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Adolescent Athletes Achieve High Levels of Athletic and Daily Function After Arthroscopic Marrow Stimulation for Elbow Capitellar Osteochondritis Dissecans

Open AccessPublished:September 29, 2022DOI:https://doi.org/10.1016/j.asmr.2022.08.007

      Purpose

      To determine the functional outcomes of adolescent athletes treated with arthroscopic marrow stimulation/microfracture for elbow capitellar osteochondritis dissecans (OCD).

      Methods

      The medical records for all patients younger than 18 years of age with capitellar OCD who underwent arthroscopic treatment at a single institution were retrospectively reviewed. The variables examined included patient characteristics, bone age, pre- and postoperative lesion grade/size and range of motion (ROM), intraoperative lesion grade/size, time to postoperative return to sport, and validated outcome scores.

      Results

      Twenty patients with 21 treated elbows met the study’s inclusion criteria. Three patients were not available for follow-up, leaving 18 of 21 (85.7%) elbows in the final cohort. Mean age and follow-up was 14.1 and 4.4 years, respectively. All 18 elbows were treated with diagnostic arthroscopy, arthroscopic debridement with loose body removal as indicated, and marrow stimulation. Sixteen of 18 (88.9%) elbows returned to sports postoperatively, with 12 of 18 (66.7%) elbows returning to their primary sport at the same level or higher. Overall, there were significant improvements in elbow ROM (132.8°, range 120°-140° postoperatively, compared with 122.1°, range 80°-140° preoperatively) (P = .002) and excellent Quick Disabilities of the Arm, Shoulder and Hand scores (mean 2.3 ± 5.1), as well as Kerlan-Jobe Orthopaedic Clinic Overhead Athlete Shoulder and Elbow scores (mean 94.1 ± 8.7) in those who returned to sports. There was no correlation with outcome or return to sport for preoperative lesion grade/size, bone age, physeal status or open versus arthroscopic treatment.

      Conclusions

      Arthroscopic debridement and marrow stimulation for capitellar OCD in adolescent athletes leads to improvements in ROM, as well as a high rate of return to sport, and high levels of athletic and daily functional activity during follow-up, regardless of bone age and lesion grade/size at time of surgery.

