Unstable Osteochondritis Dissecans Lesions Research Articles

Osteochondral Allograft Transplantation for the Unstable Capitellar Osteochondritis Dissecans Lesion: An Anconeus Preserving Approach

Background: Osteochondritis dissecans (OCD) of the capitellum can be a disabling condition that typically affects adolescent, overhead athletes. To date, a variety of different surgical treatment options have been described. Indications: Surgical indications for osteochondral allograft transplantation (OCA) for capitellar OCD lesions include failure of nonsurgical management or prior surgery and unstable, full-thickness lesions of almost any size affecting both bone and cartilage. The anconeus preserving approach specifically provides wide access to nearly the entire capitellum and can be used for lesions in almost any location. Technique Description: The anconeus preserving approach for OCA utilizes the interval between the anconeus and the ulna. With the patient positioned supine and the elbow flexed on an arm table, an incision is made approximately 1 cm lateral to the olecranon and is carried down to the fascia. Electric cautery is used to dissect the interval between the ulna and the anconeus. The anconeus is elevated off the ulna and retracted laterally to expose the underlying joint capsule. An L-shaped capsulotomy is performed over the center of the capitellum, just proximal to the annular ligament of the radial head. A pin is placed into the center of the lesion, perpendicular to the capitellum. A cannulated reamer 0.5 mm smaller than the lesion is used to ream the lesion to a depth of approximately 5 mm. Depth measurements are taken at all 4 poles of the defect. About 3 cc of bone marrow aspirate harvest is then obtained from the ulna using a cannulated needle. The oscillating saw is used to cut the graft to size using the prior measurements. The bone marrow aspirate is placed onto the osseous side of the graft before the osteochondral graft is impacted into the recipient site. The capsulotomy is then closed, and the anconeus is repaired back to the ulna. Postoperatively, patients begin range of motion as soon as tolerated, initiate strengthening at 6 weeks, and initiate return-to-sport programming at 3 months. Results: Lesions treated with OCA typically demonstrate improvement in all outcome measures, including functional scores, graft incorporation, articular surface congruity, and return-to-sport. Complications and graft failure is rare. Discussion/Conclusion: OCA using an anconeus preserving approach is a reliable option for surgical management of unstable OCD lesions. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Internal Fixation of Unstable Osteochondritis Dissecans of the Knee: Long-term Outcomes in Skeletally Immature and Mature Patients

Background: Osteochondritis dissecans (OCD) is a disorder originating in the subchondral bone, leading to focal lesions with risk of fragmentation and secondary damage of the articular cartilage. It remains controversial if surgical treatment of such lesions is equally successful in skeletally immature and mature patients. Purpose: To determine (1) the long-term clinical success rate after internal fixation of unstable OCD in skeletally immature and mature patients based on physeal status, (2) if patient-specific and procedural variables influence the risk of failure, and (3) patient-reported outcome measures over time. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective cohort study was conducted investigating skeletally immature and mature patients treated for unstable OCD lesions of the knee between 2000 and 2015. The healing rate was assessed by radiological imaging and clinical follow-up. Failure was defined as any definitive reoperation for the initially treated OCD lesion. Results: A total of 81 patients met inclusion criteria, including 25 skeletally immature patients and 56 patients with closed physes at the time of surgery. After a mean follow-up time of 11.3 ± 4 years, 58 (71.6%) patients had healed lesions, whereas the lesions failed to heal in 23 (28.4%) patients. No significant difference in risk of failure was observed based on physeal maturation status (hazard ratio, 0.78; 95% CI, 0.33-1.84; P = .56). Lateral versus medial condylar lesion location conferred an increased risk of failure (P < .05) for both skeletally immature and mature patients. Multivariate analysis of skeletal maturity status showed that a lateral femoral condylar location was an independent risk factor for failure (hazard ratio, 0.22; 95% CI, 0.1-0.5; P < .05). The mean patient-reported outcome scores (International Knee Documentation Committee [IKDC] score and Knee injury and Osteoarthritis Outcome Score [KOOS]) increased significantly after surgery and remained high at the final follow-up (P < .05). The final scores (mean ± SD) at a mean follow-up of 135.8 months (range, 80-249 months) were IKDC, 86.6 ± 16.7; KOOS Pain, 88.7 ± 18.1; KOOS Symptoms, 89.3 ± 12.6; KOOS Activities of Daily Living, 89.3 ± 21.6; KOOS Sport and Recreation, 79.8 ± 26.3; and KOOS Quality of Life, 76.7 ± 26.3. Conclusion: The long-term results after internal fixation of OCD fragments show high rates of healing and sustainable subjective improvement of knee function and quality of life. A healing rate of 72% was noted at a mean follow-up of 11.3 years. The stage of skeletal maturity had no significant influence on the rate of failure. Lateral femoral condylar lesion location is an independent risk factor for failure in skeletally mature and immature patients.

