Osteochondritis dissecans of the elbow

Comprehensive Elbow Joint Morphology Changes in Surgically Treated Osteochondritis Dissecans of the Capitellum: Clinical Implications

Background

Capitellar osteochondritis dissecans (OCD) frequently results in radial head enlargement. However, due to the elbow joint's complex anatomy, deformities likely extend beyond just the radial head.

Hypothesis/Purpose

It was hypothesized that in patients with OCD treated with surgery, imbalances in bone morphology during growth would affect the entire joint, leading to postoperative clinical symptoms. The purpose of this study was to test this hypothesis through a 3-dimensional evaluation of morphological changes.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

After retrospective identification, this study enrolled 47 patients who had undergone surgery, with a mean postoperative follow-up of 6.8 years. After in-person evaluation and bilateral computed tomography scanning, 3-dimensional bone models of the affected and contralateral elbows were created. The bone morphology of the radial head, the distal humerus, and the proximal ulna at the anatomic points were evaluated and compared between affected and contralateral sides. These measurements were correlated with clinical symptoms, and risk factors for these changes were identified.

Results

The mean age at examination was 20.6 ± 3.3 years and at surgery was 13.9 ± 1.3 years, with a mean follow-up of 6.8 ± 3.2 years. In the radial head, morphological enlargement was observed for radioulnar diameter (26.3 ± 1.9 vs 22.9 ± 1.5 mm; P < .001) and dorsovolar diameter (26.5 ± 1.9 vs 24.2 ± 1.5 mm; P < .001). In the humeral trochlea, enlargement was noted at the lateral trochlea (28.2 ± 1.7 vs 25.0 ± 1.3 mm; P < .001), trochlear groove (20.4 ± 1.7 vs 17.9 ± 1.6 mm; P < .001), and medial trochlea (30.5 ± 2.1 vs 25.5 ± 1.6 mm; P < .001) as well as the ulnar trochlear notch (28.2 ± 1.7 vs 25.0 ± 1.3 mm; P < .001). Restricted elbow flexion was associated with radial head enlargement in radioulnar and dorsovolar diameters (R = 0.60, P < .001; R = 0.44, P = .002). Lesion size was identified as a risk factor for these changes (odds ratio [OR], 1.36; P = .019), as was development of OCD during skeletal growth (OR, 0.82; P = .006).

Conclusion

Over mid- to long-term follow-up, the entire elbow joint underwent cylindrical-like morphological changes, leading to restricted motion. Enlargement typically developed during skeletal growth, with larger lesions resulting in more severe enlargement. Awareness of these natural postoperative changes is crucial, and it is clinically important to provide appropriate treatment during skeletal growth when treating OCD.

The role of MRI in elbow osteochondritis dissecans: correlations with intraoperative findings and implications for clinical management

Osteochondritis dissecans (OCD) of the elbow is common in adolescent athletes, causing functional impairment. This study examined the clinical, imaging, and intraoperative characteristics of OCD lesions, evaluating MRI's diagnostic and prognostic value, and identifying factors affecting recovery. The study included 119 athletes, 22 with confirmed OCD. Data on demographics, clinical features, and MRI findings were collected, along with preoperative assessments and outcomes (time to return to sport and QuickDASH scores). MRI lesion size correlated with intraoperative measurements (r = 0.81, p < 0.001) but was poor at assessing stability (r = -0.088, p = 0.696). Larger lesions and lateral wall involvement were associated with instability and prolonged recovery. Factors like lesion size, Tanner Stage III, and left-handed dominance were linked to OCD risk. Larger lesions predicted delayed recovery. MRI is useful for lesion characterization but limited in predicting stability and outcomes. Early detection and management are crucial for optimal recovery.

Are Elbow Osteochondritis Dissecans Lesions Different for Gymnasts and Baseball Players?

OBJECTIVE

Gymnasts and baseball players have different mechanisms of loading their elbows, and there is little data comparing osteochondritis dissecans (OCD) lesions between these 2 sports. Our objective is to compare the clinical and imaging characteristics of elbow OCD lesions between weight-bearing and throwing athletes.

DESIGN

Review from 2015 to 2022.

SETTING

Sports medicine clinics at a large academic center.

PATIENTS

Thirty-four patients were included.

INDEPENDENT VARIABLES

Patients were divided into 2 groups: gymnastics and baseball.

