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Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans... Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 DOI 10.1007/s00167-017-4516-8 ELBOW Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis 1,2 1 2 2,3,4 Rens Bexkens  · Paul T. Ogink  · Job N. Doornberg  · Gino M. M. J. Kerkhoffs  · 2,5 1 6 Denise Eygendaal  · Luke S. Oh  · Michel P. J. van den Bekerom   Received: 16 November 2016 / Accepted: 6 March 2017 / Published online: 8 April 2017 © The Author(s) 2017. This article is an open access publication Abstract Results Eleven studies including 190 patients were Purpose To determine the rate of donor-site morbidity included. In eight studies, grafts were harvested from the after osteochondral autologous transplantation (OATS) for femoral condyle, in three studies, from either the 5th or 6th capitellar osteochondritis dissecans. costal-osteochondral junction. The average number of grafts Methods A literature search was performed in PubMed/ was 2 (1–5); graft diameter ranged from 2.6 to 11  mm. In MEDLINE, Embase, and Cochrane Library to identify the knee-to-elbow group, donor-site morbidity was reported studies up to November 6, 2016. Criteria for inclusion were in 10 of 128 patients (7.8%), knee pain during activity (7.0%) OATS for capitellar osteochondritis dissecans, reported and locking sensations (0.8%). In the rib-to-elbow group, outcomes related to donor sites, ≥10 patients, ≥1 year one of 62 cases (1.6%) was complicated, a pneumothorax. follow-up, and written in English. Donor-site morbidity The proportion in the knee-to-elbow group was 0.04 (95% was defined as persistent symptoms (≥1 year) or cases that CI 0.0–0.15), and the proportion in the rib-to-elbow group required subsequent intervention. Patient and harvest char- was 0.01 (95% CI 0.00–0.06). There were no significant dif- acteristics were described, as well as the rate of donor-site ferences between both harvest techniques (n.s.). morbidity. A random effects model was used to calculate Conclusions Donor-site morbidity after OATS for capi- and compare weighted group proportions. tellar osteochondritis dissecans was reported in a consider- able group of patients. Level of evidence Level IV, systematic review of level IV studies. Electronic supplementary material The online version of this article (doi:10.1007/s00167-017-4516-8) contains supplementary material, which is available to authorized users. Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Harvard Medical * Rens Bexkens School, 175 Cambridge Street, Boston, MA 02114, USA rensbexkens@gmail.com Department of Orthopaedic Surgery, Academic Medical Paul T. Ogink Center, University of Amsterdam, Meibergdreef 9, ptogink@gmail.com 1105 AZ Amsterdam, The Netherlands Job N. Doornberg Academic Center for Evidence based Sports medicine doornberg@traumaplatform.org (ACES), Amsterdam, The Netherlands Gino M. M. J. Kerkhoffs Amsterdam Collaboration for Health and Safety in Sports g.m.kerkhoffs@amc.uva.nl (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, Denise Eygendaal The Netherlands deygendaal@amphia.nl Department of Orthopaedic Surgery, Amphia Hospital, Luke S. Oh Molengracht 21, 4818 CK Breda, The Netherlands loh@mgh.harvard.edu Department of Orthopaedic Surgery, Shoulder and Elbow Michel P. J. van den Bekerom Unit, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, bekerom@gmail.com 1091 AC, Amsterdam, The Netherlands Vol.:(0123456789) 1 3 2238 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 Keywords Osteochondritis dissecans · Capitellum · Graft relevant in surgical decision making, as well as it is essen- harvesting · Osteochondral autologous transplantation · tial to be able to counsel patients about the risk for possible Knee · Donor-site morbidity. donor-site effects. To our knowledge, the risk of donor-site morbidity after OATS in this particular population is still unknown. Introduction The purpose of this study was to determine the rate of donor-site morbidity following osteochondral autologous Osteochondritis dissecans (OCD) of the capitellum is a transplantation for capitellar osteochondritis dissecans. The disorder of the subchondral bone and articular cartilage hypothesis op the study was that there would be no dif- [3, 23, 32]. This condition is primarily seen in teenagers ference in the proportion of donor-site morbidity between engaged in sporting activities in which the elbow is repeti- graft harvesting from the femoral condyle or costal-osteo- tively exposed to extensive valgus forces, such as baseball chondral junction. and gymnastics [3, 23, 32]. In early phases, a stable capitel- lar OCD may cause pain and effusion, while in advanced stages, the OCD may become unstable and cause locking, Materials and methods restricted range of motion, and instability [3, 23, 32]. Sta- ble OCD may initially be treated nonoperatively with activ- Protocol ity modification and physical therapy [17, 18], whereas unstable lesions require operative treatment. Several surgi- The findings of this systematic review were reported cal options have been developed over the past two decades according to the Preferred Reporting Items for Systematic including arthroscopic debridement with or without mar- Review and Meta-Analyses (PRISMA) guidelines [14]. row stimulation [13, 26, 29], fragment fixation [7, 10, 31], and osteochondral autologous transplantation (OATS) [15, Selection criteria 16, 24, 33]. OATS has become a popular treatment option for large, Studies that met the following inclusion criteria were unstable lesions (diameter > 10  mm) with lateral wall included: (1) osteochondral autologous transplantation for involvement, as well as also for athletes without an accept- capitellar OCD, (2) reported outcomes related to the donor able outcome after less invasive techniques [8, 15, 22, 24]. site, (3) minimum inclusion of 10 patients, (4) minimum In OATS, a single or multiple osteochondral grafts are follow-up of one year, and (5) written in English. Case harvested from either the less-weight-bearing parts of the reports, reviews, and cadaveric studies were excluded. femoral condyle [8, 11, 15, 24] or the costal-osteochondral Donor-site morbidity was defined as the presence of persis- junction [22, 30]. The cylindrical donor plug consisting tent symptoms (≥1 year) after graft harvesting, as well as of hyaline cartilage and subchondral bone is then trans- the need for subsequent intervention to treat complications planted into the defect area to restore the integrity of the related to the donor site. articular surface of the capitellum. A major disadvantage of this procedure is the need to harvest one or multiple grafts Search strategy from an asymptomatic knee or the rib area in an adoles- cent athlete and thus the risk for morbidity at the donor A literature search was performed in the following data- site [2, 12, 27]. Recently, a review conducted by Andrade bases up to November 6, 2016: PubMed/MEDLINE, et  al. reported knee donor-site morbidity rates of 17% and Embase, and the Cochrane Library. The PubMed/MED- 6% for ankle and knee mosaicplasty procedures, respec- LINE search strategy was adjusted into similar search strat- tively [2]. In contrast, two studies involving adolescent egies for other databases (Online Appendix  1). Reference athletes who underwent OATS for OCD of the capitellum lists of retrieved studies were manually searched for addi- found no adverse effects related to the donor site [9, 35]. tional studies potentially meeting the inclusion criteria. Interestingly, Weigelt et  al. reported substantial donor-site morbidity in eight of 14 patients treated for capitellar OCD Study selection [33]. The vast majority of patients with capitellar OCD are high-demand athletes who are younger than patients Study selection was independently performed by two with knee and ankle OCD [2, 9]. Also, as opposed to