The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 6

Scientific Articles | June 01, 2007

Classification, Treatment, and Outcome of Osteochondritis Dissecans of the Humeral Capitellum

Masatoshi Takahara, MD, PhD¹; Nariyuki Mura, MD, PhD¹; Junya Sasaki, MD¹; Mikio Harada, MD, PhD¹; Toshihiko Ogino, MD, PhD¹

¹ Department of Orthopaedic Surgery, Yamagata University School of Medicine, Iida-Nish 2-2-2, Yamagata City, 990-9585, Japan. E-mail address for M. Takahara: mtakahar@med.id.yamagata-u.ac.jp

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families 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 authors, or a member of their immediate families, are affiliated or associated.

Note: The authors are grateful to Kiyoshi Kaneda, MD, Akio Minami, MD, and Isao Sasaki, MD, Hokkaido University School of Medicine, for their assistance.

Investigation performed at the Department of Orthopaedic Surgery, Yamagata University School of Medicine, Yamagata City, Japan

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Jun 01;89(6):1205-1214. doi: 10.2106/JBJS.F.00622

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Abstract

Background: Indications for the treatment of osteochondritis dissecans of the humeral capitellum have remained unclear. The aims of this study were to analyze the outcomes and to determine the most useful classification for the choice of treatment.

Methods: The cases of 106 patients with osteochondritis dissecans of the capitellum were studied retrospectively. At the time of the initial presentation, the mean age of the patients was 15.3 years. The capitellar growth plate was open in eighteen patients and closed in eighty-eight. Thirty-six patients were treated nonoperatively. Fifty-five patients underwent fragment removal alone, twelve underwent fragment fixation with a bone graft, and three underwent reconstruction of the articular surface with use of osteochondral plug grafts from the lateral femoral condyle. The mean follow-up period was 7.2 years. The outcomes in terms of pain in the elbow, return to sports, and radiographic findings were analyzed and compared.

Results: An osteochondritis dissecans lesion with an open capitellar physis and a good range of elbow motion resulted in a good outcome. Continued elbow stress resulted in the worst outcome in terms of pain and radiographic findings. In patients with a closed capitellar physis, surgery provided significantly better results than elbow rest (p < 0.01). Fragment fixation or reconstruction provided significantly better results than fragment removal alone (p < 0.05). The results of removal alone were dependent on the size of the defect in the capitellum. The outcome in terms of pain was closely associated with sports activity and radiographic findings.

Conclusions: We believe that osteochondritis dissecans of the capitellum can be classified as stable or unstable. Stable lesions that healed completely with elbow rest had all of the following findings at the time of the initial presentation: an open capitellar growth plate, localized flattening or radiolucency of the subchondral bone, and good elbow motion. Unstable lesions, for which surgery provided significantly better results, had one of the following findings: a capitellum with a closed growth plate, fragmentation, or restriction of elbow motion of =20°. For large unstable lesions, fragment fixation or reconstruction of the articular surface leads to better results than simple excision.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

The prevalence of osteochondritis dissecans (OCD) of the humeral capitellum is high among individuals who have played baseball actively since childhood^1-5. During the acceleration phase of throwing, the elbow joint is stressed in a valgus direction and the capitellum is subjected to compression and shear forces^1-5. Many authors have suggested that repetitive force applied to the capitellum is the main etiological factor in osteochondritis dissecans and makes the lesions unstable^1-6.

Recent studies have shown that the earliest feature of osteochondritis dissecans is subchondral bone flattening, over which new bone subsequently forms, and that such early osteochondritis dissecans can heal spontaneously^7,8. However, it has been shown that most elbows fail to heal with nonoperative treatment⁹. Numerous surgical treatments for osteochondritis dissecans have been reported^10-27. Fragment removal alone is a common and minimally invasive procedure^10-16, but the long-term results may be poor if a large osteochondral defect of the capitellum remains¹⁶. Fragment fixation with a bone graft is an alternative procedure, for which some authors have reported good results^17-20. However, it is often difficult to fix a grossly unstable cartilaginous fragment securely to unhealthy subchondral bone. Recently, autologous osteochondral plug-grafting^21-25 and autologous chondrocyte transplantation²⁶ have been proposed for the reconstruction of articular surface defects, with good short-term results. Closing-wedge osteotomy of the lateral condyle has also been proposed as an alternative procedure to reduce the pressure on the lesion and promote healing²⁷.

