SURGICAL TECHNIQUES PEDIATRIC 2022, Dec, 22 | 12:00 am

Elbow Arthroscopy for Panner’s Disease and Osteochondritis Dissecans

 

Chapter 19‌

Elbow Arthroscopy for Panner’s Disease and Osteochondritis Dissecans

Theodore J. Ganley, Gilbert Chan, Aaron B. Heath, and

J. Todd R. Lawrence

 

DEFINITION

Panner’s Disease

  • A term often used synonymously with osteochondritis dissecans (OCD) of the capitellum, Panner’s disease is a condition in which there is diminished blood supply to the developing ossific nucleus within the distal humerus chondral epiphysis in preadolescents.7

  • Those affected are typically 6 to 10 years old, and symptoms usually respond to a reduction of the offending repetitive microtrauma.7

    Osteochondritis Dissecans of the Capitellum

  • This term is used to describe the condition of compromised subchondral bone in the capitellum of adolescents, which can lead to secondary articular surface separation.6

  • OCD of the capitellum is most commonly seen in children ages 10 to 17, particularly those who engage in overhead throwing sports and activities in which the elbow serves as a load-bearing joint.

    ANATOMY

  • The three articulations in the elbow are the ulnohumeral joint, the radiocapitellar joint, and the proximal radioulnar joint.

  • The ulnohumeral joint is a hinge joint that allows for flexion and extension of the elbow, while the radiocapitellar and radioulnar joints are trochoid joints that allow for axial rotation and pivoting of the elbow.

  • The capitellum articulates with the rim of the radial head throughout flexion–extension and pronation–supination.

  • Secondary ossification centers are involved in the formation of the distal humerus, proximal radius, and ulna. The ossification center of the capitellum appears at 18 months and completely fuses by age 14.

  • Descending extraosseous branches of the brachial artery supply the capitellum. Chondral vessels supply the osseous nucleus, which in turn supplies the chondroepiphysis.

    PATHOGENESIS

  • It is theorized that both Panner’s disease and OCD of the capitellum result from abnormal valgus forces exerted across the radiocapitellar joint.3,4,9,10

  • The result of this abnormal stress on the radiocapitellar joint may depend on the age of the patient, with those exposed to the stress at a younger age (6 to 10 years) developing Panner’s disease and those exposed to the stress at a later age (10 to 17 years) developing OCD of the capitellum.

  • The development of the lesions also depends on the limited blood supply of the capitellum, which allows for limited repair potential.

    NATURAL HISTORY

  • With activity restriction, reossification and resolution of symptoms typically occur in Panner’s disease.5

  • The natural history of OCD is articular surface separation for patients who do restrict their activities. Even with activity modification and brief periods of immobilization, elbow OCD lesions will progress in most patients treated nonoperatively.

  • Initially, radiographs show irregularity and fragmentation of the capitellum. Erosion, lysis, and sclerosis may be observed in later stages.

     

    PATIENT HISTORY AND PHYSICAL FINDINGS

  • Early stages

    • Patients have full motion but complain of vague aching discomfort during throwing and load-bearing activities as well as swelling at the lateral elbow. They typically have full range of motion.

    • Synovitis: occasional mild palpable effusion

  • Later stages: Patients complain of mechanical symptoms, including locking and catching and limited flexion and extension; palpable synovial thickening and an effusion may also be found.

     

    IMAGING AND OTHER DIAGNOSTIC STUDIES

  • High-quality, standard anteroposterior (AP) and lateral radiographs of the elbow are needed to evaluate both conditions. In Panner’s disease the size of the ossific nucleus and the degree of radiolucency can be determined from the radiographs. In OCD lesions, subchondral lysis or cystic changes may be seen on radiographs (FIG 1A).

  • MRI findings in OCD may reveal bone edema, synovitis, and loose bodies, as well as subchondral and cartilage separation (FIG 1B).

