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Arthroscopic Debridement of the Humeral Capitellum for Osteochondritis Dissecans: Radiographic and Clinical Outcomes
SCIENTIFIC ARTICLE
Arthroscopic Debridement of the Humeral Capitellum for Osteochondritis Dissecans: Radiographic and Clinical Outcomes Junichi Miyake, MD, Takashi Masatomi, MD
Purpose Although arthroscopic debridement of the humeral capitellum is an accepted procedure for osteochondritis dissecans, some patients develop radial head enlargement or osteoarthritic lesions after the procedure. The aim of this study was to investigate the radiographic and clinical outcomes of arthroscopic debridement and consider its indications. Methods We retrospectively evaluated 106 patients who had arthroscopic debridement between 1997 and 2007. Surgery was performed after closure of the capitellar physis. We categorized the patients into 4 groups by lesion size and by whether the proximal radial physis was open or closed. The average patient age at surgery was 15 years (range, 12–18 y), and the average follow-up period was 13 months (range, 8 – 46 mo). Results In patients with large lesions and open proximal radial physes, radiographic and clinical outcomes were poor. Three of 4 patients developed early osteoarthritic lesions of the radiohumeral joint, secondary to radial head enlargement. Radial head resection was required in 2 of 3 patients. Conversely, osteoarthritic lesions did not occur, and we observed noteworthy improvement in elbow pain routinely after the procedure in the other 3 groups. For range of motion, clinically important changes were not observed. Overall, postoperative elbow pain was absent in 89 patients. Mild pain was present in 15 patients and moderate or severe pain in 2 patients. A total of 90 patients returned to sports at pre-injury levels. Time of return to sports varied from 1 month to 5 months (mean, 2.4 mo). Conclusions Arthroscopic debridement of the capitellum can provide excellent short-term results for the treatment of osteochondritis dissecans. However, it is contraindicated in cases with large lesions when the proximal radial physis remains open. (J Hand Surg 2011;36A:1333–1338. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Arthroscopic debridement, elbow, humeral capitellum, osteochondritis dissecans. the humeral capitellum commonly occurs in young athletes whose sport involves considerable use of the arms, such as baseball players. Those in whom the
O
STEOCHONDRITIS DISSECANS OF
From the Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Orthopaedic Surgery, Yukioka Hospital, Osaka, Japan. Received for publication February 10, 2011; accepted in revised form May 9, 2011. TheauthorsacknowledgethecontributionofKoichiroTakahi,MD,fromtheDepartmentofOrthopaedic Surgery, Toneyama National Hospital. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
capitellar physis remains open can make a good recovery by avoiding stress on the radiocapitellar joint.1,2 After closure of the capitellar physis, however, major remodeling cannot be expected, and conservative treatThis work was performed at Osaka Kosei-nenkin Hospital. Correspondingauthor:JunichiMiyake,MD,DepartmentofOrthopaedicSurgery,OsakaUniversity Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan; e-mail: miyake-osk@ umin.ac.jp. 0363-5023/11/36A08-0013$36.00/0 doi:10.1016/j.jhsa.2011.05.024
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FIGURE 1: A A 13-year-old boy complained of elbow pain. The capitellar growth plate was open, and we advised avoidance of throwing and weight-bearing on the arm. B After 9 months, the capitellar growth plate was closed, and obvious remodeling was observed. However, osteochondritis dissecans remained, and arthroscopic debridement was performed. C The patient resumed pitching 2 months after surgery. No pain or other symptoms were observed 2 years after surgery.
ment results in poor outcome.1,2 In such cases, surgical treatment is normally selected, but there is no standardized surgical method. Arthroscopic debridement for osteochondritis dissecans is a common and minimally invasive procedure.3–7 A wide range of variations in lesion conditions (as classified by the International Cartilage Repair Society8), lesion sizes, and bone ages exist in patients with osteochondritis dissecans of the humeral capitellum. Moreover, a few patients develop radial head enlargement or osteoarthritic lesions after the procedure.4,5 In patients with an open capitellar physis, we treated osteochondritis dissecans of the humeral capitellum conservatively by forbidding throwing and weightbearing on the arm and monitoring progress using plain radiographs (Fig. 1A). In contrast, if the capitellar physis was closed, we obtained informed consent and performed arthroscopic debridement with the objective of enabling an early return to athletics (Figs. 1B, 1C). The purpose of this study was to present our experience with arthroscopic debridement for osteochondritis dissecans of the humeral capitellum in 106 patients, to investigate the radiographic outcomes and clinical outcomes in 4 groups based on lesion size and the state of the radial head physis, and to consider its indications. MATERIALS AND METHODS After we obtained approval from the institutional review board, we conducted a retrospective review that identified 106 patients who had been treated with arthroscopic debridement for osteochondritis dissecans of the humeral capitellum between December 1997 and June 2007. We excluded patients in whom reconstruc-
tion of the ulnar collateral ligament was performed simultaneously or in whom osteoarthritis was already apparent. In 102 cases, the sport that caused the injury was baseball. There were 105 boys and 1 girl. Age at surgery ranged from 12 to 18 years, with an average age of 15 years. All surgery was performed by the senior author (T.M.). Radiographic and clinical evaluation We reviewed patient medical records for radiographic and clinical data. Radiographic evaluation included review of a consistent series of preoperative and postoperative radiographs. Using preoperative radiographs, we classified the 106 patients into 4 groups, based on lesion size and the state of the radial head physis. Lesion size was categorized according to the classification of Takahara et al.9 The state of the radial head physis was categorized according to whether the physis was open or closed. Patients with a small or moderate lesion and an open proximal radial physis were assigned to group SMo (n⫽8). Patients with a small or moderate lesion and a closed proximal radial physis were assigned to group SMc (n⫽85). Patients with a large lesion and an open proximal radial physis were assigned to group Lo (n⫽4). Patients with a large lesion and closed proximal radial physis were assigned to group Lc (n⫽9). After surgery, we investigated radiographic changes such as remodeling and radial head enlargement (that defines progressive deformation of the radial head compared with before surgery) and osteoarthritic lesions of the radiohumeral joint.
