Capitellar Osteochondritis Dissecans Lesions of the Elbow: A Systematic Review of Osteochondral Graft Reconstruction Options

Management of osteochondritis dissecans lesions of the elbow including return to sport remains variable among orthopaedic surgeons

INTRODUCTION

Management of osteochondritis dissecans (OCD) lesions of the capitellum is challenging. Historically, variability exists between surgeons in the evaluation, treatment, and return to sport criteria. The purpose of this study was to define the current trends regarding evaluation, nonoperative and surgical management, and return to sport criteria for capitellar OCD lesions among surgeons.

METHODS

A 21-question cross-sectional survey was administered to 24 Orthopaedic surgeons specializing in elbow OCDs. The survey included questions concerning imaging, specific non-operative treatments trialed, indications for surgery for stable and unstable lesions, preferred surgical techniques, osteochondral autograft utilization, and factors determining return to sport.

RESULTS

Twenty-one surgeons responded (88%). The most common surgical indications for stable lesions were time (≥ 6 months, 68%) and mechanical symptoms (52%). Drilling (45%) and fragment fixation (35%) were most preferred. For unstable lesions, factors in order of importance for determining surgical procedure were lesion size, lateral wall integrity, location on capitellum, skeletal maturity, and sport. For small (< 1 cm2), centralized lesions, 81% preferred debridement with microfracture. For large (> 1 cm2), lateralized lesions, 52% preferred debridement and microfracture and 48% preferred osteochondral autograft transfer (OAT). OAT was considered for 80% of failed procedures, 47% with lateral wall involvement, and 27% > 1 cm2. Return to sport after debridement was typically 2-3 months (52%), fragment fixation was 4 months (52%), and OAT was 4-6 months, while microfracture had wide variability (3-6 months). The factors in order of importance were lack of pain, time, then imaging. Two-thirds of surgeons wait longer to release overhead athletes or gymnasts.

CONCLUSIONS

There is significant variability in the management of capitellar OCD in athletes. Small, centralized lesions are likely to be treated with debridement and microfracture with faster return to sport. Treatment of large, lateral lesions remains variable. Regarding OAT procedures, perceived morbidity, reimbursement, and limited evidence dissuade use. There is no consensus on return to sport, though lack of pain and time were most important; overhead athletes and gymnasts are restricted longer from returning to sport. Level of Evidence Level 5, diagnostic, cross-sectional survey.

Morrey Award 2023: radial head donor plug for capitellum osteochondral autograft transfer: a cadaveric biomechanical analysis

Background

Limitations to using the knee as donor cartilage include cartilage thickness mismatch and donor site morbidity. Using the radial head as donor autograft for capitellar lesions may allow for local graft harvest without distant donor site morbidity. The purpose of this study is to demonstrate the feasibility of performing local osteochondral autograft transfer from the nonarticular cartilaginous rim of the radial head to the capitellum. Additionally, we sought to determine the load to failure of the radial head after harvest.

Methods

Sixteen matched cadaveric elbows were used. A Kaplan approach was performed in half of the specimens and an extensor digitorum communis split in the other half. 6-mm and 8-mm capitellar cartilage defects were created. A donor plug was harvested from the rim of the radial head and transferred to the capitellum. In half of the specimens, the donor site was backfilled with autograft from the recipient plug. The other half was backfilled with calcium phosphate cement. The radial head was removed from the specimen and biomechanical analysis performed.

Results

Both surgical approaches had adequate exposure to access the lateral two-third capitellar lesions in all specimens. The medial third of the capitellum was less accessible in extensor digitorum communis split approaches (1/8) compared to the Kaplan approach (6/8; P = .01). The average cartilage thickness of the peripheral rim of the radial head and capitellum was 2.5 mm (range 1.8-3.2, standard deviation 0.4) and 2.2 mm (range 1.8-3, standard deviation 0.3), respectively. During the procedure, 2 of 8 radial heads fractured in the 8-mm plug group. No radial heads fractured in the 6-mm group (P = .47). Biomechanical testing demonstrated a mean load to failure of 1993N with no difference between groups when stratified by donor plug size or type of backfill.