Arthroscopically, osteochondritis dissecans lesions can show various features or conditions, as classified by the International Cartilage Repair Society (ICRS)²⁸. However, little is known about the outcomes of these individual patterns, and the specific indications for treatment have remained unclear. We are not aware of any report that has provided an overview of a large number of osteochondritis dissecans lesions of the capitellum and has evaluated the outcomes on the basis of the specific features of the lesion or the treatments provided. The aims of this study were to analyze the outcome of osteochondritis dissecans lesions of the capitellum in patients with early and advanced lesions and in those managed with nonoperative or operative treatment and to determine a classification that might be useful for treatment.

Materials and Methods

Materials and Methods | Results | Discussion | References

This study was carried out in accordance with the World Medical Association Declaration of Helsinki. Between 1965 and 2005, we were involved in the care of 137 elbows with osteochondritis dissecans, 107 of which were followed for more than six months. One patient with bilateral involvement was excluded because the etiology was probably constitutional, leaving 106 elbows in 106 patients for retrospective review. Some of the data from sixty-nine of these patients have been reported previously^7-9,16,19,29. The age of the patients at the time of clinical presentation ranged from ten to thirty-four years (mean, 15.3 years). The sport related to the onset of the symptoms was baseball for ninety-eight patients, gymnastics for two, table tennis for two, and ice hockey, badminton, sumo wrestling, and kendo for one patient each. The mean period between the onset of symptoms and clinical presentation was 2.9 years (range, one month to nineteen years). In ninety-five patients, the mean range of elbow motion was -13.6° of extension and 128.0° of flexion. These measurements were not known for eleven patients. At the time of clinical presentation, the growth plate of the capitellum was open in eighteen patients and was closed in eighty-eight. The radiographic findings were classified into three grades: grade I indicated localized flattening or radiolucency; grade II, a nondisplaced fragment; and grade III, a displaced or detached fragment^16,30. Anteroposterior and lateral radiographs of the elbow made at the time of clinical presentation showed a grade-I lesion in twenty-one patients, a grade-II lesion in twenty-seven, and a grade-III lesion in fifty-four; the initial radiographs of four patients were lost (Table I).

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TABLE I Clinical Data at the Time of Initial Presentation

					Mean Range of Motion^*
	No. of Elbows	Mean Age (yr)	Mean Period from Onset to Presentation (yr)	Mean Age at Onset (yr)	Loss of Extension (deg)	Flexion (deg)
Total	106	15.3	2.9	12.4	13.6	128.0
Capitellar physics
Open	18	11.6†	0.5†	11.2	4.8	138.2†
Closed	88	15.9	3.3	12.6	15.9	125.8
Grade of radiographic findings‡
I	21	12.9	1.1	11.8	7.6	134.6
II	27	13.4	1.8	11.6	12.8	131.2
III	54	17.2†	4.0†	13.2†	16.4	125.0†
Sport played
Baseball	98	14.9†	2.5†	12.4	13.7	127.9
Other	8	20.1	6.9	13.2	11.9	128.8

The data were not known for eleven patients at the time of the initial presentationThe difference between the subgroups was significant (p < 0.05)The grade was not known for four patients

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TABLE I Clinical Data at the Time of Initial Presentation

					Mean Range of Motion^*
	No. of Elbows	Mean Age (yr)	Mean Period from Onset to Presentation (yr)	Mean Age at Onset (yr)	Loss of Extension (deg)	Flexion (deg)
Total	106	15.3	2.9	12.4	13.6	128.0
Capitellar physics
Open	18	11.6†	0.5†	11.2	4.8	138.2†
Closed	88	15.9	3.3	12.6	15.9	125.8
Grade of radiographic findings‡
I	21	12.9	1.1	11.8	7.6	134.6
II	27	13.4	1.8	11.6	12.8	131.2
III	54	17.2†	4.0†	13.2†	16.4	125.0†
Sport played
Baseball	98	14.9†	2.5†	12.4	13.7	127.9
Other	8	20.1	6.9	13.2	11.9	128.8

The data were not known for eleven patients at the time of the initial presentationThe difference between the subgroups was significant (p < 0.05)The grade was not known for four patients

