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1
Department of Orthopaedic Surgery, Yamagata University School of Medicine,
Iida-Nishi 2, Yamagata City, 990-9585 Japan.
2
Department of Radiology, Hokkaido University School of Medicine, Kita 15,
Nishi 7, Sapporo City, 060-8638 Japan.
Received March 29, 1999;
accepted after revision July 7, 1999.
Address correspondence to M. Takahara.
Abstract
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SUBJECTS AND METHODS. Twenty-seven patients with capitellar osteochondritis dissecans (27 males; range, 11-20 years; mean age, 14 years) underwent radiography and sonography performed with a 7.5-MHz mechanical sector probe. Lesions were assessed as stable or unstable. The sonographic assessment was compared with radiographic assessment in 27 patients, MR assessment obtained in 10, and surgical findings in 15.
RESULTS. Sonographic assessment agreed with radiographic assessment in 23 of the 27 patients, MR assessment in nine of the 10, and surgical findings in 14 of the 15. Sonography revealed that two lesions, which had been underestimated on radiography, were unstable.
CONCLUSION. Sonography facilitates the assessment of capitellar lesions so that treatment can be optimized.
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Few studies have reported on the assessment of osteochondritis dissecans using sonography. Gregersen and Rasmussen [7] reported that sonography showed fragmentation of the subchondral bone in patients with osteochondritis dissecans of the knee, and it enabled assessment of osteochondral fragments and the condition of the overlying articular cartilage. Bruns and Lüssenhop [8] obtained sonograms of loose bodies in elbow joints, and recently Frankel et al. [9] suggested that sonography was effective for detecting intraarticular bodies. However, we are not aware of any reports addressing whether sonography enables the observer to distinguish between stable and unstable lesions. The aim of this study was to determine the efficacy of sonography for assessing osteochondritis dissecans of the capitellum.
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The examination began with the patient supine and the elbow fully extended in the anterior longitudinal view. In the posterior longitudinal view, the elbow was fully flexed to obtain a sufficient view of the anterior aspect of the capitellum (Fig. 1A). The anterior longitudinal view showed the proximal and middle parts of the anterior capitellum, and the posterior longitudinal view showed the middle and distal parts. The capitellum was closely observed from the anterior to the lateral sections by moving the probe. In the posterior longitudinal view, dynamic scanning was performed with elbow motion (Fig. 1A, 1B).
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Ten of the patients also underwent MR imaging, which was performed using a 1.5-T magnet (Magnetom H15; Siemens, Erlangen, Germany). Coronal and sagittal T1-weighted spin-echo images and sagittal T2*-weighted gradient-echo images were obtained. Patients gave informed consent after the nature of the procedures had been fully explained, and the Declaration of Helsinki principles [12] were followed.
The capitellar lesions were assessed as either stable or unstable (Figs. 2A, 2B, 2C, 2D, 3A, 3B, 3C, 3D, 3E, 4A, 4B, 4C, 4D). When imaging showed that the fragment had become displaced or separated from the underlying capitellar bony floor, the lesion was assessed as unstable [13, 14]. When imaging showed a nondisplaced fragment in the capitellar subchondral bone, the lesion was assessed as stable. If radiography showed localized capitellar bony flattening without any loosened fragment, and if sonography showed localized capitellar bony flattening and an intact overlying articular cartilage, the lesion was assessed as stable [11]. When T2*-weighted images showed MR findings of instability, such as a high-signal-intensity interface beneath the lesion, a high-signal-intensity line through the articular cartilage, or a focal articular defect, the capitellar lesion was assessed as unstable [4, 5, 6]. However, a lesion was assessed as stable when T2*-weighted images showed no evidence of instability despite the presence of a low-signal-intensity area in the capitellum on T1-weighted images [11].
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In general, stable lesions were treated conservatively and unstable lesions surgically. In the surgical cases, a macroscopic assessment of lesion stability was made.
The following analyses were performed. First, sonographic assessment was compared with the radiographic assessment in each patient. Second, for the patients treated surgically, image assessment was compared with the surgical findings. Third, using the surgical or MR assessment as a gold standard, agreement of sonographic assessment in determining lesion stability was calculated.
