Mikio Harada

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.

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.

Outcomes of an Open Autologous Osteochondral Plug Graft for Capitellar Osteochondritis Dissecans Time to Return to Sports

Background: Autologous osteochondral plug grafts have been used for capitellar osteochondritis dissecans (OCD), and good clinical results have been described. However, little is known about the optimal timing of return to sports. Purpose: To investigate the clinical outcomes of open autologous osteochondral plug grafts for capitellar OCD and to address the timing of return to sports. Study Design: Case series; Level of evidence, 4. Methods: Thirty-three male patients with a mean age at the time of surgery of 13.6 years (range, 11-17 years) and with advanced lesions of capitellar OCD underwent a procedure using open autologous osteochondral plug grafts. All patients played baseball, and the lesion affected their throwing side. Thirteen lesions were arthroscopically classified as International Cartilage Repair Society (ICRS) OCD III and 20 lesions as ICRS OCD IV. The mean size of the lesions (sagittal × coronal) was 16 × 14 mm. One to 3 osteochondral plug grafts, with a mean diameter of 7 mm (range, 5-9 mm), were harvested from the lateral femoral condyle and transplanted to the defects. Patients were allowed to begin throwing after 3 months and to return to sports after 6 months. The mean follow-up was 28.4 months (range, 12-76 months), during which elbow pain, Timmerman and Andrews scores, return to sports, and radiographs were evaluated. Results: After surgery, 30 patients (91%) had no elbow pain, and 3 patients (9%) had occasional mild throwing pain. The mean total arc of elbow motion increased significantly from 116° to 133° (P < .05). The mean Timmerman and Andrews score improved significantly from 143 to 190 (P < .05). All except 2 patients returned to a competitive level at which they had previously played after a mean of 6.9 months (range, 6-14 months). One patient chose another sport, and another retired from baseball after high school graduation. All patients achieved graft incorporation, and there was no postoperative enlargement of osteophytes on radiographs. One patient had mild anterior knee pain at the donor site during exercise. The remaining patients had no knee pain. The mean Lysholm score was 99.8. Conclusion: The results of this study indicate that an open autologous osteochondral plug graft allows a return to the previous competitive level of throwing by a mean of 7 months postoperatively.

Preoperative imaging criteria for unstable osteochondritis dissecans of the capitellum.

BackgroundThe stability of an osteochondritis dissecans (OCD) lesion of the humeral capitellum may be determined by intraoperative probing with unstable lesions being displaceable. Although preoperative imaging is used to diagnose and determine treatment of these lesions, it is unclear whether unstable lesions on imaging correspond to those found intraoperatively.Questions/PurposesWe therefore examined the concordance between preoperative imaging and intraoperative instability and examined the imaging features of the patients who healed without surgery.MethodsWe retrospectively reviewed 61 patients who underwent OCD of the humeral capitellum surgery or nonoperative treatment. All patients had plain radiography, MRI, and/or CT scans. The presence or absence of stability was determined intraoperatively by the International Cartilage Repair Society OCD classification. We determined the sensitivity, specificity, and predictive value of various imaging findings to predict instability.ResultsThe following preoperative imaging features were associated with intraoperative instability: a displaced fragment, epiphyseal closure of the capitellum, or a lateral epicondyle observed on radiographs; irregular contours of the articular surface or a high signal interface on T2-weighted MRI; and a displaced fragment observed on CT. Unstable lesions were more common when the epiphysis of the capitellum was closed. Intralesional segmentation was sensitive for detecting an unstable lesion, whereas displaced type on the radiographs and displaced fragment on the CT were specific. The following imaging findings were not seen in nonoperative patients: displaced type and closure of the epiphyseal line on radiographs, irregular contours of the articular surface, articular defects, and T2 high signal intensity interface between the fragments and their bed on the MRI or a displaced fragment on the CT.ConclusionsAlthough we found high sensitivity for some preoperative findings on imaging, none reached 100% of sensitivity. Preoperative MRI related to the intraoperative assessment of stability.Level of EvidenceLevel III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Assessment of medial elbow laxity by gravity stress radiography: comparison of valgus stress radiography with gravity and a Telos stress device

