MRI findings of osteochondritis dissecans of the capitellum with surgical correlation

Lawrence J, Polousky JD, Saper M, Uquillas C, Nissen CW, Kostyun RO, Albright J, Bae D, Bohn D, Chan C, Crepeau A, Edmonds E, Fabricant P, Ganley T, Little K, Lee Pace J, Pacicca D, Pennock A, Saluan P, Shea K, Wall E, Wilson P, Nissen CW. MRI Features That Contribute to Decision-Making for Treatment of Capitellar OCD Lesions: An Expert Consensus Using the Delphi Method

Background

Most healthcare providers utilize magnetic resonance imaging (MRI) to assist in diagnosing and treating osteochondritis dissecans (OCD) of the capitellum. However, consensus on imaging features that portend clinically relevant information in the care of these lesions has not been determined.

Purpose

To conduct a survey on the MRI features of a capitellar OCD that are salient for clinical decision-making using a classic Delphi protocol.

Study Design

A consensus statement.

Methods

Invitations to participate were sent to 33 healthcare providers identified as capitellar OCD experts. A classic 3-round survey method was used to gather agreement and consensus on the level of importance for clinical decision-making on 33 MRI features. A concise list of features that guide decision-making on the stability of an OCD lesion and the ability of an OCD lesion to heal with nonoperative care was also identified. Agreement and consensus were determined a priori as ≥66%.

Results

Of the 33 identified experts, 20 agreed to participate, and 17 (52%) completed all 3 rounds. Of the 33 MRI features evaluated, 17 reached agreement as important for clinical decision-making by the experts. Consensus was reached for a concise list of MRI features that were significant to decision-making (94%), suggestive of a stable lesion (100%), had the potential to heal with nonoperative treatment (94%), were suggestive of an unstable lesion (100%), and had low potential to heal with nonoperative treatment (88%).

Conclusion

This 3-round Delphi process produced consensus on clinically relevant MRI features that contribute to clinical decision-making for capitellar OCD. The results of this study will be used as the basis for an interrater reliability assessment of the identified salient features, creating the foundation for developing a reliable MRI assessment tool rooted in clinical experiences. The development of a standardized assessment of capitellar OCD is intended to improve clinical practice and patient outcomes.

Return to Play in Youth Athletes: Role of the Radiologist with Focus on the Upper Extremity

Increase in youth sports participation, longer duration of play, and earlier starting points have increased the prevalence of acute and repetitive overuse musculoskeletal injuries. This rise in injury rates has led to increased efforts to better understand the susceptible sites of injury that are unique to the growing immature skeleton. Upper extremity injuries are currently the best studied, particularly those that occur among pediatric baseball players and gymnasts. The weak link in skeletally immature athletes is the growth plate complex that includes those injuries located at the epiphyseal and apophyseal primary physes and the peripherally located secondary physes. This article reviews the anatomy and function of these growth plate complexes, followed by a discussion of the pathophysiologic mechanisms, spectrum of imaging findings, and existing evidence-based guidelines for injury prevention and return to play.

Imaging of Cartilage and Chondral Defects: An Overview

A healthy articular cartilage is paramount to joint function. Cartilage defects, whether acute or chronic, are a significant source of morbidity. This review summarizes various imaging modalities used for cartilage assessment. While radiographs are insensitive, they are still widely used to indirectly assess cartilage. Ultrasound has shown promise in the detection of cartilage defects, but its efficacy is limited in many joints due to inadequate visualization. CT arthrography has the potential to assess internal derangements of joints along with cartilage, especially in patients with contraindications to MRI. MRI remains the favored imaging modality to assess cartilage. The conventional imaging techniques are able to assess cartilage abnormalities when cartilage is already damaged. The newer imaging techniques are thus targeted at detecting biochemical and structural changes in cartilage before an actual visible irreversible loss. These include, but are not limited to, T2 and T2* mapping, dGEMRI, T1ρ imaging, gagCEST imaging, sodium MRI and integrated PET with MRI. A brief discussion of the advances in the surgical management of cartilage defects and post-operative imaging assessment is also included.

Reliability of Radiographic Imaging Characteristics for Osteochondritis Dissecans of the Capitellum

BACKGROUND

A primary challenge in the treatment of capitellar osteochondritis dissecans (OCD) is accurate imaging assessment. Radiographic classification consensus is not available in the current literature, and correlation of radiographs with lesion stability and resultant best treatment is lacking.

PURPOSE

To determine the inter- and intrarater reliability of the presence or absence and common radiographic characteristics of capitellar OCD lesions.

STUDY DESIGN

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

METHODS

Anteroposterior, lateral, and oblique radiographs for 29 cases were reviewed by 7 orthopaedic surgeons. Images were assessed for elbow anthropometry and morphology, OCD presence, lesion characteristics, the presence of progeny bone and progeny features, and radial head abnormalities. Intra- and interrater reliability was assessed using Fleiss and Cohen kappa for nominal variables and intraclass correlation coefficients (ICCs) for continuous variables.

RESULTS

Surgeons demonstrated substantial to excellent inter- and intrarater reliability when assessing elbow characteristics: anthropometric (interrater ICC, 0.94-0.99; intrarater ICC, 0.82-0.96) and morphologic (Fleiss, 0.61-0.76; Cohen, 0.68). When the OCD lesion was assessed, fair to moderate interrater agreement was found for classifying the absence or presence of a lesion (Fleiss, 0.28-0.46) and the location of the OCD (Fleiss, 0.24-0.52), poor agreement for assessing the contour of the lesion (Fleiss, 0.00-0.09), and excellent agreement for measuring the size of the lesion (ICC, 0.82-0.94). Poor to fair interrater agreement was found for radial head abnormalities (Fleiss, 0.00-0.27). Progeny bone visualization and fragmentation demonstrated moderate interrater agreement (Fleiss, 0.43-0.47) where displacement of the bone demonstrated poor interrater agreement (Fleiss, 0.11-0.16). Intrarater agreement for OCD lesion characteristics, progeny bone visualization, and progeny bone features was moderate to excellent.

CONCLUSION

Given only the fair to moderate agreement among raters for identifying OCD on radiographs, this imaging modality may not serve as a dependable screening tool in isolation. Additional imaging should be obtained if the clinical presentation suggests capitellar OCD and a definitive diagnosis is not possible with radiographs. However, clinicians can reliability measure the size of radiographically apparent OCD, suggesting that radiographs may serve as an appropriate imaging modality for follow-up care.

MRI of the Elbow: Interpretation of Common Orthopaedic Injuries

MRI is a valuable diagnostic tool that has become an essential part of an orthopaedic surgeon's practice. When acquired in the appropriate clinical setting, an MRI can direct patient management as surgical versus nonsurgical, guide surgical decision making, and even predict patient outcomes. The quality of MRI obtained and quality of the radiology report received varies. Ultimately, the orthopaedic surgeon must interpret the available imaging and apply these findings to treat the patient. The current day practicing orthopaedic surgeon should be familiar with interpreting common MRIs. Although subspecialized orthopaedic surgeons usually have experience and understanding of MRIs in their field, the general orthopaedic surgeon and those in-training will encounter the gamut of musculoskeletal MRIs. This review focuses on common injuries that can occur in the elbow and provides an approach to minimize missed findings.

