Osteochondral transplantation to treat osteochondral lesions in the elbow.
ABSTRACT Effective treatment of osteochondral lesions in the elbow remains challenging. Arthroscopic débridement and microfracture or retrograde drilling techniques are often insufficient and provide only temporary symptomatic relief. The purpose of this study was to evaluate the treatment of these lesions with osteochondral autografts.
From 1999 to 2002, seven patients with osteochondral lesions of the capitellum humeri (five patients), trochlea (one patient), or radial head (one patient) were treated with cylindrical osteochondral grafts, which were harvested from the non-weight-bearing area of the proximal aspect of the lateral femoral condyle. The patients (three female and four male patients with an average age of seventeen years) were evaluated preoperatively and postoperatively, with an average follow-up of fifty-nine months. The Broberg and Morrey score was chosen for functional evaluation of the elbow (with regard to motion, pain, strength, activities of daily living, and stability), and the American Shoulder and Elbow Surgeons score was used for the analysis of pain. All patients had imaging studies done preoperatively to evaluate the defect and postoperatively to assess the ingrowth and viability of the graft. The ipsilateral knee was examined for donor-site morbidity.
The Broberg and Morrey score improved from a mean (and standard deviation) of 76.3 +/- 13.2 preoperatively to 97.6 +/- 2.7 postoperatively, and pain scores were significantly reduced (p < 0.05). The mean elbow extension lag of 4.7 degrees +/- 5.8 degrees was reduced to 0 degrees postoperatively. Compared with the contralateral side, there was a mean preoperative flexion lag of 12.9 degrees +/- 13.8 degrees . At the time of the final follow-up, flexion was free and was equal bilaterally in all patients. None of the plain radiographs made at the time of follow-up showed any degenerative changes or signs of osteoarthritis. The postoperative magnetic resonance imaging scans showed graft viability and a congruent chondral surface in all seven patients. No donor-site morbidity was noted at one year postoperatively.
The osteochondral autograft procedure described in the present study provides the opportunity to retain viable hyaline cartilage for the repair of osteochondral lesions in the elbow while restoring joint congruity and function and perhaps reducing the risk of osteoarthritis. These medium-term results suggest that the risks of a two-joint procedure are modest and justifiable. In addition, the described technique provides an option for revision surgery after the failure of other surgical procedures.
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ABSTRACT: Magnetic resonance imaging (MRI) has been widely used to characterize osteochondritis dissecans (OCD) lesions. However, the usefulness of MRI for predicting fragment stability in OCD of the humeral capitellum (capitellar OCD) remains unclear. Preoperative MRI cannot accurately diagnose fragment instability of capitellar OCD in overhead athletes. Cohort study (diagnosis); Level of evidence, 1. Twenty-seven male overhead athletes who had undergone surgery for capitellar OCD were included in the study. A single senior musculoskeletal radiologist blindly reviewed preoperative MRI of these OCD lesions. The radiologist reported the presence or absence of each of the 4 MRI signs indicating fragment instability as described by De Smet et al. The lesions were also classified according to the MRI staging system of Dipaola et al for characterizing the lesions. Intraoperative assessment of fragment stability was used as the gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined for fragment instability as assessed by MRI. According to the MRI criteria by De Smet et al and the Dipaola et al staging system, 21 (78%) and 20 (74%) lesions were defined as unstable, respectively. The obtained results yielded a sensitivity of 89% and a specificity of 44% for diagnosing fragment instability using the De Smet et al MRI criteria and a sensitivity of 83% and a specificity of 44% using the Dipaola et al MRI staging system. The PPV and NPV for fragment instability were 76% and 67% using the De Smet et al criteria and 75% and 57% according to the Dipaola et al staging system, respectively. The overall correlation rate of Dipaola et al MRI and intraoperative stages was 41%. Preoperative MRI cannot precisely diagnose fragment instability of capitellar OCD that requires operative treatments in overhead athletes. Especially, MRI indicating stable lesions is considered not to be useful in predicting intraoperative instability of capitellar OCD in this study population.The American journal of sports medicine 12/2011; 40(3):624-30. · 3.61 Impact Factor
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ABSTRACT: There is a need to clarify the usefulness of and problems associated with cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans. Twenty-six patients with advanced osteochondritis dissecans of the humeral capitellum were treated with use of cylindrical costal osteochondral autograft. All were males with elbow pain and full-thickness articular cartilage lesions of ≥15 mm in diameter. Clinical, radiographic, and magnetic resonance imaging outcomes were evaluated at a mean follow-up of thirty-six months (range, twenty-four to fifty-one months). All patients had rapid functional improvement after treatment with costal osteochondral autograft and returned to their former activities, including sports. Five patients needed additional minor surgical procedures, including screw removal, loose body removal, and shaving of protruded articular cartilage. Mean elbow function, assessed with use of the clinical rating system of Timmerman and Andrews, was 111 points preoperatively and improved to 180 points at the time of follow-up and to 190 points after the five patients underwent the additional operations. Mean elbow motion was 126° of flexion with 16° of extension loss preoperatively and improved to 133° of flexion with 3° of extension loss at the time of follow-up. Osseous union of the graft on radiographs was obtained within three months in all patients. Revascularization of the graft depicted on T1-weighted magnetic resonance imaging and congruity of the reconstructed articular surface depicted on T2-weighted or short tau inversion recovery imaging were assessed at twelve and twenty-four months postoperatively. Functional recovery was good, and all patients were satisfied with the final outcomes. Cylindrical costal osteochondral autograft was useful for the treatment of advanced osteochondritis dissecans of the humeral capitellum. Functional recovery was rapid after surgery. Additional operations were performed for five of the twenty-six patients, whereas the remaining patients showed essentially full recovery within a year. All patients were satisfied with the results at the time of short-term follow-up.The Journal of Bone and Joint Surgery 06/2012; 94(11):992-1002. · 3.23 Impact Factor
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ABSTRACT: To theoretically minimize complications of osteochondral graft harvest from the knee, grafts should be obtained from the site of lowest stress distribution across the joint. Long-term stress distribution over the patellofemoral (PF) joint surface is not equal in athletes. Cross-sectional study; Level of evidence, 3. Measurement of subchondral bone density can determine long-term resultant stress acting on an articular surface in living joints. Our analysis was performed using computed tomography (CT) image data obtained from bilateral knees of 10 college baseball fielders (fielder group) and 10 college baseball pitchers (pitcher group) and 2 control groups, including 10 college soccer players (soccer group) and 10 nonathletes (nonathlete group). The distribution pattern of subchondral bone density throughout the articular surface of the PF joint was assessed using the CT osteoabsorptiometry method. The quantitative analysis focused on the location of the low-density area at the articular surface to assess potential osteochondral donor sites. All participants in the pitcher and fielder groups demonstrated a low-density area widely distributed in the proximal part of the lateral trochlea. On the other hand, a high-density area was located in the distal part of the lateral notch, of the medial notch, and of the medial trochlea. No apparent differences in the distribution pattern were found between the baseball groups and the control groups. Our analysis, based on CT osteoabsorptiometry, indicates that the proximal lateral trochlea of the distal femur has the highest percentage area of low bone density at the PF joint level in donor knees of baseball players, soccer players, and nonathlete controls. From a biomechanical viewpoint, the proximal lateral trochlea is the optimal site for harvesting osteochondral grafts in performing mosaicplasty for baseball players. This selection for the donor site may minimize postoperative PF joint symptoms.The American journal of sports medicine 02/2012; 40(4):909-14. · 3.61 Impact Factor