BACKGROUND Valgus instability was reported to be higher with the elbow in 60° of flexion, rather than in 30° of flexion, although there are no studies using valgus stress radiography by gravity (gravity radiography) with the elbow in 60° of flexion. METHODS Fifty-seven patients with medial elbow pain participated. For both elbows, valgus stress radiography by use of a Telos device (Telos radiography) and gravity radiography, with the elbow in 60° of flexion, were performed for the assessment of medial elbow laxity. In both radiographs, the medial elbow joint space (MJS) on the affected side was compared with that on the opposite side, and the increase in the MJS on the affected side was assessed. RESULTS For the Telos radiographs, the mean MJS was 4.7 mm on the affected side and 4.0 mm on the opposite side, with the mean increase in the MJS on the affected side being 0.7 mm. For the gravity radiographs, the mean MJS was 5.0 mm on the affected side and 4.2 mm on the opposite side, with the mean increase in the MJS on the affected side being 0.8 mm. There were significant correlations between the Telos and gravity radiographs in the MJS on the affected side, the MJS on the opposite side, and the increase in the MJS on the affected side (respectively, P < .0001). There was also a high level of intraobserver and interobserver reliability for the assessment of the gravity radiographs. CONCLUSIONS Gravity radiography is useful for assessment of medial elbow laxity, similar to Telos radiography.

Outcome of Nonoperative Treatment for Humeral Medial Epicondylar Fragmentation Before Epiphyseal Closure in Young Baseball Players

Background: Nonoperative treatment for humeral medial epicondylar fragmentation in baseball players, involving prohibition and limitation of throwing, has been reported to give good results. However, in some cases, such nonoperative treatment fails to yield an acceptable outcome. Hypothesis: In nonoperative treatment for patients with medial epicondylar fragmentation, achievement of bone union of the fragmentation provides better clinical outcomes compared with those of patients with delayed bone union or nonunion. Study Design: Cohort study; Level of evidence, 3. Methods: Fifty-five young baseball players with medial epicondylar fragmentation before epiphyseal closure, aged between 9 and 13 years (mean, 11.0 years), participated in this study. They belonged to baseball teams in a youth league and underwent nonoperative treatment involving prohibition of throwing for an average of 2.0 months and subsequent limitation of throwing for an average of 1.8 months. We investigated whether achievement of bone union of the fragmentation was associated with better clinical outcomes. Results: Bone union was achieved in 40 (73%) of 55 participants at 6 months after initial presentation, 31 (76%) of 41 participants at 1 year, and 32 (94%) of 34 participants at 2 years. Elbow pain was present in 7 participants (17%) at 1 year after initial presentation and in 6 participants (18%) at 2 years. At 1 year after initial presentation, statistical analysis showed that most participants with elbow pain had significant fragmentation (P = .0055). At 2 years after initial presentation, there was no significant relationship between elbow pain and medial epicondylar fragmentation (P = .32). Statistical analysis also showed that, at both 6 months and 1 year after initial presentation, bone union was significantly delayed in most participants who had not accepted nonoperative treatment and consequently resumed throwing vigorously before bone union. Conclusion: At 1 year after initial presentation, bone union of the medial epicondylar fragmentation was correlated with a decreased prevalence of elbow pain. At 6 months and 1 year after initial presentation, delayed bone union of the medial epicondylar fragmentation was associated with resumption of throwing at maximum strength before bone union had occurred.

