Clinical Outcome After Arthroscopic

Debridement and Microfracture

for Osteochondritis Dissecans
of the Capitellum
Rens Bexkens,*yz§ MD, Kim I.M. van den Ende,y MD, Paul T. Ogink,§|| MD,
Christiaan J.A. van Bergen,y MD, PhD, Michel P.J. van den Bekerom,{ MD,
and Denise Eygendaal,yz MD, PhD, Prof.
Investigation performed at the Amphia Hospital, Breda, the Netherlands

Background: Various surgical treatment techniques have been developed to treat capitellar osteochondritis dissecans; however,
the optimal technique remains the subject of ongoing debate.
Purpose: To evaluate clinical outcomes after arthroscopic debridement and microfracture for advanced capitellar osteochondritis
dissecans.
Study Design: Case series; Level of evidence, 4.
Methods: Between 2008 and 2015, the authors followed 77 consecutive patients (81 elbows) who underwent arthroscopic
debridement and microfracture, and loose body removal if needed, for advanced capitellar osteochondritis dissecans.
Seventy-one patients (75 elbows) with a minimum follow-up of 1 year were included. The mean age was 16 years (SD, 63.3 years;
range, 11-26 years) and the mean follow-up length was 3.5 years (SD, 61.9 years; range, 1-8.2 years). Based on CT and/or MRI
results, 71 lesions were classified as unstable and 4 as stable. Clinical elbow outcome (pain, function, and social-psychological
effect) was assessed using the Oxford Elbow Score (OES) at final follow-up (OES range, 0-48). Range of motion and return to
sports were recorded. Multivariable linear regression analysis was performed to determine predictors of postoperative OES.
Results: Intraoperatively, there were 3 grade 1 lesions, 2 grade 2 lesions, 10 grade 3 lesions, 1 grade 4 lesion, and 59 grade 5
lesions. The mean postoperative OES was 40.8 (SD, 68.0). An open capitellar physis was a predictor of better elbow outcome
(5.8-point increase; P = .025), as well as loose body removal/grade 4-5 lesions (6.9-point increase; P = .0020) and shorter duration
of preoperative symptoms (1.4-point increase per year; P = .029). Flexion slightly improved from 134° to 139° (P \ .001); exten-
sion deficit slightly improved from 8° to 3° (P \ .001). Pronation (P = .47) and supination did not improve (P = .065). Thirty-seven
patients (55%) returned to their primary sport at the same level, and 5 patients (7%) returned to a lower level. Seventeen patients
(25%) did not return to sport due to elbow-related symptoms, and 10 patients (13%) did not return due to non–elbow-related
reasons. No complications were recorded.
Conclusion: Arthroscopic debridement and microfracture for advanced capitellar osteochondritis dissecans provide good clin-
ical results, especially in patients with open growth plate, loose body removal, and shorter duration of symptoms. However, only
62% of patients in this study returned to sports.
Keywords: osteochondritis dissecans; capitellum; arthroscopy; debridement; microfracture

Osteochondritis dissecans (OCD) of the capitellum is a condi-
tion of the articular cartilage and subchondral bone that typ-
ically affects young gymnasts and overhead athletes such as
baseball and tennis players.1,13,25,30,36 It is hypothesized that
repetitive loading at the relatively poorly vascularized
capitellum leads to this condition.1,25,30,36 In early stages, sta-
ble lesions may cause pain during and after physical
The American Journal of Sports Medicine, Vol. XX, No. X
DOI: 10.1177/0363546517704842
Ó 2017 The Author(s)
activity.1,25,30,36 Advanced (unstable) lesions, in which the
cartilage is detached and loose bodies may have formed,
can lead to severe pain, loss of motion, and locking of the
elbow joint, eventually leading to cessation of sporting activ-
ities.1,25,30,36 Nonoperative treatment is recommended for
early-stage lesions in skeletally immature patients and con-
sists of rest, analgesics, and physical therapy,19,20,33 whereas
surgical treatment is recommended in advanced symptom-
atic lesions.#
#
References 4, 13, 18, 22, 23, 27, 28, 31, 32, 35, 40, 42.

