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Osteochondritis dissecans of the capitellum: Arthroscopic-assisted treatment of large, full-thickness defects in young patients
Technical Note
Osteochondritis Dissecans of the Capitellum: Arthroscopic-Assisted Treatment of Large, Full-Thickness Defects in Young Patients Stephan G. Pill, M.S., P.T., Theodore J. Ganley, M.D., John M. Flynn, M.D., and John R. Gregg, M.D.
Abstract: Methods of treatment for mild juvenile osteochondritis dissecans (OCD) of the capitellum include activity modification and periods of immobilization, followed by therapy and range of motion exercises. Surgical treatment may be indicated if there are persistent symptoms, a loose body, the child is approaching skeletal maturity, or if magnetic resonance imaging reveals a fracture through the articular cartilage. We describe a technique of arthrotomy, using an arthroscope as a visual aid, for the treatment of large, full-thickness OCD lesions of the capitellum in young patients. The arthroscopic camera allows the surgeon to view difficult-to-see areas, and photographs can be taken throughout the procedure for documentation. Key Words: Osteochondritis dissecans—Panner’s disease—Capitellum—Arthroscopy—Treatment—Children.
O
steochondritis dissecans (OCD) of the capitellum is most commonly seen in children between the ages of 10 and 17 years who engage in overhead throwing sports and activities in which the elbow functions as a weight-bearing joint, such as gymnastics and weightlifting.1,2 Patients with capitellar OCD complain of pain with activity, dull aching at rest, catching, and locking. Objective findings include swelling, tenderness over the anterior radiocapitellar joint, and limitations in elbow motion, particularly extension and flexion.
From the Department of Orthopaedic Surgery and the Sports Medicine and Performance Center at The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A. Address correspondence and reprint requests to Theodore J. Ganley, M.D., Department of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 2nd Floor Wood Center, 34th & Civic Center Blvd, Philadelphia, PA 19104-4399, U.S.A. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 0749-8063/03/1902-3148$30.00/0 doi:10.1053/jars.2003.50043
222
Panner’s disease, a term often used synonymously with OCD of the capitellum, is an avascular necrosis of the developing ossific nucleus within the chondral epiphysis and is analogous to Legg-Calve-Perthes disease of the hip. It has a similar presentation to capitellar OCD, but those affected are younger, typically 6 to 10 years old,2 and symptoms usually resolve with appropriate rest and activity modification to reduce the offending repetitive microtrauma. Capitellar OCD is typically managed by activity modification, immobilization, and if necessary, surgery. Surgical techniques include debridement of loose bodies, subchondral drilling, bone grafting with or without internal fixation, and periosteal transplantation. Surgical treatment depends on the size and location of the lesion, stability of the fragment, and on the preference of the surgeon. Previous studies have reported on surgical methods with varying results. Although short-term studies on arthroscopic procedures report excellent results,2 longer follow-up can show a return of symptoms and development of degenerative joint changes.3 Children
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp 222-225
OSTEOCHONDRITIS DISSECANS OF THE CAPITELLUM
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who participate in elite athletic activities and develop OCD of the elbow often cannot return to compete at the same level postoperatively.4 However, children with OCD of the elbow tend to do well as a group over time. Some lesions in smaller patients may be difficult to visualize and treat arthroscopically, and open arthrotomy can involve extensive dissection to visualize the entire defect. We present a technique that combines miniarthrotomy with arthroscopic assistance for fullthickness OCD lesions of the capitellum. TECHNIQUE The patient is placed in a lateral decubitus position or a supine position with a bolster under the affected side. This allows an optimal view for both the surgeon and the assistant. An anconeous-extensor carpi ulnaris incision (3 to 5 cm) is made over the lateral capitellum. The joint capsule and lateral collateral ligament is partially incised to improve the view of the lesion. Care is taken to avoid extensive dissection posterior to the capitellum so that its blood supply is not compromised. Through the small arthrotomy, a 30° arthroscope is used to view the joint surface in a method analogous to the use of a dental mirror (Fig 1). The arthroscope is placed to the border of, but not into, the radiocapitellar joint and angled toward the capitellum. The camera is focused on the cavity for complete visualization. The arthroscope can be used simultaneously with the drill to treat the medial aspect of the capitellum, or the camera can be removed and reintroduced to confirm treatment. Frequently, the lateral aspect of the capitellum can be seen adequately without assistance from the arthroscope. Loose bodies are removed, and the lytic cavity beneath the lesion is curetted. This cavity, which can be quite deep, is commonly filled with fibrous and granulation tissue. The underlying sclerotic bone is drilled with a 0.62 smooth K-wire until bleeding is noted. Drilling is performed as perpendicular as possible to the capitellum in a distal-to-proximal direction through the arthrotomy site. The patient is started on a continuous passive motion (CPM) machine. CPM has been shown to stimulate the development of a compensatory articular surface with fibrocartilage and potentially some hyalinelike cartilage.5 Initially, the CPM machine is set with flexion to tolerance, but the intended range is 0° to 40° of elbow motion. The amount of flexion allowed by the machine is increased gradually until full flexion is
FIGURE 1. (A) Schematic drawing showing an arthroscope directed at the capitellum and a K-wire used to drill through the OCD lesion. (B) Schematic drawing showing the incision at the lateral elbow. The arthroscope illuminates the affected area to allow better visualization for drilling the OCD lesion with a K-wire.