    DIFFERENTIAL DIAGNOSIS

  • Familial OCD

  • Hemophilia and variants

  • Multiple epiphyseal dysplasia

  • Autoimmune vasculitis

  • Steroid-induced avascular necrosis

    NONOPERATIVE MANAGEMENT

  • Treatment for Panner’s disease consists of:

    • Sling for several weeks

    • Cessation of all offending activity

    • Range-of-motion exercises

  • Nonoperative treatment of OCD is reserved for cases in which the cartilage is intact. Nonoperative treatment consists of:

    • Rest until symptoms resolve

       

      1144

       

       

       

      A
      B

       

      FIG 1 • A. AP radiograph of the elbow showing a large osteochondral lesion of the capitellum. B. MRI image showing an osteochondritis dissecans lesion of the capitellum.

       

      • Range-of-motion exercises

      • Follow-up radiographs through resorption and reconstitu-tion phases prior to resumption of sport-specific exercises.

SURGICAL MANAGEMENT

  • Surgical management is largely dependent on the character of the lytic lesion and the presence or absence of symptoms.

  • Cartilage intact but persistent pain and swelling

    • Arthroscopic evaluation, search for loose bodies

    • Consider drilling of lesion to stimulate subchondral bone healing.

      Preoperative Planning

  • All imaging studies obtained before surgery should be reviewed. An MRI may be helpful to determine the extent of the lesion and the location and size of chondral or small osteochondral loose bodies in the joint.

  • A thorough physical examination should be performed under anesthesia to note range of motion and appropriate or pathologic degrees of laxity.

    Positioning

  • The patient is adequately padded and placed in the lateral decubitus position.

  • The involved elbow is placed over a padded bump that places the elbow in 90 degrees of flexion.

  • The extremity is then properly prepared and draped in a standard manner.

  • The landmarks over the elbow are marked with a marking pen (FIG 2).

    Approach

  • Arthroscopy-assisted mini-arthrotomy (Children’s Hospital of Philadelphia approach) is used for large to massive loose bodies and osteochondral defects.

  • After the patient is positioned, prepared, and properly draped and the anatomic landmarks are identified, a 3- to 5-cm incision is carried over the capitellum. If during the course of arthroscopy a larger incision is required, then the superior and inferior arthroscopy portals can be incorporated into an incision of 1.5 cm. Deep dissection can be in the plane of the anconeus–extensor carpi ulnaris approach.

  • The incision is carried down to the fascia, and the plane between the anconeus and the extensor carpi ulnaris is identified and entered.

  • The joint capsule is incised to allow adequate visualization of the lesion.

  • A 30-degree arthroscope is then inserted and used to view the joint surface (TECH FIG 3B). The arthroscope is placed on the outer border of the radiocapitellar joint and angled to allow a complete view of the capitellum and radiocapitellar interval.

     

     

     

     

    FIG 2 • The patient is positioned in the lateral decubitus position with the elbow in 90 degrees of flexion. The landmarks, including the path of the ulnar nerve located posterior to the medial epicondyle (black arrow) as well as the radiocapitellar interval (white arrow), are identified with a marking pen.

     

     

    ARTHROSCOPIC TREATMENT

    • The patient is positioned, prepared, and draped in a lateral decubitus position as previously described.

    • After the landmarks in the elbow are drawn with a marking pen and the tourniquet is inflated, 15 to 25 mL of sterile saline is injected into the joint, depending on the size of the patient.

    • A smaller set of instruments (2.9 mm) is used (TECH

      FIG 1A).

    • The arthroscopic portals are identified (TECH FIG 1B).

 

  • An incision is made using a no. 15 blade at a position that is equidistant from the lateral epicondyle, radial head, and capitellum.

    TECHNIQUES

     

  • The arthroscope is inserted and a careful and thorough inspection of the elbow is performed (TECH FIG 1C,D).

  • The lesion is identified, along with any concomitant injuries to the elbow (TECH FIG 1E).

  • A portal 1 cm superior to the initial portal is made for insertion of graspers and shavers.

