Capitellar OCD

 

Capitella OCD 1Capitella OCD 2

 

Epidemiology

 

Adolescents 12 - 20

Boys > girls

 

Repetitive overhead or loading actitivities

- throwing athletes / baseball

- gymnastics

- tennis

 

Kida et al Am J Sports Med 2014

- 2433 adolescent baseball players

- incidence of capitellar OCD on screening was 3.4%

- players with OCD had started baseball earlier and had played longer

 

DDx

 

Panner's disease / osteochondrosis

- child 4 - 8 years old

- entire capitellar epiphysis

- ischaemia and necrosis of the capitellum

- followed by regeneration and recalcification

- benign self limiting disease that resolves with rest

 

Aetiology

 

Excessive valgus compression across elbow joint

 

Common throwing sports / gymnastics

- dominant limb

- repetitive overuse

- valgus overload on radiocapitellar joint 

- injury to the vascular supply of the subchondral bone

- localized avascular necrosis

 

Symptoms

 

Dominant arm / history of over-use

 

Lateral elbow pain

 

Limited range of motion

 

Clicking, grinding, catching, locking - loose bodies

 

Examination

 

Tender over lateral aspect elbow

 

Loss of extension

 

Radio-capitellar compression test

- active supination and pronation with arm fully extended

 

Examine MCL

 

Xray

 

Kijowski et al Skeletal Radiology 2005

- 50% of capitellar OCD not identified on xray

 

Capitellar OCDCapitella OCD 1

Localized flattening and translucency                        Lucency in capitellum

 

CT

 

Elbow OCD Type 2BElbow OCD Type 2B CT

 

Capitella OCD 2Capitellar OCD CT

 

MRI

 

Fluid interface denotes detachment / instability

 

Capitellar OCD MRIElbow OCD MRI displaced

 

MRI Classification

 

Stable

- cartilage intact

- no fluid behind lesion

 

Unstable

- cartilage breach

- fluid behind lesion

 

Bexkens et al Should Elbow 2020

- inter-observer reliability of MRI classification

- acceptable reliability for stable v unstable only

 

ICRS Arthroscopic Classification

 

Grade 1:  Stable lesion - soft, but cartilage continuous

Grade 2:  Partially discontinuous

Grade 3:  Complete discontinuity but not dislocated

Grade 4:  Empty defect

 

Locations

 

Central - lateral wall intact, contained, easier to manage

Lateral wall - uncontained lesion

 

Lateral wall capitella OCDCentral contained defect

Lateral capitellar OCD                                Central contained capitellar OCD

 

Size

 

< half diameter radial head

> half diameter radial head

 

Management

 

Non operative

 

Indications

 

Stable lesion

- intact cartilage

- nil detachment / no synovial fluid behind OCD

 

Option

 

Protected ROM

- hinged brace

- attempt to reduce axial load

- nil sports until full ROM

- 3-6 months

 

Results

 

Sakata et al Am J Sports Med 2021

- nonoperative treatment of 81 youth baseball players

- return to play 70%

 

Mihara et al Am J Sports Med 2009

- 39 baseball players mean age 13 years

- cessation of throwing, weights, push ups

- healing of lesion in 16/17 patients with open growth plates

- healing of lesion in 11/22 with closed growth plates

- 25/30 early stage lesions healed

- only 1/9 advanced stage lesions healed

- suggest early surgical intervention in advanced OCD

- recommend surgical intervention if no sign of healing in 3-6 months

 

Operative

 

Indications

 

1.  Failure nonoperative treatment

2.  Unstable lesions

3.  Loose bodies

 

Outcomes

 

Westermann et al Orthop J Sports Med 2016

- systematic review of surgical management of capitellar OCD

- 24 studies and 492 patients

- return to sport 64% OCD fixation

- return to sport 71% OCD removal and marrow stimulation

- return to sport 94% osteochondral autograft

 

Large & salvageable fragments

 

Options

 

Drill in situ

Fixation

 

Drill in situ

 

Indications

 

Stable lesion

Failed nonoperative treatment

 

Elbow OCD InsituElbow OCD Retrograde Drilling

Capitellar OCD viewed via anterior portals, being drilled in retrograde fashion using ACL jig

 

Arthroscopic technique

1.  Anterograde

2.  Retrograde using ACL jig

 

B.  Unstable - Fixation

 

Indications

 

Acute injury

Large fragment

Minimal bony fragmentation

 

Technique

 

Vumedi open capitellar OCD fixation

 

Outcomes

 

Hennrikus et al J Paediatr Orthop 2015

- 26 unstable OCD fixed

- 20/26 healed

 

Small or unsalvageable fragments

 

Options

 

Arthroscopic debridement

Arthroscopic debridement + marrow stimulation

Osteochondral autograft

 

Outcomes

 

Debridement versus debridement + microfracture

 

McLaughlin et al Arthros Sports Med Rehab 2021

- systematic review comparing debridement versus debridement + microfracture

- both procedures improved pain, ROM, outcome scores and return to play

- return to play 40 - 100% after debridement

- return to play 55 - 75% after microfracture

- comparable midterm outcomes

 

Debridement + microfracture versus osteochondral autograft

 

Westermann et al Orthop J Sports Med 2016

- systematic review of surgical management of capitellar OCD

- 24 studies and 492 patients

- return to sport 71% OCD removal and marrow stimulation

- return to sport 94% osteochondral autograft

 

Natural history

 

Ueda et al Orthop J Sports Med 2017

- 38 elbows treated with fragment removal followed for minimum 5 years

- lesions < half radial head had better outcomes than lesions > half radial head

- increased radiological osteoarthritis in group with smaller lesions

 

Arthroscopic debridement of loose fragments +/- marrow stimulation

 

Technique

 

Elbow arthroscopy

Posterior portals

- capitellar OCD viewed by flexing elbow

 

Arthroscopic technique of debridement and microfracture PDF

 

Vumedi video capitellar debridement + microfracture

 

Elbow Scope Capitellar OCDElbow Scope OCD Debridement

Arthroscopic debridement of loose fragments

 

Elbow Scope OCDElbow scope OCD Microfracture

Arthroscopic debridement of loose fragments and microfracture

 

Elbow OCDElbow OCD Abrasion

Arthroscopic debridement of loose fragments and abrasionplasty

 

Capitellar Osteochondral Defects

 

Options

 

Osteochondral autograft / mosaicplasty

Osteochondral allograft

MACI

 

Mosaicplasty

 

Indications

 

Unsalvageable OCD

Loose body

Failed arthroscopic debridement and marrow stimulation

 

Technique

 

Osteochondral plugs from lateral femoral condyle of knee

Anconeus split approach

 

Capitellar mosaicplasty surgical technique PDF

 

Vumedi technique

 

AO surgery foundation lateral approach to distal elbow

 

Outcomes

 

Maruyama et al Am J Sports Med 2014

- 33 male baseball players mean age 13

- mean defect size 1.5 x 1.5

- plugs from lateral femoral condyle

- 91% no pain

- good improvement in ROM

- 31/33 return to sport at 7 months

 

Matsuura et al Am J Sports Med 2017

- compared mosaicplasty for 43 central lesions versus 44 lateral lesions

- lateral lesions larger and needed more grafts than central lesions

- better ROM and return to sport in central lesions

- more osteoarthritis with lateral lesions

- no difference in outcomes