obtained. When the CPM machine is not in use, the patient’s arm should be placed in a bivalved extension cast. This promotes a full return of elbow extension, yet allows the patient to regain flexion through CPM use.
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FIGURE 2. (A) View of the radiocapitellar joint of a right elbow using an arthroscopic camera through a small arthrotomy. The capitellum with an OCD lesion (arrow) is on the left, and the radial head is on the right. This view is similar to the view seen by a surgeon performing an arthrotomy. (B) A closer view of the same capitellum made possible by the arthroscopic camera, showing enhanced visualization of the large OCD lesion (arrows).
Patients are encouraged to perform gentle range of motion and isometric exercises as tolerated. Shoulder, wrist, and hand exercises that do not stress the elbow are performed to preserve the health of adjacent joints. At 6 weeks, the patients are placed on a low-impact rehabilitation program. Impact loading activities are prohibited for 6 to 9 months depending on the individual patient’s rate of healing and recovery. In the event of development of early synovitis or pain with exercise, the rehabilitation program is temporarily altered or halted. Although the ultimate goal is to return the child to normal activities, young baseball pitchers, gymnasts, and others who perform weight-bearing activities with their upper extremities are occasionally counseled about the benefits of seeking alternative forms of recreation or playing positions. DISCUSSION The ideal management of a large hinged or detached OCD lesion of the capitellum is controversial. Options include close observation with activity modification, debridement, drilling or curettage, bone grafting, or reattachment.
At the initial presentation of a patient with suspected capitellar OCD, we obtain plain radiographs and consider obtaining magnetic resonance imaging (MRI). If the articular cartilage appears intact, the patient receives nonsurgical treatment and close follow-up. Patients with an intact OCD lesion that is persistently symptomatic despite nonsurgical treatment regimen are treated with arthroscopic drilling. However, if the MRI reveals a fracture through subchondral bone and the articular cartilage, the described technique using an arthrotomy with arthroscopic assistance is performed. In younger, smaller patients, an arthrotomy with incision of the lateral capsule and a portion of the lateral collateral ligament allows the use of multiple instruments simultaneously while effectively visualizing the defect (Fig 2). Portions of the articular cartilage of the radial head and capitellum are difficult to see with a small lateral incision, and the operative lights alone often cannot illuminate this area sufficiently. The arthroscope, therefore, assists with visualization and illumination. Throughout the procedure, photographs can be taken to document damaged and
OSTEOCHONDRITIS DISSECANS OF THE CAPITELLUM treated areas. The arthrotomy also allows harvesting of a local bone graft if this is required. The development of a flexion contracture is a concern after open arthrotomy of the elbow. Brown et al.6 reported that 42% of patients in their series developed an average flexion contracture of 10° at follow-up. However, we believe that the proposed postoperative course of CPM and early active range of motion using a bivalved extension cast helps patients maximize range of motion while protecting the joint. In conclusion, we believe this technique of arthroscopic assisted “miniarthrotomy” is a viable option for treating young patients with large, full-thickness OCD lesions of the capitellum.
225
REFERENCES 1. Haraldsson S. On osteoshondrosis deformans juvenilis capituli humeri, including investigation of intra-osseous vasculature in the distal humerus. Acta Orthop Scand 1959;38:9-232 (suppl). 2. 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. 3. Bauer M, Jonsson K, Josefsson PO, Linden B. Osteochondritis dissecans of the elbow: A long-term follow-up study. Clin Orthop 1992;156-160. 4. Jackson DW, Silvino N, Reiman P. Osteochondritis in the female gymnast’s elbow. Arthroscopy 1989;5:129-136. 5. Salter RB, Simmonds DF, Malcolm BW, et al. The biological effect of continuous passive motion on the healing of fullthickness defects in articular cartilage: An experimental investigation in the rabbit. J Bone Joint Surg Am 1980;62:1232-1251. 6. Brown R, Blazina ME, Kerlan RK, et al. Osteochondritis of the capitellum. J Sports Med 1974;2:27-46.