Complications of Distal Radius Fractures Treated by Volar Locking Plate Fixation

The current study investigated the incidence of complications after surgery for distal radial fractures. This multicenter retrospective study was conducted at 11 institutions. A total of 824 patients who had distal radius fractures that were treated surgically between January 2010 and August 2012 were identified. The study patients were older than 18 years and were observed for at least 12 weeks after surgery for distal radius fractures with a volar locking plate. Sex, age, fracture type according to AO classification, implants, wrist range of motion, grip strength, fracture consolidation rate, and complications were studied. Analysis included 694 patients, including 529 women and 165 men, with a mean age of 64 years. The mean follow-up period was 27 weeks. The fracture consolidation rate was 100%. There were 52 complications (7.5%), including 18 cases of carpal tunnel syndrome, 12 cases of peripheral nerve palsy, 8 cases of trigger digit, 4 cases of tendon rupture (none of the flexor pollicis longus), and 10 others. There was no rupture of the flexor pollicis longus tendon because careful attention was paid to the relationship between the implant and the tendon. Peripheral nerve palsy may have been caused by intraoperative traction in 7 cases, temporary fixation by percutaneous Kirschner wires in 3 cases, and axillary nerve block in 1 case; 1 case appeared to be idiopathic. Tendon ruptures were mainly caused by mechanical stress. [Orthopedics.2016; 39(5):e893-e896.].

Characteristics and prognosis of medial epicondylar fragmentation of the humerus in male junior tennis players.

BACKGROUND Although medial epicondylar fragmentation of the humerus is a reported elbow injury in junior tennis players, there have been only a few studies on this entity, and none have investigated the characteristics and prognosis of medial epicondylar fragmentation. METHODS Forty-one male junior tennis players, aged 11 to 14 years (mean, 13 years), underwent elbow examination by ultrasonography. Elbow re-examination was performed in subjects with medial epicondylar fragmentation at an average of 20 months (12-30 months) after the initial examination. RESULTS On examination, 9 subjects (22%) had elbow pain. Ultrasonography showed that 6 subjects (15%) had medial epicondylar fragmentation, all of whom had elbow pain. Medial epicondylar fragmentation was present in 5 (38%) of 13 subjects aged 11 to 12 years and in 1 (4%) of 28 aged 13 to 14 years. More subjects aged 11 to 12 years had medial epicondylar fragmentation (P = .0084). All 6 subjects with medial epicondylar fragmentation continued to play tennis between the initial elbow examination and the re-examination. At re-examination, although ultrasonography showed that 5 developed bone union and 1 had nonunion, 3 subjects (50%) reported elbow pain. CONCLUSIONS Our results demonstrated that subjects aged 11 to 12 years had a high frequency (38%) of medial epicondylar fragmentation. Although medial epicondylar fragmentation was the main cause of elbow pain (67%) at the initial elbow examination, all 6 players with medial epicondylar fragmentation continued to play tennis between the initial elbow examination and the re-examination. At re-examination, 5 subjects presented spontaneous bone union (83%), but 3 subjects (50%) reported elbow pain.

The response of costal cartilage to mechanical injury in mice.

Background: The healing potential of articular cartilage in response to injury is poor, because articular cartilage lacks blood vessels or perichondrium. Costal cartilage is covered with a vascularized perichondrium, which is known to have chondrogenic potential. The purpose of this study was to determine whether costal cartilage can heal in response to mechanical injury. Methods: Sixty-five ICR mice were used. Under anesthesia, the left tenth costal cartilage was dissected using microscissors. At 1 day and at 1, 2, 3, and 12 weeks after injury, the mice were killed and paraffin sections were prepared. Safranin O staining, in situ hybridization of type II collagen, and immunostaining for CD44 were performed. Localization of cell proliferation was performed using immunohistochemistry with bromodeoxyuridine monoclonal antibody. In situ detection of apoptosis (deoxynucleotidyl transferase-mediated dUTP nick end labeling) was performed using an Apop Tag Kit. Results: From 1 to 2 weeks after costal cartilage injury, bromodeoxyuridine-positive cells were observed in the perichondrium. Two weeks after injury, the dissected cartilage fragments had combined with newly formed safranin O–positive tissue. Type II collagen mRNA was strongly expressed in the cells of the newly formed tissue. Apoptosis was detected in newly formed cartilaginous tissue at 1 and 2 weeks after injury. The cartilage fragments failed to unite at 12 weeks after injury. CD44 immunoreactivity was detected on the surface of the cavity between the cartilage fragments. Conclusion: Although the dissected fragments of costal cartilage can combine with newly formed cartilaginous tissue temporarily, they fail to unite ultimately.