Osteochondritis

Case Reports

We treated a patient with extensive osteochondritis dissecans of the elbow by an osteochondral graft from

a rib. It had consolidated seven months after operation. When seen at follow-up, after seven years and eight months, the elbow was free from pain with an improvement in the range of movement of 24deg.

J Bone Joint Surg [Br] 2001;83-B:738-9. Received 3 October 2000; Accepted 12 December 2000

The object of the treatment of osteochondritis dissecans of the elbow is to allow early repair of the defect and thereby prevent the future development of degenerative changes. We have treated this condition satisfactorily using peg bone grafts, but this method cannot be used if the osteochondral defect is very large. We have treated a patient with extensive osteochondritis dissecans of the elbow by transferring rib cartilage and bone, with a good longterm outcome.

Case report

An 18-year-old man who played baseball presented with a history of pain in the right elbow for six years. The range of movement was from 6deg to 120deg with local tenderness and pain at the limit of extension. Radiographs showed extensive lucency of the capitellum and loose bodies (Fig. 1). At operation, through a posterolateral approach, the loose bodies were removed and the large segmental fragment of the capitellum excised. The defect involved the lateral two-thirds of the capitellum and was filled with a graft harvested from the osteochondral junction of the fifth rib comprising 5 mm each of bone and cartilage. The cartilage portion of the graft was introduced so that it became the articular surface. The graft was secured by two bone pegs (3 mm X 20 mm) taken from the proximal metaphysis of the ulna.

Subsequent radiographs showed satisfactory incorporation of the graft seven months later with consolidation at one year (Fig. 2). Currently, seven years and eight months after the operation, the radiological appearance remains satisfactory. The range of movement of the elbow is from 0deg to 138deg, representing an improvement of 24deg. He uses a computer at work and plays golf and baseball with only occasional minor discomfort.

Discussion

We have frequently used peg bone grafts1 in the surgical treatment of osteochondritis dissecans of the elbow. We reviewed, retrospectively, 32 cases with a minimum follow-up of two years. The improvement of pain and range of movement, and radiological union at the site of the defect, were significantly better when compared with those treated conservatively or by simple removal of the fragment. In the cases which were followed for more than five years, degenerative changes progressed more slowly in those treated with peg bone grafts compared with other methods of management. The indications for using peg bone grafts are limited to cases in which the articular cartilage remains relatively intact; they cannot be used to treat large defects. Recently, reconstruction of the articular cartilage in the knee and other small joints has been attempted by using rib perichondrimm2,3 and periosteal4-6 grafts. A technique involving osteochondral graft collected from non-weight-bearing areas of the knee may be used. Rib perichondrium and periosteal grafts may not be sufficient for reconstructing very extensive defects in the articular surface.

Donor sites for osteochondral grafts from the ribs are abundant and the adverse effects of collection are minimal. The diameter and shape of the ribs, however, restrict the surface area and shape of the graft. A good clinical and radiological outcome may be obtained using this technique. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

References

1. Oka Y, Ohta K, Fukuda H. Bone-peg grafting for osteochondritis dissecans of the elbow. Int Orthop 1999;23:53-7.

2. Skoog T, Ohlsen L, Sohn SA. Perichondrial potential for cartilagenous regeneration. Scand J Plast Reconstr Surg 1972;6:123-5.

3. Homminga GN, van der Linden TJ, Terwindt-Rouwenhorst EAW, Drukker J. Repair of articular defects by perichondral grafts: experiments in the rabbit. Acta Orthop Scand 1989;60:326-9.

4. Rubak JM. Reconstruction of articular cartilage defects with free periosteal graft: an experimental study. Acta Orthop Scand 1982;53:175-80.

5. O'Driscoll SW, Salter RB. The repair of major osteochondral defects in joint surfaces by neochondrogenesis with autogenous osteoperiosteal grafts stimulated by continuous passive motion: an experimental investigation in the rabbit. Clin Orthop 1986;208:131-40.

6. Hoikka VEJ, Jaroma HJ, Ristila VA. Reconstruction of the patellar articulation with periosteal grafts: 4-year follow-up study. Acta Orthop Scand 1990;61:36-9.

Y. Oka, M. Ikeda

From tokai University Oiso Hospital, Kanagawa, Japan

Y. Oka, MD, Associate Professor

M. Ikeda, MD, Lecturer

Department of Orthopaedic Surgery, Tokai University Oisa Hospital, 21-1 Gakkyo Oiso Kanagawa, 259-0198, Japan.

Correspondence should be sent to Dr Y. Oka.

Copyright British Editorial Society of Bone & Joint Surgery Jul 2001
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