Surgery was recommended to the patients who had moderate or severe pain, an episode of locking, or loose bodies demonstrated radiographically. Thirty-six patients were advised to stop vigorous activities of the elbow, such as throwing and weight-bearing on the affected upper extremity, and were followed for more than six months; they constituted the nonoperative group. Thirty of these patients accepted the advice (the rested group), whereas six, including three with an osteochondritis dissecans lesion with an open physis and three with closed physis, continued with vigorous elbow activity (the active group). Seventy patients were treated surgically. Fifty-five of those patients underwent fragment removal alone, twelve underwent fragment fixation with a bone graft, and three underwent reconstruction of the articular surface with use of osteochondral plug grafts from the lateral femoral condyle. The follow-up period for all patients ranged from 0.5 to twenty-five years (mean, 7.2 years); the nonoperative group was followed for a mean of 5.2 years and the operative group for a mean of 8.2 years (Table II). The minimum follow-up period was six months because a few patients had failure of nonoperative treatment and surgery was undertaken within a short period of time.

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TABLE II Treatment and Outcome

		Initial Presentation												Results at Final Examination
			Mean Range of Motion^*(deg)			Grade†(no. of elbows)						Pain (no. of elbows)					Return to Sports (no. of elbows)					Mean Range of Motion^*(deg)	Radiographic Findings‡(no. of elbows)
	No. of Elbows	Mean Age (yr)	Loss of Extension	Flexion	I	II	III	Mean Duration of Follow-up (yr)	None	Mild	Mod. or Severe	Competitive	Recreational	Substantial Limitation	Loss of Extension	Flexion	A	B	C	Extracapitellar Free Bodies	Progressive Degeneration
Nonoperative treatment§	36	13.1	7.6	135.9	15	12	9	5.2	10	11	15	6	17	13	4.8	137.3	10	8	9	6	1
Rest	30	13.3	9.9	135.2	13	8	9	5.7	10	8	12	4	13	13	3.1	137.2	10	6	5	2	1
Active	6	12.2	4.0#	139.6	2	4	0	2.7	0	3	3	2	4	0	11.3	137.5	0	2	4	4	0
Operative treatment^**	70	16.4	16.4	124.2	6	15	45	8.2	28	22	20	32	20	18	9.1	128.6	17	29	13	8	4
Removal alone	55	17.3	15.7	123.3	4	5	42	9.6	19	17	19	27	14	14	10.0	126.7	12	20	12	7	4
Fixation or reconstruction	15	13.1	18.7	127.0	2	10	3	2.9	9	5	1	5	6	4	6.7	133.7	5	9	1	1	0

The data on range of motion were unavailable for eleven elbows at the time of inital presentation and for twenty-eight elbows at the final examinationRadiographs were not available for four patients. Grade I indicates localized flattening or radiolucency; grade II, a nondisplaced fragment; and grade III, a displaced or detached fragmentType A indicates a normal capitellum or localized flattening of <50% of the width of the capitellar articular surface; B, a nondisplaced fragment or flattening of 50% to 70%; and C, a displaced fragment or flattening of >70%. The radiographic findings were unknown for twenty elbowsThe group treated with elbow rest stopped vigorous activities of the elbow for more than six months, and the active group continued with vigorous elbow activityHyperextensionThe removal alone group underwent fragment removal alone, and the fixation or reconstruction group underwent fragment fixation with a bone graft or reconstruction of the articular surface with use of osteochondral plug grafts

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TABLE II Treatment and Outcome

		Initial Presentation												Results at Final Examination
			Mean Range of Motion^*(deg)			Grade†(no. of elbows)						Pain (no. of elbows)					Return to Sports (no. of elbows)					Mean Range of Motion^*(deg)	Radiographic Findings‡(no. of elbows)
	No. of Elbows	Mean Age (yr)	Loss of Extension	Flexion	I	II	III	Mean Duration of Follow-up (yr)	None	Mild	Mod. or Severe	Competitive	Recreational	Substantial Limitation	Loss of Extension	Flexion	A	B	C	Extracapitellar Free Bodies	Progressive Degeneration
Nonoperative treatment§	36	13.1	7.6	135.9	15	12	9	5.2	10	11	15	6	17	13	4.8	137.3	10	8	9	6	1
Rest	30	13.3	9.9	135.2	13	8	9	5.7	10	8	12	4	13	13	3.1	137.2	10	6	5	2	1
Active	6	12.2	4.0#	139.6	2	4	0	2.7	0	3	3	2	4	0	11.3	137.5	0	2	4	4	0
Operative treatment^**	70	16.4	16.4	124.2	6	15	45	8.2	28	22	20	32	20	18	9.1	128.6	17	29	13	8	4
Removal alone	55	17.3	15.7	123.3	4	5	42	9.6	19	17	19	27	14	14	10.0	126.7	12	20	12	7	4
Fixation or reconstruction	15	13.1	18.7	127.0	2	10	3	2.9	9	5	1	5	6	4	6.7	133.7	5	9	1	1	0

