Costal Osteochondral Autograft for Advanced Osteochondritis Dissecans of the Humeral Capitellum in Adolescent and Young Adult Athletes: Clinical Outcomes with a Mean Follow-up of 4.8 Years

Revision rate after surgery for elbow osteochondritis dissecans: a systemic review

BACKGROUND

Humeral capitellum osteochondritis dissecans (OCD) is a common condition among overhead throwing athletes and is typically treated surgically. While stable lesions can be treated nonoperatively, untreated unstable lesions can lead to significant elbow discomfort and impaired quality of life. This study reviews the revision rate and interval in athletes with elbow OCD following primary surgery.

METHODS

Data was extracted from PubMed, Embase, and Medline between 1990 and 2022, and two reviewers independently screened the duplicate reports of complications and revision surgeries. The Methodological Index for Nonrandomized Research score was used for risk of bias assessment. Inclusion criteria were as follows: studies in the English language, those involving humans, those reporting complications, and those performing revision surgeries following capitellar OCD surgery. Logit transformation and random effects were calculated using the Der Simonian Laired estimator, and the Shapiro-Wilk test was first performed to determine whether revision interval data followed a normal distribution. The Wilcoxon rank sum test was used for nonparametric data comparison, while Spearman's rank correlation assessed whether shorter follow-up periods underestimated the revision rate.

RESULTS

A total of 6,457 studies were identified through the initial literature search (PubMed: 1,924; Embase: 2,532; Medline: 2,001), with 4,147 duplicates removed, leaving 2,310 unique studies for screening. After applying the inclusion criteria, 20 full-text articles were selected, all of which were level IV case series with MINORS scores ranging from 7 to 14 (mean: 10.65), demonstrating moderate heterogeneity (I2 = 41%) and strong inter-reviewer agreement across screening phases (κ = 0.78-0.98). Twenty studies involving 477 elbows (474 athletes) were included, 55 of which underwent revision surgery. The athletes were divided into debridement, microfracture, and osteochondral grafting groups. The overall revision rate was 11.53%, and the revision rate of the three groups were 11.2%, 14.2%, and 9.19%, respectively. Eleven of the 20 studies (24 of 175 athletes underwent revision surgery) with complete data were included in interval analysis of revision surgery. The mean intervals of all participants and three groups were 25, 41.8, 10.4, and 24.2 months, respectively. Spearman's rank correlation showed no significant association between the follow-up duration and the revision rate (rho = -0.31, p = 0.18) or the revision interval (rho = 0.02, p = 0.95) in the overall cohort. Correlation coefficients across surgical subgroups also varied in direction and were not statistically significant.

CONCLUSION

Approximately 11% of patients required revision surgery following primary treatment for elbow OCD, with an average interval of 25 months. No significant association between follow-up duration and either revision rate or revision interval. Thus, further investigations, rehabilitation programs may be required to decrease this revision rate.

Case report: Free autologous costal cartilage transplantation for osteochondral lesions of the talus: three cases with 2-5 years follow-up

Background

Osteochondral lesions of the talus (OLT) is a common and clinically challenging condition with no consensus on the optimal treatment. The prospective case series aim to evaluate the feasibility and clinical outcomes of free autologous costal cartilage transplantation (ACCT) for OLT.

Methods

From April 2018 to October 2022, three patients who were diagnosed with OLT underwent free ACCT. Demographic characteristics, including age, gender, lesion size and location were collected at baseline. Functional and imaging outcomes were evaluated at 1 year, 2 years, and 5 years postoperatively. The primary outcomes were American Orthopedic Foot and Ankle Society (AOFAS) score and Foot and Ankle Ability Measure (FAAM) score. Secondary outcomes included Numeric Rating Scale (NRS), Tegner Activity Scale, and evaluations of images. A paired t-test was used for preoperative and postoperative comparison of the paired-design dataset.

Results

Three patients (37.33 ± 16.50 years old) were included in the study with 2-5 years follow-up. AOFAS score improved from 60 ± 11 at baseline to 96 ± 6.93 at 2 years (p < 0.01) and 94 ± 8.49 at 5 years. FAAM/ADL improved from 60.97 ± 6.58 at baseline to 98 ± 1.83 at 2 years (p < 0.01) and 97 ± 0.85 at 5 years. FAAM/Sports improved from 56.4 ± 11.95 at baseline to 88.23 ± 11.34 at 2 years (p < 0.01) and 89 ± 4.67 at 5 years. Other functional scores in patient reported outcomes also showed significant improvements. Postoperative CT and MRI showed complete defect filling and robust tissue integration after ACCT. Arthroscopic evaluations further confirmed solid integration of costal cartilage into the underlying subchondral bone with a smooth surface over the repair site.

