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Osteochondritis Dissecans of the Capitellum

Capitellar OCD: Panner vs OCD, stable/unstable lesions, imaging for stability, and the ladder from rest to debridement/microfracture, fixation and osteochondral autograft.

Overview

Osteochondritis dissecans of the capitellum is a condition where repetitive throwing in adolescent athletes often leads to long-term problems, with long-term results demonstrating continued elbow symptoms and degenerative joint disease in approximately 50% of patients despite appropriate and aggressive treatment [1, 5]. Clinical assessment requires caution when assigning grades using magnetic resonance classifications due to interobserver reliability concerns [2]. While nonoperative management is associated with modest healing and return to play rates, surgical options like osteochondral grafting may offer better durability for larger or unstable lesions but carry donor site morbidity or cost [15].

Current surgical strategies demonstrate variable efficacy depending on the lesion characteristics and patient age. Arthroscopic debridement and microfracture can produce good to excellent outcomes in the majority of patients with osteochondritic lesions, showing a low incidence of progressive radiographic changes and high rates of return to sport in the short-term [4, 9]. Osteochondral autograft transplantation demonstrates excellent clinical and radiographic outcomes, minimal short-term donor site morbidity, and a high level of return to sport in pediatric patients [3]. Closed-wedge osteotomy is useful for young baseball players, as the bone revascularized and remodeled within 6 months with minimal osteoarthritic changes observed [6]. Functional outcomes and radiological findings after both osteochondral grafting and arthroscopic fragment resection for unstable large lesions in adolescent athletes were satisfactory with a mean follow-up of 8 years [7]. Arthroscopy for this condition demonstrated an excellent return-to-play rate and satisfactory subjective questionnaire scores with a 12% failure rate following a minimum 2-year follow-up period [11]. However, a lack of extensive studies with long-term follow-up of mosaicplasty in the elbow renders the application of this operation less clear for capitellar osteochondritis dissecans as compared to knee lesions [13]. Until outcomes improve, it may be wise to counsel symptomatic pitchers and catchers to consider switching to another position or sport [5].

Anatomy & Pathophysiology

Long-term outcomes for osteochondritis dissecans of the capitellum indicate that approximately 50% of patients continue to experience elbow symptoms and degenerative joint disease despite appropriate and aggressive treatment [1]. Over mid- to long-term follow-up, the entire elbow joint undergoes cylindrical-like morphological changes leading to restricted motion in surgically treated cases [20].

Osseous Morphology: Osteochondral defects demonstrate location- and size-dependent alterations in valgus angulation and radiocapitellar contact characteristics in both UCL-strained and native conditions [17]. Preoperative radiographic findings of radial head enlargement serve as predictors of advanced-stage capitellar osteochondritis dissecans [19]. Additionally, advanced skeletal age of the throwing side compared with the nonthrowing side is a predictor of advanced-stage capitellar osteochondritis dissecans [19].

Prognostic Indicators: Preoperative radiographic findings of advanced skeletal age of the throwing side compared with the nonthrowing side are predictors of unsuccessful nonoperative management [19].

Diagnostic Modalities: A deep learning-based computer-aided diagnosis system achieved high accuracy in detecting osteochondritis dissecans lesions on ultrasound images in all four directions of the elbow [25].

Classification

Outcomes and Etiology: Despite appropriate and aggressive treatment, long-term results for osteochondritis dissecans of the capitellum demonstrate continued elbow symptoms and degenerative joint disease in approximately 50% of patients [1]. Repetitive throwing in adolescent athletes often leads to long-term problems associated with osteochondritis dissecans of the capitellum [5]. A case report identifies a possible link between a bone bruise sustained during a single injury and a subsequent osteochondritis dissecans-like change of the capitellum [8]. A case report of fraternal twins with almost identical osteochondritis dissecans lesions in the nondominant arms without a history of repetitive microtrauma supports the idea of a genetic predisposition to the disease [10].