      Level of Evidence

      Level IV, therapeutic case series.
      Osteochondrosis of the capitellum was described in 1929 by Panner as an incidental finding in young children that typically resolves spontaneously.
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      Surgical options consist of open and arthroscopic debridement, fragment excision, fragment fixation, abrasion chondroplasty, marrow stimulation via microfracture/drilling, and, more recently, osteochondral autograft transplantation, or mosaicplasty, for larger high-grade lesions. Mosaicplasty has shown good short- to mid-term results
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      • Toh S.
      Osteochondral autograft transplantation for osteochondritis dissecans of the elbow in juvenile baseball players: Minimum 2-year follow-up.
      but requires an open arthrotomy, which can lead to elbow stiffness
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      • Wiesel B.B.
      • Sankar W.N.
      • Ganley T.J.
      Arthroscopic management of osteochondritis dissecans of the capitellum: Mid-term results in adolescent athletes.
      and potentially lengthy recoveries.
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      • Ishikawa J.
      • Masuko T.
      • Funakoshi T.
      • Minami A.
      Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes.
      ,
      • Iwasaki N.
      • Kato H.
      • Ishikawa J.
      • Saitoh S.
      • Minami A.
      Autologous osteochondral mosaicplasty for capitellar osteochondritis dissecans in teenaged patients.
      ,
      • Yamamoto Y.
      • Ishibashi Y.
      • Tsuda E.
      • Sato H.
      • Toh S.
      Osteochondral autograft transplantation for osteochondritis dissecans of the elbow in juvenile baseball players: Minimum 2-year follow-up.
      Arthroscopic treatment is therefore preferable when possible. While early arthroscopic studies focused on debridement and abrasion chondroplasty,
      • Jones K.J.
      • Wiesel B.B.
      • Sankar W.N.
      • Ganley T.J.
      Arthroscopic management of osteochondritis dissecans of the capitellum: Mid-term results in adolescent athletes.
      • Baumgarten T.E.
      • Andrews J.R.
      • Satterwhite Y.E.
      The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum.
      • Ruch D.S.
      • Cory J.W.
      • Poehling G.G.
      The arthroscopic management of osteochondritis dissecans of the adolescent elbow.
      • Byrd J.W.
      • Jones K.S.
      Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: Minimum three-year follow-up.
      • Brownlow H.C.
      • O'Connor-Read L.M.
      • Perko M.
      Arthroscopic treatment of osteochondritis dissecans of the capitellum.
      • Miyake J.
      • Masatomi T.
      Arthroscopic debridement of the humeral capitellum for osteochondritis dissecans: Radiographic and clinical outcomes.
      • Ueda Y.
      • Sugaya H.
      • Takahashi N.
      • et al.
      Arthroscopic fragment resection for capitellar osteochondritis dissecans in adolescent athletes: 5- to 12-year follow-up.
      with mixed outcomes and varying return to sport rates (25%-86%), some studies have suggested increased risk for early OA with arthroscopic debridement alone.
      • Baumgarten T.E.
      • Andrews J.R.
      • Satterwhite Y.E.
      The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum.
      ,
      • Byrd J.W.
      • Jones K.S.
      Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: Minimum three-year follow-up.
      ,
      • Miyake J.
      • Masatomi T.
      Arthroscopic debridement of the humeral capitellum for osteochondritis dissecans: Radiographic and clinical outcomes.
      In response, more recent studies have focused on marrow stimulation/microfracture,
      • Bojanić I.
      • Ivković A.
      • Borić I.
      Arthroscopy and microfracture technique in the treatment of osteochondritis dissecans of the humeral capitellum: Report of three adolescent gymnasts.
      • Wulf C.A.
      • Stone R.M.
      • Giveans M.R.
      • Lervick G.N.
      Magnetic resonance imaging after arthroscopic microfracture of capitellar osteochondritis dissecans.
      • Lewine E.B.
      • Miller P.E.
      • Micheli L.J.
      • Waters P.M.
      • Bae D.S.
      Early results of drilling and/or microfracture for grade IV osteochondritis dissecans of the capitellum.
      • Bexkens R.
      • van den Ende K.I.M.
      • Ogink P.T.
      • van Bergen C.J.A.
      • van den Bekerom M.P.J.
      • Eygendaal D.
      Clinical outcome after arthroscopic debridement and microfracture for osteochondritis dissecans of the capitellum.
      • Matsuura T.
      • Iwame T.
      • Suzue N.
      • et al.
      Long-term outcomes of arthroscopic debridement with or without drilling for osteochondritis dissecans of the capitellum in adolescent baseball players: A ≥10-year follow-up study.
      with good-to-excellent results commonly reported. However, most of these studies had small sample sizes, a short duration of follow-up, no comment on bone age, and vague characterization of the return to sport (e.g., level of play). The purpose of this study was to determine the functional outcomes of adolescent athletes treated with arthroscopic marrow stimulation/microfracture for elbow capitellar OCD. We hypothesized that arthroscopic marrow stimulation of capitellar OCD in the adolescent athlete would result in improved symptoms, high return to sport rates, and good functional outcomes in a majority of those treated.

