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Klug A, Sauter M, Hoffmann R. [Bone-cartilage transfer for osteochondritis dissecans of the humeral capitellum]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2024; 36:198-210. [PMID: 39075306 DOI: 10.1007/s00064-024-00848-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/10/2023] [Accepted: 12/05/2023] [Indexed: 07/31/2024]
Abstract
OBJECTIVE Treatment of focal cartilage defects of the humeral capitellum with autologous bone-cartilage cylinders to prevent development of arthritis of the elbow joint. INDICATIONS High-grade, unstable lesions (> 50% of the capitellum, grade III-IV according to Dipaola), including those involving the lateral edge of the capitellum and with a depth of up to 15 mm. CONTRAINDICATIONS Stable lesions and generalized osteochondritis of the capitellum (including Panner's disease), as well as a relative contraindication for lesions > 10 mm, as the largest punch has a maximum diameter of 10 mm. SURGICAL TECHNIQUE Arthroscopy of the elbow joint, transition to open surgery. First, the size of the cartilage defect in the capitellum is determined. Then, one (or several) osteochondral cylinders (OATS Arthex) are removed, which as far as possible completely encompass the defect zone. Corresponding intact bone-cartilage cylinders are obtained from the ipsilateral proximal lateral femoral condyle, each with a 0.3 mm larger diameter via an additive miniarthrotomy. The "healthy" cylinders are then inserted into the defect zone in a "press fit" technique. POSTOPERATIVE MANAGEMENT An upper arm cast in neutral position of the hand for 10-14 days, simultaneously beginning physiotherapy (active-assisted movements) and lymphatic drainage. As soon as painless range of motion (ROM) is restored (goal: by week 6), isometric training can be started. Resistance training starts from week 12. Competitive sports are only recommended after 6(-8) months. RESULTS The current state of research on the surgical treatment of OCD of the humeral capitellum using autologous osteochondral grafts shows mostly promising results. A recent meta-analysis of 24 studies reports a significantly higher (p < 0.01) rate of return to sports (94%) compared to fragment fixation (64%) or microfracture and debridement (71%) [41]. However, the increased donor-site morbidity must be taken into account (ca. 7.8%).
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Affiliation(s)
- Alexander Klug
- Unfallchirurgie und Orthopädische Chirurgie, BG Unfallchirurgie Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland.
| | - Matthias Sauter
- Unfallchirurgie und Orthopädische Chirurgie, BG Unfallchirurgie Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
| | - Reinhard Hoffmann
- Unfallchirurgie und Orthopädische Chirurgie, BG Unfallchirurgie Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt am Main, Deutschland
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Matković A, Ferenc T, Dimnjaković D, Jurjević N, Vidjak V, Matković BR. Osteochondritis Dissecans of the Elbow in Overhead Athletes: A Comprehensive Narrative Review. Diagnostics (Basel) 2024; 14:916. [PMID: 38732330 PMCID: PMC11083537 DOI: 10.3390/diagnostics14090916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
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.
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Affiliation(s)
- Andro Matković
- Department of Diagnostic and Interventional Radiology, Merkur University Hospital, 10000 Zagreb, Croatia; (A.M.)
| | - Thomas Ferenc
- Department of Diagnostic and Interventional Radiology, Merkur University Hospital, 10000 Zagreb, Croatia; (A.M.)
| | - Damjan Dimnjaković
- Department of Orthopedic Surgery, University Hospital Centre Zagreb, 10000 Zagreb, Croatia
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
| | - Nikolina Jurjević
- Department of Diagnostic and Interventional Radiology, Merkur University Hospital, 10000 Zagreb, Croatia; (A.M.)
| | - Vinko Vidjak
- Department of Diagnostic and Interventional Radiology, Merkur University Hospital, 10000 Zagreb, Croatia; (A.M.)
- School of Medicine, University of Zagreb, 10000 Zagreb, Croatia
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Akins XA, Javid K, Stone AV. Management of Capitellar Osteochondritis Dissecans: A Critical Analysis Review. JBJS Rev 2024; 12:01874474-202404000-00006. [PMID: 38635768 DOI: 10.2106/jbjs.rvw.24.00020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
» 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.
