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Address correspondence to Thilo Patzer, M.D., Ph.D., Department of Orthopedics, University Hospital of Duesseldorf, Moorenstr. 5, D-40225 Duesseldorf, Germany.
Osteochondritis dissecans of the humeral capitellum is characterized by separation of a circumscript area of the articular surface and the subchondral bone in juvenile patients. In advanced lesions, arthroscopic fragment refixation or fragment removal with microfracturing or drilling can be successful. The purpose of this technical note is to describe an all-arthroscopic surgical technique for 3-dimensional purely autologous chondrocyte transplantation for osteochondral lesions of the humeral capitellum.
Technique Video
See video under supplementary data.
Osteochondritis dissecans of the humeral capitellum is characterized by separation of a circumscript area of the articular surface and the subchondral bone. Without intervention osteochondritis dissecans of the elbow can result in ongoing pain, restriction of motion, and limitation of activities.
In grade III “dead in situ” lesions with cartilage discontinuity and subchondral bone instability as well as grade IV lesions with dislocation of the fragment, according to the International Cartilage Repair Society classification system,
Lewine EB, Miller PE, Micheli LJ, Waters PM, Bae DS. Early results of drilling and/or microfracture for grade IV osteochondritis dissecans of the capitellum [published online June 17, 2015]. J Pediatr Orthop. doi:10.1097/BPO.0000000000000575.
In regard to the restoration of predominantly hyaline cartilage, autologous chondrocyte transplantation (ACT) is an established technique for osteochondral lesions in the knee joint and provides favorable long-term results.
Clinical and radiological long-term outcomes after matrix-induced autologous chondrocyte transplantation: A prospective follow-up at a minimum of 10 years.
The purpose of this technical note is to describe an all-arthroscopic surgical technique for 3-dimensional purely ACT for osteochondral lesions of the humeral capitellum.
Operative Technique
Diagnostic Arthroscopy and Chondrocyte Harvest
The patient is placed in the lateral decubitus position (Fig 1). Using a spinal needle, the elbow joint is instilled with 15-mL sodium chloride solution via the distal posterolateral soft spot portal. Following the skin incision, a 4-mm steel cannula (Karl Storz, Tuttlingen, Germany), providing constant water inflow, is inserted in the anterior elbow joint via the anterolateral portal using a sharp trocar. A water inflow pressure of 30 mm Hg is adjusted. Now a 4-mm 30° arthroscope is inserted in the proximal posterolateral portal and the olecranon fossa is visualized. If debridement of the fossa is necessary, an accessory proximal posterolateral portal is established further proximally next to the triceps tendon. Now the tip of the olecranon is evaluated and the arthroscope is directed in the radiohumeral joint between the radial head and the humeral capitellum. Now the radiohumeral and the ulnohumeral aspect of the joint can be inspected. Afterward a working portal directly above the radial head is created in the distal posterolateral portal. If necessary a 3.0-mm shaver (Sabre; Arthrex, Naples, FL) can be used for resection of a radiohumeral plica. Now the cartilage of the humeral capitellum can be evaluated and debridement of the defect can be conducted. For cartilage harvesting the arthroscope is directed into the olecranon fossa again and a curette (Arthrex) can be inserted via the accessory proximal posterolateral portal to harvest a stripe of cartilage from the tip of the olecranon. The cartilage can be retained using a grasper. The harvested cartilage is placed in sterile buffer solution. Together with 200 mL patient blood for the cell culture the cartilage is immediately sent to the company providing the cartilage cultivation (co.don AG, Teltow, Germany). The anterior aspect of the joint can now be visualized with the arthroscope in the anterolateral portal or anteromedial portal.
Fig 1Right elbow in left lateral decubitus position and 90° elbow flexion, cannula for continuous water flow placed in the anterolateral portal (X), view from medial (Y) and lateral (Z). 1: olecranon; 2: ulnar epicondylus; 3: radial epicondylus; 4: radial head; A: anterolateral portal; B: proximal posterolateral portal; C: distal posterolateral portal; D: anteromedial portal.
The cartilage is cultured in monolayer followed by condensation of single chondrocytes to spheroids (chondrospheres [co.don AG]). Each chondrosphere is reported to consist of approximately 200,000 hyaline cartilage cells.
Six to 8 weeks after the first arthroscopy with cartilage harvest, the chondrospheres are delivered in prefabricated syringes and can be implanted in a second arthroscopic operation (Fig 2).
Fig 2Syringes delivered prefabricated and filled with the chondrospheres (arrows) and nutrient solution in the applicator tip to facilitate the implantation.
Before implantation, the cartilage defect is debrided with the arthroscope in the proximal posterolateral portal using a 3.0-mm shaver (sabre) and curette in the distal posterolateral portal (Fig 3 A-C). The important step is to create sharp edges of the cartilage defect and to debride the subchondral bone of soft tissue while preserving the bone to create a stable “nest” for the chondrospheres. After debridement the defect is oriented horizontally by abduction and extension of the arm in the shoulder by the assistant (Video 1). For implantation, correct positioning of the defect and sufficient aeroscopy is crucial (Table 1). Oblique or vertical positioning of the defect bears the risk for adhesion of the chondrospheres to the capsule or misplacement due to gravity.
