Osteochondrosis

Dr. Gajanan Pandit

Mumbai Port Trust Hospital

What is Osteochondrosis ?

A defect in ossification at either the bone epiphysis (growing plate), the joint surface itself, or at an apophysis (bony projection);associated with avascular necrosis and sclerosis.

Except kienbock’s disease

Incidence

children and young people (growth phase of epiphyses)

boys than girls ex. Freiberg’s disease

Etiology

Repetitive stress (microtrauma) -Buchman’s traumatic osteoporosis of carpus

( esp. perthes > talus ),

Congenital malformation,

? Infection ( no inflammation ),? vascular, hormonal, genetic & metabolic factors.

Types of epiphysis

Pressure epiphysis

Traction epiphysis or apophysis

Atavistic epiphysis

crushing / Splitting / Pulling osteochondrosis

Primary epiphyses

Vertebral body: Calve Carpal scaphoid: Preiser * Lunate, adult: Kienbock * Patella: Kohler Talus: Mouchet Tarsal scaphoid: Kohler * Medial Cuneiform: Buscke Femoral trochanter: Monde Felix Patella: Sinding-Larsen * Tibial head: Ritter Tibial tubercle: Osgood-Schlatter * Os calcis: Sever * Metatarsal head: Freiberg *

Secondary ephiphyses

Vertebral epiphysis: Scheuermann’s * Sternal end clavicle: Friedrich Humeral head: Hass Humeral capitellum: Panner * Radial head: Brailsford Distal ulna: Burns Metacarpal heads: Mauclaire Iliac crest: Buchman Pubic symphysis: Van Neck Ischiopubic region: Oldberg Femoral head: Legg-Calve – Perthes *

Classification

Articular osteochondrosis

Non-articular osteochondrosis &

Epiphyseal osteochrondrosis

Examples

Articular osteochondrosis Legg-Calve-Perthes disease (hip/femur) Kohler’s bone disease (ankle navicular bone) Freiberg’s disease (2nd metatarsal head) Panner’s disease (capitulum of humerus) Kienbock’s ( Lunate) Preiser ( Scaphoid )

Examples

Non-articular osteochondrosis Osgood-Schlatter disease (tibial tuberosity) Sever’s disease (calcaneus) Sinding-Larsen-Johansson syndrome

(inferior tip of patella)

Examples

Epiphyseal osteochrondrosis Scheuermann’s disease (vertebral bodies) Blount’s disease (proximal tibial epiphysis)

Legg-calve-perthes disease

Inherited thrombophilia (hypercoagulability or a deficiency in protein C activity) venous occlusion bone death in the femoral head.

Perinatal HIV itself, HIV-associated complications, or HIV-related therapies.

Irritable Hip

Transient Synovitis

Boys 2:1

Age ~ 3 yrs

Duration ~ 6 days

Legg-calve-perthes Disease

Boys 3:1

Age ~ 7 yrs

Duration 6 wks

Bone age 2 yrs behind

Classification

Caterall et al.

Group I- partial or 1/2 head involved;

Groups II and III- 1/2 head involvement and sequestrum formation;

Group IV involvement of the entire epiphysis.

Head-at-risk signs

1. Lateral subluxation of femoral head , 2. Speckled calcification lateral to capital

epiphysis,3. Diffuse metaphyseal reaction (metaphyseal

cysts),4. A horizontal physis &5. Gage sign, a radiolucent V-shaped defect in the

lateral epiphysis and adjacent metaphysis

Classification

Salter and Thompson- simple and accurate and can be applied early

Type A- extent of subchondral fracture (line) is less than 50% of the superior dome of the femoral head

Type B- fracture is more than 50% of the dome

Type B > 50% of femoral head

ClassificationHerring et al.Lateral pillar classification based on height of lateral pillar.

Imaging

plain radiographic -delayed ≥6 weeks from clinical onset

Bone scintigraphy and MRI -early Δsis

compare uptake with contralateral hip,

if uptake decreased < 50% Catterall group I or II.

If uptake decreased > 50% Catterall group III or IV, Salter type B, or lateral pillar type C.

Henderson et al. MRI for extent & location also early accurate head sphericity

Song et al.- widened medial joint space (1) overgrown cartilage in the initial stage, (2) overgrown cartilage and widened true medial joint space at the fragmentation stage, and (3) widened true medial joint space at the healing stage decreased or normalized because of ossification of overgrown cartilage despite the existence of lateral subluxation owing to coxa magna.

Treatment1. Noncontainment methods > good results (84%).