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

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

Pediatric Imaging of the Elbow: A Pictorial Review

The elbow is a complex joint, subject to a wide range of traumatic, inflammatory, metabolic and neoplastic insults. The pediatric elbow has several diagnostic pitfalls due to the normal developmental changes in children. Knowledge of these normal variants is essential for both diagnosis and management of their elbow injuries. Radiography remains the first imaging modality of choice. Magnetic resonance imaging is excellent in evaluating lesions within the bone and soft tissues. In this pictorial essay, we provide insights into pediatric elbow imaging, show a range of entities specific to the pediatric elbow, and discuss diagnostic pitfalls that result from normal elbow growth in children.

Uniquely pediatric upper extremity injuries

The pediatric population is prone to unique upper extremity injuries that are not typically seen in adults. The normal dynamic maturation pattern of ossification centers and open physis can potentially confuse radiologists who are not familiar with the pediatric patients. In this review article, we discuss the normal anatomy and commonly encountered acute and chronic upper extremity injuries such as supracondylar distal humeral fracture and osteochondritis dissecans, in pediatric patients. Diagnosing the correct type of fracture (e.g., buckle vs Salter-Harris) is important for proper management of the injury. With an increasing number of adolescents participating in competitive sports, specific sports related injuries such as little league shoulder, gymnast wrist, and medial epicondyle apophysitis, are also discussed in this review. We examine late complications of injuries, such as physeal bar formation and fishtail deformity of the distal humerus.

Magnetic Resonance Imaging in Osteochondritis Dissecans of the Humeral Capitellum: Preoperative Assessment of Lesion Size and Lateral Wall Integrity

PURPOSE

Magnetic resonance imaging (MRI) is a helpful tool in the evaluation of osteochondritis dissecans (OCD) of the humeral capitellum. The relationship between MRI appearance and clinically relevant intraoperative findings is incompletely understood. The goal of this study was to evaluate capitellar OCD lesions via preoperative MRI and to determine its accuracy in predicting lesion characteristics including lesion size and capitellar lateral wall integrity.

METHODS

Patients surgically treated for capitellar OCD between January 2010 and June 2018 were reviewed. Preoperative MRI images were assessed by a musculoskeletal radiologist with documentation of lesion size, location, violation of the lateral wall, and stage, in accordance with previously established criteria. These data were compared with intraoperative findings. Involvement of the lateral wall of the capitellum was defined using 2 methods: (1) subchondral edema or articular cartilage disruption in the lateral third of the capitellum (lateral third method) or (2) disruption of the proximal-distal subchondral line along the lateral border of the capitellum descending vertically before the subchondral bone turns horizontally to form the radiocapitellar articulation (capitellar lateral wall sign method). Diagnostic test characteristics were compared for both methods.

RESULTS

We reviewed the preoperative MRIs of 33 elbows with capitellar OCD and found no significant difference in mean lesion size between preoperative MRI (1.12 cm²) and intraoperative measurement (1.08 cm²). For detection of lateral wall integrity, preoperative MRI evaluation using the capitellar lateral wall sign method had an accuracy of 93%, sensitivity of 80%, specificity of 96%, positive predictive value of 80%, and negative predictive value of 96%.

CONCLUSIONS

Preoperative MRI is a valid predictor of lesion size. The capitellar lateral wall sign method is highly accurate in the identification of lateral wall involvement, which may influence preoperative planning.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Tennis overuse injuries in the upper extremity

OBJECTIVE

Tennis is a popular sport with high levels of participation. This article aims to describe how upper extremity overuse injuries occur in relation to tennis biomechanics and to review their imaging characteristics and implications for management. In particular, we will review the imaging patterns of internal impingement, scapular dyskinesis, lateral and medial epicondylitis, ulnar collateral ligament insufficiency, valgus extension overload, capitellar osteochondritis dissecans, extensor carpi ulnaris tendinosis and instability, tenosynovitis, triangular fibrocartilage complex injuries, and carpal stress injuries.

CONCLUSION

Tennis is a complex and physically demanding sport with a wide range of associated injuries. Repetitive overloading commonly leads to injuries of the upper extremity. An understanding of the underlying mechanisms of injury and knowledge of these injury patterns will aid the radiologist in generating the correct diagnosis in both the professional and recreational tennis athlete.

A novel three-dimensional MRI-CT image fusion technique for precise preoperative evaluation and treatment of capitellar osteochondritis dissecans

OBJECTIVES

We developed a novel method to create three-dimensional magnetic resonance imaging-CT (3D MRI-CT) fusion images for detailed lesion evaluation and surgical simulation in capitellar osteochondritis dissecans (COCD). This study aimed to clarify its usefulness.

METHODS

We enrolled 12 boys with COCD (mean age, 13.8 years) and preoperatively constructed 3D models of the humerus and articular cartilage from MR images obtained with a 3-T imager. For better visualization of the articular cartilage outline, we applied 7 kg of axial traction to the elbow during MRI. We also constructed a 3D model of the humerus from CT images. 3D MRI-CT fusion images were created using both models. The average distance difference between two corresponding points as per the 3D CT and 3D MRI models of the humerus was evaluated. Using the 3D MRI-CT fusion images, we measured longitudinal and transverse lesion diameters; evaluated articular cartilage fissures and defects, articular surface deformities, and the International Cartilage Repair Society (ICRS) classification; and validated the results using intraoperative findings.

RESULTS

The mean average distance difference was 0.75 mm. The 3D MRI-CT fusion images accurately reproduced lesion conditions in every case and correctly predicted the ICRS classification with 100% accuracy. Preoperatively measured longitudinal and transverse lesion diameters were not significantly different from intraoperative measurements (p = 0.79, 0.32 respectively).

CONCLUSION

3D MRI-CT fusion images provide a detailed evaluation of COCD lesion severity by presenting the exact positional relationship between the articular cartilage and subchondral bone.

KEY POINTS

• We developed a novel method to create three-dimensional magnetic resonance imaging-computed tomography (3D MRI-CT) fusion images for the evaluation of capitellar osteochondritis dissecans. • 3D MRI-CT fusion images enabled the accurate prediction of lesions and provided a detailed evaluation of lesion severity by presenting the exact positional relationship between the articular cartilage and subchondral bone.

Effect of elbow MRI with axial traction on articular cartilage visibility-a feasibility study

OBJECTIVE

Accurate evaluation of the articular cartilage of the elbow using MRI is sometimes challenging because of its anatomical complexity and relatively small size. Moreover, the articular cartilage of the humerus is in close contact with the opposing cartilage surfaces. Magnetic resonance arthrography with traction was reported to resolve this issue; however, less invasive methods are desirable. This study aimed to assess the effect of MRI with axial traction (without arthrography) on joint space widening and cartilage outline visibility of the elbow.

