Humeral Capitellum Research Articles

Outcomes of Concentrated Bone Marrow Aspirate with Extracellular Matrix in Pediatric and Adolescent Patients with Capitellar Osteochondritis Dissecans.

Humeral capitellar osteochondritis dissecans (OCD) lesions can be challenging to treat. Past studies have demonstrated grafting with extracellular matrix with bone marrow aspirate concentrate (ECM-BMAC) to be a viable technique for treatment of talar dome OCD, though little literature exists regarding application of this technique to the capitellum. This study aimed to report patient-reported outcomes (PROs) and return to sport (RTS) of pediatric patients at ≥1-year postoperatively who underwent ECM-BMAC grafting for capitellar OCD lesions. A consecutive, single surgeon series of patients aged <18 years with unstable, contained humeral capitellum OCD who underwent ECM-BMAC grafting and had ≥1-year of clinical follow-up were included. Elbow range of motion (ROM), RTS time, postoperative sport level, and complications were recorded at follow-up visits. PROs, including Hospital for Special Surgery (HSS) Pedi-FABS, QuickDASH, Patient-Reported Outcomes Measurement Information System (PROMIS) Mobility, PROMIS Pain Interference, and PROMIS Upper Extremity, were obtained at baseline and ≥1-year postoperatively. Both PROs and ROM were compared pre- and postoperatively using Wilcoxon Signed-Rank tests based on normality testing with Shapiro-Wilk tests. Twenty patients were included (mean age 12.8 ± 1.4 years) with an average 22.2 ± 13.0 months follow-up. Fifteen (75%) patients were female. The most common primary sports were gymnastics, baseball/softball, and racquet sports. Flexion improved significantly at ≥1-year postoperative, while extension remained close to full pre- and postoperatively. PROs improved from pre- to postoperative for all assessed instruments except for the HSS Pedi-FABS. Eighteen patients returned to their primary sport at the same competitive level or higher at a mean 5.8 ± 1.2 months. The two patients who did not return to their primary sport changed sports due to preferences unrelated to their elbow. There were no complications (e.g. infection, stiffness, revision surgery). This study demonstrated that ECM-BMAC grafting is a viable treatment strategy for pediatric patients with unstable, contained capitellar OCD lesions. We observed favorable PROs with a ∼90% RTS rate ≥1-year postoperatively, supporting the results of this technique that has demonstrated success in other anatomic regions and adult populations. These findings suggest ECM-BMAC grafting to be a viable treatment option for contained capitellar OCD lesions. Although these early results are promising, longer-term research studies are paramount in determining the outcomes of patients with capitellum OCD lesions treated with ECM-BMAC grafting.

Treatment and Early Outcomes of Capitellar Osteochondritis Dissecans.

Treatment for osteochondritis dissecans (OCD) of the humeral capitellum has been predominantly guided by fragment stability and articular cartilage integrity. Nonoperative management is recommended for stable lesions, whereas surgical intervention is indicated for unstable lesions and those that fail nonoperative care. Several surgical options may be considered, although limited information is available regarding indications for specific surgical techniques and comparative postoperative results. To assess surgical outcomes of patients with capitellar OCD treated according to a decision-making approach focused on subchondral bone involvement. Cohort study; Level of evidence, 3. Patients diagnosed with capitellar OCD at a tertiary academic center were enrolled in a prospective longitudinal cohort study. Patient information was collected at the time of enrollment, and OCD lesions were classified according to the Nelson grade. Clinical and radiologic data were collected both pre- and postoperatively for those undergoing surgical treatment. Surgical procedures were performed based on an evolving treatment framework that included considerations specifically for lesion containment and depth of subchondral bone disease. Timmerman scores were obtained to assess patient functional outcomes. A total of 154 patients were prospectively enrolled, 19 of whom had bilateral disease. The mean age at presentation was 13.7 years; 39% were gymnasts and 28.5% were primary baseball or softball athletes. Surgery was performed on 145 elbows, including 43 drilling/microfracture procedures, 21 internal fixations, and 63 autologous osteochondral grafting (OG) procedures. Clinically, there were significant improvements in pain, elbow motion, and mechanical symptoms. Timmerman scores significantly improved after each type of surgical procedure. A total of 76% of patients returned to their primary sport. When stratified by the Nelson grade, patients with OG had lower revision surgery rates than those treated with drilling/microfracture and fixation. Furthermore, for Nelson grade 2 lesions, patients treated with OG had significantly better postoperative elbow motion and higher Timmerman scores compared with those treated with other procedures. Using a treatment framework incorporating lesion containment and depth of subchondral bone disease, surgery for capitellar OCD provides clinical, radiologic, and functional improvements. Patients treated with OG may have lower revision rates and better functional outcomes compared with those treated with other surgical techniques, with OG warranting consideration even for lower-grade OCD lesions.

