KOHLER'S DISEASE

THOMAS D. BECK JR., D.O., Resident Orthopaedic Surgery

J. RICHARD BOWEN , M.D., Attending Pediatric Orthopaedic Surgeon

May 28, 1996

CLINICAL CASE PRESENTATION

ORTHOPAEDIC DEPARTMENT

THE ALFRED I. DUPONT INSTITUTE

WILMINGTON, DELAWARE

CASE HISTORY:

Patient is a six year old male with a three week history of right foot pain. Mother and patient relate no history of trauma. Patient came home from school three weeks ago with pain and swelling over the medial aspect of the right foot. Symptoms have persisted for past three weeks. Mother states patient has been ambulating with a limp.

PHYSICAL EXAM : There is tenderness to palpation and minimal swelling over the medial aspect of the right navicular. The lateral border of the foot is straight without significant metatarsus adductus. The hindfoot is supple and there is a normal arch. Examination of the left foot is unremarkable.

RADIOGRAPHS : AP, lateral and oblique views bilateral feet demonstrate bilateral avascular necrosis of the navicular.

ASSESSMENT : Kohler's disease right foot.

TREATMENT : Patient was placed in a short leg walking cast on the right for five weeks. Patient was asymptomatic after cast removal. Patient returned to full activity and was still asymptomatic at return visit six weeks later. Patient was to return on a PRN basis.

INTRODUCTION:

• osteochondrosis of the tarsal navicular
• described in 1908 by Kohler
• characterized by the radiographic findings of flattening, sclerosis and irregular rarefaction
• more common in boys
• approximate age of onset :
• boys : 5 years
• girls : 4 years
• one third of cases have involvement of both feet

ETIOLOGY:

• the cause of Kohler's disease is unknown
• etiology may be mechanical
• result of repetitive compressive force
• navicular is the last bone in the foot to ossify
• irregularities of ossification are not uncommon and are more often seen in :
• boys
• navicular which ossifies late
• Waugh
• serial radiographic study of normal children
• post- mortem injection studies naviculars of varying ages
• radiographic analysis of children with Kohler's disease
• conclusions :
• abnormal ossification results from compression of the bony nucleus at a critical phase during growth of a navicular bone whose appearance is delayed
• symptoms in Kohler's disease are related to further compression which produces vascular changes in the bony nucleus, ischemia and pain

CLINICAL FEATURES

• limp ( may ambulate on lateral border of foot )
• pain and tenderness localized to region of the navicular
• swelling (may or may not be present )
• normal range of motion in the ankle and subtalar joints

RADIOGRAPHIC FINDINGS

• flattening of the navicular
• narrowing of the navicular AP diameter in the lateral view
• irregular rarefaction and sclerosis
• irregular ossification of the navicular is seen in normal feet
• diagnosis of Kohler's disease should only be made when symptoms are present

TREATMENT

various treatment have been suggested

• skillful neglect
• shoe inserts
• rest
• casting

Williams and Cowell

• no difference in final outcome despite method of treatment
• type of treatment did effect duration of symptoms
• not casted
• asymptomatic in average of 15.2 months
• casted > 8 weeks
• asymptomatic in average of 2.5 months
• casted < 8 weeks
• asymptomatic in average of 4 months

LONG TERM RESULTS

Ippolito

• 12 patients with average of 33 year follow-up
• no symptomatic patients
• radiographically normal appearing navicular in an average of 8 months
• independent of the type of treatment
• no patients with degenerative changes

Williams and Cowell

• 20 patients with average of 9.5 year follow-up
• all patients asymptomatic at follow-up
• no evidence of arthritis
• all patients had navicular with normal radiographic appearance

Borges, Guille and Bowen

• 14 patients with average of 31.5 year follow-up
• 12 asymptomatic, 2 symptomatic
• symptomatic patients
• one patient with flatfoot and an accessory navicular
• one patient with tarsal coalition and degenerative changes
• patients with continued symptoms should be carefully examined for other causes of pain

REFERENCES:

1. Borges, et al. : Kohler's Bone Disease of the Tarsal Navicular. JPO 15:596-598, 1995.
2. Ippolito, et al. : Kohler's Disease of the Tarsal Navicular : Long-Term Follow-up of 12 Cases. JPO 4:416-417, 1984.
3. Karp : Kohler's Disease of the Tarsal Scaphoid. JBJS 19:84-96, 1937.
4. Morrissy and Weinstein : Lovell and Winter's Pediatric Orthopaedics : Volume II, p.1101, Fourth Edition
5. Siffert : Classification of the Osteochondroses. CORR 158: 10-18, 1981.
6. Waugh : The Ossification and Vascularization of the Tarsal Navicular and Their Relation to Kohler's Disease. JBJS 40-B:765-777, 1958.
7. Williams, et al. : Kohler's Disease of the Tarsal Navicular. CORR 158: 53-58, 1981.