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Affiliation(s)
- Xavier A Akins
- Department of Orthopaedic Surgery and Sports Medicine, University of Kentucky, Lexington, Kentucky
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van den Bekerom MPJ, de Klerk HH, van Riet R. Update in diagnosis, treatment, and prevention of osteochondritis dissecans of the capitellum. Shoulder Elbow 2024; 16:24-34. [PMID: 38425733 PMCID: PMC10901169 DOI: 10.1177/17585732231190011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 06/23/2023] [Accepted: 06/24/2023] [Indexed: 03/02/2024]
Abstract
Osteochondritis dissecans of the capitellum is debilitating and is a potentially sports career-ending injury in a young and athletic population. Osteochondritis dissecans typically occurs in patients between the ages of 10 and 24 years, and boys are more commonly affected than girls. Conventional radiographs have low diagnostic accuracy, and magnetic resonance imaging (with or without contrast) or computed tomography may aid in accurate diagnosis. The primary indication for non-operative treatment is the presence of an intact cartilage cap on magnetic resonance imaging, indicating a "stable lesion." However, if operative treatment is necessary, various surgical procedures are available when operative treatment for an osteochondritis dissecans of the capitellum is considered, including open or arthroscopic removal of loose bodies, with or without microfracturing, fragment fixation, osteochondral autograft transplantation, and osteochondral allograft transplantation. The decision-making process for selecting the appropriate treatment considers factors such as the patient's characteristics, functional limitations, and lesion morphology.
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Affiliation(s)
- Michel PJ van den Bekerom
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, The Netherlands
- Faculty of Behavioural and Movement Sciences, Vrije Universiteit, Amsterdam, The Netherlands
| | - Huub H de Klerk
- Amsterdam Shoulder and Elbow Center of Expertise (ASECE), OLVG, Amsterdam, The Netherlands
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Orthopaedic Surgery, University Medical Center Groningen (UMCG) and Groningen University, Groningen, The Netherlands
| | - Roger van Riet
- Orthopedic Center Antwerp, Antwerp, Belgium
- Monica Hospital, Antwerp, Belgium
- University Hospital Antwerp, Antwerp, Belgium
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George A, Holderread BM, Phelps BM, Erwin ER, Singer W, Jack RA. Rehabilitation and return to sport criteria following surgical treatment of osteochondritis dissecans of the capitellum: a systematic review. JSES Int 2024; 8:355-360. [PMID: 38464452 PMCID: PMC10920138 DOI: 10.1016/j.jseint.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Background Osteochondritis dissecans (OCD) of the capitellum is a well-described condition that most commonly affects adolescent throwing athletes and gymnasts. There is no gold standard rehabilitation protocol or timing for return to sport (RTS) after surgical management of OCD of the capitellum. Hypothesis/Purpose The purpose of the study was to identify in the existing literature any criteria used for RTS following surgical treatment of OCD of the capitellum. The hypothesis was that surgeons would utilize length of time rather than functional criteria or performance benchmarks for RTS. Methods Level 1 to 4 studies evaluating athletes who underwent surgery for OCD of the capitellum with a minimum follow-up of 1-year were included. Studies not describing RTS criteria, including less than 1-year follow-up, non-operative management only, and revision procedures were excluded. Each study was analyzed for RTS criteria, RTS rate, RTS timeline, sport played, level of competition, graft source (if utilized), and postoperative rehabilitation parameters. Assessment of bias and methodological quality was performed using the Coleman methodology score and RTS value assessment. Results All studies reported a rehabilitation protocol with immobilization followed by bracing with progressive range of motion. RTS rate was 80.9% (233/288). The majority of studies reported using time-based criteria for RTS (11/15). The most commonly reported timeline was 6 months (range: 3-12 months). Conclusion The overall RTS rate after surgical treatment of capitellar OCD is high with no consensus on RTS criteria. The two most consistent RTS criteria reported in the literature are return of elbow range of motion and healing demonstrated on postoperative imaging. There is a wide range of time to RTS in the literature, which may be sport dependent. Further research is needed to develop functional and performance-based metrics to better standardize RTS criteria and rehabilitation protocols.
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Affiliation(s)
- Andrew George
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
| | | | - Brian M Phelps
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
| | - Emily R Erwin
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
| | - William Singer
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
| | - Robert A Jack
- Houston Methodist Orthopedics & Sports Medicine Houston, Houston, TX, USA
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Sayani J, Plotkin T, Burchette DT, Phadnis J. Treatment Strategies and Outcomes for Osteochondritis Dissecans of the Capitellum. Am J Sports Med 2021; 49:4018-4029. [PMID: 33886390 DOI: 10.1177/03635465211000763] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Joideep Phadnis
- Brighton and Sussex University Hospital, Brighton, UK.,Brighton and Sussex Medical School, Brighton, UK
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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. Knee Surg Sports Traumatol Arthrosc 2021; 29:4041-4066. [PMID: 33620512 DOI: 10.1007/s00167-021-06489-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/03/2021] [Indexed: 11/27/2022]
Abstract
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.