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When either radiography or sonography showed unstable findings, the lesion was assessed as unstable. These criteria indicated that seven lesions were stable and 20 unstable. The seven patients with a stable lesion were treated conservatively. Among the 20 patients with an unstable lesion, 15 underwent surgery within a few months after examination and five did not.
The 15 lesions treated surgically were confirmed macroscopically to be unstable: 11 lesions had an unstable and displaced fragment that was still attached to the underlying capitellar bony floor, and four had a capitellar osteochondral defect with a completely loosened fragment. Radiographic assessment agreed with the surgical findings in 13 of the 15 cases; two lesions were underestimated radiographically. Sonographic assessment agreed with the surgical findings in 14 of the 15; one lesion was underestimated on sonography. MR assessment agreed with the surgical findings in six of six cases.
Twelve lesions were treated nonoperatively, and of these, only four were assessed by MR imaging. MR imaging revealed that three lesions were stable and one was unstable, although sonography depicted all four lesions as stable.
In determining lesion stability, sonographic results agreed with the surgical or MR gold standard in 17 (89%) of 19 cases, and radiographic results agreed in 16 (84%) of 19 cases. However, eight cases were excluded from this investigation because surgical or MR assessment was not performed.
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This study is the first to our knowledge to compare sonographic assessment of osteochondritis dissecans of the capitellum with radiographic and MR assessments and surgical findings. Sonographic assessment agreed with radiographic assessment in 23 of 27 patients, with MR assessment in nine of 10, and with surgical findings in 14 of 15. Sonographic results in determining lesion stability agreed with surgical or MR assessment in 17 (89%) of 19 cases. These results show that sonography is useful for assessing osteochondritis dissecans of the capitellum. In this study, the scanner operators were aware of the patients' clinical histories, physical examination findings, and radiographic assessments. Therefore, we recommend sonography as an additional means of assessing osteochondritis dissecans of the capitellum.
Obvious findings of osteochondritis dissecans have commonly been obtained by viewing the anterolateral aspect of the capitellum, because this area is the most commonly affected by osteochondritis dissecans [13]. Because stable osteochondritis dissecans initially affects a small area [11], close observation of the anterolateral aspect of the capitellum is essential. Such early lesions were well visualized in the anterior longitudinal view (Fig. 3B).
Sonography showed nondisplaced and slightly displaced fragments as double high-echogenic areas in the capitellar subchondral bone (Figs. 3C and 3D). When the fragment had completely separated from the underlying bone, the osteochondral defect was usually observed in the capitellum (Fig. 3E). Because this kind of defect often appears to be repaired with fibrocartilaginous tissue, sonography shows the hypoechoic structure at the surface of the defect. Such an osteochondral defect must be distinguished from a stable lesion. The outline of the cartilaginous tissue is irregular in unstable lesions (Figs. 3E and 7A), whereas it is almost intact in stable lesions. The free bone fragment was detected as a highly echoic fragment overlying the intact subchondral bone (Fig. 7B); however, detecting the missing bone fragment was sometimes difficult using sonography alone. To avoid missing the free fragment, sonography should be performed carefully around the elbow joint after the scanner operators know the patients' clinical histories, physical examination findings, and radiographic assessments.
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Sonography can provide dynamic images and visualize both the subchondral bone and the overlying articular cartilage simultaneously. In addition, sonography can show a cartilage-rich fragment that has little or no osseous content [9]. However, we found that the images of the articular cartilage were sometimes obscure, because they were subject to interference from the effects of reactive synovitis (Fig. 3D). In addition, sonography cannot provide sufficient images of the capitellum in cases associated with elbow joint contracture. Therefore, in patients with such severe synovitis or contracture, MR imaging should be used to obtain more information [4, 5, 6].
In this study, we classified lesions with a nondisplaced fragment as stable. However, for lesions with a nondisplaced fragment, good results were not obtained by nonoperative treatment [13, 14]. Our results suggest that these lesions can be either stable or unstable. Therefore, the criteria we used in this study should be modified: When radiography or sonography shows a nondisplaced fragment, the stability is not established. For lesions with a nondisplaced fragment, we recommend the use of MR imaging to assess the stability of the lesion precisely [4, 5, 6, 11]. The correlation between classification and clinical outcome remains to be determined.
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