At the time of the final examination, all 106 patients were asked about their elbow pain and return to sports during an interview conducted in person or by telephone or by completing a written questionnaire. The assessment of elbow pain as established by the Japanese Orthopaedic Association^22,31 was modified and divided into three categories¹⁶: none (no pain), mild (pain only after intense activity, such as sports or work), and moderate or severe (pain after daily activities or even at rest). The assessment of return to a former sports activity as established by the American Shoulder and Elbow Surgeons³² was modified and divided into three categories¹⁶: competitive (a complete return), recreational (an incomplete return), and substantial limitation (a change or cessation of the sport). The range of elbow motion at the final examination was obtained for seventy-eight patients, including twenty patients in the nonoperative group and fifty-eight patients in the operative group. Final radiographs of the elbow were made for eighty-six patients: twenty-seven in the nonoperative group and fifty-nine in the operative group. Outcomes assessed on anteroposterior radiographs of the capitellum were divided into three types: A, which indicated a normal capitellum or localized flattening of <50% of the width of the capitellar articular surface; B, a nondisplaced fragment or flattening of 50% to 70%; and C, a displaced fragment or flattening of >70%. In addition, we assessed the presence or absence of both extracapitellar free bodies and progressive degeneration such as osteophyte formation.

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Fig. 1: A thirteen-year-old boy with a grade-I osteochondritis dissecans lesion of the left elbow with an open capitellar growth plate that was treated with rest. Anteroposterior radiographs of the elbow in 45° of flexion made at the time of the initial presentation (A), two months later (B), four months later (C), and one year and eight months later (D). The radiograph made at the time of initial presentation (A) shows localized flattening and radiolucency of the capitellum. During the period of elbow rest, progressive ossification of the flattened bone was observed (B, C, and D). Healing of the lesion began initially in the lateral area of the lesion (B and C) and progressed medially (C). At one year and eight months after he was first seen, the lesion had completely healed (D).

To investigate the clinical features of osteochondritis dissecans of the capitellum, we analyzed and compared the data obtained at the clinical presentation, including patient age, stage, range of elbow motion, and grade. During the observation period in the nonoperative group, we assessed radiographic changes in the lesions, such as ossification, narrowing, or healing. In the group that had fragment removal alone, the defect size was compared with the capitellar size¹⁶ as measured on postoperative anteroposterior radiographs. To clarify the indications for the choice of treatment, we analyzed the results and compared them among the treatments provided.

We used the Student t test to analyze the differences in patient age, duration of symptoms, and range of elbow motion, and we used the Mann-Whitney U test to compare the outcome in terms of pain, return to sports, and radiographic findings of the capitellum. The Fisher exact probability test was used to compare the prevalence of free bodies and degenerative changes. We used the Spearman correlation coefficient by rank test to confirm relationships among outcomes in terms of pain, return to sports, and radiographic findings of the capitellum. A difference was considered significant when the p value was <0.05.

Results

Materials and Methods | Results | Discussion | References

Data at Initial Presentation

The age of the patients at the time of initial presentation ranged from ten to thirteen years (mean, 11.6 years) for those who had an osteochondritis dissecans lesion involving an open capitellar physis and from eleven to thirty-four years (mean, 15.9 years) for those who had a lesion with a closed physis (Table I). The mean period between the onset of symptoms and the initial presentation was 0.5 year in patients with an open physis and 3.3 years in those with a closed physis. The patients with a closed physis had a significantly longer period from the onset of symptoms to the time of initial presentation (p < 0.01). The mean age of the patients with an open physis and those with a closed physis at the onset of symptoms was 11.2 years and 12.6 years, respectively. However, in patients with a closed physis who initially presented when they were thirteen years old or less, the mean age at the onset of symptoms was 11.4 years; this was not different from that in patients with an osteochondritis dissecans lesion with an open physis.

