Invasive diagnostic and therapeutic measures are unnecessary in patients with symptomatic van Neck-Odelberg disease (ischiopubic synchondrosis): a retrospective single-center study of 21 patients with median follow-up of 5 years.

Background and purpose - Van Neck-Odelberg disease (VND) is a self-limiting skeletal phenomenon characterized by a symptomatic or asymptomatic uni- or bilateral overgrowth of the pre-pubescent ischiopubic synchondrosis. It is frequently misinterpreted as a neoplastic, traumatic, or infectious process, often resulting in excessive diagnostic and therapeutic measures. This study assessed the demographic, clinical, and radiographic features of the condition and analyzed diagnostic and therapeutic pathways in a large single-center cohort.Patients and methods - We retrospectively analyzed 21 consecutive patients (13 male) with a median age of 10 years (IQR 8-13) and a median follow-up of 5 years (IQR 42-94 months), who were diagnosed at our department between 1995 and 2019.Results - VND was unilateral in 17 cases and bilateral in 4 cases. Initial referral diagnoses included suspected primary bone tumor (n = 9), fracture (n = 3), osteomyelitis (n = 2), and metastasis (n = 1). The referral diagnosis was more likely to be VND in asymptomatic than symptomatic patients (4/6 vs. 2/15). More MRI scans were performed in unilateral than bilateral VND (median 2 vs. 0). All 15 symptomatic patients underwent nonoperative treatment and reported a resolution of symptoms and return to physical activity after a median time of 5 months (IQR 0-6).Interpretation - By understanding the physiological course of VND during skeletal maturation, unnecessary diagnostic and therapeutic measures can be avoided and uncertainty and anxiety amongst affected patients, their families, and treating physicians can be minimized.

Blount Disease and Obstructive Sleep Apnea: An Under-recognized Association?

BACKGROUND: Obesity is strongly associated with both Blount disease and obstructive sleep apnea (OSA). Obesity increases risks for anesthetic and postoperative complications, and OSA can further exacerbate these risks. Since children with Blount disease might have both conditions, we sought to determine the perioperative complications and the prevalence of OSA among these children. METHODS: Patients younger than 18 years undergoing corrective surgery for Blount disease were identified from 2 sources as follows: a retrospective review of records at a single institution and querying of the Kids' Inpatient Database, a nationally representative database. RESULTS: At our institution, the prevalence of OSA among patients surgically treated for Blount disease was 23% (42/184). Blount patients were obese (100%), and predominately African American (89%), and male (68%). Patients were treated for OSA before surgery, and 2 patients (1%) had postoperative hypoxemia. In contrast, of 1059 cases of Blount disease from the Kids' Inpatient Database, 3% were diagnosed with OSA. In total, 4.4% of all the Blount children experienced complications, including hypoxemia, respiratory insufficiency, atelectasis, and arrhythmias. Complications were associated with 4.3 additional days of hospitalization (P<0.0001) and 39% additional hospital charges (P=0.002). CONCLUSIONS: Data from the national database showed a low rate of OSA prevalence but high respiratory and OSA-associated complications, perhaps indicating that OSA may be underdiagnosed in children with Blount disease. Affected patients, especially ones with untreated OSA, sustain increased surgical morbidity. A high index of suspicion and preoperative planning helps alleviate the burden of OSA among these patients. LEVEL OF EVIDENCE: Level III-case-control study.

Hemiepiphyseodesis for Juvenile and Adolescent Tibia Vara Utilizing Percutaneous Transphyseal Screws.

BACKGROUND: In juvenile and adolescent tibia vara patients with sufficient growth remaining, implant-controlled hemiepiphyseodesis, or guided growth, can be used to correct deformity. Recent reports have described hardware failure of certain hemiepiphyseodesis implants in overweight patients with tibia vara. We describe our experience using transphyseal screws to correct deformity in this patient population. METHODS: A retrospective chart and radiograph review was conducted on all juvenile and adolescent tibia vara patients who underwent lateral proximal tibial hemiepiphyseodesis using a single transphyseal screw. Charts were queried for preoperative and postoperative mechanical axis deviation, medial proximal tibial angle, lateral distal femoral angle, and postoperative complications or need for further surgery. RESULTS: In total, 14 affected limbs in 9 patients (6 males) who underwent lateral proximal tibial transphyseal screw hemiepiphyseodesis were considered. Average chronologic age at implantation was 10.4 years and average body mass index was 31.7 kg/m. At average 23-month follow-up, the average mechanical axis deviation improved from 46 to 0 mm (P<0.001), and the average medial proximal tibial angle improved from 81 to 92 degrees (P<0.001). No limbs underwent further surgery to correct residual deformity. There were no complications or instances of implant failure associated with the transphyseal screws. CONCLUSIONS: Hemiepiphyseodesis using transphyseal screws is an effective technique to correct deformity in juvenile and adolescent tibia vara patients with sufficient growth remaining. This method can be used safely with few complications and with minimal risk of mechanical failure, even in overweight patients. LEVEL OF EVIDENCE: Level IV-therapeutic.