knee authors. First, title and abstract were screened to identify and ankle OCD, grafts have been harvested from both the potentially relevant papers (R.B. and P.O.). These results femoral condyle and costal-osteochondral junction in the were verified by two senior authors (L.O. and M.v.d.B.). treatment of capitellar OCD [9, 30]. Knowing the overall Subsequently, manuscripts were retrieved when title or risk for donor-site morbidity following capitellar OATS is abstract revealed insufficient information to determine the 1 3 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 2239 appropriateness for inclusion. Disagreement was resolved used to calculate weighted group proportions for each har- by discussion or with arbitration when necessary by the vest technique, and to compare proportions between the senior authors (L.O. and M.v.d.B.) when differences two techniques [19, 34]. A p value <0.05 was considered remained. significant. Statistical analyses were performed with the use of Stata 13.0 (College Station, TX, USA). Data extraction The main outcome of interest was the presence or absence Results of donor-site morbidity (persistent symptoms or need for subsequent intervention) after capitellar OATS. The fol- Population and harvest characteristics lowing data were extracted from each study: author names, year of publication, patient demographics, follow-up time, A detailed summary of patient and harvest characteristics harvest method, graft characteristics, and the use of fill- for each study is given in Table  1. A total of 11 studies ers. The following outcomes related to the donor site were including 190 patients met the criteria after careful sys- extracted: symptoms (e.g., pain, locking, and instability), tematic selection (Fig. 1) [9, 11, 15, 16, 21, 22, 24, 28, 30, physical examination (e.g., effusion and range of motion), 33, 35]. The mean age across the selected studies was 15 complications (e.g., infection, nerve injury, or subse- years (range, 14–18), and the mean follow-up length was quent treatment), patient reported outcome scores, imag- 37 months (range, 22–84). ing evaluation [e.g., radiographs, computed tomography, The knee served as the donor site in 128 patients across or magnetic resonance imaging (MRI)], and anatomic and eight studies (Table  1) [9, 11, 15, 16, 21, 24, 33, 35]. The histological outcomes. Data extraction was independently average number of grafts harvested was 2 (range 1–5) performed by two authors (R.B. and P.O.) and verified by [9, 16, 21, 33, 35], and graft diameter ranged from 2.6 two senior authors (L.O. and M.v.d.B.). Articles were not to 11  mm [9, 16, 21, 33, 35]. In 62 patients across three blinded for author, affiliation, and source. studies, either the 5th or 6th costal-osteochondral junction served as the harvest site [22, 28, 30]. Either one or two Methodological quality assessment grafts were harvested for each patient [22, 28, 30]. Two authors (R.B. and P.O.) independently judged the Donor-site morbidity methodological quality of included studies using the check- list for quality appraisal of case series studies that was A detailed summary of donor-site effects per study is given developed at the Institute of Health Economics (IHE) [5, in Table 2. In the knee-to-elbow group, donor-site morbid- 20]. Each of the 20 criteria of the checklist were answered ity after capitellar OATS was reported in 10 of 128 patients, with either ‘yes,’ ‘no,’ or ‘partial’ or ‘unclear.’ For esti- resulting in a donor-site morbidity rate of 7.8%. Knee pain mating the risk of bias for each study, ‘partial’ responses while stair climbing and heavy lifting were reported in nine were considered ‘yes,’ and ‘unclear’ responses were con- patients (7.0%) and locking sensations in one patient (0.8%) sidered ‘no.’ A study with 0–2 ‘no’ responses was consid- (Table  2) [9, 16, 33]. In the rib-to-elbow group, donor-site ered to have a low risk of bias, 3–5 ‘no’ responses a moder- morbidity was reported in one of 62 patients, resulting in ate risk, 6–8 ‘no’ responses a high risk, and 9 or more ‘no’ a donor-site morbidity rate of 1.6%. One case was com- responses a very high risk of bias. In case of disagreement, plicated by a pneumothorax due to damage to the costal two senior authors (L.O. and M.v.d.B.) were involved to pleura, which required insertion of a chest tube [30]. solve the differences. The proportion of donor-site morbidity in the knee-to- elbow group was 0.04 (95% CI 0.0–0.15), and the propor- Statistical analysis tion in the rib-to-elbow group was 0.01 (95% CI 0.00–0.06) (Fig.  2). There was no significant difference between the Categorical data were displayed as absolute numbers with two harvest techniques in terms of proportion of donor-site frequencies; continuous data were displayed as means with morbidity (p > 0.05). sample range. The main outcomes of interest were the rate of donor- Methodological quality site morbidity within the knee-to-elbow group and rib-to- elbow group. Proportions of donor-site morbidity were The results of methodological quality assessment of indi- calculated for each study using the Freeman-Tukey dou- vidual studies using the IHE scale are presented in Table 3. ble arcsine transformation. Subsequently, a random effects According to the criteria of the IHE checklist for critical model, to account for heterogeneity across studies, was appraisal of case series studies, the estimated potential 1 3 2240 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 1 3 Table 1 Patient and harvest characteristics Author Year No. of patients Age, years Follow- Harvest method Donor site Side No. of grafts Graft diameter, mm Graft depth, mm Use of fillers up, months Knee-to-elbow osteochondral autologous transplantation (N = 128)  Yamamoto 2006 18 14 42 Arthroscopy Lateral intercondy- – 1–3 5–9 10 No lar notch or lateral side of the PF joint  Iwasaki 2007 11 14 26 Arthrotomy Superolateral FC Contralateral 3.4 (2–5) 2.6–6.0 10–15 Bone wax  Ovesen 2011 10 18 30 Arthrotomy Superolateral FC Ipsilateral – – – No  Nishimura 2011 12 14 34 – Superolateral FC Contralateral 2.1 (1–3) 6–8 – Bone graft from capitellum  Kosaka 2013 19 14 59 – None-weight bear- – – – – No ing areas FC  Maruyama 2014 33 14 28 Arthrotomy Superolateral FC Ipsilateral 1.8 (1–3) 7 (5–9) 14 (9–20) No Weigelt 2015 14 18 84 Arthrotomy Superolateral FC Ipsilateral 1 8–11 – No  Lyons 2015 11 15 23 Arthrotomy Lateral trochlear Ipsilateral – – – Tru-Fit plug if diam- ridge FC eter > 10 mm or 2 × 8 mm Rib-to-elbow Osteochondral Autologous Transplantation (N = 62)  Sato 2008 14 16 22 Open 5th/6th costal-osteo- Ipsilateral 1–2 – – No chondral junction  Shimada 2012 26 16 36 Open 5th/6th costal-osteo- Ipsilateral 1–1.5 – 18 No chondral junction  Nishinaka 2014 22 14 27 Open 6th costal-osteo- ‘Right side’ – – 20 No chondral junction PF patellofemoral, FC femoral condyle Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 2241 Fig. 1 Flowchart of search strategy following PRISMA (preferred reporting items for systematic reviews and meta- analyses) guidelines risk of bias was low for one study [21], moderate for nine significant difference in proportion of donor-site morbid- studies [9, 11, 15, 16, 22, 24, 30, 33, 35], and high for one ity between the two harvest techniques. The findings of this study [28]. Solely ‘no’ responses were awarded to question systematic review emphasize the importance of associated 3 and 11, which are related to the patient recruitment pro- donor-site morbidity following graft harvesting in the treat- cess and blinding of outcome assessors, respectively. Here, ment of capitellar OCD. no study recruited patients from multiple centers, nor was The rate of donor-site morbidity in our study is com- outcome assessment blinded. Three more questions, also parable to the morbidity rate after knee-to-knee OATS related to outcome measures (10, measures established (6%), as reported by Andrade