Minimally invasive treatment of elbow articular cartilage injury

Abstract

Osteochondritis dissecans of the elbow is characterized by disruption of the articular surface and subchondral bone, likely due to a combination of tenuous vascularity of the articular surface and repetitive stress exerted upon the vulnerable epiphysis of the young adolescent patient. This condition is most common among throwing athletes and most frequently affects the capitellum, as significant compressive force is exerted upon the radiocapitellar articulation in throwers. These patients present with insidious onset of lateral elbow pain and often demonstrate a flexion contracture on examination. It is imperative to include an examination for concomitant pathology that can affect the throwing elbow, including valgus extension overload and ulnar collateral ligament disruption. Radiographs demonstrate radiolucency, flattening, fragmentation, or formation of loose bodies. Cyst formation or linear increased signal at the periphery of the lesion suggests instability of the lesion. Patients with open physes, near-normal range of motion, and a stable lesion on imaging can be treated conservatively with a period of absolute rest and careful rehabilitation. Those patients that fail conservative management or skeletally mature patients who present with a frankly unstable lesion on imaging and a significant flexion contracture may instead require operative intervention. Treatment options include arthroscopic debridement with or without microfracture or drilling, fragment fixation, osteochondral autograft reconstruction, autologous chondrocyte implantation, or distal humeral osteotomy. Arthroscopic debridement represents a common first-line treatment for most patients, with reasonable results. However, larger lesions accounting for more than 50 % of capitellar width, or those without a stable lateral border, are less effectively treated with an arthroscopic approach. For these cases, osteochondral autograft has shown promise in restoring the hyaline cartilage architecture and in reestablishing the lateral shoulder of uncontained lesions. By tailoring the treatment strategy to each unique patient and lesion, improvement in pain, increased range of motion, and return to sport can be achieved.