Are bone bruises a possible cause of osteochondritis dissecans of the capitellum? A case report and review of the literature

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

Background

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

Methods

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

Results

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

Discussion

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

[Treatment of osteochondritis dissecans]

Osteochondritis dissecans (OD) is a rare condition with an incidence of 30/100,000. It especially affects male patients aged 10-20 years old. During the staged progression the osteochondral fragments can detach from their base. These can damage the adjacent articular cartilage, which can lead to premature osteoarthritis. Most commonly affected are the knee, ankle and elbow joints. The exact pathogenesis of OD has so far not been clearly confirmed. Several risk factors that can lead to the development of OD are discussed. These include repeated microtrauma and vascularization disorders that can lead to ischemia of the subchondral bone and to a separation of the fragments close to the joint and therefore to the development of free joint bodies. For an adequate clarification patients should undergo a thorough radiological evaluation including X‑ray imaging followed by magnetic resonance imaging (MRI) to assess the integrity of the cartilage-bone formation with determination of the OD stage. The assessment is based on criteria of the International Cartilage Repair Society (ICRS). The instability of the cartilage-bone fragment increases with higher stages. Stages I and II with stable cartilage-bone interconnection can be treated conservatively. For stages III and IV, i.e., instability of the OD fragment or the presence of free fragments, surgical treatment should be performed. Primarily, refixation of a free joint body should be carried out depending on the size and vitality of the fragment. In cases of unsuccessful conservative treatment or fixation, a debridement, if necessary in combination with a bone marrow stimulating procedure, can be employed corresponding to the size of the defect. For larger cartilage defects, an osteochondral graft transplantation should be considered. Overall, OD lesions in stages I and II show a good healing tendency under conservative treatment. In cases of incipient unstable OD, refixation can also lead to good clinical and radiological results.

Osteochondritis Dissecans of Smaller Joints: The Elbow

This review presents the current understanding of the etiology, pathogenesis, and how to diagnose and treat osteochondritis dissecans (OCD) at the elbow joint followed by an analysis of particular characteristics and outcomes of the treatment. OCD is seen in patients with open growth plates (juvenile OCD [JOCD] and in adults [AOCD] with closed growth plates [adult OCD). The etiology at smaller joints remains as unclear as for the knee. Mechanical factors (throwing activities [capitulum] seem to play an important role. Clinical symptoms are unspecific. Thus, imaging techniques are most important for the diagnosis. In low-grade and stable lesions, treatment involves rest and different degrees of immobilization until healing. When surgery is necessary, the procedure depends on the OCD stage and on the state of the cartilage. With intact cartilage, retrograde procedures are favorable while with damaged cartilage, several techniques are used. Techniques such as drilling and microfracturing produce a reparative cartilage while other techniques reconstruct the defect with osteochondral grafts or cell-based procedures such as chondrocyte implantation. There is a tendency toward better results when reconstructive procedures for both the bone and cartilage are used. In addition, comorbidities at the joint have to be treated. Severe grades of osteoarthritis are rare.

Qualitative and quantitative assessments of radiographic healing of osteochondritis dissecans of the humeral capitellum

Background

Little is known about the optimal timing of early return to sports after which the osteochondritis dissecans (OCD) lesion can completely heal. The aims of this study were to investigate the clinical outcomes of nonoperative treatment and elucidate the relationship between the radiographic findings and the timing for the return to sports.

Methods

We performed a retrospective review of 32 patients who presented with stable OCD of the capitellum and were treated nonoperatively for a minimum of 3 months. The mean follow-up period was 22.1 months. OCD lesions were assessed qualitatively and quantitatively on anteroposterior radiographs of the elbow at 45° of flexion every 3 months. The width of the OCD lesion (OCDw) and lateral width of the normal capitellum were measured and were associated with return to sports activities.

Results

In 21 patients (66%), the progression of ossification was seen at a mean period of 4.1 months. Eighteen (56%) had partial union at a mean period of 4.3 months. Twenty-nine cases (91%) returned to sports activities after a mean of 4.6 months. Nine cases (28%) achieved complete union after a mean period of 15.0 months. Fifteen (47%) required surgery after a mean period of 11.8 months. The mean OCDw (%) was 10.2 ± 3.9 mm (56%) at the initial presentation and 8.0 ± 6.0 mm (41%) at the final follow-up examination, and the decrease in OCDw was 2.2 ± 3.1 mm (15%). The mean decrease in OCDw in patients with progression of ossification during the first 3 months was significantly larger than in patients without progression of ossification (4.9 ± 4.7 mm and -0.7 ± 4.5 mm, respectively; P = .002). In patients who had both an OCDw value of <8.0 mm and a lateral width value of >2.0 mm at the time of the return to sports, the rate of successful nonoperative treatment (86%) and complete union (71%) was significantly higher in comparison with other patients (P = .03 and P = .02).

