Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-013-2733-3
ELBOW
Arthroscopic treatment of osteochondral lesion of olecranon O. Bilge • M. Yel • O. Buyukbebeci M. N. Doral
•
Received: 16 July 2013 / Accepted: 14 October 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Introduction
Case report
Osteochondral lesions (OCLs) are rarely seen in the elbow joint. These lesions are most commonly seen in the capitellum and radial head [5]. Although their exact mechanism is not very well understood, repetitive microtrauma and ischaemia are accepted as the two main aetiological factors [1, 5]. The term ‘‘osteochondral lesion’’ was used in this text, because it seems recently to cover all the definitions used for osteochondral abnormalities. Generally, the treatment aims for the pain relief and the return of the patient to the previous level of activities. Conservative follow-up and different surgical methods are possible for the treatment. The surgical treatment options include arthroscopic debridement, drilling, fragment excision or fixation, and osteochondral autografting. Among surgical modalities, arthroscopic excision of the fragments and subchondral abrasion or drilling of the lesion resulted in satisfactory short-term clinical outcomes [1, 2].
A 35-year-old male amateur basketball player was admitted to our clinic with right elbow pain, limitation in the range of motion and sensation of clacking, after 8 weeks following a fall on his elbow. The physical examination revealed that the range of motion of the affected elbow was limited and painful. The radiograph was normal without an obvious bony pathology. Furthermore, osteochondral pathology was suspected. The radiological evaluation revealed an osteochondral lesion of 5 mm diameter on the humeral surface of the olecranon on the computed tomography (CT) (Fig. 1). Arthroscopic evaluation and treatment of the lesion was performed after getting the formal written informed consent of the patient. In lateral decubitus position, the midlateral and superomedial portals for elbow arthroscopy were used. The arthroscopic evaluation revealed the lesion on the mid-ulnohumeral surface of the olecranon. This osteochondral lesion was very loosely attached to the underlying bone and had sclerotic margins, suggesting that it was a chronic lesion. This lesion can be staged as stage III (unstable on probing, fragment not dislocated, complete discontinuity of the ‘‘dead in situ lesion’’), according to the surgical staging of International Cartilage Repair Society [3]. As a treatment choice, the lesion was totally excised arthroscopically, and the underlying bony surface was debrided with shaver and microfractured at the end of surgery. The approximate sizes were measured as 0.9 9 0.5 9 0.5 cm (Fig. 2). Post-operatively no immobilization was applied. The complaints of the patient were decreased dramatically 1 week after the surgery. The patient returned back to play basketball with full range of motion at first month after the operation. The patient was followed up for 26 months,
O. Bilge (&) M. Yel O. Buyukbebeci Department of Orthopaedics and Traumatology, Meram Faculty of Medicine, Konya N.E. University, Konya, Turkey e-mail: [email protected] O. Bilge M. Yel Department of Sports Medicine, Meram Faculty of Medicine, Konya N.E. University, Konya, Turkey M. N. Doral Department of Orthopaedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey M. N. Doral Department of Sports Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Knee Surg Sports Traumatol Arthrosc
Fig. 1 Computed tomography (CT) image of the osteochondral lesion on the humeral articular surface of the olecranon (right elbow)
they are not treated properly. Although the general attitude for stable, small lesions is usually more conservative such as resting, the surgical treatment is reserved for unstable lesions and lesions that are unresponsive to conservative follow-up [2]. The described surgical options for OCLs around elbow include open debridement and fragment excision, arthroscopic debridement with bone-marrow stimulation, fragment fixation, closing wedge osteotomy and osteochondral autograft transplantation [2, 4–6]. On one hand, the shortterm results of them seem to be satisfactory; on the other hand, the evaluation of the long-term effects of these modalities is difficult due to the rarity of the OCL of the elbow. The most commonly performed technique has been arthroscopic debridement with bone-marrow stimulation [1, 5]. As a result, an amateur sportsman having the diagnosis of OCL of the articular surface of the olecranon was presented in this case report. Arthroscopic excision of the lesion together with debridement and microfracture to the lesion bed was performed. The patient returned back to his previous level of activity of sports at the end of 26 months of follow-up. As far as the literature has been investigated, this case is the first description of successful arthroscopic debridement, fragment excision and microfracture of osteochondral lesion of olecranon in a sportsman. Conflict of interest of interest.
