Elbow Arthroscopy for Panner Disease and Osteochondritis Dissecans
DEFINITION
Panner Disease
Panner disease is a condition in which there is compromised subchondral bone, potentially due to repetitive microtrauma and diminished blood supply to the developing ossific nucleus within the distal
humerus chondral epiphysis in preadolescents.9
Those affected are typically 6 to 10 years old, and symptoms usually respond to a reduction of the offending repetitive microtrauma.9
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.8
Osteochondritis dissecans (OCD) of the capitellum is most commonly seen in children ages 10 to 17 years old, particularly those who engage in overhead throwing sports and activities in which the elbow serves as a loadbearing 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, whereas 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 years.
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 disease and OCD of the capitellum arise from repetitive submaximal stresses, which in summation result in abnormal valgus forces exerted across the radiocapitellar joint.3,4,11,13
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 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 disease.7
The natural history of OCD is articular surface separation for patients who do not restrict their activities. Even with activity modification and brief periods of immobilization, elbow OCD lesions will progress in most patients treated nonoperatively.
In OCD of the capitellum, radiographs will initially 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 lateral elbow discomfort during throwing and loadbearing 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.
Examination may reveal palpable synovial thickening, elbow effusion, decreased range of motion, and tenderness over the radiocapitellar joint.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Anteroposterior (AP) and lateral radiographs of the elbow are needed to evaluate both conditions. In Panner disease, the size of the ossific nucleus and the degree of radiolucency can be determined from the radiographs. In OCD lesions, fragmentation, erosion, subchondral lysis, or cystic changes may be seen on radiographs (FIG 1A).
Magnetic resonance imaging (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
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FIG 1 • A. AP radiograph of the elbow showing an area of subchondral lysis in the capitellum, representing a large osteochondral lesion (arrow). B. MRI image showing the same OCD lesion of the capitellum with subchondral separation (arrow).
Autoimmune vasculitis
Steroid-induced avascular necrosis
NONOPERATIVE MANAGEMENT
Treatment for Panner disease consists of the following: Sling for 4 to 6 weeks
Range-of-motion exercises
Cessation of all offending activity
Follow-up radiographs through resorption and reconstitution phases at 3-month intervals prior to resumption of sport-specific exercises.
Nonoperative treatment of OCD is reserved for cases in which the cartilage is intact. It consists of the following:
Immobilization in a posterior splint or sling for 6 weeks
Removal of the splint or sling for a few minutes several times per day to perform range-of-motion exercises Rest until symptoms resolve
Follow-up radiographs through resorption and reconstitution phases prior to resumption of sport-specific exercises
SURGICAL MANAGEMENT
Surgical management is largely dependent on the character of the lytic lesion (stable vs. unstable, intact vs. partially or completely detached articular cartilage) and the presence or absence of symptoms.
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FIG 2 • A. The patient is positioned in the lateral decubitus position with the elbow in 90 degrees of flexion over a paint roller. B. The landmarks, including the path of the ulnar nerve located posterior to the medial epicondyle, as well as the radiocapitellar interval (white arrow), and the olecranon are identified with a marking pen. C. Both the incision for the arthroscopy-assisted miniarthrotomy approach (dashed line) and the incision for arthroscopy portals only (solid portion of line) are marked out of the skin.
Surgery is generally reserved for unstable lesions with partially or completely detached articular cartilage.
Persistent pain and swelling despite intact cartilage may warrant arthroscopic evaluation with a search for loose bodies as well as consideration of lesion drilling 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 prepared and draped, allowing unhindered flexion and extension of the elbow and internal and external rotation of the shoulder (FIG 2A).
The landmarks over the elbow are marked (FIG 2B).
Approach
Arthroscopy-assisted miniarthrotomy (Children’s Hospital of Philadelphia approach) is used for large to massive loose bodies and osteochondral defects.
After the patient is positioned, prepared, and draped and the anatomic landmarks are identified, a 3- to 5-cm incision is carried over the capitellum (FIG 2C).
The incision is carried down to the fascia, and the plane between the anconeus and the extensor carpi ulnaris is identified and entered.
Alternatively, if during the course of arthroscopy a larger incision is required, then the superior and inferior arthroscopy
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portals can be incorporated into an incision of 1.5 cm. Again, the deep dissection can be in the plane of the anconeus-extensor carpi ulnaris interval.
For both miniarthrotomy and connecting the superior and inferior arthroscopy portals, care is taken to avoid the annular ligament during the deep dissection. Then, 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. 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.
TECHNIQUES
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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 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.
The arthroscopic portals are identified using the palpable landmarks (TECH FIG 1A).
