Bone deformity in sports-related elbow osteoarthritis: influence of osteochondritis dissecans of the capitellum-a cross-sectional study.

INTRODUCTION: Sports activity can cause elbow osteoarthritis, which subsequently induces bone deformity. Osteochondritis dissecans (OCD) of the capitellum develops defects of articular surfaces and can exacerbate bone deformity. This study aimed to investigate whether OCD exacerbates deformities in sports-related elbow osteoarthritis. MATERIALS AND METHODS: Twenty-one patients who underwent bilateral computed tomography preoperatively followed by surgery for sports-related elbow osteoarthritis were included. Patients were divided into two groups according to the presence or absence of an OCD history: OCD + (n = 6) and OCD- (n = 15). Bilateral three-dimensional bone models of the humerus, ulna, and radius were created using computed tomography data, and bone deformities were extracted by subtracting healthy mirror models from the affected models using a Boolean operation. Bone deformities were divided into 22 regions in the 3 bones. The volume of the deformity was estimated by correlating the anteroposterior and lateral diameters of the OCD and by comparing the two groups. RESULTS: The anteroposterior diameter of the OCD correlated with the articular surface of the medial trochlear notch, whereas the lateral diameter correlated with the whole ulna, medial gutter of the ulna, whole radius, and lateral side of the radial head. The deformities were 2.2 times larger in the whole humerus, 1.9 times larger in the whole ulna, and 3.0 times larger in the whole radius in the OCD + group than in the OCD- group. The deformities were significantly larger in the OCD + group than in the OCD- group in the radial fossa, posterior capitellum, medial gutter, and lateral gutter in the humerus, medial gutter in the ulna, and lateral, anterior, and posterior sides of the radial head. CONCLUSION: Larger OCD exacerbated deformity in elbow OA, and the presence of OCD exacerbated deformities in sports-related elbow OA. These results demonstrate the highlight of preventing OCD progression.

Risk of nerve injury during elbow arthroscopy: ultrasonographic evaluation of preoperative patients.

BACKGROUND: To clarify the real risk of nerve injury during elbow arthroscopy, the distances of the radial and median nerves to the elbow joint were investigated using ultrasonography in patients who underwent surgery. METHODS: A total of 35 patients who underwent arthroscopic surgery of the elbow were investigated. The distances of the nerves to the capsule and bony landmarks were measured using ultrasonography. The radial nerve distances were measured at the capitellum, joint space, radial head, and radial neck levels. The median nerve distances were measured at the trochlear, joint space, and coronoid process levels. The patients were divided into 2 groups: nine patients in the hydrarthrosis (HA) group and 26 patients in the non-hydrarthrosis (non-HA) group. HA was defined as the intra-articular effusion on magnetic resonance imaging scans. RESULTS: The radial nerve ran closer to the capsule at the radial neck level in the HA group than in the non-HA group (2.0 mm vs. 5.9 mm, P < .01). In the non-HA group, the radial nerve ran closer to the radial head than in the HA group (6.3 mm vs. 8.5 mm, P = .01). The median nerve ran closer to the capsule at the trochlear level in the HA group than in the non-HA group (5.2 mm vs. 8.8 mm, P < .01). Nerves at a distance of ≤2 mm from the capsule were found in 7 patients at the radial neck of the radial nerve and in 2 patients at the trochlear region of the median nerve in the HA group. In the non-HA group, they were found in 3 patients at the radial head and in 1 patient at the joint space of the radial nerve. CONCLUSIONS: The dangerous locations for nerve injury during elbow arthroscopy vary according to hydrarthrosis, and this risk should be recognized during arthroscopic surgery.

Arthroscopic Debridement for Refractory Lateral Epicondylitis Results for Substantial Improvement in Tendinosis Scores and Good Clinical Outcomes: Qualitative and Quantitative Magnetic Resonance Imaging Analysis.