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Clinical data collected included preoperative and postoperative range of motion, preoperative and postoperative elbow pain, return to sports, and time taken to return to sports. Postoperative elbow pain at the final examination was graded as none (no pain), mild (pain only after intense activity, such as sports or work), and moderate or severe (pain after daily activities or even at rest).2,9 The assessment of return to sports at the final examination was graded as complete return, incomplete return, and change or cessation of the sport.2,9 Surgical technique Elbow arthroscopy was performed with patients under general anesthesia, prone, and with a 3.5-mm arthroscope. Diagnostic arthroscopy was performed in the anterior compartment, using anterolateral and anteromedial portals. If synovitis or loose bodies were present, they were removed first. Two posterior portals were then established to complete the procedure. After evaluation of the lesion, unstable areas and bone fragments, which were already detached, were removed. Drilling was also performed using a 1.2-mm K-wire if bleeding was poor after focal excision. If an empty crater was found in the capitellum, we performed a careful search of both compartments for the loose body. Range-ofmotion exercises were started on the day after surgery, and permission to return to athletics was given after physical conditioning and training. Follow-up periods ranged from 8 to 46 months, with an average of 13 months. Statistical analysis The comparison of the distribution of radial head enlargement in the 4 groups was investigated by means of the chi-square test. The differences between the preoperative and postoperative range of motion in groups SMo, SMc, and Lc were determined using the Student’s t-test; preoperative and postoperative scores for pain in groups SMo, SMc, and Lc were compared using the Wilcoxon signed-rank sum test. Due to the small sample size, no statistical analyses were performed for group Lo. The postoperative scores for pain and return to sports among the 4 groups were compared using the Steel–Dwass test. The results were deemed significant if P⬍.05. RESULTS Radiographic assessment Radiographs were unchanged in 86 patients, and obvious remodeling was observed in 13 group SMc patients (Table 1). Radial head enlargement was present in all 4 group Lo patients, in 2 group SMo patients (P⫽.01),
TABLE 1. Results of Radiographic Assessment Remodeling
Unchanged
Radial Head Enlargement*
SMo (n ⫽ 8)
0
6
2
SMc (n ⫽ 85)
Group
13
72
0
Lo (n ⫽ 4)
0
0
4†
Lc (n ⫽ 9)
0
8
1
*Progressive deformation of the radial head compared with before surgery. †Osteoarthritic lesions of the radiohumeral joint had appeared in 3 of 4 cases.
none in group SMc (P⬍.01), and 1 in group Lc (P⬍.01). Moreover, osteoarthritic lesions of the radiohumeral joint secondary to radial head enlargement appeared 6 to 18 months after the procedure in 3 group Lo patients. Radial head resection was performed in 2 of these patients (Fig. 2). Osteoarthritic lesions did not occur in group SMo, SMc, and Lc patients. Range of motion No clinically meaningful changes in range of motion were observed in any group. Only flexion in group SMc patients significantly improved after surgery (P⫽.04, Table 2). However, the average change was only 3°, and it would probably be less than a measurement error. Overall, average flexion changed from 133° ⫾ 10° before surgery to 135° ⫾ 8° (P⫽.07) after surgery, and the average range of flexion contracture significantly improved from 8° ⫾ 13° before surgery to 5° ⫾ 9° after surgery (P⫽.03), but the average change in extension was also only 3°. Elbow pain All patients experienced elbow pain before surgery (Table 3). Significant improvement in elbow pain was observed in groups SMo, SMc, and Lc after the procedure (P⬍.01, for all, Table 4). In patients from group Lo (n⫽4), however, 2 patients experienced moderate or severe pain after the procedure. The postoperative scores for elbow pain in group Lo patients were significantly lower than those in group SMc patients (P⬍.01). Overall, there was no postoperative elbow pain in 89 patients, mild pain in 15 patients, and moderate or severe pain in 2 patients. Return to sports In group SMo patients (n⫽8), return to sports was complete in 6 patients and incomplete in 2 patients. In group SMc patients (n ⫽ 85), return to sports was
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FIGURE 2: A group Lo patient in whom radial head enlargement and osteoarthritic lesions developed. A Before arthroscopic debridement, the capitellar growth plate was closed, and the proximal radial physis was open. B Four months after surgery, the patient returned to baseball but was returned after 18 months due to pain and restricted movement. The radiograph showed radial head enlargement and radiohumeral osteoarthritis. C Radial head resection was performed. The patient returned to sports at a recreational level after the procedure.