Conclusion

Free ACCT is a feasible method for improving ankle function and quality of life for at least 2 years in patients with OLT. Promising long-term outcomes may be possible because of the good integration between the recipient talus and the implanted ACCT.

Autologous osteoperiosteal transplantation for cystic osteochondral lesions of the talus: Bone reconstruction is essential

PURPOSE

Autologous osteoperiosteal transplantation (AOPT) is one of the most feasible and effective techniques for cystic osteochondral lesions of the talus (OLT). However, few reports have been reported about the process of graft-host bone healing and bone articular surface reconstruction, which help us to further understand the actual situation of bone healing and modify surgical methods.

METHODS

The case series study retrospectively evaluated 33 osteochondral lesions in 30 patients undertaking AOPT for OLT with subchondral cysts from December 2016 to October 2021. According to CT observation, we used 4 variables to describe the bony articular repair, including the integration of the articular surface, the height of the bone filling, the status of bone union, and the appearance of bone resorption or cystic change. We also analyzed the demographic data and clinical function. Descriptive statistics were used for demographic and clinical variables. Normally distributed data were presented as mean ± SD, and non-normally distributed data were presented as median (Q1, Q3). Associations between these variables and the primary clinical outcomes were examined using t-test or one-way ANOVA test for continuous variables.

RESULTS

The patients' mean age was (41.7 ± 14.0) years old and the mean follow-up time was (29.6 ± 17.8) months. The chondral lesion size was (14.3 ± 4.1) mm. The cyst depth was (10.9 ± 3.7) mm. Significant improvements were observed in functional outcomes (according to the numeric rating scale for pain when walking and the American orthopedic foot and ankle society score) between the preoperative and latest follow-up evaluations, from 4.2 ± 2.1 to 2.2 ± 2.0 (p < 0.001), and from 66.8 ± 12.9 to 83.2 ± 10.4, respectively (p < 0.001). The overall satisfaction reached 8.3 of 10 points. All patients returned to sports and their median daily steps reached 8000 steps with 27 (81.8%) patients walking over 6000 steps daily. According to CT observation, "discontinuous bony articular surface and gap > 1 mm" was found in 27 grafts (81.8%), and "below the level of the adjacent articular surface, ≤ 1 mm" in a third of the grafts. Abnormal height of bone filling affected numeric rating scale score (p = 0.049) and American Orthopedic Foot and Ankle Society score (p = 0.027). Of note, bone resorption or cystic changes appeared in up to 13 autografts (39.4%).

CONCLUSIONS

AOPT is an effective and acceptable technique for cystic OLT. Bone reconstruction is essential for large cystic OLT. How to get better bony articular reconstruction and avoid cyst recurrence should still be paid more attention.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

OBJECTIVE

Treatment of focal cartilage defects of the humeral capitellum with autologous bone-cartilage cylinders to prevent development of arthritis of the elbow joint.

INDICATIONS

High-grade, unstable lesions (> 50% of the capitellum, grade III-IV according to Dipaola), including those involving the lateral edge of the capitellum and with a depth of up to 15 mm.

CONTRAINDICATIONS

Stable lesions and generalized osteochondritis of the capitellum (including Panner's disease), as well as a relative contraindication for lesions > 10 mm, as the largest punch has a maximum diameter of 10 mm.

SURGICAL TECHNIQUE

Arthroscopy of the elbow joint, transition to open surgery. First, the size of the cartilage defect in the capitellum is determined. Then, one (or several) osteochondral cylinders (OATS Arthex) are removed, which as far as possible completely encompass the defect zone. Corresponding intact bone-cartilage cylinders are obtained from the ipsilateral proximal lateral femoral condyle, each with a 0.3 mm larger diameter via an additive miniarthrotomy. The "healthy" cylinders are then inserted into the defect zone in a "press fit" technique.

POSTOPERATIVE MANAGEMENT

An upper arm cast in neutral position of the hand for 10-14 days, simultaneously beginning physiotherapy (active-assisted movements) and lymphatic drainage. As soon as painless range of motion (ROM) is restored (goal: by week 6), isometric training can be started. Resistance training starts from week 12. Competitive sports are only recommended after 6(-8) months.

