Management of osteochondritis dissecans lesions of the elbow including return to sport remains variable among orthopaedic surgeons

Abstract

Introduction

Management of osteochondritis dissecans (OCD) lesions of the capitellum is challenging. Historically, variability exists between surgeons in the evaluation, treatment, and return to sport criteria. The purpose of this study was to define the current trends regarding evaluation, nonoperative and surgical management, and return to sport criteria for capitellar OCD lesions among surgeons.

Methods

A 21-question cross-sectional survey was administered to 24 Orthopaedic surgeons specializing in elbow OCDs. The survey included questions concerning imaging, specific non-operative treatments trialed, indications for surgery for stable and unstable lesions, preferred surgical techniques, osteochondral autograft utilization, and factors determining return to sport.

Results

Twenty-one surgeons responded (88%). The most common surgical indications for stable lesions were time (≥ 6 months, 68%) and mechanical symptoms (52%). Drilling (45%) and fragment fixation (35%) were most preferred. For unstable lesions, factors in order of importance for determining surgical procedure were lesion size, lateral wall integrity, location on capitellum, skeletal maturity, and sport. For small (< 1 cm²), centralized lesions, 81% preferred debridement with microfracture. For large (> 1 cm²), lateralized lesions, 52% preferred debridement and microfracture and 48% preferred osteochondral autograft transfer (OAT). OAT was considered for 80% of failed procedures, 47% with lateral wall involvement, and 27% > 1 cm². Return to sport after debridement was typically 2–3 months (52%), fragment fixation was 4 months (52%), and OAT was 4–6 months, while microfracture had wide variability (3–6 months). The factors in order of importance were lack of pain, time, then imaging. Two-thirds of surgeons wait longer to release overhead athletes or gymnasts.

Conclusions

There is significant variability in the management of capitellar OCD in athletes. Small, centralized lesions are likely to be treated with debridement and microfracture with faster return to sport. Treatment of large, lateral lesions remains variable. Regarding OAT procedures, perceived morbidity, reimbursement, and limited evidence dissuade use. There is no consensus on return to sport, though lack of pain and time were most important; overhead athletes and gymnasts are restricted longer from returning to sport.

Level of Evidence

Level 5, diagnostic, cross-sectional survey.