TABLE 2. Group SMo
Results of Range of Motion
Parameter Flexion (°) Extension (°)
SMc
Flexion (°)
Lo
Flexion (°)
Extension (°) Extension (°) Lc
Flexion (°) Extension (°)
TABLE 4. Elbow Pain After Surgery
Preoperative
Postoperative
P value
138 ⫾ 7
139 ⫾ 8
.61
5⫾7
1⫾4
133 ⫾ 10
136 ⫾ 7
7 ⫾ 11
4⫾9
126 ⫾ 11
121 ⫾ 21
15 ⫾ 4
14 ⫾ 12
133 ⫾ 9 20 ⫾ 24
None
Mild 3
5 53
Lo (n ⫽ 4)
0
0
4
Lc (n ⫽ 9)
0
1
8
0
10
0
1
2
.13
Lc (n ⫽ 9)
6
3
0
Moderate or Severe
32
1
1
.15
0
7 75
7⫾8
0
SMo (n ⫽ 8) Lo (n ⫽ 4)
.76
SMc (n ⫽ 85)
Moderate or Severe
SMc (n ⫽ 85)
134 ⫾ 5
SMo (n ⫽ 8)
Mild
.2
Elbow Pain Before Surgery
Group
None
.04*
*Indicates statistical significance, but the average change was only 3°.
TABLE 3.
Group
complete in 77 patients and incomplete in 8 patients. In group Lo patients (n⫽4), return to sports was complete in 1 patient, incomplete in 2 patients, and there was a change or cessation of the sport in 1 patient. One of 2 patients with radial head resection could return to sports at a recreational level (incomplete return) after radial head resection (Fig. 3), but the other could not return to sports after arthroscopic debridement and radial head
Significant improvement was observed in groups SMo, SMc, and Lc (P⬍.01, for all). The scores in group Lo were significantly lower than those in group SMc (P⬍.01).
resection. In group Lc patients (n⫽9), return to sports was complete in 6 patients and incomplete in 3 patients. The scores for return to sports in group Lc patients were significantly lower than those in group SMc patients (P⬍.01). Overall, all patients except 1 in group Lo were able to return to their sport (complete or incomplete). Overall 90 patients returned to participate in their sport at their pre-injury levels (complete). Time of return to sports varied from 1 to 5 months, with an average of 2.4 months. DISCUSSION Several small studies have reported clinical outcomes of arthroscopic debridement for osteochondritis dissecans of the humeral capitellum. Ruch et al reported that remodeling was confirmed in all 12 patients followed up for 2 to 5 years and that satisfactory results were obtained in 92% of cases.5 Baumgarten et al reported that 82% of 17 patients followed up for an average of 4 years returned to their sport at the pre-injury level and that osteoarthritic lesions were not observed in any
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FIGURE 3: A group Lc patient. A This patient had a large lesion and the proximal radial physis was closed before surgery. B The patient resumed baseball 4 months after surgery, and no progressive deformation of the radial head was observed 2 years after surgery.
cases.3 Jones et al also reported that 86% of 21 patients returned to participate in their sport at their pre-injury level.6 In contrast, Byrd et al found that, although clinical outcome was evaluated as excellent in all 10 patients who were followed up for 2 to 5 years, plain radiographs showed osteoarthritic lesions in 2 cases, and only 4 patients were able to return to their sport at the same level as before their injuries.4 Prognosis thus varies in different reports. In this study, good clinical outcomes were obtained in the majority of the patients. Perhaps owing to the low invasiveness of arthroscopic surgery, 105 patients were able to return to their sports after an average of 2.4 months. Ninety patients (85%) returned to their sport at their pre-injury levels. Therefore, most patients who were junior and senior high school students could compete in the national high school baseball tournament, which was the ultimate aim for these patients. In this study, 7 patients (7%) showed radial head enlargement after the procedure. Previous researchers also noted that radial head enlargement sometimes occurred after the procedure.4,5 Lesion size has been reported to be a contributing factor in prognosis.9 However, we noticed that, although some patients with large lesions experienced radial head enlargement, others did not. With respect to skeletal maturation, because sur-
gery was performed after closure of the capitellar physis, we considered these patients to constitute a uniform group. However, because we noticed that there were a few patients in whom the proximal radial physis remained open, patients were classified according to whether the proximal radial physis was open or closed. Radial head enlargement was seen only in 1 patient with large lesions and a closed proximal radial physis (group Lc). On the other hand, radial head enlargement was seen in all 4 patients with large lesions and an open proximal radial physis (group Lo). Radial head enlargement also occurs in patients with longstanding nonunion after a lateral condyle fracture in childhood.10,11 Therefore, radial head enlargement might have resulted from the absent capitellar articular surface in patients with remaining growth potential of the radial head. Radial head enlargement can lead to early osteoarthritis of the radiohumeral joint after the procedure. Three group Lo patients with radial head enlargement showed early osteoarthritis of the radiohumeral joint, and 2 required excision of the radial head (Fig. 2). Clinical outcomes were also poor in group Lo patients. This indicates that arthroscopic debridement is contraindicated in patients with large lesions and an open proximal radial physis. On the other hand, the group Lc patients showed good clinical outcomes. Arthroscopic
