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Klug A, Sauter M, Hoffmann R. [Bone-cartilage transfer for osteochondritis dissecans of the humeral capitellum]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2024; 36:198-210. [PMID: 39075306 DOI: 10.1007/s00064-024-00848-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/10/2023] [Accepted: 12/05/2023] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Treatment of focal cartilage defects of the humeral capitellum with autologous bone-cartilage cylinders to prevent development of arthritis of the elbow joint. INDICATIONS High-grade, unstable lesions (> 50% of the capitellum, grade III-IV according to Dipaola), including those involving the lateral edge of the capitellum and with a depth of up to 15 mm. CONTRAINDICATIONS Stable lesions and generalized osteochondritis of the capitellum (including Panner's disease), as well as a relative contraindication for lesions > 10 mm, as the largest punch has a maximum diameter of 10 mm. SURGICAL TECHNIQUE Arthroscopy of the elbow joint, transition to open surgery. First, the size of the cartilage defect in the capitellum is determined. Then, one (or several) osteochondral cylinders (OATS Arthex) are removed, which as far as possible completely encompass the defect zone. Corresponding intact bone-cartilage cylinders are obtained from the ipsilateral proximal lateral femoral condyle, each with a 0.3 mm larger diameter via an additive miniarthrotomy. The "healthy" cylinders are then inserted into the defect zone in a "press fit" technique. POSTOPERATIVE MANAGEMENT An upper arm cast in neutral position of the hand for 10-14 days, simultaneously beginning physiotherapy (active-assisted movements) and lymphatic drainage. As soon as painless range of motion (ROM) is restored (goal: by week 6), isometric training can be started. Resistance training starts from week 12. Competitive sports are only recommended after 6(-8) months. RESULTS The current state of research on the surgical treatment of OCD of the humeral capitellum using autologous osteochondral grafts shows mostly promising results. A recent meta-analysis of 24 studies reports a significantly higher (p < 0.01) rate of return to sports (94%) compared to fragment fixation (64%) or microfracture and debridement (71%) [41]. However, the increased donor-site morbidity must be taken into account (ca. 7.8%).
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Affiliation(s)
- Alexander Klug
- Unfallchirurgie und Orthopädische Chirurgie, BG Unfallchirurgie Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland.
| | - Matthias Sauter
- Unfallchirurgie und Orthopädische Chirurgie, BG Unfallchirurgie Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Reinhard Hoffmann
- Unfallchirurgie und Orthopädische Chirurgie, BG Unfallchirurgie Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
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van den Bekerom MPJ, de Klerk HH, van Riet R. Update in diagnosis, treatment, and prevention of osteochondritis dissecans of the capitellum. Shoulder Elbow 2024; 16:24-34. [PMID: 38425733 PMCID: PMC10901169 DOI: 10.1177/17585732231190011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 06/23/2023] [Accepted: 06/24/2023] [Indexed: 03/02/2024]
Abstract
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.
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Affiliation(s)
- Michel PJ van den Bekerom
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, The Netherlands
- Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Huub H de Klerk
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, The Netherlands
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, University Medical Center Groningen (UMCG) and Groningen University, Groningen, The Netherlands
| | - Roger van Riet
- Orthopedic Center Antwerp, Antwerp, Belgium
- Monica Hospital, Antwerp, Belgium
- University Hospital Antwerp, Antwerp, Belgium
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De Nordenflycht D, Matus G, Aravena JP, Toloza H. Osteochondritis dissecans of the temporomandibular joint: a scoping review. Oral Maxillofac Surg 2024; 28:29-38. [PMID: 36631710 DOI: 10.1007/s10006-022-01134-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 12/13/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE To perform a scoping review to identify the available evidence regarding osteochondritis dissecans (OCD) of the temporomandibular joint (TMJ). METHODS An electronic search of the PubMed, Web of Science and Scopus databases was performed using the following terms: 'Temporomandibular Joint Disorders', 'Osteochondritis Dissecans', 'Joint Loose Bodies' and 'Temporomandibular Joint'. Full-text articles were obtained from the records after applying the inclusion/exclusion criteria. RESULTS Ten articles were included in the analysis - six case reports, one case series, one retrospective study, one comparative study and one correlational study - with a total of 39 patients. The most frequently reported clinical presentation involved TMJ pain, locked jaw and articular noises (clicking and crepitus). The imaging methods used to identify OCD were radiographs, tomography, arthrography and magnetic resonance imaging. The reported imaging findings varied widely, but the most frequent were (single or multiple) calcified intra-articular loose bodies, signs of degenerative osseous changes, disc displacements, widening of the joint space and alterations in condylar morphology. Seven articles reported treatments (surgical or conservative), but the treatment outcome was not reported in all of the articles, which makes it difficult to make comparisons. CONCLUSION OCD of the TMJ may present various non-specific clinical characteristics, and given the heterogeneous imaging findings, multiplanar images are required for an accurate diagnosis. Finally, the results do not allow recommending a standard treatment for OCD of the TMJ.