Osteochondritis Dissecans of the Capitellum: Arthroscopic-Assisted Treatment of Large, Full-Thickness Defects in Young Patients Stephan G. Pill, M.S., P.T., Theodore J. Ganley, M.D., John M. Flynn, M.D., and John R. Gregg, M.D.
Abstract: Methods of treatment for mild juvenile osteochondritis dissecans (OCD) of the capitellum include activity modification and periods of immobilization, followed by therapy and range of motion exercises. Surgical treatment may be indicated if there are persistent symptoms, a loose body, the child is approaching skeletal maturity, or if magnetic resonance imaging reveals a fracture through the articular cartilage. We describe a technique of arthrotomy, using an arthroscope as a visual aid, for the treatment of large, full-thickness OCD lesions of the capitellum in young patients. The arthroscopic camera allows the surgeon to view difficult-to-see areas, and photographs can be taken throughout the procedure for documentation. Key Words: Osteochondritis dissecans—Panner’s disease—Capitellum—Arthroscopy—Treatment—Children.
O
steochondritis dissecans (OCD) of the capitellum is most commonly seen in children between the ages of 10 and 17 years who engage in overhead throwing sports and activities in which the elbow functions as a weight-bearing joint, such as gymnastics and weightlifting.1,2 Patients with capitellar OCD complain of pain with activity, dull aching at rest, catching, and locking. Objective findings include swelling, tenderness over the anterior radiocapitellar joint, and limitations in elbow motion, particularly extension and flexion.
From the Department of Orthopaedic Surgery and the Sports Medicine and Performance Center at The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, U.S.A. Address correspondence and reprint requests to Theodore J. Ganley, M.D., Department of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 2nd Floor Wood Center, 34th & Civic Center Blvd, Philadelphia, PA 19104-4399, U.S.A. E-mail: [email protected] © 2003 by the Arthroscopy Association of North America 0749-8063/03/1902-3148$30.00/0 doi:10.1053/jars.2003.50043
222
Panner’s disease, a term often used synonymously with OCD of the capitellum, is an avascular necrosis of the developing ossific nucleus within the chondral epiphysis and is analogous to Legg-Calve-Perthes disease of the hip. It has a similar presentation to capitellar OCD, but those affected are younger, typically 6 to 10 years old,2 and symptoms usually resolve with appropriate rest and activity modification to reduce the offending repetitive microtrauma. Capitellar OCD is typically managed by activity modification, immobilization, and if necessary, surgery. Surgical techniques include debridement of loose bodies, subchondral drilling, bone grafting with or without internal fixation, and periosteal transplantation. Surgical treatment depends on the size and location of the lesion, stability of the fragment, and on the preference of the surgeon. Previous studies have reported on surgical methods with varying results. Although short-term studies on arthroscopic procedures report excellent results,2 longer follow-up can show a return of symptoms and development of degenerative joint changes.3 Children
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 19, No 2 (February), 2003: pp 222-225
OSTEOCHONDRITIS DISSECANS OF THE CAPITELLUM
223
who participate in elite athletic activities and develop OCD of the elbow often cannot return to compete at the same level postoperatively.4 However, children with OCD of the elbow tend to do well as a group over time. Some lesions in smaller patients may be difficult to visualize and treat arthroscopically, and open arthrotomy can involve extensive dissection to visualize the entire defect. We present a technique that combines miniarthrotomy with arthroscopic assistance for fullthickness OCD lesions of the capitellum. TECHNIQUE The patient is placed in a lateral decubitus position or a supine position with a bolster under the affected side. This allows an optimal view for both the surgeon and the assistant. An anconeous-extensor carpi ulnaris incision (3 to 5 cm) is made over the lateral capitellum. The joint capsule and lateral collateral ligament is partially incised to improve the view of the lesion. Care is taken to avoid extensive dissection posterior to the capitellum so that its blood supply is not compromised. Through the small arthrotomy, a 30° arthroscope is used to view the joint surface in a method analogous to the use of a dental mirror (Fig 1). The arthroscope is placed to the border of, but not into, the radiocapitellar joint and angled toward the capitellum. The camera is focused on the cavity for complete visualization. The arthroscope can be used simultaneously with the drill to treat the medial aspect of the capitellum, or the camera can be removed and reintroduced to confirm treatment. Frequently, the lateral aspect of the capitellum can be seen adequately without assistance from the arthroscope. Loose bodies are removed, and the lytic cavity beneath the lesion is curetted. This cavity, which can be quite deep, is commonly filled with fibrous and granulation tissue. The underlying sclerotic bone is drilled with a 0.62 smooth K-wire until bleeding is noted. Drilling is performed as perpendicular as possible to the capitellum in a distal-to-proximal direction through the arthrotomy site. The patient is started on a continuous passive motion (CPM) machine. CPM has been shown to stimulate the development of a compensatory articular surface with fibrocartilage and potentially some hyalinelike cartilage.5 Initially, the CPM machine is set with flexion to tolerance, but the intended range is 0° to 40° of elbow motion. The amount of flexion allowed by the machine is increased gradually until full flexion is
FIGURE 1. (A) Schematic drawing showing an arthroscope directed at the capitellum and a K-wire used to drill through the OCD lesion. (B) Schematic drawing showing the incision at the lateral elbow. The arthroscope illuminates the affected area to allow better visualization for drilling the OCD lesion with a K-wire.