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debridement is suggested even for large lesions if the proximal radial physis is closed (Fig. 3). Recently, osteochondral autografting from the knee or rib has been performed for advanced osteochondritis dissecans of the elbow to restore the articular surface.12–16 In patients with large lesions, reconstructive surgery is recommended.2 If a near-normal contour of the capitellum is restored, reconstructive surgery might avoid radial head enlargement in patients with large lesions and open proximal radial physes. There have been reports, however, that reconstruction with osteochondral autografting is difficult if the lesion extends across a wide area and the external wall no longer exists.12,13 In this series, radial head enlargement was not observed in 85 patients with small or moderate lesions and a closed proximal radial physis (group SMc), and their functional outcomes were good. Therefore, SMc lesions are good indications for arthroscopic debridement. Of 8 patients with small or moderate lesions and an open proximal radial physis (group SMo), radial head enlargement occurred in 2 cases. Therefore, whether the proximal radial physis is open or closed can be considered an important prognostic factor, even when the lesion is small or moderate. Nevertheless, this is a factor that might be avoided by postponing surgery until closure of both the proximal radial physis and the capitellum. A few reports cite the long-term clinical outcomes of focal resection for osteochondritis dissecans of the elbow. Takahara et al reported 39 patients who were followed up for 3 to 25 years (average, 15 y).9 All 7 patients with large lesions had poor outcomes, whereas 6 of 25 patients with small or moderate lesions had poor outcomes. Because the age of their patients at surgery ranged from 10 to 34 years (average, 18 y), the prognosis could have varied depending on the status of the radial head physis. Furthermore, osteoarthritis might have already been present before surgery in some of the older patients. Bauer et al found that, after an average of 23 years, osteoarthritic lesions were observed in 61% of patients, although symptoms were mild.17 Similarly, there is a danger that osteoarthritis or pain might develop in these patients, despite their good early prognosis, particularly in those with large lesions. A survey of long-term prognosis is therefore required, and we intend to report on this in the future. This study has some limitations. It was not prospective, and the follow-up period was shorter than those in
previous reports. This investigation did not address magnetic resonance imaging, computed tomography, or arthroscopic assessment. However, it contains a large number of osteochondritis dissecans patients who had arthroscopic debridement, and we think that the status of the radial head physis influences the clinical outcome. REFERENCES 1. Mihara K, Tsutsui H, Nishinaka N, Yamaguchi K. Nonoperative treatment for osteochondritis dissecans of the capitellum. Am J Sports Med 2009;37:298 –304. 2. Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. J Bone Joint Surg 2007;89A:1205–1214. 3. Baumgarten TE, Andrews JR, Satterwhite YE. The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520 –523. 4. Byrd JW, Jones KS. Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: minimum three-year follow-up. Am J Sports Med 2002;30 – 4:474 – 478. 5. Ruch DS, Cory JW, Poehling GG. The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797– 803. 6. Jones KJ, Wiesel BB, Sankar WN, Ganley TJ. Arthroscopic management of osteochondritis dissecans of the capitellum: mid-term results in adolescent athletes. J Pediatr Orthop 2010;30:8 –13. 7. Schoch B, Wolf BR. Osteochondritis dissecans of the capitellum: minimum 1-year follow-up after arthroscopic debridement. Arthroscopy 2010;26:1469 –1473. 8. Brittberg M, Winalski CS. Evaluation of cartilage injuries and repair. J Bone Joint Surg 2003;85A:58 – 69. 9. Takahara M, Ogino T, Sasaki I, Kato H, Minami A, Kaneda K. Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop Relat Res 1999;363:108 –115. 10. Miyake J, Shimada K, Masatomi T. Osteosynthesis for longstanding nonunion of the lateral humeral condyle in adults. J Shoulder Elbow Surg 2010;19:958 –964. 11. Toh S, Tsubo K, Nishikawa S, Inoue S, Nakamura R, Harata S. Long-standing nonunion of fractures of the lateral humeral condyle. J Bone Joint Surg 2002;84A:593–598. 12. Shimada K, Yoshida T, Nakata K, Hamada M, Akita S. Reconstruction with an osteochondral autograft for advanced osteochondritis dissecans of the elbow. Clin Orthop Relat Res 2005;435:140 –147. 13. Yamamoto Y, Ishibashi Y, Tsuda E, Sato H, Toh S. Osteochondral autograft transplantation for osteochondritis dissecans of the elbow in juvenile baseball players: minimum 2-year follow-up. Am J Sports Med 2006;34:714 –720. 14. Iwasaki N, Kato H, Ishikawa J, Saitoh S, Minami A. Autologous osteochondral mosaicplasty for capitellar osteochondritis dissecans in teenaged patients. Am J Sports Med 2006;34:1233–1239. 15. Mihara K, Suzuki K, Makiuchi D, Nishinaka N, Yamaguchi K, Tsutsui H. Surgical treatment for osteochondritis dissecans of the humeral capitellum. J Shoulder Elbow Surg 2010;19:31–37. 16. Oka Y, Ikeda M. Treatment of severe osteochondritis dissecans of the elbow using osteochondral grafts from a rib. J Bone Joint Surg 2001;83:738 –739. 17. Bauer M, Jonsson K, Josefsson PO, Linden B. Osteochondritis dissecans of the elbow. A long-term follow-up study. Clin Orthop Relat Res 1992;284:156 –160.