Knee osteochondritis dissecans-treatment technical aspects

Purpose and objectiveCurrent treatments of different stages of knee osteochondritis Dissecans (OCD) are depending on the age of the patients and the stability of the diseased osteochondral area. The purpose of this paper was to summarize the treatment alternatives in order to simplify the choice for the treating surgeon. Background and principle resultsOsteochondritis dissecans (OCD) of the knee is an idiopathic and local osteochondral abnormality that affects mainly children and adolescents with risk of loosening of osteochondral fragments. A good clinical result can be expected when the physes are still open, when the osteochondritis is small and when the osteochondritis can be assessed as stable by MRI. Unstable OCD lesions most often need to be treated operatively by different fixation methods and when the osteochondral cannot be refixated, different local chondral and osteochondral repairs are available to fill up the defect area to congruity Summary and major conclusionsThe final choice of which treatment to use is depending on fragment viability and forms. Viable fragments are refixated while poor quality fragments are removed followed by a local biological osteochondral repair. Such osteochondral resurfacing may be single bone marrow stimulation with or without scaffold augmentation or different cell seeded grafts.

Internal Fixation of Lateral Trochlear Groove Osteochondritis Dissecans With Simultaneous Lateral Retinacular Lengthening in Adolescent Athletes

Background: The goals of operative treatment for the adolescent athlete with unstable osteochondritis dissecans (OCD) lesion are rigid fixation and prevention of recurrence. Purpose: To evaluate clinical and radiological outcomes of internal fixation of lateral trochlear groove OCD with simultaneous lateral retinacular lengthening. Study Design: Case series; Level of evidence, 4. Methods: Adolescent athletes who had undergone internal fixation and simultaneous lateral retinacular lengthening for an unstable OCD lesion of the lateral trochlear groove were retrospectively reviewed. Subjective assessments included the Lysholm score, International Knee Documentation Committee (IKDC) subjective score, Tegner activity scale, and an athletic questionnaire. Functional tests included isokinetic muscle strength, single-leg hop for distance, single-leg vertical jump, and Y-balance. Pre- and postoperative radiographs and magnetic resonance images were reviewed. Results: The mean ± SD age of the 17 patients included in this study was 15.9 ± 0.9 years; last clinical follow-up duration was 37.7 ± 8.1 months. At the last follow-up, the Lysholm score improved from 68.7 ± 15.3 to 93.4 ± 12.4 and the IKDC subjective score from 60.2 ± 14.7 to 88.7 ± 12.7 (P < .001). The mean Tegner activity scale score was 9.4 ± 0.5 before injury and 8.9 ± 1.2 at the last follow-up (P = .059). The limb symmetry indices of isokinetic muscle strength, single-leg hop for distance, single-leg vertical jump, and Y-balance improved at the last follow-up; the mean limb symmetry index was ≥85% in each functional test. Regarding the athletic questionnaire, 16 (94.1%) patients were satisfied with the surgery. At the last follow-up, 2 patients had higher ability after returning to sports, 11 had the same ability, and 3 had lower ability than the preinjury level. Postoperative magnetic resonance imaging at 12-month follow-up showed that the OCD lesion appeared healed in 7 (41.2%) patients and partially healed in 9 (52.9%). Conclusion: Internal fixation of lateral trochlear groove OCD with simultaneous lateral retinacular lengthening in adolescent athletes achieved satisfactory clinical and radiological outcomes. Therefore, this combined surgical technique could be considered an effective treatment for lateral trochlear groove OCD, with a high rate of return to sport.

Osteochondritis Dissecans of the Knee: Pearls and Pitfalls of Anatomical Reduction and Secure Fixation

Osteochondritis dissecans of the knee is characterized by sterile necrosis of the subchondral bone and typically affects skeletally immature patients. When left untreated, osteochondritis dissecans can lead to early-onset osteoarthritis, resulting in pain and disability. This study shows the pearls and pitfalls of an arthroscopic technique of fixation performed successfully using a bioabsorbable nail for unstable osteochondritis dissecans lesions located in the medial femoral condyle of the knee.