RESULTS

The current state of research on the surgical treatment of OCD of the humeral capitellum using autologous osteochondral grafts shows mostly promising results. A recent meta-analysis of 24 studies reports a significantly higher (p < 0.01) rate of return to sports (94%) compared to fragment fixation (64%) or microfracture and debridement (71%) [41]. However, the increased donor-site morbidity must be taken into account (ca. 7.8%).

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

Osteochondritis Dissecans of the Elbow in Overhead Athletes: A Comprehensive Narrative Review

Osteochondritis dissecans (OCD) of the elbow mainly occurs in overhead athletes (OHAs). This narrative review aimed to comprehensively analyze the epidemiological data, etiological factors, clinical and imaging features, treatment options, and outcomes of OHAs with the diagnosis of elbow OCD. A literature search was performed in PubMed/MEDLINE, Scopus, and Web of Science. Individuals with elbow OCD were usually 10-17 years of age with incidence and prevalence varying between studies, depending on the sport activity of the patients. The etiology of OCD lesions is multifactorial, and the main causes are believed to be repetitive trauma, the biomechanical disproportion of the articular surfaces, poor capitellar vascular supply, and inflammatory and genetic factors. Athletes usually presented with elbow pain and mechanical symptoms. The mainstay for the diagnosis of elbow OCD is MRI. The treatment of elbow OCD lesions should be conservative in cases of stable lesions, while various types of surgical treatment are suggested in unstable lesions, depending mainly on the size and localization of the lesion. The awareness of medical practitioners and the timely diagnosis of OCD lesions in OHAs are key to favorable outcomes.

Bone deformity in sports-related elbow osteoarthritis: influence of osteochondritis dissecans of the capitellum-a cross-sectional study

INTRODUCTION

Sports activity can cause elbow osteoarthritis, which subsequently induces bone deformity. Osteochondritis dissecans (OCD) of the capitellum develops defects of articular surfaces and can exacerbate bone deformity. This study aimed to investigate whether OCD exacerbates deformities in sports-related elbow osteoarthritis.

MATERIALS AND METHODS

Twenty-one patients who underwent bilateral computed tomography preoperatively followed by surgery for sports-related elbow osteoarthritis were included. Patients were divided into two groups according to the presence or absence of an OCD history: OCD + (n = 6) and OCD- (n = 15). Bilateral three-dimensional bone models of the humerus, ulna, and radius were created using computed tomography data, and bone deformities were extracted by subtracting healthy mirror models from the affected models using a Boolean operation. Bone deformities were divided into 22 regions in the 3 bones. The volume of the deformity was estimated by correlating the anteroposterior and lateral diameters of the OCD and by comparing the two groups.

RESULTS

The anteroposterior diameter of the OCD correlated with the articular surface of the medial trochlear notch, whereas the lateral diameter correlated with the whole ulna, medial gutter of the ulna, whole radius, and lateral side of the radial head. The deformities were 2.2 times larger in the whole humerus, 1.9 times larger in the whole ulna, and 3.0 times larger in the whole radius in the OCD + group than in the OCD- group. The deformities were significantly larger in the OCD + group than in the OCD- group in the radial fossa, posterior capitellum, medial gutter, and lateral gutter in the humerus, medial gutter in the ulna, and lateral, anterior, and posterior sides of the radial head.

CONCLUSION

Larger OCD exacerbated deformity in elbow OA, and the presence of OCD exacerbated deformities in sports-related elbow OA. These results demonstrate the highlight of preventing OCD progression.

Surgical approaches to the capitellum: a comparative anatomic study

BACKGROUND

Osteochondritis dissecans (OCD) of the humeral capitellum is an important cause of elbow disability in young athletes. Large and unstable lesions sometimes require joint reconstruction with osteochondral autograft. Several approaches have been described to expose the capitellum for the purpose of treating OCD. The posterior anconeus-splitting approach and the lateral approach with or without release of the lateral ligamentous complex are the most frequently used for this indication. The surface accessible by these approaches has not been widely studied. This study compared the extent of the articular surface of the capitellum that could be exposed with the Kocher approach (without ligament release) vs. the posterior anconeus-splitting approach. A secondary outcome was the measurement of any additional area that could be reached with lateral ulnar collateral ligament release (Wrightington approach).

METHODS

The 3 approaches were performed on 8 adult cadaveric elbows: first, the Kocher approach; then, the anconeus-splitting approach; and finally, the Wrightington approach. The visible articular surface was marked out after completion of each approach.