1
2 Bexkens et al The American Journal of Sports Medicine

Figure 1. (A) Coronal view of plain radiograph demonstrating a flattening and radiolucent osteochondritis dissecans (OCD) lesion
in a skeletally immature patient. (B) Sagittal view of magnetic resonance image showing a large OCD lesion with interruption of the
cartilage. (C) Sagittal view of computed tomography (CT) scan demonstrating an OCD lesion. (D) Three-dimensional CT scan
showing an OCD lesion with lateral wall involvement and associated loose bodies.

Over the past 2 decades, several surgical treatment options
have been developed to treat advanced capitellar OCD, includ-
ing arthroscopic debridement and loose body removal with or
without microfracture or drilling,4,5,12,16,22,28,29,42 fragment fix-
ation,8,26,34,35 and osteochondral autologous transplanta-
tion.3,10,11,17,18,24,32,40,41 A paucity of studies have reported on
clinical outcome after arthroscopic debridement and micro-
fracture, and published studies report only small series of
patients.4,16,42
The purpose of this study was to evaluate clinical out-
comes after arthroscopic debridement and microfracture,
and loose body removal if needed, for advanced capitellar
OCD in terms of elbow pain, function, range of motion,
return to sporting activities, and complications.
METHODS
In this retrospective study, we evaluated prospectively col-
lected data of patients who were treated in our institution
between 2008 and 2015. Included in the study were
patients who underwent arthroscopic debridement and
microfracture, and loose body removal if needed, for
advanced capitellar OCD. All patients had failed nonoper-
ative treatment. Excluded were patients with less than 1
year of follow-up. The diagnosis was made based on his-
tory, physical examination, radiographs, and computed
tomography (CT) and/or magnetic resonance imaging
(MRI) (Figure 1). In our orthopaedic practice, a CT scan
was performed to diagnose OCD and to identify potential
(small) loose bodies. Based on preliminary data concerning
25 patients in our cohort (advanced OCD), CT seems to be
the optimal imaging technique to diagnose OCD and to
detect loose bodies.36 In all patients who were referred
from an outside hospital, preoperative imaging (CT or
MRI) had been performed before patients visited our prac-
tice. Additional imaging was ordered if the images from
outside institutions were not conclusive after review.
Debridement and microfracture were indicated if CT dem-
onstrated a fragmented lesion with or without loose bodies
and/or if MRI showed an unstable lesion. No restrictions
were imposed regarding lesion size. All procedures were
either performed or supervised by the senior author (D.E.).
Seventy-seven patients (81 elbows) underwent debride-
ment and microfracture within this time period. Exclusion
of patients with less than 1 year of follow-up resulted in
71 patients (75 elbows) included in this study (93% follow-
up rate). The patients were 41 females (58%) and 30 males
(42%) with a mean age of 16 years (SD, 63.3 years; range,
11-26 years) at the time of surgery. The mean follow-up
length was 3.5 years (SD, 61.9 years; range, 1-8.2 years).
Twenty patients (27%) had previously undergone surgical
treatment for OCD of the capitellum and/or the presence
of intra-articular loose bodies. A summary of patient charac-
teristics and the types of prior surgery is shown in Table 1.
This study was waived for review by the institution–
medical ethics committee of our hospital because data
were collected as part of routine clinical care and patients
had given consent that data would be used for scientific
purposes.