In the soft spot between the lateral epicondyle or capitellum and radial head laterally and olecranon medially, a position equidistant from the lateral epicondyle or capitellum or radial head is marked.
Just inferior to this position is the location of the inferior lateral coaxial portal, and just superior to this position is the location of the superior lateral coaxial portal.
The inferior lateral coaxial portal is created first. A no. 15 scalpel is brought through the skin and subcutaneous tissues. A hemostat is used to enter the capsule bluntly. If there is the potential for creating a miniarthrotomy, the skin incision should be oriented so that it would easily connect with the superior portal.
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TECH FIG 1 • A. The arthroscopic portals are identified, just superior and inferior to an equidistant point. B,C. The arthroscope is placed through the inferior lateral portal, and an 18-gauge needle placed into the olecranon fossa can be used as both an outflow portal (arrow in B) and as an instrument to secure loose bodies (asterisk in C) to prevent them from migrating (arrow in C). D. Drilling is performed through the inferior percutaneous approach with a 0.62-mm Kirschner wire (arrow). 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 arthroscope is inserted, and a careful and thorough inspection of the elbow is performed, examining the chondral surfaces of the radial head and capitellum, An 18-gauge needle may be placed into the olecranon fossa under direct visualization to act as an outflow (TECH FIG 1B,C).
A portal 1 cm superior to the initial portal is made under direct visualization for insertion of graspers and shavers. A spinal needle is used to confirm the location and trajectory, and again, a no. 15 blade is used as before to incise the skin.
Definitive management depends on the intraoperative findings.
For stable and intact lesions, we prefer drilling of the lesion to stimulate healing.
For unstable lesions that are partially detached or “hinged” with appropriate subchondral bone, we prefer screw fixation.
For completely detached lesions that are contained defects, we prefer marrow stimulation.
For completely detached lesions that are uncontained, we prefer osteochondral autograft transfer through an arthroscopic-assisted miniarthrotomy. The osteochondral transplant procedure is described elsewhere in this textbook (check Index).
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Cartilage Stable and Intact
Drilling of the lesion is performed to stimulate healing.
A 0.62 or 0.45-mm 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 distal and posterior to the inferior portal.
For the inferior percutaneous approach, the entry point is between the radial head-neck junction and olecranon. The wire is biased toward the olecranon and away from radius to avoid the posterior interosseous nerve (TECH FIG 1D).
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 Unstable and Partially Detached or “Hinged” with Appropriate Subchondral Bone
Débridement and fixation of the lesion is performed to both stimulate healing and provide stability for healing.
After thorough inspection of the joint, the lesion is explored.
For lesions with appropriate viable subchondral bone, the lesion can be secured with compression screws arthroscopically.
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TECH FIG 2 • A,B. A capitellar OCD débrided back to a stable base.
For lesions with underlying granulation tissue or nonviable bone, this can be débrided to a healthy subchondral base for healing.
If a bony defect is present after débridement, bone grafting and fixation via arthrotomy may be necessary.
For lesions with fractured cartilage, without healthy subchondral bone, the fractured hinged piece is removed, and salvage procedures such as marrow stimulation and osteochondral transplant are performed.
Cartilage Completely Detached from a Contained Lesion
Curettage and drilling of the lesion is performed to stimulate formation of fibrocartilage.
After thorough inspection of the joint is performed, any loose bodies found within the joint are removed.
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 circumferentially (TECH FIG 2A,B).
The underlying sclerotic bone is exposed.
Drilling of the lesion is performed using a 0.62 or 0.45-mm Kirschner wire. Drilling is performed as perpendicular to the capitellum as possible, in a distal to proximal direction. The previously described inferior percutaneous approach is performed (see TECH FIG 1D).
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 Miniarthrotomy
The patient is positioned, prepared, and draped as previously described.
The miniarthrotomy approach is carried through the plane of the anconeus and extensor carpi ulnaris. The capsule is incised to access the lesion (TECH FIG 3A).9
A 30-degree arthroscope is inserted through the arthrotomy site to view and assess the entire lesion (TECH FIG 3B).
The arthroscope can be used to assess the portions of the capitellum not clearly visualized through the arthrotomy site, much like a dental mirror (TECH FIG 3C).
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 transplant 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.
A sterile dressing and a posterior splint are applied.
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TECH FIG 3 • A. For massive lesions and loose bodies, a miniarthrotomy can be performed through the plane of the anconeus and extensor carpi ulnaris. B. A 30-degree arthroscope is inserted, and the lesion is identified. When a miniarthrotomy is performed, the arthroscope can be used like a dental mirror to enhance visualization and minimize the need for extensive open dissection. C. The arthroscopic view of the prepared lesional bed. D. Image of the elbow demonstrating an uncontained lesion treated with multiple osteochondral grafts.
