Imaging and classification of osteochondritis dissecans of the capitellum: X-ray, magnetic resonance imaging or computed tomography?

Background: Diagnosing capitellar osteochondritis dissecans (OCD) can be difficult, causing delay in treating young athletes. The main aim of this retrospective diagnostic study was to determine which radiological technique is preferred to identify and classify elbow OCD. Methods: We identified young patients who underwent elbow arthroscopy because of symptomatic OCD. We included all patients who had pre-operative radiographs, a computed tomography (CT) scan and magnetic resonance imaging (MRI) available. We assessed whether the osteochondral lesion could be identified using the various imaging modalities. All lesions were classified according to previous classifications for X-ray, CT and MRI, respectively. These results were compared with findings at arthroscopy. Results: Twenty-five patients had pre-operative radiographs as well as CT scans and MRI. In six patients, the lesion was not visible on standard X-ray. In 20 patients, one or two loose bodies were found during surgery, consistent with an unstable lesion. Pre-operatively, this was seen on 11 X-rays, 13 MRIs and 18 CT scans. Conclusions: Capitellar OCD lesions are not always visible on standard X-rays. A CT appears to be the preferred imaging technique to confirm diagnosis of OCD. Loose bodies are often missed, especially on standard X-rays and MRIs

Osteochondritis dissecans of the capitellum in adolescents

Osteochondritis dissecans (OCD) is a disorder of articular cartilage and subchondral bone. In the elbow, an OCD is localized most commonly at the humeral capitellum. Teenagers engaged in sports that involve repetitive stress on the elbow are at risk. A high index of suspicion is warranted to prevent delay in the diagnosis. Plain radiographs may disclose the lesion but computed tomography and magnetic resonance imaging are more accurate in the detection of OCD. To determine the best treatment option it is important to differentiate between stable and unstable OCD lesions. Stable lesions can be initially treated nonoperatively with elbow rest or activity modification and physical therapy. Unstable lesions and stable lesions not responding to conservative therapy require a surgical approach. Arthroscopic debridement and microfracturing has become the standard initial procedure for treatment of capitellar OCD. Numerous other surgical options have been reported, including internal fixation of large fragments and osteochondral autograft transfer. The aim of this article is to provide a current concepts review of the etiology, clinical presentation, diagnosis, treatment, and outcomes of elbow OC

Biomechanical considerations in the pathogenesis of osteoarthritis of the elbow

Osteoarthritis is the most common joint disease and a major cause of disability. Distinct biological processes are considered crucial for the development of osteoarthritis and are assumed to act in concert with additional risk factors to induce expression of the disease. In the classical weightbearing joints, one such risk factor is an unfavourable biomechanical environment about the joint. While the elbow has long been considered a non-weightbearing joint, it is now assumed that the tissues of the upper extremity may be stressed to similar levels as those of the lower limb, and that forces across the elbow are in fact very high when the joint is extended from a flexed position. This review examined the available basic science, preclinical and clinical evidence regarding the role of several unfavourable biomechanical conditions about the elbow on the development of osteoarthritis: post-traumatic changes, osteochondritis dissecans, instability or laxity and malalignment. Post-traumatic osteoarthritis following fractures is well recognized, however, the role of overload or repetitive microtrauma as risk factors for post-traumatic osteoarthritis is unclear. The natural course of untreated cartilage defects in general, and osteochondritis dissecans at the elbow in particular, remains incompletely understood to date. However, larger lesions and older age seem to be associated with more symptoms and radiographic changes in the long term. Instability seems to play a role, although the association between instability and osteoarthritis is not yet clearly defined. No data are available on the association of malalignment and osteoarthritis, but based on force estimations across the elbow joint, it seems reasonable to assume an associatio

Pediatric Radial Neck Fractures: A Systematic Review Regarding the Influence of Fracture Treatment on Elbow Function

Background: This review aims to identify what angulation may be accepted for the conservative treatment of pediatric radial neck fractures and how the range of motion (ROM) at follow-up is influenced by the type of fracture treatment. Patients and Methods: A PRISMA-guided systematic search was performed for studies that reported on fracture angulation, treatment details, and ROM on a minimum of five children with radial neck fractures that were followed for at least one year. Data on fracture classification, treatment, and ROM were analyzed. Results: In total, 52 studies (2420 children) were included. Sufficient patient data could be extracted from 26 publications (551 children), of which 352 children had at least one year of follow-up. ROM following the closed reduction (CR) of fractures with <30 degrees angulation was impaired in only one case. In fractures angulated over 60 degrees, K-wire fixation (Kw) resulted in a significantly better ROM than intramedullary fixation (CIMP; Kw 9.7% impaired vs. CIMP 32.6% impaired, p = 0.01). In more than 50% of cases that required open reduction (OR), a loss of motion occurred. Conclusions: CR is effective in fractures angulated up to 30 degrees. There may be an advantage of Kw compared to CIMP fixation in fractures angulated over 60 degrees. OR should only be attempted if CR and CRIF have failed

Osteochondritis dissecans of the humeral capitellum: reliability of four classification systems using radiographs and computed tomography