Imaging and Diagnostic Reliability: When added to standard AP and lateral radiographs, 45° flexion anteroposterior elbow radiographs improve diagnostic accuracy such that capitellum osteochondritis dissecans can be diagnosed in 100% of cases [16]. One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans due to interobserver reliability concerns [2].

Clinical Presentation

Long-term outcomes for osteochondritis dissecans of the capitellum remain poor despite appropriate and aggressive treatment, with approximately 50% of patients developing continued elbow symptoms and degenerative joint disease [1]. Repetitive throwing in adolescent athletes frequently precipitates these long-term problems [5]. While the condition is often chronic, a case report identifies a possible link between a bone bruise sustained during a single injury and subsequent osteochondritis dissecans-like changes of the capitellum [8]. Conversely, a case report of fraternal twins with almost identical lesions in the nondominant arms, absent a history of repetitive microtrauma, supports a genetic predisposition to the disease [10].

Diagnostic accuracy is enhanced by specific imaging protocols. When added to standard AP and lateral radiographs, 45° flexion anteroposterior elbow radiographs improve diagnostic accuracy, allowing capitellar OCD to be diagnosed in 100% of cases [16]. Clinicians must exercise caution when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans due to interobserver reliability concerns [2]. Preoperative sagittal CT images are critical for surgical planning, as posterior or large osteochondral defects of the humeral capitellum affect the outcomes of arthroscopic debridement for capitellar OCD in adolescent baseball players [18].

Investigations

Plain radiography: Standard anteroposterior and lateral views are insufficient for definitive diagnosis; adding 45° flexion anteroposterior elbow radiographs improves diagnostic accuracy to 100% [16]. Preoperative findings of radial head enlargement and advanced skeletal age of the throwing side compared with the nonthrowing side predict advanced-stage disease and unsuccessful nonoperative management [19]. Despite aggressive treatment, long-term outcomes remain poor with continued elbow symptoms and degenerative joint disease in approximately 50% of patients [1].

MRI: Magnetic resonance classifications for capitellar osteochondritis dissecans should be used with caution due to documented interobserver reliability concerns [2].

CT: Posterior or large osteochondral defects of the humeral capitellum identified on preoperative sagittal CT images negatively affect the outcomes of arthroscopic debridement in adolescent baseball players [18]. Osteochondral defects induce location- and size-dependent alterations in valgus angulation and radiocapitellar contact characteristics in both UCL-strained and native conditions [17].

Other Considerations: Surgical treatment effectively restores subchondral bone density distribution to normal patterns regardless of the technique employed [27]. A single bone bruise may be linked to subsequent osteochondritis dissecans-like changes of the capitellum [8], while a case of fraternal twins with identical nondominant arm lesions without repetitive microtrauma suggests a genetic predisposition [10].

Treatment

Despite appropriate and aggressive treatment, long-term results for osteochondritis dissecans of the capitellum demonstrate continued elbow symptoms and degenerative joint disease in approximately 50% of patients [1]. A possible link exists between a bone bruise sustained during a single injury and a subsequent osteochondritis dissecans-like change of the capitellum [8]. Nonoperative management is associated with modest healing and return to play rates, while surgical options like osteochondral grafting may offer better durability for larger or unstable lesions but carry donor site morbidity or cost [15].

Operative

Indications: Surgery is considered when nonoperative management fails or for unstable large lesions in adolescent athletes. One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans [2]. Repetitive throwing in the adolescent athlete often leads to long-term problems, and until outcomes improve, it may be wise to counsel symptomatic pitchers and catchers to consider switching to another position or sport [5].