Advances in Ultrasound-Guided Surgery and Artificial Intelligence Applications in Musculoskeletal Diseases.

Ultrasound imaging is a vital imaging tool in musculoskeletal medicine, with the number of publications on ultrasound-guided surgery increasing in recent years, especially in minimally invasive procedures of sports, foot and ankle, and hand surgery. However, ultrasound imaging has drawbacks, such as operator dependency and image obscurity. Artificial intelligence (AI) and deep learning (DL), a subset of AI, can address these issues. AI/DL can enhance screening practices for hip dysplasia and osteochondritis dissecans (OCD) of the humeral capitellum, improve diagnostic accuracy for carpal tunnel syndrome (CTS), and provide physicians with better prognostic prediction tools for patients with knee osteoarthritis. Building on these advancements, DL methods, including segmentation, detection, and localization of target tissues and medical instruments, also have the potential to allow physicians and surgeons to perform ultrasound-guided procedures more accurately and efficiently. This review summarizes recent advances in ultrasound-guided procedures for musculoskeletal diseases and provides a comprehensive overview of the utilization of AI/DL in ultrasound for musculoskeletal medicine, particularly focusing on ultrasound-guided surgery.

Sagittal computed tomography evaluation of osteochondritis dissecans of the capitellum correlates with clinical outcomes of arthroscopic debridement in adolescent baseball players

ObjectivesTo investigate the relationship between the size and location of osteochondral defects in capitellar osteochondritis dissecans (OCD) measured on coronal and sagittal reconstructed computed tomography (CT) images and the clinical outcomes of arthroscopic debridement in adolescent baseball players. MethodsThis retrospective study investigated the clinical outcomes of arthroscopic debridement for capitellar OCD in adolescent baseball players with ≥24 months of follow-up after surgery between 2008 and 2020. On preoperative coronal CT images, medial and lateral distance (%) were used to evaluate the location of the defect. Defect size (%) was also evaluated. On preoperative sagittal CT images, superior and inferior angles (deg) were used to evaluate the location of the defect. The size of the defect was evaluated using the defect angle (deg). Outcome measures were determined using the Timmerman–Andrews score at the latest follow-up. Spearman’s rank correlation coefficient was used to examine relationships between these parameters and the Timmerman–Andrews score. Statistical significance was set at p ​< ​0.05. ResultsThirty players [mean age, 14 (range, 11–16) years] underwent arthroscopic debridement: 5 were pitchers, 7 were catchers, 13 were infielders, and 5 were outfielders. Mean follow-up duration was 26 (range, 24–66) months. The median Timmerman–Andrews score at the latest follow-up was 193 [interquartile range (IQR), 181–200] points. Inferior angle showed statistically significant positive correlations with Timmerman–Andrews score (rs ​= ​0.520, p ​< ​0.01), pain (rs ​= ​0.478, p ​< ​0.01), and sagittal arc of motion (rs ​= ​0.409, p ​= ​0.025). Defect angle showed statistically significant negative correlations with Timmerman–Andrews score (rs ​= ​−0.462, p ​= ​0.010) and flexion contracture (rs ​= ​-0.424, p ​= ​0.020). Medial distance, lateral distance, defect size, and superior angle were not correlated with the Timmerman–Andrews score or any of its subscores. ConclusionPosterior or large osteochondral defects of the humeral capitellum on preoperative sagittal CT images affected the outcomes of arthroscopic debridement for capitellar OCD in adolescent baseball players. Level of evidenceLevel V, case series.

Fresh Osteochondral Allograft Transplantation of the Capitellum for the Treatment of Osteochondritis Dissecans

