446
Osteochondral Lesions of the Elbow Christopher Pettis, MD1
1 Department of Radiology, Florida Hospital, Orlando, Florida
Semin Musculoskelet Radiol 2013;17:446–454.
Abstract
Keywords
► osteochondral lesions ► osteochondritis dissecans ► elbow ► MRI ► CT
Christopher Wasyliw, MD1
Laura Varich, MD1
Address for correspondence Laura W. Bancroft, MD, Department of Radiology, Florida Hospital, 601 E. Rollins, Orlando, FL 32803 (e-mail: Laura.bancroft.md@flhosp.org).
Osteochondral lesions of the elbow are injuries that disrupt the cartilage and subjacent bone, and they most commonly involve the capitellum. The staging, prognosis, and treatment of osteochondral lesions in the elbow are based on a combination of radiographic, magnetic resonance imaging, and arthroscopic findings. Radiographic staging includes the radiolucent, separation, and free (advanced) stages. MR imaging features of instability include cysts, osteochondral fracture, T2 hyperintense rim, subchondral plate defects, and fluid-filled osteochondral defects. Finally, arthroscopic grading of osteochondral lesions increases in severity based on findings of softened cartilage, cartilage fissuring, exposed bone, loose but nondisplaced fragments, and eventually displaced fragments resulting in intra-articular bodies. This pictorial review focuses on osteochondral lesions in the capitellum and trochlea including osteochondritis dissecans, Panner disease, and acute trauma.
Osteochondral lesions of the elbow are injuries that disrupt the cartilage and subjacent bone. They most commonly involve the capitellum. The staging, prognosis, and treatment of osteochondral lesions in the elbow are based on a combination of radiographic, MR imaging, and arthroscopic findings. Radiographic staging includes the radiolucent, separation, and free (advanced) stages. MR imaging features of instability include cysts, osteochondral fracture, T2 hyperintense rim, subchondral plate defects, and fluid-filled osteochondral defects. Finally, arthroscopic grading of osteochondral lesions increases in severity based on findings of softened cartilage, cartilage fissuring, exposed bone, loose but nondisplaced fragments, and eventually displaced fragments resulting in intra-articular bodies. This pictorial review focuses on osteochondral lesions in the capitellum and trochlea including osteochondritis dissecans (OCD), Panner disease, and acute trauma.
Etiology Overuse OCD is a localized injury that separates a segment of cartilage and subchondral bone, occurring in patients from early adolescence to 20 years of age.1,2 Osteochondritis of the elbow most often occurs in the capitellum, but it can also involve the
Issue Theme Sport Injuries of the Elbow and Fingers; Guest Editor, Mario Padrón, MD
radial head and olecranon, and less commonly the trochlea.3 Although the exact etiology of this condition is still debated, most scientists agree that OCD of the elbow is an overuse injury caused by repetitive trauma to the poorly vascularized capitellum.2,4 The capitellum is primarily supplied by posterior end arteries that cross the epiphyseal cartilage without collateral circulation from the metaphysis, making the capitellum prone to ischemia.4 Histopathologic assessment of removed articular cartilage and osteochondral loose bodies in patients with OCD has shown changes consistent with damage from repeated stress following degenerative and reparative process of articular cartilage and subchondral fracturing.5 Capitellar OCD most frequently occurs in the dominant arm of teenage baseball pitchers (particularly pitchers), handball and water polo players, and both arms in sports that turn the elbow into a weightbearing joint such as gymnastics and weightlifting.1,2,6,7 With throwing sports, the elbow is cyclically stressed in a valgus direction during the late cocking and early acceleration phase of throwing, resulting in loading the capitellum in compression and shear.6,8–10 Medial collateral ligament rupture or attenuation results in increased compressive forces of the radiocapitellar joint, and it may result in osteochondral injuries of the capitellum and radial head from repetitive radiocapitellar impaction.11
Copyright © 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1360665. ISSN 1089-7860.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Laura W. Bancroft, MD1
Osteochondral Lesions of the Elbow
Acute trauma may cause a variety of osteochondral fractures about the elbow and involve the capitellum, radius, and ulna depending on the mechanism of injury. A complete discussion of osteochondral fractures of the elbow is beyond the scope of this article. They are commonly found with subluxations, dislocations, impaction, and shear-type injuries.11
Osteochondrosis Panner disease is an osteochondrosis involving the entire capitellum that was first described by Hans Jessen Panner in 1927.12 This lesion causes rarefaction and fragmentation of the capitellar ossification center, occurs in children < 10 years old, and is a self-limiting process.13 Panner disease can be differentiated from OCD because it is not associated with repetitive trauma, is self-limited, and rarely causes longterm complications.13 Of note, there has been debate as to whether or not Panner disease and osteochondritis dissecans may represent different stages of alterations of enchondral ossification with outcomes related to patient age, activity level, and severity of the lesion.14
Imaging Radiographic Evaluation The imaging evaluation of elbow pain and suspected osteochondral lesions should begin with anteroposterior (AP) and lateral radiographs, and the addition of an AP image with 45 degrees of flexion may further increase lesion detection.17,18 Radiographs in patients with capitellar OCD may be normal, show flattening of the articular surface, lucency in the anteroinferior aspect of the capitellum (►Figs. 1 and 2), subchondral sclerosis, separated and/or displaced bony fragments, in addition to effusion in the acute setting.19,20 The radiographic stages of OCD are the radiolucent stage, separation stage, and free (advanced) stage (►Table 2).21 Negative radiographs do not exclude an osteochondral lesion, and Kijowski and colleagues reported a 66% sensitivity of radiographs in the detection of capitellar OCD and only a 57% detection rate of intra-articular bodies when compared with arthroscopic findings.22 In general, lesions observable on radiographs do not have a good prognosis with conservative management, and delayed surgery may worsen the prognosis.10
Sonography Ossification Defects and Genetic Causes Defects of enchondral ossification as well as genetic predisposition have also been proposed as possible etiologies for osteochondral lesions of the elbow.2,6,7
Clinical Presentation and Evaluation Osteochondritis of the capitellum may be asymptomatic, but patients may present with lateral elbow pain, tenderness and swelling, flexion contracture, restricted range of motion, clicking or locking, and instability.11,15 The arthroscopic classification system for OCD, as defined by the International Cartilage Repair Society, is as follows: (1) grade I is intact but soft ballotable cartilage, (2) grade II is fissuring of the overlying cartilage, (3) grade III is exposed bone or attached osteoarticular cartilage, (4) grade IV is loose but nondisplaced osteoarticular fragment; and (5) grade V is displaced fragment with resultant intra-articular body ( ►Table 1).16
Sonography has proven efficacious for the evaluation of elbow OCD.23–25 Takahara and colleagues found an 89% correlation with sonographic and intraoperative or MRI findings in the 19 cases they studied, and they also performed screening sonography in young baseball players to detect capitellar OCD.23,24 Furthermore, Harada and colleagues detected medial epicondylar fragmentation and capitellar OCD with sonography in a sonographic study of 153 male baseball players between the ages of 9 and 12 years.25
Computed Tomography and Computed Tomography Arthrography Computed tomography (CT) is advocated for better characterization of fractures (►Fig. 3), and CT arthrography is
Table 1 International Cartilage Repair Society classification of osteochondritis dissecans lesions Grade
Description
I
Intact but soft ballotable cartilage
II
Fissuring of the overlying cartilage
III
Exposed bone or attached osteoarticular cartilage
IV
Loose, but nondisplaced, osteoarticular fragment
V
Displaced fragment with resultant intra-articular body.
Source: Baumgarten et al.16
447
Fig. 1 Radiolucent stage of osteochondritis dissecans (OCD) of the elbow in a 14-year-old boy. Anteroposterior radiograph shows a focal lucency in the capitellum (arrow) caused by OCD in this boy complaining of elbow pain and swelling. Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Acute Trauma
Bancroft et al.
