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Midterm Results of New Treatment for Elbow Osteochondritis Dissecans in Teenage Athletes

Posted on: 10/29/2009
Imagine you are a teenage male athlete heavily involved in baseball. Now imagine how you would feel if severe, constant pain was keeping you out of the game. You have a condition called osteochondritis dissecans (OCD) of the elbow. For some unknown reason, the layer of joint cartilage just above the bone has separated and pulled away from the bone. No treatment has helped. Despite six months of conservative care (think: doing nothing -- no throwing, no lifting, no sports activities), there's been no change in your symptoms. Anyone in this situation will welcome the news from this study.

Nineteen boys between 11 and 19 years of age with severe osteochondritis dissecans (OCD) of the elbow had a surgical procedure called mosaicplasty. The surgeon removed any loose fragments of cartilage in the elbow. Any rough or frayed portions of the joint surface was shaved and smoothed down. Then the surgeon drilled what look like tiny postholes in the articular surface of the elbow joint. Using plugs of bone harvested from the knee opposite the elbow, the holes were filled in and the surface smoothed over.

The donor plugs were taken from an area of the knee where there's less pressure when standing and walking to avoid any knee problems. The holes left by removing the plugs were filled in with a special bone wax to prevent bleeding. Within two days, the patients were up and about putting partial weight on the knee and gradually returning to full weight-bearing status by the end of a week's time. The elbow was placed in a cast in a position of 90-degree flexion for two weeks. This allowed some time for healing before starting to move it again.

For those baseball players who could return to the game, it was a wait of eight to 12 months depending on the position played. Pitchers who would stress the surgical site more had to wait longer than fielders. During that wait, rehab under the supervision of a physical therapist focused on regaining motion, strength, and full function.

This mosaicplasty technique has been used with success in the knee and ankle. Its use with the elbow is fairly new, so the results of this study are important. The authors used a variety of ways to measure this success. X-rays, elbow range-of-motion, pain, and function were the main outcome measures. Players were asked about any locking and/or catching of the elbow during movement and activity. Function included return-to-sports activity at a level equal to previous play before the OCD developed. Patients were followed for at least two years (some as long as long as seven years), which makes this a midterm study.

In terms of pain, motion, and function, all but one patient had a good result. Everyone was pain free with the exception of that one player who still had mild elbow pain. Elbow range of motion (flexion and extension) increased significantly for most of the players. Forearm rotation (palm up and palm down) was unaffected by the condition or the surgery. A few didn't get full elbow extension, which affected throwing but not catching the ball.

A quick check of the donor knee showed that only one patient had any problems and that was just a mild bit of pain when going up and down stairs. Follow-up X-rays and MRIs of the elbows and the knees of all players showed near-normal to normal joint surfaces. A mild thickening of the elbow grafts was observed but this did not seem to cause any symptoms or problems. The big fear was that osteoarthritis would develop in the affected elbows, but at least in the midterm follow-up, that was not the case. No one had any signs of developing osteoarthritis.

Seventeen of the 19 players went back to competitive sports at a level equal to their previous playing ability. The two who did not go back to baseball switched to rugby or soccer. Their results were considered good enough to play baseball again, but they made a conscious choice to change playing fields. Compared to other surgical methods used for OCD (e.g., arthroscopic chondroplasty, abrasion arthroplasty, wiring loose fragments of cartilage back in place), mosaicplasty had much better return-to-play results.

The authors concluded that mosaicplasty is a very good treatment choice for teenage athletes suffering from advanced osteochondritis dissecans of the elbow. The procedure may work best in younger players who have smaller defects requiring smaller grafts but more research is needed to confirm this finding. Although no one in this study showed any signs of osteoarthritis, long-term studies are still needed to see if there are later developments of this kind. Comparing results using graft donors from different sites is another area of suggested study.

References:
Norimasa Iwasaki, MD, PhD, et al. Autologous Osteochondral Mosaicplasty for Osteochondritis Dissecans of the Elbow in Teenage Athletes. In The Journal of Bone and Joint Surgery. October 2009. Vol. 91-A. No. 10. Pp. 2359-2366.

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