Safety and performance of biodegradable magnesium-based implants in children and adolescents

AimsBiodegradable magnesium-based alloy implants represent a promising option in orthopedic surgery, as the clinical outcomes have been reported to be comparable to those of titanium implants and no surgical interventions are required for removal. To date, little is known about the results of the use of these implants in children and adolescents. Therefore, the aim of the present study was to analyze the safety and performance of these implants in children and adolescents. Patients and MethodsEighty-nine patients treated with magnesium-based implants for fracture stabilization, osteotomy and osteochondral refixation were analyzed; 38 were treated by osteosynthesis; 18, osteotomy; and 33, osteochondral refixation. The mean follow-up duration was 8.2 months (range, 1.5–30 months). Clinical and radiographical follow-up examinations were performed at 4–8 weeks and 3–6 months, respectively, to evaluate implant performance and osseous consolidation. ResultsClinical outcomes were rated as good to very good in all patients. Radiolucent zones were apparent after surgery in all patients but were noted to decrease in size during the follow-up period. Revision surgery was necessary in 1 of 89 patients who had a highly unstable osteochondritis dissecans lesion of the knee. None of the magnesium-based implants required surgical removal. ConclusionMagnesium-based implants in children and adolescents results in good clinical outcomes when used for fracture stabilization, osteotomy and osteochondral defect refixation. Future studies are needed to further analyze the significance of the transient appearance and temporal development of radiolucent zones in the growing skeleton as well as the long-term performance of these implants.

Comparison Between Osteochondral Autograft Transplantation and Arthroscopic Fragment Resection for Large Capitellar Osteochondritis Dissecans in Adolescent Athletes: A Minimum 5 Years’ Follow-up

Background: The choice of surgical option for unstable large capitellar osteochondritis dissecans (OCD) lesions in skeletally immature athletes remains controversial. Purpose/Hypothesis: The purpose was to investigate functional and radiographic outcomes after arthroscopic fragment resection and osteochondral autograft transplantation (OAT) for unstable large capitellar OCD lesions in skeletally immature athletes with a minimum 5 years’ follow-up. We hypothesized that the outcomes after OAT for large capitellar OCD lesions would be superior to those after arthroscopic fragment resection. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 19 elbows in 19 patients (17 male and 2 females) who underwent arthroscopic resection were assigned to group 1 (mean age, 14 years [range, 13-15 years]), whereas 29 elbows in 29 patients (29 male) who underwent OAT were assigned to group 2 (mean age, 14 years [range, 13-15 years]), with the mean follow-up of 8 (range, 5-11 years) and 7 (range, 5-13 years) years, respectively. All OCD lesions were larger than one-half of the radial head diameter. Functional scores, patient satisfaction, and range of motion were compared between the groups. Radiographic changes, including superior migration, radial head enlargement, and osteoarthritis (OA) grade, were examined. Results: All patients returned to sports activity. Functional scores, patient satisfaction, and flexion at the final follow-up were significantly improved in both groups compared with preoperative values, and differences were not significant between groups at the final follow-up. Extension showed a significant improvement in both groups (group 1: –17° to 0°; group 2: –18° to −6°; P < .001). Extension in group 1 was significantly better than that in group 2 at the final follow-up (P = .045). No elbows developed postoperative severe OA in group 1, whereas 3 elbows in group 2 had grade 3 OA; these 3 elbows had preoperative superior migration and radial head enlargement. Conclusion: No differences were observed in clinical and radiographic outcomes between patients undergoing arthroscopic fragment resection and OAT, except for elbow extension, at a minimum 5 years’ follow-up. We believe that for adolescents with large capitellar OCD lesion, OAT is a good option for skeletally immature elbows and that arthroscopic fragment resection is a reliable and less invasive surgical option for relatively mature elbows.

Internal Fixation of Osteochondritis Dissecans Using PushLock Suture Anchors

Osteochondritis dissecans (OCD) of the knee is a subchondral bone abnormality that results in the separation of the articular cartilage and bone with subsequent progression to osteoarthritis. Unstable OCD lesions should undergo fixation to preserve the natural contour of the articular surface. Although several fixation procedures have been reported, the appropriate procedure remains unknown. Because the bony portion of the OCD lesion is usually thin, it is difficult to fix firmly with conventional methods. We began fixing OCD lesions with knotless PushLock anchors and sutures and have obtained satisfactory results. This report describes this fixation method that uses the PushLock suture anchor to treat unstable OCD lesions. This procedure also can be applied for traumatic osteochondral fractures.

Bioabsorbable Unsintered Hydroxyapatite/Poly-l-Lactic Acid Pin Fixation of Osteochondritis Dissecans in Adolescents: Initial Experiences.

