Osteochondritis Dissecans of the Capitellum: Current Concepts

Review Article Osteochondritis Dissecans of the Capitellum: Current Concepts

Abstract David E. Ruchelsman, MD Osteochondritis dissecans (OCD) of the capitellum is an Michael P. Hall, MD uncommon disorder seen primarily in the adolescent overhead athlete. Unlike Panner disease, a self-limiting condition of the Thomas Youm, MD immature capitellum, OCD is multifactorial and likely results from microtrauma in the setting of cartilage mismatch and vascular susceptibility. The natural history of OCD is poorly understood, and degenerative joint disease may develop over time. Multiple modalities aid in diagnosis, including radiography, MRI, and magnetic resonance arthrography. Lesion size, location, and grade determine management, which should attempt to address subchondral bone loss and articular cartilage damage. Early, stable lesions are managed with rest. Surgery should be considered for unstable lesions. Most investigators advocate arthroscopic débridement with marrow stimulation. Fragment ﬁxation and bone grafting also have provided good short-term results, but concerns persist regarding the healing potential of advanced lesions. Osteochondral autograft transplantation appears to be promising and should be reserved for larger, higher grade lesions. Clinical outcomes and return to sport are variable. Longer-term follow-up studies are necessary to fully assess surgical management, and patients must be counseled appropriately. From the Department of Orthopaedic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, and steochondritis dissecans (OCD) comes. Means of optimal manage- Newton-Wellesley Hospital and Tufts Oof the capitellum is a disabling ment remains unknown. University School of Medicine, condition that affects immature ath- Panner disease is another disorder Newton, MA (Dr. Ruchelsman), and the Department of Orthopaedic letes who undergo repetitive com- of the immature capitellum and must Surgery, New York University pression of the radiocapitellar joint. be differentiated from OCD. Panner Hospital for Joint Diseases, New This localized lesion involves a seg- disease was initially described in York, NY (Dr. Hall and Dr. Youm). ment of articular cartilage with dis- 1927 as a clinical and radiographic None of the following authors or any ruption of associated subchondral entity similar to Legg-Calvé-Perthes immediate family member has bone. The exact etiology of the disor- disease of the hip.2 It is an osteo- received anything of value from or owns stock in a commercial der remains unclear, and the natural chondrosis of the entire capitellum, company or institution related history of OCD lesions suggests that with fissuring and fragmentation directly or indirectly to the subject of radiocapitellar degenerative changes seen on initial radiographs (Figure this article: Dr. Ruchelsman, 1 Dr. Hall, and Dr. Youm. occur in up to 50% of patients. 1). Unlike OCD, Panner disease is Management is determined based on not associated with trauma and is J Am Acad Orthop Surg 2010;18: the integrity of the articular cartilage seen almost exclusively in boys aged 557-567 and the stability of the lesion. Many <10 years.3 Clinical reports have Copyright 2010 by the American surgical procedures have been de- found it to be a self-limiting disease, Academy of Orthopaedic Surgeons. scribed, with varied short-term out- with reossification and resolution of

September 2010, Vol 18, No 9 557 Osteochondritis Dissecans of the Capitellum: Current Concepts

Figure 1 sic mechanical properties of the radiocapitellar articular cartilage to be responsible for the development of OCD. The authors divided the radial head and capitellum into multiple osteochondral segments and found that the lateral capitellum had softer segments compared with the stiffer mid radial head segments. They concluded that the disparate mechanical properties, or “mismatch,” may increase strain in the lateral capitellum, leading to the initiation and localiza- tion at the most reported location of OCD lesion.