Background: Osteochondritis dissecans (OCD) of the humeral capitellum is a rare and challenging condition to treat. Several surgical options exist, but in the last few years, the pendulum has swung from debridement and microfracture to restoration of the articular surface. Osteochondral autografts from the rib and knee have been described, but donor-site morbidity is a concern. Purpose: To expand the results of fresh osteochondral allograft transplantation (FOCAT) in a previously published report with inclusion of additional patients and a longer follow-up period. Study Design: Case series; Level of evidence, 4. Methods: After institutional review board approval, the charts of patients who underwent FOCAT for OCD of the capitellum between 2006 and 2022 by a single surgeon were reviewed. The majority of cases (94%) had unstable lesions (Minami grades 2 and 3). A trial of nonoperative treatment had failed in all. All patients underwent diagnostic arthroscopy, followed by a mini-open, ligament-sparing approach with grafting using commercially available guides and instruments. Results: A total of 35 patients were identified, of whom 25 were male. The mean age was 16 ± 3.9 years (range, 11-32 years). There were 24 baseball players (19 pitchers and 5 position players), 5 gymnasts, 3 cheerleaders/tumblers, 1 tennis player, 1 student (who did not participate in athletics), and 1 patient with avascular necrosis from chemotherapy. Eighteen patients had a mean flexion contracture of 14.1°± 11.9°. A single osteochondral allograft plug was used in 23 patients (mean diameter, 11.3 ± 2.8 mm), and 12 patients required 2 plugs (Mastercard technique). The mean follow-up was 92.6 ± 54.5 months (range, 24-204 months). There was significant improvement in Oxford (from 25.5 ± 4.9 to 46.7 ± 3.5; P < .00001) and visual analog scale for pain (from 7.5 ± 2 to 0.3 ± 1.0; P < .0001) scores. The mean Single Assessment Numeric Evaluation score at the time of follow-up was 90.6 ± 10.8 (range, 60-100). In overhead athletes, there was significant improvement in the Kerlan-Jobe Orthopaedic Clinic score (from 40.8 ± 11.8 to 90.6 ± 10.8; P < .00001). A postoperative magnetic resonance imaging scan was obtained in 16 (46%) patients at a mean of 32.6 months. In all cases, the graft was incorporated. All overhead athletes were able to return to their sport and perform at the same level or higher for >2 years. Two elbows required a subsequent arthroscopy for loose-body removal; otherwise, there were no other complications. Conclusion: FOCAT is an excellent option for treating OCD lesions of the humeral capitellum. Excellent outcomes and high return-to-sport rates were observed, with midterm follow-up showing no graft failures. FOCAT eliminates donor-site morbidity.

Autologous minced cartilage implantation for focal cartilage lesions of the humeral capitellum

The goal of minced cartilage implantation (MCI) is to restore an intact cartilage surface in focal osteochondral lesions of the humeral capitellum. The indications for MCI are limited osteochondral lesions at the humeral capitellum, also at the head of the radius, with intact cartilage border as well as in situ or acompletely detached fragment, and free joint bodies (gradeII-gradeV according to Hefti). Contraindications for MCI are already concomitant or associated cartilage damage as well as bilateral osteochondral lesions and insufficient available cartilage material. After diagnostic arthroscopy to detect possible concomitant pathologies and to exclude already corresponding cartilage lesions, the arthroscope is flipped posterolaterally over the high posterolateral portal and asecond portal is created under visualization via the soft spot. Initially, debridement of the focal cartilage defect, assessment of the marginal zone, and/or salvage of free joint bodies. Using asmooth shaver and the filter provided, the partially or even completely detached cartilage fragment is unidirectionally fragmented under continuous suction. The remaining defect with astable marginal zone is cleanly curetted, and the joint is completely dried. The fragmented cartilage collected in the filter is bonded to amembrane using autologous conditioned plasma (ACP) and then arthroscopically applied to the defect via acannula, sealed using thrombin and fibrin. Postoperative immobilization in acast for at least 24 h is required. Afterwards, free exercise of the joint is possible, but no loading should be maintained for 6weeks. Return to sport after 3months. Good to very good clinical and MRI morphologic results are already evident in the short-term course. Prospective and retrospective multicenter studies are needed to evaluate future long-term results.

Bone-cartilage transfer for osteochondritis dissecans of the humeral capitellum

Treatment of focal cartilage defects of the humeral capitellum with autologous bone-cartilage cylinders to prevent development of arthritis of the elbow joint. High-grade, unstable lesions (> 50% of the capitellum, gradeIII-IV according to Dipaola), including those involving the lateral edge of the capitellum and with adepth of up to 15 mm. Stable lesions and generalized osteochondritis of the capitellum (including Panner's disease), as well as arelative contraindication for lesions > 10 mm, as the largest punch has amaximum diameter of 10 mm. Arthroscopy of the elbow joint, transition to open surgery. First, the size of the cartilage defect in the capitellum is determined. Then, one (or several) osteochondral cylinders (OATS Arthex) are removed, which as far as possible completely encompass the defect zone. Corresponding intact bone-cartilage cylinders are obtained from the ipsilateral proximal lateral femoral condyle, each with a0.3 mm larger diameter via an additive miniarthrotomy. The "healthy" cylinders are then inserted into the defect zone in a"press fit" technique. An upper arm cast in neutral position of the hand for 10-14days, simultaneously beginning physiotherapy (active-assisted movements) and lymphatic drainage. As soon as painless range of motion (ROM) is restored (goal: by week6), isometric training can be started. Resistance training starts from week12. Competitive sports are only recommended after 6(-8) months. The current state of research on the surgical treatment of OCD of the humeral capitellum using autologous osteochondral grafts shows mostly promising results. Arecent meta-analysis of 24studies reports asignificantly higher (p < 0.01) rate of return to sports (94%) compared to fragment fixation (64%) or microfracture and debridement (71%) [41]. However, the increased donor-site morbidity must be taken into account (ca. 7.8%).