Osteochondral Lesions of the Elbow
Bancroft et al.
Fig. 2 Chronic osteochondritis dissecans (OCD) of the elbow. Anteroposterior radiographs of the elbow of (a) a 62-year-old woman and (b) a 53year-old man show well-circumscribed lucencies in the capitella (arrowhead) due to OCD. No free fragments were identified.
Table 2 Radiographic stages of osteochondritis dissecans I
Radiolucent stage
II
Separation stage
III
Free (advanced) stage
Source: Takeba et al.21
another imaging modality occasionally used for evaluating elbow lesions (►Fig. 3). If there is a contraindication to MRI, CT arthrography can detect intra-articular bodies and evaluate the integrity of the articular cartilage for fissures, defects, or separated osteochondral fragments (►Fig. 4).26,27
MR Imaging and Arthrography Prior to discussing actual osteochondral injuries of the elbow, normal locations in the elbow that lack cartilage and are observable on MRI should be mentioned: the pseudodefects of the trochlea and the capitellum.11,19,20,28–30 Because only anterior 180 degrees of the capitellum is covered by articular coverage, the posterior bare area contributes to the pseudodefect of the capitellum (►Fig. 5a). In addition, the trochlear
Fig. 4 Unstable capitellar osteochondritis dissecans. Coronal oblique reconstruction from computed tomography arthrogram through the radiocapitellar joint demonstrates extension of contrast (arrowheads) through a cartilaginous defect and partially beneath the osteochondral fragment (asterisk).
Fig. 3 Chronic capitellar osteochondral impaction injury. (a) Coronal and (b) sagittal reconstructions from computed tomography show marked irregularity and impaction deformity of the posterior and central aspects of the capitellum (arrowheads). Notice the widening of the radiocapitellar joint due to disruption of the ulnar collateral ligament complex. Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
448
Bancroft et al.
Fig. 5 Pseudodefects in a normal 41-year-old woman. (a) Sagittal fast spin-echo (FSE) proton-density fat-suppressed image images through the radiocapitellar joint demonstrates the normal capitellar pseudodefect (arrowhead) that reflects the transition between the articular cartilage only covering the anterior 180 degrees of the capitellum and the more posterior bare area. (b) Sagittal FSE proton-density fat-suppressed image images through the ulnohumeral joint shows the normal midtrochlear notch (arrowhead) between the anterior and posterior trochlear facets, normally devoid of cartilage.
Table 3 MR imaging classification system of osteochondritis dissecans Grade
Description
0
Normal
1
Intact cartilage with signal change
2
High-signal breach of overlying cartilage
3
Thin high-signal rim (fluid) extending about the osteochondral fragment
4
Mixed- or low-signal loose body, either in center of lesion or free in joint
Source: Nelson et al.31
Fig. 6 Capitellar osteochondritis dissecans. Sagittal fast spin-echo (FSE) T2-weighted fat-suppressed image shows a cartilaginous defect involving the anterior and inferior capitellum (between the arrowheads), with areas of partial- and full-thickness cartilage loss. Notice the subjacent capitellar marrow edema-like signal changes without osseous instability, in addition to synovitis and joint effusion.
notch of the ulnar has a complex figure-of-eight pattern of articular coverage and distinctive osseous contour that should be recognized. The midtrochlear notch is the normal interruption of the articular surface between the anterior and posterior facets of the trochlea, which can simulate a cartilaginous defect (►Fig. 5b).11,19,20,28–30 MR imaging has become the imaging standard for the assessment of osteochondral fragment size, location, stability, and viability.11,15,19,20,26,31–33 In the MRI classification system of OCD described by Nelson et al, there are four grades of lesions: (1) grade 1, intact cartilage with signal change; (2) grade 2, high-signal breach of overlying cartilage; (3) grade 3, thin high-signal rim of fluid extending about the osteochondral fragment; and (4) grade 4, mixed- or low-signal intraarticular body, either in the center of the lesion or free in the joint (►Table 3).31,34 Early OCD demonstrates focal low-signal intensity in the anterior capitellum on T1-weighted MR images, with or without high T2-weighted signal, and flattening of the subchondral bone plate. Instability can be suggested when there is a cyst-like lesion beneath the osteochondral fragment, an osteochondral fracture, T2 hyperintense rim, subchondral plate defect, and/or fluid-filled osteochondral defect (►Figs. 6, 7, 8, and 9).35 Severe lesions show an osteochondral fragment, either in situ or displaced Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
449
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Osteochondral Lesions of the Elbow
Osteochondral Lesions of the Elbow
Bancroft et al.
Fig. 7 Unstable osteochondritis dissecans of the capitellum in a 12-year-old girl. MRI was obtained after patient complained of 2 months of elbow pain. Coronal fast spin-echo (FSE) (a) T1-weighted, (b) axial T2-weighted fat-suppressed, and (c) sagittal proton-density fat-suppressed images show subcortical cystic change of the capitellum (arrowheads). Instability can be suggested when there is a cyst-like lesion beneath the osteochondral fragment. (d) Adjacent sagittal proton-density image shows extension of hyperintense fluid (arrow) beneath the capitellar osteochondral fragment.
into the joint (►Fig. 10).11 Unstable osteochondral fragments show linear hyperintense T2-weighted signal or enhancement along the interface between the fragment and capitellum (secondary to either fluid and/or granulation tissue), and some advocate MR arthrography for further conspicuity and confidence in staging OCD lesions.26,27,29,35 Furthermore,
fragment enhancement implies presence of vascularity and viability.7,18,36 Takamara and colleagues proposed a comprehensive classification system for OCD stability based on a combination of imaging and clinical features (►Table 4). In a 9-year review by Jars and colleagues, the prevalence and sensitivity of unstable osteochondral lesions in the elbow
Fig. 8 Osteochondritis dissecans in 15-year-old boy. (a) Coronal T1-weighted image shows a focal hypointense focus in the anterior and central aspect of the capitellum (arrow). (b, c) Coronal and sagittal images define the extent of the osteochondral lesion (arrows) and underlying cystic change (arrowheads).
Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
450
Bancroft et al.
Fig. 9 Superoposterior trochlear groove osteochondral lesion in a 17-year-old boy. (a) Axial and (b) sagittal fast spin-echo T2-weighted fatsuppressed images demonstrate a 3-mm osteochondral lesion (arrow) located in the posterior articular surface of the trochlea and adjacent marrow edema-like signal changes (arrow).
Fig. 10 Unstable capitellar osteochondral fragment in a 60-year-woman. (a) Axial and (b) coronal fast spin-echo T2-weighted fat-suppressed images obtained after reduction of posterior elbow dislocation show a rectangular fragment (arrows) separated from the remaining capitellum. Notice the subjacent capitellar edema-like signal changes (arrowhead) caused by shearing forces.
were reported.36 Of all osteochondral elbow injuries, 70% of lesions demonstrated MRI imaging features of instability that included cysts (11% had multiple cysts and 8% had large cysts), osteochondral fracture in 11%, T2 hyperintense rim and subchondral plate defects in 50%, and fluid-filled osteochondral defects in 23% of elbows.36 The sensitivity of MRI for detecting unstable osteochondral lesions of the elbow was 100% if all of the following characteristics are present: T2 signal rim, cysts, high T2 signal intensity cartilage fracture line, and fluid-filled OCD. If only evaluating a single imaging feature, a T2 signal rim with multiple breaks in the cartilage proved to be most sensitive at 63%.36 Superoposterior trochlear groove osteochondral lesions and posterior synovial hypertrophy have been reported in athletes with hyperextension elbow forces caused by repetitive elbow locking in full extension in swimmers or basketball players.37 Osteochondral lesions involving the trochlea are less common than those of the capitellum, and they have similar imaging characteristics as those presented previously for the capitellum.38 Unlike capitellar OCD, trochlear defects vary in their appearances based on lesion location. Osteochondral lesions involving the medial trochlea tend to be
small (< 6 mm) and located in the posterior articular surface of the medial trochlea, whereas lateral lesions are typically larger (10–13 mm), circumscribed, and located in the posteroinferior lateral trochlea (►Fig. 8).38 Medial lesions typically show chondral fissuring, subchondral osseous pitting, and surrounding marrow edema-like signal changes.38 In contradistinction, lateral lesions have the classic imaging appearance of OCD, in which lesions are well circumscribed and have a narrow zone of transition with the adjacent bone.