RESULTS

The mean articular surface of the capitellum was 708 mm2 (range, 573-830 mm2). The mean visible articular surface was 49% (range, 43%-60%) of the total surface with the Kocher approach, 74% (range, 61%-90%) with the posterior anconeus-splitting approach, and 93% (range, 91%-97%) with the Wrightington approach. Although the Kocher approach provided access to the anterior part of the capitellum, the anconeus-splitting approach showed adequate exposure to the posterior three-quarters of the articular surface and overlapped the most posterior part of the Kocher approach. A combination of the 2 lateral ulnar collateral ligament-preserving approaches allowed access to 100% of the joint surface.

CONCLUSION

Most OCD lesions are located in the posterior area of the capitellum and can therefore be reached with the anconeus-splitting approach. When OCD lesions are located anteriorly, the Kocher approach without ligament release is efficient. A combination of these 2 approaches enabled the entirety of the joint surface to be viewed.

Autologous Costal Chondral/Osteochondral Transplantation and Costa-Derived Chondrocyte Implantation for Articular Cartilage Repair: Basic Science and Clinical Applications

There has been increasing application of autologous costal chondral/osteochondral transplantation (ACCT/ACOT) and costa-derived chondrocyte implantation (ACCI) for articular cartilage repair over the past three decades. This review presents the major evidence on the properties of costal cartilage and bone and their qualifications as grafts for articular cartilage repair, the major clinical applications, and the risks and strategies for costal chondral/osteochondral graft(s) harvest. First, costal cartilage has many specific properties that help restore the articular surface. Costa, which can provide abundant cartilage and cylindrical corticocancellous bone, preserves permanent chondrocyte and is the largest source of hyaline cartilage. Second, in the past three decades, autologous costal cartilage-derived grafts, including cartilage, osteochondral graft(s), and chondrocyte, have expanded their indications in trauma and orthopaedic therapy from small to large joints, from the upper to lower limbs, and from non-weight-bearing to weight-bearing joints. Third, the rate of donor-site complications of ACCT or ACOT is low, acceptable, and controllable, and some skills and accumulated experience can help reduce the risks of ACCT and ACOT. Costal cartilage-derived autografting is a promising technique and could be an ideal option for articular chondral lesions with or without subchondral cysts. More high-quality clinical studies are urgently needed to help us further understand the clinical value of such technologies.

Massive traumatic articular bone loss of the capitulum humeri treated by costal osteochondral autograft reconstruction: A case report

INTRODUCTION

Articular traumatic bone loss is a severe condition with heterogeneous outcomes, often necessitating complex technical solutions and posing challenges in managing both bone and cartilage loss. Thus, some surgeons have used a technique of osteochondral autograft using a rib to fix an articular bone loss to manage both of these tissue losses.

PRESENTATION OF CASE

We present the case of a 25-years-old patient, who had a complex open elbow injury. He presented an association of a terrible triad of the elbow injury with an open traumatic bone loss of the capitulum humeri and unfixable lesion of the lateral collateral ligament complex of the elbow. We initially managed these lesions with an external fixator for 2 months followed by a reconstruction of the capitulum humeri using a costal osteochondral autograft. Unfortunately, the patient was lost to follow-up after the 1 month post-operative consultation but he had some encouraging results.

DISCUSSION

In this case report, we describe our technique using an osteochondral autograft to address complex bone and cartilaginous losses, thereby expanding the treatment options available to trauma surgeons.

CONCLUSION

This case report shows that a reconstruction of the capitellum humeri for a traumatic bone loss with an osteochondral autograft using the eighth rib can be easily performed. More generally, this technique could even help to manage complex traumatic substance loss of both bone and cartilage in other locations.

Autologous Costal Osteochondral Transplantation for Cystic Osteochondral Lesions of the Talus: Feasible and Effective

OBJECTIVE

Osteochondral lesions of the talus (OLT) is a common and clinically challenging disease. The optimal management is still under debate. The purpose of this prospective study was to investigate the feasibility and clinical outcomes of autologous costal osteochondral transplantation (ACOT) for the treatment of cystic OLT.

METHODS

From November 2021 to April 2023, five patients underwent autologous costal osteochondral transplantation (ACOT) for cystic OLT. The demographic data was described, including age, gender, lesion size and location. We prospectively evaluated their functional and imaging outcomes of the five patients for 12 months postoperatively, including numeric rating score (NRS) for pain when walking, Tegner score, American Orthopedic Foot & Ankle Society (AOFAS) score and Foot and Ankle Ability Measure (FAAM) score, and imaging results. A paired t-test was used for preoperative and postoperative comparison of the paired-design dataset.

