- Email: [email protected]
Arthroscopic and Open Surgery for Osteochondritis Dissecans
Arthroscopic and Open Surgery for Osteochondritis Dissecans Robert Nelson Mead, MD, MBA, Michael J. O’Brien, MD, and Felix H. Savoie III, MD Osteochondritis dissecans lesions of the elbow occur in 3.4% of adolescent baseball players, and the lesions will inevitably progress without intervention. Fifty percentage of patients who initially presented with advanced lesions had decreased range of motion and pain with activities of daily living. Patients treated early have high return to sports rates. After radiographs are obtained, patients suspected of having an osteochondritis dissecans lesion in the elbow should undergo a magnetic resonance arthrogram to determine the integrity of the cartilage cap. Central lesions with an intact cartilage cap can often be successfully treated with bracing and a course of formal therapy. Patients who fail conservative treatment with a violated cartilage cap can undergo microfracture or fragment fixation. Patients with lesions that extend to the lateral wall require an autograft transfer to restore the structural integrity of the capitellum and prevent instability. Oper Tech Sports Med ]:]]]-]]] C 2017 Elsevier Inc. All rights reserved.
KEYWORDS osteochondritis, dissecans, capitellum, elbow, overhead
Definition (1) Osteochondritis dissecans (OCD) is a noninflammatory lesion in which an area of discrete articular surface begins to separate from the subchondral bone.1,2 (2) Within the elbow, OCD lesions most commonly occur in the capitellum, but they have been reported in the radial head, olecranon, olecranon fossa, and trochlea.3
Anatomy (1) The overhead throwing motion generates significant valgus and extension moments in the elbow, which causes tension across the medial side of the elbow and compression laterally.4 The anterior bundle of the ulnar The Department of Orthopaedic Surgery, Tulane School of Medicine, New Orleans, LA. Conflict of interest: R. Nelson Mead—No conflict. Michael J. O’Brien—DePuy, Mitek, Smith & Nephew. Felix H. Savoie, III—Biomet, Exactech, Mitek, Rotation Medical, Smith & Nephew. Address reprint requests to Felix H. Savoie, MD, Tulane University Department of Orthopedic Surgery, 1430 Tulane Ave, SL-32, New Orleans La. USA 70112. E-mail: [email protected]
http://dx.doi.org/10.1053/j.otsm.2017.08.003 1060-1872//& 2017 Elsevier Inc. All rights reserved.
collateral ligament is the primary restraint to valgus force from 30°-120° of flexion—the flexion range in which overhead throwing occurs. The anterior bundle tries to reduce forces as it resists the valgus moment.1,4 (2) Two terminal arteries branching off the radial recurrent and interosseus recurrent arteries provide the blood supply to the epiphysis of the capitellum. The area lacks collaterals or metaphyseal blood supply.5,6
Pathogenesis (1) The late cocking and early acceleration phases of throwing generate significant valgus moments that cause repetitive radiocapitellar compression. (2) Repetitive valgus loads during the late cocking and early acceleration phase of throwing generates compression and, more importantly, shearing forces at the radiocapitellar joint.1 These loads result in stress fractures in the subchondral bone, which initiate the progressive separation of the articular surface from the subchondral bone.5 (3) The presence of lateral capitellar defects, in contrast to central defects, actually increases radiocapitellar contact 1
R.N. Mead et al.
2 pressures. As the contract pressures increase the lesion progresses and, in turn, the contact pressures further increase. This sequence creates a constant cycle of lesion progression.1 (4) As described earlier, the blood supply to the capitellum is limited, which limits its ability to recover from repetitive insult.7
Natural History (1) OCD lesions in the capitellum are not self-limiting. In the absence of intervention, the natural history of these lesions is to progress in severity. (2) Most patients wait until the lesions have progressed to seek medical attention. As the lesions progress they become more difficult to treat.8 (3) If diagnosed in the early stages then these lesions have a chance to heal. By treating them with strict rest, Mihara et al reported that 88% of their patients with early signs of an OCD lesion went on to heal.9 (4) The natural history of OCD lesions that are diagnosed in the late stages is much worse. Studies have reported that at long-term follow-up 50% of patients with advanced lesions at the time of diagnosis experienced decreased range of motion and symptoms that impaired activities of daily living.10,11
Patient History and Physical Examination (1) Patients typically complain of progressive, generalized elbow pain that is relieved by rest.12 (2) Patients often report stiffness associated with a loss of terminal extension. (3) Physical examination. (a) Tenderness to palpation at the radiocapitellar joint. (b) Tender posterolateral plica. (c) Positive active radiocapitellar compression test.13 (d) Loss of terminal extension.