A, AP radiograph of the right elbow in a 6-year-old boy. Note the irregular ossiﬁcation of the capitellum (arrow), consistent with Panner disease. B, AP Vascular Anatomy radiograph of the left elbow in a 14-year-old boy demonstrating a focal The vascular anatomy of the distal osteochondritis dissecans lesion (arrow). (Reproduced from Kobayashi K, Burton K, Rodner C, Smith B, Caputo A: Lateral compression injuries in the humerus supports ischemia as a pos- pediatric elbow: Panner’s disease and osteochondritis dissecans of the sible contributing factor to OCD of capitellum. J Am Acad Orthop Surg 2004;12[4]:246-254.) the capitellum. The capitellum is primarily supplied by posterior end ar- symptoms with nonsurgical manage- the late cocking phase across the ra- teries that traverse the epiphyseal ar- ment.4,5 diocapitellar articulation, which is ticular cartilage without metaphyseal 19,20 the major secondary stabilizer to val- collateral contribution (Figure 2). gus stress.12-14 The radiocapitellar ar- Repetitive compression of the tenu- Etiology ticulation has also been shown to ous capitellar blood supply may result in subchondral ischemia and the The etiology of OCD of the capitel- experience up to 60% of axial com- 15 characteristic osteonecrosis seen in lum is unknown, but trauma and pression forces across the elbow. OCD. Loss of subchondral support ischemia are believed to play a signif- This may help support a traumatic may then lead to articular cartilage icant role.5-7 No conclusive evidence etiology in female gymnasts, who re- fragmentation and loose body for- exists for a genetic predisposition, petitively load the radiocapitellar 21 but several case studies have re- joint with their arms in extension.16 mation. ported patients with OCD in consec- The findings in OCD mimic the utive generations as well as one case pathophysiology following mechani- Histopathology in fraternal twins.8-11 cal trauma to articular cartilage. Tallqvist17 found that cyclical mi- Despite its name, no evidence of in- Trauma crotrauma to articular cartilage led flammation has been observed in his- OCD occurs predominantly in the dom- to fatigue fracture, resorption, and topathologic studies of OCD.22 In a inant arm of male throwing athletes and fragment separation of the subchon- recent histologic analysis of capitel- in female gymnasts, which supports the dral bone in rabbits when fractures lar lesions, changes similar to those idea that repetitive trauma is the ma- failed to heal. As fragments become of osteoarthritis were found in the jor inciting event.3,5-7 Overuse with avascular, the overlying articular car- articular cartilage.23 Kusumi et al23 throwing, with or without poor me- tilage may become progressively used histochemical analysis to de- chanics, can cause fatigue of the me- more susceptible to increased shear tect the presence of matrix dial elbow complex—specifically, of stresses because of failure of the sub- metalloproteinase-3 and -13, which the medial collateral ligament and chondral osseous support. This ulti- are important markers in chondro- flexor pronator origin.12-14 This has mately leads to separation, fragmen- cyte apoptosis and cartilage remodel- been shown to lead to increased tation, and loose body formation. ing. The authors suggested that the compression and shear forces during Schenck et al18 believed the intrin- primary pathologic changes in OCD

558 Journal of the American Academy of Orthopaedic Surgeons David E. Ruchelsman, MD, et al

Figure 2 comparison. Supplemental views, such as a 45° flexion AP or oblique view, may help demonstrate the lesion.21 The classic finding with OCD is a focal lesion in the anterolateral capitellum with rarefaction and irregularity of the articular surface. A rim of sclerotic bone often surrounds the lesion. As the condition pro- gresses, loose bodies may form if the articular surface becomes detached (Figure 3). Healing is normally demonstrated by ossification of the ra- diolucent area; this may take several years.11 Plain radiographs are essential in the diagnosis of OCD lesions; however, additional studies may be indicated, especially for determining lesion stability.26 CT may be used to Blood supply of the capitellum. (Reproduced from Kobayashi K, Burton KJ, better delineate the osseous detail Rodner C, Smith B, Caputo AE: Lateral compression injuries in the pediatric and extent of the lesion. CT arthrog- elbow: Panner’s disease and osteochondritis dissecans of the elbow. JAm raphy has been demonstrated to Acad Orthop Surg 2004;12[4]:246-254.) more accurately define loose bodies and the articular surface.27 Ultra- sonography also has been used to de- were damage to articular cartilage and should prompt consideration of tect flattening in early stages, but its induced by repeated stress following other pathologic processes. use is limited due to operator depen- remodeling of articular cartilage and Physical examination may demon- dence.28 subchondral microfractures. In ad- strate a small effusion or swelling MRI has become the most com- vanced stages, separation of deep ar- with tenderness over the radiocapi- mon diagnostic modality after plain ticular cartilage as well as of sub- tellar articulation. Patients occasion- radiography. It is useful in assessing chondral bone occurs. ally have a loss of terminal extension the surface of the articular cartilage of up to 15° to 20°.7,24,25 Crepitus or and has been shown to detect early pain may be demonstrated on the OCD lesions when no changes were Clinical Presentation active radiocapitellar compression evident on radiographs29 (Figure 4). test.6 Passive forearm pronation and OCD of the capitellum primarily af- In early lesions, T1-weighted images supination is done during midrange fects athletes aged 11 to 21 years demonstrate decreased signal inten- elbow flexion and extension with an (average, 12 to 14 years).5-7 OCD is sity within the lesion, whereas T2- axial load applied to the radiocapi- more common in males than females, weighted images remain normal.21 tellar joint. The posterolateral rota- and it tends to be associated with High signal intensity and cyst forma- tory instability test should be done to sports such as baseball, gymnastics, tion around a lesion on T2-weighted evaluate for potential elbow instabil- tennis, weight lifting, and cheerlead- images has also been found to corre- ity. ing. The dominant arm is almost al- late with lesion instability found on ways involved, with bilateral in- arthroscopy.30 Pseudodefect is a com- volvement occasionally reported. Diagnosis mon finding that is mistaken for Patients typically report insidious on- OCD on magnetic resonance im- set of lateral elbow pain that is in- Radiography of the elbow is the di- ages31 (Figure 5). This normal ana- creased with activity and relieved with agnostic test of choice. Radiographs tomic finding is the cleft that appears rest. Stiffness and mechanical symp- are often negative early in the disease at the posteroinferior capitellum as toms, such as locking and catching, are process, and views of the contralat- the posterior articular surface meets often noted late. Pain at night is rare eral elbow should be obtained for the nonarticulating capitellum.

