Osteochondritis dissecans of the elbow: excellent results in teenage athletes treated by arthroscopic debridement and microfracture

Fresh Osteochondral Allograft Transplantation of the Capitellum for the Treatment of Osteochondritis Dissecans

BACKGROUND

Osteochondritis dissecans (OCD) of the humeral capitellum is a rare and challenging condition to treat. Several surgical options exist, but in the last few years, the pendulum has swung from debridement and microfracture to restoration of the articular surface. Osteochondral autografts from the rib and knee have been described, but donor-site morbidity is a concern.

PURPOSE

To expand the results of fresh osteochondral allograft transplantation (FOCAT) in a previously published report with inclusion of additional patients and a longer follow-up period.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

After institutional review board approval, the charts of patients who underwent FOCAT for OCD of the capitellum between 2006 and 2022 by a single surgeon were reviewed. The majority of cases (94%) had unstable lesions (Minami grades 2 and 3). A trial of nonoperative treatment had failed in all. All patients underwent diagnostic arthroscopy, followed by a mini-open, ligament-sparing approach with grafting using commercially available guides and instruments.

RESULTS

A total of 35 patients were identified, of whom 25 were male. The mean age was 16 ± 3.9 years (range, 11-32 years). There were 24 baseball players (19 pitchers and 5 position players), 5 gymnasts, 3 cheerleaders/tumblers, 1 tennis player, 1 student (who did not participate in athletics), and 1 patient with avascular necrosis from chemotherapy. Eighteen patients had a mean flexion contracture of 14.1°± 11.9°. A single osteochondral allograft plug was used in 23 patients (mean diameter, 11.3 ± 2.8 mm), and 12 patients required 2 plugs (Mastercard technique). The mean follow-up was 92.6 ± 54.5 months (range, 24-204 months). There was significant improvement in Oxford (from 25.5 ± 4.9 to 46.7 ± 3.5; P < .00001) and visual analog scale for pain (from 7.5 ± 2 to 0.3 ± 1.0; P < .0001) scores. The mean Single Assessment Numeric Evaluation score at the time of follow-up was 90.6 ± 10.8 (range, 60-100). In overhead athletes, there was significant improvement in the Kerlan-Jobe Orthopaedic Clinic score (from 40.8 ± 11.8 to 90.6 ± 10.8; P < .00001). A postoperative magnetic resonance imaging scan was obtained in 16 (46%) patients at a mean of 32.6 months. In all cases, the graft was incorporated. All overhead athletes were able to return to their sport and perform at the same level or higher for >2 years. Two elbows required a subsequent arthroscopy for loose-body removal; otherwise, there were no other complications.

CONCLUSION

FOCAT is an excellent option for treating OCD lesions of the humeral capitellum. Excellent outcomes and high return-to-sport rates were observed, with midterm follow-up showing no graft failures. FOCAT eliminates donor-site morbidity.

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.

Arthroscopy and Microfracture for Osteochondritis Dissecans of the Capitellum in Adolescent Athletes Shows Favorable Return to Sport: A Systematic Review

PURPOSE

To assess return to sport (RTS) in the high-risk young athlete population with capitellar osteochondritis dissecans (OCD) undergoing arthroscopic microfracture (MFX) with or without debridement as well as associated indications, clinical outcomes, radiographic outcomes, and complications.

METHODS

A literature search of all published literature in the English language from PubMed, EMBASE, Scopus, and Cochrane from database inception to April 4, 2022, was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included studies presented demographics and outcomes for adolescent (<21 years old) patients diagnosed with capitellar OCD who underwent arthroscopic MFX (or drilling/subchondral drilling) or MFX (or drilling/subchondral drilling) with debridement (or loose body removal/chondroplasty). Studies containing multiple surgical techniques that did not distinguish characteristics and outcomes of individual patients by surgical technique were excluded. Additionally, if there was overlap in patient populations between 2 studies, the study with less outcome data was excluded. Extracted data included study properties, patient demographics, lesion characteristics, surgery details, and patient outcomes, including range of motion, outcome scores, and RTS rates. Bias was assessed via the Methodological Index for Non-Randomized Studies (MINORS).

