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    Managing Osteochondritis Dessicans of the Capitellum

    A young gymnast presents with 16-month history of recurrent left elbow pain, swelling, and occasional locking and catching. Conservative treatment has failed to provide relief. Is surgery the best treatment option at this point?

    Authors

    Edward S. Chang, MD, and Christopher C. Dodson, MD

    Disclosures

    The authors have no disclosures relevant to this article.

    Background

    Osteochondritis dissecans of the capitellum (OCD) is a rare disorder generally seen in the immature athlete. The exact etiology is unclear, however there is an association between this condition and athletes that sustain repetitive trauma to the radiocapitellar joint (ie overhead athletes, gymnasts).

    The typical presentation is in a young athlete with lateral elbow pain and swelling that is worse with activity and improves with rest. A detailed history and physical examination, along with advanced imaging modalities, can lead to early diagnosis.

    Treatment of OCD lesions depends on the size, grade, and location. Stable, low-grade lesions can be treated with rest and activity modification, with gradual return to sports.

    Operative treatment is generally indicated for:

    • Unstable lesions
    • Presence of loose bodies
    • Mechanical symptoms
    • Failure of non-operative treatment

    Surgical techniques range from debridement to fragment fixation to osteochondral autograft transplantation surgery (OATS). Clinical outcomes and return to sport vary by surgical technique, and long-term results are still needed to assess its efficacy.

    The following case illustrates a classic presentation of a young gymnast with OCD of the capitellum who underwent successful treatment via arthroscopic repair.

    Case Presentation

    Patient History

    An 11-year-old female gymnast presents with 16-month history of recurrent left elbow pain, swelling, and occasional locking and catching. Despite conservative treatment, she continued to have persistent pain and swelling.

    She eventually switched from gymnastics to diving, and although the symptoms improved, she continued to have intermittent pain along with catching and clicking. Cessation of sports did not fully alleviate her symptoms.

    Physical Examination

    • Inspection of the left elbow revealed no identifiable effusion.
    • Palpation demonstrated tenderness over the radiocapitellar joint.
    • Range of motion of the elbow showed +10° of extension to 140° of flexion.
    • Pronation and supination were both 90°.
    • Radiocapitellar compression test demonstrated pain with crepitus.

    Differential Diagnosis

    • OCD (unstable lesion)
    • Panner disease
    • Loose body

    Imaging

    Radiographs

    • Plain radiographs (Figures 1 and 2) demonstrated a central lucency in the capitellum consistent with OCD.

    Figures 1 and 2. X-rays of the elbow show an osteochondritis dissecans lesion of the capitellum.

    Magnetic resonance imaging (MRI)

    • MRI showed evidence of an osteochondral lesion of the capitellum measuring 0.7mm x 0.8mm by 0.3mm.
    • There was increased signal enhancement undermining the bone, representing an unstable lesion.

    Diagnosis

    • Unstable, grade 2 OCD of the capitellum

    Treatment

    The patient underwent right elbow arthroscopy, removal of loose body, and microfracture of the OCD lesion.

    • Arthroscopy was performed in the supine position with general anesthesia.
    • The arm was suspended utilizing an arm holder.
    • The joint was distended with 20 to 30 mL of saline through the soft spot portal.
    • The arthroscope was introduced into the proximal lateral portal. Diagnostic arthroscopy of the anterior compartment revealed no pathology.
    • A posterolateral portal was established and a diagnostic arthroscopy confirmed a capitellar OCD lesion (Figure 3).
    • The loose body was removed (Figures 4 and 5).
    • Microfracture of the lesion was performed (Figures 6 and 7).

    Figures 3 and 4. Diagnostic arthroscopy revealed a loose body.

    Figure 5. The loose body was subsequently removed and measured to be approximately 10 mm in length.

    Figure 6. Microfracture of the capitellum was performed,

    Figure 7. Resultant blood flow confirmed following microfracture.

    Postoperative Care

    • The patient was placed in a soft dressing and sling.
    • Gentle passive and active assisted range of motion was allowed immediately.
    • Strengthening was permitted at 2 weeks, with restrictions on exercises placing axial load across the elbow.
    • Return to sport was allowed at 4 months.

    Final Follow-up

    The patient presented at 6 months following surgery with no subjective complaints of pain. She ultimately made the choice to switch from gymnastics to diving and has had no difficulty participating. Physical examination showed full range of motion.

    Discussion

    Osteochondritis dessicans of the capitellum represents a difficult condition mainly afflicting adolescents participating in overhead sports and gymnastics. Patients generally complain of pain with activity and present with a small effusion and tenderness over the radiocapitellar joint.

    These lesions are classified as either stable or unstable:

    • Unstable lesions demonstrate better results with operative treatment. Status of the physis and restricted motion are important factors in determining lesion stability.
    • Non-operative treatment is generally reserved for stable lesions. Although early studies showed discouraging results with non-surgical management, recent studies have demonstrated spontaneous healing and good outcomes in patients with a stable lesion and an open capitellar physis.

    Multiple surgical options are available, ranging from debridement and marrow stimulation to fragment fixation to OATS from the knee. Optimal surgical treatment remains controversial. In general, debridement and microfracture has been the mainstay of treatment, with good results described.

    Fragment fixation has become popular over the past decade, with several small studies reporting good short-term outcomes. However, concerns about long-term healing, in particular the advanced lesions, persist.

    Lesions greater than 50% of the articular surface or more than 1cm in diameter are associated with worse outcomes when treated with debridement. OATS represents a promising solution for the treatment of large OCD lesions.

    Additional studies are necessary to compare treatment methods in unstable lesions, with long-term follow-up needed to determine incidence of degenerative joint disease.

    References

    1. Ahmad C, ElAttrache N: Treatment of capitellar osteochondritis dissecans. Tech Shoulder Elbow Surg. 2006;7(4):169-174.
    2. Iwasaki N, Kato H, Ishikawa J, Masuko T, Funakoshi T, Minami A: Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athlets. J Bone Joint Surg Am. 2009;91(10)2369-2366.
    3. Takahar M, Ogino T, Sasaki I, Kato H, Minami A, Kaneda K: Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop Related Res 1999;363:108-115
    4. Takahara M, Mura N, Sasaki J, Harada M, Ogino T: Classification, treatment and outcome of osteochondritis dissecans of he humeral capitellum. J Bone Joint Surg Am 2007; 89:1204-1214.
    5. Takeda H, Watarai K, Matsushita T, Saito T, Terashima Y. A surgical treatment for osteochondritis dissecans lesions of the humeral capitellum in adolescent baseball players. Am J Sports Med. 2002;30(5): 713-717

    Author Information

    Edward S. Chang, MD, and Christopher C. Dodson, MD, are from The Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

    Sports Medicine Section Editor, Rothman Institute Grand Rounds

    Fotios P. Tjoumakaris, MD