MAIN OUTCOME MEASURES

Location of elbow OCD lesion on the capitellum, stability of lesion, lesion size, and the presence of a radial head deformity.

RESULTS

Twenty-two (65%) baseball players and 12 (35%) gymnasts were included with 97% (33/34) of athletes presenting with a capitellar lesion. Seventy-six percent of athletes had a radial head deformity with no difference in frequency between groups ( P = 0.61). There was also no difference in frequency of lesion instability ( P = 0.56) or lesion size. Baseball players had a higher frequency of lesions located anteriorly on the capitellum compared with gymnasts (28% vs 0%, P = 0.02), and gymnasts had a higher frequency of lesions located centrally (24% vs 58%, P = 0.02). Gymnasts had significantly different presenting symptoms ( P = 0.03) with a higher frequency of isolated pain.

CONCLUSIONS

There are no significant differences in the size, stability, or location of OCD lesions in weight-bearing and throwing athletes. The presence of an associated radial head deformity was seen on most radiographs without any difference between sport. Lesion location and symptoms at presentation are significantly different between gymnastics and baseball.

LEVEL OF EVIDENCE

III.

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.

Management of Capitellar Osteochondritis Dissecans: A Critical Analysis Review

» Osteochondritis dissecans of the capitellum is a localized compromise of bone that may lead to subchondral collapse with articular cartilage damage and loose body formation.» The etiology is multifactorial; proposed mechanisms include repetitive microtrauma, vascular insufficiency, and genetic predisposition.» Diagnosis is based on patient presentation, clinical examination, diagnostic imaging, and intraoperative findings.» Management is dependent on lesion characteristics, with stable lesions amenable to nonoperative treatment and unstable lesions managed with surgical intervention.» Adolescent athletes can expect a return to their preinjury level of activity or competition following indicated surgical intervention.

A Comparative Analysis of Osteochondritis Dissecans and Avascular Necrosis: A Comprehensive Review

Musculoskeletal disorders, standing as the fifth leading cause of disability-adjusted life years globally, present significant challenges in orthopedics. Osteochondritis dissecans (OCD) and avascular necrosis (AVN) are distinct but closely related conditions within this spectrum, impacting patients' quality of life with pain, limited mobility, and dysfunction. OCD, involving cartilage and bone detachment in joints, predominantly affects young athletes, but its exact etiology and optimal management remain subjects of ongoing research. Conversely, AVN, marked by bone tissue death due to compromised blood supply, is linked to systemic factors like corticosteroid use and traumatic injuries. Diagnosis for both conditions relies on radiography and magnetic resonance imaging. Conservative treatment for AVN includes the use of a cane or crutches, pharmacological therapy, or physical therapy. On the other hand, in OCD, the primary approach is activity/sports restriction. Surgical treatment options for AVN patients encompass core decompression, bone grafting, or, in the most advanced cases, total hip arthroplasty. OCD may be surgically treated through subchondral drilling or fixation of unstable lesions. Advanced cases of OCD involve cartilage salvage with resurfacing techniques. The presentation of differences between these conditions enhances our understanding, facilitating improved diagnosis and management strategies.

Osteochondritis dissecans of the knee: Epidemiology, etiology, and natural history

Osteochondritis dissecans of the knee is a disease that typically affects skeletally immature patients. Clinically manifested with knee pain, limping, and joint disfunction, this condition has remained misunderstood and undervalued for a long period. Although being a rare condition, its awareness is of utmost clinical interest because of the possible severe consequences it can bring when misrecognized or inadequately treated. Its etiology remains unclear and is still debated. Many theories have been proposed, including inflammation, local ischemia, subchondral ossification abnormalities, genetic factors, and repetitive mechanical microtrauma, with a likely interplay of the same. This review article aims to deliver and discuss current and up-to-date concepts on epidemiology, etiology, and natural history of this pediatric condition. Level of evidence: level V.

Advantages of CT Versus MRI for Preoperative Assessment of Osteochondritis Dissecans of the Capitellum

BACKGROUND

Magnetic resonance imaging (MRI) is considered to be the gold standard for imaging of osteochondritis dissecans (OCD).

