Clinical Recommendations for Osteochondritis Dissecans of the ElbowThe best way to treat a condition called osteochondritis dissecans (OCD) of the capitellum (elbow bone) when it is unstable has not been determined. That's the conclusion of orthopedic surgeons specializing in the treatment of this problem. And in this review article, they will tell you why high-level evidence is lacking to support one form of treatment over another.
Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to this odd and troubling elbow condition. In the past, this condition was called Little Leaguer's elbow. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, primarily gymnastics and racket sports, put similar forces on the elbow. These sports can also lead to elbow OCD in adolescent athletes.
The forceful and repeated actions of these sports can strain the immature surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. That's when the condition is referred to as unstable.
Surgery is usually required for unstable OCD. The surgeon has several choices: the fragment can be reattached called fragment fixation. The broken piece can be removed with the remaining bone smoothed over (called debridement). Or osteochondral autograft transfer (OAT) can be done. The autograft transfer involves taking a fresh, healthy piece of bone from the patient's knee and transferring or "grafting" it into the defective area.
By looking at past studies and reported outcomes, the researchers were able to get an idea of short-, mid-, and long-term results with each of these surgical approaches. They reviewed studies from 1992 to the present. They discovered the data is inconclusive and the studies are not consistent in how they collect and analyze information. There was not enough high-level evidence to support one approach over another.
They were able to glean a few bits of information that might be helpful until better studies are done. For example, debridement is able to get up to 85 per cent of competitive athletes with unstable capitellar OCD back to full sports participation. Debridement can even be used with defects that are large enough to cover more than half of the joint surface. But outcomes are usually worse with debridement in this group compared with debridement of smaller defects.
Osteochondral autograft transfer (OAT) is really used most often for those large, unstable defects. It can also be used as a revision (second) surgery if debridement is unsuccessful in reducing pain and restoring elbow function. Studies have not been done long enough to show whether the donor site (in the knee) develops osteoarthritis years later. That would be an important piece of information to have before recommending the OAT procedure. Poor results with OAT are likely when the defect location is along the edge of the joint where it is difficult for the surgeon to get a graft in there.
Fixation was the other surgical method studied in this review. In fragment fixation, wires or bioabsorbable screws are used to hold the pieces of bone together until healing can occur. With this treatment approach, the player can get back to overhead (throwing) activities about six months after surgery.
Those who have the wires used must have them removed in a second surgery. Outcomes reported with fixation include good resolution (or at least improvement) of pain in 85 per cent of the athletes. X-ray evidence of healing without joint degenerative changes was observed in most cases.
Problems that can occur after surgical correction of OCD include persistent pain, sensation of "catching" in the joint with motion, and an inability to return to full sports participation. In general, the larger the lesion, the poorer the results. And the farther out from the injury and surgery, the less favorable the outcomes reported in the studies available.
In conclusion, the authors call for a long-term study conducted at multiple centers with large numbers of patients. This is the only way surgeons will be able to determine the best, most optimal surgical treatment for athletes who suffer from unstable capitellar OCD defects.
Matthew V. Smith, MD, et al. Surgical Treatment for Osteochondritis Dissecans of the Capitellum. In Sports Health. September/October 2012. Vol. 4. No. 5. Pp. 425-432.
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