Fig. 2 Arthroscopic view of the osteochondral lesion of the olecranon (black circle) of the right elbow (H humerus, O olecranon, ulnohumeral articular surface)
without any complaint of pain and any loss of muscle strength.
Discussion The literature on OCL of the elbow is mostly about the lesions of the capitellum and radial head. There have been more than 20 studies reported till now [2]. These are the two most common areas of the elbow joint where OCLs are observed [5]. These lesions are mainly seen in the adolescent overhead athletes. The natural history is not well understood yet. The risk of degenerative joint disease stays ahead, if
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The authors declare that they have no conflict
References 1. Cain EL Jr, Dugas JR, Wolf RS, Andrews JR (2003) Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med 31:621–635 2. De Graaff F, Krijnen MR, Poolman RW, Willems WJ (2011) Arthroscopic surgery in athletes with osteochondritis dissecans of the elbow. Arthroscopy 27:986–993 3. International Cartilage Repair Society (2008) ICRS evaluation. Available at: www.cartilage.org 4. Ruch DS, Cory JW, Poehling GG (1998) The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 14:797–803 5. Ruchelsman DE, Hall MP, Youm T (2010) Osteochondritis dissecans of the capitellum: current concepts. J Am Acad Orthop Surg 18:557–567 6. Tsuda E, Ishibashi Y, Sato H, Yamamoto Y, Toh S (2005) Osteochondral autograft transplantation for osteochondritis dissecans of the capitellum in nonthrowing athletes. Arthroscopy 21:1270–1274
ELBOW
Arthroscopic treatment of osteochondral lesion of olecranon O. Bilge • M. Yel • O. Buyukbebeci M. N. Doral
•
Received: 16 July 2013 / Accepted: 14 October 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Introduction
Case report
Osteochondral lesions (OCLs) are rarely seen in the elbow joint. These lesions are most commonly seen in the capitellum and radial head [5]. Although their exact mechanism is not very well understood, repetitive microtrauma and ischaemia are accepted as the two main aetiological factors [1, 5]. The term ‘‘osteochondral lesion’’ was used in this text, because it seems recently to cover all the definitions used for osteochondral abnormalities. Generally, the treatment aims for the pain relief and the return of the patient to the previous level of activities. Conservative follow-up and different surgical methods are possible for the treatment. The surgical treatment options include arthroscopic debridement, drilling, fragment excision or fixation, and osteochondral autografting. Among surgical modalities, arthroscopic excision of the fragments and subchondral abrasion or drilling of the lesion resulted in satisfactory short-term clinical outcomes [1, 2].