et  al. [2]. Interestingly, the a priori; 12, appropriateness of measures; 13, before and authors reported a higher rate after knee-to-ankle OATS after intervention measured), were awarded with ‘no’ or (17%) [32]. The higher rate compared to our findings may ‘partial’ responses in more than half of the included stud- be the result of more grafts that were harvested (three ver- ies. By contrast, most criteria with regard to the study aim sus two) [2], although the influence of the number of grafts (question 1), study population (question 5–7), intervention on morbidity is controversial [1, 2, 25, 27]. Patient charac- (question 8), statistical analysis (question 14), results/con- teristics may have played a role as well. The vast majority clusions (question 15–19), and sources of support (question of patients in our study were adolescent (15 years), high- 20) were awarded a ‘yes’ response. demanding athletes, while patients with talar OCD are typi- cally older (32 years [25]). We hypothesized that patients in our study may have been in a better physical condition Discussion before treatment, and therefore faster recovery with less donor-site effects may be expected. The most important finding of the present study is that In the present study, the rate of donor-site morbidity donor-site morbidity after osteochondral autologous trans- ranged from 0 to 57% in studies in whom grafts were har- plantation for capitellar osteochondritis dissecans occurred vested from the knee. Weigelt et  al. reported morbidity in in 7.8% within the knee-to-elbow group and 1.6% within eight of 14 patients (57%): occasional pain during heavy the rib-to-elbow group. In the knee-to-elbow group, knee lifting in seven patients and intermittent locking sensations pain during daily activities (7.0%) and locking sensa- in one patient [33]. The advanced age after a relative long tions (0.8%) were reported; in the rib-to-elbow group, one follow-up (7 years) may be the reason for more morbidity, case was complicated by a pneumothorax. There was no as well as it may be the result of large grafts (8–11  mm) 1 3 2242 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 Table 2 Donor-site effects after osteochondral autologous transplantation for capitellar osteochondritis dissecans Author Complications Physical examination Patient reported outcomes Imaging Knee-to-elbow osteochondral autologous transplantation (N = 128)  Yamamoto No No effusion No pain –  Iwasaki No Effusion up to 5 weeks in 8 pts Lysholm 99.6 (range 96–100), MRI: 50–100% defect fill in 6 pts (mean: 3 weeks); full range of IKDC normal, 1 pt had knee (67%), normal signals in 4 pts motion; thigh and calf girth pain with stair climbing at final at donor sites (44%), effusion in 100% follow-up 1 pt, no subchondral edema or hypertrophic changes at donor site  Ovesen No – No pain –  Nishimura No No effusion at 3 months; 80% Lysholm 100 at 6 months; Visual Radiographs: absence of osteoar- muscle strength at 6 months, Analog Scale 0 at 3 months; thritis at 2 years 11 pts regained strength at 100% return to sports without 1 year any donor knee disturbances  Kosaka No – ‘None of the donor knees which – were removed of osteocartilagi- nous tissues experienced nega- tive effects’  Maruyama No Full range of motion Lysholm 99.8; 1 pt had mild ante- – rior knee pain during exercise  Weigelt No – Lysholm 90.9; 7 patients occa- – sional pain during lifting, 1 locking sensations  Lyons No – ‘No complaints regarding the – donor knee at final follow-up’ Rib-to-elbow osteochondral autologous transplantation (N = 62)  Sato No – 2–3 days pain postoperatively; – no complaints during athletic activities  Shimada Pneumothorax, Hard scar tissue Few days pain postoperatively Radiographs: subperiostal bone resolved after tube formation in some pts insertion  Nishinaka No – No pain or symptoms – IKDC International Knee Documentation Committee, MRI magnetic resonance imaging, pt patient that were harvested [1, 2, 25, 27]. Two included studies Three studies that were included in this review harvested focused on donor-site effects in particular [9, 21]. Despite grafts from either the 5th or 6th costal-osteochondral junc- encouraging clinical results reported by Iwasaki et al., MRI tion to repair capitellar OCD [22, 28, 30]. Although hard evaluation revealed alterations in signal intensity in 89% of scar tissue was detected in palpation, radiographs showed donor sites, suggesting fibrous filling of donor holes [9]. new subperiostal bone formation and no long-term symp- Long-term follow-up is needed to see if these changes in toms were observed [30]. However, harvesting grafts from signal intensity are permanent and clinically meaningful. the rib area is a technically demanding procedure that has Nishimura et  al. found a delay in recovery of quadriceps been described by only a few studies. Most surgeons who muscle strength [21]. This indicates that even if symptoms perform capitellar OATS are more familiar with knee anat- may resolve quickly after harvesting, the donor knee is at omy rather than rib anatomy. Moreover, risk for devastating risk for injury due to muscle weakness within the first year. donor-site morbidity remains as harvesting may be com- Three studies attempted to prevent postoperative bleed- plicated by a pneumothorax due to close proximity to the ing by filling donor tunnels [9, 15, 21]. As included stud- costal pleura, which may lead to a prolonged hospital stay ies were limited by small case series, potential beneficial [30]. If familiar with this technique, this may be an option effects remain unclear. Favorable results have been reported in the treatment of large capitellar OCDs (>15  mm). As using synthetic implants in repair of knee OCD [4, 6], large lesions usually require multiple cylindrical grafts, one although literature lacks large sample comparison studies. may want to avoid the risk for donor-site morbidity of the knee. 1 3 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 2243 unable to investigate associations between morbidity and harvest characteristics including donor-site location and the size or number of grafts. Second, included studies are limited by case series with small numbers of patients because capitellar OCD is a rare condition in the general population, and capitellar OATS is a relatively new pro- cedure. Third, after pooling the data of included stud- ies, we found no significant difference between the pro- portions of donor-site morbidity for the knee-to-elbow group and the rib-to-elbow group (p > 0.05). One may argue whether it is valid to combine study data because of between-study variance; however, we attempted to alleviate statistical heterogeneity with the use of a ran- dom effects model. This model has been used previously in systematic reviews who pooled data from case series studies [19, 34]. Future studies should comprehensively evaluate effects related to the donor site. Patient’s symptoms and physical examination should be reported for each patient. Addi- tionally, the use of a patient reported outcome measure Fig. 2 Forest plot analysis demonstrating donor-site morbidity pro- to assess knee function should be a routine part of clini- portions after capitellar osteochondral autologous transplantation. The proportion of donor-site morbidity in the knee-to-elbow group cal evaluation, both preoperatively and postoperatively. was 0.04 (95% CI 0.0–0.15), and the proportion in the rib-to-elbow Radiographs should be performed to evaluate potential group was 0.01 (95% CI 0.0–0.06). There was no difference between progression to osteoarthritis at 1 year and may be per- harvest techniques in terms of proportion of donor-site morbidity formed in cases in which donor fillers were used. MRI (n.s.) evaluation should, because of cost-effectiveness reasons, only be ordered in case of persistent symptoms. Besides Using the IHE scale to evaluate the methodological