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Arthroscopic Debridement of the Humeral Capitellum for Osteochondritis Dissecans: Radiographic and Clinical Outcomes Junichi Miyake, MD, Takashi Masatomi, MD
Purpose Although arthroscopic debridement of the humeral capitellum is an accepted procedure for osteochondritis dissecans, some patients develop radial head enlargement or osteoarthritic lesions after the procedure. The aim of this study was to investigate the radiographic and clinical outcomes of arthroscopic debridement and consider its indications. Methods We retrospectively evaluated 106 patients who had arthroscopic debridement between 1997 and 2007. Surgery was performed after closure of the capitellar physis. We categorized the patients into 4 groups by lesion size and by whether the proximal radial physis was open or closed. The average patient age at surgery was 15 years (range, 12–18 y), and the average follow-up period was 13 months (range, 8 – 46 mo). Results In patients with large lesions and open proximal radial physes, radiographic and clinical outcomes were poor. Three of 4 patients developed early osteoarthritic lesions of the radiohumeral joint, secondary to radial head enlargement. Radial head resection was required in 2 of 3 patients. Conversely, osteoarthritic lesions did not occur, and we observed noteworthy improvement in elbow pain routinely after the procedure in the other 3 groups. For range of motion, clinically important changes were not observed. Overall, postoperative elbow pain was absent in 89 patients. Mild pain was present in 15 patients and moderate or severe pain in 2 patients. A total of 90 patients returned to sports at pre-injury levels. Time of return to sports varied from 1 month to 5 months (mean, 2.4 mo). Conclusions Arthroscopic debridement of the capitellum can provide excellent short-term results for the treatment of osteochondritis dissecans. However, it is contraindicated in cases with large lesions when the proximal radial physis remains open. (J Hand Surg 2011;36A:1333–1338. Copyright © 2011 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Therapeutic IV. Key words Arthroscopic debridement, elbow, humeral capitellum, osteochondritis dissecans. the humeral capitellum commonly occurs in young athletes whose sport involves considerable use of the arms, such as baseball players. Those in whom the
O
STEOCHONDRITIS DISSECANS OF
From the Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Orthopaedic Surgery, Yukioka Hospital, Osaka, Japan. Received for publication February 10, 2011; accepted in revised form May 9, 2011. TheauthorsacknowledgethecontributionofKoichiroTakahi,MD,fromtheDepartmentofOrthopaedic Surgery, Toneyama National Hospital. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
capitellar physis remains open can make a good recovery by avoiding stress on the radiocapitellar joint.1,2 After closure of the capitellar physis, however, major remodeling cannot be expected, and conservative treatThis work was performed at Osaka Kosei-nenkin Hospital. Correspondingauthor:JunichiMiyake,MD,DepartmentofOrthopaedicSurgery,OsakaUniversity Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan; e-mail: miyake-osk@ umin.ac.jp. 0363-5023/11/36A08-0013$36.00/0 doi:10.1016/j.jhsa.2011.05.024
© ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 1333
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FIGURE 1: A A 13-year-old boy complained of elbow pain. The capitellar growth plate was open, and we advised avoidance of throwing and weight-bearing on the arm. B After 9 months, the capitellar growth plate was closed, and obvious remodeling was observed. However, osteochondritis dissecans remained, and arthroscopic debridement was performed. C The patient resumed pitching 2 months after surgery. No pain or other symptoms were observed 2 years after surgery.
ment results in poor outcome.1,2 In such cases, surgical treatment is normally selected, but there is no standardized surgical method. Arthroscopic debridement for osteochondritis dissecans is a common and minimally invasive procedure.3–7 A wide range of variations in lesion conditions (as classified by the International Cartilage Repair Society8), lesion sizes, and bone ages exist in patients with osteochondritis dissecans of the humeral capitellum. Moreover, a few patients develop radial head enlargement or osteoarthritic lesions after the procedure.4,5 In patients with an open capitellar physis, we treated osteochondritis dissecans of the humeral capitellum conservatively by forbidding throwing and weightbearing on the arm and monitoring progress using plain radiographs (Fig. 1A). In contrast, if the capitellar physis was closed, we obtained informed consent and performed arthroscopic debridement with the objective of enabling an early return to athletics (Figs. 1B, 1C). The purpose of this study was to present our experience with arthroscopic debridement for osteochondritis dissecans of the humeral capitellum in 106 patients, to investigate the radiographic outcomes and clinical outcomes in 4 groups based on lesion size and the state of the radial head physis, and to consider its indications. MATERIALS AND METHODS After we obtained approval from the institutional review board, we conducted a retrospective review that identified 106 patients who had been treated with arthroscopic debridement for osteochondritis dissecans of the humeral capitellum between December 1997 and June 2007. We excluded patients in whom reconstruc-
tion of the ulnar collateral ligament was performed simultaneously or in whom osteoarthritis was already apparent. In 102 cases, the sport that caused the injury was baseball. There were 105 boys and 1 girl. Age at surgery ranged from 12 to 18 years, with an average age of 15 years. All surgery was performed by the senior author (T.M.). Radiographic and clinical evaluation We reviewed patient medical records for radiographic and clinical data. Radiographic evaluation included review of a consistent series of preoperative and postoperative radiographs. Using preoperative radiographs, we classified the 106 patients into 4 groups, based on lesion size and the state of the radial head physis. Lesion size was categorized according to the classification of Takahara et al.9 The state of the radial head physis was categorized according to whether the physis was open or closed. Patients with a small or moderate lesion and an open proximal radial physis were assigned to group SMo (n⫽8). Patients with a small or moderate lesion and a closed proximal radial physis were assigned to group SMc (n⫽85). Patients with a large lesion and an open proximal radial physis were assigned to group Lo (n⫽4). Patients with a large lesion and closed proximal radial physis were assigned to group Lc (n⫽9). After surgery, we investigated radiographic changes such as remodeling and radial head enlargement (that defines progressive deformation of the radial head compared with before surgery) and osteoarthritic lesions of the radiohumeral joint.
