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Arthroscopic and open management of osteochondritis dissecans of the elbow


Overview

Chapter synopsis

  • Osteochondritis dissecans is a multifactorial focal insult to the articular surface resulting in separation of the articular cartilage and subchondral bone. In the elbow, the most common location for osteochondritis dissecans is the capitellum and generally it occurs in younger (12–14 years old) athletes with a history of overuse. Most often patients present with pain and inability to participate in sports and radiographs are the initial study of choice. Treatment is based primarily on the stability of the articular cartilage but also on lesion size and location. Stable lesions can be treated nonoperatively, whereas unstable lesions typically require surgery. Arthroscopic debridement and microfracture is the treatment of choice except when the lesion involves over 50% of the articular surface or disrupts the lateral buttress. In these cases, or for smaller lesions in higher level athletes, open osteochondral autograft transplantation may have better results with regards to return to play.

Important points

  • Stable lesions in patients with open growth plates should be treated conservatively.

  • Unstable lesions can be treated arthroscopically with the following indications:

    • Lesions less than 50% of the articular surface

    • Intact lateral buttress

  • Arthroscopic or open fixation of lesions with intact subchondral bone may be considered but may not provide better results than simple debridement and microfracture.

  • Osteochondral autograft transplantation should be considered in large lesions involving the lateral buttress.

  • Novel cartilage regeneration procedures (autologous cartilage implantation, bone marrow derived stem cell therapy, allogenic cartilage scaffolds, etc.) have been used in small case series with success but are expensive and further research is needed to determine their role in the treatment algorithm.

Clinical/surgical pearls

  • Mark surface landmarks prior to arthroscopy.

  • Insufflate the elbow prior to making portals.

  • Lesion is best visualized with a 70-degree scope from the posterior or direct lateral portal.

  • Two direct lateral portals may be useful for bigger lesions or when visualization is difficult.

  • Debride the lesion through the direct lateral (soft-spot) portal.

Clinical/surgical pitfalls

  • Mechanical symptoms are typically indicative of an unstable lesion.

  • More chronic lesions typically present with loss of motion and mechanical symptoms.

  • Poor results after arthroscopic treatment have been reported in lesions that involve the lateral buttress.

Introduction

Osteochondritis dissecans (OCD) of the elbow is a frequent source of elbow pain in the active adolescent patient. OCD is a focal idiopathic articular cartilage disorder which disrupts and segments the articular cartilage from the underlying subchondral bone. While mainly seen in baseball players and gymnasts of ages 11 to 21 years, the exact etiology is unknown. , Most commonly the lesion presents on the central or anterolateral aspect of the capitellum. , However, lesions have been reported throughout the elbow. The pathogenesis is likely multifactorial including altered biomechanics, localized ischemia, genetic predisposition, and repetitive overuse. It is thought that overhead athletes have significant risk secondary to the high loads seen in the lateral elbow with recurrent valgus stress at the radiocapitellar joint.

The clinical presentation can be variable with presenting symptoms including pain, loss of motion, instability, and mechanical symptoms. Furthermore, the duration of symptoms is variable upon presentation and commonly is a chronic issue that eventually leads to inability to participate in sport. Treatment is based on multiple factors focusing on the stability of the lesion, age of the patient, level of activity, and goals for return to sport. If treated with benign neglect, OCD is a potentially career ending diagnosis and can have devastating consequences on elbow function into adulthood. , However, with prompt diagnosis and appropriate treatment, many patients are able to return to sport successfully.

Pre-operative considerations

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