Osteochondritis by a resident presentation seminar

Presentation on osteochondritis of different bones

1. . Osteochondritis By :-Solomon Ti . (OR -2) Moderator:-Dr. Yoseph Z . (Orthopedic and Trauma Surgeon ) April 30,2020

2. Osteochondritis Introduction Osteochondritis Dissecans Some other specific osteochondritis Complications References

3. Osteochondritis Disorders of actively growing epiphyses. May be localized to a single epiphysis or occasionally may involve two or more epiphyses simultaneously or successively. Etiology Unknown Lack of vascularity Trauma, Infection, Congenital malformation Multifactorial

4. Types of Osteochondritis Splitting type:- small fragment of articular cartilage and the adjacent bone may be separated as an avascular fragment Osteochondritis dissecans Crushing type:- spontaneous necrosis of the ossific nucleus Koehlers of the navicular bone, Keinbocks disease of the lunate bone Traction type : - excessive pull by tendon may damage the unfused apophysis Tibial tuberosity[Osgood- schlatters disease] , Calcaneal apophysis [ sever’s disease]

5. Osteochondritis Of Different B ody Sites Talar (ankle) OCD Calcaneus.. sever’s disease Navicular… Koehler disease 5 th MT base… Iselin disease M T heads …Freiberg infarction Knee OCD Patella OCD Superior pole…Menelaus-Batten syndrome Inferior pole…Larsen-Johansson Disease Proximal tibia tubercle….Osgood schlatter disease Capitellum OCD( panner Disease) Lunate…. Keinbocks disease Hip OCD… Perthes disease

6. Osteochondritis Dissecans(OCD) Definition Is a localized lesion in which a segment of subchondral bone and articular cartilage separates from the underlying bone, leaving either a stable or unstable bone fragment .

7. Osteochondritis Dissecans(OCD) Definition Osteonecrosis of subchondral bone( Ambroise Pare in 1558 after finding loose bodies in a patient’s knee) “Quiet necrosis” (Paget in 1870) Konig( In 1887 to 1888) The loose bodies resulted from a combination of trauma acting on the necrotic lesion underneath Osteochondritis …inflammation of the osteochondral joint surface;dessicans .. latin word dissec….to separate.

8. Osteochondritis Dissecans(OCD) Definition Misnomer:- Histologic examination shows no evidence of inflammation Unlike osteonecrosis,the underlying bone from which the fragment separates has normal vascularity Juvenile OCD in patients with open physes ;adult OCD in skeletally mature patients.

9. Osteochondritis Dissecans(OCD) Etiology Unknown Repetitive micro-trauma Soccer, American football, basketball Overhead throwing athlete (eg, baseball pitcher) or gymnast Local ischemia after a single injury Genetic predisposition ex. multiple epiphyseal dysplasia Anatomic: tall tibial spine,varus or valgus deviations Disturbance of epiphyseal development Etc……

10. Osteochondritis Dissecans Epidemiology Rare cause of joint pain in children( knee OCD in 15 to 29/100,000 pts) Boys :Girls =2 -3 :1 Peak ages between 10 and 20 years Ankle OCD lesion is rare in children ;common in adults Knee OCD are the most common lesions

11. Osteochondritis Dissecans Epidemiology Knee – 75 %, often in lateral portion of MFC(high load) Elbow – 6 %, usually the capitellum Ankle – 4 %, particularly the talar dome (57 % medial and 43% lateral ) Other joints( hip,shouder ,…) – Approx.. 15 % Bilateral in up to 20 to 30% of patients

12. Knee OCD Sites of lesions of osteochondritis dissecans of knee according to Hefti et al. (A) and Aichroth (B) .

13. Pathophysiology

14. .

15. OCD :-Classification Stage Radiographic findings MRI findings Arthroscopic findings I Depressed osteochondral fragment Articular cartilage thickening and low signal changes Irregular and softened articular cartilage with no fragment II Partially detached fragment Articular cartilage breached, low signal rim behind fragment representing fibrous attachment Articular cartilage breached with definable fragment that is not displaceable III Detached, nondisplaced fragment Articular cartilage breached, high signal changes behind fragment indicating synovial fluid between fragment and subchondral bone Articular cartilage breached with definable fragment that is displaceable but attached by overlying articular cartilage IV Loose foreign body Loose foreign body Loose foreign body

16. Osteochondritis Dissecans Clinical features Depends on location, size and severity of lesion Insidious pain (worsened by exercise) in the knee, elbow, or ankle Crepitus , catching, or locking during later stages, especially with loose body Tenderness , effusion ,Wilson test(knee), radiocapitellar compression test