Conclusion

This study demonstrates that the nonarticulating peripheral cartilaginous rim of the radial head could be a local harvest site for osteochondral autograft transfer for capitellar lesions up to 8 mm in diameter. The cartilage thickness of the radial head closely approximates the capitellum. Biomechanical analysis did not demonstrate a significant difference in load to fracture when backfilling the radial head harvest site with autograft bone or calcium phosphate cement. After harvest, the radial head could withstand forces much greater than those seen across the elbow when nonweight-bearing. Further investigation is needed to determine how to mitigate the risk of iatrogenic fracture with this operation.

The Literature that Commercial Insurance Payers Use to Substantiate Knee Osteochondral Allograft Policies Are of a Low Level of Evidence

OBJECTIVE

The purpose of this study is to analyze how the largest insurance companies support their medical necessity policies regarding osteochondral allograft transplantation (OCA) and to determine whether the literature they cite in their policies is of a high level of evidence (LOE).

DESIGN

The 10 largest national health insurance companies were identified. Each payer was contacted via phone or email to obtain their coverage policy regarding OCA. For each policy, the medical necessity criteria were recorded, and all cited references were screened. For all references applicable to OCA, the LOE was recorded, and each reference was screened to determine whether they mentioned the specific criteria reported in the policies.

RESULTS

The medical policies for 6 of the 10 national health insurance companies were identified. These 6 policies cited a collective total of 102 applicable references. Most of these studies were an LOE of IV (n = 58, 56.9%) and an LOE of V (n = 18, 17.6%). There were similarities amongst the medical necessity criteria between different commercial payers; however, most criteria were poorly supported by the cited literature.

CONCLUSIONS

Our results demonstrate that commercial insurance companies utilize studies that are of a low LOE when justifying their medical necessity criteria. Moreover, these cited studies infrequently support or mention the commercial payers' criteria. Future studies should continue to explore how well-supported insurance policies are with the goal of potentially increasing access and authorization for well-supported treatment modalities.

[Bone-cartilage transfer for osteochondritis dissecans of the humeral capitellum]

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%).

Outcomes and return to sport after osteochondral autograft transplantation for osteochondritis dissecans of the capitellum: a systematic review

Background

Capitellar osteochondritis dissecans (OCD) lesions are common in athletes. Osteochondral autograft transfer (OAT) is one possible treatment option, though outcomes including return to sport (RTS) data are limited to small series. The purpose of this study was to systematically review RTS following OAT for capitellar OCD lesions. Our secondary objectives were to evaluate patient-reported outcomes (PROs), range of motion (ROM), and complications after OAT.

Methods

PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature were searched for peer-reviewed articles on "osteochondral autograft transfer" and related terms for capitellar OCD lesions. Articles were included if they reported an RTS rate and had a follow-up time point of at least 12 months. Data on RTS rates, PRO measures, complications, and ROM were extracted. Articles were assessed for methodological quality using the Methodological Index for Non-randomized Studies criteria.

Results

Six hundred sixty-six articles were retrieved, and 24 articles (470 patients) met the inclusion criteria. In total, 454/470 patients (97%) returned to sports following OAT for OCD. The RTS rate ranged from 79% to 100%. Return to previous level of performance ranged from 10% to 100%. Timmerman-Andrews postoperative scores (range = 169-193) were most often reported, with 87% of patients showing scores within the excellent range. Disabilities of the Arm, Shoulder, and Hand and Japanese Orthopedic Association scores were also excellent postoperatively for all studies reporting, with higher scores among centralized lesions vs. lateral.

Conclusions

Following OAT for capitellar OCD lesions, RTS rates are high; however, athletes should be counseled on the potential of a return to lower performance or the need to change positions. Lateral lesion location may negatively impact outcomes. PRO scores are typically excellent and postoperative ROM consistently improves. This information helps counsel patients regarding expectations and outcomes of OAT for OCD of the capitellum.