PURPOSE/HYPOTHESIS

The purpose was to determine the additional value of a preoperative computed tomography (CT) scan in adolescent patients with capitellar OCD of the elbow. Consistent with the fact that OCD is a lesion involving the subchondral bone, the hypothesis was that CT would be superior to MRI for imaging OCD of the capitellum.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

All patients being treated surgically for an OCD of the capitellum between 2006 and 2016 at one institution were reviewed for preoperative imaging. A total of 28 patients met the inclusion criteria. Corresponding MRI and CT scans were compared retrospectively. Multiple parameters were recorded, with special emphasis on OCD lesion size, fragmentation, and tilt as well as joint surface integrity, loose bodies, and osteophytes.

RESULTS

The OCD lesions were best seen on CT scans, whereas MRI T1-weighted images overestimated and T2-weighted images underestimated the size of defects. A subchondral fracture nonunion was found on CT scans in 18 patients, whereas this was seen on MRI T1-weighted images in only 2 patients (P < .001) and MRI T2-weighted images in 4 patients (P < .001). Fragmentation of the OCD fragment was found on CT scans in 17 patients but on MRI scans in only 9 patients (P = .05). Osteophytes as a sign of secondary degenerative changes were seen on CT scans in 24 patients and were seen on MRI scans in 15 patients (P = .02). Altogether, only 51 of 89 secondary changes including loose bodies, effects on the radial head and ulnohumeral joint, and osteophytes that were seen on CT scans were also seen on MRI scans (P = .002).

CONCLUSION

OCD fragmentation and secondary changes were more often diagnosed on CT. These factors indicate OCD instability or advanced OCD stages, which are indications for surgery. In an adolescent who is considered at risk for OCD (baseball, gymnastics, weightlifting, tennis) and who has lateral elbow joint pain with axial or valgus load bearing, CT is our imaging modality of choice for diagnosing and staging OCD of the capitellum.

Management of osteochondritis dissecans (OCD) of the elbow trochlea in the adolescent population: A systematic review

Background

Elbow trochlea osteochondritis dissecans (OCD) is rare with limited information on it. The aim of this systematic review is to assess the published evidence on trochlea OCD in terms of presenting symptoms, location of OCD and outcome of management in adolescent patients.

Patient & Methods

A review of the online databases MEDLINE and Embase was conducted according to PRISMA guidelines. The review was registered prospectively in the PROSPERO database. Clinical studies reporting on any aspect of trochlea OCD management were eligible for inclusion and appraised using the Methodological Index for Non-Randomized Studies (MINORS) tool.

Results

16 studies were eligible for inclusion with a total of 75 elbow. Mean age was 14 years (8-19) of which 46 were males. The main presenting symptoms were pain (95%). Non-operative care was reported in 86% of elbows with resolution of symptoms in 76%. Surgical management was described in 14%. There were equal number of arthroscopic and open procedures. 94% had successfully resolution of symptoms post-operatively.

Conclusion

Elbow trochlea OCD is a rare pathology and one that can be managed non-operatively in the majority of cases with good resolution of symptoms. However, if this fails, operative options are available with excellent results reported.

Level of evidence

Level IV, Systematic review.

A Quantitative Analysis of Subchondral Bone Density Around Osteochondritis Dissecans Lesions of the Capitellum

PURPOSE

In capitellar osteochondritis dissecans (OCD), unstable lesions generally demonstrate signs of subchondral sclerosis. We postulate that OCD lesions have abnormal subchondral bone density. We aimed to quantify the subchondral bone thickness around OCD lesions using conventional computed tomography (CT) imaging.

METHODS

This retrospective study included 15 patients with capitellar OCD (OCD group) and 12 patients with an unaffected radio-capitellar joint (control group). We constructed 3-dimensional humerus models using CT data and quantified the bone density with colored contour mapping to determine the subchondral bone thickness. We measured the thickness relative to the condylar height at the centroid and lateral, medial, superior, and inferior edge points of the OCD lesion, and compared the findings between the groups. We then correlated the CT measurements with the magnetic resonance imaging measurements.

RESULTS

Subchondral bone thickness at the centroid and lateral, medial, superior, and inferior edges in the OCD group was significantly higher than that in the control group. Correlation analyses revealed that the magnetic resonance imaging measurements highly correlated with the CT subchondral bone measurements.

CONCLUSIONS

We found that there is a zone of increased subchondral bone thickness around OCD lesions that should be considered during drilling, microfracture, or other reconstruction methods. We observed a high correlation with low errors between the measurements taken from conventional CT images and the measurements from magnetic resonance imaging, suggesting that both modalities are useful in clinical decision making.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic IV.