This study sought to retrospectively evaluate the clinical and magnetic resonance imaging (MRI) outcomes of u-HA/PLLA pin (u-HA/PLLA: hydroxyapatite/poly-L-lactic acid) pin fixation of unstable osteochondritis dissecans (OCD) lesions of the knee. Seven adolescent patients (four females and three males) with arthroscopically unstable OCD lesions of the knee were included. The mean age at diagnosis was 13.1 years. Clinical results were evaluated preoperatively and during follow-up using the Ogilvie-Harris score (0 - 15 points). MRI scans were performed preoperatively and during follow-up, with results evaluated using the Dipaola classification (grades 1 - 4). Mean follow-up time was 29 months. The median Ogilvie-Harris score improved from 13 points (range: 10 - 14 points) to 15 points (range: 13 - 15 points). Separately, the median Dipaola score improved from 3 points (range: 2 - 4 points) to 1 point (range: 1 - 4 points). No complications such as infection, synovitis, or intra-articular adhesion were observed. Initial experiences using bioabsorbable u-HA/PLLA pins for the refixation of unstable OCD lesions in adolescents in the knee are promising, and MRI provides excellent monitoring of healing.

Fixation of Unstable Osteochondritis Dissecans Lesions and Displaced Osteochondral Fragments Using New Biodegradable Magnesium Pins in Adolescents.

Fixation of unstable osteochondritis dissecans (OCD) lesions and displaced osteochondral fragments are frequently performed procedures in pediatric orthopedic surgery. Since 2018, CE-certified MAGNEZIX pins are used in our institution in these cases. The aim of this study was (1) to analyze safety, efficiency, and limitations of magnesium-pin-based fixation of unstable OCD lesions and displaced osteochondral fragments and (2) to report clinical and radiological outcomes at short-term follow-up (FU). In this prospective cohort study, 19 patients (10 girls and 9 boys) were included. Inclusion criteria were (1) magnetic resonance imaging-confirmed unstable OCD lesion or displaced osteochondral fragment, (2) fixation with magnesium-based pins, and (3) minimum FU of 6 months. X-rays were taken 6 weeks and 6 months after operation and magnetic resonance imaging scans every 4 to 6 months to assess the healing progress. In total 67 pins were used, with a mean of 3.6 ± 1.4 per patient. Average age at surgery was 13.7 years (11-17 years). Mean time of operation was 56 ± 31 minutes, including arthroscopy, fixation, and patellar realignment (n = 6). No intraoperative complications occurred. Average FU was 11.3 ± 4.2 months (6-20 months). No redislocation or new dislocation occurred. Until now a complete radiographic healing occurred in 12 cases. Due to an implant failure in one case 11 weeks after the index surgery a revision became necessary. In short-term FU of 11 ± 4 months MAGNEZIX pins provide high stability after fixation of unstable OCDs and displaced osteochondral fragments leading to uncomplicated and timely healing.

Osteochondritis Dissecans of the Elbow in Children: MRI Findings of Instability.

OBJECTIVE. The purpose of this study was to investigate the performance of MRI criteria for predicting instability of osteochondritis dissecans (OCD) lesions of the elbow in children. MATERIALS AND METHODS. This retrospective study included 41 children with 43 OCD lesions of the elbow who underwent an MRI examination between April 1, 2010, and May 31, 2018. Two radiologists blinded to clinical outcomes reviewed MRI studies to determine the presence or absence of joint effusion, osteochondral defect, intraarticular body, overlying cartilage changes, subchondral bone disruption, rim of high signal intensity on T2-weighted images, cysts, marginal sclerosis, and perilesional bone marrow edema. The stability of OCD lesions was determined with clinical follow-up and surgical findings as reference standards. Mann-Whitney U, chi-square, Fisher exact, and Cochran-Armitage tests were used to compare MRI findings between stable and unstable OCD lesions. RESULTS. There were 20 stable and 23 unstable OCD lesions. An osteochondral defect (p = 0.01), intraarticular body (p < 0.001), overlying cartilage changes (p = 0.001), subchondral bone plate disruption (p = 0.02), and hyperintense rim (p = 0.01) were significantly more common in unstable than stable OCD lesions. However, only osteochondral defect and intraarticular body were 100% specific for OCD instability. There was no significant difference between stable and unstable OCD lesions in the presence of joint effusion (p = 0.10), cysts (p = 0.45), marginal sclerosis (p = 0.70), or perilesional bone marrow edema (p = 1.00). CONCLUSION. MRI findings of OCD instability of the elbow include an osteochondral defect, intraarticular body, overlying cartilage changes, subchondral bone disruption, and rim of high signal intensity on T2-weighted MR images.