Surgical Approach / Technique: Arthroscopic debridement and microfracture can produce good to excellent outcomes in the majority of patients with osteochondritic lesions of the capitellum, with a low incidence of progressive radiographic changes and high rates of return to sport in the short-term [4]. A combination of arthroscopy and the microfracture technique is a reliable method with excellent short-term results in the treatment of osteochondritis dissecans of the elbow [9]. Arthroscopy for osteochondritis dissecans of the capitellum demonstrated an excellent return-to-play rate and satisfactory subjective questionnaire scores with a 12% failure rate following a minimum 2-year follow-up period [11]. Osteochondral autograft transplantation demonstrates excellent clinical and radiographic outcomes, minimal short-term donor site morbidity, and a high level of return to sport in pediatric patients with osteochondritis dissecans of the capitellum [3]. Functional outcomes and radiological findings after both osteochondral grafting and arthroscopic fragment resection for unstable large capitellar osteochondritis dissecans lesions in adolescent athletes were satisfactory with a mean follow-up of 8 years [7]. A novel acellular cartilage repair technique based on ultrapurified alginate gel implantation is a useful, minimally invasive approach for treating cartilaginous lesions in athletes with advanced capitellar osteochondritis dissecans [12]. Closed-wedge osteotomy is useful for osteochondritis dissecans of the capitellum in young baseball players, as the bone revascularized and remodeled within 6 months, minimal osteoarthritic changes were observed, and six of seven patients returned to full athletic activity [6].

Other Considerations: A lack of extensive studies with long-term follow-up of mosaicplasty in the elbow renders the application of this operation less clear for capitellar osteochondritis dissecans as compared to knee lesions [13].

Complications

Long-term Outcomes: Long-term results of osteochondritis dissecans of the capitellum demonstrate continued elbow symptoms and degenerative joint disease in approximately 50% of patients despite appropriate and aggressive treatment [1]. Repetitive throwing in adolescent athletes often leads to long-term problems associated with osteochondritis dissecans of the capitellum [5].

Surgical Failure and Progression: Arthroscopy for osteochondritis dissecans of the capitellum is associated with a 12% failure rate [11]. Conversely, arthroscopic debridement and microfracture for capitellar osteochondritis dissecans is associated with a low incidence of progressive radiographic changes [4].

Classification and Diagnosis: Assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans requires caution due to interobserver reliability concerns [2]. Osteochondral defects in the capitellum show location- and size-dependent alterations in valgus angulation and radiocapitellar contact characteristics [17].

Other Considerations: The overall incidence of symptomatic capitellar osteochondritis dissecans between the ages of 10 and 24 years was 6.0 per 100,000 over a 25-year period in the studied US subpopulation [30]. A case report identifies a possible link between a bone bruise sustained during a single injury and subsequent osteochondritis dissecans-like changes of the capitellum [8]. A case report of fraternal twins with almost identical osteochondritis dissecans lesions in the nondominant arms without a history of repetitive microtrauma supports the idea of a genetic predisposition to the disease [10]. The application of autologous osteochondral mosaicplasty for capitellar osteochondritis dissecans is less clear compared to knee lesions due to a lack of extensive studies with long-term follow-up [13].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity or driving; however, arthroscopic debridement and microfracture yields high rates of return to sport in the short-term [4], and closed-wedge osteotomy results in bone revascularization and remodeling within 6 months [6].

Full activity (months): Return to full athletic activity is achieved in six of seven patients treated with closed-wedge osteotomy [6]. Osteochondral autograft transplantation results in a high level of return to sport for pediatric patients [3]. Arthroscopy for osteochondritis dissecans of the capitellum demonstrates an excellent return-to-play rate [11].

Complete recovery / outcome plateau (months): Functional outcomes and radiological findings after osteochondral grafting for unstable large lesions in adolescent athletes are satisfactory with a mean follow-up of 8 years [7]. Similarly, functional outcomes and radiological findings after arthroscopic fragment resection for unstable large lesions in adolescent athletes are satisfactory with a mean follow-up of 8 years [7]. Arthroscopy for osteochondritis dissecans of the capitellum is associated with satisfactory subjective questionnaire scores with a mean follow-up period of 8.3 years [11]. Long-term results demonstrate continued elbow symptoms and degenerative joint disease in approximately 50% of patients despite appropriate and aggressive treatment [1].