MATERIALS AND METHODS

We enrolled 10 volunteers (female = 1; mean age, 36.7 ± 8.6; range 28-56) and performed MRI with and without axial traction on the elbow. Joint space widths were measured, and the humeral articular cartilage outline visibility was evaluated at the radiocapitellar joint and lateral one-third and medial one-third of the ulnohumeral joints. Measurements were compared using the Wilcoxon signed-rank test. Significance was set at p < 0.05. Volunteers scored pain and discomfort during MRI with traction using the visual analog scale in a questionnaire format.

RESULTS

Traction significantly increased joint space width at the radiocapitellar joint. Humeral articular cartilage outline visibility also significantly improved at the radiocapitellar joint. Pain and discomfort scores during traction MRI were low.

CONCLUSION

MRI of the elbow with traction widens joint space and enables better articular cartilage visibility at the radiocapitellar joint. Anatomical features of the elbow might have affected these results. Therefore, it would be safe and useful for evaluating elbow injuries involving articular cartilage lesions.

Magnetic resonance imaging of the elbow

Elbow pain can cause disability, especially in athletes, and is a common clinical complaint for both the general practitioner and the orthopaedic surgeon. Magnetic resonance imaging (MRI) is an excellent tool for the evaluation of joint pathology due to its high sensitivity as a result of high contrast resolution for soft tissues. This article aims to describe the normal imaging anatomy and biomechanics of the elbow, the most commonly used MRI protocols and techniques, and common MRI findings related to tendinopathy, ligamentous and osteochondral injuries, and instability of the elbow.

Interobserver reliability of the classification of capitellar osteochondritis dissecans using magnetic resonance imaging

AIM

(1) To determine the interobserver reliability of magnetic resonance classifications and lesion instability criteria for capitellar osteochondritis dissecans lesions and (2) to assess differences in reliability between subgroups.

METHODS

Magnetic resonance images of 20 patients with capitellar osteochondritis dissecans were reviewed by 33 observers, 18 orthopaedic surgeons and 15 musculoskeletal radiologists. Observers were asked to classify the osteochondritis dissecans according to classifications developed by Hepple, Dipaola/Nelson, Itsubo, as well as to apply the lesion instability criteria of DeSmet/Kijowski and Satake. Interobserver agreement was calculated using the multirater kappa (k) coefficient.

RESULTS

Interobserver agreement ranged from slight to fair: Hepple (k = 0.23); Dipaola/Nelson (k = 0.19); Itsubo (k = 0.18); DeSmet/Kijowksi (k = 0.16); Satake (k = 0.12). When classifications/instability criteria were dichotomized into either a stable or unstable osteochondritis dissecans, there was more agreement for Hepple (k = 0.52; p = .002), Dipaola/Nelson (k = 0.38; p = .015), DeSmet/Kijowski (k = 0.42; p = .001) and Satake (k = 0.41; p < .001). Overall, agreement was not associated with the number of years in practice or the number of osteochondritis dissecans cases encountered per year (p > .05).

CONCLUSION

One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans. When making treatment decisions, one should rather use relatively simple distinctions (e.g. stable versus unstable osteochondritis dissecans; lateral wall intact versus not intact), as these are more reliable.

Osteochondral lesions of the lateral trochlear ridge: a rare, subtle but important finding on advanced imaging in patients with elbow pain

OBJECTIVE

To characterize the radiographic, CT, and MRI appearance of clinically and/or surgically proven osteochondral lesions of the lateral trochlear ridge.

MATERIALS AND METHODS

Ten years of medical charts with elbow radiographic, CT, and MRI studies were retrospectively reviewed. Patients with pathology isolated to the lateral trochlear ridge were included. Studies were reviewed by two radiologists. Identifiable pathology on each type of study was noted and characterized.

RESULTS

Ten elbow studies were included, all from males aged 15 to 58 years (mean 29 years). Five elbow radiographs were normal, one showed mixed lucency and sclerosis of the lateral trochlear ridge, and four demonstrated small osseous fragments adjacent to the ridge. In all cases, CT demonstrated focal lucency at the cortical surface of the lateral trochlear ridge; 8 contained small osseous fragments, axial plane maximum width ranged from 5 to11 mm, depth from 1 to 2 mm. Focal bone marrow edema in the subchondral lateral trochlear ridge was found in the 6 cases with MR images. Two demonstrated linear high signal underlying the in situ osseous fragment, faintly visible on MRI. In 9 cases, arthroscopy was performed within 3 months of imaging. The remaining patient was treated conservatively with casting.

CONCLUSIONS

Osteochondral lesions of the lateral trochlear ridge are rare but important, as these patients go on to arthroscopy at a high rate. If an abnormality of the lateral trochlear ridge is seen or suspected, we recommend CT as the best imaging study to define these lesions.

Osteochondritis Dissecans of the Capitellum :Review of the Literature

Osteochondritis dissecans (OCD) of the capitellum is a leading cause of elbow disability in adolescent baseball players. Previous studies have not found an association of player position with capitellar OCD. Elbow pain and a longer playing history might be related to progression of capitellar OCD but do not in themselves increase the risk of development of the condition. The cause of capitellar OCD is likely to include a combination of repetitive microtrauma and internal factors, such as ischemia and genetic predisposition. A combination of radiography, computed tomography, magnetic resonance imaging, and ultrasonography have aided our understanding of the pathology of capitellar OCD. Screening using ultrasonography enables early detection and provides an opportunity for successful conservative treatment. Treatment has conventionally included both operative and nonoperative measures based on the stage and size of the lesion, skeletal maturity, subjective symptoms, and structural integrity of the cartilage. Early-stage lesions respond better to nonoperative treatment than those in more advanced stages. Operative indications include persistent symptoms despite nonoperative treatment, symptomatic loose bodies, and displacement or detachment of fragments. J. Med. Invest. 67 : 217-221, August, 2020.

Magnetic resonance imaging of elbow injuries in children

Evaluating elbow injuries is challenging because of the complex anatomy of the joint. In children, injury patterns depend on the sports-specific mechanism as well as the stage of skeletal maturity. This article reviews the anatomy of the elbow and common injury patterns seen in children, with an emphasis on MRI and the throwing athlete. Imaging pitfalls specific to children are described.

Demographics and Epidemiology of Osteochondritis Dissecans of the Elbow Among Children and Adolescents

Background

Osteochondritis dissecans (OCD) of the elbow is a disorder of subchondral bone and articular cartilage, of which the incidence among children is not clearly known.