Poster 173: Evaluation of Radius of Curvature of the Humeral Capitellum in Young Athlete Osteochondritis Dissecans Lesion Sites

Objectives: Elbow Osteochondritis dissecans (OCD) lesions are often seen in young baseball players and gymnasts. Prior studies have suggested that capitellar OCD lesions are frequently found in two distinct and separate locations in these two populations: at 58° and 28° inclination angles from the humeral axis in baseball players and gymnasts respectively. As treatment of OCD lesions with osteochondral allografts and autografts have gained popularity, an increased emphasis has been placed on the utilization of measurements of capitellar radius of curvature (ROC) to minimize articular incongruity or ROC mismatch between the recipient elbow and donor knee. The purpose of this study was to further characterize the coronal-axial ROC in these two distinct locations and potentially identify morphological differences between the two OCD lesion locations. Methods: Elbow MRIs of thirty pediatric patients between the ages of eight and seventeen with no history of elbow injuries were retrospectively studied. Using the radiographic diagnostic viewing software, eUnity, two reviewers measured capitellar ROCs encompassing at least a ten-millimeter plug at both 58° and 28° inclination angles from the humeral axis on coronal-axial elbow MRIs for each patient. Coronal-axial views were established by using the 3D function to orient the axial plane in parallel with the capitellar articular surface and the coronal plane perpendicular to the capitellar surface. 58° and 28° inclination angles from the humeral axis were measured in the sagittal plane, and coronal-axial images were transformed in phase with each inclination angle. For each observer, paired two-tail t-tests were performed to evaluate statistical differences in ROC measurements between the two locations. Inter-observer absolute agreement was examined using the “irr” Intraclass Correlation Coefficient R package. Using a Fisher’s test, p values from the individual observer paired t-tests were combined and reviewed. Results: The Intraclass Correlation Coefficients were 0.886 for the 58° inclination angle and 0.921 for the 28° inclination angle, respectively denoting good and excellent inter-observer reliability. Paired two-tailed t-tests of each observer’s 58° and 28° capitellar ROC measurements yielded p&lt;0.001. The unweighted average t-value of 10.49 with 29 degrees of freedom and the combined Fisher p-value of &lt;0.001 suggest there is a significant difference between the ROC measurements at the 58° and 28° humeral capitellar locations. Average ROC measurements ranged between 13.94mm ± 1.31mm and 14.3mm ± 1.42mm at the 58° capitellar location and 11.7mm ± 1.53mm and 11.76mm ± 1.30mm at the 28° capitellar location. Measurements at the 28° inclination angle from the humeral axis tended to be smaller than those of the 58° inclination angle from the humeral axis. On average the ROC at the 28° inclination was between 2.18mm and 2.50mm smaller than the ROC at the 58° inclination. Conclusions: Prior studies have identified differences in capitellar OCD lesion location between baseball players and gymnasts. This study offers further characterization of both morphologic locations. The capitellar radii of curvature at 58° and 28° inclination angles from the humeral axis statistically differed, as demonstrated by both observer measurements. The ROC at the 28° inclination was on average between 2.18mm and 2.50mm smaller than the ROC at the 58° inclination. Therefore, because of evident ROC differences between these two locations, it may be beneficial to consider anatomic morphologic differences between distinct humeral capitellum regions when selecting graft locations to achieve an optimal osteochondral autograft match. Future research on optimizing donor-to-recipient ROC may improve articular congruity restoration and long-term outcomes.

Deep Learning-Based Computer-Aided Diagnosis of Osteochondritis Dissecans of the Humeral Capitellum Using Ultrasound Images.

Ultrasonography is used to diagnose osteochondritis dissecans (OCD) of the humerus; however, its reliability depends on the technical proficiency of the examiner. Recently, computer-aided diagnosis (CAD) using deep learning has been applied in the field of medical science, and high diagnostic accuracy has been reported. We aimed to develop a deep learning-based CAD system for OCD detection on ultrasound images and to evaluate the accuracy of OCD detection using the CAD system. The CAD process comprises 2 steps: humeral capitellum detection using an object-detection algorithm and OCD classification using an image classification network. Four-directional ultrasound images of the elbow of the throwing arm of 196 baseball players (mean age, 11.2 years), including 104 players with normal findings and 92 with OCD, were used for training and validation. An external dataset of 20 baseball players (10 with normal findings and 10 with OCD) was used to evaluate the accuracy of the CAD system. A confusion matrix and the area under the receiver operating characteristic curve (AUC) were used to evaluate the system. Clinical evaluation using the external dataset resulted in high AUCs in all 4 directions: 0.969 for the anterior long axis, 0.966 for the anterior short axis, 0.996 for the posterior long axis, and 0.993 for the posterior short axis. The accuracy of OCD detection thus exceeded 0.9 in all 4 directions. We propose a deep learning-based CAD system to detect OCD lesions on ultrasound images. The CAD system achieved high accuracy in all 4 directions of the elbow. This CAD system with a deep learning model may be useful for OCD screening during medical checkups to reduce the probability of missing an OCD lesion. Diagnostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Deep learning-based osteochondritis dissecans detection in ultrasound images with humeral capitellum localization.