Benign bone tumours of tibial tuberosity clinically mimicking Osgood-Schlatter disease: a case series.

INTRODUCTION: Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tubercle and a common cause of anterior knee pain in growing adolescents. A variety of benign neoplasms can also cause bony prominence over the tibial tubercle in adolescents that might clinically imitate OSD. Therefore, the differential diagnosis of tumours mimicking OSD is critical and considered the primary goal of this study. METHODS: Eleven patients who were referred to our orthopaedic oncology department with clinical suspicions of OSD and obscure radiographic presentation were identified. The final diagnosis was OSD in three cases. The demographic, clinical, and radiologic characteristics of the remaining eight patients in whom a tumour mimicked OSD were evaluated. The diagnosis was confirmed by pathologic examination. RESULTS: The final diagnosis was periosteal chondroma in four cases, osteochondroma in three cases, and dysplasia epiphysealis hemimelica (DEH) in one case. The average age of the patients was 10.5 ± 3.1 years. In the majority of patients (62.5%), the lesion was painless. The mean size of the bump was 6.5 ± 1.2 cm2. In patients with a painful knee, the pain was constant and activity-independent. At history taking, the pain and bump size were progressive. CONCLUSION: Lack of pain, progressive pain and bump, activity-independent pain, a bump size larger than 5 cm2 at presentation, and age fewer than ten years could be considered in favour of tumours and against OSD.

Juvenile osteochondritis dissecans of the knee is a result of failure of the blood supply to growth cartilage and osteochondrosis.

OBJECTIVE: Juvenile osteochondritis dissecans (JOCD) is similar to osteochondrosis dissecans (OCD) in animals, which is the result of failure of the cartilage canal blood supply, ischemic chondronecrosis and delayed ossification, or osteochondrosis. The aim of the current study was to determine if osteochondrosis lesions occur at predilection sites for JOCD in children. METHOD: Computed tomographic (CT) scans of 23 knees (13 right, 10 left) from 13 children (9 male, 4 female; 1 month to 11 years old) were evaluated for lesions consisting of focal, sharply demarcated, uniformly hypodense defects in the ossification front. Histological validation was performed in 11 lesions from eight femurs. RESULTS: Thirty-two lesions consisting of focal, uniformly hypodense defects in the ossification front were identified in the CT scans of 14 human femurs (7 left, 7 right; male, 7-11 years old). Defects corresponded to areas of ischemic chondronecrosis in sections from all 11 histologically validated lesions. Intra-cartilaginous secondary responses comprising proliferation of adjacent chondrocytes and vessels were detected in six and two lesions, whereas intra-osseous responses including accumulation of chondroclasts and formation of granulation tissue occurred in 10 and six lesions, respectively. One CT cyst-like lesion contained both a pseudocyst and a true cyst in histological sections. CONCLUSION: Changes identical to osteochondrosis in animals were detected at predilection sites for JOCD in children, and confirmed to represent failure of the cartilage canal blood supply and ischemic chondronecrosis in histological sections.

Guided Growth Implant Failure is a Result of Cyclic Fatigue: Explant Analysis With Scanning Electron Microscopy.

BACKGROUND: Guided growth is often used to correct limb deformity and yet implant screw failure in modular systems has been reported. There have been no reports of plate failure and we do not know the exact mode of failure when screws do break. METHODS: We report the first published case of a fractured plate in a modular plate and screw construct that was used to correct Blount disease in a child through guided growth. The implants were removed and analyzed for method of failure using scanning electron microscopy. RESULTS: Scanning electron microscopy of the explant confirms that the mode of failure was not a result of static tension from growth. Rather, analysis confirms cyclic fatigue that led to crack propagation across the anterior side of the plate until overload caused complete plate failure. CONCLUSIONS: This analysis confirms an in vivo cyclic compression-relaxation of the growth plate presumably to weight-bearing, and that when excessive may lead to implant failure as seen here in this case. LEVEL OF EVIDENCE: Level V.

