Osgoo

d S

chla

tter th

roug

h th

e a

ges

Ph

. Lan

dre

au

Asp

eta

r, Do

ha, Q

ata

r

Intro

ductio

n

•In

19

03

, Ro

bert B

ayle

y Osg

oo

d a

nd

Karl S

chla

tter

sep

ara

tely d

escrib

ed

a p

ain

ful c

ond

ition o

f the a

nte

rior

tibia

l tub

erc

le c

hara

cte

rized

by p

artia

l sep

ara

tion o

f the

tong

ue-lik

e e

pip

hys

is o

f the tib

ial tu

bero

sity, a

pp

are

ntly

caused

by c

ontin

ued

stra

in p

laced

up

on it b

y the p

ate

llar

tend

on.

Intro

ductio

n

•O

sg

oo

d S

chla

tter s

ynd

rom

e (O

SS

) invo

lves th

e tib

ial

tub

ero

sity in

gro

win

g c

hild

ren a

nd

pre

sents

with

local

pain

, sw

ellin

g a

nd

tend

ern

ess o

f the tu

bero

sity.

•T

he c

om

mo

n a

ge o

f pre

senta

tion in

bo

ys is

betw

een th

e

ag

es o

f 12

and

15

years

and

in g

irls is

betw

een th

e a

ges

of 8

and

12

years

.

•T

he o

ccurre

nce is

rep

orte

d to

be g

reate

r in b

oys

than

girls

and

it freq

uently p

resents

bila

tera

lly (20

–3

0%

).

Etio

path

og

enesis

•C

urre

ntly it is

wid

ely a

ccep

ted

that O

SS

is a

tractio

n

ap

op

hys

itis o

f the tib

ial tu

berc

le d

ue to

rep

etitive

stra

in

and

chro

nic

avu

lsio

n o

f the s

eco

nd

ary o

ssific

atio

n c

ente

r

of th

e tib

ial tu

bero

sity.

Matu

ratio

n o

f Tib

ial Tu

bero

sity

•(a

) Cartila

gin

ous s

tag

e (a

ged

0–1

1 ye

ars

).

•(b

) Ap

op

hys

eal s

tag

e (a

ged

11

–1

4 ye

ars

).

•(c

) Ep

iphys

eal s

tag

e, th

e tib

ial

ap

op

hys

is c

oale

sces w

ith tib

ial

ep

iphys

is (a

ged

14

–1

8 ye

ars

).

•(d

) Bo

ny s

tag

e, th

e e

pip

hys

is is

fused

(ag

ed

>1

8 ye

ars

).

Ad

ap

ted

and

mo

difie

d fro

m

Eh

ren

bo

rg a

nd

La

ge

rgre

n ra

dio

log

ica

l sta

ge

s in

ma

tura

tion

of tib

ial tu

be

rosity

Etio

path

og

enesis

•(a

) Ap

peara

nce o

f the

seco

nd

ary o

ssific

atio

n

cente

r of tib

ial tu

bero

sity.

•(b

) Fra

gm

enta

tion o

f the

bo

ny o

ssific

atio

n c

ente

r.

•(c

) Co

mp

lete

healin

g a

nd

fusio

n o

f the a

po

phys

is

with

pro

min

ent tu

bero

sity.

•(d

) Ununite

d fre

e o

ssic

le.

Pre

dis

po

sin

g fa

cto

rs?

•R

ectu

s fe

mo

ris c

ontra

ctu

re, p

ate

lla a

lta.   A

paric

io e

t al.

•S

ho

rt leng

th o

f the p

ate

llar lig

am

ent. L

anco

urt a

nd

Chris

tini

•P

ate

llar te

nd

on a

ttached

mo

re p

roxim

ally w

ith b

road

er

insertio

n a

bo

ve th

e tib

ial p

hys

is. D

em

irag

et a

l.

•In

cre

ased

co

nd

ylom

alle

ola

r ang

le a

nd

exte

rnal tib

ial

rota

tion. G

igante

et a

l.

No

evid

ence a

nd

no

co

nsensus

Clin

ical fe

atu

res

•B

oys

beco

me s

ymp

tom

atic

betw

een th

e a

ges o

f 12

and

15

years

and

girls

betw

een th

e a

ges o

f 8 a

nd

12

years

.