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Affiliation(s)
- Diego De Nordenflycht
- Universidad Andres Bello, Faculty of Dentistry, Quillota # 980 Torre E, Viña del Mar, Chile.
| | | | | | - Héctor Toloza
- Universidad Andres Bello, Faculty of Dentistry, Quillota # 980 Torre E, Viña del Mar, Chile
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George A, Holderread BM, Phelps BM, Erwin ER, Singer W, Jack RA. Rehabilitation and return to sport criteria following surgical treatment of osteochondritis dissecans of the capitellum: a systematic review. JSES Int 2024; 8:355-360. [PMID: 38464452 PMCID: PMC10920138 DOI: 10.1016/j.jseint.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
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.
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Affiliation(s)
- Andrew George
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
| | | | - Brian M Phelps
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
| | - Emily R Erwin
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
| | - William Singer
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
| | - Robert A Jack
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
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Wegmann S, Hackl M, Krane F, Wegmann K, Mueller LP, Leschinger T. Accessibility of osteochondral lesion at the capitellum during elbow arthroscopy: an anatomical study. Arch Orthop Trauma Surg 2024; 144:1297-1302. [PMID: 38172435 PMCID: PMC10896769 DOI: 10.1007/s00402-023-05172-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/03/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION Osteochondrosis dissecans (OCD) at the capitellum is a common pathology in young patients. Although arthroscopic interventions are commonly used, there is a lack of information about the accessibility of the defects during elbow arthroscopy by using standard portals. MATERIALS AND METHODS An elbow arthroscopy using the standard portals was performed in seven fresh frozen specimens. At the capitellum, the most posterior and anterior cartilage surface reachable was marked with K-wires. Using a newly described measuring method, we constructed a circular sector around the rotational center of the capitellum. The intersection of K-wire "A" and "B" with the circular sector was marked, and the angles between the K-wires and the Rogers line, alpha angle for K-Wire "A" and beta angle for K-wire "B", and the corridor not accessible during arthroscopy was digitally measured. RESULTS On average, we found an alpha angle of 53° and a beta angle of 104°. Leaving a sector of 51° which was not accessible via the standard portals during elbow arthroscopy. CONCLUSION Non-accessible capitellar lesions during elbow arthroscopy should be considered preoperatively, and the informed consent discussion should always include the possibility of open procedures or the use of flexible instruments. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- S Wegmann
- Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | - M Hackl
- Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - F Krane
- Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - K Wegmann
- OCM (Orthopädische Chirurgie München) Clinic, Steinerstr. 6, 81369, Munich, Germany
| | - L-P Mueller
- Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - T Leschinger
- Faculty of Medicine and University Hospital, Center for Orthopedic and Trauma Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
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Bowman EN. Current concepts: pathology in the overhead athlete's lateral elbow. J Shoulder Elbow Surg 2024; 33:507-511. [PMID: 37774828 DOI: 10.1016/j.jse.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/10/2023] [Accepted: 08/20/2023] [Indexed: 10/01/2023]
Abstract
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.
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Affiliation(s)
- Eric N Bowman
- Department of Orthopaedics, Vanderbilt University Medical Center, Nashville, TN, USA.
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Oeding JF, Graden NR, Krych AJ, Sanchez-Sotelo J, Barlow JD, Camp CL. Early Arthroscopic Debridement May Be More Cost-Effective Than Nonoperative Management for Symptomatic Osteochondritis Dissecans Lesions of the Capitellum. Arthrosc Sports Med Rehabil 2024; 6:100836. [PMID: 38162589 PMCID: PMC10756960 DOI: 10.1016/j.asmr.2023.100836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/31/2023] [Indexed: 01/03/2024] Open
Abstract
Purpose To compare the cost-effectiveness of an initial trial of nonoperative treatment to that of early arthroscopic debridement for stable osteochondritis dissecans (OCD) lesions of the capitellum. Methods A Markov Chain Monte Carlo probabilistic model was developed to evaluate the outcomes and costs of 1,000 simulated patients undergoing nonoperative management versus early arthroscopic debridement for stable OCD lesions of the capitellum. Health utility values, treatment success rates, and transition probabilities were derived from the published literature. Costs were determined on the basis of the typical patient undergoing each treatment strategy at our institution. Outcome measures included costs, quality-adjusted life-years (QALYs), and the incremental cost-effectiveness ratio (ICER). Results Mean total costs resulting from nonoperative management and early arthroscopic debridement were $5,330 and $21,672, respectively. On average, early arthroscopic debridement produced an additional 0.64 QALYS, resulting in an ICER of $25,245/QALY, which falls well below the widely accepted $50,000 willingness-to-pay (WTP) threshold. Overall, early arthroscopic debridement was determined to be the preferred cost-effective strategy in 69% of patients included in the microsimulation model. Conclusion Results of the Monte Carlo microsimulation and probabilistic sensitivity analysis demonstrated early arthroscopic debridement to be a cost-effective treatment strategy for the majority of stable OCD lesions of the capitellum. Although early arthroscopic debridement was associated with higher total costs, the increase in QALYS that resulted from early surgery was enough to justify the cost difference based on an ICER substantially below the $50,000 WTP threshold. Level of Evidence Level III, economic computer simulation model.