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Xiao R, Cirino C, Williams C, Hausman M. Arthroscopy of the Pediatric Elbow: Review of the Current Concepts. REVISTA IBEROAMERICANA DE CIRUGÍA DE LA MANO 2021. [DOI: 10.1055/s-0041-1730394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
AbstractAs surgeons have become more familiar with elbow arthroscopy, the indications for arthroscopy of the pediatric elbow have expanded to include contracture releases, fracture fixation, treatment of osteochondritis dissecans (OCD) lesions, correction of elbow deformity, and debridement of soft tissue and bony pathologies. The treatment of various pathologies via an arthroscopic approach demonstrates equal, if not better, efficacy and safety as open surgery for the pediatric elbow. Arthroscopy provides the unique advantage of enabling the performance of extensive surgeries through a minimally-invasive approach, and it facilitates staged interventions in cases of increased complexity. For fracture work, arthroscopy enables direct visualization to assess reduction for percutaneous fixations. While future research is warranted to better evaluate the indications and outcomes of pediatric elbow arthroscopy, this update article presents a review of the current literature, as well as several innovative cases highlighting the potential of arthroscopy.
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Affiliation(s)
- Ryan Xiao
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United Sates
| | - Carl Cirino
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United Sates
| | - Christine Williams
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United Sates
| | - Michael Hausman
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, United Sates
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Gouveia K, Zhang K, Kay J, Memon M, Simunovic N, Garrigues GE, Pollock JW, Ayeni OR. The Use of Elbow Arthroscopy for Management of the Pediatric Elbow: A Systematic Review of Indications and Outcomes. Arthroscopy 2021; 37:1958-1970.e1. [PMID: 33539972 DOI: 10.1016/j.arthro.2021.01.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 01/08/2021] [Accepted: 01/12/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this review was to systematically examine the literature surrounding elbow arthroscopy for pediatric patients and to assess indications, functional outcomes, and complication rates. METHODS This systematic review was carried out in accordance with PRISMA guidelines. EMBASE, PubMed, and MEDLINE were searched for relevant literature from inception until December 2019, and studies were screened by 2 reviewers independently and in duplicate for those investigating elbow arthroscopy in a pediatric population (<18 years). Editorials, review articles, and case reports were excluded. Demographic data and data on surgical indications, treatment outcomes, and complications were recorded. A methodological quality assessment was performed for all included studies using the Methodological Index for Non-Randomized Studies. RESULTS Overall, 19 studies, all of level IV evidence, were identified with a total of 492 patients (513 elbows). The patient population was 22.3% female with a mean age of 14.0 years (range, 4.0-15.7) and a mean follow-up time of 33.0 months (range, 7.4-96 months). Twelve studies (263 patients) exclusively recruited patients with osteochondritis dissecans (OCD), although other indications for elbow arthroscopy included arthrofibrosis (50 patients), elbow fracture (37 patients), medial ulnar collateral ligament injury (31 patients), and posterior impingement (17 patients). All 13 reporting studies showed a significant improvement in the elbow flexion-extension arc, and 4 of 5 that reported a functional outcome score before and after surgery demonstrating a significant improvement. Last, the overall complication rates ranged from 0% to 23.8%, with a total of 8 instances of neurological injury (5 ulnar, 2 radial, 1 unspecified), all being transient and resolving within 3 to 6 months. CONCLUSION Although elbow arthroscopy is primarily being performed for OCD in children and adolescents, there is evidence surrounding several other potential indications. Case series published to date have demonstrated significant improvements in functional outcomes and low rates of major complications. LEVEL OF EVIDENCE Level IV, systematic review of level IV studies.