The range of elbow motion in the patients with an osteochondritis dissecans lesion with a closed physis was significantly more restricted than that in patients with an open physis (p < 0.01) (Table I).

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Fig. 2: A twelve-year-old male baseball player with a grade-II osteochondritis dissecans lesion of the right elbow with an open capitellar growth plate. A: Anteroposterior radiograph with the elbow in 45° of flexion made at the time of initial presentation showed a nondisplaced fragment. B: Degeneration of the capitellar cartilage was observed. Fragment fixation was performed with two bone-pegs (arrows) from the olecranon. C: A bone-peg. D: Radiograph made three weeks postoperatively shows the two bone-pegs (arrows). E: Radiograph made seven months postoperatively shows complete healing.

The radiographic findings for osteochondritis dissecans lesions with an open physis were grade I in thirteen patients, grade II in four, and grade III in none. For those with a closed physis, the findings were grade I in eight patients, grade II in twenty-three, and grade III in fifty-four. The grades were significantly lower for patients with an open physis (p < 0.01). The mean ages of the patients were 12.9 years for those with a grade-I lesion, 13.4 years for those with a grade-II lesion, and 17.2 for those with a grade-III lesion; a grade-III lesion was associated with older age (p < 0.01) (Table I).

Outcomes of Nonoperative Treatment

During the periods of elbow rest, progressive ossification of the lesion was observed in all ten patients with an osteochondritis dissecans lesion with an open physis and in seven of eleven patients with a closed physis. Narrowing of the lesion during the observation period was observed in nine of the ten patients with an open physis and in four of the eleven with a closed physis. This repair process began initially in the lateral area of the lesion and progressed medially (Fig. 1).

The results in the patients who continued to stress the affected elbow (the active group) were significantly worse than in those who rested the elbow with respect to the radiographic findings (p < 0.05) and the formation of free bodies (p < 0.05) (Tables II and III). Patients who continued to stress the elbow and had an osteochondritis dissecans lesion with an open physis had a worse outcome with respect to pain (p < 0.05), radiographic findings (p < 0.05), and healing (p < 0.01). With elbow rest, almost complete healing was obtained in seven of the ten patients with an open physis and in one of the eleven with a closed physis. Osteochondritis dissecans lesions with an open physis that were managed with elbow rest showed significantly better healing (p < 0.001) and a better outcome with respect to pain (p < 0.01), return to sports (p < 0.05), and radiographic findings (p < 0.05) than did lesions with a closed physis (Table III). Elbow rest for patients with a closed physis did not provide a good outcome in terms of pain, return to sports, or radiographic findings.

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TABLE III Comparisons of Outcome

	Pain (no. of elbows)					Return to Sports (no. of elbows)					Radiographic Findings^*(no. of elbows)
	None	Mild	Moderate or Severe	Competitive	Recreational	Substantial Limitation	A	B	C	Free Bodies	Progressive Degeneration	Healed
Nonoperative treatment							10	6	5†	2†	1	8
Rest	10	8	12	4	13	13	0	2	4	4	0	0
Active	0	3	3	2	4	0†	7	3	0†	1	0	7†
Open capitellar physis							0	1	2	2	0	0
Rest	8	2	1†	3	6	2	7	3	0†	1	0	7†
Active	0	2	1	2	1	0	3	3	5	1	1	1
Rest							6	1	0	0	0	6
Open capitellar physis	8	2	1†	3	6	2†	1	2	0	1	0	1
Closed capitellar physis	2	6	11	1	7	11	12	20	12	7	4
Rest with open capitellar physis							5	9	1	1	0
Grade I	7	1	0	2	4	2	11	8	0†	3	0
Grade II	1	1	1	1	2	0	1	12	11	4	3
Operative treatment							7	4	2	3	0
Removal alone	19	17	19	27	14	14	1	1	2	0	1
Fixation or reconstruction	9	5	1†	5	6	4	3	4	7	3	1
Removal							16	28	11	8	3
Small defect	10	7	4†	12	4	5	24	35	20	14	5
Large defect	5	8	11	10	6	8	3	2	2	0	0
Open capitellar physis
Nonoperative treatment	8	4	2	5	7	2	7	4	2	3	0
Operative treatment	1	2	1	2	1	1	1	1	2	0	1
Closed capitellar physis
Nonoperative treatment	2	7	13	1	10	11	3	4	7	3	1
Operative treatment	27	20	19†	30	19	17†	16	28	11	8	3
Sport
Baseball	36	29	33	34	36	28	24	35	20	14	5
Other sports	2	4	2	4	1	3	3	2	2	0	0
Range of motion
155° to 121°	22	9	8†	17	16	6†	17	11	7†	7	0
=120°	15	21	20	17	16	23	10	25	12	7	4