RESULTS

Nine studies of 136 patients and 138 elbows met criteria. Included articles were published between 2005 and 2020 with MINORS scores of 8 to 14 (50% to 88%). The age ranged from 12.7 to 15.7 years with most patients being involved in baseball or gymnastics and a rate of dominant elbow involvement of 55% to 100%. Patient follow-up ranged from 16 to 138 months. All 9 studies reported RTS, ranging from 65% to 100%. Six of these studies categorized the level to which the patient returned, with patients RTS at the same level of competition ranging from 60% to 100%. Six studies reported complications, with a range rate of 0% to 43%; there were a total of 10 complications, 7 of which required reoperations.

CONCLUSIONS

Arthroscopic MFX with or without arthroscopic debridement is a safe and effective treatment for OCD lesions of the capitellum in young, athletic patients. Included studies reported improved clinical, radiographic, and patient-reported outcomes. Aside from 1 study reporting an RTS of 65%, the rate of RTS ranged from 86% to 100%. The percentage of patients returning to sport at the same level of competition ranged from 60% to 100% with a time to RTS ranging from 4.1 to 5 months. A single study reported a complication rate of 43%, while remaining studies reported complication rates between 0% and 19%, with loose bodies being the most common complication requiring reoperation. Follow-up ranged from 16 to 138 months.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

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.

Accessibility of osteochondral lesion at the capitellum during elbow arthroscopy: an anatomical study

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

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

Purpose

To (1) report the long-term outcomes associated with both operative and nonoperative management of capitellar osteochondritis dissecans (OCD), (2) identify factors associated with failure of nonoperative management, and (3) determine whether delay in surgery affects final outcomes.

Methods

All patients who received a diagnosis of capitellar OCD from 1995-2020 within a geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. The cohort was divided into 3 groups: (1) nonoperative management, (2) early surgery, and (3) delayed surgery. Delayed surgery (surgery ≥6 months after symptom onset) was considered failure of nonoperative management.

Results

Fifty elbows with a mean follow-up period of 10.5 years (median, 10.3 years; range, 1-25 years) were studied. Of these, 7 (14%) were definitively treated nonoperatively, 16 (32%) underwent delayed surgery after at least 6 months of failed nonoperative treatment, and 27 (54%) underwent early surgical intervention. When compared with nonoperative management, surgical management resulted in superior Mayo Elbow Performance Index pain scores (40.1 vs 33, P = .04), fewer mechanical symptoms (9% vs 50%, P < .01), and better elbow flexion (141° vs 131°, P = .01) at long-term follow-up. Older patients trended toward increased failure of nonoperative management (P = .06). The presence of an intra-articular loose body predicted failure of nonoperative management (P = .01; odds ratio, 13). Plain radiography and magnetic resonance imaging had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes after early versus delayed surgical management were not observed.

Conclusions

Nonoperative management of capitellar OCD failed 70% of the time. Elbows that did not undergo surgery had slightly more symptoms and decreased functional outcomes compared with those treated surgically. The greatest predictors of failure of nonoperative treatment were older age and presence of a loose body; however, an initial trial of nonoperative treatment did not adversely impact the success of future surgery.

Level of Evidence

Level III, retrospective cohort study.

Overuse Elbow Injuries in Youth Gymnasts

BACKGROUND

Gymnastics is a unique sport that places significant loads across the growing elbow, resulting in unique overuse injuries, some of which are poorly described in the current literature.

PURPOSE

To provide a comprehensive review of the unique overuse elbow injuries seen in youth gymnasts and to provide an up-to-date synthesis of the available literature and clinical expertise guiding treatment decisions in this population.

STUDY DESIGN

Narrative review.

METHODS

A review of the PubMed database was performed to include all studies describing elbow biomechanics during gymnastics, clinical entities of the elbow in gymnasts, and outcomes of operative and/or nonoperative treatment of elbow pathology in gymnasts.