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Affiliation(s)
- Kyle Gouveia
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kailai Zhang
- Department of Physical Medicine and Rehabilitation, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey Kay
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Muzammil Memon
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Grant E Garrigues
- Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - J W Pollock
- Division of Orthopaedic Surgery, Department of Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
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Kiyomatsu H, Takeba J, Imai H, Fujibuchi T, Inoue T, Jono A, Hino K, Miura H. Treatment of osteochondritis dissecans of the humeral capitellum with a fragment fixation method using absorbable pins. JSES Int 2021; 5:564-570. [PMID: 34136872 PMCID: PMC8178622 DOI: 10.1016/j.jseint.2020.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/24/2020] [Accepted: 12/30/2020] [Indexed: 11/14/2022] Open
Abstract
Hypothesis This study aimed to investigate the results, indications, and limitations of absorbable pin fixation for osteochondritis dissecans of the humeral capitellum in the separation stage. Methods This study included 35 patients (mean age, 14.0 years). Patients were divided into two groups: Group A included those who obtained complete union within 6 months and Group B included those who did not observe complete union within 6 months. The clinical findings were compared between the groups. Results There were 26 and 6 patients in Groups A and B, respectively. Two patients did not obtain complete union. Clinical outcomes improved after the procedure. In univariate analysis, delayed union was associated with larger major diameter (P = .0004) and more depth (P = .03) of the osteochondral fragment measured by computed tomography, the presence of osteosclerosis in the subchondral bed on X-ray imaging (P = .003), and the presence of comminution of subchondral bone on ultrasound imaging (P = .01). In multivariate analysis, there was a significant difference only in the major diameter of the osteochondral fragment (P = .03). Receiver operating characteristic curves analysis shows that if the major diameter of the osteochondral fragment is 11 mm or less, 85% of patients achieve complete union of the osteochondral fragments within 6 months. Conclusion Absorbable pin fixation may be considered for the osteochondral fragments with major diameter of 11 mm or less and should not be considered for patients who demonstrate osteosclerosis in the subchondral bed or comminution of subchondral bone.
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Affiliation(s)
- Hiroshi Kiyomatsu
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon-City, Ehime, 791-0295 JAPAN
| | - Jun Takeba
- Department of Aeromedical Services for Emergency and Trauma Care, Ehime University Graduate School of Medicine, Shitsukawa, Toon-City, Ehime, 791-0295 JAPAN
| | - Hiroshi Imai
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon-City, Ehime, 791-0295 JAPAN
| | - Taketsugu Fujibuchi
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon-City, Ehime, 791-0295 JAPAN
| | - Takashi Inoue
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon-City, Ehime, 791-0295 JAPAN
| | - Akihiro Jono
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon-City, Ehime, 791-0295 JAPAN
| | - Kazunori Hino
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon-City, Ehime, 791-0295 JAPAN
| | - Hiromasa Miura
- Department of Bone and Joint Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon-City, Ehime, 791-0295 JAPAN
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Treatment of advanced stage osteochondrosis dissecans in the adolescent elbow using a hyaloronic acid-based scaffold: a case series of 5 patients. Arch Orthop Trauma Surg 2021; 141:1541-1549. [PMID: 33543384 PMCID: PMC8354908 DOI: 10.1007/s00402-021-03773-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/06/2021] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Osteochondrosis dissecans (OCD) is considered to be one of the main causes for pain, discomfort and morbidity in the pediatric elbow joint. Few treatment options, such as microfracture or autologous transplantation, of osteochondral bone grafts have been described to address advanced OCD. The aim of this retrospective case series is to present preliminary clinical and radiologic findings following advanced stage OCD repair using a novel combination of a hyaluronic acid-based scaffold with autologous iliac crest bone grafting. MATERIALS AND METHODS Five adolescents, who underwent treatment of OCD (grade 3 or 4 according to Nelson) using a combination technique of defect debridement, transplantation of cancellous iliac crest bone and application of a HYALOFAST® membrane (Anika Therapeutics S.r.L., Italy), were re-assessed using clinical and radiologic examinations (defect diameter, depth, sclerosis, congruency, fragmentation, dissection, radiolucency, growth plate status; MRI) after a minimum of 2 years (mean, 34 months; range, 24-45) postoperatively. Dedicated outcome scores (Numeric Rating Scale [NRS], Pediatric Outcome Data Collection Instrument [PODCI], Mayo Elbow Performance Score [MEPS], and Timmerman-Andrews Score [TIMM] were collected. RESULTS All patients reported a NRS score of 0. The mean total TIMM, MEPS and PODCI (Global Functioning Scale) scores were 189 (range 165-200), 94 (range, 70-100), and 92 (range 83-98; normative score 47; range 35-55), respectively, indicating good to excellent clinical outcomes. The radiographic analysis showed overall improvements with regard to OCD width and depth reduction (35%, - 27-100%; 52%, 4-100%), but full resolution in only 2 of 5 cases. Elbow motion improved slightly after surgery. No complications were noted. CONCLUSION This study showed promising clinical short- to mid-term results in adolescent patients with advanced OCD using a novel surgical treatment combination. Radiographic results showed partial healing; hence, residual changes should be monitored over a longer period.