PURPOSE: To qualify and quantify the changes in magnetic resonance imaging (MRI) signals in the extensor tendons after arthroscopic debridement for lateral epicondylitis and evaluate the association between MRI findings and temporal clinical results by comparisons between recovered and unrecovered cases. METHODS: Thirty-four patients with refractory lateral epicondylitis treated with arthroscopic debridement were divided into recovered (n = 24) and unrecovered (n = 10) groups according to the Japanese Orthopaedic Association-Japan Elbow Society score. This study included any patients who underwent both the pre- and postoperative MRI and excluded patients with a previous history of any elbow surgery. Pre- and postoperative MRI findings were qualitatively categorized into 4 grades, quantified by measuring the percentage of tendinopathy area, and compared between the groups. RESULTS: Preoperatively, grading scores and percentages did not show significant differences between groups (P = .050 and .519). The respective numbers of patients with grades 1, 2, 3, and 4 were 1 (4%), 3 (13%), 10 (42%), and 10 (42%) in the recovered group; and 1 (10%), 2 (20%), 7 (70%), and 0 (0%) in the unrecovered group. The average percentages in the recovered and unrecovered groups were 42.3% (73.9 mm2/168.4 mm2); and 36.5% (50.5 mm2/131.0 mm2). However, postoperatively, they were significantly lower in the recovered group than in the unrecovered group (P = .007 and .014). The numbers and percentages in the recovered and unrecovered groups were 15 (63%), 8 (33%), 1 (4%), and 0 (0%) and 17.0% (28.6mm2/169.8mm2) and 2 (20%), 3 (30%), 5 (50%), and 0 (0%) and 30.5% (39.0 mm2/131.8 mm2). CONCLUSIONS: Qualitative and quantitative MRI is useful for evaluating the progress of tendon healing after arthroscopic debridement. In the recovered and unrecovered groups, improvement of tendinopathy area were 60% versus 16%, indicating that postoperative MRI findings reflect clinical outcomes. LEVEL OF EVIDENCE: IV, case series with subgroup analysis.

Arthroscopic Partial Excision of the Radial Head for Advanced Rheumatoid Elbow.

We treated humeroradial joint disorder in rheumatoid elbows with arthroscopic partial excision of the radial head, in which the radial head is minimally resected under arthroscopy to ensure adequate joint space and articular congruity. To examine the effect of this method, we investigated outcomes using a retrospective case series. The hypothesis of this study was that this method decreases symptoms related to the humeroradial joint and ensures articular congruity. Since 2008, we have performed arthroscopic partial excision of the radial head for 14 patients (15 rheumatoid elbows) with more than 2 years of follow-up. Surgical indications for this method were motion pain with crepitus around the humeroradial joint and joint narrowing and sclerosis on plain radiography. After synovectomy, the surface of the radial head was resected 4 to 5 mm under arthroscopy, ensuring adequate joint space and articular congruity. Osteophyte removal and anterior capsular release were performed if necessary. At the final follow-up of 54 months, pain around the humeroradial joint had resolved in all cases. Range of motion improved from 115° flexion, -39° extension, 55° pronation, and 54° supination preoperatively to 127° flexion, -27° extension, 60° pronation, and 65° supination postoperatively. The articular congruity of the humeroradial joint was well maintained at final follow-up, with the exception of 2 cases in which the space decreased after 4 years. Arthroscopic partial excision of the radial head is a promising procedure for improvement of humeroradial symptoms. This method is effective, even for advanced cases, and should be considered before total arthroplasty. [Orthopedics. 2022;45(4):209-214.].

A Quantitative Analysis of Subchondral Bone Density Around Osteochondritis Dissecans Lesions of the Capitellum.

