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Osteochondritis dissecans of the capitellum: diagnosis and treatment.

Osteochondritis dissecans (OCD) of the capitellum is an articular cartilage lesion with disruption of the subchondral bone. It commonly affects young adolescents and especially immature athletes who undergo repetitive compression of the radiocapitellar joint. It is seen in baseball players, notably pitchers, as well as gymnasts.

OCD was first described in the mid-nineteenth century. (1) Pare is credited with first describing the removal of osteochondral fragments from joints in 1840. Later, Paget termed the process that led to these fragments as a "quiet necrosis." Konig in 1888 described the pathologic process that led to the formation of these loose fragments. He called these fragments "arthrophytes" or "corpora mobile." He noted that these fragments were not related to any traumatic episode and believed them to be the result of an inflammatory reaction resulting in osteonecrosis of the fragment and thus coined the term osteochondritis dissecans from the Latin word "dissecare" meaning 'to cut apart.' The name of this entity implies an inflammatory process; however, the amount of inflammatory cells present on histologic exam is not significant, which underscores the controversy regarding the underlying etiology. (2)

Etiology

The precise etiology of osteochondritis dissecans of the capitellum is not entirely understood. Most agree that both trauma and ischemia play an important role in the development of this lesion, which accounts for about 5% of all OCD lesions. (3) Genetics also plays a role, as there is an increased predisposition to the development of OCD seen in consecutive generations of fraternal twins. (4)

Trauma

Repetitive microtrauma is one of the major underlying etiologies for the development of OCD in the capitellum seen in high-level athletes, especially pitchers and gymnasts. (5) During the early acceleration phase of throwing, there is a valgus load to the elbow in which the ulnar collateral ligament (UCL) absorbs 54% of the load, with the remaining forces distributed within the radiocapitellar joint. (3) During this phase, the elbow is pushed into extension with pronation of the forearm and a valgus thrust, causing sheer forces along the radiocapitellar joint. (6) Injury results due to tension on the medial side of the elbow leading to compression of the lateral radiocapitellar joint, which worsens if the UCL becomes incompetent and is not able to absorb a majority of the transmitted forces. (6-10) Gymnasts are also predisposed to OCD lesions of the capitellum since the majority of the forces (60%) along a fully extended elbow are transmitted across the radiocapitellar joint. (5)

Schenck and colleagues (11) found that the capitellum has decreasing stiffness with the lateral portion being significantly softer than the medial part. The radial head, on the other hand, is much stiffer, which explains the predisposition for OCD lesions to develop on the central and anterolateral capitellar surfaces. (12)

Vascular

Vascular insult is another cause that contributes to the development of capitellar OCD lesions. (13, 14) An understanding of the anatomy at the lateral aspect of the elbow helps to explain the pathophysiology of this disorder. The blood supply to the capitellum is limited as its main blood supply enters posteriorly, traversing the epiphyseal articular cartilage with no metaphyseal collateral contribution. This blood supply is derived from the two major branches of the brachial artery that contribute to the collateral circulation around the capitellum: the profunda brachii and the radial collateral artery.

The profunda brachii arises from the brachial artery 86% of the time and courses posterior with the radial nerve and divides into the radial collateral and middle collateral arteries. (13) These branches otherwise arise from the brachial artery directly if the profunda brachii is not present. The capitellum ultimately receives its blood supply from the lateral arcade composed of the radial collateral, radial recurrent (branch from the radial artery distal to the capitellum), and the interosseous recurrent arteries (branch from the posterior interosseous artery originating from the ulnar artery). This arcade penetrates the posterior portion of the lateral epicondyle and radiates anteriorly and medially finally terminating at the epiphyseal articular cartilage with no collateral contribution. (14) Epiphyseal injury, thus, renders the capitellum susceptible to osteonecrosis due to its limited vascularity and ability to heal.

Histopathology

The histology of OCD lesions in the capitellum shows similarities with that of osteonecrosis and osteoarthritis. Studies looking at the histology of osteochondral cylinders taken from the capitellum before the implantation of an osteochondral autograft (12) have shown discontinuity of the cartilage surface, as well as chondrocyte cloning, indicative of degenerative change and reparative change respectively of the damaged articular cartilage. Specific assays to target metal metalloproteinases (MMPs) as markers of apoptosis found that MMP-3 and MMP-13 were expressed throughout the samples in the superficial and deep zones of the cartilage. The degenerative changes along with the positive staining of MMPs are both similar to patterns found in osteoarthritis. In addition, fractures of the subchondral bone with localized sites of necrosis were also present. Kusumi and coworkers concluded that the primary pathologic change in OCD lesions is damaged articular cartilage induced by repeated stress followed by a degenerative and reparative process of articular cartilage and subchondral fracturing resulting in separation of loose bodies. (12)

Clinical Presentation

OCD lesions of the capitellum mainly affect young individuals and athletes between the ages of 11 to 21 years old. The dominant arm is more frequently affected, and up to 20% of patients have bilateral lesions. (15) Athletes are at a higher predisposition for these lesions, including baseball pitchers, gymnasts, tennis players, and weight lifters.

