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Alpine Physical Therapy
Three Locations
In North, South, and Downtown Missoula
Missoula, MT 59804
Ph: 406-251-2323
Fax: 406-251-2999

Child Orthopedics
Pain Management
Spine - Cervical
Spine - General
Spine - Lumbar
Spine - Thoracic

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I have something the doctors call an "unstable" OCD fragment in my elbow. I am being evaluated at a sports medicine center for the best way to treat this problem so I can get back to competitive sports. I'm wondering if you have any suggestions for the best, fastest way to recover from this problem.

We can summarize for you a recent report investigating this very question. Surgeons at several orthopedic centers conducted a review of all the studies done from 1992 to the present. They selected articles that specifically discussed treatment of unstable bone fragments caused by osteochondritis dissecans (OCD) of the capitellum (elbow bone). To cut right to the chase, we'll tell you they concluded that the best way to treat OCD when it is unstable has not been determined. High-level evidence is lacking to support one form of treatment over another. Here's a little background on the condition and more about their findings. Young gymnasts and overhand athletes, particularly baseball pitchers and racket-sport players, are prone to this odd and troubling elbow condition. In the past, this condition was called Little Leaguer's elbow. It got its name because it was so common in baseball pitchers between the ages of 12 and 20. Now it is known that other sports, primarily gymnastics and racket sports, put similar forces on the elbow. These sports can also lead to elbow OCD in adolescent athletes. The forceful and repeated actions of these sports can strain the immature surface of the outer part of the elbow joint. The bone under the joint surface weakens and becomes injured, which damages the blood vessels going to the bone. Without blood flow, the small section of bone dies. The injured bone cracks. It may actually break off. That's when the condition is referred to as unstable. It sounds like that's what you have. Surgery is usually required for unstable OCD. The surgeon has several choices: the fragment can be reattached called fragment fixation. The broken piece can be removed with the remaining bone smoothed over (called debridement). Or the surgeon can do a procedure called osteochondral autograft transfer (OAT). The autograft transfer involves taking a fresh, healthy piece of bone from your knee and transferring or "grafting" it into the defective area. By looking at past studies and reported outcomes, the researchers were able to get an idea of short-, mid-, and long-term results with each of these surgical approaches. Despite the lack of firm conclusions, hey were able to glean a few bits of information that might be helpful until better studies are done. For example, debridement is able to get up to 85 per cent of competitive athletes with unstable capitellar OCD back to full sports participation. Debridement can even be used with defects large enough to cover more than half of the joint surface. But outcomes are usually worse with debridement in this group compared with debridement of smaller defects. Osteochondral autograft transfer (OAT) is really used most often for those large, unstable defects. It can also be used as a revision (second) surgery if debridement is unsuccessful in reducing pain and restoring elbow function. Studies have not been done long enough to show whether the donor site (in the knee) develops osteoarthritis years later. That would be an important piece of information to have before recommending the OAT procedure. Poorer results with OAT are likely when the defect is located along the edge of the joint because it is difficult to get a graft in there. Fixation was the other surgical method studied in this review. In fragment fixation, wires or bioabsorbable screws are used to hold the pieces of bone together until healing can occur. With this treatment approach, you may be able to get back to overhead (throwing) activities about six months after surgery. Those who have the wires used must have them removed in a second surgery. Outcomes reported with fixation include good resolution (or at least improvement) of pain in 85 per cent of the athletes. X-ray evidence of healing without joint degenerative changes has been observed in most cases. Problems that can occur after surgical correction of OCD include persistent pain, sensation of "catching" in the joint with motion, and an inability to return to full sports participation. In general, the larger the lesion, the poorer the results. And the farther out from the injury and surgery, the less favorable the outcomes reported in the studies available. In conclusion, there is a need for a long-term study conducted at multiple centers with large numbers of patients. This is the only way surgeons will be able to determine the best, most optimal surgical treatment for athletes who suffer from unstable capitellar OCD defects. Until then, your team of surgeons will take all aspects of your case into consideration when making a treatment decision. Your age, activity level, and type, location, and severity of the lesion will all be examined carefully. Hopefully, with the information we have provided here, you will have a better understanding of your choices and the reason(s) why one procedure might be recommended over another.


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