17. Osteochondritis Dissecans Diagnosis Clinical Plain radiographs MRI Arthroscopy Other imaging  —  CT, U/S, and bone scan

18. Special knee views Tunnel/ intercondylar notch view Merchant /sunrise view

19. OCD:-MRI Imaging study of choice for diagnosis Assess surrounding cartilage and subchondral bone Differentiate normal ossification centers from OCD Identifies early changes before changes seen on r adiographs Associated ligamentous and meniscal injuries Assess stability of the bony fragment

20. OCD:-MRI Suggestive of unstable fragments Presence of an underlying high-signal intensity line between the lesion and underlying bone , Subchondral cysts Focal articular defect Displacement of the osteochondral fragment Articular cartilage discontinuity with synovial fluid tracking below the lesion

21. OCD:-MRI Determines treatment plan Juvenile OCD lesions…..mostly non-operative Lesions less than 3cm in diameter… Arthroscopic Lesions of 3 to 8 cm in diameter… Open Lesions of greater than 8 cm in diameter…. Open removal and defect treatment

22. OCD:-Treatment Goals of treatment Promote healing before physeal closure Prevent detachment of the lesion

23. OCD:-Treatment Non-Operative treatment Operative treatment (Open or arthroscopic)

24. OCD:-Treatment Non-operative treatment Most skeletally immature patients with stable and small lesions Knee :- <2 cm in length, <6 % scaled surface area or <200 mm 2 on MRI; Elbow :- affecting <50 % of the capitellum surface Stage I, II, or III juvenile osteochondritis Adult OCD with small, stable (Stage I or II) lesions

25. OCD:-Treatment Non-operative treatment Rest, Immobilization (casting, splinting, or brace) Until resolution of symptoms Evidence of healing on imaging Immobilization for 6 to 12 weeks NSAIDs for short term pain relief Physical Therapy after the lesion healed

26. OCD:-Treatment Healing is largely determined by Skeletal maturity, Lesion characteristics (size or stability), and Joint affected Usually occur within 6 months.

27. OCD:-Treatment Healing rate Juvenile OCD Approx…. 50 to 90 %for lesions in the knee or elbow Approx….45 to 60% for lesions of ankle Highest in patients with Stage I OCD Adult OCD with small, stable (Stage I or II) lesions Healing rate is approx.. 50% or less

28. OCD:-Treatment Operative Treatment No response after 4 to 6 months of nonoperative therapy(Juvenile OCD) Most patients with adult OCD Large lesions (Knee :- >2 cm in length ;Elbow :- >50 % of the capitellum surface) Intra articular foreign bodies (Stage IV lesion ) Unstable lesions

29. OCD:-Treatment Operative treatment options depends on Lesion characteristics ( size,stability , stage) Patient’s skeletal maturity Pre ..op evaluation of the lesion Weight-bearing nature of the lesion

30. OCD:-Treatment Operative Treatment options Drilling ( antegrade ,retrograde) Fragment fixation Fragment excision Debridement/microfracture of the crater Osteochondral grafting to replace larger defects and restore articular congruity. Autologous osteochondral graft (mosaicplasty ) Autologous chondrocyte transplantation

31. OCD:-Treatment Drilling Of The Lesion With 1.6-mm K -wire to a depth of 1.0 to 1.5 cm at intervals of 3 to 4 mm to promote vascular healing. For stable lesions(stage I & II ) in immature patients Less successful in adult OCD Antegrade (transarticular) or retrograde techniques Care not to cross the physis

32. Antegrade vs retrograde drilling

33. OCD:-Treatment Fragment fixation Headless(Herbert) screws, cannulated screws, and biodegradable pins and screws.

34. OCD:-Treatment Excision of loose bodies Small fragments (<2 cm ) Multiple fragments Fragments with inadequate bone stock (usually purely cartilaginous) Fragments that cannot be secured with internal fixation Unsalvageable fragment

35. OCD:-Treatment Debridement/Microfracture of crater If the fragment is not salvageable To stimulate fibrocartilage coverage of smaller defects (< 1cm ) without excessive lesion depth. Curette all fibrous tissue to expose subchondral, bleeding bone. At 4-mm intervals, with return of fat droplets confirming depth of penetration .

36. OCD of t he Patella Rare Subchondral bone and cartilage of articular surface Painful and quite debilitating. Boys age 10 to 15 years Should be differentiated from a dorsal defect of the patella

37. Patella OCD

38. Dorsal defect of the patella

39. Patella OCD :-Treatment Non-operative treatment Restriction of activities and immobilization Surgical treatment If conservative treatment fails Defect with viable loose body Refresh crater and the loose body Fix it small-diameter Herbert screw Defect with old loose body Remove loose body and debride and drill the crater

40. OCD :- Prognosis Depends on Age of the patient, Type of treatment Lesion characteristics(progression , size , stability) Amount of subchondral bone present, and Location of the lesion, especially as it relates to weight bearing.