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Surgical
technique
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When performing the miniarthrotomy, posterior dissection of the capitellum is
avoided to prevent devascularization.
Drilling of
the lesion
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When drilling the lesion, the Kirschner wires should be maintained perpendicular
to the capitellum. They may be inserted through the inferior portal with the elbow flexed or through a portal placed distal to the radiocapitellar joint. Care should be taken to place this adjacent ulna and not the radial head to avoid injury to the posterior interosseous nerve.
Arthroscopic ▪ The bony landmarks and the location of the ulnar nerve are drawn carefully
technique before the procedure to avoid inadvertent neurovascular injury. Draping the hand free also allows for more flexibility in the procedure.
PEARLS AND PITFALLS
POSTOPERATIVE CARE
For stable and intact lesions where drilling is performed, strengthening and range of motion are the early goals of therapy. A gradual return to activity and axial loading is permitted, as healing is seen radiographically.
For unstable and detached lesions where fixation is performed and for full-thickness defects where marrow stimulation is performed, a sling is used and early-assisted motion is instituted. Patients are sent to physical therapy to ensure appropriate elbow range of motion and core strengthening, although impact loading of the elbow is avoided. After 6 weeks, a gradual return to activity of daily living is instituted; however, axial loading, impact loading, and throwing are prohibited for up to 6 months.
OUTCOMES
Panner disease
Full recovery is expected in 12 to 18 months, but longterm noncompliance can result in lesion progression.
OCD of the capitellum
The arthroscopic-assisted miniarthrotomy procedure described has demonstrated promising midterm results. Twenty-five patients, 10 with arthroscopic débridement and drilling alone and 12 requiring miniarthrotomies for bone grafting or loose body removal, were shown at 48 months postoperatively to have gained an average of 17 degrees of extension and 10 degrees of flexion compared to their
preoperative range of motion.6 Average elbow function rating using the Single Assessment Numerical Evaluation score (0% to 100%) was 87%. Eighteen out of 21 patients returned to sport at their preinjury level.
Ruch and coworkers10 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.
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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.
Shimada et al12 reported on 26 patients with advanced OCD of the capitellum treated by cylindrical costal osteochondral autograft, with an average follow-up of 36 months. All patients had rapid functional recovery and returned to sport. Extension improved by 7 degrees and flexion by 13 degrees postoperatively. Five patients required minor additional procedures such as screw removal, loose body removal, and articulate cartilage shaving, but all remaining patients showed full recovery within 1 year.
Iwasaki et al5 described 19 male athletes who underwent autologous osteochondral transfer for capitellar OCD. Mean total arc of elbow motion improved by an average of 16 degrees. All patients except one had a good or excellent clinical result, and all but two returned to their prior level of sport.
COMPLICATIONS
Angular deformity
Avascular necrosis of the capitellum Detachment and capitellum overgrowth Early arthritis
REFERENCES
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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.
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Byrd JW, Jones KS. Arthroscopic surgery for isolated capitellar osteochondritis dissecans in adolescent baseball players: minimum threeyear follow-up. Am J Sports Med 2002;30:474-478.
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Douglas G, Rang M. The role of trauma in the pathogenesis of the osteochondroses. Clin Orthop Relat Res 1981;(158):28-32.
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Duthie RB, Houghton GR. Constitutional aspects of the osteochondroses. Clin Orthop Relat Res 1981; (158):19-27.
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Iwasaki N, Kato H, Ishikawa J, et al. Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes: surgical technique. J Bone Joint Surg Am 2010;92(suppl 1, pt 2): 208-216.
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Jones KJ, Wiesel BB, Sankar WN, et al. Arthroscopic management of osteochondritis dissecans of the capitellum: mid-term results in adolescent athletes. J Pediatr Orthop 2010;30(1):8-13.
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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.
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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.
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Ruch DS, Cory JW, Poehling GG. The arthroscopic management of osteochondritis dissecans of the adolescent elbow. Arthroscopy 1998;14:797-803.
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Ruch DS, Poehling GG. Arthroscopic treatment of Panner’s disease. Clin Sports Med 1991;10:629-636.
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Shimada K, Tanaka H, Matsumoto T, et al. Cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans. J Bone Joint Surg Am 2012;94:992-1002.
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Singer KM, Roy SP. Osteochondrosis of the humeral capitellum. Am J Sports Med 1984;12:351-360.