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Arthroscopic osteochondral autograft transfer in the treatment of an osteochondral defect of the humeral head: Report of one case
Arthroscopic osteochondral autograft transfer in the treatment of an osteochondral defect of the humeral head: Report of one case Tae-Soo Park, MD, Tai-Sung Kim, MD, and Jae-Hyun Cho, MD, Guri-City, Korea
O
steochondritis dissecans of the humeral head is an uncommon disorder in young patients. It is a localized involvement of part of the articular cartilage of the humeral head that results in the separation of a segment of the articular cartilage and subchondral bone and eventually causes defects in the cartilage and incongruity of the joint. Its etiology is unclear, and it is hard to get good results after the treatment. We present a case of an osteochondral defect of the humeral head in an adolescent patient that may have been caused by osteochondritis dissecans. It was treated with an arthroscopic osteochondral autograft transfer.
CASE REPORT A 13-year-old right-handed boy visited our hospital because of dull pain over the posterosuperior aspect of the left shoulder for 6 months. He was a nonsmoker. There was no clear relationship between the symptoms and a history of trauma, but the pain was aggravated after heavy exercise. On physical examination, there was only tenderness on the posterosuperior portion of the left humeral head area. Radiographic evaluation showed an irregular articular surface and a radiolucent bony defect in the posterosuperior aspect of the humeral head, approximately 10 mm in diameter, which was surrounded by a sclerotic margin (Figure 1). Magnetic resonance imaging (MRI) before operation showed a 9-mm osteochondral defect in the posterosuperior aspect of the left humeral head, without bony fragments or loose bodies (Figure 2). Reconstruction of the humeral head lesion was performed by arthroscopic osteochondral autograft transfer in the beach chair position. Arthroscopy showed the osteochondral defect, 9 mm in diameter, was located in the posterosuperior aspect of the humeral head and was filled with granulation tissues, but there was neither bony fragments nor loose bodies (Figure 3, A). The donor graft was Department of Orthopaedic Surgery, Kuri Hospital, Hanyang University College of Medicine. Reprint requests: Tae-Soo Park, MD, Department of Orthopaedic Surgery, Guri Hospital, Hanyang University College of Medicine, 249-1 Gyomoon-Dong, Guri-City Gyunggi-Do, 471-701, Korea (E-mail: [email protected]). J Shoulder Elbow Surg 2006;15:e31-e36. Copyright © 2006 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2006/$32.00 doi:10.1016/j.jse.2005.10.008
Figure 1 Radiographic evaluation showed a radiolucent area in the posterosuperior aspect of the humeral head, but no bony fragments were found. A radiolucent area had a sclerotic margin (arrows)
obtained from the ipsilateral sulcus of the lateral femoral condyle as a single, cylinder-shaped core 10 mm in diameter and 12 mm deep. It was transferred into the cylindrical defect site of the humeral head (9 mm in diameter, 11 mm deep), which had been prepared using the Osteochondral Autograft Transfer System (OATS) (Arthrex, Naples, FL) through a posteroinferior portal 20 mm caudal to the posterior portal. The defect site was filled with the donor graft by a press-fit technique (Figure 3, B). The patient was kept in an arm sling for a week after the operation. Active assisted and passive range-of-motion exercise was started the day after the operation. At 3 weeks, active range-of-motion exercise was permitted. At 5 weeks, strengthening exercise and, at 6 months, overhead sports were started. At 5 months, a second-look arthroscopic surgery was performed. Arthroscopy showed the defects of both donor and recipient sites were healed completely and cov-
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Figure 2 The initial magnetic resonance images showed an osteochondral defect in the posterosuperior aspect of the humeral head. A and B, Coronal (arrow) and (C and D) axial (open arrow) sections demonstrated an area of low signal intensity on T1-weighted image (A and C) and high signal intensity on T2-weighted image (B and D) surrounded by a band of low-signal intensity.
ered with congruent articular cartilage (Figure 3, C). A specimen of the recipient site taken by using a 16-gauge bone biopsy needle at the second-look arthroscopy showed a normal pattern of the hyaline cartilage (Figure 4). The follow-up MRI showed healing of the osteochondral defect at the top portion of the humeral head (Figure 5). However, a new osteochondral lesion had developed on the posterolateral aspect of the humeral head (Figure 5, C and D) . The new lesion showed MRI characteristics
that were similar to the previous lesion (Figure 2) and was compatible with the developing stage of the osteochondritis dissecans. At 2 years and 7 months after the operation, he had no symptoms with good functional results, even though a new osteochondral lesion was developing on the posterolateral aspect of the humeral head. The follow-up radiograph (Figure 6) showed resolution of the bony defect of the humeral head.