Purpose

To assess the demographics and epidemiology of OCD of the elbow among children.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A retrospective chart review of an integrated health system for the years 2007 through 2011 was performed for patients with elbow OCD aged 2 to 19 years. Lesion location, laterality, and all patient demographics were recorded. OCD incidence was determined for the group as a whole as well as by sex and age group (2-5, 6-11, 12-19 years). Patient differences based on age, sex, and ethnicity were analyzed, and multivariable logistic regression models were used to assess the risk of elbow OCD by group.

Results

A total of 37 patients with 40 OCD lesions fit the inclusion criteria. No lesion was found among 2- to 5-year-olds. A majority of lesions (n = 39, 97.5%) were in the capitellum, and 1 (2.5%) was in the trochlea. Twenty-five patients (67.6%) had right-sided lesions; 9 (24.3%), left-sided; and 3 (8.1%), bilateral. The incidence of elbow OCD for patients aged 6 to 19 years was 2.2 per 100,000 overall and 3.8 and 0.6 per 100,000 for males and females, respectively. The majority of OCD cases were seen in those aged 12 to 19 years, with an incidence of 3.4 per 100,000 versus 0.38 among 6- to 11-year-olds. Multivariable logistic regression analysis revealed a 21.7-times increased odds ratio of elbow OCD among patients aged 12 to 19 years versus 6 to 11 years, and males had a 6.8-times greater odds ratio of elbow OCD than females (P < .0001 for both). Based on race and ethnicity, non-Hispanic whites had the highest incidence of elbow OCD as compared with all other ethnic groups.

Conclusion

In this population-based cohort study of pediatric elbow OCD, males had almost 7 times the risk of elbow OCD as compared with females, and 12- to 19-year-olds had nearly 22 times the risk of elbow OCD versus 6- to 11-year-olds. In keeping with many prior studies, the majority of patients had right-sided lesions.

Arthroscopic treatment for elbow intraarticular loose bodies

We present a case of 29 years old man, diver, exposed to heavy work. He accused pain at the level of right elbow. Plain radiographs suggested a calcified intra-articular body. Intra-articular bodies are generally composed of cartilage in some cases, or cartilage and bone in other cases and result from several processes that leads to degradation of the articular surface. They derive nutrition in great extent from synovial fluid and contain any type of the cells of bone or cartilage. The surface cells compose more cartilaginous layers, enlarging in this way the body over time. Most deeper cells receive less nutrition than the others, leading to cell death and calcification An MRI was performed in this study to better characterize not only the location but also consistency and mobility of this body. An arthroscopic procedure was done to remove all these bodies. The results were good with disappearing of pain.

Nonoperative management of stable pediatric osteochondritis dissecans of the capitellum: predictors of treatment success

BACKGROUND

Osteochondritis dissecans (OCD) of the capitellum is a rare but potentially debilitating condition. We sought to determine the healing potential of stable capitellar OCD treated nonoperatively, as well as factors predictive of successful nonoperative management.

METHODS

We performed a retrospective review of patients younger than 19 years who presented with stable OCD of the capitellum and were treated nonoperatively for a minimum of 2 months. The average clinical and radiographic follow-up period was 12.1 months (range, 3.1-63.7 months). A multivariable logistic regression model was used to determine independent predictors of healing.

RESULTS

The study included 89 patients (93 elbows), including 49 male patients (55%); the mean age was 12.7 years (range, 8.9-18.6 years). Of the 93 elbows, 50 (53.8%) had successfully healed at a mean of 8.3 months. The symptom duration was significantly shorter in the healing group than the nonhealing group (5.3 ± 4.4 months vs 8.8 ± 9.0 months, P = .02). There were no significant differences in age, physeal status, sex, hand dominance, or sport. Hefti stage I lesions had a higher rate of healing (64.3%) than stage II (31.4%, P = .004), as did OCDs without cyst-like lesions (CLLs, 62.0%) compared with those with CLLs (20.8%, P = .001). The normalized lesion area was significantly larger in the nonhealing group (26.9% vs 18.6%, P < .001). A smaller normalized area and the absence of CLLs were independent predictors of healing.

CONCLUSIONS

Over half of stable capitellar OCD lesions have the potential to heal with activity restriction. Smaller lesions without CLLs are more likely to heal with nonoperative treatment.

A Magnetic Resonance Imaging-Based Staging System for Osteochondritis Dissecans of the Elbow: A Validation Study Against the International Cartilage Repair Society Classification

Background:

Evaluations of the stability of osteochondritis dissecans (OCD) lesions of the elbow using magnetic resonance imaging (MRI) have resulted in reports with variable accuracy. Therefore, the International Cartilage Repair Society (ICRS) classification remains the gold standard to determine OCD lesion stability. Because OCD commonly occurs in pediatric patients, a noninvasive method comparable with the ICRS classification is desired.

Hypothesis/Purpose:

Based on the previous literature, the capitellum of unstable OCD lesions has an irregular outline on MRI because of displacement or dislocation of the lesion via synovial fluid inflow. Therefore, we defined a 4-stage classification, similar to the ICRS classification, which focused on the outline of the capitellum and articular cartilage status on MRI without subchondral bone information. The purpose of this study was to validate this MRI-based staging system against the ICRS classification and to verify its accuracy in diagnosing unstable OCD lesions of the elbow.

Study Design:

Cohort study (diagnosis); Level of evidence, 2.

Methods:

A total of 81 patients with OCD of the elbow who were surgically treated were evaluated. The MRI-based stages were as follows: stage 1, normal-shaped capitellum and articular cartilage without signal intensity change; stage 2, normal-shaped capitellum and articular cartilage with signal intensity change; stage 3, irregular-shaped capitellum and discontinuity of the articular cartilage; and stage 4, dislocated lesion with an articular cartilage defect. Agreement between the MRI and ICRS classifications was evaluated, and the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for lesion instability were determined. The intraclass correlation coefficient (ICC) for intrarater and interrater reliability of the MRI-based staging system was calculated.

Results:

Agreement between the MRI-based staging system and the ICRS classification was 88.9%, with a sensitivity of 98.4%, specificity of 84.2%, PPV of 95.3%, and NPV of 94.1% for diagnosing an unstable lesion. The ICC was high for both intrarater (0.925) and interrater (0.915-0.939) reliability.

Conclusion:

The MRI-based staging system corresponded well with the ICRS classification, providing an accurate preoperative assessment of OCD lesions of the elbow, even with minimal subchondral bone information.

Comparison of Clinical and Radiographic Outcomes Between Central and Lateral Lesions After Osteochondral Autograft Transplantation for Osteochondritis Dissecans of the Humeral Capitellum

BACKGROUND

Clinical studies have reported satisfactory results after osteochondral autograft transplantation (OAT) for central lesions of unstable osteochondritis dissecans (OCD) of the elbow. However, the outcomes after OAT for lateral lesions remain unclear.