Table 4 Takahara’s proposed classification of capitellar osteochondritis dissecans lesions Stable
Unstable
Capitellar growth plate
Open
Closed
Radiographic grade
I
II or III
Range of motion
Normal
Restricted
ICRS classification
I
II, III, or IV
ICRS, International Cartilage Repair Society. Source: Takahara et al.17
Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
451
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Osteochondral Lesions of the Elbow
Osteochondral Lesions of the Elbow
Bancroft et al.
Fig. 11 Postoperative fixation of capitellar osteochondral fracture in an 11-year-old boy. (a) Lateral elbow radiograph shows a proximally displaced and rotated anterior capitellar osteochondral fracture in a boy who fell off his bike and landed on his elbow. (b) Sagittal two-dimensional and (c) three-dimensional surface rendered images obtained 3 weeks after open reduction and internal fixation of the capitellar defect with two Acutrak Mini screws (Acumed, Hillsboro, OR) (arrowheads). The osteochondral fragment (arrows) has been reduced to near anatomical alignment and incorporated before screw removal 6 weeks later.
Treatment Conservative Early stages of OCD are treated with conservative therapy that consists of modification or rest from the throwing activity, nonsteroidal anti-inflammatory medications, and occasionally immobilization.1,21
Conclusion
Surgical Treatment Lesions that are best treated surgically include those that do not improve with appropriate nonoperative treatment, have loose bodies with mechanical symptoms, are unstable lesions with fragmentation or result in restricted elbow motion over 20 degrees, or in patients with closed capitellar growth plates (►Fig. 11).1,21 Surgical correction is performed to avoid or delay degenerative change. Various surgical treatments for advanced stages of OCD include resection of the loose bodies with or without drilling or curettage, reattachment of the fragments, chondroplasty, mosaicplasty with autograft from the patient’s knee or rib, allograft, chondrocyte implantation, and valgus/closing wedge humeral osteotomy to unload the radiocapitellar joint.2,6,8,9,13,17,21,38–55 Free fragment resection and marrow stimulation techniques are generally reserved for smaller lesions, and osteochondral transplantation has become more commonly used, especially for chronic free fragments that generally do not heal.47 Osteochondral autograft transplantation mosaicplasty of the elbow has shown encouraging results. It is indicated for capitellar lesions involving > 50% of the capitellar surface area in the absence of associated radiocapitellar degenerative changes.15,48–50,53,55
Osteochondral lesions of the elbow most commonly involve the capitellum but may involve the trochlea, radial head, and olecranon. The interpretive radiologist must be aware of the comprehensive staging classifications, prognosis, and treatment of osteochondral lesions based on the radiographic, MR imaging, and arthroscopic findings. Although radiographs are the initial study of choice for the detection of OCD in the elbow, they are generally insensitive for the detention of osteochondral lesions and intra-articular body. Sonography has been used both as screening and diagnostic tools for evaluating capitellar osteochondral lesions, and CT arthrography is a valid substitute for patients with contraindications to MRI. MR imaging and MR arthrography are the most useful imaging tools in determining the presence of lesions and the likelihood of instability. Osteochondral lesion instability is strongly suggested by cysts, osteochondral fracture, T2 hyperintense rim, subchondral plate defects, and fluid-filled osteochondral defects on MR imaging.
References 1 Ruchelsman DE, Hall MP, Youm T. Osteochondritis dissecans of the
Imaging after Treatment Because grafted cartilage from the knee or rib is usually thicker than the adjacent capitellar cartilage, a radiographic defect often persists due to the radiolucency of the graft cartilage.42 However, a minority of patients may develop some mineralization of the graft that will be detectable on radiography.42 In a Seminars in Musculoskeletal Radiology
study by Iwasaki et al of postoperative MR imaging after mosaicplasty for young athletes with OCD of the capitellum, fluid was found to surround all grafts at 3 months, 40% of grafts at 6 months, but none at 12 months.9 Graft incorporation documented on MRI is crucial in determining the return to play for athletes to prevent graft subsidence or tilt.9
Vol. 17
No. 5/2013
capitellum: current concepts. J Am Acad Orthop Surg 2010;18(9): 557–567 2 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. Knee Surg Sports Traumatol Arthrosc 2006;14(5):491–496
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
452
Bancroft et al.
3 Patel N, Weiner SD. Osteochondritis dissecans involving the
25 Harada M, Takahara M, Sasaki J, Mura N, Ito T, Ogino T. Using
trochlea: report of two patients (three elbows) and review of the literature. J Pediatr Orthop 2002;22(1):48–51 Yamagushi K, Sweet FA, Bindra R, Morrey BF, Gelberman R. The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg [Am] 1997;79-A:1653–1662 Kusumi T, Ishibashi Y, Tsuda E, et al. Osteochondritis dissecans of the elbow: histopathological assessment of the articular cartilage and subchondral bone with emphasis on their damage and repair. Pathol Int 2006;56(10):604–612 Baker CL III, Romeo AA, Baker CL Jr. Osteochondritis dissecans of the capitellum. Am J Sports Med 2010;38(9):1917–1928 Bradley JP, Petrie RS. Osteochondritis dissecans of the humeral capitellum. Diagnosis and treatment. Clin Sports Med 2001;20(3): 565–590 Iwasaki N, Kato H, Ishikawa J, Masuko T, Funakoshi T, Minami A. Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes: surgical technique. J Bone Joint Surg Am 2010;92(Suppl 1 Pt 2):208–216 Iwasaki N, Kato H, Kamishima T, Minami A. Sequential alterations in magnetic resonance imaging findings after autologous osteochondral mosaicplasty for young athletes with osteochondritis dissecans of the humeral capitellum. Am J Sports Med 2009; 37(12):2349–2354 Byrd JWT, Jones KS. Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: minimum three-year follow-up. Am J Sports Med 2002;30(4):474–478 Hayter CL, Giuffre BM. Overuse and traumatic injuries of the elbow. Magn Reson Imaging Clin N Am 2009;17(4):617–638, v Panner HJ. A peculiar affection of the capitellum humeri resembling Calve-Perthes disease of the hip. Acta Radiol 1927;10:234–242 Tis JE, Edmonds EW, Bastrom T, Chambers HG. Short-term results of arthroscopic treatment of osteochondritis dissecans in skeletally immature patients. J Pediatr Orthop 2012;32(3):226–231 Singer KM, Roy SP. Osteochondrosis of the humeral capitellum. Am J Sports Med 1984;12(5):351–360 Wahegaonkar AL, Doi K, Hattori Y, Addosooki A. Technique of osteochondral autograft transplantation mosaicplasty for capitellar osteochondritis dissecans. J Hand Surg Am 2007;32(9):1454–1461 Baumgarten TE, Andrews JR, Satterwhite YE. The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26(4):520–523 Takahara M, Ogino T, Sasaki I, Kato H, Minami A, Kaneda K. Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop Relat Res 1999;(363):108–115 Kijowski R, Tuite MJ. Pediatric throwing injuries of the elbow. Semin Musculoskelet Radiol 2010;14(4):419–429 Stevens KJ, McNally EG. Magnetic resonance imaging of the elbow in athletes. Clin Sports Med 2010;29(4):521–553 Stevens KJ. Magnetic resonance imaging of the elbow. J Magn Reson Imaging 2010;31(5):1036–1053 Takeba J, Takahashi T, Hino K, Watanabe S, Imai H, Yamamoto H. Arthroscopic technique for fragment fixation using absorbable pins for osteochondritis dissecans of the humeral capitellum: a report of 4 cases. Knee Surg Sports Traumatol Arthrosc 2010; 18(6):831–835 Kijowski R, De Smet AA. Radiography of the elbow for evaluation of patients with osteochondritis dissecans of the capitellum. Skeletal Radiol 2005;34(5):266–271 Takahara M, Shundo M, Kondo M, Suzuki K, Nambu T, Ogino T. Early detection of osteochondritis dissecans of the capitellum in young baseball players. Report of three cases. J Bone Joint Surg Am 1998;80(6):892–897 Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. Surgical technique. J Bone Joint Surg Am 2008; 90(Suppl 2 Pt 1):47–62
sonography for the early detection of elbow injuries among young baseball players. AJR Am J Roentgenol 2006;187(6):1436–1441 Delport AG, Zoga ACMR. MR and CT arthrography of the elbow. Semin Musculoskelet Radiol 2012;16(1):15–26 Hayes CW, Daffner RH, Weissman BN, et al; Expert Panel on Musculoskeletal Imaging. American College of Radiology (ACR) Appropriateness Criteria chronic elbow pain. Reston, VA: ACR; 2011 Rosenberg ZS, Beltran J, Cheung YY. Pseudodefect of the capitellum: potential MR imaging pitfall. Radiology 1994;191(3): 821–823 Kijowski R, De Smet AA. MRI findings of osteochondritis dissecans of the capitellum with surgical correlation. AJR Am J Roentgenol 2005;185(6):1453–1459 Tuite MJ, Kijowski R. Sports-related injuries of the elbow: an approach to MRI interpretation. Clin Sports Med 2006;25(3): 387–408, v Nelson DW, DiPaola J, Colville M, Schmidgall J. Osteochondritis dissecans of the talus and knee: prospective comparison of MR and arthroscopic classifications. J Comput Assist Tomogr 1990;14(5): 804–808 Ouellette H, Bredella M, Labis J, Palmer WE, Torriani M. MR imaging of the elbow in baseball pitchers. Skeletal Radiol 2008; 37(2):115–121 Steinbach LS, Palmer WE, Schweitzer ME. Special focus session. MR arthrography. Radiographics 2002;22(5):1223–1246 Trattnig S, Winalski CS, Marlovits S, et al. Magnetic resonance imaging of cartilage repair: a review. Cartilage 2011;2:15–26 Thornton R, Riley GM, Steinbach LS. Magnetic resonance imaging of sports injuries of the elbow. Top Magn Reson Imaging 2003; 14(1):69–86 Peiss J, Adam G, Casser R, Urhahn R, Günther RW. Gadopentetatedimeglumine-enhanced MR imaging of osteonecrosis and osteochondritis dissecans of the elbow: initial experience. Skeletal Radiol 1995;24(1):17–20 Wiesler ER, Sarlikiotis T, Rogers S, Papadonikolakis A, Poehling GG. Arthroscopic debridement for osteochondral injury of the elbow trochlea: a case report with a long-term follow-up. J Shoulder Elbow Surg 2011;20(2):e18–e22 Marshall KW, Marshall DL, Busch MT, Williams JP. Osteochondral lesions of the humeral trochlea in the young athlete. Skeletal Radiol 2009;38(5):479–491 Smith MV, Bedi A, Chen NC. Surgical treatment for osteochondritis dissecans of the capitellum. Sports Health 2012;4(5):425–432 Allagui M, Koubaa M, Bellaj Z, et al. Osteochondritis dissecans of the capitellum: autologous osteochondral mosaicplasty: a case report. Chir Main 2012;31(4):206–209 Shimada K, Tanaka H, Matsumoto T, et al. Cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans. J Bone Joint Surg Am 2012;94(11):992–1002 Vogt S, Siebenlist S, Hensler D, et al. Osteochondral transplantation in the elbow leads to good clinical and radiologic long-term results: an 8- to 14-year follow-up examination. Am J Sports Med 2011;39(12):2619–2625 de Graaff F, Krijnen MR, Poolman RW, Willems WJ. Arthroscopic surgery in athletes with osteochondritis dissecans of the elbow. Arthroscopy 2011;27(7):986–993 Jans LB, Ditchfield M, Anna G, Jaremko JL, Verstraete KL. MR imaging findings and MR criteria for instability in osteochondritis dissecans of the elbow in children. Eur J Radiol 2012;81(6): 1306–1310 Ovesen J, Olsen BS, Johannsen HV. The clinical outcomes of mosaicplasty in the treatment of osteochondritis dissecans of the distal humeral capitellum of young athletes. J Shoulder Elbow Surg 2011;20(5):813–818
4
5
6 7
8
9
10
11 12 13
14 15
16
17
18 19 20 21
22
23
24
26 27
28
29
30
31
32
33 34 35
36
37
38
39 40
41
42
43
44
45
Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
453
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Osteochondral Lesions of the Elbow
Osteochondral Lesions of the Elbow
Bancroft et al.
46 Mihara K, Suzuki K, Makiuchi D, Nishinaka N, Yamaguchi K, Tsutsui
51 Tsuda E, Ishibashi Y, Sato H, Yamamoto Y, Toh S. Osteochondral
H. Surgical treatment for osteochondritis dissecans of the humeral capitellum. J Shoulder Elbow Surg 2010;19(1):31–37 Miyamoto W, Yamamoto S, Kii R, Uchio Y. Oblique osteochondral plugs transplantation technique for osteochondritis dissecans of the elbow joint. Knee Surg Sports Traumatol Arthrosc 2009;17(2): 204–208 Ansah P, Vogt S, Ueblacker P, Martinek V, Woertler K, Imhoff AB. Osteochondral transplantation to treat osteochondral lesions in the elbow. J Bone Joint Surg Am 2007;89(10):2188– 2194 Micheli L, Curtis C, Shervin N. Articular cartilage repair in the adolescent athlete: is autologous chondrocyte implantation the answer? Clin J Sport Med 2006;16(6):465–470 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. Am J Sports Med 2006;34(5):714–720
autograft transplantation for osteochondritis dissecans of the capitellum in nonthrowing athletes. Arthroscopy 2005;21(10): 1270 Krijnen MR, Lim L, Willems WJ. Arthroscopic treatment of osteochondritis dissecans of the capitellum: report of 5 female athletes. Arthroscopy 2003;19(2):210–214 Nakagawa Y, Matsusue Y, Ikeda N, Asada Y, Nakamura T. Osteochondral grafting and arthroplasty for end-stage osteochondritis dissecans of the capitellum. A case report and review of the literature. Am J Sports Med 2001;29(5):650–655 Oka Y, Ikeda M. Treatment of severe osteochondritis dissecans of the elbow using osteochondral grafts from a rib. J Bone Joint Surg Br 2001;83(5):738–739 Bilsel K, Demirhan M, Atalar AC, Akkaya S. A new surgical technique to facilitate osteochondral autograft transfer in osteochondral defects of the capitellum: a case report. Acta Orthop Traumatol Turc 2010;44(1):82–87
47
48
49
50
Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
52
53
54
55
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
454
Copyright of Seminars in Musculoskeletal Radiology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Copyright of Seminars in Musculoskeletal Radiology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Osteochondral Lesions of the Elbow Christopher Pettis, MD1
1 Department of Radiology, Florida Hospital, Orlando, Florida
Semin Musculoskelet Radiol 2013;17:446–454.
