Jeffrey Guttman, M.D.
John Flynn, M.D., Craig Morgan, M.D.
Alfred I. duPont Institute
1600 Rockland Road
Wilmington, Delaware 19803
INTRODUCTION: Osteochondritis dissecans (OCD) of the humeral capitellum occurs primarily in young throwing athletes between the ages of 13 and 16. The cause is not entirely clear, but trauma and excessive use appear to play a major role. Valgus stress during throwing is the principal pathologic mechanism and causes compression overload of the lateral articular surface of the elbow. Many surgical techniques have been employed in the treatment of this condition, mostly with poor results. Arthroscopy has been utilized with success in the treatment of intraarticular processes of other joints, but its role in the elbow is still being defined. There have been no previous studies dealing with only arthroscopic treatment of OCD of the capitellum. This study investigates the usefulness of arthroscopy in the evaluation and treatment of OCD of the capitellum and offers a new surgical technique for the drilling of these lesions.
MATERIALS AND METHODS: Over an 8 year period, we identified nine consecutive patients (eleven elbows) with symptomatic osteochondritis dissecans capitellum treated arthroscopically. We reviewed charts and radiographs of these patients and recorded patient age at presentation, involved side, duration of symptoms, athletic participation, physical findings, radiographic findings, operative findings, treatment, and initial disposition. A telephone questionnaire was conducted to evaluate long term follow up of pain, elbow motion, return to sports, satisfaction with surgery, and subjective overall assessment of elbow function. Of the 10 surgically treated cases, 4 cases involved diagnostic arthroscopy and debridement of the lesion or removal of loose bodies. Six cases, which form the focus of this study, involved diagnostic arthroscopy and arthroscopically/fluoroscopically assisted drilling of the lesion. Arthroscopy was performed with the patient in the prone position. Standard anteromedial and anterolateral elbow arthroscopy portals were then created, and the arthroscope was maneuvered to visualize the elbow joint, paying particular attention to the capitellum and radial head. Intact lesions (Type I) without evidence of fragmentation of the articular surface of the capitellum were then drilled with a 0.062 smooth Steinman pin percutaneously from proximal posterolateral to distal anteromedial. Drilling was done under direct arthroscopic visualization to prevent violation of the intact cartilaginous surface, and fluoroscopy was used briefly to guide pin placement. Lesions that were partially detached (Type II) were debrided with an intraarticular shaver. Completely detached loose bodies (Type III) were excised. Standard posteromedial and posterolateral portals were made as needed to excise loose bodies located in these regions. Partial synovectomy was also performed as needed. Post-operatively the patients treated with drilling were placed in a sling for 3-7 days followed by active ROM exercises. Participation in sports was resumed in 3-6 months when clinical and radiographic evidence of healing of the lesion was present. Patients treated with debridement or removal of loose bodies were permitted to resume sports as soon as their symptoms allowed.
RESULTS: There were 6 males and 3 females. There were 2 cases with bilateral involvement and the other 7 involved the dominant elbow. The average age at presentation was 13.8 years (range 12-16 years) and the average duration of symptoms prior to presentation at this institution was about 1 year. In all cases arthroscopy provided excellent visualization of the osteochondritic lesion. Of the 6 cases treated with drilling of the lesion, 4 were true Type I lesions, 1 was a Type II lesion, and 1 was a Type III lesion. Of the remaining 4 cases, there was 1 Type II and 3 Type III lesions, and these were treated by debridement and excision of loose bodies. There were no wound or neurovascular complications. There were 3 reoperations in 2 patients (1Type II lesion, 1 Type II lesion, 1 Type III lesion. The average length of follow up of the 6 patients treated with drilling of the lesion was 5.9 years (range 6 months to 8 years). Initially, all of the patients had radiographic evidence of OCD lesions of the capitellum, and on follow up, 5/6 showed radiographic evidence of healing of the lesion. 3 of these patients (all Type I lesions) experience no pain, and 3 experience pain with strenuous activity. 4/6 (all Type I lesions) feel that they have full range of motion of their elbows, and 2/6 feel that they have slightly decreased range of motion. All 6 patients returned to sports, and 4/6 (3 Type I and 1 Type II) felt they did so at their previous level. 5/6 patients were satisfied with their surgery (the Type III patient was not). 5/6 patients felt there elbow was normal or nearly normal (the Type III patient felt his elbow was slightly abnormal).
DISCUSSION: OCD of the capitellum is considered one of the leading causes of permanent elbow disability in young throwing athletes. Previous studies have shown that these patients have a poor prognosis regardless of treatment and rarely return to hard painless throwing. Surgery is indicated in patients with persistent symptoms. Arthroscopy serves a valuable role in diagnosing the exact nature of the lesion (intact vs. partially detached vs. completely detached). Drilling of intact lesions appears to stimulate revascularization and healing. In this study, healing was evident both radiographically and on a second-look arthroscopy. The percutaneous outside to inside technique described in this study offers the advantage of preserving the intact cartilage of the articular surface of the capitellum.
It would seem that if lesions can be stimulated to heal, these patients would experience resolution of their symptoms and be able to return to sports. Although the number of patients in this review was small, almost all of them became pain-free and resumed athletic activity at their pre-injury level. Two of the lesions that were drilled were not Type I lesions and both underwent additional surgical procedures. This study was not done in a prospective fashion and so the indications for drilling were not standardized. One of these patients did well after the second procedure. The other patient (Type III lesion) did not do well, and this lesion was probably too far advanced to benefit from drilling. This paper does not claim that drilling provides better results than debridement or removal of loose bodies as these procedures were generally performed on different stage lesions. Instead, our study suggests that intact OCD lesions of the capitellum may benefit from early drilling at a time when healing can still occur.
[Return to Table of Contents, Back to Research Symposium Home Page, Orthopaedic Department Home Page]