On exam, there may be a small effusion present over the radiocapitellar joint, as well as crepitus with motion, and tenderness with palpation. There is usually a loss of extension with a flexion contracture of 5[degrees] to 23[degrees], usually without loss of pronation or supination. (3, 16, 17) Any clicking, catching, grinding, or locking on exam suggests the presence of loose bodies, and the OCD lesion is likely advanced and unstable. (15) A provocative maneuver called the active radiocapitellar compression test helps identify OCD lesions. (15) In this maneuver, the patient pronates and supinates the arm in full extension causing compression of the radiocapitellar joint due to dynamic muscle forces, and if found to be painful, it is suggestive of an OCD lesion of the capitellum.

Another condition seen in adolescents and commonly confused with OCD lesions of the capitellum is Panner's disease, which is an osteochondrosis of the capitellum. It is similar in presentation and radiographic appearance, yet treated differently from OCD lesions. Patients with Panner's disease present young and are frequently less than 10 years of age. Radiographs show a diffuse flattening and patchy global sclerosis of the capitellum similar to a Perthes-type picture of the hip. (4) As opposed to OCD lesions of the capitellum, Panner's disease is treated with modification of activities and splinting until the capitellum reconstitutes itself, as this is a self-limited condition, which can take up to a year to resolve. (1)

Classification

There are several ways of classifying OCD lesions of the capitellum, and these classifications help surgeons to categorize the lesions and decide on treatment algorithms. Minami grouped OCD lesions of the capitellum into three groups based on radiographic interpretation. (3) Grade 1 lesions showed a translucent cystic shadow in the capitellum. Grade 2 showed a clear zone or split line between the lesion and the adjacent subchondral bone. And Grade 3 lesions showed loose bodies. Minami went on to further describe the lesions as either stable, unstable but still attached, and unstable and detached.

Another method of classifying these lesions is based on patient characteristics. Jobe described three groups of patients. (6) Group 1 is composed of children up to age 13 years old with minimal to no symptoms. These patients rarely need operative intervention and activity restriction is usually enough for a good outcome. Group 2 consists of adolescents to young adults that are involved in competitive sports. These patients report significant pain and although activity restriction does play a role, arthroscopic treatment is sometimes required. Finally, group 3 consists of adult patients with fragmented loose bodies and arthritis presenting with joint incongruity. The prognosis is poor in these patients due to the inability to properly reconstruct the articular cartilage. The challenge is early identification and intervention to prevent patients from falling into this third group.

The more common classification system used in the literature to describe OCD lesions is the International Cartilage Repair Society (ICRS) Score as described in Table 1. This classification is based on arthroscopic evaluation of the OCD lesion. A careful evaluation of the lesion with probing is requiring for proper classification as unrecognized fragment instability can drastically change the management of the lesion (Fig. 1). Most importantly, surgeons need to be able to determine the stability of the lesion (i.e. whether or not the lesion can be displaced) since this is a key factor in management. Stability can be assessed preoperatively based on radiographs and magnetic resonance imaging (MRI), but an arthroscopic evaluation is the most accurate method. (3, 15, 18)

Diagnostic Imaging

Plain radiographs should be obtained on presentation as an initial test. These lesions may be difficult to see on radiographs early in the disease process since only subtle changes may be noticed. An AP radiograph with the elbow in 45[degrees] of flexion is recommended for the best visualization of the lesion. (19, 20) This allows for the lesion to present itself in line with the x-ray beam without bony overlap since its location is commonly anterior and lateral.

