Abstract
Background:
Osteochondritis dissecans (OCD) of the elbow is an idiopathic lesion of subchondral bone resulting in delamination and sequestration with or without articular cartilage involvement; for patients with persistent symptoms, surgical treatment is often recommended. While traditionally performed in the supine or prone position, arthroscopic debridement and microfracture of OCD of the capitellum in the lateral decubitus position permits strategic arm positioning and placement of portals to optimize visualization and reduce the risk of damage to neurovascular structures.
Indications:
Arthroscopic debridement and microfracture in the context of OCD is utilized when conservative management with rest, physical therapy, and nonsteroidal anti-inflammatory drugs does not provide improvement in pain. This technique is also preferred for smaller defects not suitable for fragment fixation or osteochondral autograft transplantation.
Technique Description:
After induction of anesthesia, the patient is placed in the lateral decubitus position with the operative extremity supported with an arm holder at 90°. The left side is then prepped and draped sterilely. A diagnostic arthroscopy of the elbow is first performed to identify any concomitant pathologies. The OCD defect is then mobilized with a probe to enhance visualization. The lesion is thoroughly debrided with a shaver to create a stable rim and the base decorticated with a curette. An arthroscopic microfracture instrument is used to create microfracture sites at the base of the lesion.
Results:
It is the senior author’s belief that management of OCD with arthroscopic debridement and microfracture in the lateral decubitus approach provides superior visualization and allows free manipulation of the joint throughout the procedure. This facilitates direct treatment of the OCD lesion to ensure a stable rim is created while permitting comprehensive evaluation of the joint. Additionally, the risk of iatrogenic injury to nearby neurovascular structures while instrumenting the joint is diminished with proximally placed portals.
Discussion/Conclusion:
Arthroscopic debridement and microfracture for OCD in the lateral decubitus position with the operative extremity supported proximally in an arm holder has been shown to optimize arthroscopic viewing of the OCD lesion, thereby ensuring the lesion is stabilized and comprehensively treated.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
This video will demonstrate the senior author’s (N.N.V.) preferred surgical approach to arthroscopic debridement and microfracture of osteochondritis dissecans (OCD) of the capitellum in the lateral decubitus position.
Author disclosures are as listed.
Background
OCD of the elbow is an idiopathic lesion of subchondral bone resulting in delamination and sequestration with or without articular cartilage involvement. Although the exact cause is unclear, repetitive microtrauma and vascular compromise are thought to contribute. Patients typically have elbow pain, limited motion, and mechanical symptoms such as locking and catching. 5 Symptoms refractory to conservative therapy are generally managed surgically. Surgical treatment ranges from debridement with or without drilling or microfracture, fragment fixation, and osteochondral autograft transplantation. 7 The lateral decubitus approach allows for strategic arm positioning and placement of portals to optimize visualization and reduce the risk of damage to neurovascular structures.
Indications
Our patient is a 25-year-old man, left hand–dominant baseball pitcher with no history of elbow dysfunction. He presented with persistent left elbow pain for 4 months despite an adequate trial of conservative treatments. On examination, he had pain with both flexion and extension of the elbow as well as tightness at end range of motion. The patient also had mild medial tenderness and a slightly positive moving valgus stress test. There was no evidence of ulnar nerve subluxation. He had a negative Tinel’s sign and was neurovascularly intact. Standard 3-view radiographs showed a loose body in the ulnohumeral joint as well as posterior osteophyte formation. Magnetic resonance imaging revealed an intact ulnar collateral ligament and bone edema of the capitellum.
Technique Description
The patient is positioned supine on a standard operating table under general anesthesia with an interscalene block placed preoperatively. The patient is then placed into the lateral decubitus position using a bean bag positioner. Sequential compression devices are secured onto both legs for intraoperative deep vein thrombosis prophylaxis, and all bony prominences are well padded to prevent nerve compression. A seatbelt is placed across the patient’s torso for added safety measures. The proximal aspect of the operative extremity is supported by an arm holder such that the humerus is parallel to the floor, the antecubital fossa is clear, and the elbow is allowed to hang at 90° of flexion. After prepping and draping the operative extremity, a sterile, well-padded, upper limb tourniquet is placed and inflated to 250 mm Hg. Intravenous antibiotics are administered before surgical incision.
Important bony landmarks are then mapped out, and the joint is insufflated through the lateral soft spot. Using a nick-and-spread technique, the superomedial viewing portal is established after confirming that the ulnar nerve is reduced. Diagnostic arthroscopy is performed first to evaluate the anterior and posterior compartments. With the arthroscope placed through the superomedial portal, a proximal anterolateral portal is established 2 cm proximal to the lateral epicondyle and anterior to the humerus. Any synovitis that is appreciated here should be gently debrided using a shaver, and any concomitant pathologies in the anterior aspect of the joint should be addressed.