RESULTS

Participation in gymnastics among youth athletes is high, being the sixth most common sport in children. Early specialization is the norm in this sport, and gymnastics also has the highest number of participation hours of all youth sports. As a result, unique overuse elbow injuries are common, primarily on the lateral side of the elbow. Beyond common diagnoses of radiocapitellar plica and osteochondritis dissecans of the capitellum, we describe a pathology unique to gymnasts involving stress fracture of the radial head. Additionally, we synthesized our clinical experience and expertise in gymnastics to provide a sport-specific rehabilitation program that can be used by providers treating surgical and nonsurgical conditions of the elbow and wishing to provide detailed activity instructions to their athletes.

CONCLUSION

Overuse injuries of the elbow are common in gymnastics and include osteochondritis dissecans of the capitellum, radiocapitellar plica syndrome, and newly described radial head stress fractures. A thorough understanding of the psychological, cultural, and biomechanical aspects of gymnastics are necessary to care for these athletes.

Magnetic Resonance Imaging Assessment of Cartilage Appearance Following Marrow Stimulation of Osteochondritis Dissecans of the Humeral Capitellum

PURPOSE

Osteochondritis dissecans (OCD) of the capitellum is often treated by marrow stimulation techniques with good long-term outcomes. Magnetic resonance imaging (MRI) can be used to characterize the healing of cartilage repair tissue. However, no formal system exists for assessment of cartilage healing after marrow stimulation in capitellar OCD. The aims of this study were to describe the postoperative MRI appearance of capitellar repair cartilage after debridement and marrow stimulation for capitellar OCD and assess differences between symptomatic and asymptomatic patients.

METHODS

This was a retrospective study of patients with capitellar OCD who underwent arthroscopic debridement and marrow stimulation and had a postoperative MRI to assess healing. The classification system developed by Marlovits and colleagues (Magnetic Resonance Observation of Cartilage Repair Tissue) was used to quantitatively profile the cartilage repair tissue in comparison to adjacent "normal" cartilage. Study participants completed an online survey to correlate outcomes with cartilage appearance.

RESULTS

Eleven patients who underwent MRI for routine evaluation (asymptomatic), and 18 who underwent MRI for symptoms were identified. Overall, 59% of defects were completely filled, and in 83%, the cartilage surface had ulcerations or fibrillations. The cartilage variables were similar between symptomatic and asymptomatic patients. Capitellar subchondral bone edema was observed on the MRI of every patient who underwent a reoperation and was present in only 62% of those who did not. Clinical scores did not correlate with MRI cartilage findings, but the small sample size limited conclusions regarding clinical outcomes related to postoperative cartilage features seen on MRI.

CONCLUSIONS

This detailed assessment of cartilage appearance by MRI after marrow stimulation for capitellar OCD demonstrated that incomplete cartilage fill was common in both symptomatic and asymptomatic patients. Those requiring a second surgery were more likely to demonstrate subchondral bone edema.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

Pediatric elbow arthroscopy: clinical outcomes and complications after long-term follow-up

BACKGROUND

Elbow arthroscopy is becoming increasingly important for the treatment of a wide range of acute and chronic elbow pathologies. Even if elbow arthroscopy is technically demanding, in the pediatric population this minimally invasive technique is preferred by many surgeons for the treatment of pathologies such as osteochondritis dissecans (OCD), posttraumatic stiffness (PTS), or elbow posterior impingement (PI). The aim of this study is to evaluate outcomes and safety of elbow arthroscopy in the pediatric and adolescent population after long-term follow-up.

MATERIALS AND METHODS

In this retrospective study, 26 patients younger than 18 years old undergoing elbow arthroscopy were evaluated. All surgeries were performed by a single senior surgeon. Patients were divided into three subgroups based on preoperative diagnosis: OCD, PTS, and PI. After at least 60 months follow-up, several outcome measures, including range of motion (ROM), Mayo Elbow Performance Score (MEPS), and visual analog scale (VAS) were evaluated in relation to preoperative values. The level of patient satisfaction on a five-level Likert scale, any limitation or change in sport activity, and the onset of any possible complications were also evaluated.

