Arthroscopic treatment of osteochondritis dissecans of the capitellum

The results of arthroscopic debridement and loose body retrieval for osteochondritis dissecans (OCD) of the capitellum in 29 symptomatic patients who had failed conservative management are described. There were no complications of surgery. At an average of 77 months after operation the majority of patients had mild or no pain but with some discomfort during heavy lifting and sport. All were capable of performing simple activities of daily living, and all but one had good or excellent outcomes and rated their satisfaction highly. Only 4 of 27 patients had to give up their preferred sport because of persistent elbow problems. Thirty-eight percent of patients had recurrence of locking or catching, although these symptoms were described as better than the condition before operation and none wanted further surgical intervention. It is concluded that arthroscopic debridement and removal of loose bodies is a safe and reliable procedure for patients with persistent symptoms from OCD of the capitellum.     

Radiography of the elbow for evaluation of patients with osteochondritis dissecans of the capitellum

Objective This study was performed to determine the ability of a routine radiographic examination of the elbow to detect osteochondritis dissecans of the capitellum and associated intra-articular loose bodies.Design and patients The study group consisted of 15 patients with osteochondritis dissecans of the capitellum confirmed by surgery or magnetic resonance imaging. Seven of the 15 patients had associated intra-articular loose bodies confirmed by surgery. All 15 patients had anteroposterior and lateral radiographs and magnetic resonance imaging of their symptomatic elbow. Nine of the 15 patients had subsequent elbow surgery. We reviewed the original interpretations of the radiographic examinations of the elbow of all 15 patients to determine whether osteochondritis dissecans of the capitellum and associated intra-articular loose bodies had been identified prospectively. We also reviewed the elbow radiographs of all 15 patients to determine whether osteochondritis dissecans of the capitellum and associated intra-articular loose bodies could be identified retrospectively.Results Osteochondritis dissecans of the capitellum was detected during the initial interpretations of the radiographic examinations of the elbow in seven of 15 patients. Osteochondritis dissecans of the capitellum was detected during retrospective review of the elbow radiographs in 10 of 15 patients. Intra-articular loose bodies were detected during the initial interpretations of the radiographic examinations of the elbow in three of seven patients. Intra-articular loose bodies were detected during retrospective review of the elbow radiographs in four of seven patients.Conclusions A routine radiographic examination of the elbow has limited sensitivity for detecting osteochondritis dissecans of the capitellum and associated intra-articular loose bodies.     

肱骨小头剥脱性骨软骨炎的MRI表现与手术对照分析

目的:探讨肱骨小头稳定型和不稳定型剥脱性骨软骨炎的MRI表现.方法:回顾性分析16例MRI诊断为肱骨小头剥脱性骨软骨炎患者的病例资料,其中有10例经手术证实.结果:I0例患者中病变均位于肱骨小头的前外侧面.6例为稳定型、4例为不稳定型剥脱性骨软骨炎.不稳定型病变在T2 WI上骨软骨片与母骨间有条状高信号或囊状高信号;稳...     

Oblique osteochondral plugs transplantation technique for osteochondritis dissecans of the elbow joint

Autologous osteochondral transplantation is an established surgical procedure for osteochondritis dissecans (OCD) of the knee, and has recently been applied in cases of advanced-staged OCD of the elbow. The elbow procedure; however, is more technically demanding than for the knee. One reason is the difficulties of perpendicular insertion of large-diameter osteochondral plugs to the humeral capitellum with a small, narrow operative field in the humeroradial joint. Furthermore, if the OCD lesion is located on the lateral site of the capitellum, the creation of recipient holes perpendicular to the joint surface is difficult due to the risk of damaging the lateral wall of the capitellum. To avoid such difficulties, we developed a new technique by which 6.5 and/or 8.5 mm diameter plugs are harvested from the ipsilateral knee, having an oblique cartilage surface relative to the long axis of the plugs. These are then inserted into the recipient holes which are created obliquely from the lateral and distal to medial and proximal directions in the capitellum at an angle complimentary to the harvested plugs. This technique allows easy insertion of large-diameter plugs into recipient holes in a restricted operative field, even if the OCD lesion is located in the lateral site.     