Osteochondral Autograft Transportation vs Arthroscopic Fragment Resectionfor Large Capitellar Osteochondritis Dissecans in Adolescent Athletes - A Minimum of 5-year Follow-up

Objectives: Small capitellar osteochondritis dissecans (OCD) lesions have shown excellent functional and radiographic outcomes after arthroscopic (AS) fragment resection in previous studies. However, surgical options for unstable large capitellar OCD lesions in skeletally immature athletes remains controversial. Before 2007, we exclusively performed AS fragment resection for all inviable lesions regardless of lesion size. However, we initiated to perform osteochondral grafting for selected larger lesions in the year of 2007. The purpose of this study is to investigate functional outcomes and radiographic changes after osteochondral grafting and AS fragment resection for unstable large capitellar OCD lesions(&gt;1/2 radial head diameter) in skeletally immature athletes with a minimum of 5-years follow-up. Methods: Group 1 consisted of 19 elbows in 19 patients (19 males; 16 baseball, 2 badminton and 1 gymnastics) that underwent osteochondral grafting for capitellar OCD (mean age, 14; range, 13-15), and the mean follow-up was 8 years (range; 5-11). Group 2 consisted of 21 elbows in 19 patients (17 males and 2 females; 16 baseball, 2 gymnastics and1 handball) that underwent AS fragment resection (mean age, 14. range, 13-15), and the mean follow-up was 8 years (range, 5-10). Preoperatively, the mean transverse diameter of lesions was 13 mm (range, 11-14) in Group 1 and 13 mm (range, 10-16) in Group 2. Superior migration of the radial head (&gt;2-mm side-to-side difference) was seen in four elbows in Group 1 and one elbow in Group 2. Radial head enlargement with more than 20% of the contralateral side was seen in seven elbows in Group 1 and one elbow in Group 2. Functional scores (JOA score, DASH score and patient satisfaction), range of motion (ROM), and radiographic findings including Kellgren-Lawrence osteoarthritis (OA) grade were evaluated and compared between the groups. Results: All patients returned to sports activity. Functional scores at the final follow-up were not different between Group 1 and 2: JOA score, 90 (range, 68-100) vs 91 (range, 82-100); DASH score, 1 (range, 0-7) vs 3 (range, 0-14); Patient satisfaction, 84 (range, 50-100) vs 81 (range, 50-100). Flexion ROM at the final follow-up did not show significant improvement in both groups compared to preoperative values, though there was a significant difference at the final follow-up between the groups: Group 1, 133º (range, 115-150º); Group 2, 133º (range, 120-145º). Extension ROM showed significant improvement in both groups (P&lt;.001 for both): Group 1, -18º (range, -35-0º) to -8º (range, -22-10º); Group 2, -17º (range, -50-0º) to 0º (range, -10-20º). Group 2 had significantly better extension than Group 1 at the final follow-up (P =.003). OA change progressed in 12 elbows (63%) in Group 1 and in 9 elbows (47%) in Group 2. There were four grade 3 OA elbows in Group 1, which preoperatively had superior migration and enlargement of the radial head. No elbows showed severe OA change in Group 2. Conclusion: Functional outcomes and radiological findings after both osteochondral grafting and AS fragment resection for unstable large capitellar OCD lesions in adolescent athletes were satisfactory with a mean follow-up of 8 years. However, grade 3 OA were seen after osteochondral grafting in four elbows with preoperativesuperior migration of the radial head. Osteochondral grafting should be performed before radiographical changes become severe.

Open Reduction, Bone Grafting, and Internal Fixation of Osteochondritis Dissecans Lesion of the Knee.

Osteochondritis dissecans (OCD) of the femoral condyle is an idiopathic focal bone abnormality affecting the subchondral bone and can result in unstable osteochondral lesions. The treatment of unstable OCD lesions with open reduction and internal fixation with metallic compression screws is well documented in the literature. Fixation is performed to prevent dislodgement of unstable OCD lesions or fix displaced fragments that have been surgically reduced. The procedure is performed by approaching the knee through a midline incision and medial parapatellar arthrotomy. The lesion is identified, and a scalpel is used to incise the cartilage circumferentially, leaving 1 side intact, to create a "trap door" flap. The OCD fragment is lifted from the bed, and the bed is prepared by debriding the fibrocartilage scar and bone-grafting the bed. The osteochondral fragment is reduced back to the bed, and guidewires are placed to secure the reduction and plan screw trajectories. Guide pins are overdrilled and Herbert compression screws are placed to secure the OCD fragment. The wound is irrigated and closed. Complications are rare, but later screw removal is typically recommended. Reported outcomes are satisfactory, with an 80% rate of radiographic healing and good-to-excellent patient-reported outcomes.

