What is the treatment for osteochondral defects of the elbow?

Treatment for Elbow Osteochondral Bodies

Surgery is indicated for osteochondral abnormalities causing mechanical symptoms or refractory pain, with the specific surgical approach determined by lesion location, stability, and skeletal maturity. 1

Initial Management Algorithm

Conservative Treatment (Stable Lesions in Skeletally Immature Patients)

Cast immobilization is the first-line treatment for stable osteochondritis dissecans lesions before epiphyseal closure, as it achieves significantly faster healing and earlier return to sports compared to activity restriction alone. 2

• Cast immobilization for 3-4 weeks followed by splinting for 7-8 weeks produces complete healing in 92% of patients within 5.5 months, compared to only 41% healing at 16.4 months with activity restriction alone. 2
• Activity restriction without immobilization requires 1-2 years for complete healing and results in lower healing rates. 2
• Return to sports occurs at 4.4 months with cast immobilization versus 8.2 months with activity restriction alone. 2

Surgical Indications

Surgery is recommended for:

• Unstable or displaced osteochondral fragments 1
• Loose intra-articular bodies causing mechanical symptoms (locking, catching) 1
• Stable lesions that fail conservative management after appropriate immobilization 1, 2
• Advanced-stage lesions with cartilage separation 3, 4

Surgical Treatment by Lesion Type

Centralized and Lateral Localized Lesions

Osteochondral autograft transplantation (OATS) from the knee is the treatment of choice, providing excellent outcomes with return to sports within 6 months. 3, 5

• Achieves good-to-excellent mid-term results at 7-year follow-up with mean Broberg-Morrey scores of 95.1 points. 5
• MRI demonstrates graft viability in all patients at mid-term follow-up. 5
• Range of motion returns to equal the contralateral side. 5

Lateral Widespread Lesions

Fragment fixation using small osteochondral plugs combined with large osteochondral plug transplantation for remaining defects is the recommended approach, though outcomes are less predictable than for localized lesions. 3

• Poor osseous integration of fixed fragments occurs in some cases, preventing return to sports. 3
• Complete reconstruction of the entire capitellar lesion area may be necessary for optimal outcomes. 3
• Range of motion improvement is less reliable compared to centralized or lateral localized lesions. 3

Loose Body Removal

Arthroscopic or open removal of loose bodies with curettage or drilling of the base is indicated when fragments are completely detached. 1, 6

• Early diagnosis and treatment provide good prognosis. 6
• Untreated loose bodies progress to degenerative joint disease. 6

Diagnostic Imaging to Guide Treatment

Plain radiographs are the mandatory first step to identify loose bodies, heterotopic ossification, and osteochondral lesions. 1, 7

MRI or MR arthrography determines lesion stability and surgical planning:

• MR arthrography has 100% sensitivity for detecting intra-articular bodies. 1
• Instability features include cysts, osteochondral fracture, T2 hyperintense rim, subchondral plate defects, and fluid-filled osteochondral defects. 4
• CT arthrography evaluates osteochondral lesion stability with 93% sensitivity for loose bodies. 1

Common Pitfalls

Avoid activity restriction alone without immobilization in skeletally immature patients, as this delays healing by over a year and reduces complete healing rates from 92% to 41%. 2

Do not assume all lateral widespread lesions can be salvaged with fragment fixation alone—complete capitellar reconstruction may be required to achieve return to sports. 3

Recognize that untreated osteochondral lesions progress to degenerative arthritis, making early surgical intervention critical when conservative measures fail. 6

Order MRI or MR arthrography before surgery to assess lesion stability and plan the appropriate surgical technique, as arthroscopic findings alone may be insufficient. 1, 4