Ultrasound is another modality for early detection of OCD lesions. Takahara used ultrasound to detect early changes in baseball pitchers and found flattening of the subchondral bone, leading the investigators to believe that an impaction fracture and delayed ossification of the capitellum contributes to this condition. (20)

Significant literature exists on the utilization of MRI in evaluating OCD lesions of the capitellum and determining the stability of the lesion. Kijowski and colleagues looked at MRI findings in OCD lesions of the capitellum and correlated them with intraoperative findings. (21) They described the following MRI findings commonly seen on T2 weighted imaging with unstable lesions: 1. a line of high signal intensity at the interface between the lesion and the subchondral bone (most common), 2. lesions showing a discrete area of high signal intensity beneath the OCD lesion indicative of a cyst, 3. high signal intensity line traversing the articular cartilage and subchondral bone plate into the OCD lesion, and 4. focal defect in the articular cartilage of the OCD lesion. Stable lesions, on the other hand, had similar appearances to unstable lesions when looking at T1-weighted imaging and therefore cannot be distinguished with this type of imaging. (21)

One study looked at stable lesions in 106 elbows in an attempt to predict stability based on radiographic and patient-specific characteristics. (22) The investigators concluded that patients with stable lesions tend to always have the following three characteristics: an open capitellar growth plate, a radiolucent OCD lesions on radiograph, and less than 20[degrees] of restricted elbow motion compared to the unaffected contralateral elbow. The basis for the range of motion criteria is that patients with more restricted range of motion tend to have loose bodies and therefore unstable lesions. In addition, one can identify an unstable lesion with 80% specificity and sensitivity if the following characteristics are found with diagnostic imaging: 1. articular irregularity on MRI, 2. T2-high signal intensity interface surrounding the lesions, and 3. a high-signal intensity line through the articular cartilage or CT scan showing fragmentation. (22) Some of these characteristics are demonstrated in Figure 2.

Researchers have also used MRI to evaluate the viability of OCD lesions in the capitellum. (23) Knowing whether or not a lesion is viable can help predict the likelihood that fixation will lead to union or whether a debridement procedure is more appropriate. Patients in this study were injected with intravenous gadopentetate dimeglumine during imaging of their elbows. It was postulated that if the fragment enhanced, it would suggest perfusion and hence a good chance of viability. On the other hand, enhancement at the fragment-subchondral bone interface would suggest a non-viable and loose fragment. Based on this study, two out of three patients showing fragment enhancement were treated non-operatively with good clinical outcomes. The third patient showed peripheral enhancement surrounding the lesion, and this patient went on to have surgery due to continued symptoms from non-operative management.

Lastly, there is a normal anatomic variant referred to as a pseudo-defect of the capitellum, which can mimic an OCD lesion or subchondral fracture of the capitellum. (24) This defect results from an abrupt transition between the articular surface of the posterior-inferior capitellum and the non-articular surface of the adjacent lateral epicondyle.

Management

Managing OCD lesions of the capitellum can be a difficult problem. The indications for surgery are not always clear, as there can be inconsistencies regarding the stability of the lesion based on MRI analysis versus intraoperative examination. In addition, there are a number of surgical options available to deal with these lesions and no good prospective randomized trial to prove the superiority of one method over another. Surgical management is mainly driven by the integrity of the articular cartilage, as well as the stability and characteristics of the lesion, such as grade, location, and size (Table 2). The surgical arsenal is varied and includes arthroscopy, debridement, fragment excision or fixation, bone marrow stimulation, and grafting of the defect.

Natural History

Managing OCD lesions in the capitellum requires an understanding of the natural history. Researchers have come a long way in understanding which of these lesions heal with conservative treatment and which ones require more aggressive treatment. Takahara examined 17 patients with non-displaced fragments and followed them over time to determine lesion characteristics that help predict good clinical outcomes. (25) He noticed that seven of these patients were skeletally immature (average age 11.7 years-old) and presented with radiographs showing capitellar flattening. Another nine patients were skeletally mature (average age 13.1 years-old) and presented with radiographs showing non-displaced fragments. At final follow-up, the patients with capitellar flattening showed new bone formation around the capitellum, and five of the seven patients (71%) went on to completely heal. Among the skeletally mature patients with non-displaced fragments, six of nine patients showed new bone formation, but only three of nine (33%) improved significantly. The investigator concluded that patients with open physes or capitellar flattening demonstrate an early stage of OCD lesions that generally goes on to fully heal if treated conservatively. However, the same rate of success is not seen in patients who present with non-displaced lesions on radiographs and closed physes. (25)

Non-operative Treatment

Non-operative treatment is reserved for low grade (stable) lesions and lesions in skeletally immature patients. Low grade refers to Minami grade I (a translucent cystic shadow in the capitellum) or capitellar flattening or sclerosis on radiographs. (3) An MRI should be obtained to assess lesion stability as it has a high sensitivity and specificity. Once there is no concern for an unstable lesion, the patient can rest the elbow in a sling and avoid strenuous activities for 3 weeks followed by therapy with range of motion exercises and a slow return to sports between 3 to 6 months. (3, 4, 15) The patient should be followed every 3 months with radiographs. Return to full sports without restrictions can occur once symptoms are relieved and no sooner than 6 months from the initiation of treatment. Radiographs lag behind clinical symptoms. Therefore, it is best to rely on the patient's exam rather than x-rays showing a fully healed lesion.