RESULTS

In the study population, we found an improvement in ROM (flexion of 14.4 ± 13.6°, extension of 19.5 ± 13.9°, pronation of 5.8 ± 5.7°, and supination of 8.5 ± 11.6°) and in validated outcome measures (MEPS of 21.0 ± 13.5 points and VAS of 3.8 ± 2.2 points). The satisfaction rate was 4.5, with no dissatisfaction. Eighty-seven percent of patients fully recovered their performance levels, 9% changed sport, and 4% were unable to return to sport. We identified one major and one minor complication, with an overall complication rate of 7.7%. No neurovascular injuries were detected.

CONCLUSIONS

Elbow arthroscopy in a pediatric population can be considered an effective and safe procedure for selected pathologies when performed by an experienced surgeon. At long-term follow-up, we reported excellent clinical outcomes (both objective and subjective), with a relatively low complication rate without permanent injuries.

LEVEL OF EVIDENCE

Level IV-case series.

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.

Early Improvement in Patient-Reported Outcome Scores After Operative Treatment of Osteochondritis Dissecans of the Humeral Capitellum

PURPOSE

Outcome measures that lack sensitivity for the detection of clinical changes early after surgery for capitellar osteochondritis dissecans (OCD) make it difficult to determine the optimal treatment for these defects. We sought to evaluate the early responsiveness of patient-reported outcomes measurement information system (PROMIS) scores in a cohort of patients operatively treated for capitellar OCD.

METHODS

Four PROMIS questionnaires (mobility, upper extremity [UE], pain interference, and peer relations) were electronically administered to patients treated for capitellar OCD at a single tertiary academic medical center between January 1, 2015, and July 1, 2018. The questionnaires were administered at the initial preoperative outpatient clinic visit as well as at the 2-week, 6-week, and final return-to-play (RTP) visits.

RESULTS

Twenty-nine patients (31 elbows, mean age 12.9 years) with available preoperative and postoperative PROMIS data were included. The mean final follow-up period was 26 weeks. Compared with that before surgery, there was a significant improvement in the mobility, pain interference, and UE scores at 6 weeks following surgery. The scores improved most significantly by 6 weeks, reached a relative plateau, and remained significantly improved through the RTP visit thereafter. Patients with preoperative, intra-articular loose bodies scored significantly better than those without them during the 6-week and RTP visits. Patients with lesions >1 cm², compared with those with lesions ≤1 cm², demonstrated greater improvement in the UE scores during the RTP visit.

CONCLUSIONS

In patients undergoing operative treatment for capitellar OCD, a significant improvement in the PROMIS domains of mobility, pain interference, and UE can be expected early in the postoperative period, with majority of patients reaching their greatest improvement in scores by 6 weeks following surgery.

CLINICAL RELEVANCE

This is important information for preoperative counseling. In addition, this information is helpful in confirming that PROMIS scores are responsive in the detection of changes in outcomes during the early postoperative period in this population.

Performance of Patient-Reported Outcomes Measurement Information System (PROMIS) scores compared with legacy metrics in evaluating outcomes after surgical treatment for osteochondritis dissecans of the humeral capitellum

BACKGROUND

Patient-Reported Outcomes Measurement Information System (PROMIS) scores have not previously been used to measure long-term outcomes in operatively treated capitellar osteochondritis dissecans (OCD) patients. The aims of our study were to (1) assess patients' long-term outcomes using PROMIS scores, (2) compare the performance of PROMIS with other validated elbow legacy metrics, and (3) evaluate ceiling and floor effects in these outcome measures in patients undergoing surgical treatment for capitellar OCD.

METHODS

We evaluated demographic characteristics, procedure details, preoperative PROMIS scores, and associated sports information in surgically treated pediatric capitellar OCD patients. An online survey was sent to the study participants, including the Kerlan-Jobe Orthopaedic Clinic (KJOC) shoulder and elbow score, the quick Disabilities of the Arm, Shoulder and Hand questionnaire, and the Liverpool Elbow Score patient-answered questionnaire, as well as the Mobility, Pain Interference, and Upper Extremity questionnaires from the PROMIS pediatrics bank. Correlations were evaluated between outcome measures. Ceiling and floor effects were evaluated for each outcome measure.