September 2010, Vol 18, No 9 559 Osteochondritis Dissecans of the Capitellum: Current Concepts

Figure 3

Radiographic progression of osteochondritis dissecans of the capitellum. AP radiographs obtained with the elbow in 45° of ﬂexion demonstrating localized subchondral bone ﬂattening without fragments (arrows) (A) and nondisplaced bone fragments (arrowheads) (B). C, AP radiograph demonstrating a displaced fragment (arrow). D, AP radiograph demonstrating a loose fragment (arrowheads) and a bone defect (arrow). (Reproduced with permission from Takahara M, Ogino T, Takagi M, Tsuchida H, Orui H, Nambu T: Natural progression of osteochondritis dissecans of the humeral capitellum: Initial observations. Radiology 2000;216:207-212.)

Figure 4

A, AP radiograph demonstrating central lucency (arrow) in the capitellum consistent with osteochondritis dissecans in a 15-year-old male baseball pitcher with left elbow pain. Further delineation of the lesion is noted on coronal T1- weighted (arrow) (B) and sagittal T2-weighted (arrow) (C) magnetic resonance images.

Gadolinium-enhanced magnetic Enhancement may suggest an intact by a clear zone or split line between resonance arthrography may provide blood supply to the fragment, but the lesion and the adjacent subchon- additional diagnostic accuracy and this technique has had limited use. dral bone. Grade III lesions were as- can improve staging by identifying sociated with the presence of loose unstable osteochondral fragments.29 bodies. This is demonstrated by intervening Classiﬁcation MRI has since been used to im- fluid signal on T2-weighted images. prove diagnosis and guide treatment. However, it is unlikely that all unsta- Minami et al34 first categorized OCD The classification system developed ble lesions will have these findings.32 lesions of the capitellum based on AP for OCD lesions of the knee and ta- Intravenous gadopentetate dimeglu- radiographs. Grade I lesions demon- lus by Nelson et al35 (Table 1) is mine–enhanced MRI has been used strated a translucent cystic shadow commonly used for lesions of the to evaluate the viability of the at- in the lateral or middle capitellum. capitellum. A rim of high signal in- tached osteochondral fragments.32,33 Grade II lesions were characterized tensity surrounding the lesion on T2-

560 Journal of the American Academy of Orthopaedic Surgeons David E. Ruchelsman, MD, et al

Figure 5 Figure 6

Sagittal T2-weighted fat- suppressed magnetic resonance image demonstrating a normal pseudodefect (arrow) in a 45-year- old man. (Reproduced with permission from Rosenberg ZS, A, Sagittal T2-weighted fat-suppressed fast spin-echo magnetic resonance Blutreich SI, Schweitzer ME, image of the elbow in a 16-year-old male baseball pitcher with surgically Zember JS, Fillmore K: MRI proven stable osteochondritis dissecans (OCD) of the capitellum. Areas of features of posterior capitellar subtle high signal intensity can be seen within the OCD lesion (arrow), but impaction injuries. Am J no surrounding rim is evident. B, Sagittal T2-weighted fat-suppressed fast Roentgenol 2008;190:435-441.) spin-echo magnetic resonance image of the elbow in an 18-year-old man with surgically proven unstable OCD of the capitellum demonstrating a rim of high signal intensity surrounding the OCD lesion (arrow). Note the irregularity Table 1 of articular cartilage overlying the OCD lesion (arrowhead). (Reproduced with permission from Kijowski R, De Smet AA: MRI ﬁndings of osteochondritis MRI Grading of Osteochondritis dissecans of the capitellum with surgical correlation. Skeletal Radiol Dissecans Lesions35 2005;185:1453-1459.) Grade Description

