Osgood Schlatter disease is a painful swelling of the tibial tubercle that occurs in adolescents, usually caused by trauma from repetitive knee bending and quadriceps contraction. It results when the tibial tubercle separates from the tibia due to pulling from the quadriceps before fusion is complete, leading to avascular necrosis. Conservative treatment with rest, bracing, and physical therapy is usually effective. Surgery to remove bony fragments may be considered for persistent severe symptoms but long term outcomes are generally no better than non-surgical treatment.

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.
1. The tubercle undergoes aseptic necrosis
2. The Neighboring bone undergoes active
hyperemia leading to osteoporosis
3. 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 :
1. swelling of the unossified cartilage and overlying
soft tissues
2. fragmentation and irregularity of the ossification
center
3. thickening of the distal patellar tendon
4. 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 similar 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.
1. Tibial sequestrectomy (removal of the fragments)
may relieve acute symptoms, but long-term results
are no better than conservative treatment.
2. 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.
• All 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.