A 35-year-old male amateur basketball player was admitted to our clinic with right elbow pain, limitation in the range of motion and sensation of clacking, after 8 weeks following a fall on his elbow. The physical examination revealed that the range of motion of the affected elbow was limited and painful. The radiograph was normal without an obvious bony pathology. Furthermore, osteochondral pathology was suspected. The radiological evaluation revealed an osteochondral lesion of 5 mm diameter on the humeral surface of the olecranon on the computed tomography (CT) (Fig. 1). Arthroscopic evaluation and treatment of the lesion was performed after getting the formal written informed consent of the patient. In lateral decubitus position, the midlateral and superomedial portals for elbow arthroscopy were used. The arthroscopic evaluation revealed the lesion on the mid-ulnohumeral surface of the olecranon. This osteochondral lesion was very loosely attached to the underlying bone and had sclerotic margins, suggesting that it was a chronic lesion. This lesion can be staged as stage III (unstable on probing, fragment not dislocated, complete discontinuity of the ‘‘dead in situ lesion’’), according to the surgical staging of International Cartilage Repair Society [3]. As a treatment choice, the lesion was totally excised arthroscopically, and the underlying bony surface was debrided with shaver and microfractured at the end of surgery. The approximate sizes were measured as 0.9 9 0.5 9 0.5 cm (Fig. 2). Post-operatively no immobilization was applied. The complaints of the patient were decreased dramatically 1 week after the surgery. The patient returned back to play basketball with full range of motion at first month after the operation. The patient was followed up for 26 months,
O. Bilge (&) M. Yel O. Buyukbebeci Department of Orthopaedics and Traumatology, Meram Faculty of Medicine, Konya N.E. University, Konya, Turkey e-mail: [email protected] O. Bilge M. Yel Department of Sports Medicine, Meram Faculty of Medicine, Konya N.E. University, Konya, Turkey M. N. Doral Department of Orthopaedics and Traumatology, Faculty of Medicine, Hacettepe University, Ankara, Turkey M. N. Doral Department of Sports Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
123
Knee Surg Sports Traumatol Arthrosc
Fig. 1 Computed tomography (CT) image of the osteochondral lesion on the humeral articular surface of the olecranon (right elbow)
they are not treated properly. Although the general attitude for stable, small lesions is usually more conservative such as resting, the surgical treatment is reserved for unstable lesions and lesions that are unresponsive to conservative follow-up [2]. The described surgical options for OCLs around elbow include open debridement and fragment excision, arthroscopic debridement with bone-marrow stimulation, fragment fixation, closing wedge osteotomy and osteochondral autograft transplantation [2, 4–6]. On one hand, the shortterm results of them seem to be satisfactory; on the other hand, the evaluation of the long-term effects of these modalities is difficult due to the rarity of the OCL of the elbow. The most commonly performed technique has been arthroscopic debridement with bone-marrow stimulation [1, 5]. As a result, an amateur sportsman having the diagnosis of OCL of the articular surface of the olecranon was presented in this case report. Arthroscopic excision of the lesion together with debridement and microfracture to the lesion bed was performed. The patient returned back to his previous level of activity of sports at the end of 26 months of follow-up. As far as the literature has been investigated, this case is the first description of successful arthroscopic debridement, fragment excision and microfracture of osteochondral lesion of olecranon in a sportsman. Conflict of interest of interest.
Fig. 2 Arthroscopic view of the osteochondral lesion of the olecranon (black circle) of the right elbow (H humerus, O olecranon, ulnohumeral articular surface)
without any complaint of pain and any loss of muscle strength.
Discussion The literature on OCL of the elbow is mostly about the lesions of the capitellum and radial head. There have been more than 20 studies reported till now [2]. These are the two most common areas of the elbow joint where OCLs are observed [5]. These lesions are mainly seen in the adolescent overhead athletes. The natural history is not well understood yet. The risk of degenerative joint disease stays ahead, if
123
The authors declare that they have no conflict
References 1. Cain EL Jr, Dugas JR, Wolf RS, Andrews JR (2003) Elbow injuries in throwing athletes: a current concepts review. Am J Sports Med 31:621–635 2. De Graaff F, Krijnen MR, Poolman RW, Willems WJ (2011) Arthroscopic surgery in athletes with osteochondritis dissecans of the elbow. Arthroscopy 27:986–993 3. International Cartilage Repair Society (2008) ICRS evaluation. Available at: www.cartilage.org 4. Ruch DS, Cory JW, Poehling GG (1998) The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 14:797–803 5. Ruchelsman DE, Hall MP, Youm T (2010) Osteochondritis dissecans of the capitellum: current concepts. J Am Acad Orthop Surg 18:557–567 6. Tsuda E, Ishibashi Y, Sato H, Yamamoto Y, Toh S (2005) Osteochondral autograft transplantation for osteochondritis dissecans of the capitellum in nonthrowing athletes. Arthroscopy 21:1270–1274