2. Satisfactory clinical results> at long-term> despite an unsatisfactory radiographic appearance

3. The Catterall classification indicator of results, but is not applicable ~ 8.1 months after onset.

4. Head-at-risk signs added little to the Catterall classification as a prognostic indicator or therapeutic guide.

5. All of the fair and poor results were in patients with Catterall III or IV involvement and onset of the disease at age 6 or older. (equivalent to Herring groups B and C.)

Operative

Innominate Osteotomy

Lateral Shelf Procedure

Varus Derotational Osteotomy

Lateral Opening Wedge Osteotomy

Arthrodiastasis

Innominate Osteotomy

Canale et al.

Lateral Shelf Acetabuloplasty

Willett et al.

Varus derotational osteotomy

Stricker

Reconstructive Surgery

Valgus Extension Osteotomy

Valgus Flexion Internal Rotation Osteotomy

Cheilectomy

Staheli or Catterall shelf augmentation procedure

Chiari Osteotomy

Valgus osteotomy

Chiari osteotomy

Osteochondritis Dissecans

subchondral bone necrotic and degenerative cartilage overlying it gradually separate from adj. bone and cartilage to become a loose body

Knee>elbow>ankle>shoulder>hip

Theories of Etiologyischemia,

repetitive microtrauma,

familial predisposition,

endocrine imbalance,

epiphyseal abnormalities,

accessory centers of ossification,

growth disorders,

osteochondral fracture,

repetitive microtrauma & subsequent interruption of interosseous blood supply,

anatomic variations in the knee, and

congenitally abnormal subchondral bone.

Heffi et al (A) X Aichroth (B).

Young Adolescent

Male 2:1

B/L 30%

Clinical Features

vague, aching discomfort ~14 months, Catching and popping, loose body;

effusion, joint line/local tenderness, limitation of motion, McMurray sign and quadriceps atrophy;

Wilson sign- Ext. Rotation gait

Imaging

B/L X-Ray :- AP, Lateral and tunnel or intercondylar notch view;technetium-99m bone scan

Sequential SPECT scans / 8 wk

CT in coronal plane

MRI - fragment attachment, stability & viability + Soft tissue.

Cahill & Berg classification

Stage Bone scan finding

0 Normal radiographic and scintigraphic appearance

1 Lesion visible on plain radiographs, bone scan normal

2 Increased uptake in area of lesion on bone scan

3 Increased isotopic uptake in entire femoral condyle

4 Uptake in tibial plateau opposite lesion

Dipaola et al.

Stage Arthrosopy MRI Radiographs

1 Irregular & softcartilage; no definablefragment

Thickenedcartilage; low signalchanges

Compression lesion; novisible fragment

2 Cartilage breached;definable fragment, notdisplaceable

Cartilage breached;low signal rimbehind fragmentindicating fibrousattachment

Fragment attached

3 Breached; definablefragment, displaceable,but attached by someoverlying cartilage

Cartilage breached;high signal changesbehind fragment s/osyn. fluid

Nondisplaced fragmentwithout attachment

4 Loose body Loose body Displaced fragment

DD of Loose Body

(1) synovial chondromatosis,

(2) osteophytes,

(3) fractured articular surfaces and

(4) damaged menisci

Treatment

Age & degree of involvement

Conservative treatment - Cahill et al. 50% failure rate in juvenile population

Surgical treatment - drilling or excision of fragment, débridement of crater, different forms of fixation and grafting.

Operative treatment

Guhl’s indications

symptomatic knee in a patient skeletally >12 years,

a lesion >1 cm in diameter &

involvement of weight bearing surface

Arthroscopy / open arthrotomy

Excision of Loose Bodies

Indications

small fragments (<2 cm),

multiple fragments,

fragments with inadequate bone stock ( cartilaginous) &

fragments that can’t be secured with internal fixation

Mosaicplasty

Iselin Disease

a traction epiphysitis of the base of the fifth metatarsal occurring in young adolescents at the time of appearance of the proximal epiphysis of the fifth metatarsal. German literature in 1912

peroneus brevis

oblique view

Sesamoid in peroneus brevis

Ossification of epiphysis Girls 10yr & Boys 12yr fuse in 2 yrs

Enlargement and fragmentation

Nonunion after Iselin disease

Treatment

Mild symptoms- limitation of sports activity, application of ice and administration of NSAID’s

Severe symptoms- cast immobilization

No internal fixation

Freiberg Infraction

Osteochondrosis of the Metatarsal Head ( 2nd > 3rd > 4th > 5th ).

