What is the recommended treatment for osteochondritis dissecans of the capitellum with a bifurcated, minimally displaced osteochondral fragment?

Treatment Recommendation for Capitellar OCD with Minimally Displaced Fragment in a 15-Year-Old

This 15-year-old with a bifurcated, minimally displaced osteochondral fragment of the capitellum should be offered surgical intervention, specifically fragment fixation or osteochondral autograft transfer, as this represents an unstable lesion unlikely to heal without surgery and carries significant risk of early-onset osteoarthritis if left untreated. 1

Rationale for Surgical Intervention

The presence of a displaced fragment—even if minimally displaced—classifies this as an unstable OCD lesion that requires surgical management. 1, 2 The American Academy of Orthopaedic Surgeons consensus guidelines emphasize that symptomatic patients with salvageable unstable or displaced OCD lesions should be offered surgery through shared decision-making, as these lesions are unlikely to heal without treatment and pose substantial risk for developing severe osteoarthritis at a young age. 1

Key Clinical Considerations:

• Skeletal maturity status: At 15 years old, this patient may be approaching or at skeletal maturity, making spontaneous healing even less likely than in younger children with open physes 1
• Fragment characteristics: The bifurcated nature and displacement indicate instability, which is a clear indication for surgical intervention 2, 3
• Long-term morbidity prevention: Without treatment, there is high risk of cartilage loss, subchondral bone damage, and irreversible osteoarthritis with limited treatment options in young patients 1

Surgical Treatment Algorithm

Primary Surgical Options (in order of preference):

1. Fragment Fixation (if fragment is salvageable and of adequate size):

• Arthroscopic fixation using absorbable pins is less invasive and effective for reattachable fragments 4
• Maintains native cartilage and bone, which is ideal for this age group 1, 4
• Best option when the fragment is large enough and viable for reattachment 3, 5

2. Osteochondral Autograft Transfer (OAT) (if fragment is not salvageable):

• Superior outcomes compared to microfracture in adolescents aged 12-15 years, with significantly higher ICRS scores, better return to activities, and fewer failures requiring revision surgery 1
• Recommended for larger defects (>50% of articular surface) or when fragment cannot be salvaged 3, 6
• Autograft typically harvested from ipsilateral knee 6

3. Arthroscopic Debridement with Microfracture (least preferred for this case):

• May be considered only for very small lesions or as salvage when other options fail 2, 3
• Lower success rates compared to OAT in this age group, with more failures and secondary procedures 1

Critical Decision Points

Fragment Salvageability Assessment:

• Salvageable: Fragment has adequate size, viable bone, and intact cartilage → Fragment fixation 1, 4
• Unsalvageable: Fragment too small, fragmented (bifurcated), or devitalized → Osteochondral autograft transfer 1, 6

Lesion Size Considerations:

• Lesions involving >50% of capitellar articular surface or extending to lateral margin have worse outcomes with debridement alone and should be treated with fixation or OAT 3, 5

Shared Decision-Making Process

The surgical recommendation must be presented through informed consent that includes: 1

Risks of surgery:

• Bleeding, infection, neurovascular injury, anesthesia complications, surgical failure 1
• Crepitus (more common with OAT) 1

Risks of non-surgical management:

• High likelihood of progression to irreversible osteoarthritis 1
• Limited effective treatment options for severe osteoarthritis in young patients 1
• Persistent symptoms and functional limitations 1, 5

Expected benefits of surgery:

• Prevention or delay of severe osteoarthritis 1
• Symptom relief 1
• High rate of return to preinjury activity level in adolescent athletes 5

Common Pitfalls to Avoid

• Attempting conservative management for displaced fragments: Unlike stable lesions in younger children with open physes that may heal spontaneously, displaced fragments in adolescents require surgery 1, 2
• Choosing microfracture as first-line treatment: Evidence shows OAT has superior outcomes in this age group (12-15 years) with fewer failures and better functional results 1
• Delaying surgical intervention: Progression leads to irreversible cartilage and bone loss, making reconstruction more difficult and outcomes worse 1, 5

Postoperative Management

Following surgical intervention, postoperative physical therapy should be offered to address impairments including loss of motion, strength deficits, altered movement patterns, and postoperative effusion. 1