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Gadinsky NE, O'Brien MJ. Osteochondritis Dissecans of the Capitellum: Management in the Throwing Athlete. OPER TECHN SPORT MED 2020. [DOI: 10.1016/j.otsm.2020.150734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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13
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Outcomes of surgical treatment for osteochondritis dissecans of the elbow: evaluation by lesion location. J Shoulder Elbow Surg 2018; 27:2262-2270. [PMID: 30446232 DOI: 10.1016/j.jse.2018.08.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/05/2018] [Accepted: 08/11/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND For treatment of advanced elbow osteochondritis dissecans (OCD), we have used surgical treatment. Although favorable treatment outcomes have been reported for centrally located OCD, treatment outcomes are generally questionable and the choice of surgical method is controversial for laterally located OCD. Our purpose was to evaluate the treatment outcomes based on lesion location. METHODS The patients were 30 young (mean age, 14 years) male athletes who underwent surgical treatment of elbow OCD and were monitored for more than 1 year. Osteochondral autografts harvested from the knee were transplanted to centralized (13 patients) or lateral localized (9 patients) OCD lesions. For lateral widespread (8 patients) OCD lesions, a detached osteochondral fragment was fixed using small osteochondral plugs. When the remaining cartilage defect was large after fragment fixation, a large-sized osteochondral plug was transplanted to the defect. Treatment outcomes were evaluated by the Japanese Orthopaedic Association score, elbow range of motion (ROM), and radiographic findings. RESULTS The Japanese Orthopaedic Association score significantly improved in patients with centralized, lateral localized, and lateral widespread types of OCD. ROM significantly improved in patients with centralized and lateral localized, and they returned to playing sports within 6 months. However, patients with lateral widespread OCD exhibited no significant ROM improvement, and returning to sports was difficult for 3 patients because of poor osseous integration of the fixed osteochondral fragment. CONCLUSIONS Osteochondral autograft transplantation provided favorable outcomes for centralized and lateral localized elbow OCD lesions. However, for lateral widespread OCD lesions, reconstruction of the entire capitellar lesion area may be necessary.
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Griffith TB, Kercher J, Clifton Willimon S, Perkins C, Duralde XA. Elbow Injuries in the Adolescent Thrower. Curr Rev Musculoskelet Med 2018; 11:35-47. [PMID: 29442213 PMCID: PMC5825338 DOI: 10.1007/s12178-018-9457-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Lu Y, Li YJ, Guo SY, Zhang HL. Is there any difference between open and arthroscopic treatment for osteochondritis dissecans (OCD) of the humeral capitellum: a systematic review and meta-analysis. INTERNATIONAL ORTHOPAEDICS 2018; 42:601-607. [DOI: 10.1007/s00264-018-3768-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
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Bexkens R, Oosterhoff JH, Tsai TY, Doornberg JN, van den Bekerom MPJ, Eygendaal D, Oh LS. Osteochondritis dissecans of the capitellum: lesion size and pattern analysis using quantitative 3-dimensional computed tomography and mapping technique. J Shoulder Elbow Surg 2017; 26:1629-1635. [PMID: 28478896 DOI: 10.1016/j.jse.2017.03.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 02/28/2017] [Accepted: 03/07/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND The goals of this study were to evaluate the reliability of a quantitative 3-dimensional computed tomography (Q3DCT) technique for measurement of the capitellar osteochondritis dissecans (OCD) surface area, to analyze OCD distribution using a mapping technique, and to investigate associations between Q3DCT lesion quantification and demographic characteristics and/or clinical examination findings. METHODS We identified patients with capitellar OCD who presented to our orthopedic sports medicine practice between January 2001 and January 2016 and who had undergone a preoperative computed tomography scan (slice thickness ≤1.25 mm). A total of 17 patients with a median age of 15 years (range, 12-23 years) were included in this study. Three-dimensional polygon models were reconstructed after osseous structures were marked in 3 planes. Surface areas of the OCD lesion as well as the capitellum were measured. Observer agreement was assessed with the intraclass correlation coefficient (ICC). Heat maps were created to visualize OCD distribution. RESULTS Measurements of the OCD surface area showed almost perfect intraobserver agreement (ICC, 0.99; confidence interval [CI], 0.98-0.99) and interobserver agreement (ICC, 0.93; CI, 0.86-0.97). Measurements of the capitellar surface area also showed almost perfect intraobserver agreement (ICC, 0.97;CI, 0.91-0.99) and interobserver agreement (ICC, 0.86; CI, 0.46-0.96). The median OCD surface area was 101 mm2 (range, 49-217 mm2). On the basis of OCD heat mapping, the posterolateral zone of the capitellum was most frequently affected. OCDs in which the lateral wall was involved were associated with larger lesion size (P = .041), longer duration of symptoms (P = .030), and worse elbow extension (P = .013). CONCLUSIONS The ability to quantify the capitellar OCD surface area and lesion location in a reliable manner using Q3DCT and a mapping technique should be considered when detailed knowledge of lesion size and location is desired.