0 Normal ternational Cartilage Repair Society ble lesions as those that heal com- 1 Intact cartilage with signal changes (ICRS). Grade I lesions are stable pletely with rest and that are charac- 2 High signal breach of the with a continuous softened area cov- terized by all of the following: an cartilage ered by intact cartilage.37 Grade II le- open capitellar growth plate, local- 3 Thin rim of high signal sions are stable on probing but ex- ized flattening or radiolucency of the intensity extending be- hibit partial discontinuity. Grade III subchondral bone, and good elbow hind the osteochondral fragment, indicating sy- lesions have complete discontinuity range of motion (ROM) at the time novial ﬂuid around the but are not dislocated. Grade IV le- of diagnosis. Unstable lesions are fragment sions have an empty defect or a dis- characterized by one of the follow- 4 Mixed or low signal loose located fragment lying within the ing: closed capitellar growth plate, body, either in the cen- bed. Despite its ease of use, ar- fragmentation, or restriction of el- ter of the lesion or free ≥ within the joint throscopic classification of OCD le- bow motion 20° at the time of diag- sions can miss subtle changes be- nosis. Unstable lesions show im- neath the articular surface, and it has proved results with surgery. weighted images (ie, grade 3) has not been shown to have strong corre- 7,26 been demonstrated to differentiate lations with treatment outcomes. Management surgically proven stable and unstable In general, OCD lesions of the OCD30,36 (Figure 6). capitellum can be classified as stable, Management of OCD of the capitel- An arthroscopic classification simi- unstable but attached, or detached lum is controversial because the heal- lar to the Ferkel-Cheng classification and loose. Recently, Takahara et al37 ing potential and natural history for lesions of the talus was developed further simplified this classification of these lesions is poorly under- by Baumgarten et al.25 This classifi- by categorizing lesions as stable or stood.4,27,37,38 Management is based cation was later modified by the In- unstable (Table 2). They defined sta- primarily on the integrity of the ar-

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Table 2 Outcomes Proposed Classification of Osteochondritis Dissecans Lesions of the Capitellum Nonsurgical Management Capitellar Early results of nonsurgical manage- Growth Radiographic Range ICRS Classification Plate Grade of Motion Classification ment of OCD lesions suggest poor outcomes.1,26,40 Mitsunaga et al40 Stable Open I Normal I found that >50% of patients with Unstable Closed II or III Restricted II, III, or IV stable lesions treated nonsurgically had mild discomfort at a mean ICRS = International Cartilage Repair Society Adapted with permission from Takahara M, Mura N, Sasaki J, Harada M, Ogino T: follow-up of 13.6 years. Most of Classification, treatment, and outcome of osteochondritis dissecans of the humeral these lesions later detached, and the capitellum. J Bone Joint Surg Am 2007;89:1205-1214. authors recommended excision and curettage of all higher-grade lesions. ticular cartilage surface and the sta- compared with a closed capitellar In a study by Takahara et al,1 50% bility of the lesion.37,38 Nonsurgical physis. Mihara et al38 also found of patients treated nonsurgically had treatment is typically selected for pa- greater healing rates in patients with residual elbow symptoms with activ- tients with early grade, stable lesions, open physes; however, they could not ities of daily living as well as degen- and it involves activity modification detect a statistical difference when erative changes at an average with cessation of sports participa- comparing patients with early grade follow-up of 12.6 years. No patient 4,37,38 tion. The duration of activity lesions. In persons treated nonsurgi- returned to his or her previous sport. modification is dictated by symptom- cally, lesion grade may ultimately be The authors stated that failure to use atology, with 3 to 6 weeks of rest fol- a better predictor of healing and suc- diagnostic tools such as MRI, ultrasonography, and 45° AP radiographs lowed by return to sport in 3 to 6 cess than physeal status. months commonly used as a guide- may have led to underestimation of Surgical indications include the line.6,7 Strengthening and stretching some lesions that should have been presence of loose bodies, mechanical exercises are commonly incorporated managed surgically. symptoms, unstable lesions, and sta- after pain has subsided. Using radio- In a subsequent study, Takahara ble lesions that have failed 6 months graphs to determine return to activ- et al26 analyzed the outcomes of 24 of nonsurgical management.5-7,37,39 ity is discouraged because radio- patients who were treated nonsurgi- Takahara et al37 recently highlighted graphic healing lags behind clinical cally at a mean follow-up of 5.2 improvement.11 The use of nonsteroi- the importance of lesion stability and years. They found poor subjective dal anti-inflammatory drugs and recommended surgery for all lesions outcome to be independent of lesion bracing for acute symptoms also has except those that are classified as grade and reported that radiographic been advocated, but this is not sup- ICRS grade I (ie, stable with open healing and improvement were not ported by clinical evidence.11 physes). Considerable debate contin- associated with the status of the Unlike OCD in the knee, the rela- ues regarding appropriate surgical growth plate. Although the status of tionship between the healing poten- management. Surgical goals include the physis did not correlate with out- tial of OCD lesions in the elbow and stimulation of the healing response come, poor prognosis appeared to be the status of the physis is unclear. and elimination of mechanical symp- related to large, advanced lesions as Pappas4 found superior outcomes toms, with decision making being well as to the presence of degenera- with nonsurgical management in largely dependent on the grade, loca- tive changes on presentation. younger patients. However, Taka- tion, and size of the lesion.6,25,39 Sur- A recent report supports nonsurgi- hara et al26 and Ruch et al24 found no gical options include arthroscopic as cal management when OCD lesions correlation between outcome and the well as formal arthrotomy for the ex- are diagnosed early. Mihara et al38 status of the physis. In contrast to cision of loose bodies with or with- evaluated 39 baseball players with a their early results, Takahara et al37 out débridement, fragment excision, mean age of 12.8 years. At a mean recently reported significantly im- abrasion arthroplasty, drilling, mi- follow-up of 14.4 months, 25 of 30 proved radiographic healing (P < crofracture, fragment fixation, bone early lesions were healed, compared 0.001) and outcome in terms of pain grafting, osteotomy, or osteochon- with 1 of 9 advanced lesions. Heal- (P < 0.01) and return to sport (P < dral autograft transplantation ing was noted in 16 of 17 patients 0.05) in lesions with an open physis (OAT). with open physes, compared with