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Clinical data collected included preoperative and postoperative range of motion, preoperative and postoperative elbow pain, return to sports, and time taken to return to sports. Postoperative elbow pain at the final examination was graded as none (no pain), mild (pain only after intense activity, such as sports or work), and moderate or severe (pain after daily activities or even at rest).2,9 The assessment of return to sports at the final examination was graded as complete return, incomplete return, and change or cessation of the sport.2,9 Surgical technique Elbow arthroscopy was performed with patients under general anesthesia, prone, and with a 3.5-mm arthroscope. Diagnostic arthroscopy was performed in the anterior compartment, using anterolateral and anteromedial portals. If synovitis or loose bodies were present, they were removed first. Two posterior portals were then established to complete the procedure. After evaluation of the lesion, unstable areas and bone fragments, which were already detached, were removed. Drilling was also performed using a 1.2-mm K-wire if bleeding was poor after focal excision. If an empty crater was found in the capitellum, we performed a careful search of both compartments for the loose body. Range-ofmotion exercises were started on the day after surgery, and permission to return to athletics was given after physical conditioning and training. Follow-up periods ranged from 8 to 46 months, with an average of 13 months. Statistical analysis The comparison of the distribution of radial head enlargement in the 4 groups was investigated by means of the chi-square test. The differences between the preoperative and postoperative range of motion in groups SMo, SMc, and Lc were determined using the Student’s t-test; preoperative and postoperative scores for pain in groups SMo, SMc, and Lc were compared using the Wilcoxon signed-rank sum test. Due to the small sample size, no statistical analyses were performed for group Lo. The postoperative scores for pain and return to sports among the 4 groups were compared using the Steel–Dwass test. The results were deemed significant if P⬍.05. RESULTS Radiographic assessment Radiographs were unchanged in 86 patients, and obvious remodeling was observed in 13 group SMc patients (Table 1). Radial head enlargement was present in all 4 group Lo patients, in 2 group SMo patients (P⫽.01),
TABLE 1. Results of Radiographic Assessment Remodeling
Unchanged
Radial Head Enlargement*
SMo (n ⫽ 8)
0
6
2
SMc (n ⫽ 85)
Group
13
72
0
Lo (n ⫽ 4)
0
0
4†
Lc (n ⫽ 9)
0
8
1
*Progressive deformation of the radial head compared with before surgery. †Osteoarthritic lesions of the radiohumeral joint had appeared in 3 of 4 cases.
none in group SMc (P⬍.01), and 1 in group Lc (P⬍.01). Moreover, osteoarthritic lesions of the radiohumeral joint secondary to radial head enlargement appeared 6 to 18 months after the procedure in 3 group Lo patients. Radial head resection was performed in 2 of these patients (Fig. 2). Osteoarthritic lesions did not occur in group SMo, SMc, and Lc patients. Range of motion No clinically meaningful changes in range of motion were observed in any group. Only flexion in group SMc patients significantly improved after surgery (P⫽.04, Table 2). However, the average change was only 3°, and it would probably be less than a measurement error. Overall, average flexion changed from 133° ⫾ 10° before surgery to 135° ⫾ 8° (P⫽.07) after surgery, and the average range of flexion contracture significantly improved from 8° ⫾ 13° before surgery to 5° ⫾ 9° after surgery (P⫽.03), but the average change in extension was also only 3°. Elbow pain All patients experienced elbow pain before surgery (Table 3). Significant improvement in elbow pain was observed in groups SMo, SMc, and Lc after the procedure (P⬍.01, for all, Table 4). In patients from group Lo (n⫽4), however, 2 patients experienced moderate or severe pain after the procedure. The postoperative scores for elbow pain in group Lo patients were significantly lower than those in group SMc patients (P⬍.01). Overall, there was no postoperative elbow pain in 89 patients, mild pain in 15 patients, and moderate or severe pain in 2 patients. Return to sports In group SMo patients (n⫽8), return to sports was complete in 6 patients and incomplete in 2 patients. In group SMc patients (n ⫽ 85), return to sports was
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FIGURE 2: A group Lo patient in whom radial head enlargement and osteoarthritic lesions developed. A Before arthroscopic debridement, the capitellar growth plate was closed, and the proximal radial physis was open. B Four months after surgery, the patient returned to baseball but was returned after 18 months due to pain and restricted movement. The radiograph showed radial head enlargement and radiohumeral osteoarthritis. C Radial head resection was performed. The patient returned to sports at a recreational level after the procedure.
