Objective Analysis of Capitellum Exposure for Autologous Osteochondral Reconstruction
Christine Cleora Johnson, MD1; Susanne M Roberts, MD2; Lauren Wessel, MD2; Douglas Mintz, MD2; Peter D Fabricant, MD, MPH2; Robert N Hotchkiss, MD3; Aaron Daluiski, MD4; (1)Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, (2)Hospital for Special Surgery, New York, NY, (3)Hand and Upper Extremity, Hospital for Special Surgery, New York, NY, (4)Hand and Upper Extremity Surgery, Hospital for Special Surgery, New York, NY
The location of capitellar osteochondritis dissecans (OCD) lesions in the sagittal plane guides the surgical approach used for autologous osteochondral transplantation (OATS) procedures. The aim of this cadaveric study was to compare the region of capitellum accessible in the sagittal plane through three commonly used surgical approaches: 1) posterior anconeus-split; 2) lateral without release of the lateral collateral ligament (LCL-preserving lateral approach); and 3) lateral approach with release of the lateral collateral ligament (LCL-sacrificing lateral approach).
Three approaches were sequentially performed on fresh frozen cadaveric upper extremities: posterior anconeus-splitting (n=9), LCL-preserving lateral approach (n=9), and LCL-releasing lateral approach (n=9). For each approach, an OATS harvester was used to demarcate the accessible capitellar region, and the anterior and posterior extents of visualization were marked with Kirschner wires. Each elbow then underwent computed tomography, and the visible surface obtained with each approach was quantified as degrees on the capitellum. Consistent with previous methodology, the 0° axis was defined in relation to the anterior humeral line and capitellum center. Mean extent of anterior, posterior and total arc exposure was calculated for each approach. Repeated measures analysis of variance (RM-ANOVA) with Bonferroni correction was used to determine mean within-specimen, between-approach differences and test for statistical significance. All tests were two-tailed and P=0.05 was used as the threshold for statistical significance.
The LCL-preserving and LCL-sacrificing lateral approaches provided more exposure of the anterior capitellum (mean anterior extent, 0.0 degrees) than the anconeus-split approach (mean anterior extent, 82.6 degrees; p<0.001). The anconeus-split approach provided access to more posterior capitellum (mean posterior extent, 215.0 degrees) than both the LCL-preserving lateral approach (mean, 117.1 degrees, p<0.001) and the LCL-sacrificing lateral approach (mean, 145.0 degrees, p<0.001). The LCL-sacrificing lateral approach allowed for significantly more posterior exposure than the LCL-preserving lateral approach (p<0.001), as shown in Figure 1. The mean arc of visualization was significantly greater for LCL-sacrificing lateral approach (mean, 145.0 degrees) than the LCL-preserving lateral approach (mean, 117.1 degrees; p=0.002), as shown in Figure 2.
The posterior anconeus-splitting approach, the LCL-preserving lateral approach, and the LCL-releasing lateral approach allow variable access to the capitellum for autologous osteochondral reconstruction. Based on these results, posterior lesions may be most accessible through an anconeus-splitting approach, while either lateral approach may provide exposure of anterior-based lesions. This data can inform clinical decisions regarding the appropriate surgical approach for any given OCD lesion based on sagittal lesion location.
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