Rehabilitation protocol: The evidence does not detail specific immobilization durations, weight-bearing progression, or sling removal timing. However, closed-wedge osteotomy for osteochondritis dissecans of the capitellum in young baseball players results in bone revascularization and remodeling within 6 months [6].

Functional milestones: Functional outcomes and radiological findings after osteochondral grafting for unstable large capitellar osteochondritis dissecans lesions in adolescent athletes are satisfactory with a mean follow-up of 8 years [7]. Functional outcomes and radiological findings after arthroscopic fragment resection for unstable large capitellar osteochondritis dissecans lesions in adolescent athletes are satisfactory with a mean follow-up of 8 years [7]. Arthroscopy for osteochondritis dissecans of the capitellum is associated with satisfactory subjective questionnaire scores with a mean follow-up period of 8.3 years [11]. Osteochondral autograft transplantation demonstrates excellent clinical and radiographic outcomes for osteochondritis dissecans of the capitellum in pediatric patients [3]. Arthroscopic debridement and microfracture can produce good to excellent outcomes in the majority of patients with osteochondritic lesions of the capitellum [4].

Other Considerations: Long-term results of osteochondritis dissecans of the capitellum demonstrate continued elbow symptoms and degenerative joint disease in approximately 50% of patients despite appropriate and aggressive treatment [1]. Arthroscopy for osteochondritis dissecans of the capitellum has a 12% failure rate with a minimum 2-year follow-up period [11]. One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans due to interobserver reliability concerns [2]. A lack of extensive studies with long-term follow-up renders the application of autologous osteochondral mosaicplasty less clear for capitellar osteochondritis dissecans compared to knee lesions [13]. Repetitive throwing in adolescent athletes often leads to long-term problems associated with osteochondritis dissecans of the capitellum [5]. It may be wise to counsel symptomatic adolescent pitchers and catchers with osteochondritis dissecans of the capitellum to consider switching to another position or sport until outcomes improve [5]. A case report identifies a possible link between a bone bruise sustained during a single injury and a subsequent osteochondritis dissecans-like change of the capitellum [8]. A case report of fraternal twins identifies almost identical osteochondritis dissecans lesions in the nondominant arms without a history of repetitive microtrauma, supporting a genetic predisposition to the disease [10].