*Address correspondence to Rens Bexkens, MD, Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Har-
vard Medical School, 175 Cambridge Street, Boston, MA 02114, USA (email: rensbexkens@gmail.com)
y
Department of Orthopaedic Surgery, Amphia Hospital, Breda, the Netherlands.
z
Department of Orthopaedic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
§
Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,
USA.
||
Department of Orthopaedic Surgery, Spine Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
{
Department of Orthopaedic Surgery, Shoulder and Elbow Unit, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
AJSM Vol. XX, No. X, XXXX Arthroscopic Debridement and Microfracture for Capitellar OCD 3

TABLE 1 TABLE 2
Patient Characteristics (N = 75 elbows)a Preoperative Imaging Findings (N = 75 elbows)a

Age, y, mean 6 SD 16 6 3.3 Capitellar physis status

Sex Open 12 (16)
Male 30 (42) Closed 63 (84)
Female 41 (58) Radiographic classificationb
Follow-up length, y, mean 6 SD 3.5 6 1.9 Grade 1 20 (27)
Involved side Grade 2 16 (21)
Right 55 (73) Grade 3 24 (32)
Left 20 (27) No abnormalities 15 (20)
Upper limb dominance 57 (76) Fragment stability
Duration of preoperative symptoms, y, 1.5 6 1.4 Stable 4 (5)
mean 6 SD Unstable 71 (95)
Prior surgery 20 (26.5) Lesion area, mm2, mean 6 SD 80.7 6 47.6
Arthroscopic debridement 1 removal of loose 5 (6.7) Lesion depth, mm, mean 6 SD 5.4 6 2.0
body/bodies Lateral wall involvement
Arthroscopic debridement 4 (5.3) Yes 10 (13)
Arthroscopic removal of loose body/bodies 3 (4.0) No 65 (87)
Open debridement 3 (4.0)
a
Open removal of loose body 1 (1.3) Data are provided as n (%) unless otherwise indicated.
b
Debridement through arthroscopy and 1 (1.3) Minami classification.
mini-arthrotomy
Arthroscopic debridement 1 microfracture 1 (1.3)
Open fragment fixation 1 (1.3) the OCD was reviewed in coronal view and was dichotomized
Arthrotomy 1 (1.3) as lateral wall intact or lateral wall not intact.15 A summary
Sporting activities of preoperative imaging findings is shown in Table 2.
Gymnastics 23 (31)
Tennis 10 (13)
Volleyball 4 (5.3) Surgical Technique
Judo 4 (5.3)
Field hockey 4 (5.3) Before surgery, the elbow was routinely examined for stability
Handball 4 (5.3) and range of motion under general anesthesia. Then, the
Water polo 3 (4.0) patient was placed in lateral decubitus position and a tourni-
Baseball 2 (2.8) quet was inflated around the upper arm, after which the ulnar
Others (eg, wall climbing, korfball, motocross, 18 (24) nerve, bony landmarks, and portals were marked. Subse-
among others) quently, 20 mL of saline was injected in the joint from poste-
No sports 3 (4.0) rior into the olecranon fossa.38 Arthroscopy was performed by
a use of 6 portals: 1 proximal anteromedial, 1 proximal antero-
Data are provided as n (%) unless otherwise indicated.
lateral, 2 posterior, and 2 posterolateral (Figure 2). A standard
30° wide-angle scope (5-mm diameter) was used to visualize
Preoperative Imaging the radiocapitellar compartment and address the osteochon-
dral lesion. Loose bodies were removed using a grasper. A
Lesions were preoperatively graded according to the Minami 4.5-mm or 2.5-mm shaver or curette was introduced into the
classification, which is based on anteroposterior plain radio- posterolateral joint space by use of the standard soft-spot or
graphs of the elbow in 45° of flexion.21 Grade 1 lesions posterolateral portal. All unstable cartilage and necrotic
included localized flattening or radiolucency of the capitel- bone were removed. An awl (2-mm diameter) was used to cre-
lum; grade 2 lesions included a clear zone between the lesion ate 4 to 7 microfractures in the subchondral bone, depending
and the adjacent subchondral bone (nondisplaced fragment); on the size of the defect. Postoperative treatment consisted of
and grade 3 lesions included a displaced fragment (loose 24 hours of immobilization in loose dressing, followed by an
body). Capitellar physis status was also based on radio- active program under the supervision of a physical therapist.
graphs: open physis or closed physis. A CT, MRI, or both Axial loading was prohibited for 3 months. Return to sports
were reviewed to evaluate the OCD in greater detail. Based for overhead athletes and gymnasts was allowed after 4
on CT, lesions were considered unstable if the subchondral months. Return to other types of sports was allowed after 3
bone was fragmented along with the presence of loose bodies. months.
Using T2-weighted MRI results, we classified lesions as
unstable if the articular cartilage overlying the lesion was Clinical Evaluation
disrupted or if the capitellar lesion was separated from the
subchondral bone by a high signal intensity line.9,14 Lesion OCD lesions were graded intraoperatively according to the
size was measured in 3 dimensions: the width in coronal Baumgarten et al2 classification. Grade 1 lesions included