Imaging (1) Anteroposterior, lateral, 2 obliques, and an anteroposterior view with elbow in 45 degrees of flexion to better visualize the joint.6,14,15 (a) Images will show a discrete area of rarefaction and radiolucency (Fig. 1).14 (2) Magnetic resonance (MR) arthrogram (Fig. 2). (a) An arthrogram is important to determine the viability of the cartilage cap. (b) Early lesions demonstrate low signal intensity on T1weighted images and appear normal on T2-weighted images. (c) Late lesions show high signal intensity on both T1 and T2-weighted images.3
Figure 1 An AP radiograph of a right elbow demonstrating an osteochondritis dissecans lesion of the capitellum. Note the area of rarefaction and radiolucency. AP, anteroposterior.
(d) Lesions in which the cartilage cap has been violated will show a high intensity signal behind the lesion, which indicates that fluid has been able to get behind the fragment.16,17
Nonoperative Management (1) Indicated as the initial management of central lesions with intact cartilage caps as seen on MR arthrogram. (2) The patient is placed in a hinged elbow brace and may continue to participate in his or her sports as long as he or she plays in the brace. (3) The patient is started in a formal therapy program. (4) Continue the brace until the patient can participate in sport without pain.
Techniques Surgical Indications (1) Continued pain and dysfunction despite a course of bracing. (2) An unstable cartilage cap as seen on MR arthrogram. (3) Lesions extending to the lateral wall.
Osteochondritis dissecans lesions
3
Figure 3 Patient in the prone position. (Color version of figure is available online.)
Figure 2 A T1 sagittal MR arthrogram image of a stable osteochondritis dissecans of the capitellum. Note the absence of fluid behind the lesion, which suggests the cartilage cap is still intact.
anterior compartment can be removed via an anterolateral portal. (2) The posterior compartment is evaluated using a 30° and then a 70° arthroscope in the posterior central portal. Both soft spot and distal soft portals serve as working portals that enable the surgeon to remove an associated fragment, debride and microfracture a lesion, or secure a lesion.15
Positioning (1) Prone (author’s preferred position) (Fig. 3). (a) This position enables better access to the posterior compartment of the elbow. It also allows the surgeon to fully flex and extend the arm. (b) Once intubated the patient is rolled into the prone position, and the appropriate padding and chest rolls are placed. (c) The nonoperative extremity is positioned so that the shoulder is abducted to 90° and the elbow is flexed to 90° with the elbow and wrist supported on an arm board. (d) A padded arm board is placed on the operative side, centered at the shoulder. With a tourniquet in place the shoulder is placed in 90° of abduction and neutral rotation with a towel bump underneath the arm at the level of the middle of the humerus. The elbow is now suspended at 90 degrees of flexion.18
Approach (1) The anterior compartment of the elbow is evaluated via the proximal anteromedial portal. Loose bodies in the
Debridement and Microfracture (1) The procedure begins with a diagnostic arthroscopy of the joint. A proximal anteromedial portal is used to evaluate the anterior compartment. An anterolateral portal can be used to remove any loose bodies that may be present. (2) The posterior compartment of the elbow is then evaluated using a posterior central portal to look in the olecranon fossa and the medial gutter. The lateral gutter is then evaluated, and an inflamed plica can be removed via a soft spot portal. (3) The capitellar lesion is then assessed using the posterior central portal. If more work is deemed necessary then view the lesion from a superior posterolateral portal with a 70° arthroscope. The soft spot portal is then used to probe the lesion. If the lesion is completely unstable then one should use the shaver to debride the bone to a stable bed with a continuous rim of surrounding cartilage. (4) The distal soft spot portal is then used to microfracture the bed, making sure to visualize fat globules emanating from the holes15,18 (Fig. 4).