Foal Fractures: Osteochondral Fragmentation, Proximal Sesamoid Bone Fractures/Sesamoiditis, and Distal Phalanx Fractures.

Foals are susceptible to many of the same types of fractures as adult horses, often secondary to external sources of trauma. In addition, some types of fractures are specific to foals and occur routinely in horses under 1 year of age. These foal-specific fractures may be due to the unique musculoskeletal properties of the developing animal and may present with distinct clinical signs. Treatment plans and prognoses are tailored specifically to young animals. Common fractures not affecting the long bones in foals are discussed in this article, including osteochondral fragmentation, proximal sesamoid bone fractures/sesamoiditis, and distal phalanx fractures.

Prevalence of Hypertension in Pediatric Tibia Vara and Slipped Capital Femoral Epiphysis.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) and tibia vara (Blount disease) are associated with childhood obesity. However, the majority of obese children do not develop SCFE or tibia vara. Therefore, it is hypothesized that other obesity-related biological changes to the physis, in addition to increased biomechanical stress, potentiate the occurrence of SCFE and tibia vara. Considering that hypertension can impose pathologic changes in the physis similar to those observed in these obesity-related diseases we set out to determine the prevalence of hypertension in patients with SCFE and tibia vara. METHODS: Blood pressure measurements were obtained in 44 patients with tibia vara and 127 patients with SCFE. Body mass index and blood pressure were adjusted for age, sex, and height percentiles utilizing normative distribution data from the CDC. These cohorts were compared with age-matched and sex-matched cohorts derived from an obesity clinic who did not have either bone disease. A multivariable proportional odds model was used to determine association. RESULTS: The prevalence of prehypertension/hypertension was significantly higher in the tibia vara (64%) and SCFE cohort (64%) compared with respective controls (43%). Patients diagnosed with either SCFE or tibia vara had 2.5-fold higher odds of having high blood pressure compared with age-matched and sex-matched obese patients without bone disease. Sex, age, and race did not have a significant effect on a patient's blood pressure. CONCLUSIONS: This is the first study to establish that the obesity-related bone diseases, SCFE and tibia vara, are significantly associated with high blood pressure. These data have immediate clinical impact as they demonstrate that children with obesity-related developmental bone disease have increased prevalence of undiagnosed and untreated hypertension. Furthermore, this prevalence study supports the hypothesis that hypertension in conjunction with increased biomechanical forces together potentiate the occurrence of SCFE and tibia vara. If proven true, it is plausible that hypertension may represent a modifiable risk factor for obesity-related bone disease. LEVEL OF EVIDENCE: Level III-case-control study.

[Van Neck-Odelberg disease. Report of two cases]. / A van Neck-Odelberg-betegség bemutatása két eset kapcsán.

Osteochondritis ischiopubica or van Neck-Odelberg disease is characterized by atypical ossification of the ischiopubic synchondrosis. Clinical symptoms are usually pain, limping and limited range of motion of the hip joint. Radiologic images may be confused with the possibility of fracture, tumor or inflammation. In some cases it may be difficult to set up the accurate diagnosis, and during the diagnostic process it is essential that van Neck-Odelberg disease should be considered. In this paper the authors draw attention to this rare disorder and they present the history of two patients who posed diagnostic difficulties.

[The application of the biological feedback technique for the treatment of the patients presenting with chronic somatic diseases]. / Primenenie metoda biologicheskoi obratnoi svyazi pri lechenii patsientov s khronicheskimi somaticheskimi zabolevaniyami.