Treatment of unstable knee osteochondritis dissecans in the young adult: results and limitations of surgical strategies-The advantages of allografts to address an osteochondral challenge.

Joint surface incongruence resulting from osteochondritis dissecans (OCD) alters the articular physiologic congruence, increasing the contact stress on adjacent joint surfaces and accelerating wear and the cascade of joint degeneration. Accordingly, the restoration of articular surface integrity is of major importance, especially in young adults where, in lesions left untreated or following simple fragment excision, early osteoarthritis can be anticipated. Therefore, the treatment algorithm in unstable knee OCD of the young adult foresees surgical options to restore the articular surface. Several procedures have been proposed, including refixation of the detached fragment bone marrow stimulation, osteochondral autograft implantation, fresh osteochondral allograft transplantation, and cell-based or cell-free regenerative techniques. The aim of this review was to summarize the evidence for these surgical strategies, reporting their results and limitations. The overall evidence documents positive results for each of the assorted surgical procedures applied to treat unstable OCD, thus indicating support for their selected use to treat osteochondral defects paying particular attention to their specific indications for the lesion characteristics. The fixation of a good quality fragment should be pursued as a first option, while unfixable small lesions may benefit from autografts. For large lesions, available cell-based or cell-free osteochondral scaffold are a feasible solution but with limitation in terms of regenerated tissue quality. In this light, fresh allografts may offer articular surface restoration with viable physiologic osteochondral tissue providing a predictably successful outcome, and therefore they may currently represent the most suitable option to treat unstable irreparable OCD lesion in young adults. LEVEL OF EVIDENCE: V.

The Treatment of Adult Osteochondritis Dissecans with Autologous Cartilage Implantation: A Systematic Review.

We sought to evaluate the effectiveness of autologous chondrocyte implantation (ACI) for the treatment of adult osteochondritis dissecans (OCD) lesions according to patient-reported outcomes, complication rates, and failure rates. A search of MEDLINE, Scopus, and Cochrane Library was performed to identify clinical studies (levels I-IV) reporting outcomes after ACI treatment for OCD in adult knees. Our inclusion criteria included the following: (1) published between January 2000 and April 2017, (2) stable and unstable OCD lesions of the knee, (3) use of ACI in at least one group, (4) subjects ≥18 years old or skeletally mature, (5) inclusion of at least one patient-reported clinical outcome measure, and (6) written in English. A total of nine studies (179 patients), mean age of 27.6 years (range: 18-49 years), were included. There were 227 OCD lesions with an average size of 4.1 cm2 (range: 1.2-9.4 cm2). The average follow-up was 61.3 months (range: 6.5-120 months). In general, there was significant improvement in symptoms, but better results occurred among active male patients with smaller lesions as well as younger patients. Statistically significant improvement in patient-reported outcomes was reported in all studies. There were 23 complications reported (15.6%), including 12 failures (8.2%). Significant improvement in clinical outcome measures demonstrates clinical efficacy of autologous cartilage therapies for the treatment of OCD in adult patients. Better outcomes are often observed with males, active patients, smaller lesion sizes, and younger age at the time of surgery.

A Magnetic Resonance Imaging-Based Staging System for Osteochondritis Dissecans of the Elbow: A Validation Study Against the International Cartilage Repair Society Classification.

Background:Evaluations of the stability of osteochondritis dissecans (OCD) lesions of the elbow using magnetic resonance imaging (MRI) have resulted in reports with variable accuracy. Therefore, the International Cartilage Repair Society (ICRS) classification remains the gold standard to determine OCD lesion stability. Because OCD commonly occurs in pediatric patients, a noninvasive method comparable with the ICRS classification is desired.Hypothesis/Purpose:Based on the previous literature, the capitellum of unstable OCD lesions has an irregular outline on MRI because of displacement or dislocation of the lesion via synovial fluid inflow. Therefore, we defined a 4-stage classification, similar to the ICRS classification, which focused on the outline of the capitellum and articular cartilage status on MRI without subchondral bone information. The purpose of this study was to validate this MRI-based staging system against the ICRS classification and to verify its accuracy in diagnosing unstable OCD lesions of the elbow.Study Design:Cohort study (diagnosis); Level of evidence, 2.Methods:A total of 81 patients with OCD of the elbow who were surgically treated were evaluated. The MRI-based stages were as follows: stage 1, normal-shaped capitellum and articular cartilage without signal intensity change; stage 2, normal-shaped capitellum and articular cartilage with signal intensity change; stage 3, irregular-shaped capitellum and discontinuity of the articular cartilage; and stage 4, dislocated lesion with an articular cartilage defect. Agreement between the MRI and ICRS classifications was evaluated, and the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for lesion instability were determined. The intraclass correlation coefficient (ICC) for intrarater and interrater reliability of the MRI-based staging system was calculated.Results:Agreement between the MRI-based staging system and the ICRS classification was 88.9%, with a sensitivity of 98.4%, specificity of 84.2%, PPV of 95.3%, and NPV of 94.1% for diagnosing an unstable lesion. The ICC was high for both intrarater (0.925) and interrater (0.915-0.939) reliability.Conclusion:The MRI-based staging system corresponded well with the ICRS classification, providing an accurate preoperative assessment of OCD lesions of the elbow, even with minimal subchondral bone information.