      Methods

      After approval by our institutional review board, a retrospective review was performed of the medical records for all children and adolescents younger than 18 years who underwent arthroscopic treatment with marrow stimulation for elbow OCD between January 2010 and December 2019 at a single institution by a single surgeon. All patients who had undergone previous surgery of their elbow were excluded. The characteristics and details of injury were collected from the patient’s charts. Preoperative information such as primary sport played and level at of play at the onset of symptoms, history of previous trauma, arm dominance, months symptomatic before surgery, length of rest before surgery, reported mechanical and/or loss of motion, and clinical range of motion (ROM) was recorded. All patients and their parents were encouraged to attempt conservative treatment (i.e., rest from all sports) before considering surgery, unless they demonstrated a significant loss of motion and/or loose bodies were identified on imaging at the initial presentation. Preoperative radiographs and magnetic resonance imaging (MRI) were reviewed for all patients. Bone age, capitellar physeal status, lesion grade, and size were recorded. The Sauvegrain method was used for determining skeletal age based on preoperative radiographs.
      • Sauvegrain J.
      • Nahum H.
      • Bronstein H.
      Study of bone maturation of the elbow.
      Lesions were classified as either stable or unstable (Table 1), and lesion size was measured and classified as either small, moderate, or large using the classification systems proposed by Takahara et al.
      • Takahara M.
      • Ogino T.
      • Sasaki I.
      • Kato H.
      • Minami A.
      • Kaneda K.
      Long term outcome of osteochondritis dissecans of the humeral capitellum.
      ,
      • Takahara M.
      • Mura N.
      • Sasaki J.
      • Harada M.
      • Ogino T.
      Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum.
      Defect percentage was calculated as a percent width of the defect size in relation to the capitellum on anteroposterior radiographs. Defect angle was calculated as the angle created from the center of the capitellum to the upper and lower ends of the defect on lateral radiographs. Defect percentages <55% or defect angle <50° were classified as small, and defect percentages >70% or > 90° were classified as large; all others were classified as moderate. To best account for variations in skeletal maturity and lesion size, we further subclassified each lesion based on whether the radial head and capitellar physis were open or closed, similar to Miyake and Masatomi.
      • Miyake J.
      • Masatomi T.
      Arthroscopic debridement of the humeral capitellum for osteochondritis dissecans: Radiographic and clinical outcomes.
      For the capitellum and the radial head physis, lesions were labeled as either small open, small closed, moderate open, moderate closed, large open, or large closed.
      Table 1Proposed Classification for Osteochondritis Dissecans Lesions of the Capitellum
      ClassificationCapitellar Growth PlateRadiographic GradeRange of MotionICRS Classification
      StableOpenINormalI
      UnstableClosedII or IIIRestrictedII, III, or IV
      NOTE. Adapted from Takahara et al.
      • Takahara M.
      • Mura N.
      • Sasaki J.
      • Harada M.
      • Ogino T.
      Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum.
      ICRS, International Cartilage Repair Society.
      Operative reports were investigated for information related to procedure performed, number of loose bodies present, and intraoperative lesion grade (as determined using the International Cartilage Repair Society classification system).
      • Brittberg M.
      • Winalski C.S.
      Evaluation of cartilage injuries and repair.
      Grade I lesions were considered stable with softened intact cartilage; grade II lesions were stable with probing but had some partial discontinuity; grade III lesions have complete discontinuity with probing; and grade IV lesions had an empty defect or dislocated fragment laying within the defect. Diagnostic elbow arthroscopy with a short small joint 2.7-mm arthroscope was performed on all patients in the prone position with a tourniquet. Standard direct lateral, anterolateral, anteromedial, posterior, and posterolateral portals were used as indicated. Antegrade marrow stimulation/drilling was performed on grade I lesions (n = 1) with a 0.062 smooth pin using fluoroscopy in a trans-osseous articular cartilage-sparing manner. Grade III-IV lesions (n = 17) were treated with loose body removal, abrasion chondroplasty, and marrow stimulation via microfracture or drilling. Capitellar defects were debrided to fresh bleeding subchondral bone, approximately 2 to 3 mm on average, with combined use of a shaver and ringed curettes. Microfracture or drilling was then performed using an angled awl, smooth pin, or a PowerPick device (Arthrex, Naples, FL) to a depth of 4 mm based on access and patient body habitus. Inflow and tourniquet pressure were decreased after microfracture to ensure the egress of marrow elements and blood.
      All surgeries were performed as same-day procedures, with patients discharged on the day of surgery. A compressive soft dressing was applied for the initial 7 to 10 days postoperatively. An arm sling was provided for comfort. Patients were allowed to begin gentle ROM exercises immediately after surgery. Physical therapy, consisting of full active and active assisted ROM exercises in all planes, began within 1 to 2 weeks from the date of surgery. Strengthening did not begin until full or near-full ROM was achieved and no sooner than 3 months after surgery. All patients were advised to refrain from participating in sports activity for a minimum of 4 to 6 months.
      Postoperatively, patients were contacted via phone or seen in clinic at a minimum of 2 years for follow-up. Information on return to primary sport, return to other sports, level of play returned to, total recovery time, need for repeat surgery, and validated patient-reported outcome measurements (PROMs) were recorded. Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores
      • Beaton D.E.
      • Wright J.G.
      • Katz J.N.
      Development of the QuickDASH: Comparison of three item-reduction approaches.
      were collected for all patients; Kerlan-Jobe Orthopaedic Clinic (KJOC) Overhead Athlete Shoulder and Elbow scores
      • Alberta F.G.
      • ElAttrache N.S.
      • Bissell S.
      • et al.
      The development and validation of a functional assessment tool for the upper extremity in the overhead athlete.
      were only collected on those who returned to their primary sport. Both of these PROMs have been validated for acquisition of information via telephone.
      • Wilkinson J.T.
      • Clawson J.W.
      • Allen C.M.
      • Presson A.P.
      • Tyser A.R.
      • Kazmers N.H.
      Reliability of telephone acquisition of the PROMIS upper extremity computer adaptive test.
      ,
      • Erickson B.J.
      • Chalmers P.N.
      • Newgren J.
      • et al.
      Can the Kerlan-Jobe Orthopaedic clinic shoulder and elbow score be reliably administered over the phone? A randomized study.
      Length of follow-up was defined as time from surgery to collection of PROM via telephone or clinic visit. Postoperative ROM was recorded from the patient’s final postoperative clinic visit.
      Descriptive statistics were calculated for all variables. Change over time for ROM and lesion size was compared using the paired-samples t test. Bone age was compared with chronologic age using the paired-samples t test and the Pearson correlation coefficient to identify the presence of and magnitude of a linear relationship. Correlations between patient demographics or lesion characteristics and outcome scores were determined using the Spearman rho correlation coefficient. Differences between various groups of interest on outcomes scores were compared using the Mann–Whitney U test. Preoperative lesion grading was compared with intraoperative lesion grading using the χ2 test. Factors potentially associated with return to sport were evaluated with either the Mann–Whitney U test or the χ2 test, as appropriate for variable type. Analyses were performed using SPSS, version 27 (IBM Corp. [Released 2020. IBM SPSS Statistics for Macintosh], Armonk, NY). Alpha was set at P < .05 to declare significance.