RESULTS

Completed surveys were obtained for 57 patients (59 elbows). The mean patient age at surgery was 14 years (range, 10-18 years). The mean follow-up time was 6 years (standard deviation, 5 years; range, 1-18 years). The mean PROMIS Mobility score improved from 41.2 preoperatively to 55.2 postoperatively (P < .001). The mean Pain Interference score decreased from 46.9 preoperatively to 38 postoperatively (P < .001). The mean Upper Extremity score improved from 42.7 preoperatively to 53.2 postoperatively (P < .001). Significant correlations were observed between all legacy metrics and postoperative PROMIS scores (|r| > 0.54, P < .001). Ceiling or floor effects were seen in all legacy metrics and PROMIS scores. The KJOC score was least affected by ceiling or floor effects.

CONCLUSION

There is a strong correlation between PROMIS scores and legacy measures evaluating outcomes after surgical management of capitellar OCD. However, large ceiling and floor effects were present in all measures, likely owing to the favorable clinical results. The KJOC score was limited the least by ceiling and floor effects.

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.

Both Debridement and Microfracture Produce Excellent Results for Osteochondritis Dissecans Lesions of the Capitellum: A Systematic Review

Purpose

To analyze the available literature pertaining to the indications, outcomes, and complications of both microfracture (MFX) and simple debridement for capitellar osteochondritis dissecans (OCD).

Methods

A comprehensive literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Studies were included if they evaluated OCD of the capitellum that underwent either arthroscopic debridement (AD) or MFX. The risk of bias was assessed using the Methodological Index for Non-randomized Studies (MINORS) scale. Patient demographic characteristics, imaging findings, return-to-sport rates, patient-reported outcomes, range of motion (ROM), complications, failures, and reoperations were recorded.

Results

Eleven studies with 327 patients (332 elbows) met the inclusion criteria. Methodological Index for Non-randomized Studies (MINORS) scores ranged from 63% to 75% and showed considerable heterogeneity. Both AD and MFX showed improvement in patient outcome scores, ROM, and return to play, although the data precluded relative conclusions. Improvement in motion after MFX ranged from 4.9° to 5° of flexion, 5° to 22.6° of extension, 1° to 2° of pronation, and 0.5° to 2° of supination, whereas after AD, it ranged from –4° to 6° of flexion and –0.4° to 14° of extension, with prono-supination noted in only 1 study. The rate of return to play at a similar level of preinjury athletic competition ranged from 55% to 75% after MFX and from 40% to 100% after AD. Lesion location was discussed in only 1 study. Postoperative imaging trended toward early degenerative changes, most commonly of the radial head. Complications were only reported in 1 MFX study; in all cases, the complication was transient ulnar nerve neurapraxia. Reoperation rates ranged from 0% to 10%, and reoperation was most commonly performed to address radial head enlargement. Five studies reported no reoperations.

Conclusions

Both AD and MFX for capitellar OCD appear to yield excellent improvements in pain, ROM, patient outcome scores, and return to sport. Given that comparable mid-term outcomes can be achieved with debridement alone, without the use of MFX, similarly to recent prospective studies in the knee, AD alone may be a reasonable approach to relatively small OCD defects.

Level of Evidence

Level IV, systematic review of studies, all Level IV evidence.

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.

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.

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

Background:

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

Purpose:

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

Study Design:

Case series; Level of evidence, 4.

Methods:

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

Results:

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

Conclusion:

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

Predictive Role of Symptom Duration Before the Initial Clinical Presentation of Adolescents With Capitellar Osteochondritis Dissecans on Preoperative and Postoperative Measures: A Systematic Review

Background:

Osteochondritis dissecans (OCD) of the capitellum is an increasingly recognized disease affecting young athletes. Because lesion progression is common, early identification is potentially beneficial for an athlete’s treatment and recovery. However, there is currently no analysis available that evaluates the impact of symptom duration on preoperative and postoperative outcomes.

Purpose/Hypothesis:

The purpose of this study was to perform a systematic review of surgically treated OCD lesions to examine the effect of symptom duration before the initial presentation on preoperative and postoperative outcomes. We hypothesized that a longer symptom duration would correlate with more severe preoperative signs and symptoms and poorer postoperative outcomes.