R.N. Mead et al.
4
(3) If using the olecranon, one must visualize the olecranon from the posterior central portal and then harvest from the posterolateral corner of the olecranon using the posterolateral portal. With the elbow hyperflexed, the graft is then inserted into the recipient site via the portal that was used to drill the recipient hole (Fig. 7).
Postoperative Care (1) Debridement and microfracture. (a) The patient is initially placed in a hinged elbow brace, and range of motion is encouraged. (b) Within 1 week the patient is in physical therapy for range of motion, hand and wrist exercises, and edema reduction. (c) General conditioning is started within 3 weeks. (d) The brace is discontinued at 6 weeks. (e) The patient can return to sports once he or she has full, pain-free range of motion. (2) Fragment fixation and osteochondral graft transfer. (a) The patient is initially placed in a splint for 7-10 days until the sutures may be removed. (b) He or she is then transitioned into a hinged elbow brace, and started in physical therapy for edema reduction and gentle range of motion. (c) Resistance exercises are started at 6-10 weeks. (d) Activity is gradually progressed while closely monitoring radiographs for graft incorporation. The patient may return to sport once the lesion is healed radiographically and he or she has pain-free range of motion equivalent to what he or she had preoperatively.
Figure 4 A view of the lesion from the posterior central portal. The awl is coming from the soft spot portal to microfracture the bed of the lesion. (Color version of figure is available online.)
Fragment Fixation (1) Preoperative imaging and the diagnostic arthroscopy may reveal a large, hinged fragment with attached subchondral bone. These are amenable to fixation using headless compression screws or a suture anchor in which a synthetic monofilament absorbable suture replaces the normal suture. (2) The bed beneath the fragment is first debrided. A pilot hole is then drilled for the suture anchor into the bed. The sutures are then passed through the fragment in a manner that compresses the fragment to the bed (Fig. 5A and B).
Osteochondral Graft Transfer Outcomes (1) An osteochondral graft transfer is indicated for larger, peripheral lesions. The source of the graft can be from the knee, ribs, or the olecranon. (2) The bed of the lesion is debrided as discussed previously. Determine the size and depth of the defect, and then the recipient site is drilled appropriately (Fig. 6). This may be done from the soft spot, distal soft spot, or straight lateral portal.
A
(1) Nonoperative treatment. (a) Studies have demonstrated that as high as 88%-91% of early lesions healed radiographically. These studies also demonstrated return to sports rates of 79%-88%.9,19 (b) Takahara et al20 reported that patients with open physes, in particular, have significantly better healing
B
Figure 5 (A) An image of a “hinged” osteochondritis lesion that is amenable to suture fixation. (B) The depiction of an osteochondritis dissecans fragment compressed to the lesion’s bed using suture. (Color version of figure is available online.)
Osteochondritis dissecans lesions
5 (b) Maruyama et al26 followed 38 patients, and demonstrated that 94% return to play at an average of 6.9 months. Lyons et al29 followed 11 patients and reported that all the patients return to their previous levels of play at an average of 4.4 months.
Complications
Figure 6 An image of the hole drilled for the recipient site. The depth of the recipient site is measured using the drill bit. (Color version of figure is available online.)
