2. What is
Osteochondrosis ?
A defect in ossification at either the
bone epiphysis (growing plate), the joint
surface itself, or at an apophysis (bony
projection);associated with avascular
necrosis and sclerosis.
Except kienbock’s disease
3. Incidence
children and young people (growth
phase of epiphyses)
boys than girls ex. Freiberg’s disease
13. Legg-calve-perthes
disease
Inherited thrombophilia
(hypercoagulability or a deficiency in
protein C activity) ®venous occlusion
® bone death in the femoral head.
Perinatal HIV itself, HIV-associated
complications, or HIV-related therapies.
14. Irritable Hip
Transient Synovitis
Boys 2:1
Age ~ 3 yrs
Duration ~ 6 days
Legg-calve-perthes Disease
Boys 3:1
Age ~ 7 yrs
Duration 6 wks
Bone age 2 yrs behind
15. Classification
Caterall et al.
Group I- partial or 1/2 head involved;
Groups II and III- 1/2 head involvement
and sequestrum formation;
Group IV involvement of the entire
epiphysis.
16. Head-at-risk signs
1. Lateral subluxation of femoral head ,
2. Speckled calcification lateral to capital
epiphysis,
3. Diffuse metaphyseal reaction (metaphyseal
cysts),
4. A horizontal physis &
5. Gage sign, a radiolucent V-shaped defect in the
lateral epiphysis and adjacent metaphysis
17. Classification
Salter and Thompson- simple and
accurate and can be applied early
Type A- extent of subchondral fracture
(line) is less than 50% of the superior
dome of the femoral head
Type B- fracture is more than 50% of
the dome
20. Imaging
plain radiographic -delayed ≥6 weeks from clinical onset
Bone scintigraphy and MRI -early Δsis
compare uptake with contralateral hip,
if uptake decreased < 50% Catterall group I or II.
If uptake decreased > 50% Catterall group III or IV, Salter type B, or
lateral pillar type C.
Henderson et al. MRI for extent & location also early accurate
head sphericity
Song et al.- widened medial joint space (1) overgrown cartilage in the
initial stage, (2) overgrown cartilage and widened true medial joint
space at the fragmentation stage, and (3) widened true medial
joint space at the healing stage decreased or normalized because
of ossification of overgrown cartilage despite the existence of
lateral subluxation owing to coxa magna.
21. Treatment
1. Noncontainment methods > good results (84%).
2. Satisfactory clinical results> at long-term> despite an
unsatisfactory radiographic appearance
3. The Catterall classification indicator of results, but is
not applicable ~ 8.1 months after onset.
4. Head-at-risk signs added little to the Catterall
classification as a prognostic indicator or therapeutic
guide.
5. All of the fair and poor results were in patients with
Catterall III or IV involvement and onset of the
disease at age 6 or older. (equivalent to Herring
groups B and C.)
26. Reconstructive Surgery
Valgus Extension Osteotomy
Valgus Flexion Internal Rotation
Osteotomy
Cheilectomy
Staheli or Catterall shelf augmentation
procedure
Chiari Osteotomy
29. Osteochondritis
Dissecans
subchondral bone ® necrotic and
degenerative cartilage overlying it ®
gradually separate from adj. bone and
cartilage to become a loose body
Knee>elbow>ankle>shoulder>hip
30. Theories of Etiology
ischemia,
repetitive microtrauma,
familial predisposition,
endocrine imbalance,
epiphyseal abnormalities,
accessory centers of ossification,
growth disorders,
osteochondral fracture,
repetitive microtrauma & subsequent interruption of
interosseous blood supply,
anatomic variations in the knee, and
congenitally abnormal subchondral bone.
31. Heffi et al (A) X Aichroth (B).
Young Adolescent
Male 2:1
B/L 30%
32. Clinical Features
vague, aching discomfort ~14 months,
Catching and popping, loose body;
effusion, joint line/local tenderness,
limitation of motion, McMurray sign and
quadriceps atrophy;
Wilson sign- Ext. Rotation gait
33. Imaging
B/L X-Ray :- AP, Lateral and tunnel or
intercondylar notch view;
technetium-99m bone scan
Sequential SPECT scans / 8 wk
CT in coronal plane
MRI - fragment attachment, stability &
viability + Soft tissue.
34.
35. Cahill & Berg classification
Stage Bone scan finding
0 Normal radiographic and scintigraphic appearance
1 Lesion visible on plain radiographs, bone scan normal
2 Increased uptake in area of lesion on bone scan
3 Increased isotopic uptake in entire femoral condyle
4 Uptake in tibial plateau opposite lesion
36. Dipaola et al.
Stage Arthrosopy MRI Radiographs
1 Irregular & soft
cartilage; no definable
fragment
Thickened
cartilage; low signal
changes
Compression lesion; no
visible fragment
2 Cartilage breached;
definable fragment, not
displaceable
Cartilage breached;
low signal rim
behind fragment
indicating fibrous
attachment
Fragment attached
3 Breached; definable
fragment, displaceable,
but attached by some
overlying cartilage
Cartilage breached;
high signal changes
behind fragment s/o
syn. fluid
Nondisplaced fragment
without attachment
4 Loose body Loose body Displaced fragment
37.