Abstract
Keywords
► osteochondral lesions ► osteochondritis dissecans ► elbow ► MRI ► CT
Christopher Wasyliw, MD1
Laura Varich, MD1
Address for correspondence Laura W. Bancroft, MD, Department of Radiology, Florida Hospital, 601 E. Rollins, Orlando, FL 32803 (e-mail: Laura.bancroft.md@flhosp.org).
Osteochondral lesions of the elbow are injuries that disrupt the cartilage and subjacent bone, and they most commonly involve the capitellum. The staging, prognosis, and treatment of osteochondral lesions in the elbow are based on a combination of radiographic, magnetic resonance imaging, and arthroscopic findings. Radiographic staging includes the radiolucent, separation, and free (advanced) stages. MR imaging features of instability include cysts, osteochondral fracture, T2 hyperintense rim, subchondral plate defects, and fluid-filled osteochondral defects. Finally, arthroscopic grading of osteochondral lesions increases in severity based on findings of softened cartilage, cartilage fissuring, exposed bone, loose but nondisplaced fragments, and eventually displaced fragments resulting in intra-articular bodies. This pictorial review focuses on osteochondral lesions in the capitellum and trochlea including osteochondritis dissecans, Panner disease, and acute trauma.
Osteochondral lesions of the elbow are injuries that disrupt the cartilage and subjacent bone. They most commonly involve the capitellum. The staging, prognosis, and treatment of osteochondral lesions in the elbow are based on a combination of radiographic, MR imaging, and arthroscopic findings. Radiographic staging includes the radiolucent, separation, and free (advanced) stages. MR imaging features of instability include cysts, osteochondral fracture, T2 hyperintense rim, subchondral plate defects, and fluid-filled osteochondral defects. Finally, arthroscopic grading of osteochondral lesions increases in severity based on findings of softened cartilage, cartilage fissuring, exposed bone, loose but nondisplaced fragments, and eventually displaced fragments resulting in intra-articular bodies. This pictorial review focuses on osteochondral lesions in the capitellum and trochlea including osteochondritis dissecans (OCD), Panner disease, and acute trauma.
Etiology Overuse OCD is a localized injury that separates a segment of cartilage and subchondral bone, occurring in patients from early adolescence to 20 years of age.1,2 Osteochondritis of the elbow most often occurs in the capitellum, but it can also involve the
Issue Theme Sport Injuries of the Elbow and Fingers; Guest Editor, Mario Padrón, MD
radial head and olecranon, and less commonly the trochlea.3 Although the exact etiology of this condition is still debated, most scientists agree that OCD of the elbow is an overuse injury caused by repetitive trauma to the poorly vascularized capitellum.2,4 The capitellum is primarily supplied by posterior end arteries that cross the epiphyseal cartilage without collateral circulation from the metaphysis, making the capitellum prone to ischemia.4 Histopathologic assessment of removed articular cartilage and osteochondral loose bodies in patients with OCD has shown changes consistent with damage from repeated stress following degenerative and reparative process of articular cartilage and subchondral fracturing.5 Capitellar OCD most frequently occurs in the dominant arm of teenage baseball pitchers (particularly pitchers), handball and water polo players, and both arms in sports that turn the elbow into a weightbearing joint such as gymnastics and weightlifting.1,2,6,7 With throwing sports, the elbow is cyclically stressed in a valgus direction during the late cocking and early acceleration phase of throwing, resulting in loading the capitellum in compression and shear.6,8–10 Medial collateral ligament rupture or attenuation results in increased compressive forces of the radiocapitellar joint, and it may result in osteochondral injuries of the capitellum and radial head from repetitive radiocapitellar impaction.11
Copyright © 2013 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1360665. ISSN 1089-7860.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Laura W. Bancroft, MD1
Osteochondral Lesions of the Elbow
Acute trauma may cause a variety of osteochondral fractures about the elbow and involve the capitellum, radius, and ulna depending on the mechanism of injury. A complete discussion of osteochondral fractures of the elbow is beyond the scope of this article. They are commonly found with subluxations, dislocations, impaction, and shear-type injuries.11
Osteochondrosis Panner disease is an osteochondrosis involving the entire capitellum that was first described by Hans Jessen Panner in 1927.12 This lesion causes rarefaction and fragmentation of the capitellar ossification center, occurs in children < 10 years old, and is a self-limiting process.13 Panner disease can be differentiated from OCD because it is not associated with repetitive trauma, is self-limited, and rarely causes longterm complications.13 Of note, there has been debate as to whether or not Panner disease and osteochondritis dissecans may represent different stages of alterations of enchondral ossification with outcomes related to patient age, activity level, and severity of the lesion.14
Imaging Radiographic Evaluation The imaging evaluation of elbow pain and suspected osteochondral lesions should begin with anteroposterior (AP) and lateral radiographs, and the addition of an AP image with 45 degrees of flexion may further increase lesion detection.17,18 Radiographs in patients with capitellar OCD may be normal, show flattening of the articular surface, lucency in the anteroinferior aspect of the capitellum (►Figs. 1 and 2), subchondral sclerosis, separated and/or displaced bony fragments, in addition to effusion in the acute setting.19,20 The radiographic stages of OCD are the radiolucent stage, separation stage, and free (advanced) stage (►Table 2).21 Negative radiographs do not exclude an osteochondral lesion, and Kijowski and colleagues reported a 66% sensitivity of radiographs in the detection of capitellar OCD and only a 57% detection rate of intra-articular bodies when compared with arthroscopic findings.22 In general, lesions observable on radiographs do not have a good prognosis with conservative management, and delayed surgery may worsen the prognosis.10
Sonography Ossification Defects and Genetic Causes Defects of enchondral ossification as well as genetic predisposition have also been proposed as possible etiologies for osteochondral lesions of the elbow.2,6,7
Clinical Presentation and Evaluation Osteochondritis of the capitellum may be asymptomatic, but patients may present with lateral elbow pain, tenderness and swelling, flexion contracture, restricted range of motion, clicking or locking, and instability.11,15 The arthroscopic classification system for OCD, as defined by the International Cartilage Repair Society, is as follows: (1) grade I is intact but soft ballotable cartilage, (2) grade II is fissuring of the overlying cartilage, (3) grade III is exposed bone or attached osteoarticular cartilage, (4) grade IV is loose but nondisplaced osteoarticular fragment; and (5) grade V is displaced fragment with resultant intra-articular body ( ►Table 1).16
Sonography has proven efficacious for the evaluation of elbow OCD.23–25 Takahara and colleagues found an 89% correlation with sonographic and intraoperative or MRI findings in the 19 cases they studied, and they also performed screening sonography in young baseball players to detect capitellar OCD.23,24 Furthermore, Harada and colleagues detected medial epicondylar fragmentation and capitellar OCD with sonography in a sonographic study of 153 male baseball players between the ages of 9 and 12 years.25
Computed Tomography and Computed Tomography Arthrography Computed tomography (CT) is advocated for better characterization of fractures (►Fig. 3), and CT arthrography is
Table 1 International Cartilage Repair Society classification of osteochondritis dissecans lesions Grade
Description
I
Intact but soft ballotable cartilage
II
Fissuring of the overlying cartilage
III
Exposed bone or attached osteoarticular cartilage
IV
Loose, but nondisplaced, osteoarticular fragment
V
Displaced fragment with resultant intra-articular body.
Source: Baumgarten et al.16
447
Fig. 1 Radiolucent stage of osteochondritis dissecans (OCD) of the elbow in a 14-year-old boy. Anteroposterior radiograph shows a focal lucency in the capitellum (arrow) caused by OCD in this boy complaining of elbow pain and swelling. Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Acute Trauma
Bancroft et al.
