Treatment of Capitellar Osteochondritis Dissecans With a Novel Regenerative Technique: Case Report of 3 Patients After 4 Years

摘要

Osteochondritis dissecans (OCD) is a joint condition in which bone underneath the cartilage loses its vitality owing to a lack of blood flow. This disease mainly affects young people practicing sports activities, and the elbow is the second-most affected site in the body (after the knee), representing 6% of overall OCD. ~( 8 , 16 ) Indications for surgical treatment include the presence of loose bodies, mechanical symptoms (eg, articular locking), unstable lesions, and stable lesions still symptomatic after 6 months of conservative management. ~( 24 , 27 ) The ideal surgical treatment has not yet been identified, and the currently performed procedures are borrowed from experience with other major joints, such as the knee or ankle. Several treatment techniques have been described for OCD, such as debridement, drilling, microfracture, fragment fixation, osteochondral autografting or allografting, and autologous chondrocyte implantation (ACI). ~( 9 ) These techniques show well-known positive aspects but also some important drawbacks: (1) the lack of restoration of high-quality cartilaginous tissue (ie, for microfracture), (2) the high costs and patient discomfort (ie, ACI requires 2-step surgery and a dedicated laboratory for the cell culture), (3) donor site morbidity attributed to the plug’s harvest from a healthy joint, ~( 6 ) and (4) limited donor availability (ie, for autologous or homologous osteochondral grafts). Recent acquisitions in the field of regenerative medicine have demonstrated that bone marrow–derived cells (BMDCs) on a scaffold are able to replicate and regenerate bone as well as cartilaginous tissue, without any need for laboratory treatment. ~( 1 , 10 , 13 , 21 ) BMDC transplantation was proposed and successfully performed for the treatment of knee and ankle OCD. Owing to the multipotential ability of bone marrow nucleated cells, in association with platelet-rich fibrin (PRF), the osteochondral layer may regenerate and show properties similar to those of the original hyaline cartilage. ~( 2 , 3 , 29 , 30 ) The aim of this case report is to describe the surgical technique and clinical outcomes, at a mean 4 years of follow-up, for the first 3 patients affected by elbow OCD and treated by BMDC transplantation with a 1-step technique. All patients showed closed physes and had experienced no relief after 6 months of conservative management. This study was approved by an institutional review board, and all 3 patients provided informed consent. Cases Case 1 A 15-year-old boy came to our institution with right elbow pain that had developed 2 years previously; the pain had become more intense in the past months, limiting his ability to play water polo. Clinical examination showed pain in the capitellar area and a range of movement from 15° to 130° in flexion and extension, with no limitations in pronation and supination. Radiograph, computed tomography scan, and magnetic resonance imaging showed signs of OCD, with no clear signs of fluid infiltrate underlying the cartilage. Case 2 The second case involved a 12-year-old boy who had experienced elbow pain for about 7 months, with significantly worse pain in the past 2 months. He was a competitive gymnast who had to stop the agonistic activity because of the intense pain during weightbearing on the elbow: this activity, uncommon for other athletes, is often performed during gymnastics training and competitions. Pain was reported in the posterior area of the right lateral epicondyle, decreasing with nonsteroidal anti-inflammatory drugs but returning after moderate activity. He showed no range of motion limitation, and imaging reported signs of capitellar OCD. Case 3 The third case involved a 17-year-old patient who had experienced pain in his right elbow for about 3 years. The pain resulted in a reduction of volleyball from a competitive to a recreational level, and conservative therapy did not improve the symptoms over time. There was persistent pain and range of movement restrictions, and OCD was documented on imaging. Surgical Technique The surgical technique for the BMDCs consisted of several phases, all performed during the same surgical session. The procedure was performed by full arthroscopy in 2 cases and with combined arthroscopy and a mini-open procedure in 1 case. PRF Gel Production Autologous platelet gel was used to provide direct, in situ additional growth factors for stem cell proliferation and differentiation, being an “accelerator” for healing processes ~( 25 ) and containing several types of molecules that promote bone and cartilage regeneration. ~( 18 , 20 ) Moreover, PRF is rich in fibrin and is able to coagulate faster than regular platelet-rich plasma. The PRF was produced on the day before the operation. Peripheral venous blood (120 mL) was harvested and processed with the Vivostat System (Vivolution A/S) to obtain 6 mL of PRF, which was cryopreserved at –30°C until the time of surgery. Bone Marrow Aspiration Bone marrow was asp