Conclusions

OCD lesions showed difficult healing in the middle one-third of the capitellum. The progression of ossification during the first 3 months was a significant predictor of successful nonoperative treatment and complete union. Surgery should be considered for lesions without the progression of ossification during the first 3 months. We propose both an OCD lesion width of <8.0 mm and a lateral normal width of >2.0 mm as radiographic landmarks of the timing of the return to sports.

Progression of Epiphyseal Cartilage and Bone Pathology in Surgically Treated Cases of Osteochondritis Dissecans of the Elbow

BACKGROUND

Although a variety of pathologic conditions associated with osteochondritis dissecans (OCD) have been reported, the pathological progression has remained unclear.

HYPOTHESIS

Separation of the immature epiphyseal cartilage is an early event in OCD, and osteonecrosis in the articular fragment is a late event.

STUDY DESIGN

Case Series; Level of evidence, 4.

METHODS

The participants were 26 boys (mean age, 13.8 years; mean skeletal age score for the elbow, 24.6 points) with capitellar OCD who underwent osteochondral autograft transplantation. A total of 28 cylindrical osteochondral plugs, including the articular fragment, an intermediate layer, and proximal epiphyseal bone, were harvested from the central area of the capitellum and were examined histologically. The articular fragments of OCD were independently assessed by 5 observers and divided into 4 pathological variations: IA, nearly normal-cartilaginous; IB, deteriorated-cartilaginous; IIA, cartilage-ossifying; and IIB, cartilage-osteonecrotic. The reliability of assessment and the correlation of the pathological variations with the clinical data were examined.

RESULTS

The reliability of the assessment among 5 observers was almost perfect (Cohen kappa value = 0.91). OCD variations of IA, IB, IIA, and IIB were evident in 5, 10, 5, and 6 patients, respectively. OCD-I (cartilaginous) and OCD-II (osteochondral) corresponded significantly to radiographic stage I (radiolucency or slight calcification with open physis) and stage II (delayed ossification or bony fragment), respectively (Cohen kappa value = 0.79; percentage agreement = 81%). The pathological OCD variations were significantly correlated with the clinical data, including the period from symptom onset to surgery, patient age, and the skeletal age score (P < .01, in each).

CONCLUSION

The present study has revealed that the pathological variations correspond to the progression of OCD, thus proving our hypothesis. OCD-IA was shown to be an early lesion caused by separation of the immature epiphyseal cartilage. OCD-IB appeared to result from ossification arrest over a prolonged period from the onset of OCD-IA, whereas OCD-IIA showed delayed ossification in the epiphyseal cartilage where vascularization from the surrounding bone had been established. Osteonecrosis in OCD-IIB was shown to be a late pathological event caused by disruption of the vascular supply to OCD-IIA.

Osteochondritis Dissecans: Etiology, Pathology, and Imaging with a Special Focus on the Knee Joint

This article is a review of the current understanding of the etiology, pathogenesis, and how to diagnose and treat knee osteochondritis dissecans (OCD) followed by an analysis of and outcomes of the treatments available. OCD is seen in children and adolescents with open growth plates (juvenile OCD) and adults with closed growth plates (adult OCD). The etiology of OCD lesions remains unclear and is characterized by an aseptic necrosis in the subchondral bone area. Mechanical factors seem to play an important role. Clinical symptoms are unspecific. Thus, imaging techniques are most important. Regarding treatment, a tremendous number of publications exist. Spontaneous healing is expected unless there is an unstable fragment, and treatment involves rest and different degrees of immobilization until healing. Patients with open physes and low-grade lesions have good results with conservative therapy. When surgery is necessary, the procedure depends on the stage and on the state of the cartilage. With intact cartilage, retrograde procedures are favorable. When the cartilage is damaged, several techniques can be used. While techniques such as drilling and microfracturing produce reparative cartilage, other techniques reconstruct the defect with additional osteochondral grafts or cell-based procedures such as chondrocyte transplantation. There is a tendency toward better results when using procedures that reconstruct the bone and the cartilage and there is also a trend toward better long-term results when comorbidities are treated. Severe grades of osteoarthrosis are rare.