     

     

     

     

     

    TECHNIQUES

     

    A B C

    D
    E

     

     

     

     

    TECH FIG 1 • A. A smaller set of instrumentation is used. B. The arthroscopic portals are identified. C,D. The arthroscope is placed through the lateral portal, and a needle can be used as both an outflow portal (arrow in C) and as an instrument to secure loose bodies to prevent them from migrating (arrow in D). E. The osteochondral defect of the capitellum (above) is identified along with the radial head (below).

     

    • Definitive management depends on the intraoperative findings.

      Cartilage Intact

    • Drilling of the lesion is performed to stimulate healing.

    • A 0.62 or 0.45 Kirschner wire is used to drill into the subchondral bone. Drilling is performed as perpendicular to the capitellum as possible, in a distal-to-proximal direction. The Kirschner wire may be placed through the inferior portal or via an inferior percutaneous approach.

  • After satisfactory bleeding is obtained, final inspection of the area is performed and the arthroscope is removed and the wounds are closed using no. 4-0 Monocryl subcuticular sutures, followed by Steri-Strips.

  • A sterile dressing and a posterior splint are applied.

    Cartilage Fractured

  • After thorough inspection of the joint is performed, any loose bodies found within the joint are removed (TECH FIG 2A,B).

     

     

     

     

     

     

     

     

     

    A B C D

     

     

     

     

     

     

     

    E F G

    TECH FIG 2 • A,B. Loose bodies within the joint are identified and removed. C–E. Débridement of the defect is performed until a stable chondral rim is noted. F,G. Drilling is performed with a 0.62 Kirschner wire. At times it is helpful to place the wire percutaneously and flex the elbow to ensure that it is always placed perpendicular to the surface of the capitellum. Care is taken to use a posterior starting point to avoid the posterior interosseous nerve.

     

     

     

    • The defect is identified and curettage of the defect is performed to remove all granulation tissue and to ensure that a stable rim of cartilage exists circumferen-tially (TECH FIG 2C–E).

    • The underlying sclerotic bone is exposed.

    • Drilling of the lesion is performed using a 0.62 or 0.45 Kirschner wire. Drilling is performed as perpendicular to

      the capitellum as possible, in a distal-to-proximal direction (TECH FIG 2F,G).

      TECHNIQUES

       

  • Final inspection of the area is performed and the arthroscope is removed and the wounds are closed using no. 4-0 Monocryl subcuticular sutures, followed by Steri-Strips.

  • A sterile dressing and a posterior splint are applied.

     

    ARTHROSCOPIC-ASSISTED MINI-ARTHROTOMY

    • The patient is properly positioned, prepared, and draped as previously described.

    • The mini-arthrotomy approach is carried through the plane of the anconeus and extensor carpi ulnaris. The capsule is incised to access the lesion (TECH FIG 3A).7

    • A 30-degree arthroscope is inserted through the arthrotomy site to view and assess the entire lesion (TECH FIG 3B,C).

    • The arthroscope can be used to assess the portions of the capitellum not clearly visualized through the arthrotomy site, much like a dental mirror.

  • Once the entire lesion is visualized and assessed, removal of any loose bodies is performed with débridement and drilling of the lesion with Kirschner wires as described in the arthroscopic technique. For massive or uncontained lesions, osteochondral grafting can be performed (TECH FIG 3D).

  • Final inspection of the area is performed and the arthroscope is removed.

  • The capsule is repaired. A layer-by-layer closure is then performed (TECH FIG 3D).

  • A sterile dressing is applied and a posterior splint are applied.

 

 

 

TECH FIG 3 • A. For massive lesions and loose bodies, a mini-arthrotomy can be performed through the plane of the anconeus and extensor carpi ulnaris. B,C. A 30-de-gree arthroscope is inserted and the lesion is identified. When a mini-arthrotomy is performed, the arthroscope can be used like a dental mirror to enhance visualization and minimize the need for extensive open dissection. D. Arthroscopic image of the elbow demonstrating an uncontained lesion treated with multiple osteochondral grafts.