      Results

      A total of 20 patients and 21 elbows treated surgically for capitellar OCD met the study’s inclusion criteria. Of this cohort, 17 of 20 patients (85%) and 18 of 21 elbows (85.7%) were contacted via clinic follow-up or telephone with a minimum of 2-year follow-up and were included in the final cohort for our study. Our cohort included 3 female and 14 male patients. There was 1 female patient who had bilateral elbows treated surgically at different times. The mean age at time of surgery was 14.1 years (range, 11-17 years), and mean duration of follow-up was 4.4 years (2-10). Mean bone age at time of surgery was 13.9 years (12.5-15). Mean time symptomatic before surgery was 15.6 months (3.5-53.6), and duration of complete rest from sport before surgery was 4.6 months (0-14.8). In this study, primary sport played at time of symptom onset was as follows: baseball, n = 8; gymnastics/cheer, n = 4; and other (swimming, football, golf, mountain biking, tennis), n = 5. Table 2 summarizes the patient demographics for the overall study cohort.
      Table 2Demographics
      Total
      No. of athletes17
       Male14
       Female3
      No. of elbows18
      Dominant arm affected14
      Mean time symptomatic before surgery, mo15.6
      Mean time of complete rest before surgery, mo4.6
      Mean age at surgery, y14.1
      Mechanical symptoms reported9
      Loss of motion reported7
      Sport
       Baseball8
       Gymnastics, cheerleading4
       Other5
      All lesions were noted to be unstable based on the classification by Takahara et al.,
      • Takahara M.
      • Mura N.
      • Sasaki J.
      • Harada M.
      • Ogino T.
      Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum.
      indicating a requirement for surgery. Four patients were noted to have an open capitellar physis at time of surgery, and 12 had open radial head physis. Table 3 summarizes the preoperative and intraoperative lesion classifications for this study cohort.
      Table 3Preoperative and Intraoperative Classification of Lesions
      Total
      Lesion stability (Takahara)
       Stable0
       Unstable18
       Mean defect percentage43% (23.4-64.6)
       Mean defect angle59.3° (40-154.6)
      Lesion size (Takahara)
       Small13
       Moderate4
       Large1
       Open capitellar physis3
       Open radial head physis11
      Subclassification based on capitellar physis
       SMo2
       SMc11
       Mo0
       Mc4
       Lo1
       Lc0
      Subclassification based on radial head physis (Miyake and Masatomi)
       SMo8
       SMc5
       Mo2
       Mc2
       Lo1
       Lc0
      Intraoperative lesion grade (ICRS)
       I1
       II2
       III5
       IV10
      ICRS, International Cartilage Repair Society; Lc, large closed; Lo, large open; Mc, moderate closed; Mo, moderate open; SMc, small closed; SMo, small open.
      Postoperatively, 16 of 18 (88.9%) elbows returned to sports, with 12 of 18 (66.7%) elbows returning to their primary sport at the same level of play or higher. Of those who did not return to their primary sport, 2 baseball players switched to golf by choice, 1 baseball player switched to lacrosse due to fear of injuring his elbow, and 1 football player switched to golf due to fear of injuring his elbow. The 2 patients who switched sports due to fear of injuring their elbow did not report continued pain postoperatively. Of the other athletes not returning to sport, 1 discontinued swimming by choice and 1 discontinued mountain biking due to continued pain in his elbow. Of note, 2 patients had a history of previous lateral condyle fracture years before operation; one discontinued mountain biking due to his elbow pain and the other switched from baseball to golf by choice.
      There was a significant improvement in mean total arc ROM postoperatively (132.8°, range 120°-140° postoperatively, compared with 122.1°, range 80°-140° pre-operatively) (P = .002). Mean recovery time before returning to sports for those who did return was reported to be 7.7 months (4.2-19.5). Postoperatively, KJOC Overhead Athlete Shoulder and Elbow scores were collected on 12 of 16 elbows (75%) in patients who returned to sports with a mean score of 94.1 (68.5-100). Of the 4 patients who returned to sports but did not have a KJOC score, 3 were no longer playing sports competitively or recreationally and 1 refused to participate but did report that he had returned to sport. QuickDASH scores were collected on 17 of 18 elbows (94.4%) with a mean score of 2.3 (0-18.2). The patient who refused the KJOC score was the only patient without a QuickDASH score recorded. Postoperative outcome scores and ROM are presented in Table 3. There were no reoperations in our cohort or postoperative complications. When cross-analyses were performed, there was no correlation between time symptomatic prior to surgery, preoperative lesion grade, intraoperative lesion grade, bone age, radial head or capitellar physeal status, or treatment type with outcome scores, range of motion, or return to sport.