the evaluation of donor-site effects, harvest character - quality of included studies [5, 20], the estimated poten- istics should be reported in great detail, such as donor tial risk of bias ranged from low to high, with the major- location, number of grafts, graft diameter, and depth. ity of studies found to be of moderate risk of bias (9 of Also, alternative harvest methods should be investigated 11). Studies scored the lowest on criteria related to out- to have no longer the need to violate the integrity of an come measures, as well as on the fact that cases were asymptomatic knee or rib in an adolescent athlete. collected in a single center in each study. Therefore, The findings of the present investigation demonstrate a the findings of this systematic review should be inter - considerable risk for donor-site morbidity following capi- preted by taking into account some limitations. First, a tellar OATS. Although good-to-excellent results related to major limitation is the incomplete reporting regarding the elbow have been reported after capitellar OATS, sur- outcomes related to the donor site. As physical examina- geons should be aware of the risk for donor-site morbidity tion or imaging was rarely thoroughly reported, studies and patients should be counseled about this issue. Knowing lack objective assessment of donor-site effects. Addition- the overall risk for donor-site morbidity is also relevant in ally, subjective assessment of knee function by means of surgical decision making. Taking this into consideration, patient reported outcome measures was only performed surgeons could consider other resurfacing techniques such in four of eight studies (Lysholm score) [9, 16, 21, 33]. as allografting or autologous chondrocyte transplantation. In the remaining studies, no attempt was made to evaluate knee function, nor was physical examination thoroughly described [11, 15, 24, 35], as this was also the case in two rib-to-elbow studies [22, 28]. Also, in none of the Conclusions included studies, either subjective or objective preopera- tive assessment of the donor site was reported. As data Osteochondral autologous transplantation in the treat- were obtained from studies that evaluated donor-site ment of capitellar osteochondritis dissecans may lead to effects in varying degrees, we hypothesized that donor- donor-site morbidity in a considerable group of patients, site morbidity may be substantially underreported in this either after harvesting from the femoral condyle (7.8%) population. Also, due to incomplete reporting, we were or costal-osteochondral junction (1.6%). 1 3 2244 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 1 3 Table 3 Quality assessment of case series studies using the quality appraisal checklist of the institute of health economics (IHE) Yamamoto Iwasaki Ovesen Nishimura Kosaka Maruyama Weigelt Lyons Sato Shimada Nishinaka 1. Was the hypothesis/aim/objective of the study clearly stated? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 2. Was the study conducted prospectively? Unclear No Unclear Yes No Unclear No No Unclear No Unclear 3. Were the cases collected in more than one centre? No No No No No No No No No No No 4. Were patients recruited consecutively? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 5. Were the characteristics of the patients included in the study Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes described? 6. Were the eligibility criteria (inclusion and exclusion criteria) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes for entry into the study clearly stated? 7. Did patients enter the study at a similar point in the disease? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 8. Was the intervention of interest clearly described? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 9. Were additional interventions (co-interventions) clearly Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes described? 10. Were relevant outcome measures established a priori? Partial Yes Partial Yes Yes Yes Yes Partial Partial Partial Partial 11. Were outcome assessors blinded to the intervention that No No No No No No No No No No No patients received? 12. Were the relevant outcomes measured using appropriate Partial Yes Partial Yes Partial Yes Partial Partial Partial Yes Partial objective/subjective methods? 13. Were the relevant outcome measures made before and after No Partial No Partial No Partial No No No No No the intervention? 14. Were the statistical tests used to assess the relevant outcomes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes appropriate? 15. Was follow-up long enough for important events and out- Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes comes to occur? 16. Were losses to follow-up reported? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 17. Did the study provided estimates of random variability in the Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes data analysis of relevant outcomes? 18. Were the adverse events reported? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 19. Were the conclusions of the study supported by results? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 20. Were both competing interests and sources of support for the Yes Yes Yes Yes Yes Yes No Yes No Yes Yes study reported? Overall risk of bias Moderate Moderate Moderate Low Moderate Moderate Moderate Moderate High Moderate Moderate Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 2245 Acknowledgements The authors would like to thank Roos Steen- mosaicplasty for cartilaginous lesions of the elbow joint. Am J huis, medical librarian of the Onze Lieve Vrouwe Gasthuis, for the Sports Med 35:2096–2100 assistance in performing the literature search. 10. Koehler SM, Walsh A, Lovy AJ, Pruzansky JS, Shukla DR, Hausman MR (2015) Outcomes of arthroscopic treatment of Compliance with ethical standards osteochondritis dissecans of the capitellum and description of the technique. J Shoulder Elbow Surg 24:1607–1612 11. Kosaka M, Nakase J, Takahashi R, Toratani T, Ohashi Y, Kita- Conflict of interest R. Bexkens, P.T. Ogink, J.N. Doornberg, oka K, Tsuchiya H (2013) Outcomes and failure factors in sur- G.M.M.J. Kerkhoffs, D. Eygendaal, L.S. Oh, and M.P.J. van den Bek - gical treatment for osteochondritis dissecans of the capitellum. erom declare that they have no conflict of interest. J Pediatr Orthop 33:719–724 12. LaPrade RF, Botker JC (2004) Donor-site morbidity after Funding There was no outside funding or grants received that osteochondral autograft transfer procedures. Arthroscopy assisted in this study. 20:e69–e73 13. Lewine EB, Miller PE, Micheli LJ, Waters PM, Bae DS (2015) IRB/medical ethics committee Review was not needed for this Early Results of Drilling and/or Microfracture for Grade IV study since it is a systematic review. Osteochondritis Dissecans of the Capitellum. J Pediatr Orthop 36:803–809 14. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Disclaimers None. 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Am J Sports Med 34:714–720 for elbow osteochondritis dissecans in teenaged baseball players. J Shoulder Elb Surg 24:1749–1756 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Knee Surgery Sports Traumatology Arthroscopy Unpaywall

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis

Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis

Abstract

Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 DOI 10.1007/s00167-017-4516-8 ELBOW Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis 1,2 1 2 2,3,4 Rens Bexkens  · Paul T. Ogink  · Job N. Doornberg  · Gino M. M. J. Kerkhoffs  · 2,5 1 6 Denise Eygendaal  · Luke S. Oh  · Michel P. J. van den Bekerom   Received: 16 November 2016 / Accepted: 6 March 2017 / Published online: 8 April 2017 © The Author(s) 2017. This article is an open access publication Abstract Results Eleven studies including 190 patients were Purpose To determine the rate of donor-site morbidity included. In eight studies, grafts were harvested from the after osteochondral autologous transplantation (OATS) for femoral condyle, in three studies, from either the 5th or 6th capitellar osteochondritis dissecans. costal-osteochondral junction. The average number of grafts Methods A literature search was performed in PubMed/ was 2 (1–5); graft diameter ranged from 2.6 to 11  mm. In MEDLINE, Embase, and Cochrane Library to identify the knee-to-elbow group, donor-site morbidity was reported studies up to November 6, 2016. Criteria for inclusion were in 10 of 128 patients (7.8%), knee pain during activity (7.0%) OATS for capitellar osteochondritis dissecans, reported and locking sensations (0.8%). In the rib-to-elbow group, outcomes related to donor sites, ≥10 patients, ≥1 year

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Abstract

Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 DOI 10.1007/s00167-017-4516-8 ELBOW Donor-site morbidity after osteochondral autologous transplantation for osteochondritis dissecans of the capitellum: a systematic review and meta-analysis 1,2 1 2 2,3,4 Rens Bexkens  · Paul T. Ogink  · Job N. Doornberg  · Gino M. M. J. Kerkhoffs  · 2,5 1 6 Denise Eygendaal  · Luke S. Oh  · Michel P. J. van den Bekerom   Received: 16 November 2016 / Accepted: 6 March 2017 / Published online: 8 April 2017 © The Author(s) 2017. This article is an open access publication Abstract Results Eleven studies including 190 patients were Purpose To determine the rate of donor-site morbidity included. In eight studies, grafts were harvested from the after osteochondral autologous transplantation (OATS) for femoral condyle, in three studies, from either the 5th or 6th capitellar osteochondritis dissecans. costal-osteochondral junction. The average number of grafts Methods A literature search was performed in PubMed/ was 2 (1–5); graft diameter ranged from 2.6 to 11  mm. In MEDLINE, Embase, and Cochrane Library to identify the knee-to-elbow group, donor-site morbidity was reported studies up to November 6, 2016. Criteria for inclusion were in 10 of 128 patients (7.8%), knee pain during activity (7.0%) OATS for capitellar osteochondritis dissecans, reported and locking sensations (0.8%). In the rib-to-elbow group, outcomes related to donor sites, ≥10 patients, ≥1 year one of 62 cases (1.6%) was complicated, a pneumothorax. follow-up, and written in English. Donor-site morbidity The proportion in the knee-to-elbow group was 0.04 (95% was defined as persistent symptoms (≥1 year) or cases that CI 0.0–0.15), and the proportion in the rib-to-elbow group required subsequent intervention. Patient and harvest char- was 0.01 (95% CI 0.00–0.06). There were no significant dif- acteristics were described, as well as the rate of donor-site ferences between both harvest techniques (n.s.). morbidity. A random effects model was used to calculate Conclusions Donor-site morbidity after OATS for capi- and compare weighted group proportions. tellar osteochondritis dissecans was reported in a consider- able group of patients. Level of evidence Level IV, systematic review of level IV studies. Electronic supplementary material The online version of this article (doi:10.1007/s00167-017-4516-8) contains supplementary material, which is available to authorized users. Department of Orthopaedic Surgery, Sports Medicine Service, Massachusetts General Hospital, Harvard Medical * Rens Bexkens School, 175 Cambridge Street, Boston, MA 02114, USA rensbexkens@gmail.com Department of Orthopaedic Surgery, Academic Medical Paul T. Ogink Center, University of Amsterdam, Meibergdreef 9, ptogink@gmail.com 1105 AZ Amsterdam, The Netherlands Job N. Doornberg Academic Center for Evidence based Sports medicine doornberg@traumaplatform.org (ACES), Amsterdam, The Netherlands Gino M. M. J. Kerkhoffs Amsterdam Collaboration for Health and Safety in Sports g.m.kerkhoffs@amc.uva.nl (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, Denise Eygendaal The Netherlands deygendaal@amphia.nl Department of Orthopaedic Surgery, Amphia Hospital, Luke S. Oh Molengracht 21, 4818 CK Breda, The Netherlands loh@mgh.harvard.edu Department of Orthopaedic Surgery, Shoulder and Elbow Michel P. J. van den Bekerom Unit, Onze Lieve Vrouwe Gasthuis, Oosterpark 9, bekerom@gmail.com 1091 AC, Amsterdam, The Netherlands Vol.:(0123456789) 1 3 2238 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 Keywords Osteochondritis dissecans · Capitellum · Graft relevant in surgical decision making, as well as it is essen- harvesting · Osteochondral autologous transplantation · tial to be able to counsel patients about the risk for possible Knee · Donor-site morbidity. donor-site effects. To our knowledge, the risk of donor-site morbidity after OATS in this particular population is still unknown. Introduction The purpose of this study was to determine the rate of donor-site morbidity following osteochondral autologous Osteochondritis dissecans (OCD) of the capitellum is a transplantation for capitellar osteochondritis dissecans. The disorder of the subchondral bone and articular cartilage hypothesis op the study was that there would be no dif- [3, 23, 32]. This condition is primarily seen in teenagers ference in the proportion of donor-site morbidity between engaged in sporting activities in which the elbow is repeti- graft harvesting from the femoral condyle or costal-osteo- tively exposed to extensive valgus forces, such as baseball chondral junction. and gymnastics [3, 23, 32]. In early phases, a stable capitel- lar OCD may cause pain and effusion, while in advanced stages, the OCD may become unstable and cause locking, Materials and methods restricted range of motion, and instability [3, 23, 32]. Sta- ble OCD may initially be treated nonoperatively with activ- Protocol ity modification and physical therapy [17, 18], whereas unstable lesions require operative treatment. Several surgi- The findings of this systematic review were reported cal options have been developed over the past two decades according to the Preferred Reporting Items for Systematic including arthroscopic debridement with or without mar- Review and Meta-Analyses (PRISMA) guidelines [14]. row stimulation [13, 26, 29], fragment fixation [7, 10, 31], and osteochondral autologous transplantation (OATS) [15, Selection criteria 16, 24, 33]. OATS has become a popular treatment option for large, Studies that met the following inclusion criteria were unstable lesions (diameter > 10  mm) with lateral wall included: (1) osteochondral autologous transplantation for involvement, as well as also for athletes without an accept- capitellar OCD, (2) reported outcomes related to the donor able outcome after less invasive techniques [8, 15, 22, 24]. site, (3) minimum inclusion of 10 patients, (4) minimum In OATS, a single or multiple osteochondral grafts are follow-up of one year, and (5) written in English. Case harvested from either the less-weight-bearing parts of the reports, reviews, and cadaveric studies were excluded. femoral condyle [8, 11, 15, 24] or the costal-osteochondral Donor-site morbidity was defined as the presence of persis- junction [22, 30]. The cylindrical donor plug consisting tent symptoms (≥1 year) after graft harvesting, as well as of hyaline cartilage and subchondral bone is then trans- the need for subsequent intervention to treat complications planted into the defect area to restore the integrity of the related to the donor site. articular surface of the capitellum. A major disadvantage of this procedure is the need to harvest one or multiple grafts Search strategy from an asymptomatic knee or the rib area in an adoles- cent athlete and thus the risk for morbidity at the donor A literature search was performed in the following data- site [2, 12, 27]. Recently, a review conducted by Andrade bases up to November 6, 2016: PubMed/MEDLINE, et  al. reported knee donor-site