Osteochondritis dissecans of the humeral capitellum: treatment options and differential indications
Hennrikus, William Patrick
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INTRODUCTION: Osteochondritis dissecans (OCD) of the capitellum is a focal condition affecting the articular cartilage and subchondral bone, typically in adolescent athletes. Limited data exists regarding the indications and expected outcomes of the various treatment methods of capitellar OCD, and the optimal treatment strategy remains controversial. Risks of progressive capitellar OCD include osteoarthritic changes and permanent elbow disability. STUDY AIMS: The objective of this literature review is to assess the data and the conclusions to be drawn from the existing literature on the differential indications for the various treatment options for capitellar OCD, using low-level meta-analysis and qualitative observations, to suggest a course of future study with the purpose of clarifying the differential treatment indications and improving the care of capitellar OCD patients. The most recent 10 years (2004-2014) of data are the focus, in order to evaluate the most modern indications, surgical techniques, surgical skills, and clinical outcomes. DISCUSSION OF PUBLISHED DATA: Ultrasound reportedly offers a high predictive value for screening baseball players for capitellar OCD, although sensitivity, specificity, and cost-effectiveness are unknown. Plain radiographs and magnetic resonance imaging (MRI) are useful diagnostic resources for making the decision to operate, but their sensitivities and specificities are imperfect. Evidence suggest that early stage OCD in physically immature patients may recover with non-operative management, while advanced stage OCD in older patients will likely achieve a better recovery with operative management. Risk factors for poor outcomes following surgical management of capitellar OCD may reportedly include patient age, physical maturity, athletic competition level, large lesion diameter and thickness, and lateral lesion location. The advantages of removal, debridement, and marrow stimulation techniques include the minimal invasiveness associated with arthroscopy. Successful fragment fixation can preserve normal articular properties, but may risk implant complications and secondary surgeries. Mosaicplasty is frequently suggested when patient or lesion characteristics seem to preclude other surgical methods, or when prior surgical treatment attempts fail, but disadvantages of mosaicplasty include the technical complexity of the procedure and the risk of donor site morbidity. CONCLUSIONS: The capitellar OCD literature has accumulated a wealth of level IV case series reporting generally satisfactory short-term results of the various surgical options. There is little need for more descriptive literature on this topic at this time. Modern treatment strategies are incomplete and poorly defined, based upon the suggestions of small case series offering disorganized, low-quality data. A study of the cost-effectiveness of ultrasound screening in high-risk athletes would be useful. A large, comparative case-control study or prospective cohort study of higher methodological quality and better standardization is needed to advance the knowledge on this topic, and classification and regression tree analysis could be applied meaningfully. With more organized data and analysis, it will become easier to take a systematic approach to treating capitellar OCD, settle clinical controversy and improve patient outcomes.