Masatoshi Takahara

Classification, Treatment, and Outcome of Osteochondritis Dissecans of the Humeral Capitellum

BACKGROUND Indications for the treatment of osteochondritis dissecans of the humeral capitellum have remained unclear. The aims of this study were to analyze the outcomes and to determine the most useful classification for the choice of treatment. METHODS The cases of 106 patients with osteochondritis dissecans of the capitellum were studied retrospectively. At the time of the initial presentation, the mean age of the patients was 15.3 years. The capitellar growth plate was open in eighteen patients and closed in eighty-eight. Thirty-six patients were treated nonoperatively. Fifty-five patients underwent fragment removal alone, twelve underwent fragment fixation with a bone graft, and three underwent reconstruction of the articular surface with use of osteochondral plug grafts from the lateral femoral condyle. The mean follow-up period was 7.2 years. The outcomes in terms of pain in the elbow, return to sports, and radiographic findings were analyzed and compared. RESULTS An osteochondritis dissecans lesion with an open capitellar physis and a good range of elbow motion resulted in a good outcome. Continued elbow stress resulted in the worst outcome in terms of pain and radiographic findings. In patients with a closed capitellar physis, surgery provided significantly better results than elbow rest (p < 0.01). Fragment fixation or reconstruction provided significantly better results than fragment removal alone (p < 0.05). The results of removal alone were dependent on the size of the defect in the capitellum. The outcome in terms of pain was closely associated with sports activity and radiographic findings. CONCLUSIONS We believe that osteochondritis dissecans of the capitellum can be classified as stable or unstable. Stable lesions that healed completely with elbow rest had all of the following findings at the time of the initial presentation: an open capitellar growth plate, localized flattening or radiolucency of the subchondral bone, and good elbow motion. Unstable lesions, for which surgery provided significantly better results, had one of the following findings: a capitellum with a closed growth plate, fragmentation, or restriction of elbow motion of >or=20 degrees . For large unstable lesions, fragment fixation or reconstruction of the articular surface leads to better results than simple excision.

Long-Term Follow-up of Radial Shortening Osteotomy for Kienböck Disease

BACKGROUND Three previous studies have investigated the long-term outcome of radial osteotomy in the treatment of Kienböck disease. However, none used patient-based assessment. The purpose of this study was to investigate the long-term clinical and radiographic outcomes of this osteotomy, including the subjective evaluation of the patient with use of the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. METHODS A DASH questionnaire was sent to nineteen patients with Kienböck disease who had undergone a radial shortening osteotomy, and thirteen replied. The mean age at the time of surgery was thirty-nine years. On the basis of the Lichtman classification, six patients had stage-II, four had stage-IIIA, and three had stage-IIIB disease. Prior to surgery, ulnar variance was positive in six patients, neutral in four, and negative in three. The mean duration of follow-up was twenty-one years. Clinical evaluation, including calculation of the modified Mayo wrist score, and radiographic evaluation were also performed on twelve of the thirteen patients. RESULTS The mean DASH score was 8 points (range, 0 to 23 points), and patient satisfaction was high. Compared with the findings in the contralateral wrist, the mean range of motion was 81% in flexion and 82% in extension and mean grip strength was 88%. The mean modified Mayo wrist score was 83 points, and the clinical results were excellent in six patients, good in five, and moderate in one. The DASH scores tended to be worse in patients with Lichtman stage-IIIB disease. Follow-up radiographs revealed that the Lichtman stage had progressed in six of the twelve patients. CONCLUSIONS Although most patients had mild wrist pain, patient satisfaction and the clinical results were satisfactory following a radial shortening osteotomy. This procedure is a reliable long-term treatment for Lichtman stage-II and IIIA disease and may be a reasonable option for patients with stage-IIIB disease.

Long term outcome of osteochondritis dissecans of the humeral capitellum.

Long term outcome of osteochondritis dissecans of the humeral capitellum was determined for 53 patients. The average age of the patients at the time of treatment was 16.6 years (range, 10-34 years). The average followup was 12.6 years (range, 3-25 years). Seven of 14 (50%) patients who were treated conservatively and 18 of 39 (46%) who were treated by surgical removal of the fragment were found to have residual elbow symptoms associated with daily living activities (poor outcome). The initial radiographs of the elbow were available for 45 patients; a poor outcome was seen in six of 19 (32%) early lesions and 13 of 26 (50%) advanced lesions. Fourteen elbows had evidence of osteoarthritis on the initial radiographs, and a poor outcome was seen for nine (64%) of these elbows. After removal or detachment of the fragment, seven osteochondral defects were assessed as large, and all seven had a poor outcome. These long term results suggest that the residual elbow symptoms associated with daily living activities in approximately 50% of patients may be associated with advanced lesions, osteoarthritis of the elbow, and a large osteochondral defect.