Girls > Boys.

Early acute Freiberg disease

Condensation and sclerosis

Duration 6 mths - 2 yrs

No surgery

Bone Scan ? Stress #

Loose body

Treatment

Loose body removalSmillie procedure - scraping of sclerotic area & cancellous bone graft.

Gauthier and Elbaz - dorsal wedge osteotomy

Dorsal wedge osteotomy

A Outline of bony wedge to be resected

B Osteotomy of bony wedge

C Closure of osteotomy

D Fixation of osteotomy with wire

Köhler Disease

Osteochondrosis of tarsal navicular 1908

ossification centers (girls 1.5 - 2 yrs & boys 2.5 - 3 yrs ) Karp

Waugh blood supply - numerous penetrating vessels / single vessel 4 to 6 years Abnormal ossification is response of unprotected, growing nucleus to normal stresses of weight bearing.

Radiological

Köhler Disease

Cowell and Williams

Radiographic findings as Köhler disease (sclerosis, size, fragmentation) asymptomatic foot ~ irregularity of ossification

Adviced cast immobilization

Köhler Disease

Pain & Disability navicular distorted and sclerotic,

head of the talus flattened,

articular surfaces of both fibrillated & marginal osteophytes

Treatment

Arthrodesis

Midtarsal joints (talonavicular and calcaneocuboid)

naviculocuneiform joints .

Osgood-Schlatter Disease

Apophysitis of tibial tubercle due to traction injury & incomplete separation by patellar tendon.

Pain, Lump,

Tender swelling, resisted knee extension.

X-Ray - Fragmentation.

Treatment

Conservative

restriction of activities or cast immobilization for 3 to 6 weeks

Surgery - symptoms > 2 yrs, persistent and severely disabling

Surgical Treatment

Tibial sequestrectomy (removal of the fragments)

Bosworth technique of insertion of bone pegs

Ferciot and Thomson excision of ununited tibial tuberosity

Complications of OSD

Patellar subluxation,

Patella alta,

Nonunion of bony fragment and

Premature fusion of anterior part of epiphysis genu recurvatum.

Kienböck disease

osteonecrosis of the carpal lunate

age 15 - 40 yrs male

dominant wrist of manual labor

fragmentation, collapse with shortening of carpus

secondary arthritis in proximal carpal area

Radiography

A anterior pole type # & capitate pressure

B Ratio of height of carpus to length of third metacarpal

normal 0.54 ± 0.03

Classification Lichtman et al.

Stage I: MRI with gadolinium enhancement may show changes not seen on plain radiographs.

Stage II: outline is normal, but definite density changes in lunate.

Stage III: Collapse or fragmentation of lunate & proximal migration of capitate

Weiss et al. IIIA—sclerosis with fragmentation or collapse or both. & IIIB—fixed rotation of the scaphoid with IIIA changes.

Stage IV: gen. Deg. changes in carpus.

Treatment

Immobilization in a cast St. 1,2.

surgical procedures (ulna-minus variant)

Joint “leveling” procedures - ulnar lengthening and radial shortening

Osteotomies of the Distal Radius

Lunate Revascularization Procedures

Prosthetic Lunate Replacement

Panner’s Disease

Avascular necrosis of capitellum of Humerus.

Non weight bearing joint.

7-10 yrs boys (11:1).

Etiology ?endocrine / trauma.

Prognosis good.

Elbow Ossification

Panner’s Disease

Tibia Vara (BLOUNT DISEASE)

an osteochondrosis similar to coxa plana and Madelung's deformity but located at the medial side of the proximal tibial epiphysis. Blount's article 1937

Now Metaphyseal disease, Abnormal endochondral ossification.

Etiology- trauma, infection, rickets, osteonecrosis & Weight Bearing.

Tibia Vara

Infantile T.V.

< 8 yearsbilateral and symmetrical in approximately 60%

deformity increases progressively

Physiological Bowing

< 2 yearsalmost always bilateral

resolve with growth.

Langenskiöld

Deformity

varus and internal torsion of the tibia and genu recurvatum

Treatment

observation / trial bracing at 2- 5 yrs

corrective osteotomy

single-plane oblique Rab

oblique incomplete closing wedge osteotomy Laurencin et al.

chevron osteotomy Greene

hemicondylar tibial osteotomy Zayer

Physeal bar

age > 5 years,

medial physeal slope - 50° to 70°,

Langenskiöld grade IV changes,

body weight > 95th percentile and

black girls who meet the previous criteria

resection of Bar / Epiphyseodesis