Osteochondral Allograft Transplantation to the Capitellum: Technical Considerations of a Mega Osteochondritis Dissecans Technique

Osteochondritis dissecans of the elbow is a rare but debilitating pathology typically found in the adolescent repetitive overhead athlete. In the setting of unstable lesions, mechanical symptoms, or deteriorating function despite appropriate conservative management, surgical osteochondral allograft transplantation of the capitellum is a viable option for even large lesions (>10 mm), with minimal morbidity and good return of function. We describe a technique for performing a large osteochondral allograft transplantation of the capitellum.

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.

Update in diagnosis, treatment, and prevention of osteochondritis dissecans of the capitellum

Osteochondritis dissecans of the capitellum is debilitating and is a potentially sports career-ending injury in a young and athletic population. Osteochondritis dissecans typically occurs in patients between the ages of 10 and 24 years, and boys are more commonly affected than girls. Conventional radiographs have low diagnostic accuracy, and magnetic resonance imaging (with or without contrast) or computed tomography may aid in accurate diagnosis. The primary indication for non-operative treatment is the presence of an intact cartilage cap on magnetic resonance imaging, indicating a "stable lesion." However, if operative treatment is necessary, various surgical procedures are available when operative treatment for an osteochondritis dissecans of the capitellum is considered, including open or arthroscopic removal of loose bodies, with or without microfracturing, fragment fixation, osteochondral autograft transplantation, and osteochondral allograft transplantation. The decision-making process for selecting the appropriate treatment considers factors such as the patient's characteristics, functional limitations, and lesion morphology.

Osteochondritis dissecans of the temporomandibular joint: a scoping review

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.

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

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

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

Early Arthroscopic Debridement May Be More Cost-Effective Than Nonoperative Management for Symptomatic Osteochondritis Dissecans Lesions of the Capitellum

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.

A Comparison of Treatment of OCD Lesions of the Capitellum With Osteochondral Autograft and Allograft Transplantation

Osteochondritis dissecans (OCD) of the capitellum occurs relatively infrequently but can be found in young overhead-throwing athletes, most commonly in baseball players and gymnasts. Although non-operative management can effectively treat stable lesions, unstable lesions can lead to debilitating symptoms of the elbow and diminished quality of life without surgical intervention. This article reviews methods of treating OCD of the capitellum categorized by stability, size, and patient characteristics, and seeks to familiarize the reader with the appropriate selection of osteochondral allograft versus autograft in treating large, unstable lesions. We complement this review with 3 case examples, each using either an osteochondral autograft or allograft, and discuss the decision-making methodology used in each case.

Osteochondral Allograft Transplantation for the Unstable Capitellar Osteochondritis Dissecans Lesion: An Anconeus Preserving Approach

Background

Osteochondritis dissecans (OCD) of the capitellum can be a disabling condition that typically affects adolescent, overhead athletes. To date, a variety of different surgical treatment options have been described.

Indications

Surgical indications for osteochondral allograft transplantation (OCA) for capitellar OCD lesions include failure of nonsurgical management or prior surgery and unstable, full-thickness lesions of almost any size affecting both bone and cartilage. The anconeus preserving approach specifically provides wide access to nearly the entire capitellum and can be used for lesions in almost any location.

Technique Description

The anconeus preserving approach for OCA utilizes the interval between the anconeus and the ulna. With the patient positioned supine and the elbow flexed on an arm table, an incision is made approximately 1 cm lateral to the olecranon and is carried down to the fascia. Electric cautery is used to dissect the interval between the ulna and the anconeus. The anconeus is elevated off the ulna and retracted laterally to expose the underlying joint capsule. An L-shaped capsulotomy is performed over the center of the capitellum, just proximal to the annular ligament of the radial head. A pin is placed into the center of the lesion, perpendicular to the capitellum. A cannulated reamer 0.5 mm smaller than the lesion is used to ream the lesion to a depth of approximately 5 mm. Depth measurements are taken at all 4 poles of the defect. About 3 cc of bone marrow aspirate harvest is then obtained from the ulna using a cannulated needle. The oscillating saw is used to cut the graft to size using the prior measurements. The bone marrow aspirate is placed onto the osseous side of the graft before the osteochondral graft is impacted into the recipient site. The capsulotomy is then closed, and the anconeus is repaired back to the ulna. Postoperatively, patients begin range of motion as soon as tolerated, initiate strengthening at 6 weeks, and initiate return-to-sport programming at 3 months.