rates, return to sports, and pain levels than those patients with closed physes. (2) Debridement and microfracture. (a) These studies are difficult to interpret because each one is treating OCD lesions of various sizes and locations with debridement and microfracture. (b) Baumgarten et al reported a return to sport rate of 82% in 17 patients. Brownlow et al reported a return to sport rate of 69% in 29 patients. Lewine et al reported a return to any sport rate of 85.7% and a return to primary sport rate of 66.7%. These studies represent the wide range of return to sport rates, but all of these studies showed improved postoperative pain levels and range of motion.13,21,22 (3) Fragment fixation. (a) Studies demonstrate radiographic healing in 82%100% of patients, and return to sports rates of 68%100%.7,23-25 (4) Osteochondral autograft transfer. (a) Most studies show good results given the severity of the lesions. These studies show that the return to sport rate is between 75% and 100%.26-28
(1) Arthrofibrosis can occur postoperatively but will resolve most of the time with a course of therapy. However, occasionally the stiffness requires a capsular release.15 (2) Heterotopic ossification has been reported—more frequently in open than arthroscopic surgeries. Treatment involves arthroscopic excision and radiation.15 (3) Some authors have expressed concern about donor site morbidity in osteochondral autograft transfers, particularly the knee. Reddy et al reported decreased knee function in patients treated with osteochondral autografts from the knee for OCD lesions in the talus. Recent studies, including one by Nishimura et al,30 have demonstrated that patients were pain-free and full range of motion at 3 months postoperatively.
Conclusion OCD lesions in the elbow are not self-limiting conditions. Adolescent overhead athletes who present with the signs and symptoms of an OCD lesion of the elbow should obtain radiographs and an MR arthrogram. If the MR arthrogram demonstrates a central lesion with an intact cartilage cap then the patient should be placed in a hinged elbow brace and started in a formal physical therapy program. A good majority of these patients will return to sport without pain. If the patient does not improve with conservative treatment then he or she is a candidate for arthroscopic microfracture or fragment fixation. If, however, the MR arthrogram demonstrates a peripheral lesion then the patient requires an osteochondral autograft to restore the lateral wall.
References
Figure 7 An arthroscopic image depicting an osteochondral autograft that is partially inserted into the recipient site. These are necessary to restore structure lesions that extend to the lateral wall. (Color version of figure is available online.)
1. Mihata T, Quigley R, Robicheaux G, et al: Biomechanical characteristics of osteochondral defects of the humeral capitellum. Am J Sports Med 41 (8):1909-1914, 2013 2. Kusumi T, Ishibashi Y, Tsuda E, et al: Osteochondritis dissecans of the elbow: Histopathological assessment of the articular cartilage and subchondral bone with emphasis on their damage and repair. Pathol Int 56(10):604-612, 2006 3. Iagulli ND, Field LD, Savoie III FH: ed. Surgical techniques of the shoulder, elbow, and knee in sports medicine. Cole J. BJ, Sekiya K ed 2. Philadelphia: Arthroscopic and Open Management of Osteochondritis Dissecans of the Elbow. Philadelphia: Elsevier Saunders, 2013 4. Cain EL Jr, Dugas JR, Wolf RS, et al: Elbow injuries in throwing athletes: A current concepts review. Am J Sports Med 31(4):621-635, 2003 5. Kobayashi K, Burton KJ, Rodner C, et al: Lateral compression injuries in the pediatric elbow: Panner's disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg 12(4):246-254, 2004 6. Stubbs MJ, Field LD, Savoie FH 3rd: Osteochondritis dissecans of the elbow. Clin Sports Med 20(1):1-9, 2001
6 7. Baker CL 3rd, Romeo AA, Baker CL Jr: Osteochondritis dissecans of the capitellum. Am J Sports Med 38(9):1917-1928, 2010 8. Kida Y, Morihara T, Kotoura Y, et al: Prevalence and clinical characteristics of osteochondritis dissecans of the humeral capitellum among adolescent baseball players. Am J Sports Med 42(8):1963-1971, 2014 9. Mihara K, Tsutsui H, Nishinaka N, et al: Nonoperative treatment for osteochondritis dissecans of the capitellum. Am J Sports Med 37 (2):298-304, 2009 10. Takahara M, Ogino T, Sasaki I, et al: Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop Relat Res 363:108-115, 1999 11. Bauer M, Jonsson K, Josefsson PO, et al: Osteochondritis dissecans of the elbow. A