Osteochondritis dissecans (OCD) of the humeral capitellum is a common cause of elbow disorders, particularly among young throwing athletes. Conservative treatment is the preferred treatment for managing OCD, and early intervention significantly influences the possibility of complete disease resolution. The purpose of this study is to develop a deep learning-based classification model in ultrasound images for computer-aided diagnosis. This paper proposes a deep learning-based OCD classification method in ultrasound images. The proposed method first detects the humeral capitellum detection using YOLO and then estimates the OCD probability of the detected region probability using VGG16. We hypothesis that the performance will be improved by eliminating unnecessary regions. To validate the performance of the proposed method, it was applied to 158 subjects (OCD: 67, Normal: 91) using five-fold-cross-validation. The study demonstrated that the humeral capitellum detection achieved a mean average precision (mAP) of over 0.95, while OCD probability estimation achieved an average accuracy of 0.890, precision of 0.888, recall of 0.927, F1 score of 0.894, and an area under the curve (AUC) of 0.962. On the other hand, when the classification model was constructed for the entire image, accuracy, precision, recall, F1 score, and AUC were 0.806, 0.806, 0.932, 0.843, and 0.928, respectively. The findings suggest the high-performance potential of the proposed model for OCD classification in ultrasonic images. This paper introduces a deep learning-based OCD classification method. The experimental results emphasize the effectiveness of focusing on the humeral capitellum for OCD classification in ultrasound images. Future work should involve evaluating the effectiveness of employing the proposed method by physicians during medical check-ups for OCD.

Lateral approach versus anterolateral approach with Herbert screw fixation for isolated coronal shear fractures of humeral capitellum: a review article

Fractures of the capitellum, particularly coronal shear fractures, are difficult to manage. For coronal shear fracture of capitellum, the surgical approaches include the lateral approach and anterolateral approach to the elbow joint. Herein, we reviewed the recent literature about lateral against anterolateral approaches by Herbert screw fixation for humeral capitellum isolated coronal shear fractures. A web-based article search by different databases like Directory of Open Access Journals, PubMed, Scopus, Google Scholar, Embase, and Cochrane electronic databases was done.

Detection of Factors Related to the Development of Osteochondritis Dissecans in Youth Baseball Players Screening.

On-field screening for 'elbow injury in baseball', a condition commonly seen in youth baseball players, was conducted over two years on 160 elementary school students in Ibaraki Prefecture, Japan. This on-field screening was conducted in collaboration with the Ibaraki Prefecture High School Baseball Federation. Pitchers, catchers, symptomatic players, and players who had previously experienced elbow pain were given a comprehensive evaluation that included a physical exam and ultrasound. Out of the 135 students who were successfully screened, 10 were diagnosed with osteochondritis dissecans of the humeral capitellum (OCD). Notably, seven among these were asymptomatic. This assessment identified limited range of motion and pain when extending their elbow as significant risk factors for OCD. An attempt at on-field screening for baseball elbow injuries in collaboration with the local baseball federation was introduced. The risk factors for OCD were identified. Considering these factors, more efficient screening will be possible in the next attempt.

Surgical approaches to the capitellum: a comparative anatomic study

Osteochondritis dissecans (OCD) of the humeral capitellum is an important cause of elbow disability in young athletes. Large and unstable lesions sometimes require joint reconstruction with osteochondral autograft. Several approaches have been described to expose the capitellum for the purpose of treating OCD. The posterior anconeus-splitting approach and the lateral approach with or without release of the lateral ligamentous complex are the most frequently used for this indication. The surface accessible by these approaches has not been widely studied. This study compared the extent of the articular surface of the capitellum that could be exposed with the Kocher approach (without ligament release) vs. the posterior anconeus-splitting approach. A secondary outcome was the measurement of any additional area that could be reached with lateral ulnar collateral ligament release (Wrightington approach). The 3 approaches were performed on 8 adult cadaveric elbows: first, the Kocher approach; then, the anconeus-splitting approach; and finally, the Wrightington approach. The visible articular surface was marked out after completion of each approach. The mean articular surface of the capitellum was 708 mm2 (range, 573-830 mm2). The mean visible articular surface was 49% (range, 43%-60%) of the total surface with the Kocher approach, 74% (range, 61%-90%) with the posterior anconeus-splitting approach, and 93% (range, 91%-97%) with the Wrightington approach. Although the Kocher approach provided access to the anterior part of the capitellum, the anconeus-splitting approach showed adequate exposure to the posterior three-quarters of the articular surface and overlapped the most posterior part of the Kocher approach. A combination of the 2 lateral ulnar collateral ligament-preserving approaches allowed access to 100% of the joint surface. Most OCD lesions are located in the posterior area of the capitellum and can therefore be reached with the anconeus-splitting approach. When OCD lesions are located anteriorly, the Kocher approach without ligament release is efficient. A combination of these 2 approaches enabled the entirety of the joint surface to be viewed.