TABLE 2. Group SMo
Results of Range of Motion
Parameter Flexion (°) Extension (°)
SMc
Flexion (°)
Lo
Flexion (°)
Extension (°) Extension (°) Lc
Flexion (°) Extension (°)
TABLE 4. Elbow Pain After Surgery
Preoperative
Postoperative
P value
138 ⫾ 7
139 ⫾ 8
.61
5⫾7
1⫾4
133 ⫾ 10
136 ⫾ 7
7 ⫾ 11
4⫾9
126 ⫾ 11
121 ⫾ 21
15 ⫾ 4
14 ⫾ 12
133 ⫾ 9 20 ⫾ 24
None
Mild 3
5 53
Lo (n ⫽ 4)
0
0
4
Lc (n ⫽ 9)
0
1
8
0
10
0
1
2
.13
Lc (n ⫽ 9)
6
3
0
Moderate or Severe
32
1
1
.15
0
7 75
7⫾8
0
SMo (n ⫽ 8) Lo (n ⫽ 4)
.76
SMc (n ⫽ 85)
Moderate or Severe
SMc (n ⫽ 85)
134 ⫾ 5
SMo (n ⫽ 8)
Mild
.2
Elbow Pain Before Surgery
Group
None
.04*
*Indicates statistical significance, but the average change was only 3°.
TABLE 3.
Group
complete in 77 patients and incomplete in 8 patients. In group Lo patients (n⫽4), return to sports was complete in 1 patient, incomplete in 2 patients, and there was a change or cessation of the sport in 1 patient. One of 2 patients with radial head resection could return to sports at a recreational level (incomplete return) after radial head resection (Fig. 3), but the other could not return to sports after arthroscopic debridement and radial head
Significant improvement was observed in groups SMo, SMc, and Lc (P⬍.01, for all). The scores in group Lo were significantly lower than those in group SMc (P⬍.01).
resection. In group Lc patients (n⫽9), return to sports was complete in 6 patients and incomplete in 3 patients. The scores for return to sports in group Lc patients were significantly lower than those in group SMc patients (P⬍.01). Overall, all patients except 1 in group Lo were able to return to their sport (complete or incomplete). Overall 90 patients returned to participate in their sport at their pre-injury levels (complete). Time of return to sports varied from 1 to 5 months, with an average of 2.4 months. DISCUSSION Several small studies have reported clinical outcomes of arthroscopic debridement for osteochondritis dissecans of the humeral capitellum. Ruch et al reported that remodeling was confirmed in all 12 patients followed up for 2 to 5 years and that satisfactory results were obtained in 92% of cases.5 Baumgarten et al reported that 82% of 17 patients followed up for an average of 4 years returned to their sport at the pre-injury level and that osteoarthritic lesions were not observed in any
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FIGURE 3: A group Lc patient. A This patient had a large lesion and the proximal radial physis was closed before surgery. B The patient resumed baseball 4 months after surgery, and no progressive deformation of the radial head was observed 2 years after surgery.
cases.3 Jones et al also reported that 86% of 21 patients returned to participate in their sport at their pre-injury level.6 In contrast, Byrd et al found that, although clinical outcome was evaluated as excellent in all 10 patients who were followed up for 2 to 5 years, plain radiographs showed osteoarthritic lesions in 2 cases, and only 4 patients were able to return to their sport at the same level as before their injuries.4 Prognosis thus varies in different reports. In this study, good clinical outcomes were obtained in the majority of the patients. Perhaps owing to the low invasiveness of arthroscopic surgery, 105 patients were able to return to their sports after an average of 2.4 months. Ninety patients (85%) returned to their sport at their pre-injury levels. Therefore, most patients who were junior and senior high school students could compete in the national high school baseball tournament, which was the ultimate aim for these patients. In this study, 7 patients (7%) showed radial head enlargement after the procedure. Previous researchers also noted that radial head enlargement sometimes occurred after the procedure.4,5 Lesion size has been reported to be a contributing factor in prognosis.9 However, we noticed that, although some patients with large lesions experienced radial head enlargement, others did not. With respect to skeletal maturation, because sur-
gery was performed after closure of the capitellar physis, we considered these patients to constitute a uniform group. However, because we noticed that there were a few patients in whom the proximal radial physis remained open, patients were classified according to whether the proximal radial physis was open or closed. Radial head enlargement was seen only in 1 patient with large lesions and a closed proximal radial physis (group Lc). On the other hand, radial head enlargement was seen in all 4 patients with large lesions and an open proximal radial physis (group Lo). Radial head enlargement also occurs in patients with longstanding nonunion after a lateral condyle fracture in childhood.10,11 Therefore, radial head enlargement might have resulted from the absent capitellar articular surface in patients with remaining growth potential of the radial head. Radial head enlargement can lead to early osteoarthritis of the radiohumeral joint after the procedure. Three group Lo patients with radial head enlargement showed early osteoarthritis of the radiohumeral joint, and 2 required excision of the radial head (Fig. 2). Clinical outcomes were also poor in group Lo patients. This indicates that arthroscopic debridement is contraindicated in patients with large lesions and an open proximal radial physis. On the other hand, the group Lc patients showed good clinical outcomes. Arthroscopic