Study Design:

Systematic review; Level of evidence, 4.

Methods:

Ovid MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and the Database of Abstracts of Reviews of Effects were queried for studies evaluating symptom duration before the clinical presentation of capitellar OCD and surgical outcomes. A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Results:

A total of 23 studies reporting outcomes in 258 patients (mean patient age, 14.4 ± 1.5 years) were analyzed. Locking as a chief complaint predominated in a greater proportion of patients who presented with a longer history of OCD symptoms (P = .007). A longer symptom duration also correlated with a longer time to return to sport (P = .008) and older age (P < .001). Range of motion limitations as both a chief complaint and a physical examination finding correlated with a longer symptom duration (P = .014 and .001, respectively). Symptom duration did not show a relationship with most postoperative outcomes, including the return-to-sport rate (P = .172), which ranged from 70.7% to 91.1% depending on the surgical procedure performed. No significant difference was observed between symptom duration and the surgical procedure performed (P = .376).

Conclusion:

Advanced OCD lesions were observed in patients with a longer symptom duration. However, treatment specifics rather than symptom duration correlated best with return to sport for patients with advanced OCD lesions requiring surgery. The earlier detection of capitellar OCD may be valuable in reducing the severity of lesions, the time to return to sport, and potential need for surgery in young athletes.

Demographics and Epidemiology of Osteochondritis Dissecans of the Elbow Among Children and Adolescents

Background

Osteochondritis dissecans (OCD) of the elbow is a disorder of subchondral bone and articular cartilage, of which the incidence among children is not clearly known.

Purpose

To assess the demographics and epidemiology of OCD of the elbow among children.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A retrospective chart review of an integrated health system for the years 2007 through 2011 was performed for patients with elbow OCD aged 2 to 19 years. Lesion location, laterality, and all patient demographics were recorded. OCD incidence was determined for the group as a whole as well as by sex and age group (2-5, 6-11, 12-19 years). Patient differences based on age, sex, and ethnicity were analyzed, and multivariable logistic regression models were used to assess the risk of elbow OCD by group.

Results

A total of 37 patients with 40 OCD lesions fit the inclusion criteria. No lesion was found among 2- to 5-year-olds. A majority of lesions (n = 39, 97.5%) were in the capitellum, and 1 (2.5%) was in the trochlea. Twenty-five patients (67.6%) had right-sided lesions; 9 (24.3%), left-sided; and 3 (8.1%), bilateral. The incidence of elbow OCD for patients aged 6 to 19 years was 2.2 per 100,000 overall and 3.8 and 0.6 per 100,000 for males and females, respectively. The majority of OCD cases were seen in those aged 12 to 19 years, with an incidence of 3.4 per 100,000 versus 0.38 among 6- to 11-year-olds. Multivariable logistic regression analysis revealed a 21.7-times increased odds ratio of elbow OCD among patients aged 12 to 19 years versus 6 to 11 years, and males had a 6.8-times greater odds ratio of elbow OCD than females (P < .0001 for both). Based on race and ethnicity, non-Hispanic whites had the highest incidence of elbow OCD as compared with all other ethnic groups.

Conclusion

In this population-based cohort study of pediatric elbow OCD, males had almost 7 times the risk of elbow OCD as compared with females, and 12- to 19-year-olds had nearly 22 times the risk of elbow OCD versus 6- to 11-year-olds. In keeping with many prior studies, the majority of patients had right-sided lesions.

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.

Elbow arthroscopy in children and adolescents: analysis of outcome and complications

Background

Chondral or osteochondral lesions, post-traumatic contracture and loose bodies of the elbow are often associated with chronic pain, stiffness, repetitive swelling and joint blockages. Therefore, arthroscopy of the elbow is often used in the elderly for the treatment of osteochondral defects or arthrolysis. There are only a few reports and studies about arthroscopic therapy of the elbow in children and adolescents. This study assesses the clinical outcome of arthroscopic therapy in this age group.