morbidity rates of 17% and Embase, and the Cochrane Library. The PubMed/MED- 6% for ankle and knee mosaicplasty procedures, respec- LINE search strategy was adjusted into similar search strat- tively [2]. In contrast, two studies involving adolescent egies for other databases (Online Appendix  1). Reference athletes who underwent OATS for OCD of the capitellum lists of retrieved studies were manually searched for addi- found no adverse effects related to the donor site [9, 35]. tional studies potentially meeting the inclusion criteria. Interestingly, Weigelt et  al. reported substantial donor-site morbidity in eight of 14 patients treated for capitellar OCD Study selection [33]. The vast majority of patients with capitellar OCD are high-demand athletes who are younger than patients Study selection was independently performed by two with knee and ankle OCD [2, 9]. Also, as opposed to knee authors. First, title and abstract were screened to identify and ankle OCD, grafts have been harvested from both the potentially relevant papers (R.B. and P.O.). These results femoral condyle and costal-osteochondral junction in the were verified by two senior authors (L.O. and M.v.d.B.). treatment of capitellar OCD [9, 30]. Knowing the overall Subsequently, manuscripts were retrieved when title or risk for donor-site morbidity following capitellar OATS is abstract revealed insufficient information to determine the 1 3 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 2239 appropriateness for inclusion. Disagreement was resolved used to calculate weighted group proportions for each har- by discussion or with arbitration when necessary by the vest technique, and to compare proportions between the senior authors (L.O. and M.v.d.B.) when differences two techniques [19, 34]. A p value <0.05 was considered remained. significant. Statistical analyses were performed with the use of Stata 13.0 (College Station, TX, USA). Data extraction The main outcome of interest was the presence or absence Results of donor-site morbidity (persistent symptoms or need for subsequent intervention) after capitellar OATS. The fol- Population and harvest characteristics lowing data were extracted from each study: author names, year of publication, patient demographics, follow-up time, A detailed summary of patient and harvest characteristics harvest method, graft characteristics, and the use of fill- for each study is given in Table  1. A total of 11 studies ers. The following outcomes related to the donor site were including 190 patients met the criteria after careful sys- extracted: symptoms (e.g., pain, locking, and instability), tematic selection (Fig. 1) [9, 11, 15, 16, 21, 22, 24, 28, 30, physical examination (e.g., effusion and range of motion), 33, 35]. The mean age across the selected studies was 15 complications (e.g., infection, nerve injury, or subse- years (range, 14–18), and the mean follow-up length was quent treatment), patient reported outcome scores, imag- 37 months (range, 22–84). ing evaluation [e.g., radiographs, computed tomography, The knee served as the donor site in 128 patients across or magnetic resonance imaging (MRI)], and anatomic and eight studies (Table  1) [9, 11, 15, 16, 21, 24, 33, 35]. The histological outcomes. Data extraction was independently average number of grafts harvested was 2 (range 1–5) performed by two authors (R.B. and P.O.) and verified by [9, 16, 21, 33, 35], and graft diameter ranged from 2.6 two senior authors (L.O. and M.v.d.B.). Articles were not to 11  mm [9, 16, 21, 33, 35]. In 62 patients across three blinded for author, affiliation, and source. studies, either the 5th or 6th costal-osteochondral junction served as the harvest site [22, 28, 30]. Either one or two Methodological quality assessment grafts were harvested for each patient [22, 28, 30]. Two authors (R.B. and P.O.) independently judged the Donor-site morbidity methodological quality of included studies using the check- list for quality appraisal of case series studies that was A detailed summary of donor-site effects per study is given developed at the Institute of Health Economics (IHE) [5, in Table 2. In the knee-to-elbow group, donor-site morbid- 20]. Each of the 20 criteria of the checklist were answered ity after capitellar OATS was reported in 10 of 128 patients, with either ‘yes,’ ‘no,’ or ‘partial’ or ‘unclear.’ For esti- resulting in a donor-site morbidity rate of 7.8%. Knee pain mating the risk of bias for each study, ‘partial’ responses while stair climbing and heavy lifting were reported in nine were considered ‘yes,’ and ‘unclear’ responses were con- patients (7.0%) and locking sensations in one patient (0.8%) sidered ‘no.’ A study with 0–2 ‘no’ responses was consid- (Table  2) [9, 16, 33]. In the rib-to-elbow group, donor-site ered to have a low risk of bias, 3–5 ‘no’ responses a moder- morbidity was reported in one of 62 patients, resulting in ate risk, 6–8 ‘no’ responses a high risk, and 9 or more ‘no’ a donor-site morbidity rate of 1.6%. One case was com- responses a very high risk of bias. In case of disagreement, plicated by a pneumothorax due to damage to the costal two senior authors (L.O. and M.v.d.B.) were involved to pleura, which required insertion of a chest tube [30]. solve the differences. The proportion of donor-site morbidity in the knee-to- elbow group was 0.04 (95% CI 0.0–0.15), and the propor- Statistical analysis tion in the rib-to-elbow group was 0.01 (95% CI 0.00–0.06) (Fig.  2). There was no significant difference between the Categorical data were displayed as absolute numbers with two harvest techniques in terms of proportion of donor-site frequencies; continuous data were displayed as means with morbidity (p > 0.05). sample range. The main outcomes of interest were the rate of donor- Methodological quality site morbidity within the knee-to-elbow group and rib-to- elbow group. Proportions of donor-site morbidity were The results of methodological quality assessment of indi- calculated for each study using the Freeman-Tukey dou- vidual studies using the IHE scale are presented in Table 3. ble arcsine transformation. Subsequently, a random effects According to the criteria of the IHE checklist for critical model, to account for heterogeneity across studies, was appraisal of case series studies, the estimated potential 1 3 2240 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 1 3 Table 1 Patient and harvest characteristics Author Year No. of patients Age, years Follow- Harvest method Donor site Side No. of grafts Graft diameter, mm Graft depth, mm Use of fillers up, months Knee-to-elbow osteochondral autologous transplantation (N = 128)  Yamamoto 2006 18 14 42 Arthroscopy Lateral intercondy- – 1–3 5–9 10 No lar notch or lateral side of the PF joint  Iwasaki 2007 11 14 26 Arthrotomy Superolateral FC Contralateral 3.4 (2–5) 2.6–6.0 10–15 Bone wax  Ovesen 2011 10 18 30 Arthrotomy Superolateral FC Ipsilateral – – – No  Nishimura 2011 12 14 34 – Superolateral FC Contralateral 2.1 (1–3) 6–8 – Bone graft from capitellum  Kosaka 2013 19 14 59 – None-weight bear- – – – – No ing areas FC  Maruyama 2014 33 14 28 Arthrotomy Superolateral FC Ipsilateral 1.8 (1–3) 7 (5–9) 14 (9–20) No Weigelt 2015 14 18 84 Arthrotomy Superolateral FC Ipsilateral 1 8–11 – No  Lyons 2015 11 15 23 Arthrotomy Lateral trochlear Ipsilateral – – – Tru-Fit plug if diam- ridge FC eter > 10 mm or 2 × 8 mm Rib-to-elbow Osteochondral Autologous Transplantation (N = 62)  Sato 2008 14 16 22 Open 5th/6th costal-osteo- Ipsilateral 1–2 – – No chondral junction  Shimada 2012 26 16 36 Open 5th/6th costal-osteo- Ipsilateral 1–1.5 – 18 No chondral junction  Nishinaka 2014 22 14 27 Open 6th costal-osteo- ‘Right side’ – – 20 No chondral junction PF patellofemoral, FC femoral condyle Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 2241 Fig. 1 Flowchart of search strategy following PRISMA (preferred reporting items for systematic reviews