Osteochondrosis- Types, Presentation and Treatment

Osteochondrosis is a self-limiting developmental derangement of normal bone growth that primarily involves the centers of ossification in the epiphysis.

It is a kind of an aseptic ischemic necrosis in a previously normal epiphysis though the role of ischemia is not clearly proved yet.

As the research on osteochondrosis is gathering more data, few of the osteochondroses are being labeled as a phenomenon rather than disease or syndrome.

Classification of Osteochondrosis

It divides the osteochondroses into articular, nonarticular, and physeal types.

Articular osteochondrosis

•  Primary involvement of the articular and epiphyseal cartilage– Freiberg disease
•  Secondary involvement of the articular and epiphyseal– Perthes disease, Köhler disease [The primary pathology is ischemic necrosis of the bone]

Nonarticular osteochondrosis

• Tendinous attachments – Osgood-Schlatter syndrome, Monde-Felix disease
• Ligamentous attachments – Vertebral ring
• Impact sites – Sever disease

Physeal osteochondrosis

• Long bones – Tibia vara (Blount disease)
• Scheuermann disease

A List of Eponyms of Osteochondrosis is given below

Pathophysiology

A primary vascular event or trauma have been thought to result in ischemia of the ossification center. Social deprivation, dietary deficiency, and passive exposure to smoke have been implicated as causes.

Most osteochondroses occur shortly after the bony nucleus appears, around the middle of the growth spurt

Clinical Presentation and Diagnosis 

Pain that is localized to the affected site is the usual presentation in the initial stages. On examination localized swelling, tenderness, limited movement of a nearby joint may be noted. Lower limb involvement may show gait problems.

Growth disturbance and secondary deformities may occur in late stages.

Laboratory findings are mostly normal.

Xrays in the early stage show Early involvement typically results in an epiphysis of reduced size, increased opacity, and irregular architecture.
With advancement, fibrillation and fissures in the cartilage enlarge.

Revascularization phase results in osteoporosis, absorption of necrotic tissue, and deformation. Incomplete restoration of the blood supply and poor protection can lead to misshaped epiphysis.

Joint arthrosis is a late complication in cases of poor restoration.

MRI can pick up the disease at the asymptomatic stage and before x-ray changes. Early MRIs show focal hyperintensities in the epiphysis or neighboring soft tissues indicating edema. Marrow edema in the parent bone is also seen. Peripheral irregularity can be visualized.

Bone scintigraphy is again a very sensitive and specific test which can pick up the problem before symptoms. By showing an absence of tracer uptake representing low metabolic activity, and blood flow.

In the restoration stage, the scan shows increased flow or activity at the margin of the hypoactive, necrotic and neighboring physis and metaphysics.

A normal distribution marks the complete healing.

Bone scan is able to indicate the phase of disease as well and thus can be used as a prognostic marker.

Treatment

Most of the cases of osteochondrosis have a self-limiting course. Medical and supportive therapy constitute the mainstay of treatment.

The goal is to obtain a congruous, mobile, and painless joint.

Surgery is indicated only in cases where conservative therapy has failed when it would help to reduce late disability.

Medical Treatment

• Rest to joint, ice application and analgesics to prevent further trauma
• Traction, immobilization by plaster or brace, assisted weight bearing and physiotherapy to prevent secondary deformity and to reduce mechanical stress across the joint.

Surgical Treatment

Surgical treatment is usually undertaken when conservative methods are not effective. Surgery is also used when it may help restore the reparative process or way as to improve outcome over conservative means.

Arthroscopic procedures may be done to facilitate regeneration by microfracture technique or to pin or fix a salvageable fragment. Osteotomy is done to correct the deformity.

Salvage surgeries and reconstructive procedures are done in to improve situations in cases with poor outcomes. These may include arthrodesis, arthroplasty or bone lengthening procedures where required.

The surgery needs to be individualized.

Prognosis

Because osteochondrosis is a self-limiting disorder, the outcome is usually good.

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