Despite these conservative treatment recommendations, results can vary, and it is difficult to determine which patients can be treated conservatively early in the disease process. Although Takahara showed that treating patients with open physes and no fragmentation of OCD lesions leads to excellent results, the same results are not consistently seen in skeletally mature patients with similar radiographic findings in terms of pain and return to sport. (19) Patients with open physes but advanced lesions (Minami grade II--showing fragmentation on x-ray) can also have poor results if treated conservatively, suggesting that these lesions can be unstable and deteriorate over time despite the patient having an open physis. It is also important to follow x-rays over time in patients treated conservatively for OCD lesions since it has been shown that approximately 50% of patients do poorly when there is no radiographic improvement with follow-up. (26)

Operative Management

There are a variety of techniques available to treat OCD lesion, and there are no good prospective randomized trials to compare one method's superiority over another. Many management decisions are based on patient-specific and lesion-specific factors as well as surgeon preference and experience.

Fragment Removal

Fragment removal is an option for treatment of OCD lesions of the capitellum. Although the results are variable, Takahara reported significant improvement in pain for removal of small defects of less than 50% of the capitellar articular width, and none of these patients showed degenerative changes after 7.2 years of follow-up. (19) In addition, loose bodies can result from these unstable fragments, and it is important for the surgeon to look for them on MRI preoperatively and during surgery, as they can be a significant source of pain. Loose bodies can commonly hide in the olecranon, radial, and coronoid fossae as well as the posterior region of the radiocapitellar joint. (27)

Long-term studies of patients with capitellar OCD lesions treated conservatively versus surgically with fragment excision show that outcomes are related to lesion size, as expected. (19, 28) In general, large lesions treated with fragment excision alone have poor long-term results. Large lesions, defined by Takahara as having a defect size of 70% or greater of the capitellar width and a defect angle of 90[degrees] or greater, had poor outcomes. (28) Contrary to these results, there were no poor outcomes for small lesions with a defect size of less than 55% of the capitellar width and a defect angle less than 60[degrees]. Based on the available literature, large lesions should be treated operatively; however, fragment excision is likely not the best method given the poor outcomes reported.

Fragment Debridement and Marrow Stimulation

Fragment debridement with a marrow stimulation procedure is a common form of treatment for OCD lesions. These procedures show reliable results with short-term follow-up; however, long-term results can vary, and lesion characterization is poor among studies, making results difficult to interpret. (16, 29, 30) Byrd looked at 10 adolescent baseball players who failed conservative measures and had chondroplasty with abrasion arthroplasty performed on the capitellum. (29) At 3.9 years of follow-up, elbow functional scores significantly improved, although only 4 of 10 players returned to organized baseball. However, the remaining players returned to other sports with modification of their activities. Interestingly, three of the four players that returned to full baseball had high-grade unstable lesions, suggesting that lesion severity is not an indicator of clinical outcome using this technique.

Another study by Baumgarten and colleagues showed a large series of arthroscopic OCD lesions consisting of 17 patients with 48-months follow-up. (16) Following failed conservative treatment, these patients received abrasion arthroplasty of their OCD lesions. At final follow-up, 4 of 17 patients continued to have elbow pain; however, 82% of patients (14/17) returned to their pre-injury level of activity. There was no evidence of degenerative arthritis on radiographs, but capitellar flattening was noted. The investigators stated the key surgical pearl is to obtain a uniform bleeding bony surface and to start early active range of motion.

Lastly, a study by Wulf and colleagues looked at 10 patients, 8 of which were in competitive sports. (30) These patients all had ICRS grade III and IV lesions measuring an average of 98 [mm.sup.2]. Surgery consisted of lesion debridement, abrasion arthroplasty, and microfracture, followed by initiation of therapy at 48 to 72 hours and non-weightbearing for 3 months. At final follow-up of 42 months, all patients had improved range of motion, x-ray, and MRI grade, as well as elbow functional scores. Among the competitive athletes, six of eight returned to pre-injury sporting activities at 5.1 months. Lastly, 80% of patients showed evidence of congruent reparative cartilage on MRI at their 1-year follow-up. The investigators emphasize that microfracture when compared to osteochondral autograft transfer procedures allows for quicker return to play (no graft incorporation), better range of motion due to a more minimally invasive approach, and quicker biologic response to healing due to the robust mesenchymal stem cells available in young patients. (30)

Based on these studies, marrow stimulation provides better and more predictable outcomes compared with fragment excision alone. Most of these studies fail to quantify the size of the lesions treated, and there is little prospective analysis present. Nevertheless, marrow stimulation provides good results with minimally invasive techniques.