562 Journal of the American Academy of Orthopaedic Surgeons David E. Ruchelsman, MD, et al only 11 of 22 patients with closed Although the studies involve only Arthroscopic débridement and abra- physes. The authors concluded that short- to mid-term follow-up, prom- sion arthroplasty display reliable short- spontaneous healing of early lesions ising results have been seen, with term results, with good pain relief and is high, particularly in persons with pain relief and objective improve- improved elbow extension. The long- open capitellar physes, and that non- ments in elbow ROM. However, term results are mixed, however, with surgical treatment of these patients is these studies do not attempt to corre- recurrence of loose bodies and variable appropriate. late the grade of lesion with out- return to sport. These short-term stud- come, with the exception of a report ies demonstrate radiographic progres- Surgical Management by Byrd and Jones,42 who found no sion of degenerative changes over time. correlation between grade of lesion Although no significant correlation was Open Débridement and Fragment Excision and postoperative outcomes or re- found between early radiographic Long-term results following open dé- turn to sport. Long-term data are changes and return to sport, studies bridement and fragment excision needed to fully assess the effective- with longer-term follow-up are needed 37 have been evaluated in several stud- ness of these treatment options. to examine this relationship. 25 ies. Bauer et al41 reported discourag- Baumgarten et al examined 16 Some authors advocate drilling and ing outcomes at an average of 23 patients with arthroscopic Ferkel- microfracture techniques following years after diagnosis in 31 patients Cheng grade 3, 4, or 5 lesions over a débridement of OCD lesions (Figure with a mean age of 20 years. The au- 4-year period. Grade 3 lesions had a 7). As in the knee and talus, multipo- thors found a 40% recurrence of fixed osteochondral fragment, and tent marrow cells are released, and a symptoms and loss of elbow exten- grade 4 and 5 lesions showed a loose fibrocartilaginous filling of the defect 45 sion, with >60% of examined radio- but undisplaced fragment and a dis- is generated. Bojanic´ et al reported capitellar joints demonstrating de- placed fragment with loose bodies, short-term outcomes for sympto- generative joint disease. However, respectively. Thirteen patients re- matic advanced capitellar OCD le- most cases appeared to be advanced turned to sport, and 8 of the 16 pa- sions despite nonsurgical manage- lesions (20 of 31); loose bodies were tients demonstrated slight capitellar ment in three elite gymnasts. At 24 present in 20 elbows on presenta- flattening. Ruch et al followed 12 12-month follow-up, all patients tion. patients with unstable elbow lesions demonstrated full ROM and were Takahara et al1 reviewed 39 pa- (mean size, 2.5 cm) for a mean of 3.2 pain free. All three patients returned tients with an average age of 17.6 years. Improved extension was seen to full national team participation years at the time of surgery. Average postoperatively, with all elbows within 5 months postoperatively. follow-up was 14.7 years. Twenty- demonstrating capitellar remodeling. Postoperative MRI demonstrated six percent of patients reported good Mechanical symptoms resolved in 11 that the defects were filled with results, and 49% returned to full patients. However, only three pa- hyaline-like tissue. sports participation. In 2007, Taka- tients returned to sport, and six dem- hara et al37 reported similar results onstrated an enlarged radial head at Fragment Fixation 42 after adding 16 patients to their orig- follow-up. Byrd and Jones exam- Fragment fixation may be performed inal cohort. The results of fragment ined 10 patients, 7 of whom demon- with a myriad of techniques, includ- excision alone were dependent on strated grade IV or V lesions based ing Herbert screws, dynamic staples, the size of the capitellar defect, with on the American Sports Medicine In- pullout wiring, bioabsorbable im- 6,37,46-48 better results in terms of pain and ra- stitute classification system of OCD plants, and bone peg fixation diographic findings seen in patients lesions. At 4-year follow-up, only 4 (Figure 8). Reliable results have been with lesions measuring <50% of the of 10 patients had returned to sport, found in several small series of ad- capitellar articular width. and 2 demonstrated degenerative ra- vanced lesions; however, some au- diographic findings. Brownlow et thors have expressed reservations 43 Arthroscopic Débridement and al followed 29 patients for a mean about this technique because of the Marrow Stimulation of 6.4 years. Twenty-three patients possible poor healing potential of the Numerous investigators have re- returned to sport, with 38% demon- fragment.39 viewed the short-term results of ar- strating degenerative joint disease Harada et al46 evaluated dynamic throscopic débridement and abrasion and loose bodies at follow-up. Ra- staples inserted in a unicortical man- arthroplasty. The available series are husen et al44 found that 12 of 15 pa- ner with iliac crest bone graft in four retrospective in nature and include tients with unstable lesions returned patients followed for a mean of 7.5 patients with variable grade lesions. to sport following débridement. years. They reported a 100% union