The radiographic findings were unknown for twenty elbows. Type A indicates a normal capitellum or localized flattening of <50% of the width of the capitellar articular surface; B, a nondisplaced fragment or flattening of 50% to 70%; and C, a displaced fragment or flattening of >70%The difference between the subgroups was significant (p < 0.05)

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TABLE III Comparisons of Outcome

	Pain (no. of elbows)					Return to Sports (no. of elbows)					Radiographic Findings^*(no. of elbows)
	None	Mild	Moderate or Severe	Competitive	Recreational	Substantial Limitation	A	B	C	Free Bodies	Progressive Degeneration	Healed
Nonoperative treatment							10	6	5†	2†	1	8
Rest	10	8	12	4	13	13	0	2	4	4	0	0
Active	0	3	3	2	4	0†	7	3	0†	1	0	7†
Open capitellar physis							0	1	2	2	0	0
Rest	8	2	1†	3	6	2	7	3	0†	1	0	7†
Active	0	2	1	2	1	0	3	3	5	1	1	1
Rest							6	1	0	0	0	6
Open capitellar physis	8	2	1†	3	6	2†	1	2	0	1	0	1
Closed capitellar physis	2	6	11	1	7	11	12	20	12	7	4
Rest with open capitellar physis							5	9	1	1	0
Grade I	7	1	0	2	4	2	11	8	0†	3	0
Grade II	1	1	1	1	2	0	1	12	11	4	3
Operative treatment							7	4	2	3	0
Removal alone	19	17	19	27	14	14	1	1	2	0	1
Fixation or reconstruction	9	5	1†	5	6	4	3	4	7	3	1
Removal							16	28	11	8	3
Small defect	10	7	4†	12	4	5	24	35	20	14	5
Large defect	5	8	11	10	6	8	3	2	2	0	0
Open capitellar physis
Nonoperative treatment	8	4	2	5	7	2	7	4	2	3	0
Operative treatment	1	2	1	2	1	1	1	1	2	0	1
Closed capitellar physis
Nonoperative treatment	2	7	13	1	10	11	3	4	7	3	1
Operative treatment	27	20	19†	30	19	17†	16	28	11	8	3
Sport
Baseball	36	29	33	34	36	28	24	35	20	14	5
Other sports	2	4	2	4	1	3	3	2	2	0	0
Range of motion
155° to 121°	22	9	8†	17	16	6†	17	11	7†	7	0
=120°	15	21	20	17	16	23	10	25	12	7	4

Outcomes of Operative Treatment

Of the patients who were treated surgically, twenty-eight had no pain, twenty-two had mild pain, and twenty had moderate or severe pain. In terms of return to sports, thirty-two had returned to competitive sports, twenty had returned to recreational sports, and eighteen had substantial limitation. The radiographic results were type A in seventeen patients, type B in twenty-nine, and type C in thirteen. Eight patients had residual free bodies, and four showed severe progressive degeneration of the articular surface (Table II). Comparison among the surgical treatments showed a better outcome in terms of pain in patients who underwent fixation or reconstruction of the articular surface than for those who underwent fragment removal alone (p < 0.05) (Table III; Figs. 2 and 3). The results of fragment removal alone were significantly dependent on the size of the capitellar defect, with better results seen for small defects of <50% of the capitellar articular width than for larger defects in terms of pain (p < 0.05) and radiographic findings (p < 0.01) (Table III).

