Osteochondritis dissecans of the medial elbow trochlea treated with lateral clavicle autograft: a case report

Osteochondritis dissecans (OCD) is a pathology commonly found in knee joints but is also found in other sites notably ankle, hip, and elbow.³ OCD in the elbow is mostly seen in the capitellum of the humerus but can also, infrequently, develop in the medial trochlea of the humerus. OCD is most commonly seen in children and adolescents, particularly athletes in throwing sports, but it can occur less commonly in adults.³ OCD can be caused by multiple factors, including the overuse of a joint due to activity, injuries, or trauma. This results in damage to the bony vasculature, with the devascularized bone becoming necrotic, which can then break off and cause pain, locking, and consequent stiffness.

Treatments range from rest and physical therapy for early or mild cases, to surgical intervention for late or more severe cases.² Past surgical methods have described the use of osteochondral allografts for knee OCD and autologous methods using bone from the femoral condyle and articular cartilage from the femoral intercondylar notch for the elbow.1, 2, 3

We describe a novel case of a humeral medial trochlear OCD in an adult treated with a lateral clavicle autograft, with allograft cartilage paste.

Case report

A 30-year-old man with a prior history of obesity and chronic back pain had developed humeral medial trochlear OCD in his right elbow, without any known trauma or overuse. He experienced severe pain in his right elbow, without locking, and had undergone physical therapy and corticosteroid injection treatment in 3 separate outside facilities, without sustained relief. Initially he underwent a diagnostic elbow arthroscopy with osteochondroplasty of the coronoid fossa, olecranon fossa, and osteophyte resection from the coronoid and olecranon precesses. The intraoperative findings revealed a medial trochlear OCD, at the lateral most rim of the medial trochlear facet. However, he continued to report right medial elbow pain, especially when loaded with varus force and was relieved with a valgus stress. His right arm range of motion was 0°-120°. Right shoulder and elbow X-rays were obtained to evaluate the clavicle as a possible autograft for the medial trochlea defect. Radiographs found a 16-mm diameter lateral clavicle and a 13-mm trochlear defect, with loss of bone density in the medial trochlea (Fig. 1, a). Preoperative T2 sagittal and axial magnetic resonance imaging views of the right elbow showed avascular necrosis of the medial trochlea with early contour changes (Fig. 1, b and c). Surgical intervention using the lateral clavicle as an autograft was determined as a viable low-morbidity option in treating OCD. Patient consent was obtained.

Figure 1.

(a) Preoperative x-ray of right arm showing OCD in medial trochlea of humerus. (b) Sagittal T2 MRI showing preoperative necrosis in left medial trochlea of humerus. (c) Axial T2 MRI showing preoperative necrosis in right medial trochlea of humerus. OCD, osteochondritis dissecans; MRI, magnetic resonance imaging.

Surgical technique

The patient was placed on a beach chair bed in the supine position (Fig. 2), with a mid-humerus tourniquet at 250 mmHg. Firstly, an anterior ante-cubital fossa approach was utilized to identify the distal biceps and brachialis muscles. The brachialis was split, in line with the medial trochlea, to reach the anterior capsule, which was incised to visualize the coronoid process, trochlea, and coronoid fossa. A small 5-mm section of the coronoid process tip was excised with an osteotome. The area of OCD was identified by its altered color and softer texture when probed (Fig. 3, a). A circular punch of the appropriate size of the lesion was used to remove the avascular necrotic area (Fig. 3, b).

Figure 2.

Surgical site (Distal is located to the right).

Figure 3.

(a) Site of OCD necrosis in medial trochlea of humerus. (b) Healthy blood flow in medial trochlea upon lesion removal. OCD, osteochondritis dissecans.

The clavicle autograft harvest began with a 4 cm incision directly over the superior aspect of the lateral clavicle. The delto-trapezial fascia was split in line with the skin incision, and the lateral 1 cm of clavicle was circumferentially released with subperiosteal elevation. Great care was taken to avoid any breach of the coraco-clavicular ligaments. An osscilating saw was used to transect the lateral 9 mm of the clavicle. The lateral clavicle graft was shaped and fitted through multiple trials until a proper fit was achieved into the resected defect (Fig. 4, a). The lateral end of the lateral clavicle graft was oriented to fit with the articular surface of the elbow creating a cartilage-to-cartilage adhesion.