Correlation between histopathologic features and magnetic resonance images of spinal cord lesions.

The authors report a correlation between histopathologic features and magnetic resonance images of spinal cord lesions in 19 human spinal cords with various types of lesions. Abnormally high T2-weighted image signal intensities appeared nonspecifically in mildly altered lesions or areas with edema. In the gray matter, a low T1-weighted image in addition to a high T2-weighted image signal intensity appeared in severely altered lesions with necrosis, myelomalacia, or spongiform change. In the white matter, abnormally high T1-weighted image intensities appeared in severely altered lesions. Based on these preliminary results, it appears that a correlation between the degree of histopathologic alteration of the spinal cord and magnetic resonance images in clinical cases can be made. This is the first study to clarify the correlation between histopathologic features and magnetic resonance images of the diseased human spinal cord.

Nonoperative treatment of osteochondritis dissecans of the humeral capitellum

We examined 24 patients with osteochondritis dissecans of the humeral capitellum to determine the results of nonoperative treatment. The average age of the patients at the initial examination was 13.3 years (range, 11 to 16). All the patients were advised to stop heavy use of the elbow for 6 months. At the last examination, at a mean follow-up period of 5.2 years, 4 patients (17%) had no residual elbow pain, 7 (29%) had pain only with heavy activities, and 13 (54%) had pain with activities of daily living. Final radiographs were obtained for 15 lesions, of which 3 lesions were assessed as healed, 3 as improved, and 9 as not improved. Five of 11 lesions in the early stage and all 4 advanced lesions failed to show radiographic improvement. These results suggest that osteochondritis dissecans of the capitellum has only a slight tendency to heal, and that instability can cause failure of the lesion to heal.

Early detection of osteochondritis dissecans of the capitellum in young baseball players : Report of three cases

The prevalence of osteochondritis dissecans is high among individuals who have played baseball actively since childhood1,19, and repetitive throwing is considered to be one of the main etiological factors of this disease1,4,5,10,25. During the acceleration phase of throwing, the elbow joint may be stressed into a valgus position17,38,47,49 and the capitellum may be subjected to compression and shear forces4,20,21,44,48,50. However, little is known about the primary changes leading to osteochondritis dissecans. We attempted to detect these changes by examining the elbows of players on youth baseball teams with magnetic resonance imaging and ultrasonography. Forty-four young baseball players who were ten to twelve years old and had not had a previous examination of the elbow were selected for this study. Magnetic resonance imaging was performed with a 1.5-tesla magnet (Magnetom H15; Siemens Medical Systems, Erlangen, Germany), and coronal and sagittal T1-weighted spin-echo images and sagittal T2-weighted gradient-echo images were made. Anterior and posterior longitudinal ultrasonograms of the capitellum were made with a real-time linear-array scanner (Aloka SSDF-650, Tokyo, Japan) that was equipped with a 7.5-megahertz transducer27,45 (Figs. 1-A and 1-B). Figs. 1-A through 1-D: Illustration and ultrasonograms of the capitellum. Fig. 1-A: Line drawing showing the relationship of the humerus and the radial head to the ultrasonographic scanner. Fig. 1-B: Anterior longitudinal ultrasonogram of a normal capitellum, showing the subchondral bone of the capitellum as a high-signal-intensity round area (white arrows) and the articular cartilage as a low-signal-intensity round area (black arrows) over the subchondral bone. Three of the forty-four boys were found to have an abnormality of the capitellum. The T1-weighted images of …

Ultrasonographic assessment of the ulnar collateral ligament and medial elbow laxity in college baseball players.

Background: The prevalence of medial elbow instability is high in athletes who throw, such as baseball players. The aim of this study was to assess the medial aspect of the elbow with ultrasonography to detect changes in baseball players. Methods: Ultrasonography of the medial aspect of the elbow was performed, while gravity stress was applied with the elbow in 90° of flexion, on thirty college baseball players (twelve pitchers and eighteen fielders) to assess medial joint laxity and deformity of the ulnar collateral ligament. The dominant (throwing) extremity was compared with the contralateral extremity. Clinical data were correlated with ultrasonographic findings. Results: The medial joint space was significantly wider on the throwing side than it was on the contralateral side (2.7 mm and 1.6 mm, respectively; p < 0.01), and the proximal part of the ulna was shifted significantly laterally on the throwing side (p < 0.01). Angular deformity of the ulnar collateral ligament was found in five subjects, and it was significantly associated with lateral shift of the proximal part of the ulna (p < 0.01). Medial elbow pain was associated with widening of the medial joint space (p < 0.05) and with the presence of angulation of the ulnar collateral ligament (p < 0.01). Conclusions: Medial elbow laxity and elbow valgus on the throwing side of baseball players were increased compared with those in nonplayers. Angular deformity of the ulnar collateral ligament suggests that the ligament bends over the distal-medial edge of the trochlea. Ultrasonography can provide useful information about the condition of the ulnar collateral ligament and about medial elbow laxity in athletes who throw.

