Elbow – Osteochondritis Dissecans Surgery

• A localized injury and subsequent separation of articular cartilage and subchondral bone of the capitellum

Epidemiology

• Demographics
  • Usually occurs after age 10 (typically adolescents)
  • Juvenile OCD better prognosis than adult
  • Boys more common than girls
• Location
  • Typically located in capitellum of dominant upper extremity
• Risk Factors
  • Repetitive overhead and upper extremity weight bearing activities
  • Gymnasts and throwing

Pathophysiology

• Theorized to result from repetitive compression-type injury (overhead or upper extremity weight bearing activities) of the immature capitellum causing
  • Vascular insufficiency
  • Repetitive microtrauma

Associated conditions

• Panner's disease (osteochondrosis of the capitellum)
  • Typically presents in first decade of life (<10 years old)
  • Usually benign self-limiting course
  • Same mechanism of injury as OCD
  • Surgery is contraindicated for Panner disease (unlike OCD elbow)

Prognosis

• Prognosis based on physeal status
• Most heal between 6 to 18 months of nonoperative treatment
• Wide range of potential disability
  • Inability to participate in sports at same level
  • Up to 50% develop arthritic changes long term

Classification System

• Type I - Intact cartilage
  Bony stability may or may not be present
• Type II - Cartilage fracture with bony collapse or displacement
• Type III - Loose bodies present in joint

Symptoms

• Elbow pain
  • Insidious, activity-related onset of lateral elbow pain in dominant arm
• Mechanical symptoms
  • Loss of extension
    • Early sign
  • Catching / locking / grinding
    • Late signs if loose bodies present

Physical exam

• Lateral elbow tenderness
• Mild loss of extension
• Possible effusion of elbow joint
  • Usually mild
• May or may not present with crepitus

Imaging:

Radiographs

• Recommended views
  • AP and lateral of the elbow
• Findings
  • Plain radiographs can confirm the diagnosis based on bone defect
  • Capitellum is most commonly involved
  • Panner disease exhibits an irregular epiphysis, OCD a well-defined subchondral lesion

MRI

• Most useful for assessing:
  • Size
  • Extent of edema
  • Cartilage status

Treatment:

Nonoperative

• Cessation of activity +/- immobilization
  • Indications
    • Type I lesions (stable fragments)
  • Technique
    • 3-6 weeks followed by slow progression back to activities over next 6-12 weeks
  • Outcomes
    • >90% success rate

Operative

• Arthroscopic microfracture or drilling of capitellum
  • Indications (separated fragments)
    • Unstable type I lesions
    • Stable type II lesions
  • Technique
    • Microfracture of chondral lesion
    • Extra- or transarticular drilling of defects
  • Post op care
    • Pprotected early range of motion
    • Strengthening at 2 months
    • Throwing and weight bearing at 4-6 months
  • Outcomes
    • Good success rate
• Fixation of lesion
  • Indications
    • Large lesions that are incompletely displaced
  • Technique
    • Arthroscopic reduction and fixation
  • Post op care
    • Protected early range of motion
    • Strengthening at 2 months
    • Throwing and weight bearing at 4-6 months
  • Outcomes
    • Highly variable
• Arthroscopic debridement and loose body excision
  • Indications
    • Unstable type II lesion
    • Type III lesions
  • Post op care
    • Early range of motion +/- brace
    • Begin strengthening when range of motion is pain free
    • No throwing or weight bearing activities X 3 months
• Osteochondral autograft or allograft transplantation surgery (OATS)
  • Indications
    • Large type II and III capitellar lesions which engage the radial head
    • Uncontained lesions may require size-matched fresh allograft
  • Post op care
    • Early range of motion
    • Resistive/strengthening exercises at 3 months
    • Progressive throwing program begins at 5 months through 7 months