PURPOSE: In capitellar osteochondritis dissecans (OCD), unstable lesions generally demonstrate signs of subchondral sclerosis. We postulate that OCD lesions have abnormal subchondral bone density. We aimed to quantify the subchondral bone thickness around OCD lesions using conventional computed tomography (CT) imaging. METHODS: This retrospective study included 15 patients with capitellar OCD (OCD group) and 12 patients with an unaffected radio-capitellar joint (control group). We constructed 3-dimensional humerus models using CT data and quantified the bone density with colored contour mapping to determine the subchondral bone thickness. We measured the thickness relative to the condylar height at the centroid and lateral, medial, superior, and inferior edge points of the OCD lesion, and compared the findings between the groups. We then correlated the CT measurements with the magnetic resonance imaging measurements. RESULTS: Subchondral bone thickness at the centroid and lateral, medial, superior, and inferior edges in the OCD group was significantly higher than that in the control group. Correlation analyses revealed that the magnetic resonance imaging measurements highly correlated with the CT subchondral bone measurements. CONCLUSIONS: We found that there is a zone of increased subchondral bone thickness around OCD lesions that should be considered during drilling, microfracture, or other reconstruction methods. We observed a high correlation with low errors between the measurements taken from conventional CT images and the measurements from magnetic resonance imaging, suggesting that both modalities are useful in clinical decision making. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic IV.

Post-Exertional MRI Is Useful as a Tool for Diagnosis and Treatment Evaluation for Chronic Exertional Compartment Syndrome of Forearms.

Background: Chronic exertional compartment syndrome (CECS) is a rare condition, which generally occurs in athletes. Few tools are available for diagnosis and treatment evaluation. We examined pre- and post- exertional forearm magnetic resonance imaging (MRI) before and after fasciotomy since 2013. The purpose of this study was to evaluate the efficacy of pre- and post-exertional MRI before and after fasciotomy. Methods: We treated 8 forearms of 5 patients diagnosed with CECS of the forearms since 2013, including 6 forearms of 3 motocross racers, 1 forearm of 1 baseball pitcher, 1 forearm of 1 manual laborer with a history of muscle contusion. We obtained pre- and post-exertional MRI before and after fasciotomy in all cases. Pre-exertional MRI was obtained when the patient was at rest without any symptom. Post-exertional MRI was obtained after the patients repeated "grip and release" using a hand gripper with maximum effort for approximately 10 minutes until symptoms occurred. We compared MRI findings before and after fasciotomy and evaluated the correlation with clinical outcome. Results: Symptoms disappeared completely in all 3 motocross racers after fasciotomy. MRI at rest showed no abnormal high signals in all cases both before and after fasciotomy. On post-exertional MRI, T2 high area presented mainly in flexor digitorum profundus (FDP) and brachioradialis (BR) and disappeared completely after surgery. Symptoms persisted in the pitcher and the laborer after fasciotomy. T2 high area presented mainly in FDP on post-exertional MRI before fasciotomy and remained on post-exertional MRI after fasciotomy in these two patients. These intensity changes correlated strongly with their symptoms. Conclusions: We performed pre- and post-exertional MRI before and after fasciotomy. The intensity change in T2-weighted images on post-exertional MRI correlated strongly with their symptoms. Post-exertional MRI is useful for diagnosis and treatment evaluation in CECS.

Anconeus Muscle-Pedicle Bone Graft With Periosteal Coverage for Osteochondritis Dissecans of the Humeral Capitellum.

BACKGROUND: Treatment of advanced osteochondritis dissecans (OCD) of the capitellum is controversial, especially in moderate-sized lesions. PURPOSE: To establish a treatment algorithm for capitellum OCD, we tried to determine the utility of and problems associated with anconeus muscle-pedicle bone graft with periosteal coverage (ABGP) for the treatment of moderate-sized articular OCD defects of the capitellum. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: According to our protocol for elbow OCD, 16 patients (15 males, 1 female; age range, 12-17 years; mean age, 14.4 years) with a moderate-sized OCD lesion of the humeral capitellum were treated with ABGP. All patients had a full-thickness, unstable OCD lesion that was 10 to 15 mm in diameter. Clinical results and postoperative images, including radiographs and magnetic resonance imaging (MRI), were evaluated at a mean follow-up of 31 months (range, 24-66 months). RESULTS: All but 1 patient had functional improvement after the procedure and returned to previous sporting activities within 6 months. One female patient needed 1 year for functional recovery due to development of postoperative chronic regional pain syndrome (CRPS). Two patients required additional surgery, including shaving of the protruding cartilage, and they returned to their previous level of activity. Mean arc of range of flexion-extension motion was 117° preoperatively and 129° at follow-up (P = .031). Mean elbow function as assessed with the clinical rating system of Timmerman and Andrews was 136 preoperatively and 186 at follow-up (P = .00012). Bony union of the graft as demonstrated by trabecular bone bridging on radiography was obtained within 3 months in all patients. Postoperative MRI was examined for 14 patients at 6 to 12 months after the procedure; the MRIs showed near-normal articular surface integrity in 9 of the 14 patients (64%) and underlying bony structure in 10 of the 14 patients (71%). CONCLUSION: Improvement after ABGP was obtained within 6 months in all except 1 patient, who developed CRPS. Postoperative radiography and MRI revealed near-normal articular surface integrity or underlying bony structure. This procedure is useful as a surgical option for a moderate-sized articular OCD lesion in the elbow.