      Discussion

      In this study, all patients showed significant improvement in elbow ROM and excellent PROMs at final follow-up; 16 of 18 (88.9%) elbows returned to sports postoperatively, with 12 of 18 (66.7%) returning to their primary sport at the same level or higher. These results are similar to those reported previously.
      • Bojanić I.
      • Ivković A.
      • Borić I.
      Arthroscopy and microfracture technique in the treatment of osteochondritis dissecans of the humeral capitellum: Report of three adolescent gymnasts.
      • Wulf C.A.
      • Stone R.M.
      • Giveans M.R.
      • Lervick G.N.
      Magnetic resonance imaging after arthroscopic microfracture of capitellar osteochondritis dissecans.
      • Lewine E.B.
      • Miller P.E.
      • Micheli L.J.
      • Waters P.M.
      • Bae D.S.
      Early results of drilling and/or microfracture for grade IV osteochondritis dissecans of the capitellum.
      • Bexkens R.
      • van den Ende K.I.M.
      • Ogink P.T.
      • van Bergen C.J.A.
      • van den Bekerom M.P.J.
      • Eygendaal D.
      Clinical outcome after arthroscopic debridement and microfracture for osteochondritis dissecans of the capitellum.
      • Matsuura T.
      • Iwame T.
      • Suzue N.
      • et al.
      Long-term outcomes of arthroscopic debridement with or without drilling for osteochondritis dissecans of the capitellum in adolescent baseball players: A ≥10-year follow-up study.
      Our findings are presented in the context of those from similar studies in Table 4.
      Table 4Comparison of Previous Studies on Adolescent Capitellar Osteochondritis Dissecans Treated with Arthroscopic Debridement and Marrow Stimulation with Microfracture/Drilling
      AuthorYearSample No.Mean Age, yMean Time Symptomatic Before Surgery, moMean F/U, yReoperation Rate, %Return to Sport, %
      Return to sport percentage based on return to primary sport at same level or higher.
      Mean Time Until Return to Sport, moMean Patient-Reported Outcome Measures
      Bojanić et al.
      • Bojanić I.
      • Ivković A.
      • Borić I.
      Arthroscopy and microfracture technique in the treatment of osteochondritis dissecans of the humeral capitellum: Report of three adolescent gymnasts.
      2006314910%100%5N/A
      Wulf et al.
      • Wulf C.A.
      • Stone R.M.
      • Giveans M.R.
      • Lervick G.N.
      Magnetic resonance imaging after arthroscopic microfracture of capitellar osteochondritis dissecans.
      20121013.94.63.50%75%5.1Timmerman/Andrews Score: 193

      Mayo Elbow Performance Score: 97
      Lewine et al.
      • Lewine E.B.
      • Miller P.E.
      • Micheli L.J.
      • Waters P.M.
      • Bae D.S.
      Early results of drilling and/or microfracture for grade IV osteochondritis dissecans of the capitellum.
      20162113.411.62.219%66.7%Not reportedTimmerman/Andrews Score: 184
      Bexkens et al.
      • Bexkens R.
      • van den Ende K.I.M.
      • Ogink P.T.
      • van Bergen C.J.A.
      • van den Bekerom M.P.J.
      • Eygendaal D.
      Clinical outcome after arthroscopic debridement and microfracture for osteochondritis dissecans of the capitellum.
      20177515.7183.54.3%55%Not reportedOxford Elbow Score: 40.8
      Matsuura et al.
      • Matsuura T.
      • Iwame T.
      • Suzue N.
      • et al.
      Long-term outcomes of arthroscopic debridement with or without drilling for osteochondritis dissecans of the capitellum in adolescent baseball players: A ≥10-year follow-up study.
      Only 10 patients underwent marrow stimulation/drilling.
      20202314.7Not reported
      Reported a minimum of 6 months nonoperative treatment before surgery.
      11.54.3%87%4.1Timmerman/Andrews Score: 195
      Current study1814.115.64.40%66.7%7.7Kerlan-Jobe Orthopaedic Clinic Score: 94.1