Fluoroquinolone use in a child associated with development of osteochondritis dissecans

Several aetiological theories have been proposed for the development of osteochondritis dissecans. Cartilage toxicity after fluoroquinolone use has been well documented in vitro. We present a case report of a 10-year-old child who underwent a prolonged 18-month course of ciprofloxacin therapy for chronic urinary tract infections. This patient later developed an osteochondritis dissecans lesion of the medial femoral condyle. We hypothesise that the fluoroquinolone therapy disrupted normal endochondral ossification, resulting in development of osteochondritis dissecans. The aetiology of osteochondritis dissecans is still unclear, and this case describes an association between fluoroquinolone use and osteochondritis dissecans development.

Osteochondritis dissecans knee histology studies have variable findings and theories of etiology

BACKGROUND

Although many etiological theories have been proposed for osteochondritis dissecans (OCD), its etiology remains unclear. Histological analysis of the articular cartilage and subchondral bone tissues of OCD lesions can provide useful information about the cellular changes and progression of OCD. Previous research is predominantly comprised of retrospective clinical studies from which limited conclusions can be drawn.

QUESTIONS/PURPOSES

The purposes of this study were threefold: (1) Is osteonecrosis a consistent finding in OCD biopsy specimens? (2) Is normal articular cartilage a consistent finding in OCD biopsy specimens? (3) Do histological studies propose an etiology for OCD based on the tissue findings?

METHODS

We searched the PubMed, Embase, and CINAHL databases for studies that conducted histological analyses of OCD lesions of the knee and identified 1560 articles. Of these, 11 met our inclusion criteria: a study of OCD lesions about the knee, published in the English language, and performed a histological analysis of subchondral bone and articular cartilage. These 11 studies were assessed for an etiology proposed in the study based on the study findings.

RESULTS

Seven of 11 studies reported subchondral bone necrosis. Four studies reported normal articular cartilage, two studies reported degenerated or irregular articular cartilage, and five studies found a combination of normal and degenerated or irregular articular cartilage. Five studies proposed trauma or repetitive stress and two studies proposed poor blood supply as possible etiologies.

CONCLUSIONS

We found limited research on histological analysis of OCD lesions of the knee. Future studies with consistent methodology are necessary to draw major conclusions about the histology and progression of OCD lesions. Inconsistent histologic findings have resulted in a lack of consensus regarding the presence of osteonecrosis, whether the necrosis is primary or secondary, the association of cartilage degeneration, and the etiology of OCD. Such studies could use a standardized grading system to allow better comparison of findings.

Osteochondritis dissecans development after bone contusion of the knee in the skeletally immature: a case series

Osteochondritis dissecans (OCD) is thought to be an acquired osteochondral disorder, and its aetiology may be multifactorial. Trauma, both acute and repetitive events, has previously been proposed as a potential cause for OCD development. We present two cases of skeletally immature boys who developed a symptomatic OCD lesion following a femoral condyle bone contusion. These cases suggest that an acute traumatic event may lead to the development of OCD of the knee.

Prevalence of osteochondritis among preparatory and primary school children in an Egyptian governorate

Epiphyseal osteochondritis is a localized disorder in childhood. Vascular insufficiency is thought to be the most significant etiologic factor. This study had been carried on Primary and Preparatory school children in Zagazig City and surrounding villages in Sharkia Governorate, Egypt. Total number of studied children were 16,060, 7,380 males, 8,680 females. The mean age was 11.41 ± 1.99. Our results showed that the prevalence of osteochondritis was 21:10,000. Distribution of Sever's and Osgood-Shlatter diseases were significantly high compared with other osteochondritis. Regarding the sex distribution, osteochondritis was frequent in males. Our results showed that there was history of trauma especially in Sever's and Osgood-Schlatter diseases.

Pediatric sports elbow injuries

Elbow injuries in the pediatric and adolescent population represent a spectrum of pathology that can be categorized as medial tension injuries, lateral compression injuries, and posterior shear injuries. Early and accurate diagnosis can improve outcomes for both nonoperative and operative treatments. Prevention strategies are important to help reduce the increasing incidence of elbow injuries in youth athletes.