HYPOTHESIS

The clinical outcomes of OAT would be better for central lesions than for lateral lesions.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors retrospectively evaluated 103 juvenile athletes (mean age, 13.2 years; range, 11-16 years) who underwent OAT for symptomatic OCD of the humeral capitellum from 2003 to 2014. Sixteen patients were excluded because they did not fit the inclusion criteria. The final cohort of 87 patients was divided by lesion type into central lesion (n = 43) and lateral lesion (n = 44) groups. When possible, a single large plug was created for grafting and trimmed to reconstruct the rounded joint surface. The clinical, radiographic, and magnetic resonance imaging outcomes were evaluated for each group at a mean follow-up of 43 months (range, 24-100 months).

RESULTS

There were no significant differences in the age, sex, height, weight, duration of symptoms, follow-up time, preoperative range of motion, or Timmerman and Andrews score between the 2 groups. The preoperative osteoarthritic changes (0 of 43 for central vs 5 of 44 cases for lateral; P = .023), mean lesion size (12.2 ± 2.9 vs 18.2 ± 7.0 mm; P < .001), and graft number (1.6 vs 2.8; P < .001) were significantly greater in the lateral group versus the central group. The mean range of extension (2.3° ± 5.4° vs -3.2° ± 8.7°; P < .001) and Timmerman and Andrews score (194 vs 185; P = .006) at the final follow-up were significantly better for patients in the central group. More patients in the lateral group had postoperative radial head subluxation (0 of 43 vs 6 of 44; P = .012) and osteoarthritic changes (1 of 43 vs 9 of 44; P = .008). The mean MOCART score showed no significant differences between the groups (78.0 ± 15.7 vs 72.6 ± 20.9; P = .181). The rate of return to sports at the previous level was 100% in the central group and 86% in the lateral group ( P = .012).

CONCLUSION

The clinical and radiographic outcomes after OAT associated with unstable OCD of the humeral capitellum were better for central lesions than for lateral lesions. However, satisfactory outcomes and a high rate of return to sports were obtained for unstable lateral lesions after OAT.

Two-year follow-up study of subchondral surface irregularities of the capitellum on ultrasonography in baseball players under the age of 10 years

OBJECTIVE

To determine whether subchondral surface irregularities of the capitellum on ultrasonography in baseball players under the age of 10 years are indicative of early osteochondritis dissecans (OCD) of the capitellum.

MATERIALS AND METHODS

A total of 321 players aged 6-9 years underwent ultrasonographic examination, and the findings for the subchondral bone of the capitellum on the throwing side were graded as 0, 1a, 1b, 2, or 3. Subjects classified as grade 1a or 1b showed irregularities of the subchondral bone surface and were investigated radiographically for OCD. All players continued to throw and were re-examined by ultrasonography after 1 and 2 years.

RESULTS

At the first examination, 11/321 (3.4%) had irregularities at the subchondral surface of the capitellum [grade 1a in 7/321 (2.2%); grade 1b in 4/321 (1.2%)]. The seven players with grade 1a showed no evidence of OCD or Panner's disease on radiography and were reclassified as grade 0 at the 2-year follow-up. All four players with grade 1b were reclassified as grade 0 at follow-up 1 and 2 years later.

CONCLUSION

Subchondral bone surface irregularities of the capitellum on ultrasonography in children under the age of 10 years may not be indicative of disease, but rather represent variation of ossification during normal development.

Clinical Outcome After Arthroscopic Debridement and Microfracture for Osteochondritis Dissecans of the Capitellum

BACKGROUND

Various surgical treatment techniques have been developed to treat capitellar osteochondritis dissecans; however, the optimal technique remains the subject of ongoing debate.

PURPOSE

To evaluate clinical outcomes after arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between 2008 and 2015, the authors followed 77 consecutive patients (81 elbows) who underwent arthroscopic debridement and microfracture, and loose body removal if needed, for advanced capitellar osteochondritis dissecans. Seventy-one patients (75 elbows) with a minimum follow-up of 1 year were included. The mean age was 16 years (SD, ±3.3 years; range, 11-26 years) and the mean follow-up length was 3.5 years (SD, ±1.9 years; range, 1-8.2 years). Based on CT and/or MRI results, 71 lesions were classified as unstable and 4 as stable. Clinical elbow outcome (pain, function, and social-psychological effect) was assessed using the Oxford Elbow Score (OES) at final follow-up (OES range, 0-48). Range of motion and return to sports were recorded. Multivariable linear regression analysis was performed to determine predictors of postoperative OES.

RESULTS

Intraoperatively, there were 3 grade 1 lesions, 2 grade 2 lesions, 10 grade 3 lesions, 1 grade 4 lesion, and 59 grade 5 lesions. The mean postoperative OES was 40.8 (SD, ±8.0). An open capitellar physis was a predictor of better elbow outcome (5.8-point increase; P = .025), as well as loose body removal/grade 4-5 lesions (6.9-point increase; P = .0020) and shorter duration of preoperative symptoms (1.4-point increase per year; P = .029). Flexion slightly improved from 134° to 139° ( P < .001); extension deficit slightly improved from 8° to 3° ( P < .001). Pronation ( P = .47) and supination did not improve ( P = .065). Thirty-seven patients (55%) returned to their primary sport at the same level, and 5 patients (7%) returned to a lower level. Seventeen patients (25%) did not return to sport due to elbow-related symptoms, and 10 patients (13%) did not return due to non-elbow-related reasons. No complications were recorded.

CONCLUSION

Arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans provide good clinical results, especially in patients with open growth plate, loose body removal, and shorter duration of symptoms. However, only 62% of patients in this study returned to sports.

Bilateral Osteochondritis Dissecans of the Capitellum in Fraternal Twins: A Case Report

CASE

We report the cases of 15-year-old male fraternal twins with bilateral osteochondritis dissecans (OCD) of the capitellum in the absence of syndromic features. At the time of presentation, they had been actively engaged in competitive rhythmic gymnastics for 3 years. Both patients had chronic symptoms in the right elbow, and both underwent arthroscopic evaluation and management.

CONCLUSION

The cases of these 2 patients provide evidence to support the theory that the etiology of OCD may have a genetic background.

Imaging of Cartilage in the Athlete

MRI remains the optimal imaging modality to evaluate cartilage injuries in the athlete. As these injuries have no intrinsic healing capacity, early and accurate noninvasive diagnosis remains integral to determining the most appropriate treatment option in this class of patients. Although surgical success depends primarily on clinical outcomes, MRI evaluation can provide pertinent information regarding the status of the surgical repair and the progression of cartilage disease.

Elbow Imaging in Sport: Sports Imaging Series

Elbow pain is a frequent presenting symptom in athletes, particularly athletes who throw. The elbow can be injured as a result of acute trauma, such as a direct blow or a fall onto an outstretched hand or from chronic microtrauma. In particular, valgus extension overload during the throwing motion can precipitate a cascade of chronic injuries that can be debilitating for both casual and high-performance athletes. Prompt imaging evaluation facilitates accurate diagnosis and appropriate targeted interventions.