September 2010, Vol 18, No 9 563 Osteochondritis Dissecans of the Capitellum: Current Concepts

Figure 7 Figure 8

Osteochondritis dissecans fragment fixation techniques. AP radiographs of the elbow demonstrating dynamic staples (A) and bone pegs (arrows) (B). Arthroscopic view through the (Panel A reproduced with permission from Harada M, Ogino T, Takahara M, proximal anterolateral portal in a Ishigaki D, Kashiwa H, Kanauchi Y: Fragment fixation with a bone graft and left elbow demonstrating a dynamic staples for osteochondritis dissecans of the humeral capitellum. J capitellar osteochondritis dissecans Shoulder Elbow Surg 2002;11:368-372. Panel B reproduced with permission lesion after arthroscopic from Takahara M, Mura N, Sasaki J, Harada M, Ogino T: Classification, débridement and abrasion treatment, and outcome of osteochondritis dissecans of the humeral arthroplasty. capitellum. J Bone Joint Surg Am 2007;89:1205-1214.) rate, with all patients demonstrating pared with 9.6 years in the excision mean age of 14 years. Following full ROM and painless activities of group. Based on their results, the au- closing wedge osteotomy, six pa- daily living. Three of four patients thors recommended bone peg fixa- tients returned to contact sports, and returned to competitive baseball. tion for all ICRS grade II lesions and all seven demonstrated capitellar re- Takeda et al47 used pullout wires in fragment fixation with bone grafting modeling within 6 months. A mean 11 patients. All patients achieved for all ICRS grade III lesions. The increase in ROM of 12° was seen, union at an average follow-up of 57 authors admit, however, that ar- and no advanced degenerative joint months, with 10 patients demon- throscopic techniques were not eval- disease was noted. strating excellent results with return uated and that they may provide to competitive pitching. Minimal de- good results in terms of pain and re- Osteochondral Autograft generative changes were noted in turn to sport in persons with OCD Transplantation three elbows, however. Kuwahata lesions without the need for frag- OAT was recently introduced as an- and Inoue48 examined seven patients ment fixation. other treatment option for capitellar treated with Herbert screw fixation OCD. Indications include large and cancellous bone graft. At a mean Osteotomy Baumgarten grade 4 and 5 lesions, follow-up of 32 months, pain was re- Closing wedge osteotomy for the ICRS grade IV lesions, lesions in- solved in all patients and all returned management of capitellar OCD has volving >50% of the articular sur- to sports, with an average increase in been used in Japan to unload the ra- face area, disruption of the lateral ROM of 18°. diocapitellar joint. This technique is buttress, and radial head engage- In a large retrospective review, reserved for early grade lesions and ment.25,37,39 Contraindications include Takahara et al37 reported signifi- is technically demanding. degenerative changes in the lateral cantly improved outcome in terms of In 14 patients, Yoshizu49 per- (radiocapitellar) compartment and pain in 12 patients treated with frag- formed a 10° closing wedge osteot- radial head and capitellar deformity. ment fixation versus in 55 patients omy 2 cm proximal to the lateral The procedural steps of OAT are treated with open fragment excision epicondyle, with the apex medial to adapted from those performed in the alone (P < 0.05). Results were not the capitellum. All patients demon- knee and ankle. Cylindrical osteo- stratified according to grade of le- strated remodeling at 3 months post- chondral grafts are harvested from sion. Follow-up for fragment fixa- operatively. Kiyoshige et al50 evalu- the donor site—typically the lateral tion was a mean of 2.9 years, com- ated seven baseball pitchers with a femoral condyle—and the plug is in-