RESULTS

The average age was 36.6 ± 11.1 years. The average diameter of chondral lesions was 14.95 ± 2.71 mm, the average diameter of subchondral cysts was 10.66 ± 1.84 mm, and their average depth was 10.40 ± 1.86 mm. At 12 months postoperatively, the clinical function indexes improved significantly, including NRS (from 5.2 ± 2.3 to 0), Tegner score (from 3.2 ± 0.4 to 5.8 ± 0.4), AOFAS score (from 72.8 ± 10.0 to 98.2 ± 4.0), and FAAM score (FAAM/ADL from 61.2 ± 24.7 to 99.3 ± 1.6; FAAM/Sports from 32.5 ± 13.73 to 96.3 ± 8.4). Their magnetic resonance observation of cartilage repair tissue (MOCART) scores reached 78.0 ± 7.6 points. ICRS scores of three patients were nearly normal (10 or 11 points). The biopsy of the surviving grafts showed plenty of hyaline cartilage matrix and scattered chondrocytes histologically. No major severe complications were reported during the 12 months follow-up.

CONCLUSION

ACOT could significantly relieve the symptoms of patients with OLT and improve their clinical function at short-term follow-up. ACOT might be a feasible and useful method for repairing OLT with subchondral cysts.

Treatment Strategies and Outcomes for Osteochondritis Dissecans of the Capitellum

BACKGROUND

The optimum management of osteochondritis dissecans (OCD) of the capitellum is a widely debated subject.

PURPOSE

To better understand the efficacy of different surgical modalities and nonoperative treatment of OCD as assessed by radiological and clinical outcomes and return to sports.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all treatment studies published between January 1975 and June 2020 was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A total of 76 clinical studies, including 1463 patients, were suitable for inclusion. Aggregate analysis and subgroup analysis of individual patient data were performed to compare the functional and radiographic outcomes between the various nonoperative and surgical treatment options for capitellar OCD. A unified grading system (UGS; grades 1-4) was developed from existing validated classification systems to allow a comparison of patients with similar-grade OCD lesions in different studies according to their treatment. Patient-level data were available for 352 patients. The primary outcome measures of interest were patient-reported functional outcome, range of motion (ROM), and return to sports after treatment. The influences of the capitellar physeal status, location of the lesion, and type of sports participation were also assessed. Each outcome measure was evaluated according to the grade of OCD and treatment method (debridement/microfracture, fragment fixation, osteochondral autograft transplantation [OATS], or nonoperative treatment).

RESULTS

No studies reported elbow scores or ROM for nonoperatively treated patients. All surgical modalities resulted in significantly increased postoperative ROM and elbow scores for stable (UGS grades 1 and 2) and unstable lesions (UGS grades 3 and 4). There was no significant difference in the magnitude of improvement or overall scores according to the type of surgery for stable or unstable lesions. Return to sports was superior with nonoperative treatment for stable lesions, whereas surgical treatment was superior for unstable lesions. Patients with an open capitellar physis had superior ROM for stable and unstable lesions, but there was no correlation with lesion location and the outcomes of OATS versus fragment fixation for high-grade lesions.

CONCLUSION

Nonoperative treatment was similar in outcomes to surgical treatment for low-grade lesions, whereas surgical treatment was superior for higher grade lesions. There is currently insufficient evidence to support complex reconstructive techniques for high-grade lesions compared with microfracture/debridement alone.

A high rate of children and adolescents return to sport after surgical treatment of osteochondritis dissecans of the elbow: a systematic review and meta-analysis

PURPOSE

The purpose of this systematic review was to determine the return to sport rates following surgical management of ostechondritis dissecans of the elbow.

METHODS

The databases EMBASE, PubMed, and MEDLINE were searched for relevant literature from database inception until August 2020 and studies were screened by two reviewers independently and in duplicate for studies reporting rates of return to sport following surgical management of posterior shoulder instability. A meta-analysis of proportions was used to combine the rates of return to sport using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS score.