The association between cubital tunnel morphology and ulnar neuropathy in patients with elbow osteoarthritis.

BACKGROUND: Morphologic changes in the cubital tunnel during elbow motion in patients with elbow osteoarthritis have not been examined in vivo. We examined changes in cubital tunnel morphology during elbow motion and characteristics of medial osteophyte development to elucidate whether cubital tunnel area and medial osteophyte size are factors contributing to cubital tunnel syndrome in patients with elbow osteoarthritis. METHODS: We performed computed tomography of 13 primary osteoarthritic elbows in patients with cubital tunnel syndrome (group A) and 25 primary osteoarthritic elbows in patients without cubital tunnel syndrome (group B) at full extension, 90° of flexion, and full flexion. Cubital tunnel area, humeral and ulnar osteophyte area, and proportion of osteophytes within the cubital tunnel were analyzed at each position. RESULTS: Humeral osteophytes and osteophyte proportion within the cubital tunnel were larger at full flexion (24.7 mm(2) and 49.9% in group A; 18.7 mm(2) and 39% in group B) and 90° of elbow flexion (20.3 mm(2) and 45.3% in group A; 10.2 mm(2) and 30.2% in group B) than at full extension (9.0 mm(2) and 31.3% in group A; 2.3 mm(2) and 12.5% in group B). These parameters were significantly greater in group A than in group B at full extension and 90° of flexion. CONCLUSIONS: The effect of medial osteophytes on the ulnar nerve, especially on the humeral side, rather than narrowing of the cubital tunnel, may be a causative factor for cubital tunnel syndrome with elbow osteoarthritis.

Kinematic changes in elbow osteoarthritis: in vivo and 3-dimensional analysis using computed tomographic data.

PURPOSE: To investigate in vivo 3-dimensional kinematics in elbow osteoarthritis. We hypothesized that normal kinematics is preserved in an osteoarthritic elbow with a normal radiocapitellar joint (OAN). Conversely, we hypothesized that an osteoarthritic elbow with radiocapitellar degenerative changes (OAD) would show an abnormal kinematics pattern. Furthermore, the differences in osteophyte formation between groups may affect elbow kinematics. METHODS: We examined 7 normal elbows, 7 OAN elbows, and 9 OAD elbows. We investigated 3-dimensional kinematics using computed tomography registration techniques. The osteophyte location was determined using 3-dimensional bone models generated from computed tomography data. RESULTS: The kinematics is different in OAN and OAD elbows. In the OAN group, the ulna changed by 11° from a valgus to a varus position during elbow flexion and demonstrated a 4° change in the axis of elbow motion, similar to that in normal elbows. Osteophytes formed medially on the olecranon fossa. In the OAD group, the ulna changed by 4° varus during flexion from the 90° position, but only by 2° valgus during elbow extension from 90°. The change in the axis of elbow motion was 9°. Additional osteophytes formed on the anteromedial and lateral trochlea, lateral olecranon fossa, and medial olecranon of the ulnotrochlear joint, and on the radiocapitellar joint. CONCLUSIONS: Normal kinematics was preserved in the OAN group. The OAD group demonstrated marked changes in the direction of elbow motion in the extension range, and the valgus motion pattern during extension was decreased. CLINICAL RELEVANCE: The results of the current study provide a good starting point for further research into the nature of arthritic progression in the elbow joint and the role of debridement arthroplasty.

Cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans.

BACKGROUND: There is a need to clarify the usefulness of and problems associated with cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans. METHODS: Twenty-six patients with advanced osteochondritis dissecans of the humeral capitellum were treated with use of cylindrical costal osteochondral autograft. All were males with elbow pain and full-thickness articular cartilage lesions of ≥15 mm in diameter. Clinical, radiographic, and magnetic resonance imaging outcomes were evaluated at a mean follow-up of thirty-six months (range, twenty-four to fifty-one months). RESULTS: All patients had rapid functional improvement after treatment with costal osteochondral autograft and returned to their former activities, including sports. Five patients needed additional minor surgical procedures, including screw removal, loose body removal, and shaving of protruded articular cartilage. Mean elbow function, assessed with use of the clinical rating system of Timmerman and Andrews, was 111 points preoperatively and improved to 180 points at the time of follow-up and to 190 points after the five patients underwent the additional operations. Mean elbow motion was 126° of flexion with 16° of extension loss preoperatively and improved to 133° of flexion with 3° of extension loss at the time of follow-up. Osseous union of the graft on radiographs was obtained within three months in all patients. Revascularization of the graft depicted on T1-weighted magnetic resonance imaging and congruity of the reconstructed articular surface depicted on T2-weighted or short tau inversion recovery imaging were assessed at twelve and twenty-four months postoperatively. Functional recovery was good, and all patients were satisfied with the final outcomes. CONCLUSIONS: Cylindrical costal osteochondral autograft was useful for the treatment of advanced osteochondritis dissecans of the humeral capitellum. Functional recovery was rapid after surgery. Additional operations were performed for five of the twenty-six patients, whereas the remaining patients showed essentially full recovery within a year. All patients were satisfied with the results at the time of short-term follow-up.

Osteosynthesis for longstanding nonunion of the lateral humeral condyle in adults.

HYPOTHESIS: Osteosynthesis for longstanding nonunion of the lateral humeral condyle in adults has a high rate of complications, including failure of bony union and restriction of elbow motion. We hypothesized that rigid fixation may contribute to higher union rate and the placement of the condyle fragment with proper tilting may minimize the reduction of elbow motion. MATERIALS AND METHODS: Ten patients were treated with osteosynthesis. Average age at operation was 38.6 years. Three patients had dysfunction of the ulnar nerve, 2 experienced pain, and 5 had both presentations. According to Toh et al's radiographic criteria, nonunion was categorized as Group 1 in 2 patients and Group 2 in 8 (J Bone Joint Surg Am 2002;84:593-598). We performed osteosynthesis with iliac bone graft and ulnar nerve anterior transposition, with efforts to fix the fragment rigidly and to manage the fragment position properly. RESULTS: Osseous union was achieved in all 8 Group 2 patients, while 1 Group 1 case showed delayed union and the other did not achieve union. Pain resolved and ulnar nerve symptoms improved in all cases. In 9 patients with union, total arc of motion was reduced by an average of 20°. The preoperative mobility of the condyle fragment determined by maximum flexion and extension lateral radiographs had a correlation to the postoperative loss of motion (P = .047); however, loss of motion was less than that expected by radiographs. CONCLUSION: Osteosynthesis appears to be indicated for Group 2 nonunion with pain. Rigid fixation with care of the position of the fragment is important for the good outcomes.

Osteochondritis dissecans of the humeral trochlea with cubitus varus deformity. A case report.

Osteochondritis dissecans of the elbow primarily involves the capitellum. We report a rare case of osteochondritis dissecans involving the humeral trochlea in a 19-year-old male with a post-traumatic cubitus varus deformity. Biomechanics suggested that the varus malalignment caused repetitive axial force across the medial elbow, which led to microtrauma to the trochlea during the patient's daily work. In adolescents, post-traumatic cubitus varus can gradually progress to subsequent osteochondritis dissecans of the humeral trochlea.

Long-term results of surgery for forearm deformities in patients with multiple cartilaginous exostoses.

