Cylindrical Costal Osteochondral Autograft for Reconstruction of Large Defects of the Capitellum Due to Osteochondritis Dissecans

Abstract

Background: There is a need to clarify the usefulness of and problems associated with cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans. Methods: Twenty-six patients with advanced osteochondritis dissecans of the humeral capitellum were treated with use of cylindrical costal osteochondral autograft. All were males with elbow pain and full-thickness articular cartilage lesions of ‡15 mm in diameter. Clinical, radiographic, and magnetic resonance imaging outcomes were evaluated at a mean followup of thirty-six months (range, twenty-four to fifty-one months). Results: All patients had rapid functional improvement after treatment with costal osteochondral autograft and returned to their former activities, including sports. Five patients needed additional minor surgical procedures, including screw removal, loose body removal, and shaving of protruded articular cartilage. Mean elbow function, assessed with use of the clinical rating system of Timmerman and Andrews, was 111 points preoperatively and improved to 180 points at the time of follow-up and to 190 points after the five patients underwent the additional operations. Mean elbow motion was 126°of flexion with 16°of extension loss preoperatively and improved to 133°of flexion with 3°of extension loss at the time of follow-up. Osseous union of the graft on radiographs was obtained within three months in all patients. Revascularization of the graft depicted on T1-weighted magnetic resonance imaging and congruity of the reconstructed articular surface depicted on T2-weighted or short tau inversion recovery imaging were assessed at twelve and twenty-four months postoperatively. Functional recovery was good, and all patients were satisfied with the final outcomes. Conclusions: Cylindrical costal osteochondral autograft was useful for the treatment of advanced osteochondritis dissecans of the humeral capitellum. Functional recovery was rapid after surgery. Additional operations were performed for five of the twenty-six patients, whereas the remaining patients showed essentially full recovery within a year. All patients were satisfied with the results at the time of short-term follow-up. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. O steochondritis dissecans of the humeral capitellum is a common sports-related disorder in young athletes, especially baseball players and gymnasts. With severe osteochondritis dissecans, the damaged articular cartilage detaches from the capitellum and there is a full-thickness articular cartilage defect and radiocapitellar incongruity. Treatment for early-stage osteochondritis dissecans is principally nonoperative. When the lesion progresses to a large, full-thickness articular cartilage defect, treatment remains challenging. In the elbow, arthroscopic debridement has been widely applied with good Disclosure: None of the authors received payments or services, either directly or indirectly (...

Osteochondritis dissecans of the elbow

“…Potential surgical interventions include arthroscopic removal of loose bodies, abrasion chondroplasty, retrograde drilling, microfracture, in situ fixation, osteochondral autograft transplantation system (OATS), and costal osteochondral transplantation (COT) [5][6][7]10 …”

“…The procedure entails harvesting a costal osteochondral fragment with hyaline cartilage, usually from the sixth rib, for transplantation into the recipient site on the capitellum [5,42]. Zlotolow and Bae revealed that the costal hyaline cartilage layer is much thicker than in OATS grafts and must be trimmed in order to fit flush.…”

“…Shimada et al highlighted a benefit of COT in the ability to harvest larger grafts. They achieved grafts up to 15 mm, allowing greater coverage with fewer plugs [5].…”

“…At 6-12 months, 77 % of patients had congruous joint surfaces on MRI. Complications included one pneumothorax, treated with chest tube placement that ultimately resolved, and reoperation in five of the 26 patients [5]. Nishinaka et al described their technique and outcomes in 22 overhead athletes with an average followup of 27 months.…”

“…The elbow, specifically the capitellum, is one of the most common sites of these lesions and the area where their incidence is increasing most rapidly [3,4]. Many treatment strategies exist for OCD in the elbow, including rest/activity modification, arthroscopic removal of loose bodies, abrasion chondroplasty, microfracture, retrograde drilling, fixation of fragments, osteochondral autograft transplantation system, and costal osteochondral autograft [5][6][7]. The aim of this paper is to evaluate and summarize recent advances in the literature in the diagnosis and treatment of OCD of the elbow and to serve as a guide for management.…”