Semiquantitative index of symptomatic minor instability of the lateral elbow at CT arthrography (SMILE index): clinical applicability and reproducibility study.

To assess the applicability of a semiquantitative index for symptomatic minor instability of the lateral elbow (SMILE). CT arthrograms of consecutive patients with lateral elbow pain who underwent ultrasound-guided CT arthrography at our orthopedic center between April 2019 and May 2022 were included. Images were acquired at 100 kVp and 80 mAs. An expert radiologist (R1) and a radiology resident (R2) retrospectively performed an independent, blinded evaluation of the arthrograms to assess the presence of imaging findings suggestive of elbow instability. The SMILE index (0-8) was obtained adding (I) radial head chondromalacia (0 - 1); (II) humeral capitellum chondromalacia (0 - 1); (III) humeral trochlear ridge chondromalacia (0 - 1); (IV) annular ligament laxity (0 - 2); (V) synovial thickening (0 - 1); (VI) humeroradial joint asymmetry (0 - 1); and (VII) capsular tear (0 - 1). R1 repeated the assessment after 14days. Cohen's weighted κ statistic and raw concordance were used to appraise reproducibility. Eighty patients (median age 49years, interquartile range 40-53years, 49, 61% males) underwent CT arthrography at our center, and 10 (12%) of them underwent bilateral elbow examination, leading to 90 included CT arthrograms. Median SMILE index was 4 (IQR: 2-5) for R1, 4 (IQR: 2-5) for R2, and 4 (IQR: 2-5) for the second assessment by R1. Intra-reader agreement was excellent (κ = 0.94, concordance 87%), while inter-reader agreement was substantial (κ = 0.75, concordance 67%). The proposed SMILE index showed good reproducibility; further studies are warranted to correlate our index with clinical and surgical data. Our scoring system allows a standardized evaluation of patients with lateral elbow pain and instability suitable for application into clinical practice, complementing the orthopedic surgeon's clinical diagnosis with imaging findings that may aid treatment choices. • Lateral elbow pain is often interpreted clinically as lateral epicondylitis, but it can also encompass intra-articular pathology. • The proposed arthrographic index allows comprehensive quantification of lateral elbow pathology with good reproducibility and application times. • Our index provides the orthopedic surgeon with information regarding intra-articular findings, aiding treatment choices.

Correlations between 3D preoperative planning and postoperative reduction in the osteosynthesis of distal humeral fractures

BackgroundThree-dimensional preoperative planning has been applied to the osteosynthesis of distal humerus fractures. The present study investigated the correlations between 3D preoperative planning and postoperative reduction for the osteosynthesis of distal humerus fractures using 3D parameters.MethodsTwenty-three elbows of 23 distal humerus fracture patients who underwent osteosynthesis with three-dimensional preoperative planning were evaluated. 3D images of the distal humerus were created after taking preoperative CT scans of the injured elbow. Fracture reduction, implant selection, and placement simulations were performed based on 3D images. Postoperative CT images were taken 1 month after surgery. Correlations were evaluated with preoperative plans and postoperative 3D images. The longitudinal axis and coordinates of the humerus were defined on the 3D images. The coronal angle (CA) was defined as the angle formed by the long axis and the line connecting the medial and lateral margins of the trochlea of the humerus on a coronal plane image. The sagittal angle (SA) was defined as the angle formed by the long axis and the line connecting the top of the lateral epicondyle and the center of the humeral capitellum on a sagittal plane image. The axial angle (AA) was defined as the angle between the sagittal plane and the line connecting the medial and lateral margins behind the trochlea of the humerus. The intraclass correlation coefficients (ICC) of each measurement value were assessed between preoperative planning and postoperative images.ResultsPreoperative planning and postoperative measurement values were CA: 85.6 ± 5.9°/85.8 ± 5.9°, SA: 140.9 ± 8.5°/139.4 ± 7.9°, and AA: 84.0 ± 3.1°/82.6 ± 4.9°, respectively. ICCs were CA: 0.75 (P < 0.01), SA: 0.78 (P < 0.01), and AA: 0.34 (P < 0.05), respectively.ConclusionsThe 3D preoperative planning of distal humeral fractures achieved the good correlations of coronal and sagittal angles, but the relatively poor correlation of the axial angle. This may be attributed to an inability to assess the rotation angle during surgery. We propose the measurement indices shown in the present study as a three-dimensional evaluation index for distal humerus fractures.Trial registrationRegistered as NCT04349319 at ClinicalTrials.gov.