Bila

tera

l sym

pto

ms a

re o

bserve

d in

20

–3

0%

of p

atie

nts

.

•K

uja

la e

t al: 3

89

ad

ole

scent a

thle

tes; O

sg

oo

d S

chla

tter in

21

% o

f

tho

se a

ctive

ly partic

ipatin

g in

sp

orts

, as c

om

pare

d w

ith o

nly 4

.5%

in n

onp

artic

ipants

.

Clin

ical fe

atu

res

•U

sually va

gue h

isto

ry of g

rad

ual o

nset p

ain

and

sw

ellin

g in

the re

gio

n

of tib

ial tu

bero

sity.

•P

ain

is m

ild a

nd

inte

rmitte

nt in

itially. In

acute

phase th

e p

ain

is s

eve

re

and

contin

uous in

natu

re.

•P

ain

exacerb

ate

s a

fter s

portin

g a

ctivity in

volvin

g ju

mp

ing (b

asketb

all,

volle

yball, ru

nnin

g) a

nd

/or o

n d

irect c

onta

ct (e

.g. k

neelin

g).

•P

hys

ical e

xam

inatio

n re

veals

tend

ern

ess, lo

cal s

wellin

g a

nd

pro

min

ence in

the a

rea o

f the tib

ial tu

bero

sity. P

ain

can b

e

rep

rod

uced

with

exte

nsio

n o

f the k

nee a

gain

st re

sis

tance.

OS

is a

clin

ical d

iag

no

sis

Rad

iog

rap

hic

featu

res

•Irre

gula

rity of a

pop

hys

is w

ith s

ep

ara

tion

from

the tib

ial tu

bero

sity in

early s

tages o

f

OS

S a

nd

fragm

enta

tion in

the la

ter s

tages

•P

ers

iste

nt b

ony o

ssic

le m

ay b

e vis

ible

in a

few

cases a

fter fu

sio

n o

f the tib

ial

ep

iphys

is: a

dult

•A

nte

rior s

oft tis

sue s

wellin

g m

ay b

e th

e

only s

ign o

bserve

d ve

ry early in

the a

cute

phase w

hen a

vuls

ion o

ccurs

thro

ugh th

e

cartila

gin

ous p

ortio

n o

f the s

econd

ary

ossific

atio

n c

ente

r

•R

ule

out o

ther c

ond

itions s

uch a

s a

cute

tibia

l ap

op

hys

eal fra

ctu

re, o

r tum

or

MR

I

•R

ole

in d

iag

no

sis

, pro

gno

stic

atio

n a

nd

manag

em

ent is

curre

ntly lim

ited

.

•C

an b

e in

dic

ate

d in

ad

ult s

ymp

tom

atic

po

pula

tion

Diffe

rentia

l Dia

gno

sis

•S

ind

ing

–Lars

en–Jo

hansso

n s

ynd

rom

e

•H

offa

’s s

ynd

rom

e

•S

yno

vial p

lica in

jury

•Tu

mo

r

•T

ibia

l tub

erc

le fra

ctu

re

•b

oys

betw

een th

e a

ges o

f 12

and

17

years

•vio

lent c

ontra

ctio

n o

f the q

uad

ricep

s

or fo

rcefu

l flexio

n

Wats

on J

ones c

lassific

atio

n

Treatm

ent

•There

are

no p

rosp

ective

, rand

om

ized

, contro

lled

, inte

rventio

nal s

tud

ies

eva

luatin

g th

e tre

atm

ent o

f OS

S.

•N

onop

era

tive tre

atm

ent is

initia

lly recom

mend

ed

.

•S

ymp

tom

atic

treatm

ent, lim

itatio

n o

f activitie

s, p

rote

ctive

knee p

ad

din

g

•P

hys

ical th

era

py. R

ectu

s fe

moris

stre

tchin

g

•Those w

ith m

ild p

ain

and

no w

eakness a

re a

llow

ed

to c

ontin

ue

sp

ortin

g a

ctivity w

ith th

e u

se o

f antiin

flam

mato

ry med

icatio

n a

nd

knee

pad

din

g. T

hose w

ho h

ave

mod

era

te to

seve

re p

ain

may b

enefit w

ith

activity m

od

ificatio

n, re

st a

nd

antiin

flam

mato

ry med

icatio

n.