Bilateral osteochondritis dissecans of the medial trochlea femoris: an unusual case of patellofemoral pain

We report a case of bilateral osteochondritis dissecans of the medial trochlea femoris. Arthroscopic removement of loose bodies in the symptomatic left knee led to an excellent result; the untreated right knee showed effusion and locking one year later. This condition should be considered in the diagnosis of patellofemoral pain.     

MR imaging findings and MR criteria for instability in osteochondritis dissecans of the elbow in children

Purpose

Osteochondritis dissecans (OCD) of the elbow is an uncommon cause of elbow pain in adolescents and occurs at different locations in the elbow joint. Early diagnosis and treatment may prevent surgery. The aim of the study is to describe the MR imaging features of OCD at initial imaging, and to correlate these findings with surgical findings of stability and instability with arthroscopic findings as the reference standard.

Methods

Patients were identified through a keyword search of the radiology information system from 2000 to 2009. Twenty-five patients (26 elbows) with OCD of the elbow were identified (age 10.4–18 years, mean age 14 years). MR studies were retrospectively reviewed by two radiologists in consensus to define MR imaging findings and to determine the presence of previously described MR imaging criteria for OCD instability (i.e., high T2 signal rim, surrounding cysts, high T2 signal fracture line, fluid-filled osteochondral defect). Sensitivity of the individual and combined criteria was calculated.

Results

OCD occurred in the capitellum in 24 patients (92%), in the trochlea in 2 patients (8%) and radial head in 1 patient (4%). Loose bodies were identified in 11 (42%) patients. Eighteen patients demonstrated MRI findings in keeping with unstable lesions. In all 11 patients who had surgery the surgical findings of instability correlated with the MRI findings. When combined, the MR criteria were 100% sensitive for instability of OCD lesions of the elbow.

Conclusion

The vast majority of OCD of the elbow occurs in the capitellum. When used together, the MR criteria for instability were 100% sensitive for evaluation OCD lesions of the elbow.     

MR grading system of osteochondritis dissecans lesions: Comparison with arthroscopy

Objective

To assess the diagnostic performance of combined three-dimensional (3D) gradient-echo (GRE) T1-weighted and routine MR imaging protocol for the evaluation of osteochondritis dissecans (OCD).

Materials and methods

This prospective study was approved by our institutional review board and all patients gave informed consent. Three-dimensional GRE MR sequence was added to the routine protocol performed on 40 consecutive patients (35 men, 5 women; age range, 12–57 years; mean age, 20 years) with 17 juvenile and 24 adult OCD lesions (27 in knees; 14 in elbows) which were confirmed by arthroscopy. Two independent musculoskeletal radiologists reviewed all MR images. The OCD lesions were classified into five stages by assessing the signal intensity of fragment–bone interface and the integrity of articular cartilage on MR images. Stage-IV and -V lesions were considered as unstable. The sensitivity, specificity, accuracy, and interobserver agreement (κ statistics) were calculated.

Results

The sensitivity, specificity, and accuracy for detection of OCD instability were 100% (11 of 11), 100% (6 of 6), and 100% (17 of 17) in juvenile lesions; and 93% (14 of 15), 100% (9 of 9), and 96% (23 of 24) in adult lesions. The overall accuracy of MR findings in determining the staging was 90% (37 of 41) for reader 1 and 83% (34 of 41) for reader 2. Agreement between readers was substantial with a κ value of 0.75 for MR staging of OCD lesions.

Conclusions

Three-dimensional GRE T1-weighted MR imaging combined with the routine sequences demonstrates excellent diagnostic capabilities in detecting unstable OCD lesions.     

