Juvenile Osteochondrosis

Transcription

1 Juvenile Osteochondrosis Definition Objectives Anatomy and Physiology of Normal/Abnormal bone growth Types Clinical Presentation Management age e Prevention

2 Definition Group of growth cartilage abnormalities that occur at the apophysis,atthejointsurface,andatthephyseal at the surface, and at the physeal plate They have been defined by Siffert as idiopathic conditions characterized by disorderliness of endochondral ossification, 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.

3 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.

4 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 Buchman 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 5 th metatarsal base Iselin disease Talus Diaz disease Distal tibial epiphysis Lewin disease Proximal ltibial epiphysis i Blount disease Tuberosity of the tibia Osgood-Schlatter 2 0 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 Primary: ayprimary ayinvolvement e tof the eatcua articular and depp epiphyseal cartilage cat ageand dasubjace subjacent tendochondral o d 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 Physeal Osteochondrosis Long bones Tibia vara (Blount disease) Scheuermann disease/kyphosis

5 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

6 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

7 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 y, boys aged 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

8 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.

9 Case 13 year old baseball pitcher Presented 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

10 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 rehabilitation i including a thorough h biomechanical i 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.

11 3 year old girl Case Presented with spontaneous right sided dlimp On exam Tenderness over the Tarsal/Navicular Osteochondrosis?

12 Articular Type: Secondary Kohler s Disease of the Tarsal Navicular Non-Articular - Tendonous Osgood Schlatter s

13 Non-Articular Sever s Disease

14 Physeal Osteochondrosis Blount s Disease Physeal Osteochondrosis Scheuermann s Kyphosis

15 Treatment Algorithm Protection and prevention of additional trauma Prevention of secondary 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

16 Questions?

17 References Resnick D. Osteochondroses. In: Resnick D. Diagnosis of bone and joint disorders. 4. 4th. Philadelphia, Pa: WB Saunders; 2002: Symposium: the osteochondroses. Clin Orthop Relat Res. Jul-Aug 1981;(158):1-98. Bertone AL, Bramlage LR, McIlwraith CW, Malemud CJ, Malemud CL. Comparison of proteoglycan and collagen in articular cartilage of horses with naturally developing osteochondrosis and healing osteochondral fragments of experimentally induced fractures. Am J Vet Res. Nov 2005;66(11): Monfort J, Garcia-Giralt N, López-Armada MJ, Monllau JC, Bonilla A, Benito P, et al. Decreased metalloproteinase production as a response to mechanical pressure in human cartilage: a mechanism for homeostatic regulation. Arthritis Res Ther. 2006;8(5):R149. Damborg F, Engell V, Andersen M, Kyvik KO, Thomsen K. Prevalence, concordance, and heritability of Scheuermann kyphosis based on a study of twins. J Bone Joint Surg Am. 2006;88(10): Gee E, Davies M, Firth E, Jeffcott L, Fennessy P, Mogg T. Osteochondrosis and copper: histology of articular cartilage from foals out of copper supplemented and non-supplemented dams. Vet J. Jan 2007;173(1): Demirag B, Ozturk C, Yazici Z, Sarisozen B. The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation. J Pediatr Orthop B. Nov 2004;13(6): Visuri T, Pihlajamäki HK, Mattila VM, Kiuru M. Elongated patellae at the final stage of Osgood-Schlatter disease: a radiographic study. Knee. Jun 2007;14(3): Kim HK, Morgan-Bagley S, Kostenuik P. RANKL inhibition: a novel strategy to decrease femoral head deformity after ischemic osteonecrosis. J Bone Miner Res. Dec 2006;21(12): Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW. Osgood Schlatter syndrome. Curr Opin Pediatr. Feb 2007;19(1): Bradley JP. Upper extremity: elbow injuries in children and adolescents. In: Stanitski CL, DeLee JC, Drez D Jr, eds. Pediatric and Adolescent Sports Medicine. Vol 3. Baltimore, Md: WB Saunders Co; 1994: Benjamin HJ, Briner WW Jr. Little league elbow. Clin J Sport Med. Jan 2005;15(1): Congeni J. Treating and preventing little league elbow. Phys Sportsmed. 1994;22(3): Emery HM. Considerations in child and adolescent athletes. Rheum Dis Clin North Am. Aug 1996;22(3): Micheli LJ. Overuse injuries in children's sports: the growth factor. Orthop Clin North Am. Apr 1983;14(2): Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am. Jul 2000;84(4): , viii. Rudzki JR, Paletta GA Jr. Juvenile and adolescent elbow injuries in sports. Clin Sports Med. Oct 2004;23(4): , ix. Stanitski CL. Combating overuse injuries: a focus on children and adolescents. Phys Sportsmed. 1993;21(1): Stanitski CL. Pediatric and adolescent sports injuries. Clin Sports Med. Oct 1997;16(4): American Academy of Pediatrics. Risk of injury from baseball and softball in children. Pediatrics. Apr 2001;107(4):782-4.