Results

Lesions treated with OCA typically demonstrate improvement in all outcome measures, including functional scores, graft incorporation, articular surface congruity, and return-to-sport. Complications and graft failure is rare.

Discussion/Conclusion

OCA using an anconeus preserving approach is a reliable option for surgical management of unstable OCD lesions.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

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.

Long-Term Patient-Reported Outcomes After Arthroscopic Debridement of Grade 3 or 4 Capitellar Osteochondritis Dissecans Lesions

BACKGROUND

Arthroscopic debridement for osteochondritis dissecans (OCD) lesions of the capitellum is a relatively common and straightforward surgical option for failure of nonoperative management. However, the long-term outcomes of this procedure remain unknown.

HYPOTHESIS

Arthroscopic debridement of capitellar OCD would provide satisfactory long-term improvement in patient-reported outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients aged ≤18 years who underwent arthroscopic debridement procedures for OCD lesions (International Cartilage Repair Society grades 3 and 4) were identified. Procedures included loose body removal when needed and direct debridement of the lesion; marrow stimulation with drilling or microfracture was added at the discretion of each surgeon. The cohort consisted of 53 elbows. Patient evaluation included visual analog scale for pain; motion; subjective satisfaction; Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores; reoperation; and rate of return to sports.

RESULTS

At a mean 11 years of follow-up (range, 5-23 years), the median visual analog scale score for pain was 0, and 96% of patients reported being improved as compared with how they were before surgery. The mean ± SD QuickDASH score was 4 ± 9 points (range, 0-52 points), and 80% of patients returned to their sports of interest. The arc of motion significantly improved from 115°± 28° preoperatively to 130°± 17° at latest follow-up (P = .026). Seven elbows (13%) required revision surgery for OCD lesions, resulting in high rates of overall survivorship free of revision surgery: 90% (95% CI, 80%-96%) at 5 years and 88% (95% CI, 76%-94%) at 10 years. At final follow-up, 7 all-cause reoperations were performed without revision surgery on the OCD lesion.

CONCLUSION

Arthroscopic debridement of grade 3 or 4 OCD lesions of the capitellum produced satisfactory patient-reported outcomes in a majority of elbows, although a subset of patients experienced residual symptoms. The inherent selection bias of our cohort should be considered when applying these results to the overall population with OCD lesions, as we do not recommend this procedure for all patients.

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.

Elbow Osteochondral Allograft Transplantation and Lateral Ulnar Collateral Ligament Repair with Internal Brace: A Case Report

CASE

A 23-year-old woman with an Osborne-Cotterill lesion and posterolateral rotatory instability (PLRI) of the elbow was treated with osteochondral allograft transplantation (OCA) and lateral ulnar collateral ligament (LUCL) repair with internal brace. Two years after surgery, she reported resolution of pain and returned to all recreational activities. She reported no mechanical symptoms and no episodes of postoperative instability.

CONCLUSION

PLRI can present with an Osborne-Cotterill lesion in addition to LUCL injury. The purpose of this case report was to describe the use of OCA to manage bony defects in the capitellum in addition to LUCL repair for patients with PLRI.