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Figure 3 A, Arthroscopic picture showed an osteochondral defect (arrowheads), 9 mm in diameter, in the posterosuperior aspect of the humeral head, filled with granulation tissues. B, The humeral head was filled with the single core of the autogenous graft. C, Arthroscopic picture at the follow up showed the defect was healed at 5 months after operation.
DISCUSSION Osteochondritis dissecans of the humeral head is rare and only a few cases have been reported at present.1,4 – 6,9 It commonly affects young and middle-aged males,4 and its etiology is still unknown.4,9 The predominant site of involvement is the anterosuperior portion of the humeral head. In our patient, a 13-year-old boy who had no history of repeated trauma, symptoms were aggravated after exercise. A 9-mm-sized osteochondral defect was
found in the posterosuperior aspect of the humeral head of the left nondominant shoulder. Treatment options include activity restriction and surgical treatment, including débridement, removal of loose fragments,7 curettage and drilling of the lesion,4 osteochondral allograft transfer,2,3,8,10 and prosthetic hemiarthroplasty. In our patient, the osteochondral defect of the humeral head, with no associated loose, fragments, was treated by an arthroscopic osteochondral autograft transfer. At that
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articular cartilage. The specimen of the osteochondral autograft taken at that time showed a normal pattern of hyaline cartilage (Figure 4) . Histologically, the defect treated with the osteochondral autograft had recovered with hyaline cartilage. At a follow-up of 2 years and 7 months, the patient’s subjective symptom of pain was resolved completely, probably because of decompression and regained congruency of the shoulder joint. He showed an excellent functional outcome even though a new osteochondral lesion was developing on the posterolateral aspect of the humeral head. This operative procedure is complicated to perform because of preparation of both the shoulder and the knee and transfer of the autograft to the humeral head through an additional portal. However, arthroscopic osteochondral autograft transplantation is one of the effective and recommendable modalities in the treatment of osteochondral defect, 9 mm in diameter, of the humeral head in young, active patients. REFERENCES
Figure 4 A, Hyaline articular cartilage of humeral head is well preserved with endochondral ossification (hematoxylin and eosin stain, ⫻ 100 original magnification). B, Same specimen enlarged ⫻ 200 original magnification.
time, the graft, obtained from the ipsilateral sulcus of the lateral femoral condyle as a single core, was transferred into the cylindrical defect site of the humeral head, which had already been prepared by using OATS (Arthrex) through a posteroinferior portal using a press-fit technique. At a second-look arthroscopic surgery 5 months after the initial operation, the defects of both donor and recipient sites were completely healed and covered with congruent
1. Anderson WJ, Guildford WB. Osteochondritis dissecans of the humeral head. An unusual case of shoulder pain. Clin Orthop 1983;173:166-8. 2. Garrett JC. Fresh osteochondral allograft for treatment of articular defects in osteochondritis dissecans of the lateral femoral condyle in adults. Clin Orthop Relat Res 1994;303:33-7. 3. Garrett JC. Treatment of osteochondral defects of the distal femur with fresh osteochondral allografts: a preliminary report. Arthroscopy 1986;2:222-6. 4. Hamada S, Hamada M, Nishive S, Dai T. Osteochondritis dissecans of the humeral head. Case report. Arthroscopy 1992; 8:132-7. 5. Ishikawa H, Ueba Y, YonezawaT ??, Kurosaka M, Ohno O, Hirohata K. Osteochonritis dissecans of the shoulder in a tennis player. Am J Sports Med 1988;16:547-50. 6. Johnson DL, Warner JJ. Osteochondritis dissecans of the humeral head: treatment with a matched osteochondral allograft. J Shoulder Elbow Surg 1997;6:160-3. 7. Muller W. Osteochondritis dissecans. In: Hastings DE, editor. The knee: ligament and articular cartilage injuries. Berlin: Springer Verlag; 1978. p.135-42. 8. Outerbridge HK, Outerbridge AR, Outerbridge RE. The use of a lateral patellar autologous graft for the repair of a large osteochondral defect in the knee. J Bone J Surg Am 1995;77:65-72. 9. Pydisetty RV, Prasad SS, Kaye JC. Osteochondritis dissecans of the humeral head in an amateur boxer. J Shoulder Elbow Surg 2002;11:630-2. 10. Salmon MJ. Osteochondrite dissequante du coude et de l’epaule. Bull et Mem Soc Anat de Paris 1923;93:608-12.
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Figure 5 Follow-up magnetic resonance images (MRI) showed healing of the osteochondral defect at top portion of the humeral head. A, T1-weighted coronal and (C) axial images (open arrows). B T2-weighted coronal and (D)axial images (open arrows). A new osteochondral lesion that showed similar MRI characteristics as the previous lesion in Figure 2, had developed on the posterolateral aspect of the humeral head as shown by open arrowheads in the T1-weighted (C) and T2-weighted axial images (D).