The arthroscope is then redirected posteriorly. Under direct visualization, a lateral accessory portal is established between the lateral epicondyle and the radial head. Debridement of the soft tissue permits clear visualization of the capitellum and radial head. Viewing in the lateral accessory portal and working in the direct lateral portal, the OCD lesion of the capitellum can be identified. Bringing the elbow into flexion helps move the radial head away and aids in evaluation of the lesion. Before proceeding with debridement, it is important to assess the stability of the lesion rim using a probe and bring the entirety of the defect into direct view of the scope.
After evaluation of the OCD lesion, unstable fragments are removed. First, the unstable fragments are mobilized using a probe. Then, a shaver is used to debride in a sweeping motion until the base of the lesion is reached and chondral debris is removed. A curette is used to lightly decorticate the base of the OCD defect. It is of utmost importance to ensure the base is circumferentially surrounded by a rim of stable cartilage.
To perform microfracture of the OCD base, an arthroscopic microfracture instrument is inserted through the direct lateral portal. Three microfracture sites are placed in the center of the lesion; however, the number of microfracture sites may be adjusted to appropriately fit the surface area of the OCD defect and allow marrow extravasation. Once the surgeon confirms the walls of the OCD lesion are stable, all arthroscopic equipment is withdrawn. The portal sites are closed with 3-0 Prolene, and sterile dressings are applied.
Results
Although our technique describes a safe, reproducible approach to arthroscopic management of OCD of the capitellum, there is still a risk of neurovascular injury, infection, and persistent postoperative pain or instability of the lesion requiring reoperation. Postoperatively, the patient should expect to follow a stepwise rehabilitation protocol. Immediately postoperatively, the patient is placed in a posterior mold splint and a simple sling. The splint is removed at 2 weeks postoperatively, and a cock-up wrist splint is used until week 6. Range of motion is advanced as tolerated with no resisted supination or pronation and no lifting until 6 weeks postoperatively. Once motion is achieved, light lifting can begin.
For throwing athletes, an additional throwing program is implemented postoperatively. Baseline requirements to begin the program include pain-free range of motion and appropriate elbow and shoulder strength. The complete throwing program is 147 days and should provide athletes with the strength and endurance to fully return to sport (RTS) by 6 months.
Discussion/Conclusion
Investigations have shown that arthroscopic debridement and microfracture for treatment of OCD of the capitellum consistently improve patient pain, function, and range of motion.1,3 Additionally, recent studies have shown that many patients are able to return to their previous level of sports participation. 4 In a recent systematic review, Leal et al 4 found that arthroscopic microfracture with or without debridement resulted in a RTS rate ranging from 65% to 100%, with most studies reporting RTS rates between 86% and 100%. Moreover, Bexkens et al 2 demonstrated a significant decrease in defect size and partial restoration of subchondral bone on computed tomography scans postoperatively. While arthroscopic debridement and microfracture for the treatment of OCD of the capitellum generally result in favorable outcomes, osteochondral autologous transplantation (OAT) and osteochondral allograft (OCA) may provide superior outcomes for large, unstable OCD lesions. 8 Both alternative techniques have demonstrated excellent outcomes, with significant improvements in clinical scores and pain reduction, as well as high RTS rates in overhead athletes. They also have been associated with lower revision rates compared to microfracture. 6 The choice of procedure should ultimately be individualized based on lesion characteristics and patient factors. Nonetheless, there is a paucity of literature describing the outcomes and complications of the presented technique in the lateral decubitus position in comparison to other techniques, such as fragment fixation or osteochondral autograft transplantation. 8
Thank you.
Footnotes
One or more of the authors has declared the following potential conflict of interest or source of funding: N.N.V. has received hospitality payments from Abbott Laboratories, Axonics, Boston Scientific Corporation, Foundation Fusion Solutions LLC, IBSA Pharma, Nalu Medical, Nevro Corp, Orthofix Medical, Pacira Pharmaceuticals, Relievant Medsystems, Salix Pharmaceuticals, Vericel, and Vertos Medical; is a board or committee member of the American Orthopaedic Society for Sports Medicine, American Shoulder and Elbow Surgeons, and Arthroscopy Association of North America; receives IP royalties from Arthrex, Graymont Professional Products IP LLC, Smith & Nephew, and Stryker; has received research support from Arthrex, Breg, Ossur, Smith & Nephew, and Stryker; is a paid consultant for Medacta USA and Stryker; has been provided educational support from Medwest Associates; is a member of the editorial or governing board of SLACK Incorporated; and has received travel and lodging from Spinal Simplicity LLC. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