Outcomes Associated With Osteochondral Allograft Transplantation in Dogs

The purpose of this study was to retrospectively characterize outcomes and complications associated with osteochondral allograft transplantation for treating chondral and osteochondral lesions in a group of client-owned dogs with naturally-occurring disease. Records were reviewed for information on signalment, treated joint, underlying pathology (e.g., osteochondritis dissecans; OCD), and type, size, and number of grafts used. Complications were classified as “trivial” if no treatment was provided, “non-surgical” if non-surgical treatment were needed, “minor surgical” if a minor surgical procedure such as pin removal were needed but the graft survived and function was acceptable, or “major” if the graft failed and revision surgery were needed. Outcomes were classified as unacceptable, acceptable, or full function. Thirty-five joints in 33 dogs were treated including nine stifles with lateral femoral condyle (LFC) OCD and 10 stifles with medial femoral condyle (MFC) OCD treated with osteochondral cylinders or “plugs.” There were 16 “complex” procedures of the shoulder, elbow, hip, stifle, and tarsus using custom-cut grafts. In total there were eight trivial complications, one non-surgical complication, two minor surgical complications, and five major complications for a total of 16/35 cases with complications. Accordingly, there were five cases with unacceptable outcomes, all of whom had major complications while the other 30 cases had successful outcomes. Of the 30 cases with successful outcomes, 15 had full function and 15 had acceptable function. Based on these subjective outcome assessments, it appears osteochondral allograft transplantation is a viable treatment option in dogs with focal or complex cartilage defects. However, no conclusions can be made regarding the inferiority or superiority of allograft transplantation in comparison to other treatment options based upon these data.

Preoperative Evaluation and Surgical Simulation for Osteochondritis Dissecans of the Elbow Using Three-Dimensional MRI-CT Image Fusion Images

We used our novel three-dimensional magnetic resonance imaging-computed tomography fusion images (3D MRI-CT fusion images; MCFIs) for detailed preoperative lesion evaluation and surgical simulation in osteochondritis dissecans (OCD) of the elbow. Herein, we introduce our procedure and report the findings of the assessment of its utility. We enrolled 16 men (mean age: 14.0 years) and performed preoperative MRI using 7 kg axial traction with a 3-Tesla imager and CT. Three-dimensional-MRI models of the humerus and articular cartilage and a 3D-CT model of the humerus were constructed. We created MCFIs using both models. We validated the findings obtained from the MCFIs and intraoperative findings using the following items: articular cartilage fissures and defects, articular surface deformities, vertical and horizontal lesion diameters, the International Cartilage Repair Society (ICRS) classification, and surgical procedures. The MCFIs accurately reproduced the lesions and correctly matched the ICRS classification in 93.5% of cases. Surgery was performed as simulated in all cases. Preoperatively measured lesion diameters exhibited no significant differences compared to the intraoperative measurements. MCFIs were useful in the evaluation of OCD lesions and detailed preoperative surgical simulation through accurate reproduction of 3D structural details of the lesions.

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.

Editorial Commentary: Elbow Arthroscopy in the Pediatric Patient-Small Lesions in a Small Joint but With a Big Impact

Elbow arthroscopy has evolved to be a powerful tool for the treatment of a broad spectrum of pathologies over the past almost 40 years. The small joint with a complex arthroscopic anatomy demands special training and exceptional skills from the orthopaedic surgeon. On the basis of this fact and in light of the close proximity of the neurovascular structures, complication rates are somewhat higher compared with other large joints such as the knee and the shoulder. Nevertheless, elbow arthroscopy has also found its way into the treatment of joint pathologies in pediatric patients. The spectrum of pathologies differs from that in the adult population, with fewer degenerative changes and many growth-related issues such as osteochondral lesions (osteochondritis dissecans) of the capitellum. Generally speaking, clinical outcomes, return to sports, and patient satisfaction are excellent and complication rates are low. The latter remains a target for further improvement in light of the many years those pediatric elbow joints have ahead.

Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans

Background

The goal of the osteochondral autograft transplantation (OAT) procedure is to replace both the bone and cartilage that have been compromised by osteonecrosis of the capitellum, a condition known as osteochondritis dissecans (OCD). In children, the vascularity of the capitellum is limited compared with that in adults because the physis acts as a physical barrier to vascular ingrowth from the metaphysis to the epiphysis. The necrotic subchondral bone cannot keep up with the weight-bearing demands of certain high-level athletes such as gymnasts, accumulating microfractures and eventually crumbling. Without the support of the subchondral bone, the overlying cartilage fractures and eventually comes loose, often floating around the joint as a loose body. Fibrocartilage may form to fill the void left behind but cannot restore either the structural integrity of the bone or the gliding and compressive properties of hyaline cartilage. Replacement of both the bone and the cartilage requires an osteochondral transplant. Fortunately, there are regions of the articular surface of the knee in which there is minimal load or contact and that are therefore expendable as donor osteochondral plugs. We prefer a single-plug technique whenever possible because it is easier to perform and only requires union of the plug to native bone across 1 interface. If a single plug will not cover the defect or cannot be made to match the contour of the capitellum, multiple plugs may be used (i.e., mosaicplasty).

Description

Place the patient with the operative side up in the lateral decubitus position with the arm in a holder. First, perform a diagnostic elbow arthroscopy. Use the proximal anteromedial portal to insert the scope across the front of the joint. Using a switching stick, make an anterolateral portal. Place a cannula to prevent having to go in and out of the joint multiple times, as this increases the risk of neurologic injury. Perform a synovectomy if necessary and remove any loose bodies. The absence of synovitis is a sign that the lesion has likely healed. Inspect the capitellum and radial head. The anterior margin of the OCD lesion of the capitellum will be barely visible as the joint is brought to extension.If the lesion is readily visible in the anterior compartment, the lesion will be too anterior to approach from an anconeus split approach. In this case, some have advocated a takedown of the lateral collateral ligament to aid in visualization from a lateral approach¹. We have had good success with a direct anterior approach between the brachialis and brachioradialis, mobilizing the radial nerve laterally.If the chondral injury is extensive or includes the articular surface of the radial head, then the injury is too advanced to successfully treat with an OAT procedure. In these cases, we perform an interposition arthroplasty of the radiocapitellar joint. Radial head resection is not an option in a child because of the high risk of proximal radial migration. Radial head replacement likewise is not an option because of the high risk of failure.Switch the viewing and working portals again with use of switching sticks and repeat the process for the medial side of the joint. Make a direct posterior and a proximal posterolateral portal. Never debride on or near the medial gutter because the ulnar nerve is immediately adjacent. Establish a soft spot portal and place the scope through it. Loose bodies and extensive synovitis are typically seen in this area when the soft spot portal is used as a viewing portal. The OCD lesion should be visible through the soft spot portal. If the lesion is not readily visible with some elbow flexion, then the lesion is probably too anterior for an anconeus split approach and an anterior approach should be considered.Challenge the lesion with a probe. If the cartilage is damaged but the subchondral bone holds firm, perform a microfracture technique. If the cartilage is soft or unstable and the underlying bone is compromised, perform an OAT procedure. In the majority of cases in which the lesion is accessible posteriorly, connect the proximal posterolateral portal and the soft spot portal and split the anconeus. The lesion will be visible in deep flexion. There are several options for instrumentation from multiple manufacturers that each have their own advantages and disadvantages. Using a recipient harvester, remove the diseased bone and cartilage to a stable rim, keeping the harvester as perpendicular to the surface as possible.At the knee, make a 3-cm transverse incision directly over the superolateral corner of the lateral femoral condyle. Harvest an appropriately sized plug from the superolateral corner of the articular surface. Inspect the plug because it will often be slightly thicker on one side. Rotate the plug to match the contour of the defect in the capitellum. Mallet the donor plug into the recipient deficit with gentle taps, using as few taps as possible to limit chondrocyte injury. Fill the defect in the knee with your choice of bone substitute. Close both wounds in layers.

Alternatives

Other options include allograft plugs, periosteal resurfacing, bone grafting, retrograde and antegrade drilling, and observation.

Rationale

The OCD lesion involves both bone and cartilage. There is now ample evidence that replacing both as a unit yields the best outcomes.

Expected Outcomes

Approximately 90% of patients will return to sports participation, and 80% of patients can expect to return to sport at their previous level of participation^1-3.