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debridement is suggested even for large lesions if the proximal radial physis is closed (Fig. 3). Recently, osteochondral autografting from the knee or rib has been performed for advanced osteochondritis dissecans of the elbow to restore the articular surface.12–16 In patients with large lesions, reconstructive surgery is recommended.2 If a near-normal contour of the capitellum is restored, reconstructive surgery might avoid radial head enlargement in patients with large lesions and open proximal radial physes. There have been reports, however, that reconstruction with osteochondral autografting is difficult if the lesion extends across a wide area and the external wall no longer exists.12,13 In this series, radial head enlargement was not observed in 85 patients with small or moderate lesions and a closed proximal radial physis (group SMc), and their functional outcomes were good. Therefore, SMc lesions are good indications for arthroscopic debridement. Of 8 patients with small or moderate lesions and an open proximal radial physis (group SMo), radial head enlargement occurred in 2 cases. Therefore, whether the proximal radial physis is open or closed can be considered an important prognostic factor, even when the lesion is small or moderate. Nevertheless, this is a factor that might be avoided by postponing surgery until closure of both the proximal radial physis and the capitellum. A few reports cite the long-term clinical outcomes of focal resection for osteochondritis dissecans of the elbow. Takahara et al reported 39 patients who were followed up for 3 to 25 years (average, 15 y).9 All 7 patients with large lesions had poor outcomes, whereas 6 of 25 patients with small or moderate lesions had poor outcomes. Because the age of their patients at surgery ranged from 10 to 34 years (average, 18 y), the prognosis could have varied depending on the status of the radial head physis. Furthermore, osteoarthritis might have already been present before surgery in some of the older patients. Bauer et al found that, after an average of 23 years, osteoarthritic lesions were observed in 61% of patients, although symptoms were mild.17 Similarly, there is a danger that osteoarthritis or pain might develop in these patients, despite their good early prognosis, particularly in those with large lesions. A survey of long-term prognosis is therefore required, and we intend to report on this in the future. This study has some limitations. It was not prospective, and the follow-up period was shorter than those in
previous reports. This investigation did not address magnetic resonance imaging, computed tomography, or arthroscopic assessment. However, it contains a large number of osteochondritis dissecans patients who had arthroscopic debridement, and we think that the status of the radial head physis influences the clinical outcome. REFERENCES 1. Mihara K, Tsutsui H, Nishinaka N, Yamaguchi K. Nonoperative treatment for osteochondritis dissecans of the capitellum. Am J Sports Med 2009;37:298 –304. 2. Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. J Bone Joint Surg 2007;89A:1205–1214. 3. Baumgarten TE, Andrews JR, Satterwhite YE. The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520 –523. 4. Byrd JW, Jones KS. Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: minimum three-year follow-up. Am J Sports Med 2002;30 – 4:474 – 478. 5. Ruch DS, Cory JW, Poehling GG. The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797– 803. 6. Jones KJ, Wiesel BB, Sankar WN, Ganley TJ. Arthroscopic management of osteochondritis dissecans of the capitellum: mid-term results in adolescent athletes. J Pediatr Orthop 2010;30:8 –13. 7. Schoch B, Wolf BR. Osteochondritis dissecans of the capitellum: minimum 1-year follow-up after arthroscopic debridement. Arthroscopy 2010;26:1469 –1473. 8. Brittberg M, Winalski CS. Evaluation of cartilage injuries and repair. J Bone Joint Surg 2003;85A:58 – 69. 9. Takahara M, Ogino T, Sasaki I, Kato H, Minami A, Kaneda K. Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop Relat Res 1999;363:108 –115. 10. Miyake J, Shimada K, Masatomi T. Osteosynthesis for longstanding nonunion of the lateral humeral condyle in adults. J Shoulder Elbow Surg 2010;19:958 –964. 11. Toh S, Tsubo K, Nishikawa S, Inoue S, Nakamura R, Harata S. Long-standing nonunion of fractures of the lateral humeral condyle. J Bone Joint Surg 2002;84A:593–598. 12. Shimada K, Yoshida T, Nakata K, Hamada M, Akita S. Reconstruction with an osteochondral autograft for advanced osteochondritis dissecans of the elbow. Clin Orthop Relat Res 2005;435:140 –147. 13. Yamamoto Y, Ishibashi Y, Tsuda E, Sato H, Toh S. Osteochondral autograft transplantation for osteochondritis dissecans of the elbow in juvenile baseball players: minimum 2-year follow-up. Am J Sports Med 2006;34:714 –720. 14. Iwasaki N, Kato H, Ishikawa J, Saitoh S, Minami A. Autologous osteochondral mosaicplasty for capitellar osteochondritis dissecans in teenaged patients. Am J Sports Med 2006;34:1233–1239. 15. Mihara K, Suzuki K, Makiuchi D, Nishinaka N, Yamaguchi K, Tsutsui H. Surgical treatment for osteochondritis dissecans of the humeral capitellum. J Shoulder Elbow Surg 2010;19:31–37. 16. Oka Y, Ikeda M. Treatment of severe osteochondritis dissecans of the elbow using osteochondral grafts from a rib. J Bone Joint Surg 2001;83:738 –739. 17. Bauer M, Jonsson K, Josefsson PO, Linden B. Osteochondritis dissecans of the elbow. A long-term follow-up study. Clin Orthop Relat Res 1992;284:156 –160.
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