A

 

Arthroscope

K-wire

 

 

 

 

 

 

B C D

 

PEARLS AND PITFALLS

Surgical technique ■ When performing the mini-arthrotomy, posterior dissection of the capitellum is avoided to prevent devascularizing the capitellum.

Drilling of the lesion ■ When drilling the lesion, the Kirschner wires should be maintained as perpendicular to the capitellum as possible. They may be inserted through the inferior portal or through a separate inferior percutaneous portal. Care should be taken to avoid neurovascular injury.

Arthroscopic technique ■ The bony landmarks and the location of the ulnar nerve are drawn carefully before the procedure to avoid inadvertent neurovascular injury. Draping the hand free also allows for more flexibility in the procedure.

 

 

POSTOPERATIVE CARE

  • For full-thickness defects, immediate continuous passive motion and physical therapy are started for 6 weeks.

  • After 6 weeks, a gradual return to activity is instituted. Strengthening and range of motion are still the main goals of therapy. Axial loading, impact loading, and throwing are prohibited for up to 6 months.

    OUTCOMES

  • Panner’s disease

    • Full recovery is expected in 12 to 18 months, but longterm noncompliance can result in lesion progression.

  • OCD of the capitellum

    • Ruch and coworkers8 reported on 12 patients treated for OCD of the capitellum by arthroscopic débridement; 11 of them were highly satisfied. The average age was 14.5 years and the average follow-up was 3.2 years. Clinical presentation showed a contracture improvement from 23 degrees to 10 degrees.

    • Byrd and Jones2 reported on 10 baseball players treated for OCD of the capitellum by arthroscopic débridement; 4 of them were able to resume playing competitively. The average age was 14.5 years and the average follow-up was

      3.9 years. However, in this study the outcomes were poorly correlated with the lesion grade.

    • Baumgarten and associates1 reported on 14 young athletes (gymnastics or throwing sports) whose OCD of the capitellum was treated by arthroscopic débridement. Three were forced to give up their sport. The average age was 13.8 years and the average follow-up was 4 years. In this review contracture was noted to improve by 14 degrees.

      COMPLICATIONS

  • Angular deformity

  • Avascular necrosis of the capitellum

  • Detachment and capitellum overgrowth

  • Early arthritis

 

REFERENCES

  1. Baumgarten TE, Andrews JR, Satterwhite YE. The arthroscopic classification and treatment of osteochondritis dissecans of the capitellum. Am J Sports Med 1998;26:520–523.

  2. Byrd JW, Jones KS. Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: minimum three-year follow-up. Am J Sports Med 2002;30:474–478.

  3. Douglas G, Rang M. The role of trauma in the pathogenesis of the osteochondroses. Clin Orthop Relat Res 1981;158:28–32.

  4. Duthie RB, Houghton GR. Constitutional aspects of the osteochondroses. Clin Orthop Relat Res 1981;158:19–27.

  5. Kobayashi K, Burton KJ, Rodner C, et al. Lateral compression injuries in the pediatric elbow: Panner’s disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg 2004; 12:246–254.

  6. Krijnen MR, Lim L, Willems WJ. Arthroscopic treatment of osteochondritis dissecans of the capitellum: report of 5 female athletes. Arthroscopy 2003;19:210–214.

  7. Pill SG, Ganley TJ, Flynn JM, et al. Osteochondritis dissecans of the capitellum: arthroscopic-assisted treatment of large, full-thickness defects in young patients. Arthroscopy 2003;19:222–225.

  8. Ruch DS, Cory JW, Poehling GG. The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797–803.

  9. Ruch DS, Poehling GG. Arthroscopic treatment of Panner’s disease. Clin Sports Med 1991;10:629–636.

  10. Singer KM, Roy SP. Osteochondrosis of the humeral capitellum. Am J Sports Med 1984;12:351–360.