RESULTS

Overall, 31 studies met inclusion criteria and comprised of 548 patients (553 elbows) with a median age of 14 (range 10-18.5) and a median follow-up of 39 months (range 5-156). Of the 31 studies included, 14 studies (267 patients) had patients who underwent open stabilization, 11 studies (152 patients) had patients who underwent arthroscopic stabilization, and 6 studies (129 patients) had patients who underwent arthroscopic-assisted stabilization. The pooled rate of return to any level of sport was 97.6% (95% CI 94.8-99.5%, I² = 32%). In addition, the pooled rate of return to the preinjury level was 79.1% (95% CI 70-87.1%, I² = 78%). Moreover, the pooled rate of return to sport rate at the competitive level was 86.9% (95% CI 77.3-94.5%, I² = 64.3%), and the return to sport for overhead athletes was 89.4% (95% CI 82.5-95.1%, I² = 59%). The overall return to sport after an arthroscopic procedure was 96.4% (95% CI 91.3-99.6%, I² = 1%) and for an open procedure was 97.8% (95% CI 93.7-99.9%, I² = 46%). All functional outcome scores showed improvement postoperatively and the most common complication was revision surgery for loose body removal (19 patients).

CONCLUSION

Surgical management of osteochondritis dissecans of the elbow resulted in a high rate of return to sport, including in competitive and overhead athletes. Similar rates of return to sport were noted across both open and arthroscopic procedures.

LEVEL OF EVIDENCE

Level IV.

Comparison Between Osteochondral Autograft Transplantation and Arthroscopic Fragment Resection for Large Capitellar Osteochondritis Dissecans in Adolescent Athletes: A Minimum 5 Years' Follow-up

BACKGROUND

The choice of surgical option for unstable large capitellar osteochondritis dissecans (OCD) lesions in skeletally immature athletes remains controversial.

PURPOSE/HYPOTHESIS

The purpose was to investigate functional and radiographic outcomes after arthroscopic fragment resection and osteochondral autograft transplantation (OAT) for unstable large capitellar OCD lesions in skeletally immature athletes with a minimum 5 years' follow-up. We hypothesized that the outcomes after OAT for large capitellar OCD lesions would be superior to those after arthroscopic fragment resection.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 19 elbows in 19 patients (17 male and 2 females) who underwent arthroscopic resection were assigned to group 1 (mean age, 14 years [range, 13-15 years]), whereas 29 elbows in 29 patients (29 male) who underwent OAT were assigned to group 2 (mean age, 14 years [range, 13-15 years]), with the mean follow-up of 8 (range, 5-11 years) and 7 (range, 5-13 years) years, respectively. All OCD lesions were larger than one-half of the radial head diameter. Functional scores, patient satisfaction, and range of motion were compared between the groups. Radiographic changes, including superior migration, radial head enlargement, and osteoarthritis (OA) grade, were examined.

RESULTS

All patients returned to sports activity. Functional scores, patient satisfaction, and flexion at the final follow-up were significantly improved in both groups compared with preoperative values, and differences were not significant between groups at the final follow-up. Extension showed a significant improvement in both groups (group 1: -17° to 0°; group 2: -18° to -6°; P < .001). Extension in group 1 was significantly better than that in group 2 at the final follow-up (P = .045). No elbows developed postoperative severe OA in group 1, whereas 3 elbows in group 2 had grade 3 OA; these 3 elbows had preoperative superior migration and radial head enlargement.

CONCLUSION

No differences were observed in clinical and radiographic outcomes between patients undergoing arthroscopic fragment resection and OAT, except for elbow extension, at a minimum 5 years' follow-up. We believe that for adolescents with large capitellar OCD lesion, OAT is a good option for skeletally immature elbows and that arthroscopic fragment resection is a reliable and less invasive surgical option for relatively mature elbows.

Treatment of advanced stage osteochondrosis dissecans in the adolescent elbow using a hyaloronic acid-based scaffold: a case series of 5 patients

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.

Lateral wall fixation with bone pegs for advanced osteochondritis dissecans of the humeral capitellum

Background and hypothesis

It is generally considered that fragment fixation with bone pegs (FFBP) for osteochondritis dissecans (OCD) of the humeral capitellum can be indicated for stages I and II according to the International Cartilage Repair Society (ICRS) classification of OCD and it is difficult to obtain complete bone union for advanced lesions. However, the clinical and radiologic results of FFBP with cancellous bone graft for ICRS-OCD stage III with lateral wall involvement have not been described in detail. Good bone union can be achieved with the lateral wall fragment of the capitellum by FFBP in combination with refreshing the sclerotic surface at the base of the lesion and cancellous bone grafting even in ICRS-OCD stage III lesions.