Cartilage and bone morphology in osteochondritis dissecans

Osteochondritis dissecans (OD) is a syndrome that can be characterized as a non-infectious disturbance of enchondral ossification or as a post-traumatic event. OD occurs in the joint cartilage and physis of long bones, as well as in the talus or metacarpal head especially of young athletes. The medial femoral condyle is the most commonly affected site. The causes of osteochondritis dissecans are poorly understood. Thirty human osteochondral cylinders from patients (aged 16–44 years) with osteochondritis dissecans of the medial femoral condyle (grades IV and V according to Rodegerdts and Gleissner) were harvested intraoperatively from osteochondritic areas as part of a cartilage-bone transplantation. Light microscopy, electron microscopy, and immunohistochemistry using poly- and monoclonal antibodies against collagens and glycosaminoglycans revealed differences between osteochondrotic and normal cartilage. Staining with toluidine blue at pH 1 shows a decrease in acidic glycosaminoglycans in OD. Modified pentachrome staining showed a thinned subchondral growth plate compared to normal osteochondral samples. Borders to the healthy tissue are clearly visible micro- and macroscopically. Scanning electron microscopy revealed structural differences in the subchondral area. Immunohistochemistry found a general decrease in glycosaminoglycan content and a change in composition. Only faint staining for chondroitin and keratan sulfates was observed in osteochondritic cartilage, whereas increased staining was shown for keratan sulfate in bone. Received: 25 August 1996 Accepted: 31 October 1996     

Gadopentetate-dimeglumine-enhanced MR imaging of osteonecrosis and osteochondritis dissecans of the elbow: initial experience

Magnetic resonance imaging (MRI) was performed on seven patients with aseptic osteonecrosis (n=4) and osteochondritis dissecans (OCD;n=3) of the elbow. Precontrast MRI was superior to plain radiographs, which did not show any abnormality in three cases of osteonecrosis. On gadopentetate-dimeglumine-enhanced T1-weighted images, which were obtained in three patients with osteonecrosis and three patients with OCD, all cases of osteonecrosis demonstrated homogeneous enhancement of the lesions. All cases of OCD were diagnosed on plain radiographs. On MRI one showed significant enhancement of the loose body. In another case an incompletely enhancing loose body was surrounded by a diffusely enhancing region. In the third patient only a small marginal enhancement of the defect was observed. Our results suggest that MRI can improve the accuracy in diagnosis of aseptic osteonecrosis of the elbow. The use of gadopentetate dimeglumine allows the viability of the lesions or the loose bodies to be demonstrated and reparative tissue to be detected.     

Nonoperative treatment of osteochondritis dissecans of the humeral capitellum

We examined 24 patients with osteochondritis dissecans of the humeral capitellum to determine the results of nonoperative treatment. The average age of the patients at the initial examination was 13.3 years (range, 11 to 16). All the patients were advised to stop heavy use of the elbow for 6 months. At the last examination, at a mean follow-up period of 5.2 years, 4 patients (17%) had no residual elbow pain, 7 (29%) had pain only with heavy activities, and 13 (54%) had pain with activities of daily living. Final radiographs were obtained for 15 lesions, of which 3 lesions were assessed as healed, 3 as improved, and 9 as not improved. Five of 11 lesions in the early stage and all 4 advanced lesions failed to show radiographic improvement. These results suggest that osteochondritis dissecans of the capitellum has only a slight tendency to heal, and that instability can cause failure of the lesion to heal.     

Multiple epiphyseal dysplasia complicated by severe osteochondritis dissecans of the knee

Two families are described which appear to contain examples of multiple epiphyseal dysplasia. In both families a striking incidence of severe osteochondritis of the knees was encountered. It is suggested that this was caused by the fragmented and maldeveloped epiphyses characteristic of epiphyseal dysplasia.     

Herbert screw fixation and reverse guided drillings, for treatment of types III and IV osteochondritis dissecans

We evaluated the outcome in 10 young patients, ages ranging from 15 to 26, with types III and IV osteochondritis dissecans of the knee, treated with Herbert screws fixation and reverse guided drillings. The disease involved the medial femoral condyle in eight patients and the lateral in two. Diagnosis and preoperative planning based on plain radiographs (AP, lateral and tunnel view) and MRI (in seven patients). Fixation of the fragment with Herbert screws using a mini-arthrotomy technique and additional reverse drillings behind the crater of the lesion using the ACL aiming devise were performed in all patients. Post-operatively, no weight bearing was recommended for at least three months. The follow-up ranged from 15 months to 38 months (mean 27 months). According to the subjective questionnaire of the International Cartilage Repair Society (ICRS) scale, seven patients had normal knees, two had nearly normal knees and one abnormal. The Lysholm Knee score ranged 65–96 points (mean 88 points). All patients except one returned to their previous activities and they were satisfied with the result. Radiological union of the fragment was found in 9/10 patients (six grade III, three grade IV). Progressive flattening of the injured femoral condyle was noticed in two patients (grade III). Securing the lesion using Herbert screws in combination with reverse guided drillings seems to be an effective treatment choice for detached or displaced osteochondral fragments.     