obtained. When the CPM machine is not in use, the patient’s arm should be placed in a bivalved extension cast. This promotes a full return of elbow extension, yet allows the patient to regain flexion through CPM use.
224
S. G. PILL ET AL.
FIGURE 2. (A) View of the radiocapitellar joint of a right elbow using an arthroscopic camera through a small arthrotomy. The capitellum with an OCD lesion (arrow) is on the left, and the radial head is on the right. This view is similar to the view seen by a surgeon performing an arthrotomy. (B) A closer view of the same capitellum made possible by the arthroscopic camera, showing enhanced visualization of the large OCD lesion (arrows).
Patients are encouraged to perform gentle range of motion and isometric exercises as tolerated. Shoulder, wrist, and hand exercises that do not stress the elbow are performed to preserve the health of adjacent joints. At 6 weeks, the patients are placed on a low-impact rehabilitation program. Impact loading activities are prohibited for 6 to 9 months depending on the individual patient’s rate of healing and recovery. In the event of development of early synovitis or pain with exercise, the rehabilitation program is temporarily altered or halted. Although the ultimate goal is to return the child to normal activities, young baseball pitchers, gymnasts, and others who perform weight-bearing activities with their upper extremities are occasionally counseled about the benefits of seeking alternative forms of recreation or playing positions. DISCUSSION The ideal management of a large hinged or detached OCD lesion of the capitellum is controversial. Options include close observation with activity modification, debridement, drilling or curettage, bone grafting, or reattachment.
At the initial presentation of a patient with suspected capitellar OCD, we obtain plain radiographs and consider obtaining magnetic resonance imaging (MRI). If the articular cartilage appears intact, the patient receives nonsurgical treatment and close follow-up. Patients with an intact OCD lesion that is persistently symptomatic despite nonsurgical treatment regimen are treated with arthroscopic drilling. However, if the MRI reveals a fracture through subchondral bone and the articular cartilage, the described technique using an arthrotomy with arthroscopic assistance is performed. In younger, smaller patients, an arthrotomy with incision of the lateral capsule and a portion of the lateral collateral ligament allows the use of multiple instruments simultaneously while effectively visualizing the defect (Fig 2). Portions of the articular cartilage of the radial head and capitellum are difficult to see with a small lateral incision, and the operative lights alone often cannot illuminate this area sufficiently. The arthroscope, therefore, assists with visualization and illumination. Throughout the procedure, photographs can be taken to document damaged and
OSTEOCHONDRITIS DISSECANS OF THE CAPITELLUM treated areas. The arthrotomy also allows harvesting of a local bone graft if this is required. The development of a flexion contracture is a concern after open arthrotomy of the elbow. Brown et al.6 reported that 42% of patients in their series developed an average flexion contracture of 10° at follow-up. However, we believe that the proposed postoperative course of CPM and early active range of motion using a bivalved extension cast helps patients maximize range of motion while protecting the joint. In conclusion, we believe this technique of arthroscopic assisted “miniarthrotomy” is a viable option for treating young patients with large, full-thickness OCD lesions of the capitellum.
225
REFERENCES 1. Haraldsson S. On osteoshondrosis deformans juvenilis capituli humeri, including investigation of intra-osseous vasculature in the distal humerus. Acta Orthop Scand 1959;38:9-232 (suppl). 2. 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. 3. Bauer M, Jonsson K, Josefsson PO, Linden B. Osteochondritis dissecans of the elbow: A long-term follow-up study. Clin Orthop 1992;156-160. 4. Jackson DW, Silvino N, Reiman P. Osteochondritis in the female gymnast’s elbow. Arthroscopy 1989;5:129-136. 5. Salter RB, Simmonds DF, Malcolm BW, et al. The biological effect of continuous passive motion on the healing of fullthickness defects in articular cartilage: An experimental investigation in the rabbit. J Bone Joint Surg Am 1980;62:1232-1251. 6. Brown R, Blazina ME, Kerlan RK, et al. Osteochondritis of the capitellum. J Sports Med 1974;2:27-46.