Abstract
Objectives:
Debridement and marrow stimulation has historically been the surgical treatment for osteochondritis dissecans (OCD) of the capitellum. Overall, good pain relief and function have been reported with this treatment, though suboptimal return to sport and pain have been identified in some high-demand upper extremity athletes and patients with larger OCDs. The purpose of this study was to assess the 2-year outcomes of “discriminative” marrow stimulation as a treatment for capitellar OCD in pediatric patients.
Methods:
Patients <19 years of age with an unstable capitellar OCD treated with elbow arthroscopy, OCD debridement, and marrow stimulation between 4/1/2018 – 7/31/2022 were included. Patients with any history of prior elbow surgery were excluded. Patients were discriminatively indicated for this treatment with small (<100mm2) central capitellar OCDs. In contrast, patients with larger or unshouldered OCDs, particularly high-demand upper extremity athletes, were typically recommended for osteochondral allograft transplantation and not included in this study. Minimum 2-year follow-up was required. Patient reported outcome scores (PROs), including Oxford Elbow, QuickDASH, and QuickDASH sport were obtained pre-operatively and annually after surgery. In addition to PROs, outcomes included return to sport and secondary surgeries.
Results:
27 patients, 54% female, mean age 12.8 years (10.4 – 17.9) were included. 26 patients played sports, including 9 gymnastics (33%), 8 baseball (30%), 3 soccer (11%), 2 volleyball (7%), 2 basketball), 1 cheer (4%), and 1 motocross (4%). Mean OCD size was 9.7mm in width, 9.4mm in length, and 3.5mm in depth. Mean clinical follow-up was 4.5 years (2.3 – 5.2 months). Pre-operative and post-operative PROs are shown in Table 1. There were statistically significant improvements (p<0.05) in all PROs from pre-operative to 1-year and no significant change in PROs from 1- to 2-years. Among baseball players, 100% returned to baseball at 1 year and 88% remained playing at 2-years. Among gymnasts, 44% returned to gymnastics at 1-year and 33% remained in the sport at 2-years.
Secondary surgery occurred in 4 elbows (15%). An 11-year-old female gymnast with bilateral elbow OCDs treated with primary marrow stimulation had a capitellar osteochondral allograft transplantation 19 months following marrow stimulation and contralateral arthroscopic partial synovectomy and chondroplasty of the capitellum 5 years following marrow stimulation. An 11-year-old female gymnast underwent arthroscopic partial synovectomy 5 years following marrow stimulation. Lastly, a 12-year-old male baseball player with multifocal osteochondral changes in the elbow from a chronic capitellar OCD underwent arthroscopic loose body removal and chondroplasty of the capitellum 19 months after marrow stimulation.
Patients who underwent a second surgery, as compared to those who did not, were found to have larger OCD coronal width, total OCD surface area, and lower pre-operative QuickDASH scores. These patients also had inferior 1- and 2-year PROs as depicted in Table 2.
Conclusions:
Capitellar OCD debridement and marrow stimulation for small central lesions in pediatric patients is associated with high rates of improvement in elbow function and return to sport and modestly low rates of secondary surgery (15%). There remains a subset of these patients, particularly gymnasts and those with larger coronal size and inferior pre-operative function who have inferior post-operative outcomes and return to their primary sport.