564 Journal of the American Academy of Orthopaedic Surgeons David E. Ruchelsman, MD, et al

Figure 9 their previous competitive level of the osteochondral fragment and mar- sport. Loose body formation and de- row stimulation techniques to gener- generative changes were absent in all ate a fibrocartilaginous healing re- patients at follow-up. Shimada et al54 sponse. OAT is indicated for large demonstrated excellent results in 8 of lesions that make up >50% of the ar- 10 patients, with 100% graft incor- ticular surface or that engage the ra- poration and a mean increase to dial head as a result of loss of the lat- 64.2% radiocapitellar joint congru- eral buttress. ency. Diagnostic arthroscopy of the af- Short-term results appear promis- fected elbow may either be performed in the the lateral decubitis ing with OAT, but questions remain. position with the involved side up, The effect on outcomes of different the elbow flexed at 90°, and the arm morphologic characteristics between supported by a padded bolster, or in donor and recipient articular carti- the supine position with the arm bal- lage must be assessed, such as the anced in double suspension through flatter curvature and thicker articular Bone plugs inserted during sterile fingertraps as advocated by cartilage found in the femoral con- 37 osteochondral autologous Takahara et al. We prefer to use dyle. This may affect load distribu- transplantation of the capitellum in proximal anterolateral and antero- tion at the radiocapitellar articula- a 12-year-old male baseball player. medial portals for the inspection of (Reproduced with permission from tion and predispose the patient to the anterior compartment and the Takahara M, Mura N, Sasaki J, degenerative joint disease. Further Harada M, Ogino T: Classiﬁcation, anterior capitellum. The direct lat- research is needed on the characteris- treatment, and outcome of eral portal (ie, posterolateral “soft tics of chondral metabolism in the osteochondritis dissecans of the spot”) and the ancillary lateral portal humeral capitellum. J Bone Joint transplanted graft. are used to visualize the posterior ra- Surg Am 2007;89:1205-1214.) The low incidence of OCD of the diocapitellar region. The posterior capitellum makes prospective evalua- and posterolateral portals are used to tion of nonsurgical and surgical man- serted perpendicular to the subchon- gain access to the posterior compart- agement challenging. Further analysis dral bone (Figure 9). The restricted ment and posterolateral gutter where of the long-term results of surgical mo- surgical field and the lateral location loose bodies may be found. dalities is necessary to define the indi- of these lesions often make insertion Once the portals have been estab- cations for each procedure. of the grafts technically demanding, lished and the joint is examined, syn- which may result in incongruent ovectomy, débridement, and removal graft placement.51 Several authors Authors’ Preferred of loose bodies are performed to im- have advocated the use of oblique Treatment prove visualization before initiating osteochondral plugs, but no results management of the OCD lesion. The are yet available.51 Donor site mor- Initial treatment consists of activity entire joint is systematically ex- bidity is another potential complica- modification and/or sport cessation, plored, and the lesion is examined tion, but a recent report found no the use of nonsteroidal anti-inflam- and graded to determine appropriate adverse effects on donor knee func- matory drugs, and, occasionally, treatment. tion following OAT.52 bracing for acute symptoms. Elbow An open approach is used in the Early results demonstrate reason- arthroscopy is indicated in patients presence of a large OCD fragment in able outcomes with OAT. In a study who fail 3 months of nonsurgical the patient who requires fragment by Yamamoto et al,36 16 of 18 pa- treatment as well as in those who fixation, osteochondral autograft, or tients returned to sports participa- have a detached lesion with interven- osteochondral allograft. A lateral or tion by a mean of 3.5 years postoper- ing fluid signal on MRI or who have posterolateral approach is used when atively. All patients had a good to mechanical symptoms on presenta- formal arthrotomy is required, and excellent outcome. Iwasaki et al53 re- tion. OCD lesions with stable overly- approach selection is guided by the ported good to excellent results in 18 ing cartilage on examination are location of the lesion. Using a lateral of 19 male teenage athletes at a treated with drilling. Lesions with approach, a longitudinal incision is mean follow-up of 45 months post- unstable cartilage caps or loose bod- made, extending from the lateral epi- operatively; 17 patients returned to ies are managed with débridement of condyle distally and obliquely over