Methods

In a retrospective study, children and adolescents who underwent an elbow arthroscopy in the period from 2010 to 2014 were included. The children were evaluated using the validated outcome measures Mayo Elbow Performance Score (MEPS), range of motion, pain on visual analog scale (VAS), Oxford Elbow Score (OES), quick dash and postoperative satisfaction. Furthermore, all complications were analyzed.

Results

In total, 27 patients were included. The mean (range) age was 14 (11–17) years, with a follow-up of 45 months. Fourteen (52%) were female and thirteen children (48%) were male. Twenty children had an arthroscopy due to osteochondritis dissecans and seven children for post-traumatic pain and stiffness. The mean (standard deviation) MEPS improved from 65 (15) to 96 (8; p = .005). The OES and quick dash were 93 and 5.4. The mean extension improved from − 15° (± 13.8) to 3° (± 10.2; p < .001). The mean flexion improved from 131° (± 13.4) to 137° (± 9.5; p = .003). Average pain on VAS was postoperative .2 (± .5), and 81.5% of all children had excellent or good results. There were no complications such as damage of nerves or blood vessels observed.

Conclusion

Elbow arthroscopy is an appropriate and safe treatment option in children and adolescents with good and excellent postoperative results.

Grade I Osteochondritis Dissecans in a Young Professional Athlete

BACKGROUND

Osteochondritis dissecans (OCD) is a disorder primarily affecting subchondral bone, with secondary effects on the overlying articular cartilage. Knee joint (75%) and radiocapitellar joint (6%) are the most common sites for OCD lesions. The presence of an open growth plate differentiates juvenile osteochondritis dissecans from adult form of osteochondritis. Early diagnosis and treatment produce best long term results. The objective of this study is to determine the best mode of management of a Grade I osteochondritis lesion in a young athlete.

MATERIALS AND METHODS

A PubMed search was made using the keywords "OCD" and "athlete". Articles that were based on participants between the ages of 6-24 years (children, adolescent and young adult) and early stages of OCD were included in this study. A total of 25 articles were thus included for the review.

RESULTS

The healing potential is based on the age of the patient, status of physis, and stage of the lesion. Most authors have observed good to excellent results of drilling of early OCD in skeletally mature patients. Similarly, most authors also reported equally successful outcomes of nonoperative treatment for early OCD in skeletally immature patients.

CONCLUSIONS

We recommend initial nonoperative line of management in patients with open physis. In case of progression of the lesion or failure of conservative treatment a reparative, restorative or palliative surgical intervention can be done. For Stage I OCD lesions in patients with closed physis, we advocate reparative surgery either by means of retro- or trans-articular drilling.

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.

Early Results of Drilling and/or Microfracture for Grade IV Osteochondritis Dissecans of the Capitellum

BACKGROUND

Surgical treatment is recommended for patients with unstable osteochondritis dissecans (OCD) of the elbow. However, little information is available comparing the anticipated results from the host of techniques. In this investigation, clinical and radiographic resolution as well as return to sports rates were assessed in adolescent patients following loose body (LB) removal and drilling/microfracture of grade IV lesions.

METHODS

We reviewed 21 adolescents treated with LB removal and drilling/microfracture for grade IV elbow OCD. Patients with additional elbow pathology, prior elbow surgery, or <1 year follow-up were excluded. Clinical resolution was defined as resolution of tenderness and radiographic resolution as resolution of edema on magnetic resonance imaging (MRI). Return to sport rates and Timmerman scores were assessed. Mean clinical and MRI follow-up times were 2.2±1.19 and 2.4±1.54 years, respectively. Clinical and radiographic parameters associated with clinical and/or radiographic resolution or return to sports were determined using penalized likelihood logistic regression. Wilcoxon signed-rank tests were used to evaluate the change in range of motion and in Timmerman scores.