and sagittal view and the depth in sagittal view. The lesion smooth, ballotable, articular cartilage; grade 2 lesions
area was defined as the width in coronal view multiplied included fibrillations or fissuring of the articular cartilage;
by the width in sagittal view.16 Lateral wall involvement of grade 3 lesions included exposed bone with a fixed
4 Bexkens et al
Figure 2. A patient’s right elbow showing portal placement for arthroscopic debridement and microfracture in the treatment of
capitellar osteochondritis dissecans. (A) Proximal anteromedial portal (left) and proximal anterolateral portal (right). (B) Two pos-
terior portals. (C) Posterior portal (upper) and posterolateral portal with a shaver (lower). (D) Posterior portal (upper) and postero-
lateral portal with an awl (lower).
osteochondral fragment; grade 4 lesions included a loose
but nondisplaced fragment; and grade 5 lesions included
a displaced fragment with resultant loose bodies. Before
the procedure, elbow stability was tested under general
anesthesia. At final follow-up, patients completed the
Oxford Elbow Score (OES). The OES is a commonly used
12-item measure for the assessment of elbow outcome after
surgical treatment.7 The OES ranges from 0 to 48 points
and comprises the following domains: elbow function,
pain, and social-psychological effect.7 Range of motion
(flexion, extension, pronation, and supination) was either
assessed or supervised by the senior author (D.E.) using
a goniometer, before and after treatment. The ability to
return to sporting activities was divided into 4 categories:
(1) return to primary sport at the same or higher level;
(2) return to primary sport at a lower level; (3) no return
due to symptoms; and (4) no return due to other reasons.
Postoperative complications were recorded, including
hemarthrosis, infection, and nerve injury.
Data Analysis
Baseline characteristics were summarized as absolute num-
ber with frequencies for categorical variables and as means
with standard deviations for continuous variables. Bivariate
and multivariable analyses were performed to investigate
the relation between postoperative OES and the following
variables: sex, age, dominant limb, prior surgery, duration
of preoperative symptoms, capitellar physis status, lesion
area, lesion depth, lateral wall involvement, and intraoper-
ative lesion grade. Despite our relatively large sample size,
lesion grade was dichotomized into 2 groups to ensure
appropriate data analysis: grade 1 to 3 lesions (no loose
body removal) and grade 4 and 5 lesions (loose body
removal). In bivariate analysis, parametric tests were
used for normally distributed variables, and nonparametric
tests were used for nonnormally distributed variables. Var-
iables with a P value of less than .10 were inserted into
a multivariable linear regression model to assess their abil-
ity to explain the variation in OES. A Wilcoxon signed rank
test was performed to detect any significant difference in
The American Journal of Sports Medicine
TABLE 3
Intraoperative Lesion Grade (N = 75 elbows)
Lesion Gradea n (%)
Grade 1 3 (4)
Grade 2 2 (3)
Grade 3 10 (12)
Grade 4 1 (1)
Grade 5 59 (78)
a
Baumgarten et al2 classification.
preoperative and postoperative range of motion. A P value
of less than .05 was considered significant. Statistical anal-
ysis was performed with the use of Stata (StataCorp LP).
RESULTS
Under general anesthesia, 2 patients (3%) had minimal
valgus instability; however, both patients clinically had
no laxity to the medial collateral ligament. At the time of
arthroscopy, the majority of patients (78%) were found to
have a grade 5 lesion. The remaining patients had lesions
that ranged from grade 1 through grade 4 (Table 3).
The mean OES of the total group at final follow-up was
40.8 (SD, 68.0) (Table 4). In bivariate analysis, the following
variables met the criterion (P \ .10) for insertion into the
multivariable linear regression model: age, prior surgery,
duration of preoperative symptoms, capitellar physis status,
and loose body removal (grades 4 and 5). After we controlled
for potential confounders in multivariable analysis, an open
physis (P = .025), loose body removal (P = .0020), and shorter
duration of preoperative symptoms (P = .029) were indepen-
dent predictors of a higher OES score (Table 5). No difference
was found in OES scores between patients who had prior sur-
gery (38.2 6 7.7) and patients who did not have prior surgery
(41.7 6 8.0) (P = .092). Lesion area (P = .60) and lesion depth
(P = .10) did not correlate with OES. Also, no difference was
found between lesions that involved the lateral capitellar
wall (41.1 6 8.0) and lesions without lateral wall involvement
(40.8 6 8.1) (P = .75).
AJSM Vol. XX, No. X, XXXX Arthroscopic Debridement and Microfracture for Capitellar OCD 5