long-term follow-up study. Clin Orthop Relat Res 284:156-160, 1992 12. Gonzalez-Lomas G, Ahmad C, ElAttrache N: eds. AANA Advanced Arthroscopy: The Wrist and Elbow, ed 1 Philadelphia: Saunders, 2010 13. Baumgarten TE, Andrews JR, Satterwhite YE: The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 26(4):520-523, 1998 14. Ruchelsman DE, Hall MP, Youm T: Osteochondritis dissecans of the capitellum: Current concepts. J Am Acad Orthop Surg 18(9):557-567, 2010 15. Savoie III F: Osteochondritis dissecans of the elbow. Oper Tech Sports Med 16(4):187-193, 2008 16. Dipaola JD, Nelson DW, Colville MR: Characterizing osteochondral lesions by magnetic resonance imaging. Arthroscopy 7(1):101-104, 1991 17. De Smet AA, Fisher DR, Burnstein MI, et al: Value of MR imaging in staging osteochondral lesions of the talus (osteochondritis dissecans): Results in 14 patients. AJR Am J Roentgenol 154(3):555-558, 1990 18. Mead RN, O'Brien MJ, Savoie III F: Osteochondritis dissecans of the elbow, including grafts via arthroscopic and mini-open techniques. Savoie III FH, Field LD, Steinmann SP ed. The elbow and Wrist: AANA Advanced Arthroscopic Surgical Techniques, ed 2 Thorofare, NJ, SLACK Incorporated, 75, 2016 19. Matsuura T, Kashiwaguchi S, Iwase T, et al: Conservative treatment for osteochondrosis of the humeral capitellum. Am J Sports Med 36 (5):868-872, 2008
R.N. Mead et al. 20. Takahara M, Ogino T, Fukushima S, et al: Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. Am J Sports Med 27 (6):728-732, 1999 21. Lewine EB, Miller PE, Micheli LJ, et al: Early results of drilling and/or microfracture for grade IV osteochondritis dissecans of the capitellum. J Pediatr Orthop 36(8):803-809, 2016 22. Brownlow HC, O'Connor-Read LM, Perko M: Arthroscopic treatment of osteochondritis dissecans of the capitellum. Knee Surg Sports Traumatol Arthrosc 14(2):198-202, 2006 23. Nobuta S, Ogawa K, Sato K, et al: Clinical outcome of fragment fixation for osteochondritis dissecans of the elbow. Ups J Med Sci 113(2):201-208, 2008 24. Takeda H, Watarai K, Matsushita T, et al: A surgical treatment for unstable osteochondritis dissecans lesions of the humeral capitellum in adolescent baseball players. Am J Sports Med 30(5):713-717, 2002 25. Kuwahata Y, Inoue G: Osteochondritis dissecans of the elbow managed by herbert screw fixation. Orthopedics 21(4):449-451, 1998 26. Maruyama M, Takahara M, Harada M, et al: Outcomes of an open autologous osteochondral plug graft for capitellar osteochondritis dissecans: Time to return to sports. Am J Sports Med 42(9):2122-2127, 2014 27. Iwasaki N, Kamishima T, Kato H, et al: A retrospective evaluation of magnetic resonance imaging effectiveness on capitellar osteochondritis dissecans among overhead athletes. Am J Sports Med 40(3):624-630, 2012 28. Yamamoto Y, Ishibashi Y, Tsuda E, et al: Osteochondral autograft transplantation for osteochondritis dissecans of the elbow in juvenile baseball players: Minimum 2-year follow-up. Am J Sports Med 34 (5):714-720, 2006 29. Lyons ML, Werner BC, Gluck JS, et al: Osteochondral autograft plug transfer for treatment of osteochondritis dissecans of the capitellum in adolescent athletes. J Shoulder Elbow Surg 24(7):1098-1105, 2015 30. Nishimura A, Morita A, Fukuda A, et al: Functional recovery of the donor knee after autologous osteochondral transplantation for capitellar osteochondritis dissecans. Am J Sports Med 39(4):838-842, 2011
KEYWORDS osteochondritis, dissecans, capitellum, elbow, overhead
Definition (1) Osteochondritis dissecans (OCD) is a noninflammatory lesion in which an area of discrete articular surface begins to separate from the subchondral bone.1,2 (2) Within the elbow, OCD lesions most commonly occur in the capitellum, but they have been reported in the radial head, olecranon, olecranon fossa, and trochlea.3
Anatomy (1) The overhead throwing motion generates significant valgus and extension moments in the elbow, which causes tension across the medial side of the elbow and compression laterally.4 The anterior bundle of the ulnar The Department of Orthopaedic Surgery, Tulane School of Medicine, New Orleans, LA. Conflict of interest: R. Nelson Mead—No conflict. Michael J. O’Brien—DePuy, Mitek, Smith & Nephew. Felix H. Savoie, III—Biomet, Exactech, Mitek, Rotation Medical, Smith & Nephew. Address reprint requests to Felix H. Savoie, MD, Tulane University Department of Orthopedic Surgery, 1430 Tulane Ave, SL-32, New Orleans La. USA 70112. E-mail: [email protected]
http://dx.doi.org/10.1053/j.otsm.2017.08.003 1060-1872//& 2017 Elsevier Inc. All rights reserved.