•C

ast im

mob

ilizatio

n?

No

no

pera

tive tre

atm

ent: R

esults

•H

ussain

and

Hag

roo

follo

wed

26

1 p

atie

nts

with

OS

S fo

r

1– 2

years

and

rep

orte

d th

at 2

37

(91

%) p

atie

nts

resp

ond

ed

well to

activity m

od

ificatio

n, re

st a

nd

no

n

ste

roid

al a

ntiin

flam

mato

ry med

icatio

n.

Natu

ral H

isto

ry

•K

rause e

t al. re

porte

d n

atu

ral h

isto

ry of O

SS

in 6

9 k

nees o

f 50

patie

nts

. 9 ye

ars

FU

. 76%

of p

atie

nts

did

no

t have

any lim

itatio

n

of a

ctivity, a

lthough 6

0%

were

not a

ble

to k

neel w

ithout

dis

com

fort. T

hey re

porte

d lo

w in

cid

ence o

f ante

rior k

nee p

ain

and

no c

ases o

f pre

matu

re p

roxim

al tib

ial e

pip

hys

eal a

rrest.

•R

oss a

nd

Villa

rd a

ssessed

the d

isab

ility leve

ls o

f 25 c

olle

ge-

aged

male

ind

ividuals

who h

ad

his

tory o

f OS

S a

nd

com

pare

d

this

with

25 h

ealth

y colle

ge-a

ged

men w

ith n

o p

revio

us h

isto

ry

of O

SS

matc

hed

by a

ge a

nd

inte

rcolle

gia

te s

port. 7

.6 ye

ars

FU

.

Their re

sults

dem

onstra

ted

sig

nific

antly lo

wer c

linic

al s

core

s in

the O

SS

gro

up

as c

om

pare

d w

ith th

e n

orm

al h

ealth

y ad

ults

.

Surg

ical Tre

atm

ent: W

hen a

nd

Who

?

•T

he s

ymp

tom

s c

ontin

ue u

nab

ate

d in

5 –

10

% o

f patie

nts

,

desp

ite a

ll co

nserva

tive m

easure

s.

•T

hese p

atie

nts

co

mp

lain

of lo

cal p

ain

, diffic

ulty in

kneelin

g a

nd

restric

ted

activity in

to a

dulth

oo

d. D

ep

end

ing

on th

e s

ymp

tom

ato

log

y and

affe

cte

d q

uality o

f life,

surg

ical in

terve

ntio

n m

ay b

e c

onsid

ere

d a

fter s

kele

tal

matu

rity

Surg

ical Tre

atm

ent: W

hat?

•D

rilling

of th

e tib

ial tu

berc

le M

ital

•E

xcis

ion o

f the tib

ial tu

berc

le, tu

berc

lep

lasty F

low

ers

•Lo

ng

itud

inal in

cis

ion in

the p

ate

llar te

nd

on C

ole

•E

xcis

ion o

f the u

nunite

d o

ssic

le a

nd

free c

artila

gin

ous

pie

ces (tib

ial s

eq

uestre

cto

my) O

rava

•In

sertio

n o

f bo

ne p

eg

s B

osw

orth

•…

Co

mb

inatio

n o

f any o

f these p

roced

ure

s.

Excelle

nt a

nd

go

od

results

Sum

mary

•O

SS

runs a

self-lim

iting

co

urs

e w

ith re

so

lutio

n o

f

sym

pto

ms in

gre

ate

r than 9

0%

of p

atie

nts

.

•In

rare

cases, s

urg

ica

l exc

isio

n o

f the

ossic

le a

nd

/or

free c

artila

gin

ous m

ate

rial m

ay g

ive g

oo

d re

sults

in

sk

ele

tally

ma

ture

pa

tien

ts, w

ho

rem

ain

sym

pto

matic

desp

ite c

onserva

tive m

easure

s.

•T

he o

vera

ll pro

gno

sis

for O

SS

is g

oo

d, e

xcep

t for s

om

e

dis

co

mfo

rt in k

neelin

g a

nd

activity re

stric

tion in

a fe

w

cases.

Patie

nt In

form

atio

n

Thank yo

u