The objective of the present work was to study the influence of the application of the biological feedback (BFB) technique on the dynamics of the psychological and clinical status of the patients presenting with various chronic somatic diseases (CSD) and to identify the predictors of the effectiveness of the treatment by this method. PATIENTS AND METHODS: The study included 337 patients suffering from CSD who were interviewed with the use of the concise standardized multifactorial personality inventory (SMPI), the Spielberger State-Trait Anxiety Inventory (STAI), and the Beck depression inventory (BDI) scales. The patients were randomly distributed into two groups. Group 1 (main) was comprised of 168 patients who underwent psychotherapeutic treatment based on the BFB method, group 2 (control) consisted of 169 patients who did not receive the psychotherapeutic treatment. In order to identify the predictors of the effectiveness of the treatment by the biological feedback technique, the patients of the main group were subdivided into two subgroups at the end of the study period. Subgroup A contained 112 (67%) patients whose health status was normalized under the influence of psychotherapy, subgroup B included 56 (33%) patients who experienced the improvement of the somatic conditions. We undertook the comparative analysis of the background characteristics of the patients belonging to each group. RESULTS AND DISCUSSION: The study has demonstrated that by the end of the observation period the patients of the main group showed a significantly more pronounced (compared with controls) decrease of the parameters estimated based on the scales 1, 2, and 7 and an increase of those evaluated based on the (SMPI) scale 9. Simultaneously, the levels of state and trait anxiety estimated based on the Spielberger и Beck inventory scales decreased. These findings give evidence of the improvement of psychological adaptation of the patients, decrease of the anxiety level and emotional stress under the influence of the treatment with the use of the biological feedback technique; these changes were concomitant with the enhancement of the general activity of the patients, the improvement of their working capacity, mood, and feelings of optimism. The study of the predictors of the effectiveness of the BFB method revealed the significantly higher background values estimated based on the SMPI scales 1, 4, and 6 in the patients with the improvement of the health status compared with those exhibiting normalized conditions (p<0,01). In 12% of the patients in the former subgroup (but in none of the patients of the latter subgroup), the values obtained based on the Beck scale were higher than 20 scores which suggested either the moderate or high level of depression. These data give reason to conclude that the patients that exhibited a relatively weak response to the treatment with the application of the biological feedback technique were initially predisposed to the un-necessary excessive fixation of attention on their sensations in the combination with enhanced impulsivity, rigidity of attitudes, and the presence of depressive disorders.

Osteochondrosis Can Lead to Formation of Pseudocysts and True Cysts in the Subchondral Bone of Horses.

Osteochondrosis arises as a result of focal failure of the blood supply to growth cartilage. The current aim was to examine the pathogenesis of pseudocysts and true cysts in subchondral bone following failure of the blood supply to the articular-epiphyseal cartilage complex in horses. Cases were recruited based on identification of lesions (n = 17) that were considered likely to progress to or to represent pseudocysts or true cysts in epiphyseal bone in histological sections and included 10 horses ranging in age from 48 days to 5 years old. Cases comprised 3 warmbloods, 3 Standardbreds, 1 Quarter horse and 1 Arabian with spontaneous lesions and 2 Fjord ponies with experimentally induced lesions. Seven lesions consisted of areas of ischemic chondronecrosis and were compatible with pseudocysts. Two lesions were located at intermediate depth in epiphyseal growth cartilage, 2 lesions were located in the ossification front, 2 lesions were located in epiphyseal bone and 1 lesion was located in the metaphyseal growth plate (physis). Ten lesions contained dilated blood vessels and were compatible with true cysts. In 2 lesions the dilated blood vessels were located within the lumina of failed cartilage canals. In the 8 remaining lesions areas of ischemic chondronecrosis were associated with granulation tissue in the subjacent bone and dilated vessels were located within this granulation tissue. Failure of the blood supply and ischemic chondronecrosis can lead to formation of pseudocysts or dilatation of blood vessels and formation of true cysts in the epiphyseal bone of horses.

Do children with Blount disease have lower body mass index after lower limb realignment?

