with CD. My discloser is Zimra Bahmet, Acumed. It's interesting, if you look at where a lot of the OCD literature comes from, it comes from Asia, particularly Japan. In this study, looking at the incidence, I thought it was actually very interesting, about 2% over one year time period. And interesting, only 35% of players reported elbow pain. So this is an Ultratown study. So 35% of the patients are pre-injury. In other words, you can identify the lesion, but they don't have pain yet. And I think in the end, that's where we need to intervene on our patients. They do ultrasound on a lot of their young players. What happens over time with surgery, without surgery, 23 years, 13 years, there are some permanent changes to that elbow. It's not such a benign condition in majority of our patients. If you look at how many heal with non-operative treatment, and these tend to be the stage one and stage two lesions, about 50%. So I talk to the parents of these young players. I say that if it's a stage one or stage two, we've got a pretty good chance, about half the time, I say it's half the glass is half full, for activity restriction and getting these patients healed, but over an eight-month period of time. It's not three months. It's not quite a year, but it's a long time, and the parents need to understand that. Well, Professor Awosaki, who's done a lot of the work on this, is one of the first over in Asia to use osteochondral autographs and show that this can be a very successful technique, and we've adopted that in this country for many of our patients. Dave Roush at Duke was one of the first to, along with Dr. Byrd, to look at arthroscopic treatment of the OCD lesion and showing with significant debridement, not drilling, many of these patients are satisfied and happy. Now, we all know OATs can be fun. You go down on the knee. I use my knee colleagues to get the graft. I put the plugs in. It looks kind of nice. It's a fun thing, but complications can occur, and at my hospital, we see a lot of elbows referred for unusual surgery, and this is an example of one of those. A 14-year-old elsewhere, failed treatment, had a large lesion, underwent plugs, then comes in to see me about a year later looking like this, the radial head not looking good, the capitelum not looking good, and had surgery. This is his motion. It's just got a jog of motion. That's his flexion extension, and we got in there. You can see the OATs kind of proud. The plugs are kind of proud, as you can see there, and we did restore motion to his elbow, but it required resection of his radial head and an extensive release of the elbow joint itself, but as elbows tend to go, one year later, he's better, but not perfect. He's pleased, much better than he was when he came in, so I think arthroscopy overall can be a safer, earlier intervention for the OCD lesion. This is a good case. This is actually the worst you could possibly see. This is avascular necrosis in a young lady, kind of a super OCD lesion, just to show what you can do if most of the capitelum is gone. This is a 27-year-old, already had her prior elbow scoped. When I saw her in clinic, she had just two little holes, and she was stiff, and you can look at her x-rays and CT scan. You can see there probably wasn't much of a debridement the year before, so I did a very extensive debridement. You get in there, you can see just like a huge OCD lesion lifting off of the capitelum. Cleaned it up, extensive debridement, and at one week, you can see her motion. As I do most of the patients, start them on early, quick motion, and the young kids, they come in with a slight flexor contraction. You take out that painful lesion. They lose that flexor contraction, so I stop doing a capsule release, and most of the 12-year-olds, I usually get it back by playing, and she kept her motion also at one-year follow-up, and she's about three years now, and she says by email that she's continuing to keep her motion going. So this example, the worst OCD lesion supposedly you could see. So we look at some newer portals for exposure back home to make it a little bit more orthogonal. When you're looking at the lesion itself, you can see an example of how we do this. Coming up under the ankinas, you're looking right at the lesion itself, and then you can bring in your shaver, your curette, and do a very extensive debridement of the lesion itself to get down to a firm, stable edge, and I'm very aggressive about this. After I do the shaving part, I'll bring in a curette to make sure I curette a very stable cartilage edge. I don't want to leave any flap of cartilage that, you know, questionable, so I'm doing a very aggressive debridement of that for these patients. Here's an example. There's a 14-year-old man with a large lesion. Again, no history of trauma, but on the older side, these are the patients that we tend to have less successful results with non-operative treatment. You can see a large. It's a centralized lesion, which I think is great, because these are the ones that I think I'm very unlikely to do an OATS procedure on, and I would always do an arthroscopic debridement first, and you can see using the distal ulnar portal to make it more orthogonal and looking right at the lesion. I do a very aggressive debridement. In this case, with microfracture, I'm not sure what that really adds, but I don't think it hurts the patient. It's fun. We let the tourniquet down to see the blood stream into the defect itself. So this patient I actually saw five years later for his shoulder. He's an athlete. He had no elbow complaints, and I didn't get a CT scan, but I think you get a sense that it's filled in a little bit over the past five years, and he had no complaints about his elbow at all. Here's another case. I think this is a good one, because I was talking to Mark Cohen who does a lot of elbow down at Rush. This is a 14-year-old quarterback, again, the older patient, and has a lateralized lesion. These are the ones that we're sort of hinted at or we think maybe we should do an OATS procedure on, a very significant large lateral lesion. He didn't. He did a very extensive debridement, just as I do of this lesion, getting to a very stable edge of cartilage, and he was a little nervous about how this patient would do. He came back to see him at eight years. He had completed football at the University of Minnesota and was considering entering the NFL draft. He was just getting a checkup, but he had zero elbow complaints, eight years following that extensive lateral debridement, which is the one that we're not supposed to think would work necessarily arthroscopically. So I think that we're not really sure exactly who the best candidates are, but my sense is arthroscopy first in most of these patients. Here's another one of my patients. Look at that. That's a very lateral lesion, and this patient did well with an extensive aggressive debridement to stable cartilage rim. You can see the radial head down below from that portal view. If you look at the follow-up on a CT from the Netherlands on these patients, the defect size decreased after arthroscopy, but it's interesting, the CT findings did not correlate the size, location, did not correlate with clinical outcomes. So I think there's still a lot we're learning about this. And the morbidity of taking in oats, about 12% of the patients that Andreas Imhof had in Munich had unsatisfactory or very unsatisfactory results, so over 10% of attacking that knee, you may have some issues down the line, not in the elbow, but in the knee. So it's interesting, I was talking to Dr. Szabo recently, a large series, 72 patients taking a costal osteochondral autograph, which would avoid the issues in the knee, and he had excellent results, no chest complications, but I have heard of this technique requiring a little tube in your chest after you're done. So looking also at a large series of 75 elbows, also from the Netherlands, longer duration of symptoms, and again, there was no correlation, just as I've seen in my practice, between outcome and lateral wall involvement. Now this is only two baseball players, a ladder gymnast and tennis players, but again, no complications with an arthroscopic technique. So in conclusion, I think the best treatment is prevention and early detection, and what they're doing in Japan, and the baseball players are doing an ultrasound examination of these players, and identifying the lesion early before it becomes a painful lesion, and intervene at that point, because we know in the stage one lesions, it's at least 50% or greater than 50% activity modification and rest, and you'll solve the problems, almost like Pander's disease. But I think arthroscopic debridement is an effective treatment, very effective for the partial or loose lesions, but there's excellent data, most of it from Japan, that autograft transplantation is shown to be very effective for the larger lesions. Thank you very much.

osteochondritis dissecans

elbow

incidence

treatment

ultrasound examination