Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Leesa M. Galatz, MD*,
Washington University School of Medicine, St. Louis, Missouri
Posted October 2007
Osteochondral lesions of the elbow are a challenging problem
to treat because they often occur in young, active, athletic patients, many of
whom have highly competitive aspirations with regard to sporting activity. Many
surgical treatments have been used, including débridement, curettage,
microfracture arthroplasty, and fixation techniques; and many of these have
resulted in less than satisfactory outcomes. In the paper by Ansah et al., autologous
osteochondral transplantation was used for the treatment of high-grade lesions
in the elbows of seven individuals who ranged in age from fifteen to twenty-one
years at the time of surgery.
The article is a level-IV review and includes complete
preoperative and postoperative clinical and radiographic data, including an
assessment of postoperative activity level. The patients were followed for an
average of five years. All patients had stage-III or IV osteochondral lesions
at the time of surgery. Plain radiographs and magnetic resonance imaging scans
were acquired preoperatively and postoperatively for all patients. All lesions
were treated surgically with an autologous osteochondral transplantation
technique in which cylindrical osteochondral donor grafts were harvested from
the non-weight-bearing area of the proximal part of the lateral femoral condyle
of the ipsilateral knee and transplanted into the defect.
Outcomes were assessed with use of the Morrey score1,2 and the American Shoulder and Elbow Surgeons score3. The results
were highly successful at the time of follow-up. No patient demonstrated any
elbow laxity or range-of-motion deficit. All patients returned to sports with
no reported complaints or restrictions in the activities of daily living. In
only two patients did the type and level of sports activity that was performed
postoperatively differ from that performed preoperatively; however, it was
stated that this change occurred because of age and work requirements and not
because of the clinical outcome of the surgical procedure. Overall, the results
were almost surprisingly good. The only adverse event was donor-site morbidity
in one patient, and that was temporary.
The patients in this series belong to a population that
historically does not respond well to nonoperative treatment or to débridement
and curettage of the lesions. Takahara et al.4, who recently classified
osteochondral lesions of the capitellum and analyzed treatment results at the
time of mid to long-term follow-up, subclassified the lesions as stable or
unstable and identified factors that were associated with outcome for operative
and nonoperative treatment. Patients with a stable osteochondritis dissecans
defect, as defined by an immature capitellum with an open growth plate, a grade-I
lesion, and no loss of elbow range of motion, did very well with only a period
of rest and modification of activity. Conversely, patients with an unstable osteochondritis
dissecans defect did not respond well to nonoperative treatment. An unstable osteochondritis
dissecans defect was defined by a mature capitellum with a closed growth plate,
a grade-II or III lesion, and restriction of elbow range of motion to ≥20°. These
patients tended to be older and had more advanced lesions, and nearly all of
the unstable lesions required surgical treatment. Thus, all of the patients in the
series of Ansah et al. fall into the group of patients for whom surgical
treatment should be considered.
A historical review of the literature has shown very mixed
and rather unpredictable results with excision of the fragment or débridement
alone when the lesions are large and unstable5-9. Recently, however,
capitellum reconstruction with autologous hyaline cartilage transplant or bone
graft and fixation has been shown to lead to predictable and promising results
in both throwing and nonthrowing athletes10-12. These results, along
with the results reported in the current paper, substantiate the use of a
reconstructive procedure for the treatment of osteochondral lesions in
skeletally mature individuals.
The strengths of this article are that the patients were
treated in a consistent fashion with use of a novel method of osteochondral
transplantation. This was a homogeneous population that was typical of patients
who present with this problem. The use of preoperative and postoperative magnetic
resonance imaging scans, in addition to radiographs, adds another dimension to
the analysis. Magnetic resonance imaging confirms graft viability, which is
critical for the success of this procedure. The major limitation of this study is
that it included a very small number of patients. When taken in the context of
the other literature published for capitellum reconstruction, however, this
article offers further support for the procedure. Importantly, there was
minimal donor-site morbidity, justifying a two-joint procedure for the treatment
of this complicated problem.
Interestingly, only five of the seven patients had a
capitellar lesion; the other two patients had a trochlear lesion (one patient)
and a radial head lesion (one patient). The inclusion of trochlear and radial
head lesions is unique, as most of the existing literature focuses on
capitellar lesions, which are much more common.
Osteochondritis dissecans is often a limiting injury in
young athletes and can often be career ending for those with substantial athletic
potential. Recent studies have successfully delineated guidelines for operative
and nonoperative treatment4. This article, along with other recent
articles10-12, substantiates the use of autologous osteochondral
transplantation for the treatment of this problem in individuals who require
surgery after unsuccessful nonoperative treatment. The results are better than
those achieved with fragment removal or simple débridement. In addition, this
type of treatment is reproducible and yields relatively consistent results.
*The author did not receive any outside funding or grants in
support of her research for or preparation of this work. Neither she nor a
member of her immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of her
immediate family, is affiliated or associated.
References
1. Broberg MA, Morrey BF. Results of treatment of fracture-dislocations of the elbow. Clin Orthop Relat Res. 1987;216:109-19.
2. Morrey BF, An KN, Chao EYS. Functional evaluation of the elbow. In: Morrey BF, editor. The elbow and its disorders. 3rd ed. Philadelphia: WB Saunders; 1985. p 73-91.
3. King GH, Richards RR, Zuckerman JD, Blasier R, Dillman C, Friedman RJ, Gartsman GM, Iannotti JP, Murnahan JP, Mow VC, Woo SL. A standardized method for assessment of elbow function. Research Committee, American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg. 1999;8:351-4.
4. Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. J Bone Joint Surg Am. 2007;89:1205-14.
5. Bradley JP, Petrie RS. Osteochondritis dissecans of the humeral capitellum. Diagnosis and treatment. Clin Sports Med. 2001;20:565-90.
6. Baumgarten TE, Andrews JR, Satterwhite YE. The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med. 1998;26:520-3.
7. Ruch DS, Cory JW, Poehling GG. The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy. 1998;14:797-803.
8. Kiyoshige Y, Takagi M, Yuasa K, Hamasaki M. Closed-Wedge osteotomy for osteochondritis dissecans of the capitellum. A 7- to 12-year follow-up. Am J Sports Med. 2000;28:534-7.
9. Brownlow HC, O'Connor-Read LM, Perko M. Arthroscopic treatment of osteochondritis dissecans of the capitellum. Knee Surg Sports Traumatol Arthrosc. 2006;14:198-202.
10. Takeda H, Watarai K, Matsushita T, Saito T, Terashima Y. A surgical treatment for unstable osteochondritis dissecans lesions of the humeral capitellum in adolescent baseball players. Am J Sports Med. 2002;30;713-7.
11. Iwasaki N, Kato H, Ishikawa J, Saitoh S, Minami A. Autologous osteochondral mosaicplasty for capitellar osteochondritis dissecans in teenaged patients. Am J Sports Med. 2006;34;1233-9.
12. Tsuda E, Ishibashi Y, Sato H, Yamamoto Y, Toh S. Osteochondral autograft transplantation for osteochondritis dissecans of the capitellum in nonthrowing athletes. Arthroscopy. 2005;21:1270.
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