Important Tips

A diagnostic arthroscopy confirms the need for the OAT procedure and identifies other pathologies.Remove all of the diseased bone with the recipient harvester.Match the size and contour of the lesion as closely as possible with the plug.Immobilize the elbow in a cast for 4 weeks.

Osteochondritis dissecans of the glenoid: an analysis of grades, treatment, and outcomes

Background

Osteochondritis dissecans (OCD) is an idiopathic disorder of subchondral bone that causes focal articular cartilage disruption with the potential long-term consequence of premature osteoarthritis. Glenoid OCD is exceedingly rare. This case series aims to identify the grades of glenoid OCD and report its grade-specific treatment with clinical, radiological, and functional outcomes.

Methods

Prospectively collected data of consecutive patients diagnosed with a symptomatic glenoid OCD, who had a minimum 2-year follow-up, following nonoperative or surgical treatment, was retrospectively analyzed. Osteochondral defects secondary to acute trauma, instability, and primary osteoarthritis were excluded. Pretreatment and posttreatment clinical, radiological, and sports participation data were collected. This included pretreatment MRI for grading of glenoid OCD according to the International Cartilage Research Society (ICRS) OCD staging system, and postoperative MRI for grading of articular cartilage repair using the MOCART (MRI observation of cartilage repair tissue) scoring system.

Results

The study identified 7 competitive overhead athletes with symptomatic unilateral glenoid OCD, with a post-treatment minimum 2-year follow-up. Of 4 patients with ICRS OCD I, 3 healed with nonoperative treatment, whereas 1 progressed to ICRS OCD II. This patient along with another 3 patients with unstable glenoid OCD underwent arthroscopic OCD excision with bone marrow stimulation cartilage repair. All patients improved following treatment and had full passive and active range of shoulder movements, with normal strength and stability at the 2- year follow-up. The mean MOCART score on MRI at 2 years for the 4 patients who underwent surgery was 82.5 (range, 75-90). MRI documented healing in all 3 patients with ICRS OCD I who underwent nonoperative treatment. All patients returned to the same or higher level of sport following treatment, with mean time to return to sports being 8.0 months (range, 6-11 months) for nonoperative treatment, and 6.8 months (range, 5-10 months) for operative treatment. This difference was not statistically significant (P value .55). No patient had recurrence of symptoms till latest follow-up.

Conclusion

Despite the glenoid being a concave non–weight-bearing articular surface, OCD at this site has pathological grades similar to other convex weight-bearing articular surfaces. Notwithstanding the limited number of cases, it would appear that ICRS OCD I can often be successfully treated with nonoperative treatment, whereas ICRS OCD II, III, IV, warrant operative treatment. Bone marrow stimulation is a safe and predictable option for glenoid OCD cartilage repair and allows athletes a quick and successful return to sports.

Arthroscopy Annual Awards: The "Old Normal"

With sincere thanks to the Arthroscopy Association of North America Education Foundation for their support, we are pleased to announce the Annual Awards for our best Clinical Research, Basic Science Research, Resident/Fellow Research, and Systematic Reviews published in 2020, as well as the Most Downloaded and Most Cited papers published 5 years ago. We proudly introduce new members of our editorial team, and your editors update their disclosures of potential conflicts of interest.

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

Osteochondritis dissecans (OCD) of the elbow is a disease of unclear etiology that affects young children and adolescents, particularly overhead athletes and gymnasts. Common surgical options include fixation, debridement, loose body removal, and marrow stimulation (microfracture/drilling). For large, deep, and/or uncontained defects, osteochondral autograft transplantation (OAT) has been advocated. However, there are some drawbacks to OAT, particularly related to donor-site morbidity. Fresh osteochondral allograft (OCA) transplantation avoids the donor-site morbidity associated with OAT and has been shown to be effective for treating capitellar OCD. This Technical Note details a surgical technique of OCA transplantation of the capitellum in an adolescent patient using a fresh precut OCA core. This procedure addresses the cartilage defect and loss of subchondral bone associated with OCD without the drawbacks associated with harvesting an autograft. Furthermore, as the graft is readily available, it avoids delays related to the donor-recipient matching process.