Comparison of Outcomes

Although the differences between patients with an osteochondritis dissecans lesion with an open physis who rested the elbow and those who continued to stress the affected elbow were significant, the differences in patients with a closed physis were slight. For osteochondritis dissecans lesions with a closed physis, surgical treatment provided significantly better results than nonoperative treatment in terms of pain (p < 0.01) and return to sports (p < 0.01) (Table III). With the numbers studied, there were no measurable differences in outcome among radiographic grades of lesions with a closed physis. The outcome in patients who played baseball was slightly worse than in patients who participated in other sports, but the difference was not significant. The range of elbow motion at the time of initial presentation was found to be associated with the final outcome, with limited motion predictive of more pain (p < 0.01), decreased ability to return to sports (p < 0.05), and worse radiographic findings (p < 0.05) (Table III).

Relationships Among Pain, Return to Sports, and Radiographic Findings

The outcomes in terms of pain, return to sports, final radiographic findings, eventual formation of loose bodies, and progressive degeneration were compared with each other. The outcome in terms of pain was significantly associated with a decreased ability to return to sports (p < 0.01), worse radiographic findings (p < 0.01), formation of free bodies (p < 0.01), and progressive degeneration (p < 0.01). With the numbers studied, return to sports was not related to the radiographic findings.

Discussion

Materials and Methods | Results | Discussion | References

We believe that an osteochondritis dissecans lesion of the capitellum can be classified as stable or unstable. A stable lesion is one that can heal completely with elbow rest, and an unstable lesion is one for which surgery provides significantly better results. This classification is useful for the choice of treatment. From this study, we concluded that a patient with a stable osteochondritis dissecans lesion has all of the following findings at the time of initial presentation: an immature capitellum with an open growth plate, flattening or radiolucency of the subchondral bone (a grade-I lesion), and almost normal elbow motion. A patient with an unstable osteochondritis dissecans lesion has one of the following features: a mature capitellum with a closed growth plate, fragmentation (a grade-II or III lesion), or a restriction of elbow motion of =20°. According to this classification, nine of our 106 patients had a stable lesion and ninety-seven had an unstable lesion. The stable lesions can heal almost completely with elbow rest. For unstable lesions, surgery provides significantly better results.

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Fig. 3: A twelve-year-old male baseball player with a grade-III osteochondritis dissecans lesion of the right elbow with a closed capitellar growth plate. Anteroposterior radiograph with the elbow in 45° of flexion (A) and three-dimensional computed tomographic image (B) made at the time of initial presentation show the defect of the capitellum. Removal of free bodies and reconstruction of the articular surface (D) with use of osteochondral plug grafts (C) was performed. Anteroposterior radiograph with the elbow in 45° of flexion, made five months after the surgery, shows union of the osteochondral plug grafts and flattening of the capitellar subchondral bone (E).

Six of the seven patients with a stable osteochondritis dissecans lesion who were managed with elbow rest showed spontaneous healing. In two patients with a stable lesion who continued to play baseball or perform gymnastics, the lesions loosened or developed free fragments. Thus, repetitive microtrauma to the lesions disturbed the union of the newly formed bone, probably making the lesions unstable⁷. Even among the patients with a grade-I lesion with an open growth plate, four had a limited range of elbow motion with <120° at the time of the initial presentation because of severe pain, and three of the four were found to have an unstable lesion with displaced fragments at the time of surgery. The remaining patient was treated with elbow rest, and the outcome was not good. Therefore, we can conclude that a restriction of elbow motion of =20° suggests the existence of an unstable fragment.

Three patients with a grade-II lesion with an open physis and almost normal elbow motion had rested the affected elbow. Although the three showed partial healing in the lateral area of the lesion, only one achieved complete healing. These results suggest that grade-II osteochondritis dissecans lesions with an open physis are somewhat unstable and, to obtain complete healing and minimize the length of treatment, fragment fixation with use of a bone-peg may be considered as an alternative treatment (Fig. 2).

In osteochondritis dissecans lesions with a closed physis, the differences in outcome between the rested and active groups with regard to pain were slight; seven of the eleven lesions in the rested group showed no repair, and ten of the lesions in this group did not heal completely. These findings indicate that osteochondritis dissecans lesions with a closed physis are unstable and that elbow rest for such lesions is ineffective. Furthermore, the results after surgery for lesions with a closed physis were significantly better than those after nonoperative treatment. Thus, we believe that an osteochondritis dissecans lesion of the capitellum in a patient with a closed capitellar growth plate should be treated surgically.