TABLE 4
Clinical Outcome, Range of Motion, and Return to Sporting Activities (N = 75 elbows)

Oxford Elbow Score (0-48), points, mean 6 SD 40.8 6 8.0

Range of motion, deg, mean 6 SD Preoperative Postoperative
Flexion 134 6 9 139 6 6a
Extension deficit 8 6 12 3 6 6a
Pronation 77 6 6 78 6 7
Supination 78 6 6 80 6 5
Return to sports, n (%)b
Return to primary sport at same or higher level 37 (55)
Return to lower level 5 (7)
No return due to elbow symptoms 17 (25)
No return due to other reasons 10 (13)

a
Significant improvement.
b
Patients with no participation in sports were not included in the total of 71 patients.

TABLE 5
Multivariable Linear Regression Analysis: Factors Independently Associated With Oxford Elbow Score (N = 75 elbows)a

Coefficient SE Partial R2 95% CI P Value

Loose body removal (Ref: no) 6.9 2.1 0.13 2.7 to 11 .0020
Physis (Ref: open) –5.8 2.5 0.072 –11 to –0.81 .025
Duration of preoperative symptoms, per 1-mo increase –0.12 0.052 0.067 –0.22 to –0.12 .029
Prior surgery (Ref: no) –2.2 1.9 0.018 –6.1 to 1.7 .26
Age, per 1-y increase 0.15 0.29 0.0039 –0.42 to 0.72 .60

a
Adjusted R2 = 0.2112. Bolded P values indicate statistical significance (P \ .05). CI, confidence interval; SE, standard error.