Long-term clinical and radiographic outcomes after open reduction for missed Monteggia fracture-dislocations in children.

BACKGROUND There have been few reports on the long-term outcomes after the operative treatment of missed Monteggia fracture-dislocations in children. The purpose of the present study was to evaluate the long-term clinical and radiographic outcomes after open reduction for the treatment of a missed Monteggia fracture-dislocation. METHODS We postoperatively investigated the clinical and radiographic outcomes for twenty-two children with a missed Monteggia fracture. The study group included fourteen boys and eight girls who had had a mean age of ten years (range, four years to fifteen years and eleven months) at the time of open reduction. Each patient had been managed with open reduction of the radial head combined with a posterior bending elongation ulnar osteotomy and anular ligament reconstruction. Clinical and radiographic outcomes were reviewed over a mean duration of follow-up of seven years. RESULTS The postoperative Mayo Elbow Performance Index at the time of follow-up ranged from 65 to 100, with nineteen excellent, two good, one fair, and no poor results. The radial head remained in a completely reduced position in seventeen patients and was subluxated in five patients at the time of the latest follow-up. In four patients, osteoarthritic changes were observed at the radiohumeral joint. Radiographically, there were fifteen good, seven fair, and no poor results. A good radiographic result was obtained in all of the patients who had undergone open reduction within three years after the injury or before the age of twelve years, whereas a fair result was obtained in seven of the remaining eight patients. CONCLUSIONS If open reduction for the treatment of a missed Monteggia fracture is performed when the patient is less than twelve years of age or within three years after the injury, good long-term clinical and radiographic outcomes can be expected.

Risk factors for elbow injuries among young baseball players

HYPOTHESIS There are some risk factors that could predispose a young baseball player to elbow injuries. MATERIALS AND METHODS Study participants were 294 baseball players aged 9 to 12 years old. A questionnaire, physical examination, and ultrasound imaging to investigate elbow injuries were performed. Data for the groups with and without elbow injuries were analyzed statistically using multivariate logistic regression models. RESULTS Ultrasound imaging showed that 60 participants had elbow injuries, including medial epicondylar fragmentation in 58 and osteochondritis dissecans of the capitellum in 2. The odds ratio (95% confidence interval) of the risk factors that statistical analysis showed were significant were age older than 11 years, 2.82 (1.30-6.10); height exceeding 150 cm, 2.02 (1.07-3.82); pitching, 4.50 (2.42-8.37); daily training, 1.96 (1.02-3.79); range of motion (ROM) of external rotation of the shoulder below 130 degrees , 1.98 (1.01-3.87); muscle strength (MS) of external rotation of the shoulder exceeding 80 N, 4.11 (1.47-11.55); and MS of internal rotation of the shoulder exceeding 100 N, 2.04 (1.08-3.90). DISCUSSION Risk factors for elbow injuries are age, height, pitcher, days of training, grip strength, range of motion of external rotation of the shoulder, and muscle strength of the shoulder. CONCLUSION As new information, our results suggest that decrease of ROM of external rotation of the shoulder and increase of MS of external and internal rotation of the shoulder predispose elbow injuries.

Using sonography for the early detection of elbow injuries among young baseball players.

OBJECTIVE The aim of this study was to determine the usefulness of sonography for detecting elbow injuries among young baseball players. SUBJECTS AND METHODS One hundred fifty-three volunteers ranging in age from 9 to 12 years and belonging to youth baseball teams participated. Sonography of the elbow was performed in the field when baseball exercises were being conducted. We analyzed the relationship between elbow pain and sonographic abnormalities and the relationship between pitchers and sonographic abnormalities. RESULTS Sonography showed that 33 subjects had medial epicondylar fragmentation and two had early-stage osteochondritis dissecans of the capitellum. In 25 subjects who agreed to further examination and treatment, radiography confirmed the sonographic findings. All of the 23 subjects with medial epicondylar fragmentation, who stopped throwing, obtained union of the bone and returned to baseball. The two subjects with osteochondritis dissecans of the capitellum underwent surgery before the osteochondral fragment became loosened. Sonographic abnormalities correlated with episodes of elbow pain. Pitchers statistically significantly had sonographic abnormalities. CONCLUSION Sonography in the field can provide an opportunity to detect and treat elbow injuries before they become more advanced.