RESULTS

Fifteen (71.4%) patients had either clinical or radiographic resolution at most recent follow-up. Nine (50%) had complete resolution on MRI, whereas 13 (61.9%) were nontender at their follow-up. Four patients with recurrent LBs underwent revision surgery. There were no complications in the 21 index procedures. Eighteen (85.7%) patients returned to any sport, whereas 14 (66. 7%) returned to their primary sport. Elbow flexion and extension improved by medians of 12 and 21 degrees, respectively (P=0.002, 0.01). Timmerman scores improved by a median of 30 (P=0.001). Shorter duration of symptoms correlated with smaller OCD lesions (P=0.03) and with improved clinical or radiographic resolution and return to sport rates.

CONCLUSIONS

The majority of patients with grade IV elbow OCD achieves clinical and/or radiographic resolution and return to sports 2 years after LB removal and drilling/microfracture. Recurrence may be seen, however, and further investigation is needed to assess the efficacy of this technique compared with other treatment strategies.

LEVEL OF EVIDENCE

Level IV.

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.

The Incidence of Surgery in Osteochondritis Dissecans in Children and Adolescents

Background:

The frequency of osteochondritis dissecans (OCD), a disorder of the subchondral bone and articular cartilage, is not well described.

Purpose:

To assess the frequency of pediatric OCD lesions that progress to surgery based on sex, joint involvement, and age.

Study Design:

Descriptive epidemiology study.

Methods:

A retrospective chart review (2007-2011) was performed on OCD. Inclusion criteria included OCD of any joint and patients aged 2 to 19 years. Exclusion criteria included traumatic osteochondral fractures or coexistence of non-OCD intra-articular lesions. Differences in progression toward surgery were compared between age groups, sex, and joint location. Logistical regression analysis was performed by sex, age, and ethnicity.

Results:

Overall, 317 patients with a total of 334 OCD lesions were found. The majority of lesions (61.7%) were in the knee, with ankle, elbow, shoulder, and foot lesions representing 25.4%, 12.0%, 0.6%, and 0.3% of all lesions, respectively. The majority of joints needing surgery were in the knee (58.5%), with ankle and elbow lesions representing 22.9% and 18.6% of surgeries performed, respectively. The percentage of all OCD lesions progressing to surgery was 35.3%; surgical progression for knee, ankle, and elbow joints was 33.5%, 31.8%, and 55.0%, respectively. Logistic regression analysis found no statistically significant different risk of progressing to surgery for OCD of the knee, elbow, and ankle between sexes. Patients aged 12 to 19 years had a 7.4-times greater risk of progression to surgery for knee OCD lesions than 6- to 11-year-olds. Patients aged 12 to 19 years were 8.2 times more likely to progress to surgery for all OCD lesions than patients aged 6 to 11 years. Progression to surgery of ankle OCD did not significantly differ based on location. Three of 4 trochlear lesions progressed to surgery, along with 1 of 1 tibial, 1 of 3 patellar, 40.3% of lateral femoral condylar, and 28.2% of medial femoral condylar lesions.

Conclusion:

In this large cohort study of pediatric OCD patients, 35% progressed to surgery. Progression to surgery did not differ significantly between sexes with OCD of any joint. Progression to surgery for OCD of the knee, elbow, and ankle strongly correlated with patient age at the time of diagnosis.

Clinical Relevance:

The knowledge of likelihood of progression to surgery of OCD by location, sex, and age is useful in counseling patients and in planning treatment. This study confirms a worse prognosis in the nonoperative treatment of older patients with OCD.

Elbow arthroscopic surgery update for sports medicine conditions

Elbow arthroscopic surgery can now effectively treat a variety of conditions that affect athletes. Advances in instrumentation, increased surgeon familiarity, and expanded indications have led to significant growth in elbow arthroscopic surgery in the past few decades. While positioning, portal placement, and specific instruments may vary among surgeons, anatomic considerations guide surgical approaches to minimize neurovascular compromise. Arthroscopic procedures vary in difficulty, and surgeons should follow stepwise advancement with experience. Removal of loose bodies, debridement of synovial plicae, and debridement of the extensor carpi radialis brevis for lateral epicondylitis are considered simple procedures for novice elbow arthroscopic surgeons. More advanced procedures include management of osteochondritis dissecans, valgus extension overload in the throwing athlete, and capsular release. With proper technique, a variety of athletic elbow conditions can be treated arthroscopically with predictable results and minimal morbidity.