Juvenile Osteochondrosis

Objectives • Definition • Anatomy and Physiology of Normal/Abnormal bone growth • Types • Clinical Presentation • Maaageetnagement • Prevention Definition • Group of growth cartilage abnormalities that occur at the apophysis,atthejointsurface,andatthe, at the joint surface, and at the physeal plate • They have been defined by Siffert as “idiopathic conditions characterized by disorderliness of endochondral ossification,,g including both chondrogenesis and osteogenesis that comes upon a formerly normal growth mechanism”

Definition

• Etiology – Debatable; vascular , hormonal , genetic , and metabolic factors as well as infections have all been proposed as precipitating or contributing causes. • These conditions may merely represent abnormalities of maturation. • Because diagnosis typically depends on radiographic confirmation, many of the osteochondroses carry the name of the individual who first described their radiographic appearance. Normal Physiology

Pathophysiology of Osteochondrosis

• The osteochondrotic process is essentially degeneration of the epiphyseal osseous nucleus. • This process is almost certainly due to either – (1) interference with the blood supply, which leads to necrosis of the cartilage-canal vessels in the subchondral bone and adjacent epiphysis – (2) failure of the bony centrum to enlarge and disordered proliferation of the cartilaginous cells in the epiphysis. Secondary changes (eg, fragmentation, collapse, and sequestrum formation) develop in accordance with the characteristics of the affected region. Location Eponym

Carpal Scaphoid Presier disease Lunate KienbÖck disease Medial cuneiform Buschke disease Patella Köhler disease Talus Mouchet disease Tarsal Scaphoid Köhler disease Vertebral body Calvé disease (LCPD) Vertebral epiphysis Scheuermann disease Iliac crest BhBuchman disease Symphysis pubis Pierson disease Ischiopubic junction Van Neck disease Ischial Tuberosity Valtancoli disease Calcaneal apophysitis Sever disease Accessory tarsal navicular Haglund disease Second metatarsal Freiberg disease/infarction 5th metatarsal base Iselin disease Talus Diaz disease Distal tibial epiphysis Lewin disease PilProximal tibial epihiphys is Bloun t disease Tuberosity of the tibia Osgood-Schlatter

20 patellar center Sinding-Larsen-Johansson syndrome Lesser trochanter of the femur Monde-Felix disease Greater trochanter of the femur Mandl or Buchman disease Capital epiphysis of the femur LCPD Phalanges Thiemann Syndrome Metacarpal heads Mauclaire disease Proximal epiphysis of the radius Schaefer disease Distal epiphysis of the ulna Burns disease

Types

• Articular Osteochondrosis – Primaayry: Primaayry inv olv eme nt tot of th eatcuae articular a nd depp epiphysea yseacatageal cartilage and dasubjacet a subjacent eedocodandochondral ossification center – Freiberg disease – Secondary: Secondary involvement of the articular and epiphyseal cartilage as a consequence of ischemic necrosis of subjacent bone – Perthes disease, Köhler disease, osteochondritis dissecans • Non-Articular Osteochondrosis – Tendinous attachments - Osgood-Schlatter syndrome, Monde-Felix disease – Ligamentous attachments - Vertebral ring – Impact sites - Sever disease • Physea l OtOsteoc hon dros is – Long bones – Tibia vara (Blount disease) – Scheuermann disease/kyphosis Clinical Presentation of Osteochondrosis • Localized tenderness • Limited movement of adjacent joints • Swelling • Gait disturbance (when the disease affects the lower limbs) • Reactive effusion in an adjacent joint (sometimes observed)

– If systemic signs- Look for other causes!!!

Articular Type: Primary Freiberg’s Infraction Case

• 12 year old male • Presents with vague, non-localized knee pain • Endorses occasional locking symptoms • Exam: quad weakness, full knee extension lagging final 10 degrees. • Positive Wilson test (knee flexed 90 degrees and tibia internally rotated) • Diagnosis?