and meta- analyses) guidelines risk of bias was low for one study [21], moderate for nine significant difference in proportion of donor-site morbid- studies [9, 11, 15, 16, 22, 24, 30, 33, 35], and high for one ity between the two harvest techniques. The findings of this study [28]. Solely ‘no’ responses were awarded to question systematic review emphasize the importance of associated 3 and 11, which are related to the patient recruitment pro- donor-site morbidity following graft harvesting in the treat- cess and blinding of outcome assessors, respectively. Here, ment of capitellar OCD. no study recruited patients from multiple centers, nor was The rate of donor-site morbidity in our study is com- outcome assessment blinded. Three more questions, also parable to the morbidity rate after knee-to-knee OATS related to outcome measures (10, measures established (6%), as reported by Andrade et  al. [2]. Interestingly, the a priori; 12, appropriateness of measures; 13, before and authors reported a higher rate after knee-to-ankle OATS after intervention measured), were awarded with ‘no’ or (17%) [32]. The higher rate compared to our findings may ‘partial’ responses in more than half of the included stud- be the result of more grafts that were harvested (three ver- ies. By contrast, most criteria with regard to the study aim sus two) [2], although the influence of the number of grafts (question 1), study population (question 5–7), intervention on morbidity is controversial [1, 2, 25, 27]. Patient charac- (question 8), statistical analysis (question 14), results/con- teristics may have played a role as well. The vast majority clusions (question 15–19), and sources of support (question of patients in our study were adolescent (15 years), high- 20) were awarded a ‘yes’ response. demanding athletes, while patients with talar OCD are typi- cally older (32 years [25]). We hypothesized that patients in our study may have been in a better physical condition Discussion before treatment, and therefore faster recovery with less donor-site effects may be expected. The most important finding of the present study is that In the present study, the rate of donor-site morbidity donor-site morbidity after osteochondral autologous trans- ranged from 0 to 57% in studies in whom grafts were har- plantation for capitellar osteochondritis dissecans occurred vested from the knee. Weigelt et  al. reported morbidity in in 7.8% within the knee-to-elbow group and 1.6% within eight of 14 patients (57%): occasional pain during heavy the rib-to-elbow group. In the knee-to-elbow group, knee lifting in seven patients and intermittent locking sensations pain during daily activities (7.0%) and locking sensa- in one patient [33]. The advanced age after a relative long tions (0.8%) were reported; in the rib-to-elbow group, one follow-up (7 years) may be the reason for more morbidity, case was complicated by a pneumothorax. There was no as well as it may be the result of large grafts (8–11  mm) 1 3 2242 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 Table 2 Donor-site effects after osteochondral autologous transplantation for capitellar osteochondritis dissecans Author Complications Physical examination Patient reported outcomes Imaging Knee-to-elbow osteochondral autologous transplantation (N = 128)  Yamamoto No No effusion No pain –  Iwasaki No Effusion up to 5 weeks in 8 pts Lysholm 99.6 (range 96–100), MRI: 50–100% defect fill in 6 pts (mean: 3 weeks); full range of IKDC normal, 1 pt had knee (67%), normal signals in 4 pts motion; thigh and calf girth pain with stair climbing at final at donor sites (44%), effusion in 100% follow-up 1 pt, no subchondral edema or hypertrophic changes at donor site  Ovesen No – No pain –  Nishimura No No effusion at 3 months; 80% Lysholm 100 at 6 months; Visual Radiographs: absence of osteoar- muscle strength at 6 months, Analog Scale 0 at 3 months; thritis at 2 years 11 pts regained strength at 100% return to sports without 1 year any donor knee disturbances  Kosaka No – ‘None of the donor knees which – were removed of osteocartilagi- nous tissues experienced nega- tive effects’  Maruyama No Full range of motion Lysholm 99.8; 1 pt had mild ante- – rior knee pain during exercise  Weigelt No – Lysholm 90.9; 7 patients occa- – sional pain during lifting, 1 locking sensations  Lyons No – ‘No complaints regarding the – donor knee at final follow-up’ Rib-to-elbow osteochondral autologous transplantation (N = 62)  Sato No – 2–3 days pain postoperatively; – no complaints during athletic activities  Shimada Pneumothorax, Hard scar tissue Few days pain postoperatively Radiographs: subperiostal bone resolved after tube formation in some pts insertion  Nishinaka No – No pain or symptoms – IKDC International Knee Documentation Committee, MRI magnetic resonance imaging, pt patient that were harvested [1, 2, 25, 27]. Two included studies Three studies that were included in this review harvested focused on donor-site effects in particular [9, 21]. Despite grafts from either the 5th or 6th costal-osteochondral junc- encouraging clinical results reported by Iwasaki et al., MRI tion to repair capitellar OCD [22, 28, 30]. Although hard evaluation revealed alterations in signal intensity in 89% of scar tissue was detected in palpation, radiographs showed donor sites, suggesting fibrous filling of donor holes [9]. new subperiostal bone formation and no long-term symp- Long-term follow-up is needed to see if these changes in toms were observed [30]. However, harvesting grafts from signal intensity are permanent and clinically meaningful. the rib area is a technically demanding procedure that has Nishimura et  al. found a delay in recovery of quadriceps been described by only a few studies. Most surgeons who muscle strength [21]. This indicates that even if symptoms perform capitellar OATS are more familiar with knee anat- may resolve quickly after harvesting, the donor knee is at omy rather than rib anatomy. Moreover, risk for devastating risk for injury due to muscle weakness within the first year. donor-site morbidity remains as harvesting may be com- Three studies attempted to prevent postoperative bleed- plicated by a pneumothorax due to close proximity to the ing by filling donor tunnels [9, 15, 21]. As included stud- costal pleura, which may lead to a prolonged hospital stay ies were limited by small case series, potential beneficial [30]. If familiar with this technique, this may be an option effects remain unclear. Favorable results have been reported in the treatment of large capitellar OCDs (>15  mm). As using synthetic implants in repair of knee OCD [4, 6], large lesions usually require multiple cylindrical grafts, one although literature lacks large sample comparison studies. may want to avoid the risk for donor-site morbidity of the knee. 1 3 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 2243 unable to investigate associations between morbidity and harvest characteristics including donor-site location and the size or number of grafts. Second, included studies are limited by case series with small numbers of patients because capitellar OCD is a rare condition in the general population, and capitellar OATS is a relatively new pro- cedure. Third, after pooling the data of included stud- ies, we found no significant difference between the pro- portions of donor-site morbidity for the knee-to-elbow group and the rib-to-elbow group (p > 0.05). One may argue whether it is valid to combine study data because of between-study variance; however, we attempted to alleviate statistical heterogeneity with the use of a ran- dom effects model. This model has been used previously in systematic reviews who pooled data from case series studies [19, 34]. Future studies should comprehensively evaluate effects related to the donor site. Patient’s symptoms and physical examination should be reported for each patient. Addi- tionally, the