collateral ligament is the primary restraint to valgus force from 30°-120° of flexion—the flexion range in which overhead throwing occurs. The anterior bundle tries to reduce forces as it resists the valgus moment.1,4 (2) Two terminal arteries branching off the radial recurrent and interosseus recurrent arteries provide the blood supply to the epiphysis of the capitellum. The area lacks collaterals or metaphyseal blood supply.5,6
Pathogenesis (1) The late cocking and early acceleration phases of throwing generate significant valgus moments that cause repetitive radiocapitellar compression. (2) Repetitive valgus loads during the late cocking and early acceleration phase of throwing generates compression and, more importantly, shearing forces at the radiocapitellar joint.1 These loads result in stress fractures in the subchondral bone, which initiate the progressive separation of the articular surface from the subchondral bone.5 (3) The presence of lateral capitellar defects, in contrast to central defects, actually increases radiocapitellar contact 1
R.N. Mead et al.
2 pressures. As the contract pressures increase the lesion progresses and, in turn, the contact pressures further increase. This sequence creates a constant cycle of lesion progression.1 (4) As described earlier, the blood supply to the capitellum is limited, which limits its ability to recover from repetitive insult.7
Natural History (1) OCD lesions in the capitellum are not self-limiting. In the absence of intervention, the natural history of these lesions is to progress in severity. (2) Most patients wait until the lesions have progressed to seek medical attention. As the lesions progress they become more difficult to treat.8 (3) If diagnosed in the early stages then these lesions have a chance to heal. By treating them with strict rest, Mihara et al reported that 88% of their patients with early signs of an OCD lesion went on to heal.9 (4) The natural history of OCD lesions that are diagnosed in the late stages is much worse. Studies have reported that at long-term follow-up 50% of patients with advanced lesions at the time of diagnosis experienced decreased range of motion and symptoms that impaired activities of daily living.10,11
Patient History and Physical Examination (1) Patients typically complain of progressive, generalized elbow pain that is relieved by rest.12 (2) Patients often report stiffness associated with a loss of terminal extension. (3) Physical examination. (a) Tenderness to palpation at the radiocapitellar joint. (b) Tender posterolateral plica. (c) Positive active radiocapitellar compression test.13 (d) Loss of terminal extension.
Imaging (1) Anteroposterior, lateral, 2 obliques, and an anteroposterior view with elbow in 45 degrees of flexion to better visualize the joint.6,14,15 (a) Images will show a discrete area of rarefaction and radiolucency (Fig. 1).14 (2) Magnetic resonance (MR) arthrogram (Fig. 2). (a) An arthrogram is important to determine the viability of the cartilage cap. (b) Early lesions demonstrate low signal intensity on T1weighted images and appear normal on T2-weighted images. (c) Late lesions show high signal intensity on both T1 and T2-weighted images.3
Figure 1 An AP radiograph of a right elbow demonstrating an osteochondritis dissecans lesion of the capitellum. Note the area of rarefaction and radiolucency. AP, anteroposterior.
(d) Lesions in which the cartilage cap has been violated will show a high intensity signal behind the lesion, which indicates that fluid has been able to get behind the fragment.16,17
Nonoperative Management (1) Indicated as the initial management of central lesions with intact cartilage caps as seen on MR arthrogram. (2) The patient is placed in a hinged elbow brace and may continue to participate in his or her sports as long as he or she plays in the brace. (3) The patient is started in a formal therapy program. (4) Continue the brace until the patient can participate in sport without pain.