September 2010, Vol 18, No 9 565 Osteochondritis Dissecans of the Capitellum: Current Concepts the radial head to the proximal ulna. phy, and ultrasonography. Manage- Disease of the hip. Acta Radiol 1927;8: The fascia is split between the an- ment is based on the size, location, 617-618. coneus and the extensor carpi ulnaris and grade of the lesion, with at- 3. Kobayashi K, Burton KJ, Rodner C, Smith B, Caputo AE: Lateral muscles. The joint capsule is exposed tempts made to address subchondral compression injuries in the pediatric and then incised anterior to the ra- bone loss and articular cartilage elbow: Panner’s disease and damage. Early, stable lesions should osteochondritis dissecans of the dial head to protect the lateral ulnar capitellum. J Am Acad Orthop Surg collateral ligament. The annular liga- be treated with rest; surgery should 2004;12(4):246-254. ment is preserved. Depending on the be considered for unstable lesions. 4. Pappas AM: Osteochondrosis dissecans. location of the lesion, proximal re- Controversy exists regarding the Clin Orthop Relat Res 1981;(158):59- 69. lease of the lateral collateral ligament appropriate surgical management of lesions with partially detached frag- 5. Schenck RC Jr, Goodnight JM: may be necessary. This is later re- Osteochondritis dissecans. J Bone Joint ments (ie, ICRS II, III). Most investi- paired using suture anchors. For an- Surg Am 1996;78(3):439-456. gators advocate arthroscopic dé- terior lesions, a small proximal re- 6. Yadao MA, Field LD, Savoie FH III: bridement with marrow stimulation lease of the ligament of up to 2 to 3 Osteochondritis dissecans of the elbow. techniques. Good short-term results Instr Course Lect 2004;53:599-606. mm is usually sufficient. also have been observed with frag- 7. Bradley JP, Petrie RS: Osteochondritis For more central lesions, complete ment fixation and bone grafting, but dissecans of the humeral capitellum: release may be required. We prefer a Diagnosis and treatment. Clin Sports concerns persist regarding the heal- Med 2001;20(3):565-590. posterolateral approach for postero- ing potential of advanced lesions. inferior lesions, and we perform the 8. Kenniston JA, Beredjiklian PK, Bozentka OAT appears to be promising and is DJ: Osteochondritis dissecans of the arthroscopy in the supine position. indicated for higher-grade lesions capitellum in fraternal twins: Case The arm is released from double sus- report. J Hand Surg Am 2008;33(8): measuring >50% of the width of the ar- 1380-1383. pension, an arm board is rotated un- ticular surface. Despite technical ad- der the brachium, and the elbow is 9. Bednarz PA, Paletta GA Jr, Stanitski CL: vances, clinical outcomes and return to Bilateral osteochondritis dissecans of the hyperflexed. A 4- to 6-cm posterolat- knee and elbow. Orthopedics 1998; sport remain variable. Longer-term eral oblique skin incision is made 21(6):716-719. follow-up studies are necessary to fully along a line from the posterior edge 10. Inoue G: Bilateral osteochondritis assess these surgical treatments, and pa- dissecans of the elbow treated by of the lateral epicondyle to the poste- tients and family members must be Herbert screw fixation. Br J Sports Med rior aspect of the radioulnar joint. 1991;25(3):142-144. counseled to maintain realistic expec- The skin and subcutaneous tissues tations. 11. Shaughnessy WJ: Osteochondritis are incised and the investing fascia of dissecans, in Morrey BF, ed: The Elbow and Its Disorders, ed 3. Philadelphia, PA, the anconeus is identified. The an- WB Saunders, 2000, pp 255-260. coneus fascia is split in line with the References 12. Jobe FW, Nuber G: Throwing injuries of muscle fibers to the level of the un- the elbow. Clin Sports Med 1986;5(4): derlying radiocapitellar capsule. Evidence-based Medicine: Levels of 621-636. Capsulotomy is performed, and the evidence are described in the table of 13. Indelicato PA, Jobe FW, Kerlan RK, Carter VS, Shields CL, Lombardo SJ: lesion is easily seen with the elbow contents. In this article, there are no Correctable elbow lesions in professional hyperflexed. level I or III studies. References 35 and baseball players: A review of 25 cases. Am J Sports Med 1979;7(1):72-75. 37 are level II studies. References 1, 2, 4, 10, 13, 14, 16, 21, 24-26, 30, 14. Singer KM, Roy SP: Osteochondrosis of Summary the humeral capitellum. Am J Sports 34, 36, 38, and 40-54 are level IV Med 1984;12(5):351-360. OCD of the capitellum primarily af- studies. References 8, 9, and 22 are 15. An KN, Morrey BF: Biomechanics of the level V expert opinion. elbow, in Morrey BF (ed): The Elbow fects adolescent overhead athletes and Its Disorders, ed 3. Philadelphia, PA, and gymnasts. It must be clearly dif- Citation numbers printed in bold WB Saunders, 2000, pp 43-60. ferentiated from Panner disease. The type indicate references published 16. Jackson DW, Silvino N, Reiman P: etiology of OCD is multifactorial within the past 5 years. Osteochondritis in the female gymnast’s elbow. Arthroscopy 1989;5(2):129-136. and likely results from microtrauma 1. Takahara M, Ogino T, Sasaki I, Kato H, in the setting of cartilage mismatch Minami A, Kaneda K: Long term 17. Tallqvist G: The reaction to mechanical trauma in growing articular cartilage: An and vascular susceptibility. Multiple outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop experimental study on rabbits and a diagnostic modalities aid in diagno- Relat Res 1999;363:108-115. comparison of the results with the pathological anatomy of osteochondritis sis, including plain radiography, 2. Panner HJ: An affection of the capitulum dissecans. 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566 Journal of the American Academy of Orthopaedic Surgeons David E. Ruchelsman, MD, et al

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