Preoperative flexion slightly improved from 134° (SD,
69°) to 139° (SD, 66°), resulting in a 5° increase on average
(SD, 6 0°; P \ .001) (Table 4). Preoperative extension deficit
slightly improved from 8° (SD, 612°) to 3° (SD, 66°), result-
ing in a 5° increase on average (SD, 612°; P \ .001). Prona-
tion (P = .47) and supination (P = .065) did not improve.
Thirty-seven patients (55%) returned to their primary sport
at the same or higher level and an additional 5 patients (7%)
returned to a lower level (Table 4). Seventeen patients (25%)
did not return due to elbow-related symptoms, and 10 patients
(13%) did not return due to non–elbow-related reasons, such
as lack of time and changing interests. Of 23 gymnasts
included in this study, 9 (39%) returned to their previous level,
2 returned to a lower level (9%), 8 (35%) did not return due to
elbow complaints, and 4 (17%) did not return due to non–
elbow-related reasons. Among 10 tennis players, 7 players
(70%) returned to their previous level, 1 (10%) returned to
a lower level, and 2 (20%) did not return due to non–elbow-
related reasons. Both baseball players (1 pitcher and 1
catcher) in our cohort returned to previous level of activity.
No postoperative complications such as hemarthrosis,
infection, or persistent nerve injury were noted, although tran-
sient ulnar nerve neurapraxia was seen in 5 patients. To date,
none of the patients have undergone subsequent surgery.
DISCUSSION
This study investigated the clinical outcomes of arthro-
scopic debridement and microfracture in 71 patients (75
elbows) after a mean follow-up length of 3.5 years. Overall,
the patients experienced good results in terms of elbow
pain, function, range of motion, and complications, espe-
cially those with an open capitellar growth plate, those
with loose body removal, and those with a relatively short
duration of preoperative symptoms. However, only 62% of
patients returned to their primary sport, of whom 7%
returned to a lower level.
The findings of this study are in line with the current lit-
erature.4,16,42 Clinical outcomes (pain, function, and social-
psychological effect), as measured with the OES, were satis-
factory with a mean score of 41 points. This is comparable to
findings by Bojanic and colleagues,4 who reported excellent
results in 8 of 9 patients at 5-year follow-up using Mayo
Elbow Performance Index (MEPI) scores. Similar results
were reported by Wulf and colleagues,42 using MEPI and
Timmerman scores in 10 patients, as well as by Lewine
and colleagues,16 who used only Timmerman scores in 21
patients, although it should be noted that 14 of Lewine
and colleagues’ patients underwent drilling instead of
microfracture.
In accordance with previous studies evaluating nonop-
erative and surgical treatment for capitellar OCD,20,32
patients in our group with an open capitellar growth plate
had favorable elbow outcomes compared with skeletally
mature patients (5.6-point OES increase). It is thought
that in these patients, endochondral ossification at the cap-
itellar growth plate may play a role in the healing process
of OCD lesions.20 Also, patients with intra-articular loose
bodies (grades 4 and 5) had greater elbow function than
6 Bexkens et al
patients without (5.8-point OES increase). We hypothesize
that greater elbow function in patients with an OCD and
intra-articular loose bodies is the result of loose body
removal rather than the effect of debridement and micro-
fracture of the OCD.
Lesion size (area and depth) did not correlate with
elbow function, which is consistent with the cohort studied
by Lewine and colleagues.16 However, in contrast to their
findings, we found no relationship between functional out-
come and lateral wall involvement of the OCD. Despite the
satisfactory outcomes in our study, we are in agreement
with prior studies that a more aggressive approach may
be useful in advanced OCDs, especially with regard to
return to sports after treatment.10,11,17,18,23,32,40 Osteo-
chondral autologous transplantation may be indicated in
patients with large (.10 mm), unstable OCDs with lateral
wall involvement as a primary procedure or may be used as
a salvage procedure if primary surgical treatment
(debridement and marrow stimulation) has failed in ath-
letes who desire to return to preinjury or higher level of
activity.10,11,17,18,23,32,40 Further research is needed to
determine the exact influence of lesion size and lateral
wall involvement in the prognosis and treatment of capitel-
lar OCD, which may then potentially aid in surgical deci-
sion making and preoperative planning.
The average duration of preoperative symptoms until first
surgeon visit was 18 months, which is comparable with stud-
ies in the literature.2,16,32 Durations of 12 months16 and 15