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Affiliation(s)
- Rens Bexkens
- Sports Medicine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Jacobien H Oosterhoff
- Sports Medicine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, Shanghai, China; Bioengineering Laboratory, Department of Orthopaedic Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Job N Doornberg
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, SA, Australia
| | - Michel P J van den Bekerom
- Shoulder and Elbow Unit, Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Denise Eygendaal
- Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Orthopaedic Surgery, Amphia Hospital, Breda, The Netherlands
| | - Luke S Oh
- Sports Medicine Service, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Bexkens R, van den Ende KIM, Ogink PT, van Bergen CJA, van den Bekerom MPJ, Eygendaal D. Clinical Outcome After Arthroscopic Debridement and Microfracture for Osteochondritis Dissecans of the Capitellum. Am J Sports Med 2017; 45:2312-2318. [PMID: 28520461 DOI: 10.1177/0363546517704842] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Rens Bexkens
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands.,Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Paul T Ogink
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Spine Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Michel P J van den Bekerom
- Department of Orthopaedic Surgery, Shoulder and Elbow Unit, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Denise Eygendaal
- Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands.,Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Bexkens R, Ogink PT, Doornberg JN, Kerkhoffs GMMJ, Eygendaal D, Oh LS, van den Bekerom MPJ. Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2017; 25:2237-2246. [PMID: 28391550 PMCID: PMC5489608 DOI: 10.1007/s00167-017-4516-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 03/06/2017] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Rens Bexkens
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA, 02114, USA. .,Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Paul T. Ogink
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA 02114 USA
| | - Job N. Doornberg
- 0000000404654431grid.5650.6Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Gino M. M. J. Kerkhoffs
- 0000000404654431grid.5650.6Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands ,Academic Center for Evidence based Sports medicine (ACES), Amsterdam, The Netherlands ,Amsterdam Collaboration for Health and Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands
| | - Denise Eygendaal
- 0000000404654431grid.5650.6Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands ,grid.413711.1Department of Orthopaedic Surgery, Amphia Hospital, Molengracht 21, 4818 CK Breda, The Netherlands
| | - Luke S. Oh
- Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Boston, MA 02114 USA
| | - Michel P. J. van den Bekerom
- grid.440209.bDepartment of Orthopaedic Surgery, Shoulder and Elbow Unit, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, 1091 AC, Amsterdam, The Netherlands
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Patzer T, Krauspe R, Hufeland M. Arthroscopic Autologous Chondrocyte Transplantation for Osteochondritis Dissecans of the Elbow. Arthrosc Tech 2016; 5:e633-6. [PMID: 27656389 PMCID: PMC5021544 DOI: 10.1016/j.eats.2016.02.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 02/04/2016] [Indexed: 02/03/2023] Open
Abstract
Osteochondritis dissecans of the humeral capitellum is characterized by separation of a circumscript area of the articular surface and the subchondral bone in juvenile patients. In advanced lesions, arthroscopic fragment refixation or fragment removal with microfracturing or drilling can be successful. The purpose of this technical note is to describe an all-arthroscopic surgical technique for 3-dimensional purely autologous chondrocyte transplantation for osteochondral lesions of the humeral capitellum.
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Affiliation(s)
- Thilo Patzer
- Address correspondence to Thilo Patzer, M.D., Ph.D., Department of Orthopedics, University Hospital of Duesseldorf, Moorenstr. 5, D-40225 Duesseldorf, Germany.Department of OrthopedicsUniversity Hospital of DuesseldorfMoorenstr. 5D-40225 DuesseldorfGermany
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