Internal Fixation of Unstable Osteochondritis Dissecans: Do Open Growth Plates Improve Healing Rate?

Background: Osteochondritis dissecans (OCD) is a disorder of unknown origin that can affect knees in skeletally mature and immature patients. Surgical management is an important cornerstone of treatment for unstable OCD lesions. Purpose: To determine the (1) healing rate after internal fixation of unstable OCD between skeletally immature and mature knees, (2) risk factors for failure, and (3) patient-reported outcomes among healed patients. Study Design: Cohort study; Level of evidence, 3. Methods: A multicenter retrospective cohort study was conducted with patients who underwent internal fixation of unstable knee OCD lesions from 2000 to 2015. Skeletal immaturity was defined as open or partially open physes. Healing was assessed through clinical findings and imaging. Definitive reoperation for the same OCD lesion was classified as failure. Results: Among 87 patients included, 66 (76%) had healed lesions at ≥2 years postoperatively, while 21 (24%) failed. Skeletal maturity made no significant difference in failure rate (risk ratio, 0.68; 95% CI, 0.29-1.72; P = .40). For skeletally immature patients, lateral versus medial condylar location conferred an increased hazard of 18.2 (95% CI, 1.76-188.07; P < .01). Multivariate analysis factoring in skeletal maturity showed that lateral condylar location was an independent risk factor for failure (hazard ratio, 4.25; 95% CI, 1.47-19.85; P < .01). Mean patient-reported outcome scores (International Knee Documentation Committee [IKDC] and Knee injury and Osteoarthritis Outcome Score [KOOS]) increased significantly after surgery, except the KOOS symptoms score for the skeletally mature group. Final scores (mean ± SD) were as follows at a mean follow-up of 60 months (range, 24-166): IKDC, 83.5 ± 20.2; KOOS pain, 89.7 ± 14.1; KOOS symptoms, 87.4 ± 18.4; KOOS activities of daily living, 93.9 ± 12.7; KOOS sports, 80.7 ± 25.9; KOOS quality of life, 78.9 ± 23.1. Conclusion: Skeletally immature and mature patients heal at comparable rates after internal fixation of OCD lesions, resulting in functional and subjective improvement. Lateral femoral condylar lesion location is an independent risk factor for failure.

Elbow Injuries in the Adolescent Thrower.

With an increasing rate of adolescent elbow injuries, especially in throwing athletes, the purpose of this review is to investigate the current literature regarding the diagnosis, treatment, and non-operative and operative outcomes of medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures. Acceptable outcomes with both non-operative and operative treatments of medial epicondyle fractures have been reported, with surgical indications continuing to evolve. Unstable osteochondritis dissecans lesions, especially in patients with closed growth plates, require operative fixation, and emerging open and arthroscopic techniques including lesion debridement, marrow stimulation, autograft transfer, and allograft transplantation are described with good outcomes. Ulnar collateral repair has emerged as an exciting treatment option for an avulsion of either end of the ligament in young throwing athletes, with faster rehabilitation times than traditional ulnar collateral ligament reconstruction. Olecranon stress fractures are increasing in prevalence, and when a non-operative treatment course is unsuccessful, athletes have a high return-to-play rate after percutaneous cannulated screw placement. With proper indications, non-operative and operative treatment modalities are reported with a high return-to-play and acceptable clinical outcomes for common elbow injuries, including medial epicondyle fractures, ulnar collateral ligament repair, osteochondritis dissecans of the elbow, and olecranon stress fractures, in adolescent throwing athletes. Further research is needed to better define treatment algorithms, surgical indications, and outcomes.

Anconeus Muscle-Pedicle Bone Graft With Periosteal Coverage for Osteochondritis Dissecans of the Humeral Capitellum.