Fragment Fixation

Various techniques exist for fixation of a loose OCD lesion in the capitellum, including headless screws, staples, wires, bioabsorbable implants, and bone pegs. One study by Harada looked at outcomes following fragment fixation in four patients using dynamic staples inserted via the lateral nonarticular side of the capitellum and augmented with iliac crest autograft cylinders. (31) Of the four patients, three returned to competitive baseball, and the other returned to recreational activities with significant improvement in their pain. All fragments at the time of surgery were unstable on probing but still attached to the bony bed by fibrous tissue (ICRS grade III). The investigators explain that this is the best scenario for fragment fixation, and at final follow-up of 7.5 years, all lesions had united.

Fixation of osteochondral fragments is associated with specific complications such as loss of fixation, nonunion, damage to the articular cartilage, or fracture of the fragment. Although reliable results exist, there are no good studies comparing fragment fixation with abrasion arthroplasty or microfracture. In addition, it is difficult to determine fragment viability, and fixation of a non-viable fragment may result in a nonunion regardless of fixation method. One can try to assess fragment viability with contrast studies to determine fragment perfusion as previously described. (23) Ultimately, if fixation fails either intraoperatively or with follow-up, the surgeon should know how to perform an osteochondral autograft transplant procedure.

Osteochondral Autograft Transplantation

Osteochondral autograft transplantation (OAT) of the capitellum is a procedure used to deal with large ICRS grade III or IV lesions. The indications for performing this procedure are varied, and the surgeon must use it in the context of the patient's exam and lesion characteristics. It is commonly used for lesions that comprise more than 50% of the capitellar width as well as non-contained lesions involving the lateral aspect of the capitellum. Loss of this lateral buttress compromises the valgus stability of the elbow imparted by the radiocapitellarjoint. This procedure is also useful for lesions that have failed other treatments such as microfracture or fragment fixation.

Performing an OAT of the capitellum is a technically demanding operation, and it is well described in the literature. (27, 32) Particular attention is needed when harvesting the autograft from the knee. Studies have shown that osteochondral autografts heal to the subchondral and deeper bone and not along the hyaline cartilage. (33, 34) Therefore, it is important to take grafts that have an articular cartilage depth equal to the recipient site in order to have the best surface match possible and reduce shear stress at the chondral surface. Schnub performed an MRI analysis and determined the sites that best fit the capitellum are the posterior pole of the medial femoral condyle and the distal most aspect of the anterio-lateral femoral condyle. (35) When harvesting plugs from skeletally immature patients, it is imperative not to violate the physis.

Postoperatively patients can be immobilized in 80[degrees] to 90[degrees] and neutral rotation for 3 weeks followed by a rehabilitation protocol consisting of early gentle active and passive range of motion and non-weightbearing for the first 3 months. Gentle resistance exercises are begun at 3 months, progressing to full resistance by 4 months. Athletes can then begin an interval throwing program at about 6 months postoperatively if they demonstrate no pain on exam, radiographs showing signs of healing, and if their range of motion is back to their preoperative baseline. They can expect a normal level of activity 1 year postoperatively.

Capitellar OAT procedures are shown in the literature to provide good functional outcomes. One study looked at 19 patients with unstable lesions on MRI and ICRS grade III and IV defects averaging 147 [mm.sup.2] who underwent an OAT procedure averaging three plugs. (36-38) At 45 months of follow-up, functional scores significantly improved; 17 of 19 patients (89%) returned to competitive sports, and 18 of 19 patients (95%) were pain free. All grafts showed incorporation at final follow-up based on MRI analysis. Sixty percent of graft incorporation occurred at 6 months, and all grafts were fully incorporated by 1 year postoperatively. (38) Based on this study, players should not return to full activity any earlier than 6 months postoperatively, due to the prolonged timing of graft healing. The results are an improvement from the studies evaluating abrasion arthroplasty and microfracture; however, the procedure is more invasive, and the rehabilitation is more involved. (16, 29, 30) Once again, there are no prospective trials comparing any of these procedures, and the surgeon has to use the available data and surgical judgment in indicating the right patient for these procedures.