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Affiliation(s)
- Jacob F. Oeding
- School of Medicine, Mayo Clinic Alix School of Medicine, Rochester, Minnesota, U.S.A
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway
| | - Nathan R. Graden
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Aaron J. Krych
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
| | | | - Jonathan D. Barlow
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A
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Long-term preservation of metacarpophalangeal joint function in traumatic defects by metatarsophalangeal osteochondral transplantation. Arch Orthop Trauma Surg 2023; 143:1109-1115. [PMID: 35680689 DOI: 10.1007/s00402-022-04492-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/18/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION The integrity of the metacarpophalangeal (MCP) joints is essential for finger and hand function. Preservation of range-of-motion is one of the aims in reconstruction of complex injuries to these joints. Osteochondral transplants have shown to be reliable in reconstruction of various joint defects. This series presents three patients with traumatic injuries to four MCP joints, which were reconstructed by seven avascular osteochondral transplants of metatarsophalangeal (MTP) joints. The joints were examined for radiographic signs of resorption or joint space narrowing, and if this would affect the joints' function in the long term. METHODS In three patients (40, 45 and 48 years) with complex injuries to their MCP joints (one milling, two saw injuries), four joints were reconstructed by three metatarsal head and four osteochondral transplants of the base of the proximal toe phalanges. Beside the joint itself, various soft tissue defects were reconstructed in each patient. The patients were clinically and radiographically examined after 9, 6, respectively, 7 years. RESULTS All patients were satisfied with the result without any pain in the MCP joints. Range-of-motion in the four affected joints rated 25, 60, 75, and 80°, DASH scores rated 13, 29, and 17, respectively. None of the patients complained of problems at their feet. Radiographic examination revealed moderate joint space narrowing in one of the four joints. In another patient, localized osteolysis was found around the screws' heads, so that the screws were removed 7 years post-op. CONCLUSIONS Osteochondral transplants for reconstruction of MCP defects are able to preserve function in severely injured joints even in the long term. Joint space narrowing may occur, which is not accompanied by pain, however. Since localized osteolysis can cause screw head prominence, mid-term radiographic follow-up is necessary to prevent damage to the joint. In the long term, remaining bone stock may be adequate for total joint replacement.
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Padaki AS, Allahabadi S, Pandya NK. Adolescent elbow osteochondral lesions following prior elbow fracture pinning. J Child Orthop 2022; 16:475-480. [PMID: 36483653 PMCID: PMC9723868 DOI: 10.1177/18632521221133814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 10/03/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Pinning of pediatric elbow fractures has been shown to be a safe procedure with a low complication profile. This study identified patients who underwent cartilage surgery for elbow osteochondral lesions or osteochondritis dissecans who had prior ipsilateral elbow pinning. METHODS Records of patients who underwent ipsilateral cartilage surgery for osteochondritis dissecans and prior percutaneous pinning for elbow fractures were identified. Demographics were compiled and the clinical, radiographic, and surgical results were tabulated for patients with at least 1-year of follow-up from initial presentation. RESULTS In total, 6/52 (11.5%) pediatric patients from 2012 to 2021 who underwent isolated elbow osteochondritis dissecans surgery (mean age at surgery 13.4 ± 1.5 years) had a history of ipsilateral elbow pinning (mean age at surgery 6.9 ± 2.4 years). Of these, five had a history of a supracondylar fracture while one patient sustained a lateral condyle fracture. Overall, three of six patients had mechanical symptoms at presentation and three had abnormal radiographs. All patients underwent pre-operative magnetic resonance imaging and the five patients with an osteochondritis dissecans lesion <1cm2 underwent arthroscopy and microfracture while one with a 4-cm2 lesion underwent open osteochondral allograft transfer. All patients demonstrated improved motion at final follow-up and all patients were able to return to full desired activity following surgery. CONCLUSION This study demonstrates that the history of elbow fracture pinning may predispose patients to future elbow chondral injuries in adolescence. Although patients appear to do well following consequent osteochondritis dissecans surgery, patients and parents may be advised of possible association of elbow pinning and elbow osteochondral lesions. LEVEL OF EVIDENCE III, case-control study.
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Affiliation(s)
- Ajay S Padaki
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Sachin Allahabadi
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Nirav K Pandya
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA,Benioff Children’s Hospital Oakland, University of California San Francisco, Oakland, CA, USA,Nirav K Pandya, Department of Orthopaedic Surgery, Benioff Children’s Hospital Oakland, University of California San Francisco, 747 52nd Street, Oakland, CA 94609, USA.
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