Methods

In total, 10 adolescent baseball players with a diagnosis of OCD, a median age of 13.5 years at the time of surgery, and 26.7 months of postoperative follow-up were included. Preoperative imaging showed that all patients had lesions in the late detached stage and of the lateral-widespread type based on the site of the focal lesion. The intraoperative ICRS-OCD classification was stage III. We aimed to preserve and fix the lateral wall fragment with cancellous bone grafting if the condition of the articular cartilage was good and the size and thickness of the segment could withstand fixation.

Results

Bone union of the lateral wall fragment was achieved in all cases. The elbow extension range of motion was −3.9° ± 9.7° before surgery and was eventually −0.4° ± 6.7° at the final assessment. Flexion range of motion ranged from 138.1° ± 10.5° to 142.4° ± 6.2°. The Timmerman and Andrews score significantly improved from 165.5 ± 10.9 points before surgery to 197.0 ± 6.3 points after surgery, demonstrating excellent results in all patients. All patients were able to return to competitive baseball.

Conclusion

The radiographic and clinical outcomes of FFBP for lateral wall fragments with cancellous bone graft were satisfactory, showing that the indications for this procedure could be extended to ICRS-OCD stage III.

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

PURPOSE

To systematically evaluate the outcomes and complications of osteochondral autograft transfer (OAT) and osteochondral allograft transplantation (OCA) for the surgical treatment of capitellar osteochondritis dissecans (OCD).

METHODS

A literature search was conducted across 3 databases (PubMed, Cochrane, and CINAHL [Cumulative Index to Nursing and Allied Health Literature]) from database inception through December 2019 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Individual study quality was assessed using the Methodological Index for Non-randomized Studies scale. Studies were published between 2005 and 2019.

RESULTS

Eighteen studies consisting of 446 elbow OCD lesions treated with OAT surgery were included. There was a single OCA study eligible for inclusion. Patient ages ranged from 10 to 45 years. Of the OAT studies, 4 used autologous costal grafts whereas the remainder used autografts from the knee. Outcome measures were heterogeneously reported. A significant improvement in Timmerman-Andrews scores from preoperatively to postoperatively was reported in 9 of 10 studies. Return-to-play rates to the preinjury level of competitive play ranged from 62% to 100% across 16 studies. Significant improvement in motion, most often extension, was noted in most studies. Reported complication, reoperation, and failure rates ranged from 0% to 11%, 0% to 26%, and 0% to 20%, respectively. When used, knee autografts resulted in low donor-site morbidity (Lysholm scores, 70-100).

CONCLUSIONS

OAT surgery for large, unstable OCD lesions of the capitellum reliably produced good outcomes, few complications, and a high rate of return to competitive play. Complications are relatively uncommon, and donor-site morbidity is low. Less is known about the performance of OCA given the paucity of available literature.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II to IV studies.

Histologic Analysis of 2 Alternative Donor Sites of the Ipsilateral Elbow in the Treatment of Capitellar Osteochondritis Dissecans

PURPOSE

To compare the histologic features of the cartilage from the capitellum with 2 proposed alternative donor sites from the ipsilateral elbow in the treatment of capitellar osteochondritis dissecans (OCD): the nonarticulating part of the radial head and the nonarticulating lateral side of the olecranon tip.

METHODS

Ten human cadaveric elbow specimens with macroscopically normal articular surfaces were used to obtain 5-mm osteochondral grafts: 10 from the capitellum (60° anteriorly relative to the humeral shaft), 10 from the radial head (nonarticulating part at 80°), and 4 from the olecranon (lateral side of the olecranon tip). Grafts were fixated in formalin (4% formaldehyde), decalcified, and processed into standard 8-μm-thick hematoxylin and eosin-and Toluidine Blue-stained sections. These were assessed for cartilage thickness, shape of articular surface, and 13 histologic parameters of the International Cartilage Repair Society II. Olecranon scores were excluded from statistical analysis.

RESULTS

Mean cartilage thickness was 1.5 ± 0.22 mm at the capitellum; 1.3 ± 0.34 mm at the radial head; and 1.9 ± 1.0 mm at the olecranon. There was no difference in cartilage thickness between the capitellum and radial head (P = .062). All grafts demonstrated a convex articular surface. International Cartilage Repair Society II scores ranged from 82 to 100 for the capitellum, from 81 to 100 for the radial head, and from 67 to 87 for the olecranon tip. There was less chondrocyte clustering at the capitellum (84 ± 14) than in the radial head (94 ± 3.2; P = .019). Mid/deep zone assessment of the capitellum scored higher (97 ± 6.7) than the radial head (91 ± 4.6; P = .038).