38. DD of Loose Body
(1) synovial chondromatosis,
(2) osteophytes,
(3) fractured articular surfaces and
(4) damaged menisci
39. Treatment
Age & degree of involvement
Conservative treatment - Cahill et al.
50% failure rate in juvenile population
Surgical treatment - drilling or excision
of fragment, débridement of crater,
different forms of fixation and grafting.
40. Operative treatment
Guhl’s indications
symptomatic knee in a patient skeletally
>12 years,
a lesion >1 cm in diameter &
involvement of weight bearing surface
Arthroscopy / open arthrotomy
41. Excision of Loose Bodies
Indications
small fragments (<2 cm),
multiple fragments,
fragments with inadequate bone stock
( cartilaginous) &
fragments that can’t be secured with
internal fixation
43. Iselin Disease
a traction epiphysitis of the base of the
fifth metatarsal occurring in young
adolescents at the time of appearance
of the proximal epiphysis of the fifth
metatarsal. German literature in 1912
peroneus brevis
oblique view
48. Treatment
Mild symptoms- limitation of sports
activity, application of ice and
administration of NSAID’s
Severe symptoms- cast immobilization
No internal fixation
57. Köhler Disease
Cowell and Williams
Radiographic findings as Köhler
disease (sclerosis, ¯ size,
fragmentation) asymptomatic foot ~
irregularity of ossification
Adviced cast immobilization
58. Köhler Disease
Pain & Disability
navicular ® distorted and sclerotic,
head of the talus ® flattened,
articular surfaces of both ® fibrillated &
marginal osteophytes
60. Osgood-Schlatter Disease
Apophysitis of tibial tubercle due to
traction injury & incomplete separation
by patellar tendon.
Pain, Lump,
Tender swelling, resisted knee
extension.
X-Ray - Fragmentation.
61.
62. Treatment
Conservative
restriction of activities or cast
immobilization for 3 to 6 weeks
Surgery - symptoms > 2 yrs, persistent
and severely disabling
63. Surgical Treatment
Tibial sequestrectomy (removal of the
fragments)
Bosworth technique of insertion of bone
pegs
Ferciot and Thomson ®excision of
ununited tibial tuberosity
64. Complications of OSD
Patellar subluxation,
Patella alta,
Nonunion of bony fragment and
Premature fusion of anterior part of
epiphysis ® genu recurvatum.
65. Kienböck disease
osteonecrosis of the carpal lunate
age 15 - 40 yrs male
dominant wrist of manual labor
fragmentation, collapse with shortening
of carpus
secondary arthritis in proximal carpal
area
66. Radiography
A anterior pole type # & capitate pressure
B Ratio of height of carpus to length of third metacarpal
normal 0.54 ± 0.03
67. Classification Lichtman et al.
Stage I: MRI with gadolinium enhancement may show
changes not seen on plain radiographs.
Stage II: outline is normal, but definite density changes
in lunate.
Stage III: Collapse or fragmentation of lunate & proximal
migration of capitate
Weiss et al. IIIA—sclerosis with fragmentation or
collapse or both. & IIIB—fixed rotation of the
scaphoid with IIIA changes.
Stage IV: gen. Deg. changes in carpus.
68. Treatment
Immobilization in a cast St. 1,2.
surgical procedures (ulna-minus
variant)
Joint “leveling” procedures - ulnar
lengthening and radial shortening
Osteotomies of the Distal Radius
Lunate Revascularization Procedures
Prosthetic Lunate Replacement
69. Panner’s Disease
Avascular necrosis of capitellum of
Humerus.
Non weight bearing joint.
7-10 yrs boys (11:1).
Etiology ?endocrine / trauma.
Prognosis good.
72. Tibia Vara (BLOUNT DISEASE)
an osteochondrosis similar to coxa
plana and Madelung's deformity but
located at the medial side of the
proximal tibial epiphysis. Blount's article 1937
Now Metaphyseal disease, Abnormal
endochondral ossification.
Etiology- trauma, infection, rickets,
osteonecrosis & Weight Bearing.
73. Tibia Vara
Infantile T.V.
< 8 years
bilateral and
symmetrical in
approximately 60%
deformity increases
progressively
Physiological Bowing
< 2 years
almost always
bilateral
resolve with growth.
77. Physeal bar
age > 5 years,
medial physeal slope - 50° to 70°,
Langenskiöld grade IV changes,
body weight > 95th percentile and
black girls who meet the previous
criteria
resection of Bar / Epiphyseodesis
Editor's Notes
Meyer dysplasia can be easily mistaken for Legg-Calvé-Perthes disease
and lead to unnecessary diagnostic procedures and treatment.
Rowe et al. noted that Meyer dysplasia was more common in
boys younger than 4 years old, and that 59% of their patients with Meyer
dysplasia had bilateral involvement. Characteristic findings included delayed
or smaller ossification centers on radiograph, a separated or cracked epiphysis
cystic changes, and mild pain and limping.
Condensation, subchondral fractures, fragmentation, and
subluxation were not observed.
amount of capital femoral epiphysis involvement
determining the extent of involvement by describing the extent of a subchondral fracture in the superolateral portion of the femoral head