Articular Type: Secondary Osteochondritis Dessicans Knee OCD Knee

Complications

• The general rule is the younger the patient, the better the prognosis. Guidelines for treatment are outlined by the following categories: • Category 1 (ie, girls younger than 11 y, boys younger than 13 y): These patients usually do well with non-operative treatment. • Category 2 (girls aged 11-15 y, boys aged 13-17 y): These patients are near skeletal maturity. Treatment depends on the looseness of the lesions. • Category 3: Physeal closure and skeletal maturity have occurred. Treatment is based on the size and stability of the lesion . – Grade 1 - Positive radiography findings and an intact articular surface – Grade 2 - Articular injury noted at arthroscopy – Grade 3 - Loose lesion (stays within crater) – Grade 4 - Loose fragment within joint Treatment of OCD Knee Conservative

• In children with non-displaced fragments, initial treatment includes limitation of activity with the use of crutches and restricted range of motion (knee immobilizer, range-of-motion brace).

• Recommend a trial of non-operative treatment for 3-6 months. If symptoms persist or failure to unite is observed, proceed with surgical treatment

Treatment of OCD Knee Surgical

– Arthroscopy – Drilling – for improved vascularity – Pinning – for loose body stabilization – Excision of loose bodies – OATS (Osteochondral Autograft Transplantation Surgery) • Involves harvesting cylindrical osteochondral grafts from other areas of the knee to reconstruct a weight-bearing surface. A maximum 1-cm lesion (crater) depth is allowed for use of this treatment method. – Osteochondral allograft transplantation is similar to OATS except that a freshly harvested allograft condyle is used. The advantages are that the exact condyle curvature can be reconstructed and no further defect is created during autograft harvest. Case

• 13 year old baseball pitcher • PtdithlbiPresented with elbow pain • Endorses catching/locking symptoms • Exam: crepitus, muscular atrophy • Differential: Panner’s disease vs. OCD of the elbow

Elbow Osteochondrosis

• Panner’s disease: Osteochondrosis of the capitellum (Little League Elbow) – Affects children generally 5-10 yrs old – Affects growth plate – Symptoms resolve as bone matures • OCD elbow – Affects adolescents – Localized injury to subchondral bone; results from repetitive lateral compression of the elbow during overhead motions – Crepitus/locking and catching due to loose bodies Complications of Little League Elbow

• Most complications arise from a thrower attempting to return to pitching too soon before rehabilitation is complete, or from a pitcher who continues to play while symptomatic. • Presence of pain while performing competitive pitching is highly correlated with an increased risk of medial epicondylar avulsion fracture and the subsequent need for surgical stabilization. • Athletes should be counseled to stop or avoid pitching at any time when elbow pain is present, and these individuals should seek an evaluation before returning to pitching.

Little League Elbow Surgery • Medial epicondylar fractures may require either closed reduction and casting or surgical reattachment with fixation if displacement, elbow instability, or failure of conservative treatment occurs. • If loose bodies or osteophytes are present with olecranon injuries, surgical removal may be indicated in those who are symptomatic. Bone grafting may also be used in cases of olecranon nonunion when rest and immobilization have failed. • All throwers who have had surgical treatment for elbow pain require some form of progressive reha bilitati on i ncl udi ng a thhbihilihilihorough biomechanical pitching analysis. Pitchers should be counseled that many do not return to the previous level of throwing following surgical treatment of elbow injuries; however, outcomes vary based on the individual circumstances. Case • 3 year old girl • Presentedhd with spontaneous righ hddlt sided limp • On exam – Tenderness over the Tarsal/Navicular

• Osteochondrosis? Articular Type: Secondary Kohler’s Disease of the Tarsal Navicular

Non-Articular - Tendonous Osgood Schlatter’s Non-Articular Sever’s Disease Physeal Osteochondrosis Blount’s Disease

Physeal Osteochondrosis Scheuermann’s Kyphosis Treatment Algorithm

• Protection and prevention of additional trauma • Prevention of secondaryyy deformity • Reduction of the transmission of mechanical stresses to the bone during the process of reossification • Facilitation of reossification • Removal of osteochondrotic fragments that have become loose bodies • Compensation for fixed bony deformities by means of realignment • Intervention with salvage surgery if indicated

Rehab Protocol

• Typical Program 5 phases – Phase I – Decreasing inflammation – Phase II – Improving Range of Motion – Phase III – Improve Strength and Proprioception – Phase IV – Return to Functional Skills – Phase V – Return to Sport • Children Progress faster than adults • One must master 75-80% of the goals of each phase before progressing to the next phase Questions? References

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