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Figure 6 Follow-up radiography showed an almost normal shape of the humeral head with sclerotic change in the defect site.
J Shoulder Elbow Surg November/December 2006
O
steochondritis dissecans of the humeral head is an uncommon disorder in young patients. It is a localized involvement of part of the articular cartilage of the humeral head that results in the separation of a segment of the articular cartilage and subchondral bone and eventually causes defects in the cartilage and incongruity of the joint. Its etiology is unclear, and it is hard to get good results after the treatment. We present a case of an osteochondral defect of the humeral head in an adolescent patient that may have been caused by osteochondritis dissecans. It was treated with an arthroscopic osteochondral autograft transfer.
CASE REPORT A 13-year-old right-handed boy visited our hospital because of dull pain over the posterosuperior aspect of the left shoulder for 6 months. He was a nonsmoker. There was no clear relationship between the symptoms and a history of trauma, but the pain was aggravated after heavy exercise. On physical examination, there was only tenderness on the posterosuperior portion of the left humeral head area. Radiographic evaluation showed an irregular articular surface and a radiolucent bony defect in the posterosuperior aspect of the humeral head, approximately 10 mm in diameter, which was surrounded by a sclerotic margin (Figure 1). Magnetic resonance imaging (MRI) before operation showed a 9-mm osteochondral defect in the posterosuperior aspect of the left humeral head, without bony fragments or loose bodies (Figure 2). Reconstruction of the humeral head lesion was performed by arthroscopic osteochondral autograft transfer in the beach chair position. Arthroscopy showed the osteochondral defect, 9 mm in diameter, was located in the posterosuperior aspect of the humeral head and was filled with granulation tissues, but there was neither bony fragments nor loose bodies (Figure 3, A). The donor graft was Department of Orthopaedic Surgery, Kuri Hospital, Hanyang University College of Medicine. Reprint requests: Tae-Soo Park, MD, Department of Orthopaedic Surgery, Guri Hospital, Hanyang University College of Medicine, 249-1 Gyomoon-Dong, Guri-City Gyunggi-Do, 471-701, Korea (E-mail: [email protected]). J Shoulder Elbow Surg 2006;15:e31-e36. Copyright © 2006 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2006/$32.00 doi:10.1016/j.jse.2005.10.008
Figure 1 Radiographic evaluation showed a radiolucent area in the posterosuperior aspect of the humeral head, but no bony fragments were found. A radiolucent area had a sclerotic margin (arrows)
obtained from the ipsilateral sulcus of the lateral femoral condyle as a single, cylinder-shaped core 10 mm in diameter and 12 mm deep. It was transferred into the cylindrical defect site of the humeral head (9 mm in diameter, 11 mm deep), which had been prepared using the Osteochondral Autograft Transfer System (OATS) (Arthrex, Naples, FL) through a posteroinferior portal 20 mm caudal to the posterior portal. The defect site was filled with the donor graft by a press-fit technique (Figure 3, B). The patient was kept in an arm sling for a week after the operation. Active assisted and passive range-of-motion exercise was started the day after the operation. At 3 weeks, active range-of-motion exercise was permitted. At 5 weeks, strengthening exercise and, at 6 months, overhead sports were started. At 5 months, a second-look arthroscopic surgery was performed. Arthroscopy showed the defects of both donor and recipient sites were healed completely and cov-
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Figure 2 The initial magnetic resonance images showed an osteochondral defect in the posterosuperior aspect of the humeral head. A and B, Coronal (arrow) and (C and D) axial (open arrow) sections demonstrated an area of low signal intensity on T1-weighted image (A and C) and high signal intensity on T2-weighted image (B and D) surrounded by a band of low-signal intensity.
ered with congruent articular cartilage (Figure 3, C). A specimen of the recipient site taken by using a 16-gauge bone biopsy needle at the second-look arthroscopy showed a normal pattern of the hyaline cartilage (Figure 4). The follow-up MRI showed healing of the osteochondral defect at the top portion of the humeral head (Figure 5). However, a new osteochondral lesion had developed on the posterolateral aspect of the humeral head (Figure 5, C and D) . The new lesion showed MRI characteristics
that were similar to the previous lesion (Figure 2) and was compatible with the developing stage of the osteochondritis dissecans. At 2 years and 7 months after the operation, he had no symptoms with good functional results, even though a new osteochondral lesion was developing on the posterolateral aspect of the humeral head. The follow-up radiograph (Figure 6) showed resolution of the bony defect of the humeral head.
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Figure 3 A, Arthroscopic picture showed an osteochondral defect (arrowheads), 9 mm in diameter, in the posterosuperior aspect of the humeral head, filled with granulation tissues. B, The humeral head was filled with the single core of the autogenous graft. C, Arthroscopic picture at the follow up showed the defect was healed at 5 months after operation.
