What is the treatment for a pediatric osteochondral defect of the elbow?

Treatment of Pediatric Osteochondral Defects of the Elbow

For pediatric osteochondral defects of the elbow, surgery is indicated for unstable or displaced fragments, loose bodies causing mechanical symptoms (locking, catching), and stable lesions that fail conservative management after appropriate immobilization. 1

Initial Diagnostic Workup

• Plain radiographs are mandatory as the first imaging step to identify loose bodies, osteochondral lesions, and heterotopic ossification 1, 2
• MRI or MR arthrography should follow to determine lesion stability and guide surgical planning, with MR arthrography demonstrating 100% sensitivity for detecting intra-articular bodies 1
• MRI findings indicating instability include: osteochondral defect (100% specific), intraarticular body (100% specific), overlying cartilage changes, subchondral bone plate disruption, and hyperintense rim on T2-weighted images 3
• CT arthrography evaluates stability with 93% sensitivity for loose bodies when MRI is not definitive 1

Treatment Algorithm Based on Lesion Characteristics

Stable Lesions (Intact Cartilage, No Displacement)

• Conservative management with rest and immobilization until healing for low-grade stable lesions 4
• Skeletally immature patients with stable lesions should receive activity restriction and immobilization as initial treatment 5
• If conservative treatment fails after appropriate immobilization period, proceed to surgical intervention 1

Unstable or Displaced Lesions

Skeletally immature patients with salvageable unstable or displaced fragments should be offered surgical treatment 5

Surgical Options by Lesion Location and Size:

Centralized or Lateral Localized Lesions (<3 cm²):

• Osteochondral autograft transplantation (mosaicplasty) provides favorable outcomes with return to sports within 6 months 6
• This technique uses autologous osteochondral cylindrical grafts harvested from the knee, offering hyaline cartilage replacement with superior mechanical properties 5
• Indicated for patients with focal, full-thickness lesions that are contained 5

Lateral Widespread Lesions:

• Fragment fixation using small osteochondral plugs for detached fragments, with large-sized osteochondral plug transplantation for remaining cartilage defects 6
• Reconstruction of the entire capitellar lesion area may be necessary as ROM improvement is less predictable and return to sports more difficult 6

Large Defects (>2.5 cm²) or Substantial Subchondral Bone Loss:

• Osteochondral allograft transplantation (OAT) is appropriate for larger lesions, eliminating donor site morbidity while providing mechanically functioning hyaline cartilage 5

Unsalvageable Fragments:

• Debridement with or without bone marrow stimulating procedures (drilling, microfracturing) for smaller defects, though these produce reparative fibrocartilage rather than hyaline cartilage 4, 7
• Reconstructive procedures addressing both bone and cartilage show better outcomes than debridement alone 4

Skeletal Maturity Considerations

• Skeletally immature patients with symptomatic stable lesions failing ≥3 months of conservative treatment may be candidates for arthroscopic drilling, though evidence is inconclusive 5
• Skeletally mature patients with salvageable unstable or displaced lesions should be offered surgical treatment 5
• Hyperintense rim and cysts on MRI are less specific for fragment instability in children compared to adults, but MRI remains useful for treatment planning 5

Common Pitfalls to Avoid

• Do not rely on MRI findings of joint effusion, cysts, marginal sclerosis, or perilesional bone marrow edema alone to determine instability, as these show no significant difference between stable and unstable lesions 3
• Avoid ordering MRI before plain radiographs, as radiographs must be obtained first to identify calcifications and basic pathology 2
• Do not perform complete immobilization, as this leads to muscle atrophy and joint stiffness; gentle range-of-motion exercises should be incorporated 2
• For lateral widespread OCD, incomplete reconstruction of the capitellar lesion area leads to poor osseous integration and difficulty returning to sports 6

Postoperative Management

• Patients receiving surgical treatment should be offered postoperative physical therapy 5
• Patients remaining symptomatic after treatment require repeat history, physical examination, radiographs, and/or MRI to assess healing 5