Osteochondritis dissecans of the elbow

Capitellar osteochondritis dissecans (OCD) can be a significant problem in adolescent overhead athletes. The cause is likely multifactorial secondary to repetitive stresses, biomechanical mismatch, and a tenuous vascular supply of the capitellum. Recent literature reveals that the prevalence is likely higher than previously thought. This, in conjunction with increased levels of athletic competition in children at younger ages, has fed the recent interest in this topic. The literature continues to show that non-operative treatment is still successful for stable lesions. Unstable lesions, therefore, have been the focus of the new literature regarding operative management and outcomes. The aim of this paper is to provide a summary of current literature and an up-to-date approach to the diagnosis, evaluation, and treatment of osteochondritis dissecans of the capitellum.

Osteochondritis dissecans of the capitellum in adolescents

Osteochondritis dissecans (OCD) is a disorder of articular cartilage and subchondral bone. In the elbow, an OCD is localized most commonly at the humeral capitellum. Teenagers engaged in sports that involve repetitive stress on the elbow are at risk. A high index of suspicion is warranted to prevent delay in the diagnosis. Plain radiographs may disclose the lesion but computed tomography and magnetic resonance imaging are more accurate in the detection of OCD. To determine the best treatment option it is important to differentiate between stable and unstable OCD lesions. Stable lesions can be initially treated nonoperatively with elbow rest or activity modification and physical therapy. Unstable lesions and stable lesions not responding to conservative therapy require a surgical approach. Arthroscopic debridement and microfracturing has become the standard initial procedure for treatment of capitellar OCD. Numerous other surgical options have been reported, including internal fixation of large fragments and osteochondral autograft transfer. The aim of this article is to provide a current concepts review of the etiology, clinical presentation, diagnosis, treatment, and outcomes of elbow OCD.

Evaluation of Knee Donor and Elbow Recipient Sites for Osteochondral Autologous Transplantation Surgery in Capitellar Osteochondritis Dissecans

BACKGROUND

Osteochondral autologous transplantation surgery (OATS) has been advocated for treatment of osteochondritis dissecans (OCD) of the capitellum in adolescents. However, little information is available regarding the optimal knee harvest site to match the contour and cartilage thickness of the recipient elbow lesion.

PURPOSE

To characterize the capitellar anatomic structure in adolescents with and without OCD and to compare these measurements to normal adolescent knees to identify the optimal site for osteochondral graft harvest.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty-one patients with OCD were analyzed. Twenty-two patients with normal elbows and 25 age-, weight-, and height-matched patients with normal knees were also identified. Cartilage radii of curvatures (ROCs) in the sagittal and coronal-axial planes were measured on magnetic resonance imaging (MRI) of normal capitella and 5 sites (posterior lateral femoral condyle, medial and lateral middle trochlear ridges, and medial and lateral inferior trochlear ridges) in normal knees. Differences in ROC between the knee donor and capitellar recipient sites were calculated based on a 10-mm osteochondral plug diameter.

RESULTS

Overall, the mean apex differences between graft and recipient sites ranged from 0.4 to 0.9 mm, and mean edge differences ranged from 0.5 to 1.4 mm in the coronal-axial dimension. Of all knee sites tested, the posterior lateral femoral condyle had average ROCs (19.1 mm sagittal; 14.1 mm axial) most like the capitellum (10.6 mm sagittal, 12.6 mm coronal-axial), resulting in minimal apex and edge differences (apex difference = -0.6 mm; coronal-axial side difference = -0.5 mm; no sagittal side difference). Of the anterior nonweightbearing sites, the inferior medial trochlear ridge (28.3 mm sagittal ROC; 13.2 mm coronal-axial ROC) demonstrated the lowest apex and side differences when compared with the capitellum (apex difference = -0.8 mm; coronal-axial side difference = -0.8 mm; no sagittal side difference). The frequently used middle lateral trochlear ridge (28.8 mm sagittal; 8.7 mm coronal-axial ROCs) had the largest side difference (apex distance = -0.8 mm; coronal-axial side difference = -1.4 mm; no sagittal side difference).

CONCLUSION/CLINICAL RELEVANCE

In cases where a large single-plug OATS is considered, a 10-mm plug from the anterior nonweightbearing aspect of the distal femur is calculated to result in ≤1 mm of articular incongruity at the recipient capitellum. The inferior medial trochlear ridge should be considered as a donor site for OATS procedures for OCD given its accessibility and favorable geometry.

Internal Fixation of Unstable In Situ Osteochondritis Dissecans Lesions of the Capitellum

BACKGROUND

Limited data exist regarding the indications and expected outcomes of internal fixation of unstable in situ osteochondritis dissecans (OCD) lesions of the capitellum. The objective of this investigation was to characterize healing rates, clinical results, and functional outcomes of internal fixation of unstable in situ OCD lesions in adolescents.

METHODS

Retrospective analysis was performed of 26 elbows in 24 patients who underwent internal fixation for unstable in situ OCD. Mean age at surgery was 14.1 years; 7 patients had open physes. Mean lesion width and thickness were 12.0 and 5.4 mm, respectively. Demographic, clinical, and radiographic variables of patients who went on to healing versus revision procedures were compared with univariate analysis. Classification and regression tree analysis identified optimal threshold values associated with healing. Functional outcomes were assessed with the Mayo Elbow Performance Score, Timmerman, and Pediatric Outcomes Data Collection Instrument scores. Mean clinical follow-up was 39 months (range, 12 to 96 mo).

RESULTS

Twenty of 26 elbows healed. Patients who healed were younger (P=0.01) and had smaller sagittal plane lesion widths (P=0.03) than patients who underwent revision. Classification and regression tree analysis identified 15.3 years and 13 mm as the threshold values distinguishing patients who did and did not heal. Overall, mean arc of elbow motion improved from 109 degrees preoperatively to 127 degrees at last follow-up (P=0.001). Mean Mayo Elbow Performance Score improved from 68 to 92 (P<0.001). Of 18 questionnaire respondents, two thirds reported full return to their prior level of sports participation without elbow complaint; 9 had excellent final Timmerman scores, 5 good, and 4 fair. Mean Pediatric Outcomes Data Collection Instrument upper extremity and sports scores were 98 and 93, respectively.

CONCLUSIONS

Healing, return to sports, and good to excellent functional outcomes may be expected in the majority of patients undergoing internal fixation of unstable in situ OCD lesions of the capitellum, particularly in younger patients with lesions <13 mm in sagittal width. Higher levels of evidence must further differentiate the optimal surgical treatments of unstable OCD.

LEVEL OF EVIDENCE

Level IV.