CONCLUSIONS

This study demonstrates appropriate histologic similarities between the cartilage from the capitellum and 2 alternative donor sites of the ipsilateral elbow in the treatment of capitellar OCD: the nonarticulating part of the radial head and the nonarticulating lateral side of the olecranon tip.

CLINICAL RELEVANCE

From an histologic point of view, there seem to be no obstacles to use grafts from these alternative donor sites for reconstruction of the capitellum when performing osteochondral autologous transplantation.

Long-term results of closed-wedge osteotomy of the lateral humeral condyle for osteochondritis dissecans of the capitellum

BACKGROUND

Various surgical methods are used for osteochondritis dissecans of the capitellum; however, we have consistently performed a closed-wedge osteotomy of the lateral humeral condyle since 1983. The purpose of this study is to clarify the long-term results of closed-wedge osteotomy for osteochondritis dissecans of the capitellum.

METHODS

Seventy-seven elbows with all lesion types of osteochondritis dissecans of the capitellum were treated with closed-wedge osteotomy. Unstable osteochondral fragments were fixed with a bone graft and bone pegs in combination with osteotomy. The mean age of the patients was 14.0 years. The patients were clinically and radiographically evaluated at a median value of 9.0 years after surgery.

RESULTS

The range of elbow motion and standard deviation were increased significantly from 119° ± 22° preoperatively to 131° ± 18° postoperatively (P < .001). The Timmerman and Andrews score were improved significantly from 141 ± 26 points preoperatively to 184 ± 21 points postoperatively (P < .001). The Timmerman and Andrews score and the range of elbow motion at final examination in patients with preoperative osteoarthritic changes were significantly inferior to those in patients without preoperative osteoarthritic changes. Good remodeling of the capitellar lesions was radiographically observed in 53 elbows (69%). In the long-term follow-up evaluation, although 41 elbows (53%) had advanced osteoarthritic changes that were classified as grade II or III, disease progression was controlled in most of these cases.

CONCLUSIONS

Good or excellent long-term clinical results were maintained in most of our patients. Closed-wedge osteotomy of the lateral humeral condyle is a useful method that can provide acceptable long-term clinical results.

Current surgical options and innovation for repairing articular cartilage defects in the femoral head

Total hip arthroplasty is a common surgical technique, yet it has severe complications, such as loosening and repeated revision. Thus, hip-preserving surgical options should be considered first to treat cartilage defects in the femoral head, especially for younger patients. Current surgical options for chondral repair of the femoral head include microfracture, trapdoor procedure, transplantation of osteochondral allografts and autografts, and autologous chondrocyte implantation. Each of these techniques has unique advantages and limitations; however, none of them have been consented as the best practice for cartilage defects. In this review article, we also introduced a novel technique for repairing osteochondral defects of the femoral head using autologous costal cartilage grafts that may have good translational potential for cost-effective and safe applications.

The translational potential of this article

This review updates current surgical options for reparing articular cartilage defects in the femoral head. We also introduce a novel technique for repairing osteochondral defects of the femoral head using autologous costal cartilage grafts.

Osteochondritis dissecans lesions of the capitellum in overhead athletes: a review of current evidence and proposed treatment algorithm

PURPOSE OF THE REVIEW

To review the most recent literature on osteochondritis dissecans (OCD) lesions of the capitellum in overhead athletes and describe a treatment algorithm based on current best evidence and surgeon experience.

RECENT FINDINGS

Recent research has included larger cohort studies with longer follow-up as well as quality systematic reviews and meta-analyses. These studies have focused on understanding how lesion characteristics such as size, location, and appearance on advanced imaging can predict treatment success. Current literature continues to support nonoperative management for stable lesions. Operative intervention is generally required for unstable lesions and treatment strategies are largely dictated by lesion size and location: debridement or reparative techniques for small lesions while larger lesions or those in high-stress locations are better served by bone and/or cartilage restoration procedures. There has been a rising interest in the use of allograft materials and cell-based therapies. Overhead athletes are uniquely predisposed to capitellar OCD due to the nature of forces applied to the radiocapitellar joint during repeated activity in the overhead position. Despite improvements in operative techniques, successful use of alternative graft materials, and a better understanding of how lesion characteristics influence results, there is still much to learn about this challenging disorder. Future research should focus on comparing operative techniques, refining their indications, and further developing a reliable treatment algorithm that best serves the overhead athlete.