DISCUSSION Osteochondritis dissecans of the humeral head is rare and only a few cases have been reported at present.1,4 – 6,9 It commonly affects young and middle-aged males,4 and its etiology is still unknown.4,9 The predominant site of involvement is the anterosuperior portion of the humeral head. In our patient, a 13-year-old boy who had no history of repeated trauma, symptoms were aggravated after exercise. A 9-mm-sized osteochondral defect was
found in the posterosuperior aspect of the humeral head of the left nondominant shoulder. Treatment options include activity restriction and surgical treatment, including débridement, removal of loose fragments,7 curettage and drilling of the lesion,4 osteochondral allograft transfer,2,3,8,10 and prosthetic hemiarthroplasty. In our patient, the osteochondral defect of the humeral head, with no associated loose, fragments, was treated by an arthroscopic osteochondral autograft transfer. At that
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articular cartilage. The specimen of the osteochondral autograft taken at that time showed a normal pattern of hyaline cartilage (Figure 4) . Histologically, the defect treated with the osteochondral autograft had recovered with hyaline cartilage. At a follow-up of 2 years and 7 months, the patient’s subjective symptom of pain was resolved completely, probably because of decompression and regained congruency of the shoulder joint. He showed an excellent functional outcome even though a new osteochondral lesion was developing on the posterolateral aspect of the humeral head. This operative procedure is complicated to perform because of preparation of both the shoulder and the knee and transfer of the autograft to the humeral head through an additional portal. However, arthroscopic osteochondral autograft transplantation is one of the effective and recommendable modalities in the treatment of osteochondral defect, 9 mm in diameter, of the humeral head in young, active patients. REFERENCES
Figure 4 A, Hyaline articular cartilage of humeral head is well preserved with endochondral ossification (hematoxylin and eosin stain, ⫻ 100 original magnification). B, Same specimen enlarged ⫻ 200 original magnification.
time, the graft, obtained from the ipsilateral sulcus of the lateral femoral condyle as a single core, was transferred into the cylindrical defect site of the humeral head, which had already been prepared by using OATS (Arthrex) through a posteroinferior portal using a press-fit technique. At a second-look arthroscopic surgery 5 months after the initial operation, the defects of both donor and recipient sites were completely healed and covered with congruent
1. Anderson WJ, Guildford WB. Osteochondritis dissecans of the humeral head. An unusual case of shoulder pain. Clin Orthop 1983;173:166-8. 2. Garrett JC. Fresh osteochondral allograft for treatment of articular defects in osteochondritis dissecans of the lateral femoral condyle in adults. Clin Orthop Relat Res 1994;303:33-7. 3. Garrett JC. Treatment of osteochondral defects of the distal femur with fresh osteochondral allografts: a preliminary report. Arthroscopy 1986;2:222-6. 4. Hamada S, Hamada M, Nishive S, Dai T. Osteochondritis dissecans of the humeral head. Case report. Arthroscopy 1992; 8:132-7. 5. Ishikawa H, Ueba Y, YonezawaT ??, Kurosaka M, Ohno O, Hirohata K. Osteochonritis dissecans of the shoulder in a tennis player. Am J Sports Med 1988;16:547-50. 6. Johnson DL, Warner JJ. Osteochondritis dissecans of the humeral head: treatment with a matched osteochondral allograft. J Shoulder Elbow Surg 1997;6:160-3. 7. Muller W. Osteochondritis dissecans. In: Hastings DE, editor. The knee: ligament and articular cartilage injuries. Berlin: Springer Verlag; 1978. p.135-42. 8. Outerbridge HK, Outerbridge AR, Outerbridge RE. The use of a lateral patellar autologous graft for the repair of a large osteochondral defect in the knee. J Bone J Surg Am 1995;77:65-72. 9. Pydisetty RV, Prasad SS, Kaye JC. Osteochondritis dissecans of the humeral head in an amateur boxer. J Shoulder Elbow Surg 2002;11:630-2. 10. Salmon MJ. Osteochondrite dissequante du coude et de l’epaule. Bull et Mem Soc Anat de Paris 1923;93:608-12.
J Shoulder Elbow Surg Volume 15, Number 6
Park, Kim, and Cho
Figure 5 Follow-up magnetic resonance images (MRI) showed healing of the osteochondral defect at top portion of the humeral head. A, T1-weighted coronal and (C) axial images (open arrows). B T2-weighted coronal and (D)axial images (open arrows). A new osteochondral lesion that showed similar MRI characteristics as the previous lesion in Figure 2, had developed on the posterolateral aspect of the humeral head as shown by open arrowheads in the T1-weighted (C) and T2-weighted axial images (D).
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Figure 6 Follow-up radiography showed an almost normal shape of the humeral head with sclerotic change in the defect site.
J Shoulder Elbow Surg November/December 2006