for posteromedial impingement went on to require UCL surgery. We hypothesized that there would be a high rate of RTS following osteophyte resection and that players who underwent arthroscopic posteromedial osteophyte resection would have a >10% risk of requiring subsequent UCLR or UCL repair.

MATERIALS AND METHODS

All patients who underwent elbow arthroscopy from 2010-2020 at a single institution were reviewed. Patients were included if they underwent isolated arthroscopic posteromedial osteophyte resection without concomitant UCL surgery, were overhead athletes at the onset of posteromedial impingement symptoms, and had no history of elbow surgery. Primary outcomes included RTS rate, complications, and subsequent shoulder and/or elbow injury and surgery, as well as several patient-reported outcome measures (Kerlan-Jobe Orthopaedic Clinic score, Timmerman-Andrews elbow score, and Conway-Jobe score).

RESULTS

Overall, 36 overhead athletes were evaluated at 5.1 ± 3.4 years postoperatively, including 28 baseball pitchers, 3 baseball catchers, 3 softball players, 1 tennis player, and 1 volleyball player. Of the overhead athletes, 77% were able to RTS; the mean Kerlan-Jobe Orthopaedic Clinic and satisfaction scores were 70 and 75, respectively; and 89% of athletes had either excellent (73%) or good (16%) Conway-Jobe scores at long-term follow-up. Subsequent UCLR was required in 18% of baseball pitchers (n = 5) at a median of 13 months postoperatively. Of the 5 UCLRs, 3 were performed shortly after posteromedial osteophyte resection (6, 7, and 13 months postoperatively) whereas the other 2 were performed at 6.2 and 7.5 years postoperatively.

CONCLUSION

Following arthroscopic posteromedial osteophyte resection, 77% of athletes were able to RTS. Baseball pitchers who undergo arthroscopic resection of posteromedial osteophytes for posteromedial impingement have an 18% risk of subsequent UCLR.

Physical Function, to Be or Not to Be a Risk Factor for Osteochondritis Dissecans of the Humeral Capitellum?

Background

Physical risk factors for osteochondritis dissecans (OCD) of the humeral capitellum in young baseball players have not been fully elucidated. We aimed to identify the risk factors for capitellar OCD in baseball players aged 8-14 years.

Methods

Between December 2018 and December 2019, young baseball players were recruited from 8 regional baseball leagues. Ultrasonography and physical assessments were performed preseason and at the end of the study period. Bilateral passive ranges of motion (ROM) of horizontal adduction of the shoulders, internal rotation (IR) of the hips, and the thoracic kyphosis angle were measured. 1-year follow-ups were scheduled to determine the occurrence of OCD. Players with OCD were categorized into an OCD group; those without OCD and any elbow pain for one year were categorized into a non-injured group. The players’ baseline data (age, sex, position in baseball, and Rohrer's Index) were analyzed using univariate analyses. Their physical parameters were analyzed using two-way analysis of variance with repeated measures to investigate OCD-related risk factors.

Results

In total, 3651 baseball players attended the 1-year follow-up. Of these, 71 (1.9%) players had OCD of the humeral capitellum. In the OCD group, a significant association was found at baseline and at the end of the study period between a higher Rohrer index at the baseline and a smaller hip IR ROM on the nondominant side.

Conclusions

Loss of hip IR ROM on the nondominant side is a newly discovered risk factor related to physical function in the development of OCD.

Common Upper Extremity Injuries in Pediatric Athletes

PURPOSE OF REVIEW

The aim of this study is to review the most recent literature on common upper extremity injuries in pediatric athletes and discuss their diagnosis, management, and outcomes. We also highlight ultrasound as a tool in their evaluation.

RECENT FINDINGS

Shoulder conditions presented include little league shoulder, glenohumeral rotation deficit, acute traumatic shoulder dislocation, and multidirectional shoulder instability. Elbow conditions include capitellar OCD, medial epicondyle avulsion fracture, and medial epicondylitis. We also review scaphoid fractures and gymnast wrist. Not all physeal injuries lead to long-term growth disruption. Ultrasound has been shown to be useful in the diagnosis of scaphoid fracture, medial epicondyle avulsion fractures, and capitellar OCD. It can also be helpful in assessing risk for shoulder and elbow injuries in overhead athletes. There is a rising burden of upper extremity injuries among pediatric athletes. Knowledge of their sport specific mechanics can be helpful in diagnosis. As long-term outcome data become available for these conditions, it is clear, proper diagnosis and management are critical to preventing adverse outcomes. We highlight many of these injuries, best practice in care, and controversies in care in hopes of improving outcomes and preventing injury for pediatric athletes.