Techniques Surgical Indications (1) Continued pain and dysfunction despite a course of bracing. (2) An unstable cartilage cap as seen on MR arthrogram. (3) Lesions extending to the lateral wall.
Osteochondritis dissecans lesions
3
Figure 3 Patient in the prone position. (Color version of figure is available online.)
Figure 2 A T1 sagittal MR arthrogram image of a stable osteochondritis dissecans of the capitellum. Note the absence of fluid behind the lesion, which suggests the cartilage cap is still intact.
anterior compartment can be removed via an anterolateral portal. (2) The posterior compartment is evaluated using a 30° and then a 70° arthroscope in the posterior central portal. Both soft spot and distal soft portals serve as working portals that enable the surgeon to remove an associated fragment, debride and microfracture a lesion, or secure a lesion.15
Positioning (1) Prone (author’s preferred position) (Fig. 3). (a) This position enables better access to the posterior compartment of the elbow. It also allows the surgeon to fully flex and extend the arm. (b) Once intubated the patient is rolled into the prone position, and the appropriate padding and chest rolls are placed. (c) The nonoperative extremity is positioned so that the shoulder is abducted to 90° and the elbow is flexed to 90° with the elbow and wrist supported on an arm board. (d) A padded arm board is placed on the operative side, centered at the shoulder. With a tourniquet in place the shoulder is placed in 90° of abduction and neutral rotation with a towel bump underneath the arm at the level of the middle of the humerus. The elbow is now suspended at 90 degrees of flexion.18
Approach (1) The anterior compartment of the elbow is evaluated via the proximal anteromedial portal. Loose bodies in the
Debridement and Microfracture (1) The procedure begins with a diagnostic arthroscopy of the joint. A proximal anteromedial portal is used to evaluate the anterior compartment. An anterolateral portal can be used to remove any loose bodies that may be present. (2) The posterior compartment of the elbow is then evaluated using a posterior central portal to look in the olecranon fossa and the medial gutter. The lateral gutter is then evaluated, and an inflamed plica can be removed via a soft spot portal. (3) The capitellar lesion is then assessed using the posterior central portal. If more work is deemed necessary then view the lesion from a superior posterolateral portal with a 70° arthroscope. The soft spot portal is then used to probe the lesion. If the lesion is completely unstable then one should use the shaver to debride the bone to a stable bed with a continuous rim of surrounding cartilage. (4) The distal soft spot portal is then used to microfracture the bed, making sure to visualize fat globules emanating from the holes15,18 (Fig. 4).
R.N. Mead et al.
4
(3) If using the olecranon, one must visualize the olecranon from the posterior central portal and then harvest from the posterolateral corner of the olecranon using the posterolateral portal. With the elbow hyperflexed, the graft is then inserted into the recipient site via the portal that was used to drill the recipient hole (Fig. 7).
Postoperative Care (1) Debridement and microfracture. (a) The patient is initially placed in a hinged elbow brace, and range of motion is encouraged. (b) Within 1 week the patient is in physical therapy for range of motion, hand and wrist exercises, and edema reduction. (c) General conditioning is started within 3 weeks. (d) The brace is discontinued at 6 weeks. (e) The patient can return to sports once he or she has full, pain-free range of motion. (2) Fragment fixation and osteochondral graft transfer. (a) The patient is initially placed in a splint for 7-10 days until the sutures may be removed. (b) He or she is then transitioned into a hinged elbow brace, and started in physical therapy for edema reduction and gentle range of motion. (c) Resistance exercises are started at 6-10 weeks. (d) Activity is gradually progressed while closely monitoring radiographs for graft incorporation. The patient may return to sport once the lesion is healed radiographically and he or she has pain-free range of motion equivalent to what he or she had preoperatively.
Figure 4 A view of the lesion from the posterior central portal. The awl is coming from the soft spot portal to microfracture the bed of the lesion. (Color version of figure is available online.)