Background:Treatment of advanced osteochondritis dissecans (OCD) of the capitellum is controversial, especially in moderate-sized lesions.Purpose:To establish a treatment algorithm for capitellum OCD, we tried to determine the utility of and problems associated with anconeus muscle-pedicle bone graft with periosteal coverage (ABGP) for the treatment of moderate-sized articular OCD defects of the capitellum.Study Design:Case series; Level of evidence, 4.Methods:According to our protocol for elbow OCD, 16 patients (15 males, 1 female; age range, 12-17 years; mean age, 14.4 years) with a moderate-sized OCD lesion of the humeral capitellum were treated with ABGP. All patients had a full-thickness, unstable OCD lesion that was 10 to 15 mm in diameter. Clinical results and postoperative images, including radiographs and magnetic resonance imaging (MRI), were evaluated at a mean follow-up of 31 months (range, 24-66 months).Results:All but 1 patient had functional improvement after the procedure and returned to previous sporting activities within 6 months. One female patient needed 1 year for functional recovery due to development of postoperative chronic regional pain syndrome (CRPS). Two patients required additional surgery, including shaving of the protruding cartilage, and they returned to their previous level of activity. Mean arc of range of flexion-extension motion was 117° preoperatively and 129° at follow-up (P = .031). Mean elbow function as assessed with the clinical rating system of Timmerman and Andrews was 136 preoperatively and 186 at follow-up (P = .00012). Bony union of the graft as demonstrated by trabecular bone bridging on radiography was obtained within 3 months in all patients. Postoperative MRI was examined for 14 patients at 6 to 12 months after the procedure; the MRIs showed near-normal articular surface integrity in 9 of the 14 patients (64%) and underlying bony structure in 10 of the 14 patients (71%).Conclusion:Improvement after ABGP was obtained within 6 months in all except 1 patient, who developed CRPS. Postoperative radiography and MRI revealed near-normal articular surface integrity or underlying bony structure. This procedure is useful as a surgical option for a moderate-sized articular OCD lesion in the elbow.

Muscle-pedicle Bone Grafting With Periosteum Coverage for Osteochondritis Dissecans

Objective/Hypothesis: There are several treatment options for osteochondritis dissecans (OCD) of humeral capitellum. In a previous study, we reported muscle-pedicle bone grafting with periosteum coverage for OCD. The purpose of the current study was to review the results of this surgery. Materials and Methods: Eight patients who underwent muscle-pedicle bone grafting with periosteum coverage for OCD between 2011 and 2015 were reviewed retrospectively. The surgical technique is as follows: Unstable OCD lesion was debrided. Cuboid bone graft with the anconeus muscle pedicle was harvested from the posterior side of the capitellum. When obtaining the bone graft, extra periosteum was also obtained and kept attached to the bone graft. Bone tunnel was created from the harvested site to the debrided site. The bone graft was covered with the attached periosteum and inserted through the tunnel. The periosteum edge of the inserted graft was sutured with cartilage around the debrided site. The patients were placed in a long-arm splint for 2 to 3 weeks, followed by gentle mobilization. Gradual return-to-play program was started after radiographic signs of healing. Patients were usually allowed to recover to full sports activity around 6 months after surgery. The medical records of the 8 patients were reviewed for the following information: (1) sports and position; (2) preoperative and final range of motion; (3) duration from surgery to return to sports activity; (4) radiographic outcomes, including size of OCD lesion, grafted bone union, and enlargement of the radial head; and (5) complications. Enlargement of the radial head was defined as an increase in the diameter of more than 20% between preoperative and final anteroposterior radiographs. Results: Eight elbows in 8 patients (7 male and 1 female) with a mean age of 14 years (range, 12-16 years) underwent muscle-pedicle bone grafting with periosteum coverage during the period. Mean follow-up duration was 19 months (range, 6-34 months). Sports, the patients performed, include baseball (7 patients) and tennis (1 patient). In the 7 baseball players, 2 patients were pitchers, 1 was a catcher, 3 were infielders, and 1 was an outfielder. Preoperative range of flexion and extension were 129.4 ± 6.8° (mean ± SD) and −4.4 ± 8.6°, respectively. Final range of flexion and extension were 131.9 ± 11.9° and −2.5 ± 12.8°, respectively. There were no significant difference in preoperative and final range of motion. Patients returned to sports activity in 5 to 7 months after surgery. Seven of 8 patients returned to the same sports level, but 1 patient returned to other sports. The mean anteroposterior and transverse diameters of the cartilage defect were 12.0 (range, 8-14 mm) and 10.6 mm (range, 7-13 mm), respectively. Grafted bone union was achieved in all patients. Enlargement of the radial head was observed in 2 patients. Conclusions: Muscle-pedicle bone grafting with periosteum coverage was one of the acceptable treatment options for OCD of humeral capitellum. Reconstruction of articular defect in OCD was possible with minimum donor site morbidity.