Figure 4.

(a) Lateral clavicle shaped to fit into medial trochlea. (b) Placement of lateral clavicle into lesion site.

The graft was placed into the medial trochlea defect and then ConMed Cartimex collagen matrix was compressed onto its surface and into any interface spaces, with finger pressure (Fig. 4, b). The graft inset was meant to articulate with the trochlea surface with edge-to-edge contact. The ConMed Cartimex collage matrix was meant to fill in any gaps in this edge-to-edge contact. We did not consider a more limited bony débridement method due to the avascular lesion in the medial trochlea that was essentially necrotic bone which would have made the elbow joint more unstable in the patient. The elbow was tested through various range of motion exams, and it was determined that the graft was stable. After layered wound closure, the right arm was placed into a posterior splint at 90° flexion. Postoperative regiment started with the patient in a splint at 90° flexion in a sling for 2 weeks. At the 2-week follow-up, he was transitioned to a hinged-elbow brace for range of motion exercises. The patient was also instructed to attend physical therapy if needed. The time to mobilization was about 2 weeks postoperative.

At the follow-up, 3 months after surgery, the patient had significantly improved pain, 2 out of 10 on a visual analog scale. The patient had initially rated the pain 6 out of 10 preoperatively. Active extension was noted to be difficult at 10°-15° and greater force was needed to fully extend the elbow. Full flexion and normal supination and pronation were observed compared to the normal side and no rotational instability was noted. There was no pain elicited upon varus force. Postoperative T2 magnetic resonance imaging at 1 year shows stable healing of the medial trochlea autograft with good surface contact reconstituted (Fig. 5, a and b). At a 2-year clinic follow-up, he had achieved full active and passive range of motion, without any notable difficulties in terminal extension. His pain was consistent at 1 out of 10 on a visual analog scale.

Figure 5.

(a) Axial T2 MRI postoperative showing healing medial trochlea. (b) Sagittal T2 MRI postoperative of medial trochlea. MRI, magnetic resonance imaging.

Discussion

Surgical treatment of OCD in the medial trochlea of the humerus have involved various approaches. One approach utilizes arthroscopic ulnohumeral joint débridement as a less invasive technique, but authors have noted that long-term outcomes are not clearly understood.⁹ Other approaches have utilized autologous grafts to improve patient outcomes. One group utilized an autologous osteochondral graft from the femur condyle of an adult male gymnast and showed significant improvement in mobility and pain for the patient despite the trochlea lesion being significantly large.⁴

Another study utilized articular cartilage from the femoral intercondylar notch of the left knee joint and cultured this in a collagen matrix for 28 days before surgery for medial trochlear OCD and saw improvement in pain and mobility of the joint and noted that this method of tissue-engineered cartilage required less material to be removed from donor sites.⁵ Methods using allografts have also been seen in the treatment for elbow OCD, for example in capitellar OCD.⁷

Our method utilizes a novel technique that, to our knowledge, has not been recorded in the literature for treatment of medial trochlea OCD. Usage of the lateral clavicle as an autograft for medial trochlea OCD has shown to be another unique and successful treatment option for patients. Studies have reported on the usage of the lateral clavicle as an autograft in treatment of bone defects and diseases such as in coronoid process reconstruction and reverse Hill-Sachs lesions of the shoulder joint.⁸ Our patient in this study faced chronic painful dysfunction of the right elbow before surgery, recalcitrant to all nonoperative and arthroscopic surgical methods. Postoperatively, the patient was able to regain full mobility and had a significant reduction in pain, resulting in a return to full function. Our method also did not involve any other limb, and the ipsilateral ACJ site remained asymptomatic at final follow-up. Autologous transplantation also has a benefit of being safer to utilize in patients with fewer undesired effects. Another study looked at comparisons between nonoperative repair versus operative repair (arthroscopic or open surgery) in patients with OCD and found that 86% of those cases analyzed were treated nonoperatively and had a 76% resolution of symptoms.⁶

Conclusion

The usage of an autologous lateral clavicle graft to treat medial trochlea OCD in a patient with chronic painful dysfunction is a novel technique allowing for a successful return to function. The procedure significantly improved patient pain and mobility and did not affect the donor clavicle site at the acromioclavicular joint.

Disclaimers:

Funding: No funding was disclosed by the authors.

Conflicts of interest: The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

Patient consent: Obtained.