Key Evidence

  • [L5] Despite appropriate and aggressive treatment, the prognosis for osteochondritis dissecans of the capitellum remains guarded, with long-term results demonstrating continued elbow symptoms and degenerative joint disease in approximately 50% of patients. (10.1016/j.jse.2009.11.058)
  • [L4] One should be cautious when assigning grades using magnetic resonance classifications for capitellar osteochondritis dissecans. (10.1177/1758573218821151)
  • [L4] In the treatment of osteochondritis dissecans of the capitellum, osteochondral autograft transplantation demonstrates excellent clinical and radiographic outcomes, with minimal short-term donor site morbidity and a high level of return to the sport. (10.1016/j.jhsa.2021.02.024)
  • [L4] Arthroscopic debridement and microfracture can produce good to excellent outcomes in the majority of patients with osteochondritic lesions of the capitellum, with a low incidence of progressive radiographic changes and high rates of return to sport in the short-term. (10.1016/j.arthro.2010.04.034)
  • [L5] Repetitive throwing in the adolescent athlete often leads to long-term problems, and until outcomes for osteochondritis dissecans of the capitellum improve, it may be wise to counsel symptomatic pitchers and catchers to consider switching to another position or sport. (10.1016/j.arthro.2020.02.029)
  • [L4] The procedure is useful for osteochondritis dissecans of the capitellum in young baseball players, as the bone revascularized and remodeled within 6 months, minimal osteoarthritic changes were observed, and six of seven patients returned to full athletic activity. (10.1177/03635465000280041401)
  • [L3] Functional outcomes and radiological findings after both osteochondral grafting and AS fragment resection for unstable large capitellar OCD lesions in adolescent athletes were satisfactory with a mean follow-up of 8 years. (10.1177/2325967119s00368)
  • [Case_report] This is the first report of a possible link between a bone bruise sustained during a single injury and a subsequent osteochondritis dissecans-like change of the capitellum. (10.1007/s00402-005-0018-0)
  • [L4] A combination of arthroscopy and the microfracture technique is a reliable method with excellent short-term results in the treatment of osteochondritis dissecans of the elbow. (10.1007/s00167-005-0693-y)
  • [Case_report] This case report identifies almost identical osteochondritis dissecans lesions in the nondominant arms of fraternal twins without a history of repetitive microtrauma, supporting the idea of a genetic predisposition to the disease. (10.1016/j.jhsa.2008.05.008)
  • [L4] This study demonstrated an excellent return-to-play rate and satisfactory subjective questionnaire scores with a 12% failure rate following arthroscopy for OCD of the capitellum with a minimum 2-year follow-up period. (10.1016/j.jse.2023.02.121)
  • [L4] The present results suggest that this novel technique is a useful, minimally invasive approach for treating cartilaginous lesions in athletes. (10.1177/2325967121989676)
  • [L5] A lack of extensive studies with long-term follow-up of mosaicplasty in the elbow, however, renders the application of this operation less clear for capitellar OCD as compared to knee lesions. (10.1016/j.main.2012.07.003)
  • [L4] Nonoperative management is associated with modest healing and return to play rates, while surgical options like osteochondral grafting may offer better durability for larger or unstable lesions but carry donor site morbidity or cost. (10.1097/corr.0000000000003600)
  • [L3] When added to standard AP and lateral radiographs, capitellum OCD can be diagnosed in 100% of cases. (10.1177/2325967121s00081)
  • [L5] Osteochondral defects show location- and size-dependent alterations in valgus angulation and radiocapitellar contact characteristics in the UCL-strained and native conditions. (10.1177/03635465251362876)
  • [L5] Posterior or large osteochondral defects of the humeral capitellum on preoperative sagittal CT images affected the outcomes of arthroscopic debridement for capitellar OCD in adolescent baseball players. (10.1016/j.jisako.2024.07.009)
  • [L2] Preoperative radiographic findings of radial head enlargement and advanced skeletal age of the throwing side compared with the nonthrowing side were predictors of advanced-stage capitellar OCD and unsuccessful nonoperative management. (10.1177/0363546519863349)
  • [L3] Over mid- to long-term follow-up, the entire elbow joint underwent cylindrical-like morphological changes, leading to restricted motion. (10.1177/23259671251339180)
  • [L2] The proposed deep learning-based CAD system achieved high accuracy in detecting OCD lesions on ultrasound images in all four directions of the elbow. (10.2106/jbjs.23.01164)
  • [L3] Surgical treatment of capitellar OCD effectively restored the subchondral bone density distribution to normal patterns, regardless of the surgical technique. (10.2106/jbjs.25.00212)
  • [L3] In this US subpopulation, the overall incidence of symptomatic capitellar OCD between the ages of 10 and 24 years was 6.0 per 100,000 over the 25-year period studied, which is higher than previously reported US estimates. (10.1177/23259671221135933)

References

[1] Osteochondritis dissecans of the capitellum. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.11.058

[2] Interobserver reliability of the classification of capitellar osteochondritis dissecans using magnetic resonance imaging. Shoulder & Elbow. 2019. DOI: 10.1177/1758573218821151

[3] Outcomes of Osteochondral Autograft Transplantation in Pediatric Patients With Osteochondritis Dissecans of the Capitellum. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.02.024

[4] Arthroscopic Debridement and Microfracture of Capitellar Osteochondritis Dissecans of the Elbow (SS‐24). Arthroscopy. 2010. DOI: 10.1016/j.arthro.2010.04.034