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.

Osteochondritis Dissecans: Current Understanding of Epidemiology, Etiology, Management, and Outcomes

➤

Osteochondritis dissecans occurs most frequently in the active pediatric and young adult populations, commonly affecting the knee, elbow, or ankle, and may lead to premature osteoarthritis.

➤

While generally considered an idiopathic phenomenon, various etiopathogenetic theories are being investigated, including local ischemia, aberrant endochondral ossification of the secondary subarticular physis, repetitive microtrauma, and genetic predisposition.

➤

Diagnosis is based on the history, physical examination, radiography, and advanced imaging, with elbow ultrasonography and novel magnetic resonance imaging protocols potentially enabling early detection and in-depth staging.

➤

Treatment largely depends on skeletal maturity and lesion stability, defined by the presence or absence of articular cartilage fracture and subchondral bone separation, as determined by imaging and arthroscopy, and is typically nonoperative for stable lesions in skeletally immature patients and operative for those who have had failure of conservative management or have unstable lesions.

➤

Clinical practice guidelines have been limited by a paucity of high-level evidence, but a multicenter effort is ongoing to develop accurate and reliable classification systems and multimodal decision-making algorithms with prognostic value.

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

BACKGROUND

Osteochondritis dissecans of the humeral capitellum (capitellar OCD) is a common injury among youth baseball players, but there are only a few studies that report on return to play with nonoperative treatment.

PURPOSE

To evaluate the medial elbow joint laxity under valgus stress and radiocapitellar congruity in patients with capitellar OCD and evaluate their relationship to predicting rehabilitation outcome.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Capitellar OCD was diagnosed in 81 patients included in our study. All patients were elementary school students who initially received rehabilitation treatment after injury. The rates of return to the same level of play or higher (RTSP) were calculated and correlated with the joint gap difference between the dominant and nondominant elbows using ultrasound and radiocapitellar congruity (proximal, lateral, and anterior radial translation length), which was assessed using plain radiographs of the dominant elbow.

RESULTS

The overall RTSP rates of patients with nonoperative treatment was 70.4% (57/81). The multivariate logistic regression analysis identified OCD classification (stage I, odds ratio [OR], 4.076; 95% CI, 1.171-14.190) and 1 continuous variable (proximal radial translation length on anteroposterior view, OR, 0.661; 95% CI, 0.479-0.911) as the significant predictive factors for outcome after nonoperative treatment.

CONCLUSION

The early stage of capitellar OCD in youth baseball players can be successfully treated nonoperatively in the majority of cases. The presence of proximal radial translation can predict the outcome of nonoperative management of capitellar OCD.

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.

Failure of Surgery for Osteochondral Injuries of the Elbow in the Pediatric and Adolescent Population

PURPOSE OF REVIEW

With an increase in single-sport specialization, elbow injuries have become increasingly common in the pediatric and adolescent population. Osteochondritis dissecans (OCD) of the capitellum frequently requires intervention yet can be difficult to treat given high patient activity demands. The purpose of this paper is to review treatment options, understand failure rates, and provide strategies for successful revision surgery.

RECENT FINDINGS

Patients at high risk for the development of this condition are involved in high-demand upper extremity activity such as baseball or gymnastics. Treatment options include non-operative management, drilling, fixation, loose body removal/microfracture, osteochondral autograft, and osteochondral allograft. Cartilage preservation procedures (i.e., osteochondral autograft) have a significant advantage in terms of clinical and radiographic healing compared with fixation or microfracture. Capitellar OCD lesions afflict a large number of adolescent athletes today and will likely continue increasing in number from sports-related injuries. It is critical to recognize and treat these lesions in a timely and appropriate fashion to optimize clinical outcomes. When faced with failure of healing, surgeons must critically analyze reasons for failure including post-operative compliance, return to high-demand sporting activity, fixation of non-viable fragments, utilization of microfracture, alignment, and concomitant pathology.

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.

Radial Head Changes in Osteochondritis Dissecans of the Humeral Capitellum

BACKGROUND

Osteochondritis dissecans (OCD) of the elbow has almost exclusively been described in the humeral capitellum, with only a small number of reports describing secondary osteochondral changes in the radial head.

