Closed-Wedge Osteotomy of the Distal Humerus for Treating Osteochondritis Dissecans of the Capitellum in Young Patients

Abstract

Background:Even in patients with an open capitellar physis, nonsurgical treatment for advanced-stage osteochondritis dissecans (OCD) of the capitellum often yields poor outcomes. However, surgical methods for such patients are controversial. At our institution, we have consistently performed closed-wedge osteotomy of the distal humerus to treat advanced-stage OCD of the capitellum, regardless of the OCD grade or condition of the capitellar physis.Purpose:To clarify the clinical and radiological results and determine the influence of the capitellar physis on closed-wedge osteotomy for advanced-stage OCD of the capitellum in young patients.Study Design:Case series; Level of evidence, 4.Methods:A total of 32 patients with OCD of the humeral capitellum were treated surgically with closed-wedge osteotomy. Of these, 17 patients with more than 2-year follow-up were available for an evaluation. The mean patient age was 11.8 years (range, 11-12 years), and the mean follow-up period was 70.1 months (range, 25-184 months). The clinical assessment included range of motion, elbow pain, and the Japanese Orthopaedic Association (JOA) and Timmerman-Andrews scores. The radiological assessment at the final examination included cross-bridging of the physis, size and fishtail deformity of the distal part of the humerus, size of the radial head, healing of the OCD lesion, and osteoarthritis.Results:The mean range of motion and JOA and Timmerman-Andrews scores improved significantly after surgery; 13 patients were completely pain free. In 11 patients with an open capitellar physis, metaphyseal-epiphyseal, cross-bridging was observed in 1 patient. A fishtail deformity of the distal part of the humerus was not observed. Healing of the OCD lesion was defined as excellent in 9 patients, good in 3, fair in 3, and poor in 2. In 3 of the 5 patients in whom healing was described as fair or poor, there was a lesion of the lateral widespread type with osteoarthritis before surgery. Moderate osteoarthritic changes were evident in 2 patients.Conclusion:Closed-wedge osteotomy for the treatment of advanced-stage OCD of the capitellum in young patients can provide satisfactory clinical and radiological results. However, fair and poor outcomes were found in lateral widespread–type cases with osteoarthritis before surgery. We believe that patients in whom osteoarthritic changes have not yet appeared are eligible for closed-wedge osteotomy.

Osteochondritis Dissecans

“…Mirzayan and Lim performed OCA in 9 patients with juvenile OCD, and all had functional improvement and returned to sports after 2 years 207 . Lateral humeral condyle closing-wedge osteotomy, which is a less common technique, has shown promise [208][209][210] . Koda et al performed 77 osteotomies for advanced lesions, with concomitant bone-grafting and fixation, yielding good remodeling in 69% (53) of 77 elbows; however, 53% (41) of the 77 elbows had osteoarthritic changes at 9 years 209 .…”

Failure of Surgery for Osteochondral Injuries of the Elbow in the Pediatric and Adolescent Population

“…Lau et al found that compared with control patients, adolescent patients with capitellar OCD lesions had more varus carrying angles and more valgus at the distal humeral articular surface [34]. Various joint re-alignment procedures have been described including closed-wedge osteotomies of the distal humerus [35] as well as radial shortening [36] to off-load stress on the injured area.…”

Treatment of advanced stage osteochondrosis dissecans in the adolescent elbow using a hyaloronic acid-based scaffold: a case series of 5 patients

“…However, previous reports have shown that 55% of elbow OCD cases still progress to surgical treatment [ 8 ]. The options for therapy-resistant and/or advanced OCD include fragment resection alone [ 10 ], arthroscopy with antegrade or retrograde drilling [ 11 – 13 ], fixation of the fragment using bioabsorbable implants [ 14 , 15 ] or osteochondral autografts (OAG [ 16 , 17 ]), and corrective osteotomy of the distal humerus [ 18 , 19 ]. In cases with OCD grade 4 (loose body), it is unavoidable to create a new subchondral bone stock and cartilage layer in the defect area [ 20 ].…”