[5] Editorial Commentary: Should We Consider Early Retirement for Adolescent Pitchers and Catchers With Osteochonditis Dissecans of the Capitellum?. Arthroscopy. 2020. DOI: 10.1016/j.arthro.2020.02.029

[6] Closed-Wedge Osteotomy for Osteochondritis Dissecans of the Capitellum: A 7- to 12-Year Follow-up. The American Journal of Sports Medicine. 2000. DOI: 10.1177/03635465000280041401

[7] Osteochondral Autograft Transportation vs Arthroscopic Fragment Resectionfor Large Capitellar Osteochondritis Dissecans in Adolescent Athletes - A Minimum of 5-year Follow-up. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00368

[8] Are bone bruises a possible cause of osteochondritis dissecans of the capitellum? a case report and review of the literature. Archives of Orthopaedic and Trauma Surgery. 2005. DOI: 10.1007/s00402-005-0018-0

[9] Arthroscopy and microfracture technique in the treatment of osteochondritis dissecans of the humeral capitellum: report of three adolescent gymnasts. Knee Surgery, Sports Traumatology, Arthroscopy. 2005. DOI: 10.1007/s00167-005-0693-y

[10] Osteochondritis Dissecans of the Capitellum in Fraternal Twins: Case Report. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.05.008

[11] Clinical outcomes of osteochondritis dissecans lesions of the capitellum treated with arthroscopy with a mean follow-up period of 8.3 years. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.121

[12] Acellular Cartilage Repair Technique Based on Ultrapurified Alginate Gel Implantation for Advanced Capitellar Osteochondritis Dissecans. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121989676

[13] Osteochondritis dissecans of the capitellum: Autologous osteochondral mosaicplasty. A case report. Chirurgie de la Main. 2012. DOI: 10.1016/j.main.2012.07.003

[15] CORR Synthesis: How Should We Treat Capitellar Osteochondritis Dissecans in Adolescents? An Evidence-based Treatment Algorithm and Clinical Outcomes. Clinical Orthopaedics & Related Research. 2025. DOI: 10.1097/corr.0000000000003600

[16] 45° FLEXION ANTEROPOSTERIOR ELBOW RADIOGRAPHS IMPROVE DIAGNOSTIC ACCURACY OF CAPITELLUM OSTEOCHONDRITIS DISSECANS. Orthopaedic Journal of Sports Medicine. 2021. DOI: 10.1177/2325967121s00081

[17] Progressive Capitellar Osteochondral Defects Adversely Affect Valgus Angulation and Radiocapitellar Contact Based on Size and Location With Native and Strained Ulnar Collateral Ligaments: A Biomechanical Rationale for Pathogenesis. The American Journal of Sports Medicine. 2025. DOI: 10.1177/03635465251362876

[18] Sagittal computed tomography evaluation of osteochondritis dissecans of the capitellum correlates with clinical outcomes of arthroscopic debridement in adolescent baseball players. Journal of ISAKOS. 2024. DOI: 10.1016/j.jisako.2024.07.009

[19] Predictors of Unsuccessful Nonoperative Management of Capitellar Osteochondritis Dissecans. The American Journal of Sports Medicine. 2019. DOI: 10.1177/0363546519863349

[20] Comprehensive Elbow Joint Morphology Changes in Surgically Treated Osteochondritis Dissecans of the Capitellum: Clinical Implications. Orthopaedic Journal of Sports Medicine. 2025. DOI: 10.1177/23259671251339180

[25] Deep Learning-Based Computer-Aided Diagnosis of Osteochondritis Dissecans of the Humeral Capitellum Using Ultrasound Images. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.01164

[27] Normalization of Subchondral Bone Density Patterns After Surgical Treatment for Capitellar Osteochondritis Dissecans. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.25.00212

[30] Incidence and Epidemiology of Symptomatic Capitellar Osteochondritis Dissecans of the Elbow: A United States Population–Based Study Over a 25-Year Period. Orthopaedic Journal of Sports Medicine. 2022. DOI: 10.1177/23259671221135933

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iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.