HYPOTHESIS

The authors hypothesized that concomitant radial head lesions (RHLs) would be seen with capitellar OCD and that patients with RHLs would present with more advanced capitellar OCD lesions and would respond better to procedures restoring articular congruity.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 86 elbows from 82 patients (39 female patients; mean ± SD age, 13.8 ± 2.2 years; age range, 9.8-23.6 years) were treated for capitellar OCD and enrolled in a prospective registry. Clinical and radiographic data were compared between those with and without RHLs, with a median follow-up of 10.8 months (interquartile range, 6.2-17.1 months). Magnetic resonance imaging was used to characterize and measure RHLs and OCD lesions. Postoperative clinical results were compared between patients who underwent drilling and those who had osteochondral autograft transplantation surgery (OATS).

RESULTS

RHLs were present in 26 (30%) elbows-17 in the dominant arm. Edema was seen in 22 elbows; 17 had involvement of the anterior third of the radial epiphysis. Cysts were present in 4 elbows: 2 in the anterior third and 2 in the middle third. Blunting of the normal concave contour of the radial epiphysis was present in 10 elbows in the anterior third. Demographic and presenting clinical features were similar between those with and without RHLs. RHLs were more commonly seen in Nelson grade 4 OCD lesions (P = .04) as compared with elbows without RHLs. Elbows with RHLs that underwent OATS (n = 9) trended toward greater improvement in forearm range of motion (P = .058) and fewer persistent mechanical symptoms (P = .06) postoperatively as compared with elbows having RHLs that underwent drilling. There were no postoperative differences in elbows without RHLs that underwent OATS versus drilling.

CONCLUSION

RHLs were seen in one-third of elbows with capitellar OCD. Lesions predominantly occurred in the anterior RH in patients with more advanced capitellar lesions. Short-term clinical follow-up suggested greater improvement in range of motion and resolution of mechanical symptoms for patients with RHLs who were treated with OATS than with drilling.

Elbow Injuries in the Adolescent Thrower

PURPOSE OF REVIEW

With an increasing rate of adolescent elbow injuries, especially in throwing athletes, the purpose of this review is to investigate the current literature regarding the diagnosis, treatment, and non-operative and operative outcomes of medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures.

RECENT FINDINGS

Acceptable outcomes with both non-operative and operative treatments of medial epicondyle fractures have been reported, with surgical indications continuing to evolve. Unstable osteochondritis dissecans lesions, especially in patients with closed growth plates, require operative fixation, and emerging open and arthroscopic techniques including lesion debridement, marrow stimulation, autograft transfer, and allograft transplantation are described with good outcomes. Ulnar collateral repair has emerged as an exciting treatment option for an avulsion of either end of the ligament in young throwing athletes, with faster rehabilitation times than traditional ulnar collateral ligament reconstruction. Olecranon stress fractures are increasing in prevalence, and when a non-operative treatment course is unsuccessful, athletes have a high return-to-play rate after percutaneous cannulated screw placement. With proper indications, non-operative and operative treatment modalities are reported with a high return-to-play and acceptable clinical outcomes for common elbow injuries, including medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures, in adolescent throwing athletes. Further research is needed to better define treatment algorithms, surgical indications, and outcomes.

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.

Relationship between tibial spine size and the occurrence of osteochondritis dissecans: an argument in favour of the impingement theory

PURPOSE

Pathophysiology of osteochondritis dissecans (OCD) of the medial femoral condyle remains uncertain. Specifically, the relationship between the size of the anterior tibial spine (ATS) and the presence of OCD has not been explored. The purpose of this study was to evaluate the relationship between ATS size and the occurrence of OCD.

METHODS

Seventy-nine children between 8 and 17 years of age were included in two groups: OCD (n = 37) and control (n = 42). The groups were matched in terms of age, gender, BMI and weight. Two independent observers performed an MRI analysis of the size of the tibial spine and intercondylar notch relative to the size of the respective epiphyses. For this study, the "S ratio" was calculated by dividing the height of the tibial spine by the height of the tibial epiphysis. The "N ratio" was calculated by dividing the height of the notch by the height of the femoral epiphysis. These two ratios for both groups were compared using Student's t test.

RESULTS

The mean value of the S ratio in the OCD group was 0.39 ± 0.06; the mean value of the S ratio in the control group was 0.32 ± 0.03 (P = 0.004). The mean value of the N ratio in the OCD group was 0.70 ± 0.08; the mean value of the N ratio in the control group was 0.70 ± 0.07 (n.s.).

