Kohler's Disease Aetiology, Pathogenesis, diagnosis, conservative and operative management from Campbell & Turek's

1. Kohler’s Disease
Osteochondrosis of Navicular
Aseptic Necrosis of navicular
Presented by Dr Yash Oza
Moderator Dr Umesh Jain

2. • Osteochondrosis of the tarsal navicular originally
was described by Kohler in 1908.
• It is characterized by aseptic necrosis of navicular
bone, casing a painful limp in a child.

3. • Navicular is last bone to ossify.
• Ossification centers of the navicular appear
between the ages of
• 1.5 and 2 years in girls and
• 2.5 and 3 years in boys.
• Normally, navicular ossification is quite variable &
not infrequent to find flattened/dense/fragmented
ossific nucleus.

4. Pathogenesis
• Histological studies shows scattered area of aseptic
necrosis and bone absorption.
• This suggests vascular origin of the diseases.
• In first few years of life, cartilaginous navicular is
surrounded by ring of vessels.
• From this network, a single artery penetrates to the
center of the structure.
• Soon it is surrounded by developing ossifications.
• And other arteries follow and multiple area of
ossification are formed and joined into the large ossific
nucleus.

5. • Occasionally a single vessel is the sole supply until
the age of 4 to 6 years. And ossification is
dependent on a single artery.
• On weight bearing, the forces compress the
navicular constantly and may compromise vascular
supply.
• The ossification center undergoes aseptic necrosis.
• A reactive hyperemia also develops around the
bone.
 Later on, Ingrowth on new vessels leads to
resorption & replacement of necrotic bone
eventually.

6. • Thus, Delayed ossification has been suggested to be
the earliest event because the lateness of
ossification of the navicular subjects it to more
pressure.
• 2 types of abnormalities seen
1. Flattened bone with patchy area of increased density
2. Normal shaped bone with overall increased density.

7. Clinical Presentation
• Age group – 4-10 years
• Both saxes affected (M>F)
• Child limps with complaint of pain in foot
• There is a tender swelling over navicular area.
• Local heat may be present due to hyperemia.

8. Radiographic finding
• In plane radiograph navicular shows increase in
density, loss of trabecular structure & alteration in
shape and size.

9. Diagnosis
• Clinical Features + Xray finding = Kohler’s Disease
• Asymptomatic + Xray Finding = irregularity of
ossification

10. Treatment
• This is a self-limiting condition , and operative
treatment rarely is indicated.
• Cast immobilization has been reported to produce
quicker resolution of symptoms. But not hasten the
restoration process.
• Cast worn for several weeks is followed by rigid
shank shoe with thomas heel.

11. Outcome of conservative
treatment
Flattened variety with
patchy density
Normal shape with
increased density
Over a period of 2 years
the size & shape are
gradually restored, and
the trabecular pattern
reappears.
Within few months the dense
bone is gradually absorbed
until a faint ossific shadow
remains.
At about 2 years after onset,
several small ossification
make their apperience &
bone starts restoring.
It taken upto 3 years
The navicular is almost always reconstituted to normal

12. Surgical Treatment
• Pain and disability occasionally develop after
osteochondrosis when the navicular becomes
distorted and sclerotic, the head of the talus
becomes flattened, the articular surfaces of the
two bones become fibrillated, and osteophytes
form along the margin of the articular surfaces.
• Surgery is indicated when disabling symptoms
persist.

13. • Arthrodesis is the only operation of value,
• The midtarsal joints (talonavicular and
calcaneocuboid) can be arthrodesed
• The calcaneocuboid joint is included because most
of its function is lost when the talonavicular joint is
fused.
• The results of this operation usually are excellent; most
patients become symptom free but may notice loss of
lateral movements of the foot.

14. • When symptoms arise from the naviculocuneiform
joints also, these joints should be included in the
fusion.
• Here arthrodesis is difficult to secure; metallic
internal fixation and inlay grafts of autogenous
cancellous bone are helpful.