A surgical treatment for unstable osteochondritis dissecans lesions of the humeral capitellum in adolescent baseball players

BACKGROUND: Various methods of surgical treatment for unstable osteochondritis dissecans lesions of the humeral capitellum have shown the potential to lead to osteoarthritis and poor functional results in throwing activities. PURPOSE: The purpose of this study was to evaluate the results of surgical treatment with pull-out wiring and bone grafting (as established by Kondo in 1989) in patients with unstable osteochondritis dissecans lesions of the humeral capitellum. STUDY DESIGN: Retrospective review. METHODS: Eleven male baseball players (average age, 14.7 years) with unstable osteochondritis dissecans lesions underwent internal fixation with pull-out wiring and bone grafting. Follow-up was an average 57 months. At an average 17 weeks after surgery, bony union of the osteochondritis dissecans lesion was radiographically confirmed and the wires were removed. Throwing was allowed beginning at 6 months after surgery. RESULTS: At follow-up, all patients had obtained pain relief, and all except one had returned to previous throwing levels. Radiographs showed good healing, and minimal degenerative changes were found in only three joints. CONCLUSION: Healing of osteochondritis dissecans lesions of the elbow can be achieved after fragment fixation with pull-out wiring and a bone grafting technique.     

Magnetic resonance imaging in the evaluation of osteochondritis dissecans of the patella

OBJECTIVE: The objective was to evaluate the magnetic resonance (MR) appearance of patellar osteochondritis dissecans (OCD). MATERIALS AND METHODS: We retrospectively analyzed MR images of 16 patients (18 cases, mean age 20 years) using OCD of the patella. In 5 cases surgery was carried out, and we compared the surgical findings with the MR imaging findings in these cases. RESULTS: In all 18 cases, OCD was located central-inferiorly on the patella, and the average size was 11 x 11 x 7 mm. Subchondral deformities were present in 16 out of 18 cases (88.9%), subchondral cyst formation in 4 cases (22.2%), reactive bone marrow signal in 8 cases (44.4%), overlying patellar cartilage abnormality in 14 cases (77.8%), loose body in 2 cases (11.1%), patella alta in 8 cases (44.4%), hypoplastic sulcus in 7 cases (38.9%), and synovitis in 4 cases (22.2%). In all 5 cases in which surgery was carried out, the cartilage abnormality classified on the MR images was confirmed, and a loose body was removed at arthroscopy in 2 of the 5 cases. CONCLUSION: Magnetic resonance imaging of patellar OCD typically shows subchondral deformity and variable abnormalities of the overlying patellar cartilage located central-inferiorly on the patella.     

膝剥脱性骨软骨炎的X线平片与MRI诊断

目的 分析膝关节剥脱性骨软骨炎（OCD）的X线平片与MRI表现，比较各序列对病变的检出价值。方法 对膝关节摄取平片，常规行冠状面和矢状面T1WI、质子密度加权像（PDWI)、T2WI、快速小角度激发（FLASH）T2^*WI。选取资料齐全并已证实的OCD 36例（38只），采用双盲对照的方法对X线及MRI征象进行分析；比较各序列对病变的检出率。结果 （1）病变好发于股骨内侧踝（24只，63．2％），典型型、扩展型和中心下面型分别占55．3％（21／38）、15．8％（6／38）、28．9％（11／38）。（2）其X线表现为从关节面剥离的小骨片，骨片密度较高，边缘锐利，周围环绕一圈明显的透亮线，其下为容纳骨片的骨窝。（3）MRI表现为关节软骨下局灶性小病变，矢状面呈半月形38例，冠状面呈楔形14例、短条形24例。病变在T1WI上呈低或等信号，在T2WI、FLASH T2^*WI病变周边环绕一低或高信号带，软骨下骨板消失或变薄，部分可见关节软骨断裂或消失。（4）T1WI对病变的检出率较高。结论 （1）OCD有较独特的X线与MRI表现，MRI可对其作出较明确的诊断。（2）T1WI对病变的检出率较高。     