CONCLUSION

This study's findings confirm our hypothesis that patients with OCD have a more prominent tibial spine than in patients without OCD.

LEVEL OF EVIDENCE

IV.

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.

Radiographic comparison of adolescent athletes with elbow osteochondritis dissecans to ulnar collateral ligament injuries and controls

BACKGROUND

There are excellent data supporting recommendations to prevent elbow injuries (osteochondritis dissecans [OCD] and ulnar collateral ligament [UCL] injuries), such as pitch count and pitch type in baseball, but anatomic risk factors have not been thoroughly examined. This study aimed to evaluate radiographic measurements in adolescents with elbow OCD lesions or UCL injuries and controls.

METHODS

We retrospectively identified adolescent patients between 2011 and 2016 with isolated capitellum OCD, UCL tear, or normal elbows based on magnetic resonance imaging. Nineteen patients (mean age, 13.5 years) had isolated OCD defects of the capitellum, 8 patients (mean age, 16.9 years) had isolated UCL complete tear, and the remaining 16 patients (mean age, 14.6 years) were normal controls. Radiographic measurements from corresponding anterior-posterior elbow radiographs were taken, including carrying angle, distal humeral articular surface angle, and radial neck-shaft angle. On the lateral radiograph, anterior angulation of the articular surface of distal humerus was measured.

RESULTS

Significant differences were observed in carrying angle between controls (15.7°) and OCD patients (11.6°; P = .03) as well as between controls and UCL patients (10.3°, P = .02), with the OCD and UCL patients tending to be in more varus. Significant differences were also found between controls (88.5°) and OCD patients (93.6°; P = .01) and between controls and UCL patients (93.3°; P = .03) in distal humeral articular surface angle, with OCD and UCL patients with increased valgus at the distal humerus articular surface. There were no significant differences between groups in radial neck-shaft angle or anterior angulation of articular surface of distal humerus.

CONCLUSIONS

Patients with OCD and UCL injuries have anatomic differences compared with normal controls that can be measured radiographically.

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis

PURPOSE

To determine the rate of donor-site morbidity after osteochondral autologous transplantation (OATS) for capitellar osteochondritis dissecans.

METHODS

A literature search was performed in PubMed/MEDLINE, Embase, and Cochrane Library to identify studies up to November 6, 2016. Criteria for inclusion were OATS for capitellar osteochondritis dissecans, reported outcomes related to donor sites, ≥10 patients, ≥1 year follow-up, and written in English. Donor-site morbidity was defined as persistent symptoms (≥1 year) or cases that required subsequent intervention. Patient and harvest characteristics were described, as well as the rate of donor-site morbidity. A random effects model was used to calculate and compare weighted group proportions.

RESULTS

Eleven studies including 190 patients were included. In eight studies, grafts were harvested from the femoral condyle, in three studies, from either the 5th or 6th costal-osteochondral junction. The average number of grafts was 2 (1-5); graft diameter ranged from 2.6 to 11 mm. In the knee-to-elbow group, donor-site morbidity was reported in 10 of 128 patients (7.8%), knee pain during activity (7.0%) and locking sensations (0.8%). In the rib-to-elbow group, one of 62 cases (1.6%) was complicated, a pneumothorax. The proportion in the knee-to-elbow group was 0.04 (95% CI 0.0-0.15), and the proportion in the rib-to-elbow group was 0.01 (95% CI 0.00-0.06). There were no significant differences between both harvest techniques (n.s.).

CONCLUSIONS

Donor-site morbidity after OATS for capitellar osteochondritis dissecans was reported in a considerable group of patients.

LEVEL OF EVIDENCE

Level IV, systematic review of level IV studies.

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.

Common overuse injuries in the young athlete

Pediatric overuse injury is a common complaint presenting to pediatricians. Overuse injury can affect the soft tissues or bone, and results from an imbalance between training and load to the tissues and recovery time. In the skeletally immature athlete, physeal and apophyseal tissue is particularly vulnerable to overuse resulting in different patterns of injury compared to adults. Awareness of age-dependent patterns of overuse is necessary for proper recognition, treatment, and prevention of injury. This article reviews the most common pediatric overuse injuries with emphasis on risk factors, diagnosis, and treatment. Guidelines for prevention are included, as this is the key component for successful management of overuse injury in pediatric athletes.