The results of fragment fixation or reconstruction were significantly better than those of fragment removal alone. The outcome in terms of pain was closely correlated to the size of the lesion as seen radiographically. Our findings confirm that the optimum treatment aim is to obtain a normal capitellum. However, small defects of <50% of the capitellar articular width remaining after fragment removal alone resulted in an outcome similar to that achieved with fragment fixation or reconstruction. These findings indicate that fragment removal alone is the best option, only if the capitellar defect is small. Arthroscopic removal has the advantage of providing good results with minimum invasion^10-14. This procedure can provide prompt relief of pain and return to sports if the remaining defect of the capitellum is small. The ability to return to sports was not found to be related to radiographic findings, but it was significantly related to pain. The ability to return to sports might also be associated with other factors, such as the timing of the initial presentation of the patient as well as the motivation and circumstances of the patient.

On the basis of our findings, we propose the following guidelines for treatment. Elbow rest is appropriate for a stable osteochondritis dissecans lesion that has all of the following findings: it is classified as grade I, the capitellar growth plate is open, and the elbow motion is almost normal. Surgery should be considered for an unstable osteochondritis dissecans lesion that has one of the following findings: it is classified as grade II or III, the capitellar growth plate is closed, or there is a restriction of elbow motion of =20° (Table IV).

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TABLE IV Classification and Preferred Treatment of Osteochondritis Dissecans Lesions

Classification of Lesion	Capitellar Growth Plate	Radiographic Grade	Range of Motion	ICRS Classification^*	Preferred Treatment
Stable	Open	I	Normal	I	Elbow rest
Unstable	Closed	II or III	Restricted	II	Fixation and bone-peg graft
				III	Fixation and bone-peg or iliac bone graft
				IV	Fragment removal and reconstruction for large defect

ICRS = International Cartilage Repair Society

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TABLE IV Classification and Preferred Treatment of Osteochondritis Dissecans Lesions

Classification of Lesion	Capitellar Growth Plate	Radiographic Grade	Range of Motion	ICRS Classification^*	Preferred Treatment
Stable	Open	I	Normal	I	Elbow rest
Unstable	Closed	II or III	Restricted	II	Fixation and bone-peg graft
				III	Fixation and bone-peg or iliac bone graft
				IV	Fragment removal and reconstruction for large defect

ICRS = International Cartilage Repair Society

This study has some limitations. It was not prospective, and the data obtained were incomplete. Because of its retrospective approach, the study had limitations in terms of comparing the results of treatment. This investigation did not address the use of magnetic resonance imaging, computed tomography, ultrasonography, or arthroscopy, which can provide helpful information for lesion assessment and the selection of treatment^{7,10-13,29,33,34}.

The ICRS has suggested the following arthroscopic classification system for OCD lesions²⁸. ICRS OCD I indicates a stable lesion with a continuous but softened area covered by intact cartilage; ICRS OCD II, a lesion with partial discontinuity that is stable when probed; ICRS OCD III, a lesion with a complete discontinuity that is not yet dislocated; and ICRS OCD IV, an empty defect as well as a defect with a dislocated fragment or a loose fragment lying within the bed. The lesions we classified as stable correspond to ICRS OCD-I lesions. We believe they should be treated nonoperatively. For other lesions, the choice of surgical treatment should be determined according to the ICRS classification. We believe that bone-peg fixation is the best treatment for an ICRS OCD-II lesion (Fig. 2), and fragment fixation and bone-grafting should be done for an ICRS OCD-III lesion. In an ICRS OCD-IV lesion, the fragment should be removed and reconstruction of the articular surface should be considered if the osteochondral defect is >50% of the capitellar width (Fig. 3). ?

References

Materials and Methods | Results | Discussion | References

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Topics

elbow region ; epiphysial cartilage ; osteochondritis dissecans ; pain ; reconstructive surgical procedures ; sports ; motion of elbow ; capitellum of humerus

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Masatoshi Takahara, Nariyuki Mura, Junya Sasaki, Mikio Harada, Toshihiko Ogino; Classification, Treatment, and Outcome of Osteochondritis Dissecans of the Humeral Capitellum. The Journal of Bone & Joint Surgery. 2007 Jun;89(6):1205-1214.

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