Longitudinal long-term results of surgical treatment in patients with osteochondritis dissecans of the femoral condyles

In a longitudinal study, we performed a second follow-up examination on patients suffering from osteochondritis dissecans at the femoral condyles 10 years after a first follow-up, which had been performed 10 years after surgical treatment. Results (clinical score; radiological signs of OA) were analysed depending on the stage of the epiphyseal plate at the time of surgery, the used surgical procedure was divided into retrograde and anterograde procedures, and removal of loose bodies depending on the stage of the lesion. The analysis clearly exhibited that JOCD patients demonstrated better results than AOCD patients. The clinical score obtained after 10 years improved significantly with time, particularly for JOCD patients. Overall, when a retrograde procedure had been used in cases with an intact cartilage layer clinical results were better than those obtained in patients in whom an anterograde procedure with restoration of the joint surface or simple removal of the loose fragments had been performed. After a mean follow-up of 20 years the mean OA-stage was 0.27 in JOCD patients, whereas in AOCD patients a mean OA-stage of 1.55 was detected. Worst OA-changes were detected in patients in whom acrylic glue had been used for refixation of the loose bodies. Mark Rayf and Joern Steinhagen are Doctoral students.     

Direct coronal computed tomography arthrography of osteochondritis dissecans of the talus

Although radiographs, arthrography, tomography, and computed tomography can all be used to diagnose osteochondritis dissecans of the talus, these imaging methods may not demonstrate whether an undisplaced osteochondral fragment has any attachment to the articular cartilage or bony bed of the talus. As lack of such attachment is a relative indication for surgery, we studied the feasibility of using coronal computed tomography (CT) after double contrast arthrography to demonstrate attachment in four patients with osteochondritis dissecans seen on radiographs. Direct coronal CT arthrographic images showed intact articular cartilage in three patients. In the fourth patient, overlying cartilage was virtually absent and contrast tracked beneath the fragment, an appearance that correlated with arthroscopic findings of partial articular cartilage attachment and no union at the osteochondral fracture line. Our initial experience suggests that direct coronal CT arthrography clearly shows the state of attachment of the osteochondritic fragment to the talus.     

Internal fixation for osteochondritis dissecans of the knee

Eight knees of seven patients with osteochondritis dissecans of the knee underwent internal fixation of the fragments. The affected location was the medial femoral condyle in four knees, the lateral femoral condyle in one knee and the patellar groove in three knees. At the time of surgery, patient age ranged from 13 to 20 years (mean 16.9 years). Open reduction and internal fixation of the unstable fragments was performed with autologous bone pegs in one knee. In the other seven knees, the procedures were carried out with biodegradable poly-L-lactide pins. At a mean follow-up of 5 years (range 4–6.8 years), seven fragments were united, whereas one knee required arthroscopic removal of the loose fragment. Neither effusion nor synovitis was noticed in any of the patients treated with biodegradable pins. The technique is simple and provides satisfactory results, suggesting a valid option for the treatment of osteochondral defects where possible.     

Natural progression of osteochondritis dissecans of the humeral capitellum: initial observations

PURPOSE: To determine the earliest findings, subsequent changes, and natural course of osteochondritis dissecans of the humeral capitellum. MATERIALS AND METHODS: Among 95 patients with osteochondritis dissecans of the humeral capitellum, 16 (mean age, 12.5 years) were selected for this retrospective study because they seemed to have early osteochondritis dissecans and had been followed up without any surgical treatment for 6 months or more (mean, 3.5 years). RESULTS: The initial imaging appearances of the 16 patients' lesions were divided into two types: localized subchondral bone flattening without fragments in seven, and nondisplaced fragments in nine. Patients with lesion flattening had younger ages and significantly shorter durations of symptoms, and most had open growth plates. In five of the seven with flattening, new bone formed over the flattened bone, and the fragments united after arm motion reduction. In contrast, patients with nondisplaced fragments at clinical presentation had longer durations of symptoms with continued arm motion, and their nondisplaced fragments failed to unite. CONCLUSION: The earliest feature of osteochondritis dissecans is subchondral bone flattening, over which new bone subsequently forms. The new bone then can unite with the underlying bone. However, if subjected to repetitive forces over a given time, unstable fragments develop. These fragments, even if not yet displaced, are unable to unite.