There is a distinct subset of patients with OCD lesions of the capitellum that may benefit from an OAT procedure. Kosaka classified OCD lesions of the capitellum as being one of two types: lateral localized (< 33% of the capitellar width) or lateral widespread (> 33% of the capitellar width). (39) The lateral widespread lesions are non-contained lesions involving the lateral aspect of the capitellum along the nonarticular surface. Patients who underwent bone peg fixation of the lateral widespread lesion had a high failure rate (50% or 4 of 8) requiring revision surgery. This lateral widespread lesion results in destruction of the lateral wall of the capitellum causing instability and fixation failure along with fragmentation of the articular cartilage. Other studies have demonstrated that these non-contained lesions involving the lateral margin of the capitellum are predictive of a poor prognosis and recommend reconstruction of the lateral margin with an OAT procedure or a costochondral autograft. (39-41)

Conclusion

Osteochondritis dissecans of the capitellum is a disorder seen frequently in adolescent athletes and can be commonly treated non-operatively in skeletally immature patients with stable lesions. In general, surgery is reserved for those patients with mechanical symptoms and unstable lesions who have failed non-operative treatment. Surgical options include debridement, excision of the unstable fragment, marrow stimulation, internal fixation, and grafting. Treatment method depends on lesion characteristics such as size, location, and grade. One must take careful consideration of the patient's physical exam as well as diagnostic imaging to determine the stability of the lesion. If found to be unstable, careful evaluation and staging intraoperatively helps guide the surgeon towards the best treatment approach, be it abrasion arthroplasty with microfracture, which is minimally invasive, or an OAT procedure if the defect size is large and non-contained. The investigators provide a treatment algorithm in Figure 3 for management of OCD lesions. Overall, outcomes are good, and more prospective studies are needed to understand the indications and approaches in dealing with OCD lesions of the capitellum.

Sergio A. Glait, M.D., Andrew S. Rokito, M.D., and Laith M. Jazrawi, M.D.

Sergio A. Glait, M.D., Andrew S. Rokito, M.D., and Laith M. Jazrawi, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York.

Correspondence: Sergio A. Glait, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, 14 Floor, New York, New York 10003; sergio.glait@nyumc.org.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

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Caption: Figure 1 OCD lesions of the capitellum demonstrating the importance of arthroscopic assessment for diagnosis: A, shows a lesion that at first glance could be classified as an ICRS grade II lesion with partial discontinuity yet stable and not detached; B, upon further probing, it is discovered that the lesion shows complete discontinuity when probed but not yet detached, making it an unstable ICRS grade III lesion. To view this figure in color, see www.hjdbulletin.org.

Caption: Figure 2 Imaging modalities that help diagnose unstable OCD lesions of the capitellum. A, Three-dimensional CT-scan showing loose bodies within a capitellar defect indicative of an unstable lesion; B, A T-2 weighted coronal MRI of an elbow showing a peripheral rim of high signal intensity (arrow) and bone edema surrounding an OCD lesion; C, Arthroscopic image of that lesion demonstrating an ICRS grade III defect after probing; D, treated with fragment removal, debridement, and microfracture. To view this figure in color, see www.hjdbulletin.org.

Caption: Figure 3 A treatment algorithm for OCD lesions of the capitellum.

Table 1 International Cartilage Repair Society Scores

ICRS Score   Description

1            Continuous yet soft/frayed area of intact
             articular cartilage; stable lesion

2            Partial discontinuity but intact when
             probed; stable lesion

3            Complete discontinuity that is not fully
             dislocated; unstable when probed

4            Empty defect with loose fragments present;
             unstable lesion

Table 2 Indications for Non-Operative Versus Operative Treatment

Non-Operative Indications *       Operative Indications

Age < 13 or skeletally immature   Failed non-operative treatment
(open physis)                     for 6 months

Stable lesion on MRI              Large defects:
                                    > 70% defect size
                                    > 90[degrees] defect angle

Minami grade I: cystic shadow     ICRS grade III/IV and skeletally
on x-ray; no clear split line     mature

Capitellar flattening or          > 20[degrees] of extension deficit
sclerosis on x-ray

* Assuming no prior intervention (cessation of activity, therapy, and
so forth).


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Author:Glait, Sergio A.; Rokito, Andrew S.; Jazrawi, Laith M.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Date:Jan 1, 2016
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