      QuickDASH: 2.3
      F/U, follow-up; N/A, not available.
      Return to sport percentage based on return to primary sport at same level or higher.
      Only 10 patients underwent marrow stimulation/drilling.
      Reported a minimum of 6 months nonoperative treatment before surgery.
      In 2006, Bojanić et al.
      • Bojanić I.
      • Ivković A.
      • Borić I.
      Arthroscopy and microfracture technique in the treatment of osteochondritis dissecans of the humeral capitellum: Report of three adolescent gymnasts.
      reported on the first known study to examine outcomes from arthroscopic debridement and microfracture in 3 adolescent gymnasts with a mean follow-up of 12 months. All athletes returned to sport at the same level or higher within 5 months, and postoperative MRI showed reparative fibrocartilaginous tissue filling in the defect site. However, the short-term follow-up and small patient cohort in this study do not allow for definitive conclusions to be drawn. In 2012, Wulf et al.
      • Wulf C.A.
      • Stone R.M.
      • Giveans M.R.
      • Lervick G.N.
      Magnetic resonance imaging after arthroscopic microfracture of capitellar osteochondritis dissecans.
      examined 10 patients with a mean age of 13.9 years, 7 skeletally immature and 3 skeletally mature at time of surgery, with mean follow-up of 42 months. Postoperative ROM and outcome scores demonstrated significant improvements in all patients, with 6 of 8 patients involved in competitive athletics returning to the same level of play or higher at an average of 5.1 months. Postoperative MRIs obtained at a mean of 27 months demonstrated a reparative process occurring at the defect site in 8 of 10 patients. Similarly, Lewine et al.
      • Lewine E.B.
      • Miller P.E.
      • Micheli L.J.
      • Waters P.M.
      • Bae D.S.
      Early results of drilling and/or microfracture for grade IV osteochondritis dissecans of the capitellum.
      examined 21 patients with a mean follow-up of 2.4 years in 2016, reporting resolution on follow-up MRI in 59% of patients. They reported an 85.7% rate of return to sport, with only 66.7% of patients returning to their primary sport. They also reported 4 revision surgeries. It should be noted that patients in this study had grade IV lesions; in addition, lesion containment was found to be a better indicator of successful response more so than lesion area. This is contrary to Bexkens et al.,
      • Bexkens R.
      • van den Ende K.I.M.
      • Ogink P.T.
      • van Bergen C.J.A.
      • van den Bekerom M.P.J.
      • Eygendaal D.
      Clinical outcome after arthroscopic debridement and microfracture for osteochondritis dissecans of the capitellum.
      who examined 71 patients, with mean age of 16 years (range, 11-26 years) and mean follow-up of 3.5 years, treated with arthroscopic microfracture and found no difference between outcome with contained (intact lateral wall) versus uncontained (loss of lateral wall) lesions. Interestingly, they reported only a 55% rate of return to sport at the same level or higher. This could potentially be explained by the older patients in their cohort, as there was an association between open capitellar physis at time of surgery and improved outcomes as well as shorter length of preoperative symptoms. There was also a high proportion of patients (26.5%) who had a history of previous elbow surgeries. As a follow-up to this study, they examined computed tomography scans at a mean of 29 months, reporting evidence of decreased lesion size and healing of subchondral bone in 85% of patients.
      • Bexkens R.
      • van Bergen C.J.A.
      • van den Bekerom M.P.J.
      • Kerkhoffs G.
      • Eygendaal D.
      Decreased defect size and partial restoration of subchondral bone on computed tomography after arthroscopic debridement and microfracture for osteochondritis dissecans of the capitellum.
      It also should be noted that there was no correlation between clinical outcomes and findings on imaging. While these studies do not provide definitive evidence for articular restoration with microfracture/marrow stimulation, they do demonstrate a clear short-term benefit to this treatment and the possibility that the natural progression of this disease can potentially be altered.
      To our knowledge, the only study focused on arthroscopic microfracture with longer follow-up than ours was conducted by Matsuura et al.,
      • Matsuura T.
      • Iwame T.
      • Suzue N.
      • et al.
      Long-term outcomes of arthroscopic debridement with or without drilling for osteochondritis dissecans of the capitellum in adolescent baseball players: A ≥10-year follow-up study.
      who examined 23 adolescent baseball players with varying lesion size, mean age of 14.7 years, and mean final follow-up at 11.5 years. In this study, the 10 patients who underwent microfracture were those with evidence on imaging of a sclerotic bone bed. There were no significant differences in PROMs between groups or based on lesion size. Twenty patients (87%) were able to return to competitive play, but only 1 of 5 (20%) baseball pitchers were able to return to pitching. This is an improvement from the 40% return to sport rate reported by Byrd and Jones,
      • Byrd J.W.
      • Jones K.S.
      Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: Minimum three-year follow-up.
      in their study of baseball players who underwent arthroscopic abrasion chondroplasty alone; however, that study did not specify differences in symptoms and/or recovery between position players and pitchers. This further highlights the difficulty in evaluating outcomes in this population due to the different physical demands of various sporting activities as well as the different positions within a given sporting activity. The aforementioned results may suggest no difference between arthroscopic debridement alone and microfracture/marrow stimulation but do help to further confirm the long-term durability of arthroscopic treatment of this disease.
      Looking closer at our 6 patients who did not return to their primary sport, only 3 of these patients reported that this change was related to their elbow injury, with 2 of them citing fear of continued symptoms and only 1 citing actual pain. This highlights the importance of the psychological toll this particular injury can take on a young athlete, which should be considered when evaluating return to sport rates in the literature. In addition, as highlighted by Wulf et al.
      • Wulf C.A.
      • Stone R.M.
      • Giveans M.R.
      • Lervick G.N.
