Osteochondritis Dissecans of the Elbow: How Should We Treat?
By: Michael E. Pollack, M.D.
As with all forms of osteochondritis dissecans (OCD), OCD of the elbow involves idiopathic separation of the cartilage and the subchondral bone. Most cases involve the humeral capitellum in teenage baseball players. Unlike Panner’s disease, which is self-limited, not associated with trauma and seen in the immature capitellum (patients under 10 years old), OCD of the capitellum is primarily seen in the adolescent overhead athlete.
Despite uncertain etiology, these lesions in the throwing athlete are likely a result of compression forces applied to the humeral capitellum by valgus stress during throwing in the late cocking phase. This disorder occurs predominantly in the dominant arm of male throwing athletes and in female gymnasts, which clearly supports the notion of repetitive trauma. Regarding gymnasts, the radiocapitellar articulation has been shown to experience up to 60% of axial compression forces across the elbow. Trauma and ischemia are believed to play a significant role and there is no evidence for a genetic predisposition.
The pathophysiology of OCD of the elbow mimics mechanical trauma to articular cartilage, including fatigue fracture, resorption and subchondral bone fragment separation. As fragments become more avascular, the overlying articular cartilage becomes more susceptible to shear stresses and failure of underlying subchondral osseous support. This cycle of stress and disrepair leads to the hallmarks of unstable lesions including separation, fragmentation and loose body formation. The capitellum is primarily supplied by posterior end arteries that traverse the epiphyseal articular cartilage without metaphyseal collateral contributions.
Early stable lesions, like most throwing pathology, can be managed with rest and activity modification. Three to six weeks of rest followed by graduated return to sport in three to six months are common guidelines. Radiographic healing often lags behind clinical improvement, so this is not the best criterium for return to activity. Lesion grade may be a better predictor of nonoperative treatment success than physeal status. The natural history of elbow OCD lesions suggests that radiocapitellar degenerative changes occur in up to 50% of patients; as a result, we undertreat these lesions at our own peril. OCD lesions of the capitellum have limited potential for cartilage repair, especially in the skeletally mature patient (closed capitellar physis).
As such, surgery should be considered for unstable lesions. Unstable lesions have one of the following findings: closed growth plate, fragmentation or restriction of elbow motion greater than 20 degrees. These lesions tend to do better with surgical intervention. Other indications for surgery include presence of loose bodies, mechanical symptoms and stable lesions that have failed six months of nonsurgical treatment.
Advanced, unstable lesions have demonstrated only limited or short-term response to removal of loose bodies with or without drilling or curettage, abrasion chondroplasty or reattachment of loose fragments. As such, resurfacing may be the best way to allow return to their previous level of sporting activity without functional disturbance. Autologous osteochondral mosaicplasty or osteochondral autograft transfer system (OATS) allows for resurfacing of the osteochondral defect with normal hyaline cartilage typically from the lateral trochlea of the knee. OATS may be best indicated for large lesions that make up more than 50% of the articular cartilage. This technique has a track record in the knee and ankle and is familiar to most fellowship-trained sports medicine surgeons.
One study demonstrated good or excellent results in 18 of 19 patients with a mean follow-up of four years with no evidence of sequential arthritic changes.1A significant subset of patients treated with loose body removal, drilling or fragment repair developed arthritic changes and were unable to return to their previous level of activity.2-5
While OCD of the elbow is a relatively rare counterpart to comparable lesions in the knee and ankle, this analogous pathology should be respected and treated proactively with the same established principles that guide our treatment elsewhere.
- Iwasaki, N., Kato, H., Ishikawa, J., Masuko, T., Funakoshi, T., Minami, A. “Autologous Osteochondral Mosaicplasty for Osteochondritis Dissecans of the Elbow in Teenage Athletes.” The Journal of Bone and Joint Surgery – American Volume. 2009;2359.
- Bauer, M., Jonsson, K., Josefsson, P.O., Liden, B. “Osteochondritis Dissecans of the Elbow: A Long-Term Follow-Up Study.” Clinical Orthopaedics and Related Research. 1992;284:156-160.
- McManama, G.B., Micheli, L.J., Berry, M.V., Sohn, R.S. “The Surgical Treatment of Osteochondritis Dissecans of the Humeral Capitellum.” Clinical Orthopaedics and Related Research. 1999;363:108-115.
- Takahara, M., Mura, N., Sasaki, J., Harada, M., Ogino, T. “Classification, Treatment and Outcome of Osteochondritis Dissecans of the Humeral Capitellum.” The Journal of Bone and Joint Surgery – American Volume. 2007;89:1205-1214.
- Tivon, M.C., Anzel, S.H., Waugh, T.R. “Surgical Management of Osteochondritis Dissecans of the Capitellum.” The American Journal of Sports Medicine. 1976;4:121-128.