Osteochondral Lesions of the Elbow
Bancroft et al.
Fig. 2 Chronic osteochondritis dissecans (OCD) of the elbow. Anteroposterior radiographs of the elbow of (a) a 62-year-old woman and (b) a 53year-old man show well-circumscribed lucencies in the capitella (arrowhead) due to OCD. No free fragments were identified.
Table 2 Radiographic stages of osteochondritis dissecans I
Radiolucent stage
II
Separation stage
III
Free (advanced) stage
Source: Takeba et al.21
another imaging modality occasionally used for evaluating elbow lesions (►Fig. 3). If there is a contraindication to MRI, CT arthrography can detect intra-articular bodies and evaluate the integrity of the articular cartilage for fissures, defects, or separated osteochondral fragments (►Fig. 4).26,27
MR Imaging and Arthrography Prior to discussing actual osteochondral injuries of the elbow, normal locations in the elbow that lack cartilage and are observable on MRI should be mentioned: the pseudodefects of the trochlea and the capitellum.11,19,20,28–30 Because only anterior 180 degrees of the capitellum is covered by articular coverage, the posterior bare area contributes to the pseudodefect of the capitellum (►Fig. 5a). In addition, the trochlear
Fig. 4 Unstable capitellar osteochondritis dissecans. Coronal oblique reconstruction from computed tomography arthrogram through the radiocapitellar joint demonstrates extension of contrast (arrowheads) through a cartilaginous defect and partially beneath the osteochondral fragment (asterisk).
Fig. 3 Chronic capitellar osteochondral impaction injury. (a) Coronal and (b) sagittal reconstructions from computed tomography show marked irregularity and impaction deformity of the posterior and central aspects of the capitellum (arrowheads). Notice the widening of the radiocapitellar joint due to disruption of the ulnar collateral ligament complex. Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
448
Bancroft et al.
Fig. 5 Pseudodefects in a normal 41-year-old woman. (a) Sagittal fast spin-echo (FSE) proton-density fat-suppressed image images through the radiocapitellar joint demonstrates the normal capitellar pseudodefect (arrowhead) that reflects the transition between the articular cartilage only covering the anterior 180 degrees of the capitellum and the more posterior bare area. (b) Sagittal FSE proton-density fat-suppressed image images through the ulnohumeral joint shows the normal midtrochlear notch (arrowhead) between the anterior and posterior trochlear facets, normally devoid of cartilage.
Table 3 MR imaging classification system of osteochondritis dissecans Grade
Description
0
Normal
1
Intact cartilage with signal change
2
High-signal breach of overlying cartilage
3
Thin high-signal rim (fluid) extending about the osteochondral fragment
4
Mixed- or low-signal loose body, either in center of lesion or free in joint
Source: Nelson et al.31
Fig. 6 Capitellar osteochondritis dissecans. Sagittal fast spin-echo (FSE) T2-weighted fat-suppressed image shows a cartilaginous defect involving the anterior and inferior capitellum (between the arrowheads), with areas of partial- and full-thickness cartilage loss. Notice the subjacent capitellar marrow edema-like signal changes without osseous instability, in addition to synovitis and joint effusion.
notch of the ulnar has a complex figure-of-eight pattern of articular coverage and distinctive osseous contour that should be recognized. The midtrochlear notch is the normal interruption of the articular surface between the anterior and posterior facets of the trochlea, which can simulate a cartilaginous defect (►Fig. 5b).11,19,20,28–30 MR imaging has become the imaging standard for the assessment of osteochondral fragment size, location, stability, and viability.11,15,19,20,26,31–33 In the MRI classification system of OCD described by Nelson et al, there are four grades of lesions: (1) grade 1, intact cartilage with signal change; (2) grade 2, high-signal breach of overlying cartilage; (3) grade 3, thin high-signal rim of fluid extending about the osteochondral fragment; and (4) grade 4, mixed- or low-signal intraarticular body, either in the center of the lesion or free in the joint (►Table 3).31,34 Early OCD demonstrates focal low-signal intensity in the anterior capitellum on T1-weighted MR images, with or without high T2-weighted signal, and flattening of the subchondral bone plate. Instability can be suggested when there is a cyst-like lesion beneath the osteochondral fragment, an osteochondral fracture, T2 hyperintense rim, subchondral plate defect, and/or fluid-filled osteochondral defect (►Figs. 6, 7, 8, and 9).35 Severe lesions show an osteochondral fragment, either in situ or displaced Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
449
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Osteochondral Lesions of the Elbow
Osteochondral Lesions of the Elbow
Bancroft et al.
Fig. 7 Unstable osteochondritis dissecans of the capitellum in a 12-year-old girl. MRI was obtained after patient complained of 2 months of elbow pain. Coronal fast spin-echo (FSE) (a) T1-weighted, (b) axial T2-weighted fat-suppressed, and (c) sagittal proton-density fat-suppressed images show subcortical cystic change of the capitellum (arrowheads). Instability can be suggested when there is a cyst-like lesion beneath the osteochondral fragment. (d) Adjacent sagittal proton-density image shows extension of hyperintense fluid (arrow) beneath the capitellar osteochondral fragment.
into the joint (►Fig. 10).11 Unstable osteochondral fragments show linear hyperintense T2-weighted signal or enhancement along the interface between the fragment and capitellum (secondary to either fluid and/or granulation tissue), and some advocate MR arthrography for further conspicuity and confidence in staging OCD lesions.26,27,29,35 Furthermore,
fragment enhancement implies presence of vascularity and viability.7,18,36 Takamara and colleagues proposed a comprehensive classification system for OCD stability based on a combination of imaging and clinical features (►Table 4). In a 9-year review by Jars and colleagues, the prevalence and sensitivity of unstable osteochondral lesions in the elbow
Fig. 8 Osteochondritis dissecans in 15-year-old boy. (a) Coronal T1-weighted image shows a focal hypointense focus in the anterior and central aspect of the capitellum (arrow). (b, c) Coronal and sagittal images define the extent of the osteochondral lesion (arrows) and underlying cystic change (arrowheads).
Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
450
Bancroft et al.
Fig. 9 Superoposterior trochlear groove osteochondral lesion in a 17-year-old boy. (a) Axial and (b) sagittal fast spin-echo T2-weighted fatsuppressed images demonstrate a 3-mm osteochondral lesion (arrow) located in the posterior articular surface of the trochlea and adjacent marrow edema-like signal changes (arrow).
Fig. 10 Unstable capitellar osteochondral fragment in a 60-year-woman. (a) Axial and (b) coronal fast spin-echo T2-weighted fat-suppressed images obtained after reduction of posterior elbow dislocation show a rectangular fragment (arrows) separated from the remaining capitellum. Notice the subjacent capitellar edema-like signal changes (arrowhead) caused by shearing forces.
were reported.36 Of all osteochondral elbow injuries, 70% of lesions demonstrated MRI imaging features of instability that included cysts (11% had multiple cysts and 8% had large cysts), osteochondral fracture in 11%, T2 hyperintense rim and subchondral plate defects in 50%, and fluid-filled osteochondral defects in 23% of elbows.36 The sensitivity of MRI for detecting unstable osteochondral lesions of the elbow was 100% if all of the following characteristics are present: T2 signal rim, cysts, high T2 signal intensity cartilage fracture line, and fluid-filled OCD. If only evaluating a single imaging feature, a T2 signal rim with multiple breaks in the cartilage proved to be most sensitive at 63%.36 Superoposterior trochlear groove osteochondral lesions and posterior synovial hypertrophy have been reported in athletes with hyperextension elbow forces caused by repetitive elbow locking in full extension in swimmers or basketball players.37 Osteochondral lesions involving the trochlea are less common than those of the capitellum, and they have similar imaging characteristics as those presented previously for the capitellum.38 Unlike capitellar OCD, trochlear defects vary in their appearances based on lesion location. Osteochondral lesions involving the medial trochlea tend to be
small (< 6 mm) and located in the posterior articular surface of the medial trochlea, whereas lateral lesions are typically larger (10–13 mm), circumscribed, and located in the posteroinferior lateral trochlea (►Fig. 8).38 Medial lesions typically show chondral fissuring, subchondral osseous pitting, and surrounding marrow edema-like signal changes.38 In contradistinction, lateral lesions have the classic imaging appearance of OCD, in which lesions are well circumscribed and have a narrow zone of transition with the adjacent bone.
