OSGOOD-SCHLATTER DISEASE

JEFFREY GUTTMAN, M.D., Resident, Orthopaedic Surgery

WILLIAM MACKENZIE,M.D., Attending, Pediatric Orthopaedic Surgery

April 23, 1996

CLINICAL CASE PRESENTATION

ORTHOPAEDIC DEPARTMENT

THE ALFRED I. DUPONT INSTITUTE

WILMINGTON, DELAWARE

CASE HISTORY:

Patient is a 12 year old black male who initially presented with a history of left knee pain for 4 months. He denied any obvious history of trauma, but he claimed to play a lot of basketball and felt that the pain was worse after playing. Patient also claimed to have a "knot" over the anterior aspect of his proximal tibia. On physical examination the patient had a prominent tibial tubercle which was swollen and tender. The knee did not have an effusion, and there was no joint line tenderness. There was also no tenderness over the patellar tendon. There was full range of motion in the knee, but the patient had hamstring tightness. He also had pain with resisted knee extension. There was no instability to varus or valgus stress. McMurray test was negative. Lachman test was negative. Patellar tracking was normal, and there was no pain with loading of the patellofemoral joint. Xray of the left knee revealed an ossicle anterior to the tibial tuberosity. Patient was diagnosed with Osgood-Schlatter disease and told to refrain from playing ball for 4 weeks. He was also given a prescription for Motrin. The patient continued to play and returned complaining of increased pain and tenderness at the tibial tuberosity. The patient was then placed in a knee immobilizer for 4 weeks to be removed for stretching exercises. At his most recent follow-up, the patient's pain is resolved , although he continues to have pain with kneeling on the knee or contact on the tuberosity.

Introduction

• Originally described simultaneously by Osgood and Schlatter in 1903
• Lesion affects adolescent apophysis of proximal tibia (particularly in young athletes)
• More commonly affects boys than girls (3:1)
• Boys are older at presentation (correlates with ossification dates)
• Bilateral 25-50%
• Controversy regarding etiology, natural history, and treatment

Anatomy

• Apophysis of tibial tuberosity develops from a few ossification centers
• Calcification begins distally (average age 9 in girls, 11 in boys)
• Ossification centers then fuse with each other and coalesce with proximal tibial epiphysis (average age 12 in girls, 13 in boys)
• Blood supply from anterior, lateral and medial surfaces of tuberosity. Also vascular communication with metaphysis via traversing canals across physis (may still be open at 10-12 years)

Etiology

• Most commonly accepted: microavulsions caused by repeated traction on anterior portion of developing ossification center of tibial tuberosity. Inflammation and reparative changes cause pain , swelling, tenderness.
• Multiple studies in which patients who did not respond to conservative treatment had mobile ossicle
• Recent MRI/CT study: tendonitis may be as important as apophysitis. All patients had MR changes c/w tendonitis which showed partial resolution with symptomatic improvement
• Often referred to as osteochondrosis, but AVN seems unlikely

-excellent blood supply

-don't see stages of sclerosis, collapse, remodeling like Perthes

Signs and Symptoms

• Pain, heat, tenderness at tibial tuberosity
• Local swelling
• Prominent tibial tuberosity
• Pain with resisted knee extension

Radiography

• Limited role. Clinical diagnosis.
• Soft tissue swelling anterior to tuberosity is most common finding
• XRay: may see ossicle.

Fragmentation of tibial tubercle may be normal variation in ossification

• CT/MRI: changes at insertion of patellar tendon.

Distended infrapatellar bursa.

• U/S: Thickening of patellar tendon near insertion (more echogenic).

Hypoechoic area of soft tissue swelling anterior to tubercle

Single or multiple fragments

Differential Diagnosis

• Infection
• Malignancy
• Tibial tubercle fracture
• Patellar tendonitis (Jumper's Knee)
• Sinding-Larsen-Johansson Disease (analogous condition at inferior pole patella)

Treatment: Overview

• Variable course, symptoms often recur - makes treatment difficult
• Natural history of untreated disease:

-most with no limitation of activity

-many unable to kneel without pain

-if fragmentation on XRay, much more likely to have chronic symptoms

• Symptoms usually resolve spontaneously with closure of physis so coax along with conservative treatment

Conservative Treatment

• Withdrawal from active sports that cause pain
• Ice, NSAIDs, pad to protect tuberosity
• Infrapatellar strap during activity
• Steroid injection NOT recommended (risks; very questionable efficacy)
• Cast immobilization for 6 weeks if severe symptoms

-excellent relief of symptoms

-atrophy of muscles prolongs return to sports

-does not alter course of disease

Surgical Treatment

• Rarely indicated. Conservative treatment works >90%
• Usually after ossification of tuberosity or separate ossicles that are symptomatic
• Careful removing ossicles when apophysis not yet fused (can cause recurvatum)
• No large studies because surgery rarely indicated
• Excision of ossicles with or without excision of prominent tubercle (Thompson-Ferciot tubercle thinning procedure) can give 85-95% good results (Binazzi, et al; Flowers, et al; Mital, et al). Better results than drilling of tubercle or reattachment of non-union.
• Trail, et al showed no difference in results conservative vs. surgery. Also, 50% complications (most common was residual prominence)

Complications

• Continued pain with kneeling
• Increased incidence tibial tuberosity fracture
• Genu Recurvatum
• No good evidence to support association with patella alta, recurrent subluxation, chondromalacia

References

1. Binazzi, et al.: Surgical Treatment of Unresolved Osgood-Schlatter Lesion. CORR 289:202, 1993.
2. Flowers, et al.: Tibial Tuberosity Excision for Symptomatic Osgood-Schlatter Disease. JPO 15:292, 1995.
3. Krause, et al.: Natural History of Osgood-Schlatter Disease. JPO 10:65, 1990.
4. Kujala, et al.: Osgood-Schlatter's Disease in Adolescent Athletes. Am J Sports Med 13(4):236, 1985.
5. Lanning, et al.: Ultrasonic Features of the Osgood-Schlatter Lesion. JPO 11:538, 1991.
6. Lynch , et al.: Tibia Recurvatum as a Complication of Osgood- Schlatter's Disease: A Report of Two Cases. JPO 11:543, 1991.
7. Mital, et al.: The So-Called Unresolved Osgood-Schlatter Lesion. JBJS 62A(5):732, 1980.
8. Ogden, et al.: Osgood-Schlatter's Disease and Tibial Tuberosity Development. CORR 116:180, 1976.
9. Rosenberg, et al.: Osgood-Schlatter Lesion: Fracture or Tendonitis? CT and MR imaging features. Radiology 185:853, 1992.
10. Trail, et al.: Tibial Sequestrectomy in the Management of Osgood-Schlatter Disease. JPO 8:554, 1988.
11. Wiss, et al.: Type III Fractures of the Tibial Tubercle in Adolescents. J Orthop Trauma 5(4):475, 1991.