Paper 24: Osteochondritis Dissecans of the Capitellum of the Elbow: A Comparison of Non-Operative and Surgical Outcomes at Long-Term Follow-up

Objectives: Osteochondritis dissecans (OCD) of the humeral capitellum is an often painful condition that typically affects the adolescent athlete. There is little consensus on treatment and a scarcity of long-term outcomes data. The purpose of this study was to (1) report the long-term outcomes associated with both operative and non-operative management of capitellar OCD, (2) identify factors associated with failure of non-operative management, and (3) determine whether delay in surgery affects final outcomes. Methods: All patients diagnosed with OCD of the capitellum from 1995-2020 within a defined geographic cohort were included. Medical records, imaging studies, and operative reports were manually reviewed to record demographic data, treatment strategies, and outcomes. Surgical treatment was considered delayed if it occurred more than 6 months after symptom onset. Results: A total of 50 elbows with a mean follow-up of 9.4 years were included. Of these, 7 (14%) were treated non-operatively and never underwent surgery during follow-up, while 43 (86%) underwent surgical intervention: 27 had early surgery and 16 underwent delayed surgery after ≥ 6 months of non-operative treatment. When compared to non-operative management, surgical management resulted in superior MEPI scores (90 vs 83, p=0.05), decreased persistence of mechanical symptoms (9% vs 50%, p&lt;0.01), and better elbow flexion (141° vs 131°, p=0.01) at long-term follow up. Older patients had a trend toward increased failure of non-operative management (p=0.06). The presence of an intra-articular loose body strongly predicted failure of non-operative management (p=0.01; OR 13). Plain radiography and MRI had poor sensitivities for identifying loose bodies (27% and 40%, respectively). Differences in outcomes following early versus delayed surgical management were not demonstrated. Conclusions: Patients with capitellar OCD initially treated nonoperatively failed nonoperative management 70% of the time. Elbows that did not undergo surgery had slightly increased symptoms and decreased functional outcomes compared to those treated surgically. In this cohort, the greatest predictors for failure of non-operative treatment were older age and presence of a loose body; however, an initial trial of non-operative treatment did not adversely impact the success of future surgery at long term follow-up. [Table: see text][Table: see text][Table: see text][Table: see text]

Degree of Accuracy With Which Deep Learning for Ultrasound Images Identifies Osteochondritis Dissecans of the Humeral Capitellum

Background: Medical screening using ultrasonography (US) has been performed on young baseball players for early detection of osteochondritis dissecans (OCD) of the humeral capitellum. Deep learning (DL) and artificial intelligence (AI) techniques are widely adopted in the medical imaging research field. Purpose/Hypothesis: The purpose of this study was to calculate the diagnostic accuracy using DL for US images of OCD. We hypothesized that using DL for US imaging would improve the prediction accuracy of OCD. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: A total of 40 elbows (mean age of patients, 12.1 years) that were suspected of having OCD at a medical checkup and later confirmed by radiographs and magnetic resonance imaging were included in the study. The affected elbows were used as the OCD group and the contralateral elbows as the control group. From US videos, 100 images per elbow were captured from different angles, and 4000 images of the elbows were prepared for both groups. Of these, 80% were randomly selected by DL models and used as training data; the remaining were used as test data. Transfer learning was conducted using 3 pretrained DL models. The confusion matrix and the area under the receiver operating characteristic curve (AUC) were used to evaluate the model, and the visualization of the areas deemed important by the DL models was also performed. Furthermore, OCD regions were detected using an automatic image recognition model based on DL. Results: Classification of the OCD image by the DL model was performed; the best accuracy score was 0.87; the recall was 1.00. AUC was high for all DL models. Visualization of important features showed that AI predicted the presence of OCD by focusing on the irregularity or discontinuity of the surface of subchondral bone. In the detection of OCD task, the mean average precision was 0.83. Conclusion: The DL on US images identified OCD with high accuracy. The important features detected by the DL models correspond to the areas used by clinicians in screening the US images. The OCD was also detected with high accuracy using the object detection model. The AI model may be used in medical screening for OCD.