BACKGROUND: Surgical treatment of forearm deformities in patients with multiple cartilaginous exostoses remains controversial. The purpose of the present study was to determine the reasonable indications for operative treatment and to evaluate long-term results of forearm surgery in these patients. METHODS: We retrospectively reviewed twenty-three patients (thirty-one forearms) after a mean duration of follow-up of nearly thirteen years. The mean age at the time of the initial procedure was eleven years. The patients underwent a variety of surgical procedures, including excision of exostoses; corrective procedures (lengthening of the radius or ulna and/or corrective osteotomy of the radius and/or ulna) and open reduction or excision of a dislocated radial head. Clinical evaluation involved the assessment of pain, activities of daily living, the cosmetic outcome, and the ranges of motion of the wrist, forearm, and elbow. The radiographic parameters that were assessed were ulnar variance, the radial articular angle, and carpal slip. RESULTS: Four patients had mild pain, and five patients had mild restriction of daily activities at the time of follow-up. Eight patients stated that the appearance of the forearm was unsatisfactory. Radiographic parameters (ulnar variance, radial articular angle, carpal slip) were initially improved; however, at the time of the final follow-up visit, the deformities had again progressed and showed no significant improvement. The only procedure that was associated with complications was ulnar lengthening. Complications included nonunion (three forearms), fracture of callus at the site of lengthening (two forearms), and temporary radial nerve paresis following an ulnar distraction osteotomy (one forearm). Excision of exostoses significantly improved the range of pronation (p = 0.036). CONCLUSIONS: In our patients with multiple cartilaginous exostoses, corrective osteotomy and/or lengthening of forearm bones was not beneficial. The most beneficial procedure was excision of exostoses. Reasonable indications for forearm surgery in these patients are (1) to improve forearm rotation and (2) to improve the appearance.

Modulation of peritendinous adhesion formation by alginate solution in a rabbit flexor tendon model.

To examine the antiadhesive effect of an alginate solution following tendon surgery, unilateral subtotal laceration of the flexor digitorum communis tendon was created in one hind limb while the other side was left intact in 32 Japanese white rabbits. The lesion was coated with alginate solution in 16 animals and not coated in the other 16. Degree of adhesion formation was assessed histologically and biomechanically by measuring the flexion angle of the first toe when the flexor digitorum tendon was pulled with a specified force at 4 weeks postoperatively. When compared with the control group, the alginate-treated group demonstrated significantly greater toe flexion, with less scar tissue formation at the repair site. Histologically, complete tendon healing with longitudinal remodeling of collagen fibers was observed in the alginate-treated group, while a random pattern of fibers was observed in the control group. Reduction in adhesion formation using alginate solution represents a novel strategy for the management of tendon injury and repair in the clinical setting.

Reconstruction with an osteochondral autograft for advanced osteochondritis dissecans of the elbow.

UNLABELLED: The treatment of large, advanced osteochondritis dissecans of the elbow is controversial. To ascertain whether better results could be obtained using osteochondral autografts, we retrospectively reviewed the results in 10 young athletes (mean age, 14.3 years; range, 12-17 years) who were followed up for a mean of 25.5 months (range, 18-45 months). After abrasion of the fragments, cylindrical osteochondral bone plugs were transferred from a lateral femoral condyle. They were assessed clinically by the Japanese Orthopaedic Association elbow score and radiologically by radiocapitellar congruity. All patients achieved bony union in 3 months. The average Japanese Orthopaedic Association score was 80.6 points before surgery and improved to 93.8 points at followup. The average percentage of radiocapitellar congruity was 35.7% before surgery and improved to 64.2% at followup. Clinical and radiologic results were excellent in eight patients and poor in two. Poor results may be dependent on preexisting osteoarthritis and technical difficulty related to the location of the lesion. In eight patients, a durable load-bearing elbow was obtained with this procedure, which made hyaline-like cartilage resurfacing with healthy subchondral bony support possible. Osteochondral autograft is a reasonable surgical option for an advanced lesion of osteochondritis dissecans of the elbow, although long-term followup is needed to know whether the early results persist. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series--no, or historical control group). See the Guidelines for Authors for a complete description of levels of evidence.