      Magnetic resonance imaging after arthroscopic microfracture of capitellar osteochondritis dissecans.
      , a sooner return to activity carries significant emotional and psychological benefit for these adolescents, something that is often overlooked in orthopaedic research. This further advocates for arthroscopic interventions (when indicated) over more invasive open mosaicplasty procedures. In this study, mean time to return to sport was 7.8 months postoperatively. This is longer than some of the recovery periods (4-6 months) reported in the recent literature.
      • Bojanić I.
      • Ivković A.
      • Borić I.
      Arthroscopy and microfracture technique in the treatment of osteochondritis dissecans of the humeral capitellum: Report of three adolescent gymnasts.
      ,
      • Wulf C.A.
      • Stone R.M.
      • Giveans M.R.
      • Lervick G.N.
      Magnetic resonance imaging after arthroscopic microfracture of capitellar osteochondritis dissecans.
      ,
      • Matsuura T.
      • Iwame T.
      • Suzue N.
      • et al.
      Long-term outcomes of arthroscopic debridement with or without drilling for osteochondritis dissecans of the capitellum in adolescent baseball players: A ≥10-year follow-up study.
      This could likely be attributed to our strict postoperative protocol of no graduated return to sport for a minimum of 4 to 6 months postoperatively. As suggested by Wulf et al.,
      • Wulf C.A.
      • Stone R.M.
      • Giveans M.R.
      • Lervick G.N.
      Magnetic resonance imaging after arthroscopic microfracture of capitellar osteochondritis dissecans.
      if resolution of clinical symptoms is noted beyond 3 months, there is likely mature healing at the injury site that may even benefit from biological loading for further maturation and remodeling. While this hypothesis is only theoretical, it does suggest that earlier return to play be considered in asymptomatic cases.
      We additionally examined defect size/grade, bone age, and physeal status of the capitellum and radial head. We found no difference in ROM, outcome, or return to sport based on these factors, suggesting that marrow stimulation in adolescent patients produces mesenchymal stem cells for biologic healing, regardless of bone age or physeal status. Postoperative radial head enlargement in patients with an open radial head physis has previously been associated with a high rate of reoperation.
      • Bauer M.
      • Jonsson K.
      • Josefsson P.O.
      • Lindén B.
      Osteochondritis dissecans of the elbow. A long-term follow-up study.
      ,
      • Ruch D.S.
      • Cory J.W.
      • Poehling G.G.
      The arthroscopic management of osteochondritis dissecans of the adolescent elbow.
      ,
      • Miyake J.
      • Masatomi T.
      Arthroscopic debridement of the humeral capitellum for osteochondritis dissecans: Radiographic and clinical outcomes.
      It should be noted that in these studies, patients were treated either conservatively or with debridement alone. While we did not obtain postoperative imaging in this study, there were no reoperations in our study cohort, which suggests that if postoperative radial head enlargement had occurred in patients with an open radial head physis at the time of surgery, it did not present with any long-term functional or clinical deficits. Furthermore, the reparative process triggered by marrow stimulation may have prevented this pathology. We also found no difference in outcome based on preoperative symptom duration, although previous reports have suggested longer time to surgery could lead to worse outcomes.
      • Bexkens R.
      • van den Ende K.I.M.
      • Ogink P.T.
      • van Bergen C.J.A.
      • van den Bekerom M.P.J.
      • Eygendaal D.
      Clinical outcome after arthroscopic debridement and microfracture for osteochondritis dissecans of the capitellum.
      We continue to advocate for a period of conservative treatment and rest before considering surgical intervention, as long as there is no significant loss of motion and/or loose body present on initial presentation. With our study’s excellent outcomes and the fact that patients reported symptoms for a mean of 15.4 months preoperatively, we suggest that there is minimal downside to trialing a period of rest if the above criteria are met. However, as stated previously, many of these patients present late in the disease course and have often attempted conservative care prior to presentation. In addition, it has been well documented that compliance can be challenging in the adolescent athlete population, especially with the psychological burden that comes with the long period of conservative care required for healing.
      • Matsuura T.
      • Kashiwaguchi S.
      • Iwase T.
      • Takeda Y.
      • Yasui N.
      Conservative treatment for osteochondrosis of the humeral capitellum.
      This may explain why patients in our study only reported 3.72 months of complete rest before surgery. All of these factors should be considered and discussed with the patient and parents in order to reach the optimal treatment decision for each individual patient.
      Based on the findings of this study, we continue to advocate for initial arthroscopic treatment of capitellar OCD when indicated especially in treating the adolescent athlete to avoid potential lengthy recovery and elbow stiffness incurred from the use of osteoarticular autograft. It should be noted that all lesions in this study were contained lesions with an intact lateral wall. In addition, while all lesions were found to be unstable based on the Takahara classification,
      • Takahara M.
      • Mura N.
      • Sasaki J.
      • Harada M.
      • Ogino T.
      Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum.
      we believe using lesion size based on defect angle/percentage
      • Takahara M.
      • Ogino T.
      • Sasaki I.
      • Kato H.
      • Minami A.
      • Kaneda K.
      Long term outcome of osteochondritis dissecans of the humeral capitellum.
      and whether or not the capitellar physis is open or not, serve as better guides when deciding between arthroscopic marrow stimulation versus osteoarticular autograft. All defects in our study were either small or moderate in size with the exception of 1 patient who had a large defect but an open capitellar physis. This particular patient had follow-up at 24 months and did return to his primary sport of baseball with a KJOC Overhead Athlete Shoulder and Elbow score of 88.5. We typically reserve mosaicplasty as a salvage procedure if primary surgical treatment has failed or in rare cases with large uncontained defects and a closed capitellar physis.