Elbow magnetic resonance imaging: imaging anatomy and evaluation

The elbow is a complex joint. Magnetic resonance imaging (MRI) is often the imaging modality of choice in the workup of elbow pain, especially in sports injuries and younger patients who often have either a history of a chronic repetitive strain such as the throwing athlete or a distinct traumatic injury. Traumatic injuries and alternative musculoskeletal pathologies can affect the ligaments, musculotendinous, cartilaginous, and osseous structures of the elbow as well as the 3 main nerves to the upper limb, and these structures are best assessed with MRI.Knowledge of the complex anatomy of the elbow joint as well as patterns of injury and disease is important for the radiologist to make an accurate diagnosis in the setting of elbow pain. This chapter will outline elbow anatomy, basic imaging parameters, compartmental pathology, and finally applications of some novel MRI techniques.

Arthroscopic Articular Reconstruction of Capitellar Osteochondral Defects

BACKGROUND

Articular reconstruction is recommended for some unstable capitellar osteochondritis dissecans (OCD) lesions. Capitellar osteochondral autograft transplantation (OAT) through an open approach for optimal visualization and perpendicular graft implantation has been advocated. However, arthroscopic capitellar OAT may achieve the same treatment goals with decreased morbidity and ability to treat the entire joint for pathologic changes.

PURPOSE/HYPOTHESIS

The purpose of this study was to assess the ability to resurface the capitellum arthroscopically. The hypothesis was that arthroscopy allows sufficient access to facilitate perpendicular graft placement in most clinically significant capitellar OCD lesions.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Arthroscopy was performed on 12 fresh-frozen cadaveric elbows. Of the tunnels created, 21 were used in final analysis. A 6-mm osteochondral transplantation bone graft harvester was used to generate perpendicular recipient sites in the capitellar articular surface. Both central (n = 11) and lateral (n = 10) OCD locations were studied. Fluoroscopy was used to measure the angle of the harvest relative to the axis of the humerus and tunnel perpendicularity.

RESULTS

Among central and lateral lesions, the average (±SD) degree of perpendicularity achieved was 85.3° ± 2.9° and 85.8° ± 2.5°, respectively. Perpendicular harvests were achieved in central and lateral lesions as high as 74.9° and 80.4°, anterior to the humeral shaft, respectively. No significant relationship was noted between increasing anterior location and ability to attain perpendicular harvests. Achieving perpendicularity in lesions that were more anterior to these values was not possible due to anatomic constraints of the radial head in maximal elbow flexion.

CONCLUSION

Adequate recipient tunnels were created in lesions that were as high as 75° to 80° anterior to the humeral shaft, which encompasses most clinically relevant lesions. Moreover, increasing the anterior position of the lesion did not compromise the ability to generate perpendicular tunnels. The findings of this cadaveric study suggest that most clinically relevant capitellar osteochondral lesions can be successfully resurfaced arthroscopically.

CLINICAL RELEVANCE

This study demonstrates the feasibility of performing an arthroscopic versus open articular reconstruction when indicated for high-grade capitellar OCD lesions. These conclusions afford sports medicine surgeons another tool in the treatment of this challenging condition.

Osteochondral Lesions of Major Joints

This paper provides information about osteochondral lesions (OCL) and example cases of OCL occurring in major joints, some of which are rarely seen. This simple tutorial is presented in question and answer format.

Osteochondral autograft plug transfer for treatment of osteochondritis dissecans of the capitellum in adolescent athletes

BACKGROUND

Osteochondritis dissecans (OCD) of the capitellum is a condition most commonly seen in adolescents involved in repetitive overhead sports and can profoundly affect ability to return to play and long-term elbow function. Treatment of large, unstable defects in the elbow with osteochondral autograft plug transfer has not been adequately studied.

METHODS

We retrospectively identified 11 teenaged patients with large (>1 cm(2)) capitellar OCD treated with osteochondral autograft plug transfer. Average age at the time of surgery was 14.5 years (range, 13-17 years). Outcome measures obtained included return to play, preoperative and postoperative elbow range of motion, Disabilities of Arm, Shoulder and Hand (DASH; Institute for Work and Health, Toronto, ON, Canada) by telephone interview, and osseous integration on radiographs. All 11 patients were available for evaluation at an average of 22.7 months (range, 6-49 months) postoperatively.

RESULTS

All patients were involved in competitive high school athletics and returned to at least their preinjury level of play. Average return to play was 4.4 months (range 3-7 months). The average final DASH was 1.4 (95% confidence interval, 0.6-2.1), and the average final sport-specific DASH was 1.7 (95% confidence interval -1.8 to 5.2). Elbow range of motion significantly improved, including improvement in flexion from a preoperative average of 126° to a postoperative average of 141° (P = .009) and improvement in extension from a preoperative average of 21° to a postoperative average of 5° (P = .006).

CONCLUSIONS

Treatment of large, unstable OCD lesions of the capitellum in adolescent athletes allows reliable return to play, is safe, and has good clinical outcomes at short-term follow-up.

[Imaging of the elbow joint with focused MRI. Part 1: examination techniques and sequences for bone and ligaments]

Imaging of the elbow joint places high demands on the quality of imaging due to the challenging anatomy and the sometimes subtle findings. For the diagnosis of periarticular soft tissues, ligamentous structures and in individual cases for fracture and tumor diagnosis, magnetic resonance imaging (MRI) is mostly groundbreaking and allows a reliable diagnosis in most cases. This review article discusses the complex imaging anatomy and anatomical variants of this joint and the most common osseous and ligamentous injuries of the elbow joint are presented. The typical MRI findings and indications are illustrated and discussed and possible pitfalls are pointed out. The various examination techniques and MRI sequences are also addressed.

Imaging of tarsal navicular disorders: a pictorial review

The tarsal navicular is a bone within the midfoot that plays a critical role in maintaining the arch of the foot. This bone is clinically relevant because it may be affected by a wide array of pathologies. Our approach includes a detailed description of the imaging characteristics and disorders affecting the tarsal navicular. Organization includes (a) normal imaging, (b) accessory ossicles, (c) coalition, (d) fractures, (e) Kohler's disease, (f) osteonecrosis, (g) osteochondral lesions, (h) arthropathies, and (i) tumors. The purpose of this article is to discuss normal variants and pathological processes that can affect the tarsal navicular, with emphasis on the often-overlooked imaging findings.

Outcomes and failure factors in surgical treatment for osteochondritis dissecans of the capitellum

BACKGROUND

Osteochondritis dissecans (OCD) of the capitellum is an intra-articular lesion and one of the leading causes of permanent elbow disability. The treatment of advanced capitellar OCD remains challenging because of the limited potential of the articular cartilage for self-repair. The purpose of this study was to investigate the outcome of surgical treatment for OCD of the capitellum.

METHODS

From 2000 to 2010, 32 male patients who had advanced lesions of capitellar OCD were treated operatively. The mean age of the patients was 14.4 years at the time of surgery. Twenty-nine patients played baseball and 3 played other sports. The lesions were of the centralized type in 9 patients, the lateral type in 4 patients, and the widespread type in 19 patients. For the surgical procedure, osteochondral peg fixation was selected for 13 patients and osteochondral autograft transplantation for 19 patients. Clinical outcome was measured with the elbow rating system including range of motion, and the number of patients who returned to active sports participation within 1 year after surgery was determined.