Radial Head Stress Fracture Nonunion in Adolescent Overhead Athletes: A Case Series

Background: While osteochondritis dissecans of the humeral capitellum is well-described in adolescent overhead athletes, lateral compartment overload may also present with isolated radial head involvement. The primary goals of this study are to present a case series of radial head stress fracture nonunions in adolescent athletes and to provide guidelines regarding surgical indications and treatment. We hypothesize that surgical reduction and fixation of symptomatic lesions is safe, effective, and preserves the stability and articular congruity of the radiocapitellar joint.Methods: We retrospectively reviewed the clinical and radiographic records of nine patients presenting to a pediatric tertiary care center for radial head stress fracture nonunion from January 2008 to December 2016. Patient characteristics, presenting signs and symptoms, clinical and radiographic features, postoperative elbow motion, and radiographic healing were assessed.Results: Nine patients (five female; mean age 12.0 years [range 9.3-14.8 years] at time of injury) were treated for symptomatic radial head stress fracture nonunion. All patients reported persistent elbow pain with activities of daily living (ADLs) and athletics. Seven patients had limited elbow range of motion. Radiographically, the nonunion fragments comprised 20-45% of the radial head articular surface, and five patients had concomitant radial head subluxation. Five patients underwent open reduction internal fixation, one patient underwent microfracture and debridement, and one patient underwent intraarticular corrective osteotomy. All operative patients had improved or complete resolution of pain with ADLs. Additionally, all operative patients had either some increase in or complete regain of full elbow range of motion. Progressive or complete radiographic healing was seen at a median of 14 weeks postoperatively.Conclusions: In this case series, skeletally immature athletes with radial head stress fracture nonunions experienced pain relief, maintained or improved motion, and radiographic bony union following surgical intervention. Radiocapitellar joint stability and congruity were preserved or restored.Level of Evidence: Case series; Level IV Key Concepts•With increased participation in overhead and/or throwing sports, repetitive valgus stress on the elbow may lead to lateral compartment overload injuries.•While osteochondritis dissecans (OCD) of the capitellum is well-characterized, isolated radial head stress injuries may also occur.•Surgical treatment for symptomatic or displaced radial head stress injuries may provide pain relief, bony healing, improved range of motion, and return to sports.•Patients, families, and providers should be aware of this clinical condition, and surgical treatment should be considered in cases of persistent pain, bony nonunion, displacement, joint instability and/or incongruity.

Physical functions, to be or not to be a risk factor for osteochondritis dissecans of the humeral capitellum?

Physical risk factors for osteochondritis dissecans (OCD) of the humeral capitellum in young baseball players have not been fully elucidated. We aimed to identify the risk factors for capitellar OCD in baseball players aged 8-14 years. Between December 2018 and December 2019, young baseball players were recruited from 8 regional baseball leagues. Ultrasonography and physical assessments were performed preseason and at the end of the study period. Bilateral passive ranges of motion (ROM) of horizontal adduction of the shoulders, internal rotation (IR) of the hips, and the thoracic kyphosis angle were measured. 1-year follow-ups were scheduled to determine the occurrence of OCD. Players with OCD were categorized into an OCD group; those without OCD and any elbow pain for one year were categorized into a non-injured group. The players' baseline data (age, sex, position in baseball, and Rohrer's Index) were analyzed using univariate analyses. Their physical parameters were analyzed using two-way analysis of variance with repeated measures to investigate OCD-related risk factors. In total, 3651 baseball players attended the 1-year follow-up. Of these, 71 (1.9%) players had OCD of the humeral capitellum. In the OCD group, a significant association was found at baseline and at the end of the study period between a higher Rohrer index at the baseline and a smaller hip IR ROM on the nondominant side. Loss of hip IR ROM on the nondominant side is a newly discovered risk factor related to physical function in the development of OCD.

Use of a Small Car-Mounted Magnetic Resonance Imaging System for On-Field Screening for Osteochondritis Dissecans of the Humeral Capitellum.

Mobile magnetic resonance imaging (MRI) using a car is a recent advancement in imaging technology. Specifically, a car-mounted mobile MRI system is expected to be used for medical check-ups; however, this is still in the research stage. This study demonstrated the practicality of a small car-mounted mobile MRI in on-field screening for osteochondritis dissecans (OCD) of the humeral capitellum. In the primary check-up, we screened the throwing elbows of 151 young baseball players using mobile MRI and ultrasonography. We definitively diagnosed OCD at the secondary check-up using X-ray photography and computed tomography or MRI. We investigated the sensitivity and specificity of mobile MRI and ultrasonography for OCD. Six patients were diagnosed with OCD. The sensitivity was 83.3% for mobile MRI and 66.7% for ultrasonography, with specificity of 99.3% vs. 100%, respectively. One patient was detected using ultrasonography but was missed by mobile MRI due to poor imaging quality at the first medical check-up. Following this false-negative case, we replaced a damaged radio frequency coil to improve the image quality, and the mobile MRI could detect all subsequent OCD cases. Two patients were diagnosed by mobile MRI only; ultrasonography missed cases lacking subchondral bone irregularity, such as a healing case, and an early-stage case. Mobile MRI could screen for OCD from the very early stages through the healing process and is therefore a practical tool for on-field screening.