Fragment Fixation (1) Preoperative imaging and the diagnostic arthroscopy may reveal a large, hinged fragment with attached subchondral bone. These are amenable to fixation using headless compression screws or a suture anchor in which a synthetic monofilament absorbable suture replaces the normal suture. (2) The bed beneath the fragment is first debrided. A pilot hole is then drilled for the suture anchor into the bed. The sutures are then passed through the fragment in a manner that compresses the fragment to the bed (Fig. 5A and B).
Osteochondral Graft Transfer Outcomes (1) An osteochondral graft transfer is indicated for larger, peripheral lesions. The source of the graft can be from the knee, ribs, or the olecranon. (2) The bed of the lesion is debrided as discussed previously. Determine the size and depth of the defect, and then the recipient site is drilled appropriately (Fig. 6). This may be done from the soft spot, distal soft spot, or straight lateral portal.
A
(1) Nonoperative treatment. (a) Studies have demonstrated that as high as 88%-91% of early lesions healed radiographically. These studies also demonstrated return to sports rates of 79%-88%.9,19 (b) Takahara et al20 reported that patients with open physes, in particular, have significantly better healing
B
Figure 5 (A) An image of a “hinged” osteochondritis lesion that is amenable to suture fixation. (B) The depiction of an osteochondritis dissecans fragment compressed to the lesion’s bed using suture. (Color version of figure is available online.)
Osteochondritis dissecans lesions
5 (b) Maruyama et al26 followed 38 patients, and demonstrated that 94% return to play at an average of 6.9 months. Lyons et al29 followed 11 patients and reported that all the patients return to their previous levels of play at an average of 4.4 months.
Complications
Figure 6 An image of the hole drilled for the recipient site. The depth of the recipient site is measured using the drill bit. (Color version of figure is available online.)
rates, return to sports, and pain levels than those patients with closed physes. (2) Debridement and microfracture. (a) These studies are difficult to interpret because each one is treating OCD lesions of various sizes and locations with debridement and microfracture. (b) Baumgarten et al reported a return to sport rate of 82% in 17 patients. Brownlow et al reported a return to sport rate of 69% in 29 patients. Lewine et al reported a return to any sport rate of 85.7% and a return to primary sport rate of 66.7%. These studies represent the wide range of return to sport rates, but all of these studies showed improved postoperative pain levels and range of motion.13,21,22 (3) Fragment fixation. (a) Studies demonstrate radiographic healing in 82%100% of patients, and return to sports rates of 68%100%.7,23-25 (4) Osteochondral autograft transfer. (a) Most studies show good results given the severity of the lesions. These studies show that the return to sport rate is between 75% and 100%.26-28
(1) Arthrofibrosis can occur postoperatively but will resolve most of the time with a course of therapy. However, occasionally the stiffness requires a capsular release.15 (2) Heterotopic ossification has been reported—more frequently in open than arthroscopic surgeries. Treatment involves arthroscopic excision and radiation.15 (3) Some authors have expressed concern about donor site morbidity in osteochondral autograft transfers, particularly the knee. Reddy et al reported decreased knee function in patients treated with osteochondral autografts from the knee for OCD lesions in the talus. Recent studies, including one by Nishimura et al,30 have demonstrated that patients were pain-free and full range of motion at 3 months postoperatively.
Conclusion OCD lesions in the elbow are not self-limiting conditions. Adolescent overhead athletes who present with the signs and symptoms of an OCD lesion of the elbow should obtain radiographs and an MR arthrogram. If the MR arthrogram demonstrates a central lesion with an intact cartilage cap then the patient should be placed in a hinged elbow brace and started in a formal physical therapy program. A good majority of these patients will return to sport without pain. If the patient does not improve with conservative treatment then he or she is a candidate for arthroscopic microfracture or fragment fixation. If, however, the MR arthrogram demonstrates a peripheral lesion then the patient requires an osteochondral autograft to restore the lateral wall.
References
Figure 7 An arthroscopic image depicting an osteochondral autograft that is partially inserted into the recipient site. These are necessary to restore structure lesions that extend to the lateral wall. (Color version of figure is available online.)
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