months2 have been reported. Takahara and colleagues32
reported an even longer interval (35 months) in a large group
of 106 patients. In our group, longer duration of symptoms
was a predictor of worse elbow outcome (2.4-point OES
decrease per year). Likewise, Lewine and colleagues16
reported that patients with a longer duration of symptoms
were more likely to have mechanical symptoms. This sug-
gests that patients tend to wait before consulting a surgeon
until vague, poorly localized elbow pain gradually worsens
and more severe symptoms occur (decreased motion, locking,
and instability). If these patients present earlier, other treat-
ment options can be offered as an alternative to debridement
and microfracture, including nonoperative treatment19,20 or
fixation.8,26,34,35
As reported in previous studies,4,16,42 range of motion
improved after arthroscopic debridement and microfracture.
Although mean elbow flexion and extension deficit signifi-
cantly improved by 5°, this may not be clinically relevant,
as Vasen and colleagues39 established that functional motion
ranges from 75° to 120° of flexion. Also, preoperative ranges
of motion in patients in our study were greater compared
with 2 studies that reported improved extension deficits of
18° and 12°, which seems clinically relevant.16,42 Findings
similar to those of our study were reported in patients treated
with arthroscopic debridement alone or in combination with
antegrade or retrograde drilling.6,12,22,28,31
In this investigation, we found a slightly lower rate of
return to sport (62%) in comparison to the current litera-
ture,4,16,42 although 14% of our subjects did not return to
their primary sport due to reasons not related to the elbow
(eg, change of interest, lack of time). In the study by Wulf
and colleagues,42 6 of 8 patients (75%) who participated in
The American Journal of Sports Medicine
competitive athletics, including gymnastics and baseball,
returned to the same sport at the same level. Bojanic and
colleagues,4 who also studied a diverse group, reported
a return to sport rate of 67%. Lewine and colleagues16
found a similar rate (67%) in 21 patients. Studies in which
debridement with or without drilling was performed
reported rates ranging from 25% to 85%.2,5,6,12,22,28,29,31
Unfortunately, due to lack of recorded data, we were
unable to statistically investigate the relation between
type and level of sports and the return to sport after treat-
ment, although it seems that tennis players are slightly
more likely to return than gymnasts (70% vs 39%, respec-
tively). Return to sport rates reported in the literature
indicate that debridement with or without marrow stimu-
lation may not be sufficient for the demands of the high-
level overhead athlete or the athlete who performs weight-
bearing activities with the upper extremities (eg, gym-
nasts). This finding should be discussed with the patient,
as well as the possibility for more aggressive treatment
(osteochondral autologous transplantation).10,11,18,40
The absence of permanent postoperative complications
in this study is comparable with findings of previously pub-
lished studies.4,16,42 Like our study, Bojanic and col-
leagues4 and Wulf and colleagues42 reported no revisions
in their series. In contrast, Lewine and colleagues16
reported revision surgery in 4 patients, including chondro-
plasty and loose body removal. Similar rates have been
found in simple arthroscopic debridement.22,29,31
The strengths of this study include a large number of
patients and subjective (Oxford Elbow Score) as well as
objective outcome measures (preoperative and postoperative
range of motion). However, this study has some limitations.
First, this study lacks preoperative assessment of subjective
elbow function. Second, some patients were lost to follow-up,
although a follow-up rate of 93% is acceptable. Third, this
study did not evaluate postoperative imaging findings,
where progression of osteoarthritis is a long-term concern
after surgical treatment. Fourth, there was no control group
to compare the intervention with other techniques.
CONCLUSION
Arthroscopic debridement and microfracture for advanced
capitellar osteochondritis dissecans provide good clinical
results in terms of pain, function, range of motion, and
complications, especially in patients with an open growth
plate, loose body removal, and shorter duration of symp-
toms. However, as only 62% of our patients returned to
their primary sport, a more aggressive approach may be
needed for high-level athletes who desire to return to pre-
injury level. Long-term outcome studies are required to
demonstrate whether good clinical outcomes of arthro-
scopic debridement and microfracture are maintained.
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