Osgood schlatter disease

Aetiology, Pathogenesis, diagnosis, conservative and operative management from Campbell & Turek's

1. Osgood Schlatter Diseases Osteochondritis of the tibial tubercle, strain or partial avulsion of tibial tubercle Presented by Dr Yash Oza Moderator Dr Umesh Jain

2. It is painful disabling swelling over tibial tubercle , occurring in adolescents.

3. Etiology Trauma – frequently associated A single violent or lesser repeated Flexion of the knee against a tight quadriceps Patella alta – Strong association shortened rectus femoris Increase in patellar height may require an increase in the force by the quadriceps to achieve full extension, which could be responsible for the apophyseal lesion . It can be argued, however, that the patella alta is the result of chronic avulsion of the bony tuberosity .

4. Pathology Tibial tubercle develop as an extension of epiphysis. 1 or 2 ossification center develops within tubercle It fuses to the main epiphysis at age 16yr & to main bone at age 18yr

5. Before this fusion attachment of tubercle to tibia is by proliferating cartilage . Beneath the cartilage, the new bone is formed due to pulling strain of quadriceps – separating tubercle from tibia. The separation is minimal but sufficient to obliterate the blood supply of tubercle. The tubercle undergoes aseptic necrosis The Neighboring bone undergoes active hyperemia leading to osteoporosis Capillaries & Phagocytes invade & remove dead bone – resulting in fragmentation .

6. Clinical Presentation Pubertal age group ( because of rapid growth) More in male Often bilateral Pain, Tenderness & Soft tissue swelling without sign of inflammation at tibial tubercle. Aggravated by – climbing stairs , running ( Strong quadriceps contraction ) Kneeling is painfull Knee extension against resistance is painfull .

7. The course is chronic & recurs over period of months to years. Usually apophysis fuses to main bone at 18yrs age and symptoms resolve spontaneously. Occasionally, the symptoms persist in adult life and patients often needs psychiatric counseling.

8. Radiographic picture Xray Tibial tubercle consist of multiple fragmented-appearing area Underlying bone shows area of osteoporosis. Ossification in tubercle may be single & in continuity with upper tibial epiphysis.

9. MRI more sensitive and specific, and will demonstrate: soft-tissue swelling anterior to the tibial tuberosity loss of the sharp inferior angle of the  infrapatellar fat pad (Hoffa fat pad) thickening and edema of the distal patellar tendon Infrapatellar bursitis   (clergyman's knee) bone marrow edema may be seen at the tibial tuberosity

10. Ultrasound The sonographic appearances of Osgood- Schlatter disease include  : swelling of the unossified cartilage and overlying soft tissues fragmentation and irregularity of the ossification center thickening of the distal patellar tendon infrapatellar bursitis

11. Classification Type 1 Tibial tubercle is prominent & irregular Type 2 Additional fragmentation of the bone adjacent to anterior and superior aspects Type 3 When tubercle is normal but, there is free bone particles in simila r distribution

12. Treatment Surgery rarely is indicated as the disorder usually becomes asymptomatic without treatment or with simple conservative measures. Rest & avoid running - sports for 3 to 6 weeks . Local ultrasound & physiotherapy may be helpful. If doesn’t improve with rest then cylindrical cast or long knee brace immobilization for few weeks. This removes pull of quadriceps and permits revascularization & reossification tubercle.

13. Surgical treatment Persistent symptoms of Osgood- Schlatter disease for more than 2 years warrant exploration. ( Robertsen et al .) Surgery may be considered if symptoms are persistent and severely disabling. T ibial sequestrectomy (removal of the fragments) may relieve acute symptoms, but long-term results are no better than conservative treatment. Insertion of bone pegs into the tibial tuberosity ( Bosworth procedure ) is simple and almost always relieves the symptoms; however , an unsightly prominence remains after this operation and is rarely used.

14. Tibial sequestrectomy can be done by longitudinal incision in the patellar tendon or arthroscopic removal of the ossicle The amount to be excised ( debrided) should be determined preoperatively as described by Pihlajamakiet al . The tibial tuberosity index (TTI) assesses the relative thickness of the tuberosity on radiographs. midvertical tibial line. Line passing through base of tibial tubercle Tip of tibial tubercle TTI= B A+B

15. EXCISION OF UNUNITED TIBIAL TUBEROSITY FRAGMENT FERCIOT AND THOMSON Make a longitudinal incision centered over the tibial tuberosity. Expose the patellar tendon and incise it longitudinally . Elevate the tendon & excise any loose fragments of bone and enough tibial cortex , cartilage, and cancellous bone to remove any bony prominence completely. Do not disturb the peripheral and distal margins of the insertion of the patellar tendon . POSTOPERATIVE CARE. A cylinder walking cast is applied and worn for 2 to 3 weeks . Exercises are then begun .

16. ARTHROSCOPIC OSSICLE AND TIBIAL TUBEROSITY DEBRIDEMENT Using a mechanical shaver and radiofrequency ablation device , perform an anterior interval release. Shell out the bony lesions from their soft-tissue attachments . Remove small and loose fragments with a pituitary rongeur ; remove larger fragments with an arthroscopic burr . Extending the knee and taking tension off the patellar tendon facilitate the debridement along the anterior tibial slope. POSTOPERATIVE CARE. Patients are allowed full weight bearing and unrestricted range of motion on day of surgery.

17. TIBIAL TUBEROSITY AND OSSICLE EXCISION Make a vertical 5-cm incision over the center of the distal part of the patellar tendon Divide the distal patellar tendon longitudinally and expose the superior part of the tibial tuberosity With an osteotome and rongeur , remove prominent tibial tuberosity posterior intratendinous ossicles If present osteocartilaginous fragments +/- tibial tuberosity prominence. Make sure all fragments are removed .

18. Resect the tibial tuberosity down to the insertion of the tendon and smooth with a file. Try not to disturb the peripheral and distal margins of the patellar tendon insertion . POSTOPERATIVE CARE. On the first day after surgery, quadriceps-setting exercises are started and crutches are used for a short period of time. A ll strenuous activity should be avoided for 6 to 12 weeks.

19. Outcome Reported complications of Osgood- Schlatter disease whether treated surgically or not, include subluxations of the patella, patella alta , nonunion of the bony fragment to the tibia, and premature fusion of the anterior part of the epiphysis with resulting genu recurvatum . Because of the possibility of genu recurvatum , surgery should be delayed until the apophysis has fused. We have removed only the ossicle with satisfactory results; the entire tuberosity should be excised only if it is significantly enlarged and the apophysis is closed.