      Limitations

      This study is not without limitations. The retrospective nature of the study and relatively small sample size limit the strength of our conclusions. In addition, we did not obtain any postoperative imaging more than 3 months after surgery. While the goal of this study was to examine clinical outcomes, future studies that include the evaluation of radiographic and other advanced imaging may provide further insight into the reparative process associated with microfracture/marrow stimulation and better clarify the correlation between clinical and imaging outcomes. Lastly, our clinical follow-up in this study was short and most information was collected via telephone. However, both the PROMs used in this study have been validated for use via telephone.
      • Wilkinson J.T.
      • Clawson J.W.
      • Allen C.M.
      • Presson A.P.
      • Tyser A.R.
      • Kazmers N.H.
      Reliability of telephone acquisition of the PROMIS upper extremity computer adaptive test.
      ,
      • Erickson B.J.
      • Chalmers P.N.
      • Newgren J.
      • et al.
      Can the Kerlan-Jobe Orthopaedic clinic shoulder and elbow score be reliably administered over the phone? A randomized study.

      Conclusions

      Arthroscopic debridement and marrow stimulation for capitellar OCD in adolescent athletes leads to improvements in ROM, as well as a high rate of return to sport, and high levels of athletic and daily functional activity during follow-up, regardless of bone age and lesion grade/size at time of surgery.

      Acknowledgments

      We thank Tracey Bastrom for assistance with statistical analysis.

      Supplementary Data

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