Fig 3Arthroscopy of a right elbow in lateral decubitus position. (A-C) View from the proximal posterolateral portal (PPLP) with debridement of the defect using a shaver and curette via the distal posterolateral portal (DPLP). (D) View from the PPLP showing the defect after debridement under aeroscopy with capitellum positioned horizontal. The ground of the defect was almost intact without indication for bony augmentation. (E-F) Defect filled with chondrospheres after all-arthroscopic implantation via the DPLP. *: humeral capitellum with osteochondral defect; x: radial head; #: applicator tip.
• Placement of the applicator tip containing the chondrospheres needs to be possible straight onward to the cartilage defect without obstruction by soft tissue
• Placement of the flexible applicator tip can be guided using a half pipe cannula
• Gentle pressure on the applicator with drop-by-drop implantation; training with a same size syringe filled with saline is helpful
• Create a stable “nest” for the chondrospheres by preparing sharp edges of the cartilage defect and debriding the subchondral bone of soft tissue
• Dry arthroscopy must be sufficient; repeated inflation of air might be necessary
• Slightly misplaced chondrospheres can placed in the defect using a blunt hook
Pitfalls
• Oblique or vertical positioning of the defect bears the risk for adhesion of the chondrospheres to the capsule or misplacement due to gravity
• Kinking or manipulation of the applicator tip can prohibit implantation
• Implantation in a defect filled with fluid suddenly flushed in from another compartment of the joint can result in chondrosphere lost
The water inflow is stopped and let out. Dry arthroscopy is prepared by inflating 20 mL of air in the joint via the arthroscope using a syringe (Fig 3D, Video 1). In stable and dry conditions, the chondrospheres can now be implanted stepwise via the distal posterolateral portal using the prefabricated syringes (Fig 3 E and F, Video 1). Placement of the applicator tip containing the chondrospheres needs to be possible straight onward to the cartilage defect without obstruction by soft tissue. Kinking or manipulation can prohibit implantation. With inadequate pressure on the syringe or implantation in a defect filled with fluid flushed in from another compartment of the joint, risk for misplacement is high and retrieval of chondrospheres lost in the joint cannot be conducted sufficiently (Table 1). After chondrosphere implantation, the joint is held in place for 20 minutes by the assistant as recommended by the manufacturer to facilitate seeding and adhesion of the chondrospheres creating a certain primary stability.
Rehabilitation
After implantation, the elbow joint is immobilized in 90° of flexion in a cast for the first postoperative week. Afterward passive and active motion is unrestricted and full range of motion should be achieved until the third week. Weight load >1 kg in the hand with the elbow flexed as well as uncontrolled flexion or extension is prohibited for the first 6 weeks. The patient is instructed not to participate in any sporting activity for 12 weeks postoperative.
Discussion
The described technique for arthroscopic ACT in the elbow offers a minimal invasive method to restore predominantly anatomical hyaline cartilage for osteochondral lesions in the elbow with limited soft tissue impairment. The technique described has been well proven in the knee and hip joint for several years. Since 2014 the first author has performed this technique in 3 patients in the elbow without any complications and excellent clinical results after a current follow-up of 10 to 14 months.
The described technique allows pure chondrocyte transplantation without usage of xenogen or artificial matrices and is able to restore hyaline cartilage. Furthermore, the all-arthroscopic approach can reduce the risk for neurovascular injury and intra-articular scarring and allows free functional rehabilitation (Table 2).
Table 2Advantages and Disadvantages
Advantages
• All-arthroscopic technique offers minimized risk for neurovascular injury and intra-articular scarring
• Better cosmesis, reduced postoperative pain, and free functional rehabilitation
• Pure chondrocyte transplantation without usage of xenogen or artificial matrices
• Anatomical restoration of hyaline cartilage
Disadvantages
• Demanding arthroscopic technique
• Training of the all-arthroscopic technique for chondrosphere implantation in the knee is necessary prior to the elbow
• Visualization of the defect and aeroscopy can be difficult
• Autologous chondrocyte transplantation is limited to well-contained chondral lesion with an intact corresponding articular surface
However, the technique requires a surgeon experienced in elbow arthroscopy and familiar with all-arthroscopic ACT in the knee joint. In general, similar to the knee joint, one must keep in mind that ACT is limited to well-contained chondral defects with an intact corresponding articular surface.
For further evaluation, the results of this technique need to be confirmed by clinical studies.
A 15-year-old right-handed male active handball player with no recent history of direct trauma complained about a painful right elbow with intermittent lockings since 8 months. Magnetic resonance imaging revealed an osteochondritis dissecans like osteochondral lesion of the humeral capitellum (12 × 15 mm; International Cartilage Repair Society grade IV). The patient was operated in the left lateral decubitus position. Six weeks after the arthroscopic evaluation with chondrocyte harvest, autologous chondrocyte implantation was conducted all-arthroscopic in the described technique.
References
Takahara M.
Ogino T.
Fukushima S.
Tsuchida H.
Kaneda K.
Nonoperative treatment of osteochondritis dissecans of the humeral capitellum.
Lewine EB, Miller PE, Micheli LJ, Waters PM, Bae DS. Early results of drilling and/or microfracture for grade IV osteochondritis dissecans of the capitellum [published online June 17, 2015]. J Pediatr Orthop. doi:10.1097/BPO.0000000000000575.
Clinical and radiological long-term outcomes after matrix-induced autologous chondrocyte transplantation: A prospective follow-up at a minimum of 10 years.
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