Table 4 Takahara’s proposed classification of capitellar osteochondritis dissecans lesions Stable
Unstable
Capitellar growth plate
Open
Closed
Radiographic grade
I
II or III
Range of motion
Normal
Restricted
ICRS classification
I
II, III, or IV
ICRS, International Cartilage Repair Society. Source: Takahara et al.17
Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
451
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Osteochondral Lesions of the Elbow
Osteochondral Lesions of the Elbow
Bancroft et al.
Fig. 11 Postoperative fixation of capitellar osteochondral fracture in an 11-year-old boy. (a) Lateral elbow radiograph shows a proximally displaced and rotated anterior capitellar osteochondral fracture in a boy who fell off his bike and landed on his elbow. (b) Sagittal two-dimensional and (c) three-dimensional surface rendered images obtained 3 weeks after open reduction and internal fixation of the capitellar defect with two Acutrak Mini screws (Acumed, Hillsboro, OR) (arrowheads). The osteochondral fragment (arrows) has been reduced to near anatomical alignment and incorporated before screw removal 6 weeks later.
Treatment Conservative Early stages of OCD are treated with conservative therapy that consists of modification or rest from the throwing activity, nonsteroidal anti-inflammatory medications, and occasionally immobilization.1,21
Conclusion
Surgical Treatment Lesions that are best treated surgically include those that do not improve with appropriate nonoperative treatment, have loose bodies with mechanical symptoms, are unstable lesions with fragmentation or result in restricted elbow motion over 20 degrees, or in patients with closed capitellar growth plates (►Fig. 11).1,21 Surgical correction is performed to avoid or delay degenerative change. Various surgical treatments for advanced stages of OCD include resection of the loose bodies with or without drilling or curettage, reattachment of the fragments, chondroplasty, mosaicplasty with autograft from the patient’s knee or rib, allograft, chondrocyte implantation, and valgus/closing wedge humeral osteotomy to unload the radiocapitellar joint.2,6,8,9,13,17,21,38–55 Free fragment resection and marrow stimulation techniques are generally reserved for smaller lesions, and osteochondral transplantation has become more commonly used, especially for chronic free fragments that generally do not heal.47 Osteochondral autograft transplantation mosaicplasty of the elbow has shown encouraging results. It is indicated for capitellar lesions involving > 50% of the capitellar surface area in the absence of associated radiocapitellar degenerative changes.15,48–50,53,55
Osteochondral lesions of the elbow most commonly involve the capitellum but may involve the trochlea, radial head, and olecranon. The interpretive radiologist must be aware of the comprehensive staging classifications, prognosis, and treatment of osteochondral lesions based on the radiographic, MR imaging, and arthroscopic findings. Although radiographs are the initial study of choice for the detection of OCD in the elbow, they are generally insensitive for the detention of osteochondral lesions and intra-articular body. Sonography has been used both as screening and diagnostic tools for evaluating capitellar osteochondral lesions, and CT arthrography is a valid substitute for patients with contraindications to MRI. MR imaging and MR arthrography are the most useful imaging tools in determining the presence of lesions and the likelihood of instability. Osteochondral lesion instability is strongly suggested by cysts, osteochondral fracture, T2 hyperintense rim, subchondral plate defects, and fluid-filled osteochondral defects on MR imaging.
References 1 Ruchelsman DE, Hall MP, Youm T. Osteochondritis dissecans of the
Imaging after Treatment Because grafted cartilage from the knee or rib is usually thicker than the adjacent capitellar cartilage, a radiographic defect often persists due to the radiolucency of the graft cartilage.42 However, a minority of patients may develop some mineralization of the graft that will be detectable on radiography.42 In a Seminars in Musculoskeletal Radiology
study by Iwasaki et al of postoperative MR imaging after mosaicplasty for young athletes with OCD of the capitellum, fluid was found to surround all grafts at 3 months, 40% of grafts at 6 months, but none at 12 months.9 Graft incorporation documented on MRI is crucial in determining the return to play for athletes to prevent graft subsidence or tilt.9
Vol. 17
No. 5/2013
capitellum: current concepts. J Am Acad Orthop Surg 2010;18(9): 557–567 2 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. Knee Surg Sports Traumatol Arthrosc 2006;14(5):491–496
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
452
Bancroft et al.
3 Patel N, Weiner SD. Osteochondritis dissecans involving the
25 Harada M, Takahara M, Sasaki J, Mura N, Ito T, Ogino T. Using
trochlea: report of two patients (three elbows) and review of the literature. J Pediatr Orthop 2002;22(1):48–51 Yamagushi K, Sweet FA, Bindra R, Morrey BF, Gelberman R. The extraosseous and intraosseous arterial anatomy of the adult elbow. J Bone Joint Surg [Am] 1997;79-A:1653–1662 Kusumi T, Ishibashi Y, Tsuda E, et al. Osteochondritis dissecans of the elbow: histopathological assessment of the articular cartilage and subchondral bone with emphasis on their damage and repair. Pathol Int 2006;56(10):604–612 Baker CL III, Romeo AA, Baker CL Jr. Osteochondritis dissecans of the capitellum. Am J Sports Med 2010;38(9):1917–1928 Bradley JP, Petrie RS. Osteochondritis dissecans of the humeral capitellum. Diagnosis and treatment. Clin Sports Med 2001;20(3): 565–590 Iwasaki N, Kato H, Ishikawa J, Masuko T, Funakoshi T, Minami A. Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes: surgical technique. J Bone Joint Surg Am 2010;92(Suppl 1 Pt 2):208–216 Iwasaki N, Kato H, Kamishima T, Minami A. Sequential alterations in magnetic resonance imaging findings after autologous osteochondral mosaicplasty for young athletes with osteochondritis dissecans of the humeral capitellum. Am J Sports Med 2009; 37(12):2349–2354 Byrd JWT, Jones KS. Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: minimum three-year follow-up. Am J Sports Med 2002;30(4):474–478 Hayter CL, Giuffre BM. Overuse and traumatic injuries of the elbow. Magn Reson Imaging Clin N Am 2009;17(4):617–638, v Panner HJ. A peculiar affection of the capitellum humeri resembling Calve-Perthes disease of the hip. Acta Radiol 1927;10:234–242 Tis JE, Edmonds EW, Bastrom T, Chambers HG. Short-term results of arthroscopic treatment of osteochondritis dissecans in skeletally immature patients. J Pediatr Orthop 2012;32(3):226–231 Singer KM, Roy SP. Osteochondrosis of the humeral capitellum. Am J Sports Med 1984;12(5):351–360 Wahegaonkar AL, Doi K, Hattori Y, Addosooki A. Technique of osteochondral autograft transplantation mosaicplasty for capitellar osteochondritis dissecans. J Hand Surg Am 2007;32(9):1454–1461 Baumgarten TE, Andrews JR, Satterwhite YE. The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26(4):520–523 Takahara M, Ogino T, Sasaki I, Kato H, Minami A, Kaneda K. Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop Relat Res 1999;(363):108–115 Kijowski R, Tuite MJ. Pediatric throwing injuries of the elbow. Semin Musculoskelet Radiol 2010;14(4):419–429 Stevens KJ, McNally EG. Magnetic resonance imaging of the elbow in athletes. Clin Sports Med 2010;29(4):521–553 Stevens KJ. Magnetic resonance imaging of the elbow. J Magn Reson Imaging 2010;31(5):1036–1053 Takeba J, Takahashi T, Hino K, Watanabe S, Imai H, Yamamoto H. Arthroscopic technique for fragment fixation using absorbable pins for osteochondritis dissecans of the humeral capitellum: a report of 4 cases. Knee Surg Sports Traumatol Arthrosc 2010; 18(6):831–835 Kijowski R, De Smet AA. Radiography of the elbow for evaluation of patients with osteochondritis dissecans of the capitellum. Skeletal Radiol 2005;34(5):266–271 Takahara M, Shundo M, Kondo M, Suzuki K, Nambu T, Ogino T. Early detection of osteochondritis dissecans of the capitellum in young baseball players. Report of three cases. J Bone Joint Surg Am 1998;80(6):892–897 Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. Surgical technique. J Bone Joint Surg Am 2008; 90(Suppl 2 Pt 1):47–62
sonography for the early detection of elbow injuries among young baseball players. AJR Am J Roentgenol 2006;187(6):1436–1441 Delport AG, Zoga ACMR. MR and CT arthrography of the elbow. Semin Musculoskelet Radiol 2012;16(1):15–26 Hayes CW, Daffner RH, Weissman BN, et al; Expert Panel on Musculoskeletal Imaging. American College of Radiology (ACR) Appropriateness Criteria chronic elbow pain. Reston, VA: ACR; 2011 Rosenberg ZS, Beltran J, Cheung YY. Pseudodefect of the capitellum: potential MR imaging pitfall. Radiology 1994;191(3): 821–823 Kijowski R, De Smet AA. MRI findings of osteochondritis dissecans of the capitellum with surgical correlation. AJR Am J Roentgenol 2005;185(6):1453–1459 Tuite MJ, Kijowski R. Sports-related injuries of the elbow: an approach to MRI interpretation. Clin Sports Med 2006;25(3): 387–408, v Nelson DW, DiPaola J, Colville M, Schmidgall J. Osteochondritis dissecans of the talus and knee: prospective comparison of MR and arthroscopic classifications. J Comput Assist Tomogr 1990;14(5): 804–808 Ouellette H, Bredella M, Labis J, Palmer WE, Torriani M. MR imaging of the elbow in baseball pitchers. Skeletal Radiol 2008; 37(2):115–121 Steinbach LS, Palmer WE, Schweitzer ME. Special focus session. MR arthrography. Radiographics 2002;22(5):1223–1246 Trattnig S, Winalski CS, Marlovits S, et al. Magnetic resonance imaging of cartilage repair: a review. Cartilage 2011;2:15–26 Thornton R, Riley GM, Steinbach LS. Magnetic resonance imaging of sports injuries of the elbow. Top Magn Reson Imaging 2003; 14(1):69–86 Peiss J, Adam G, Casser R, Urhahn R, Günther RW. Gadopentetatedimeglumine-enhanced MR imaging of osteonecrosis and osteochondritis dissecans of the elbow: initial experience. Skeletal Radiol 1995;24(1):17–20 Wiesler ER, Sarlikiotis T, Rogers S, Papadonikolakis A, Poehling GG. Arthroscopic debridement for osteochondral injury of the elbow trochlea: a case report with a long-term follow-up. J Shoulder Elbow Surg 2011;20(2):e18–e22 Marshall KW, Marshall DL, Busch MT, Williams JP. Osteochondral lesions of the humeral trochlea in the young athlete. Skeletal Radiol 2009;38(5):479–491 Smith MV, Bedi A, Chen NC. Surgical treatment for osteochondritis dissecans of the capitellum. Sports Health 2012;4(5):425–432 Allagui M, Koubaa M, Bellaj Z, et al. Osteochondritis dissecans of the capitellum: autologous osteochondral mosaicplasty: a case report. Chir Main 2012;31(4):206–209 Shimada K, Tanaka H, Matsumoto T, et al. Cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans. J Bone Joint Surg Am 2012;94(11):992–1002 Vogt S, Siebenlist S, Hensler D, et al. Osteochondral transplantation in the elbow leads to good clinical and radiologic long-term results: an 8- to 14-year follow-up examination. Am J Sports Med 2011;39(12):2619–2625 de Graaff F, Krijnen MR, Poolman RW, Willems WJ. Arthroscopic surgery in athletes with osteochondritis dissecans of the elbow. Arthroscopy 2011;27(7):986–993 Jans LB, Ditchfield M, Anna G, Jaremko JL, Verstraete KL. MR imaging findings and MR criteria for instability in osteochondritis dissecans of the elbow in children. Eur J Radiol 2012;81(6): 1306–1310 Ovesen J, Olsen BS, Johannsen HV. The clinical outcomes of mosaicplasty in the treatment of osteochondritis dissecans of the distal humeral capitellum of young athletes. J Shoulder Elbow Surg 2011;20(5):813–818
4
5
6 7
8
9
10
11 12 13
14 15
16
17
18 19 20 21
22
23
24
26 27
28
29
30
31
32
33 34 35
36
37
38
39 40
41
42
43
44
45
Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
453
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Osteochondral Lesions of the Elbow
Osteochondral Lesions of the Elbow
Bancroft et al.
46 Mihara K, Suzuki K, Makiuchi D, Nishinaka N, Yamaguchi K, Tsutsui
51 Tsuda E, Ishibashi Y, Sato H, Yamamoto Y, Toh S. Osteochondral
H. Surgical treatment for osteochondritis dissecans of the humeral capitellum. J Shoulder Elbow Surg 2010;19(1):31–37 Miyamoto W, Yamamoto S, Kii R, Uchio Y. Oblique osteochondral plugs transplantation technique for osteochondritis dissecans of the elbow joint. Knee Surg Sports Traumatol Arthrosc 2009;17(2): 204–208 Ansah P, Vogt S, Ueblacker P, Martinek V, Woertler K, Imhoff AB. Osteochondral transplantation to treat osteochondral lesions in the elbow. J Bone Joint Surg Am 2007;89(10):2188– 2194 Micheli L, Curtis C, Shervin N. Articular cartilage repair in the adolescent athlete: is autologous chondrocyte implantation the answer? Clin J Sport Med 2006;16(6):465–470 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. Am J Sports Med 2006;34(5):714–720
autograft transplantation for osteochondritis dissecans of the capitellum in nonthrowing athletes. Arthroscopy 2005;21(10): 1270 Krijnen MR, Lim L, Willems WJ. Arthroscopic treatment of osteochondritis dissecans of the capitellum: report of 5 female athletes. Arthroscopy 2003;19(2):210–214 Nakagawa Y, Matsusue Y, Ikeda N, Asada Y, Nakamura T. Osteochondral grafting and arthroplasty for end-stage osteochondritis dissecans of the capitellum. A case report and review of the literature. Am J Sports Med 2001;29(5):650–655 Oka Y, Ikeda M. Treatment of severe osteochondritis dissecans of the elbow using osteochondral grafts from a rib. J Bone Joint Surg Br 2001;83(5):738–739 Bilsel K, Demirhan M, Atalar AC, Akkaya S. A new surgical technique to facilitate osteochondral autograft transfer in osteochondral defects of the capitellum: a case report. Acta Orthop Traumatol Turc 2010;44(1):82–87
47
48
49
50
Seminars in Musculoskeletal Radiology
Vol. 17
No. 5/2013
52
53
54
55
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
454
Copyright of Seminars in Musculoskeletal Radiology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Copyright of Seminars in Musculoskeletal Radiology is the property of Thieme Medical Publishing Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
