Treatment of osteochondral lesions of the elbow remains a challenge. Osteonecrosis of the capitellum (Panner disease) and the early stages of osteochondritis dissecans in young patients often heal with nonoperative treatment15,17,25,26. If nonoperative treatment fails4, patients can have persistent pain and reduced range of motion because of the presence of loose bodies in the joint and surgical intervention may become necessary. Sometimes loose fragments can be reattached27. Other methods that have been described, such as arthroscopic removal of loose bodies and débridement, microfracture, or antegrade or retrograde drilling of the defect to induce replacement tissue1,19,28-30, have not provided satisfactory overall long-term results. Bauer et al. reported on a series of thirty-two elbows (thirty-one patients) with osteochondritis dissecans with high rates of reduced range of elbow motion (eleven of thirty elbows), radiographic signs of osteoarthritis (nineteen of thirty-one elbows), and an increase in radial head diameter (eighteen of thirty-one elbows)20. In that study, twenty-three of the thirty-two elbows had been treated surgically (débridement). Brownlow et al. reported on twenty-nine patients with osteochondritis dissecans of the capitellum that was treated by arthroscopic débridement30. At a mean of seventy-seven months, the majority of the patients had mild or no pain. However, eleven of the twenty-nine patients had recurrence of locking or catching. Radiographs of eighteen elbows with mild or moderate tenderness over the capitellum demonstrated flattening of the capitellum in twelve elbows, degenerative changes in six, and loose bodies in five.
In this mid-term follow-up study of seven patients, we obtained overall good to excellent results. The radiographs did not demonstrate an increase in radial head diameter, and the postoperative magnetic resonance imaging scans showed graft viability and a congruent chondral surface in all elbows. All elbows achieved a full range of motion and were able to resume weight-bearing activity. While the patients returned to sports without limitation, two of the seven changed discipline and activity level, not because of the clinical outcome of the surgical procedure but because of their age and work requirements.
In recent years, the technique initially developed by Hangody et al. as mosaicplasty31 to treat focal cartilage defects in the femoral condyle has found widespread acceptance and has been used for several joints31-36. Good to excellent results have been reported for both the knee and ankle joints42. An obvious disadvantage of the procedure is the need to expose the knee joint to harvest the graft. For the elbow, however, the size of the defect is limited. Compared with the amount of graft that needs to be harvested for the treatment of large osteochondral lesions in the knee or ankle, only one cylinder of graft harvested through a small arthrotomy of the knee was sufficient in all seven of our patients. All of our patients regained excellent function of their knees. Six patients were pain-free after a few weeks, and only one patient complained of mild pain with high-impact loads in sports for one year, and then he became asymptomatic. As in the treatment of lesions in the knee, we believe that the success of this procedure depends on an exact fit of the graft with anatomical alignment of the cartilage surface.
There are few reports in the literature on the treatment of elbow lesions with this technique, and they have described only short-term follow-up. In 2001, Nakagawa et al. reported on osteochondral grafting and osteotomy in one patient with osteoarthritis who achieved a good result at a follow-up of thirty-five months43. Yamamoto et al. described osteochondral autograft transplantation for osteochondritis dissecans of the elbow in eighteen juvenile baseball players who had a good outcome after a minimum two-year follow-up interval24, and Tsuda et al. reported a successful outcome in a series of nonthrowing athletes44 but with short-term follow-up.
Currently, only the technique of transplantation of autologous osteochondral grafts (e.g., OATS or mosaicplasty) provides the opportunity to repair cartilage defects with hyaline cartilage. At an average follow-up of five years, our results are encouraging and we believe that the congruent repair with autologous hyaline cartilage with use of the osteochondral graft transfer system will reduce the incidence of osteoarthritis and lead to better long-term results than other procedures. According to our results, the risks of performing a two-joint procedure are justifiable because of the limited donor-site morbidity. In addition, this technique provides an option for revision surgery after previously failed attempts with other surgical procedures. We will continue to follow our patients closely to see if any degenerative joint changes occur in the future. ▪
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