Background: The radiographic appearance of osteochondritis dissecans (OCD) of the humeral capitellum varies according to the stage of the lesion. It is important to evaluate the stage of OCD lesion carefully to guide treatment. We compared the interobserver reliability of currently used classification systems for OCD of the humeral capitellum to identify the most reliable classification system. Methods: Thirty-two musculoskeletal radiologists and orthopaedic surgeons specialized in elbow surgery from several countries evaluated anteroposterior and lateral radiographs and corresponding computed tomography (CT) scans of 22 patients to classify the stage of OCD of the humeral capitellum according to the classification systems developed by (1) Minami, (2) Berndt and Harty, (3) Ferkel and Sgaglione, and (4) Anderson on a Web-based study platform including a Digital Imaging and Communications in Medicine viewer. Magnetic resonance imaging was not evaluated as part of this study. We measured agreement among observers using the Siegel and Castellan multirater kappa. Results: All OCD classification systems, except for Berndt and Harty, which had poor agreement among observers (kappa = 0.20), had fair interobserver agreement: k was 0.27 for the Minami, 0.23 for Anderson, and 0.22 for Ferkel and Sgaglione classifications. The Minami Classification was significantly more reliable than the other classifications (P <.001). Conclusions: The Minami Classification was the most reliable for classifying different stages of OCD of the humeral capitellum. However, it is unclear whether radiographic evidence of OCD of the humeral capitellum, as categorized by the Minami Classification, guides treatment in clinical practice as a result of this fair agreement. (C) 2015 Journal of Shoulder and Elbow Surgery Board of Trustee

Down syndrome: A novel risk factor for respiratory syncytial virus bronchiolitis - A prospective birth-cohort study

OBJECTIVES. Respiratory syncytial virus is the single-most important cause of lower respiratory tract infections in children. Preterm birth and congenital heart disease are known risk factors for severe respiratory syncytial virus infections. Although Down syndrome is associated with a high risk of respiratory tract infections, little is known about the incidence of respiratory syncytial virus infections in this group. The aim of our study was to determine the incidence of respiratory syncytial virus lower respiratory tract infection-associated hospitalization among children with Down syndrome. PATIENTS AND METHODS. We performed a retrospective observational study and a prospective nationwide birth-cohort study of children with Down syndrome. The retrospective cohort comprised 176 children with Down syndrome. A birth cohort of 219 children with Down syndrome was prospectively followed until 2 years of age. All 276 siblings of the birth cohort were used as controls. RESULTS. Of the 395 patients with Down syndrome, 180 (45.6%) had a known risk factor for severe respiratory syncytial virus infections; 39 (9.9%) of these were hospitalized for respiratory syncytial virus lower respiratory tract infections. Two control children (0.7%) versus 9 term children with Down syndrome without congenital heart disease (7.6%) were hospitalized for respiratory syncytial virus lower respiratory tract infections. The median duration of hospitalization was 10 days; mechanical ventilation was required for 5 children (12.8%). CONCLUSIONS. This is the first study, to our knowledge, to demonstrate that Down syndrome is a novel independent risk factor for severe respiratory syncytial virus lower respiratory tract infections. These findings should prompt studies to investigate possible mechanisms that underlie severe respiratory syncytial virus lower respiratory tract infections in children with Down syndrome. The effect of respiratory syncytial virus prophylaxis in this specific population needs to be established

Randomized feasibility trial of the Scleroderma Patient-centered Intervention Network hand exercise program (SPIN-HAND)

Purpose: The Scleroderma Patient-centered Intervention Network (SPIN) online hand exercise program (SPIN-HAND), is an online self-help program of hand exercises designed to improve hand function for people with scleroderma. The objective of this feasibility trial was to evaluate aspects of feasibility for conducting a full-scale randomized controlled trial of the SPIN-HAND program. Materials and Methods: The feasibility trial was embedded in the SPIN cohort and utilized the cohort multiple randomized controlled trial (cmRCT) design. In the cmRCT design, at the time of cohort enrollment, cohort participants consent to be assessed for trial eligibility and randomized prior to being informed about trials conducted using the cohort. When trials were conducted in the cohort, participants randomized to the intervention were informed and consented to access the intervention. Participants randomized to control were not informed that they have not received an intervention. All participants eligible and randomized to participate in the trial were included in analyses on an intent-to-treat basis. Cohort participants with a Cochin Hand Function Scale score ≥ 3/90 and an interest in using an online hand-exercise intervention were randomized (1:1 ratio) to be offered as usual care plus the SPIN-HAND Program or usual care for 3 months. User satisfaction was assessed with semi-structured interviews. Results: Of the 40 randomized participants, 24 were allocated to SPIN-HAND and 16 to usual care. Of 24 participants randomized to be offered SPIN-HAND, 15 (63%) consented to use the program. Usage of SPIN-HAND content among the 15 participants who consented to use the program was low; only five (33%) logged in more than twice. Participants found the content relevant and easy to understand (satisfaction rating 8.5/10, N = 6). Automated eligibility and randomization procedures via the SPIN Cohort platform functioned properly. The required technical support was minimal. Conclusions: Trial methodology functioned as designed, and the SPIN-HAND Program was feasibly delivered; however, the acceptance of the offer and use of program content among accepters were low. Adjustments to information provided to potential participants will be implemented in the full-scale SPIN-HAND trial to attempt to increase offer acceptance