RESULTS

The mean total arc of elbow motion increased from 123±17 degrees preoperatively to 132±14 degrees postoperatively. The mean clinical score improved significantly from 133±24 to 177±27. Within the first year after surgery, 81.3% of the patients returned to active sports playing. However, 4 of 8 patients (50%) in which osteochondral peg fixation was performed for lesions of the lateral widespread type required reoperation.

CONCLUSIONS

Our results indicate that osteochondral peg fixation and osteochondral autograft transplantation may improve elbow rating score, and may facilitate a return to active sports participation. However, osteochondral peg fixation may be insufficient for lesions of the widespread type because of their poor stability. The large lateral condyle lesions had a worse outcome, and future studies will need to develop improved treatment for these defects.

LEVEL OF EVIDENCE

Level IV (case series).

The approach to elbow pain in the pediatric and adolescent throwing athlete

Elbow pain in pediatric throwing athletes can be very concerning and challenging to diagnose. Diagnosis involves determining whether the injury is chronic or acute in nature and the anatomical location of the pain. Physicians should be aware of the sport-specific forces that predispose athletes with immature skeletons to injury and should be familiar with the common presentations of these injuries. In order to narrow the diagnosis, physicians should gather a detailed history of how and when the pain occurred in addition to performing a thorough physical exam that includes tests, such as the modified milking maneuver and the moving valgus stress test. Appropriate imaging helps physicians to confirm the diagnosis and elucidates any associated pathology in patients. In most cases, the treatment given to patients is conservative and involves rest, ice, non-steroidal anti-inflammatory drugs for pain, and an appropriate physical therapy regimen with a progressive return to play when symptoms have resolved. When patients fail to respond to conservative treatment, surgical intervention may be needed. Knowing when to refer patients for orthopedic evaluation helps athletes return to play quickly and safely.

Preoperative imaging criteria for unstable osteochondritis dissecans of the capitellum

BACKGROUND

The stability of an osteochondritis dissecans (OCD) lesion of the humeral capitellum may be determined by intraoperative probing with unstable lesions being displaceable. Although preoperative imaging is used to diagnose and determine treatment of these lesions, it is unclear whether unstable lesions on imaging correspond to those found intraoperatively.

QUESTIONS/PURPOSES

We therefore examined the concordance between preoperative imaging and intraoperative instability and examined the imaging features of the patients who healed without surgery.

METHODS

We retrospectively reviewed 61 patients who underwent OCD of the humeral capitellum surgery or nonoperative treatment. All patients had plain radiography, MRI, and/or CT scans. The presence or absence of stability was determined intraoperatively by the International Cartilage Repair Society OCD classification. We determined the sensitivity, specificity, and predictive value of various imaging findings to predict instability.

RESULTS

The following preoperative imaging features were associated with intraoperative instability: a displaced fragment, epiphyseal closure of the capitellum, or a lateral epicondyle observed on radiographs; irregular contours of the articular surface or a high signal interface on T2-weighted MRI; and a displaced fragment observed on CT. Unstable lesions were more common when the epiphysis of the capitellum was closed. Intralesional segmentation was sensitive for detecting an unstable lesion, whereas displaced type on the radiographs and displaced fragment on the CT were specific. The following imaging findings were not seen in nonoperative patients: displaced type and closure of the epiphyseal line on radiographs, irregular contours of the articular surface, articular defects, and T2 high signal intensity interface between the fragments and their bed on the MRI or a displaced fragment on the CT.

CONCLUSIONS

Although we found high sensitivity for some preoperative findings on imaging, none reached 100% of sensitivity. Preoperative MRI related to the intraoperative assessment of stability.

LEVEL OF EVIDENCE

Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Elbow injuries in the young athlete--an orthopedic perspective

Elbow injuries in young athletes are increasing with these athletes specializing in a single sport at an early age and participating in their chosen sport at a high level year-round. The majority of these injuries occur from valgus loading of the elbow, either repetitively causing an overuse injury or more acutely resulting in a fracture or dislocation. Capitellar osteochondritis dissecans, medial epicondyle injuries and ulnar collateral ligament injuries are three of the most common elbow injuries occurring in young athletes.

Throwing injuries of the upper extremity

The overhead throwing motion is a complex sequence of maneuvers that requires coordinated muscle activity in the upper and lower extremities. The shoulder and elbow are subject to multidirectional forces and are particularly vulnerable to injury during specific phases of the overhead throwing motion. Ligamentous, tendinous, neural, and osseous pathology that may occur in the shoulder or elbow of an overhead-throwing athlete will be discussed, with an emphasis on the role of MR imaging and MR arthrography.

Injuries of the elbow and the current treatment of tendon disease

OBJECTIVE

Overuse and traumatic injuries of the elbow are common, occurring in both athletes and nonathletes. This article will discuss the commonly encountered soft-tissue and osseous pathologic abnormalities around the elbow and their imaging appearance on MRI and ultrasound.

CONCLUSION

The current treatment of tendon disease of the elbow is reviewed, with a focus on platelet-rich plasma injection.

MR grading system of osteochondritis dissecans lesions: comparison with arthroscopy

OBJECTIVE

To assess the diagnostic performance of combined three-dimensional (3D) gradient-echo (GRE) T1-weighted and routine MR imaging protocol for the evaluation of osteochondritis dissecans (OCD).

MATERIALS AND METHODS

This prospective study was approved by our institutional review board and all patients gave informed consent. Three-dimensional GRE MR sequence was added to the routine protocol performed on 40 consecutive patients (35 men, 5 women; age range, 12-57 years; mean age, 20 years) with 17 juvenile and 24 adult OCD lesions (27 in knees; 14 in elbows) which were confirmed by arthroscopy. Two independent musculoskeletal radiologists reviewed all MR images. The OCD lesions were classified into five stages by assessing the signal intensity of fragment-bone interface and the integrity of articular cartilage on MR images. Stage-IV and -V lesions were considered as unstable. The sensitivity, specificity, accuracy, and interobserver agreement (κ statistics) were calculated.

RESULTS

The sensitivity, specificity, and accuracy for detection of OCD instability were 100% (11 of 11), 100% (6 of 6), and 100% (17 of 17) in juvenile lesions; and 93% (14 of 15), 100% (9 of 9), and 96% (23 of 24) in adult lesions. The overall accuracy of MR findings in determining the staging was 90% (37 of 41) for reader 1 and 83% (34 of 41) for reader 2. Agreement between readers was substantial with a κ value of 0.75 for MR staging of OCD lesions.

CONCLUSIONS

Three-dimensional GRE T1-weighted MR imaging combined with the routine sequences demonstrates excellent diagnostic capabilities in detecting unstable OCD lesions.