41. Menelaus-Batten syndrome Osteochondritis of the upper pole of patella Diagnosis Clinical Pain and tenderness Radiograph irregularity with fragmentation Treatment Resolves with rest

42. Larsen-Johansson Disease Traction apophysitis of inferior pole of patella Diagnosis Clinical features Pain and tenderness Plain radiographs (with four stages) Normal Irregular calcification Coalescence of the calcification Calcification is incorporated into the patella Treatment Resolves with rest and NSAIDs

43. Osgood Schlatter Disease Traction apophysitis of the proximal TT ( On next week session)

44. Köhler Disease Osteochondrosis of tarsal navicular (Alban Köhler in 1908) Usually occurs in boys than in girls, usually between 2 and 7 years old Navicular Ossification center The last tarsal bone to ossify Girls:- 1.5 to 2 years Boys :- 2.5 to 3 years Etiology Unknown Mechanical compression injury AVN secondary to periodic compression Genetic cause

45. Köhler Disease Diagnosis Clinical Pain and tenderness Radiograph(LA,OBL) Sclerosis D iminished in size and flattening

46. Köhler Disease Treatment Self-limiting Cast immobilization produce quicker resolution of symptoms. Operative treatment rarely is indicated When disabling symptoms persist Talonavicular arthrodesis( calcaneocuboid and naviculocuneiform joints should also be included)

47. Sever’s Disease Traction calcaneal apophysitis Common causes of heel pain in young athletes 8 to 12 years; boys >girls Bilateral in 40 to 61% of cases

48. Sever’s Disease Diagnosis Clinical features Heel pain, tenderness Calcaneal compression test Radiographs May show sclerosis and widening of the growth plate .

49. Sever’s Disease Treatment Aimed at decreasing the inflammation and stress placed on the apophysis Rest ,icing ,NSAIDs PT :- Stretching the gastrocnemius-soleus complex Heel cup or heel lift Proper footwear SLC for 3 to 4 weeks if symptoms fail to improve within 4 to 8 weeks

50. Iselin Disease Traction epiphysitis of 5 th metatarsal base (Iselin in 1912) Occur in young adolescents at the time of appearance of the proximal epiphysis of the 5 th metatarsal. Secondary center of ossification(5 th MT base) Girls at about age 10 years Boys at about age 12 years Fusion occurs about 2 years later Insertion of peroneus brevis tendon

51. Iselin Disease Diagnosis Clinical Pain on wt bearing Tenderness Swelling Oblique radiographs Enlargement and often fragmentation of the epiphysis Widening of the cartilaginous-osseous junction.

52. Iselin Disease Treatment Aimed at prevention of recurrent symptoms. Mild symptoms Rest , ice, and NSAIDs Severe symptoms C ast immobilization Internal fixation of the epiphysis is not indicated

53. Freiberg Infraction Osteochondrosis of the metatarsal head Usually the 2 nd MT but also 3 rd ,4 th and 5 th MTs

54. Freiberg Infraction Etiology Unknown AVN of the metatarsal head Repetitive stress on the metatarsal head

55. Freiberg Infraction Diagnosis Clinical Pain on wt bearing Tenderness Swelling if a synovitis is present Radiographs Flattening Irregularity Separated bone fragment

56. Freiberg Infraction Conservative treatment Hard-soled shoe Metatarsal pad in the shoe Cast immobilization Surgical treatment Not recommended during the acute stage, which may persist for 6 months to 2 years.

57. Freiberg Infraction Surgical treatment Indications Pain , deformity, and disability. Removal of loose body if present Techniques Joint debridement and metatarsal head remodeling Scraping the sclerotic area and replacing it with cancellous bone (smillie procedure), Osteochondral plug transplantation Dorsal wedge osteotomy, Total joint arthroplasty

58. Kienbock disease Osteochondritis of lunate Diagnosis Clinical Affect young adult Pain, stiffness, tenderness Radiograph Dense fragmented lunate bone Osteoarthritic change(advanced case)

59. Kienbock disease Treatment Early stage splintage Wrist arthrodesis when the pain becomes sever

60. Osteochondritis :-Complications Early degenerative changes ( ex.Osteoarthritis )especially with knee OCD ;rare with ankle OCD Chronic pain and functional impairment M echanical symptoms Nonunion /failure of fusion Confusion with fractures Can create crater

61. References

62. Thank You.