use of a patient reported outcome measure Fig. 2 Forest plot analysis demonstrating donor-site morbidity pro- to assess knee function should be a routine part of clini- portions after capitellar osteochondral autologous transplantation. The proportion of donor-site morbidity in the knee-to-elbow group cal evaluation, both preoperatively and postoperatively. was 0.04 (95% CI 0.0–0.15), and the proportion in the rib-to-elbow Radiographs should be performed to evaluate potential group was 0.01 (95% CI 0.0–0.06). There was no difference between progression to osteoarthritis at 1 year and may be per- harvest techniques in terms of proportion of donor-site morbidity formed in cases in which donor fillers were used. MRI (n.s.) evaluation should, because of cost-effectiveness reasons, only be ordered in case of persistent symptoms. Besides Using the IHE scale to evaluate the methodological the evaluation of donor-site effects, harvest character - quality of included studies [5, 20], the estimated poten- istics should be reported in great detail, such as donor tial risk of bias ranged from low to high, with the major- location, number of grafts, graft diameter, and depth. ity of studies found to be of moderate risk of bias (9 of Also, alternative harvest methods should be investigated 11). Studies scored the lowest on criteria related to out- to have no longer the need to violate the integrity of an come measures, as well as on the fact that cases were asymptomatic knee or rib in an adolescent athlete. collected in a single center in each study. Therefore, The findings of the present investigation demonstrate a the findings of this systematic review should be inter - considerable risk for donor-site morbidity following capi- preted by taking into account some limitations. First, a tellar OATS. Although good-to-excellent results related to major limitation is the incomplete reporting regarding the elbow have been reported after capitellar OATS, sur- outcomes related to the donor site. As physical examina- geons should be aware of the risk for donor-site morbidity tion or imaging was rarely thoroughly reported, studies and patients should be counseled about this issue. Knowing lack objective assessment of donor-site effects. Addition- the overall risk for donor-site morbidity is also relevant in ally, subjective assessment of knee function by means of surgical decision making. Taking this into consideration, patient reported outcome measures was only performed surgeons could consider other resurfacing techniques such in four of eight studies (Lysholm score) [9, 16, 21, 33]. as allografting or autologous chondrocyte transplantation. In the remaining studies, no attempt was made to evaluate knee function, nor was physical examination thoroughly described [11, 15, 24, 35], as this was also the case in two rib-to-elbow studies [22, 28]. Also, in none of the Conclusions included studies, either subjective or objective preopera- tive assessment of the donor site was reported. As data Osteochondral autologous transplantation in the treat- were obtained from studies that evaluated donor-site ment of capitellar osteochondritis dissecans may lead to effects in varying degrees, we hypothesized that donor- donor-site morbidity in a considerable group of patients, site morbidity may be substantially underreported in this either after harvesting from the femoral condyle (7.8%) population. Also, due to incomplete reporting, we were or costal-osteochondral junction (1.6%). 1 3 2244 Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 1 3 Table 3 Quality assessment of case series studies using the quality appraisal checklist of the institute of health economics (IHE) Yamamoto Iwasaki Ovesen Nishimura Kosaka Maruyama Weigelt Lyons Sato Shimada Nishinaka 1. Was the hypothesis/aim/objective of the study clearly stated? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 2. Was the study conducted prospectively? Unclear No Unclear Yes No Unclear No No Unclear No Unclear 3. Were the cases collected in more than one centre? No No No No No No No No No No No 4. Were patients recruited consecutively? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 5. Were the characteristics of the patients included in the study Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes described? 6. Were the eligibility criteria (inclusion and exclusion criteria) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes for entry into the study clearly stated? 7. Did patients enter the study at a similar point in the disease? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 8. Was the intervention of interest clearly described? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 9. Were additional interventions (co-interventions) clearly Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes described? 10. Were relevant outcome measures established a priori? Partial Yes Partial Yes Yes Yes Yes Partial Partial Partial Partial 11. Were outcome assessors blinded to the intervention that No No No No No No No No No No No patients received? 12. Were the relevant outcomes measured using appropriate Partial Yes Partial Yes Partial Yes Partial Partial Partial Yes Partial objective/subjective methods? 13. Were the relevant outcome measures made before and after No Partial No Partial No Partial No No No No No the intervention? 14. Were the statistical tests used to assess the relevant outcomes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes appropriate? 15. Was follow-up long enough for important events and out- Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes comes to occur? 16. Were losses to follow-up reported? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 17. Did the study provided estimates of random variability in the Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes data analysis of relevant outcomes? 18. Were the adverse events reported? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 19. Were the conclusions of the study supported by results? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 20. Were both competing interests and sources of support for the Yes Yes Yes Yes Yes Yes No Yes No Yes Yes study reported? Overall risk of bias Moderate Moderate Moderate Low Moderate Moderate Moderate Moderate High Moderate Moderate Knee Surg Sports Traumatol Arthrosc (2017) 25:2237–2246 2245 Acknowledgements The authors would like to thank Roos Steen- mosaicplasty for cartilaginous lesions of the elbow joint. Am J huis, medical librarian of the Onze Lieve Vrouwe Gasthuis, for the Sports Med 35:2096–2100 assistance in performing the literature search. 10. Koehler SM, Walsh A, Lovy AJ, Pruzansky JS, Shukla DR, Hausman MR (2015) Outcomes of arthroscopic treatment of Compliance with ethical standards osteochondritis dissecans of the capitellum and description of the technique. J Shoulder Elbow Surg 24:1607–1612 11. Kosaka M, Nakase J, Takahashi R, Toratani T, Ohashi Y, Kita- Conflict of interest R. Bexkens, P.T. Ogink, J.N. Doornberg, oka K, Tsuchiya H (2013) Outcomes and failure factors in sur- G.M.M.J. Kerkhoffs, D. Eygendaal, L.S. Oh, and M.P.J. van den Bek - gical treatment for osteochondritis dissecans of the capitellum. erom declare that they have no conflict of interest. J Pediatr Orthop 33:719–724 12. LaPrade RF, Botker JC (2004) Donor-site morbidity after Funding There was no outside funding or grants received that osteochondral autograft transfer procedures. Arthroscopy assisted in this study. 20:e69–e73 13. Lewine EB, Miller PE, Micheli LJ, Waters PM, Bae DS (2015) IRB/medical ethics committee Review was not needed for this Early Results of Drilling and/or Microfracture for Grade IV study since it is a systematic review. Osteochondritis Dissecans of the Capitellum. J Pediatr Orthop 36:803–809 14. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Disclaimers None. 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