Surgical Treatment of Osteochondritis Dissecans Leading to Normal Bone Density

Osteochondritis dissecans is a relatively poorly understood condition that most commonly affects growing bones during childhood and adolescence. Although the precise etiology is unknown, it is critical for all orthopaedic surgeons as well as other health-care professionals treating patients with open growth plates to be able to recognize this condition, and to have a clear understanding of the pathophysiology and appropriate treatment at various stages of the disease. Osteochondritis dissecans of the capitellum typically affects younger men or boys between the ages of 10 and 15 years and is thought to be related to some type of trauma. It frequently occurs in throwing athletes and should be distinguished from Panner’s disease, which occurs in younger children, ages 5 to 10. Treatment is nonoperative initially, with rest and nonsteroidal anti-inflammatory drugs, but in aspiring young athletes, surgery as outlined by the authors is indicated. For lesions that are small, ≤1 cm in diameter, and do not respond to nonoperative therapy, examination under anesthesia to evaluate the elbow for any signs of posterolateral rotatory instability followed by elbow arthroscopy to inspect the articular surface for a defect in the cartilage is important. If the cartilage is intact but lacks support from any underlying bone, the surgeon should utilize a posterior approach to the humerus with use of an image intensifier to locate and curet or burr in the lesion. Treatment will depend on the size of the lesion: e.g., the surgeon may choose to pack a defect that is ≤1 cm with cancellous autograft or allograft while preserving the articular surface, but to use a bone plug and possibly an open procedure for a larger defect. Aside from this important clinical point, I believe that the article by Miyamura et al. is an excellent one, emphasizing the importance of restoring the distal humerus to its normal density. This fact is borne out in the article by the similarity of bone density between the surgically treated side and the contralateral asymptomatic side of the same individual, as measured in Hounsfield units using computed tomography (CT). While not every patient needs CT to evaluate bone density following surgery, the article proves the important role of regaining normal density in stabilizing the distal humerus and preventing progression of the disease.