BACKGROUND: Children with Blount disease are typically obese. The goal of our study was to assess whether children with Blount disease had lower body mass index (BMI) after surgical correction of their lower limb deformity. METHODS: A surgical data base was used to identify children with Blount disease. Demographic information including age of disease onset, ethnicity, health insurance status, and laterality was noted. Preoperative and most recent BMI values were documented. Using full-length standing radiographs, the mechanical axis deviation (MAD) and leg length discrepancy (LLD) were measured preoperatively and at latest follow-up. The relationship of the change in BMI with various demographic and radiologic parameters was evaluated. RESULTS: Fifty-one children (32 males, 19 females) with Blount disease (23 early onset, 28 late onset) affecting 70 lower extremities (32 unilateral and 19 bilateral) underwent a variety of surgical procedures. All 47 children who underwent gradual correction with external fixation also underwent nutritional counseling while receiving inpatient rehabilitation. At an average follow-up of 48 months, MAD improved from 80.5 mm medial to 16.1 mm medial (P<0.0001) and LLD improved from 19.6 to 10.9 mm (P=0.0002). During the same time period, the BMI increased from 35 (95% confidence interval, 32-37) to 38 (95% confidence interval, 35-41; P=0.0006). Compared with their preoperative BMI, 76% of the children had an increase in their BMI at the latest follow-up. There was no association of the change in the patient's BMI with their age of disease onset, sex, ethnicity, health insurance status, final MAD, or LLD. There was a tendency for the patient's BMI to increase with longer follow-up (P=0.002). Using multivariate analysis, only the length of follow-up was associated with an increase in BMI (P=0.026). CONCLUSIONS: Despite improvement in limb alignment and LLD after surgery, the BMI of the majority of children with Blount disease increased over time. Other strategies for addressing obesity amongst these children are warranted. LEVEL OF EVIDENCE: Level IV--case series.

Age-associated cartilage degeneration of the canine humeral head.

The goal of this study was to determine if cartilage lesions of the humeral head in adult dogs are the consequence of osteochondrosis dissecans or degenerative joint disease. A gross and histologic survey was performed of humeral head cartilage lesions of 155 dogs ranging in age from 1 week to 19 years. The humeral head and cartilage lesion size were measured for each dog. Cartilage lesions were classified as fibrillation, fissures, erosion, and/or eburnation. The area of each lesion was multiplied by a severity score (fibrillation and fissures 1, erosion 2, and eburnation 3) to create a combined score for each humeral head. Correlations between this combined lesion score and age, humeral head size, body weight, and body condition score were assessed using a Bonferroni-corrected alpha of .01. Twenty-six humeral heads were also evaluated histologically. Of the 155 dogs, 80 (52%) had gross lesions of the articular cartilage. The presence and severity of the articular cartilage lesions were positively correlated with age, humeral head size, body weight, and body condition score. The average age of dogs with cartilage lesions was 8.8 years, and 77/105 (74%) of adult dogs had cartilage lesions. Fifty dogs were 3 years of age or younger; 3 of those had cartilage lesions, 1 of which was osteochondrosis. These data indicate that cartilage erosion of the caudal humeral head in dogs is a common degenerative lesion acquired in adult large breed dogs; osteochondrosis dissecans does not precede the lesion in the vast majority of cases.

Is there a relationship between attention deficit/hyperactivity disorder and Osgood-Schlatter disease?

PURPOSE: The purpose of this prospective study is to investigate the relationship between Osgood-Schlatter disease (OSD) and attention deficit/hyperactivity disorder (ADHD). METHODS: Seventy-four children with a diagnosis of OSD were referred to child and adolescent psychiatry department for the evaluation of ADHD. Diagnostic and Statistical Manual of Mental Disorders was used for diagnostic criteria. RESULTS: Diagnosis of ADHD was made in 56 (75.6 %) out of 74 children. CONCLUSIONS: Results of this study suggest that ADHD is a significant risk factor for OSD. During the evaluation of a patient with OSD, a thorough history should be obtained about the behavioral symptoms that indicate underlying ADHD. In case of suspicion, these patients should be referred for an additional evaluation by a child psychiatrist. LEVEL OF EVIDENCE: II.

[Osteochondrosis of the pediatric foot]. / Osteochondrosen des kindlichen Fußes.

Osteochondrosis is a heterogeneous group of self-limiting conditions characterized by disturbance of enchondral ossification caused by a lack of circulation. Foot pain is a relatively common problem in children and adolescents and may be due to osteochondrosis. Osteochondrosis of the growing foot shows painful radiological alterations including increased density, fragmentation and irregularity of the epiphyses, physes and apophyses. Lacking etiologic and pathophysiologic information, ostoechondroses have been documented in almost every bone of the foot and therefore should be considered in the differential diagnosis when evaluating pediatric foot pain. The most common localizations of osteochondroses of the growing foot include the navicular as Kohler's syndrome, the metatarsal as Freiberg's infraction and calcaneal apophysitis as Sever's disease. Prognosis and final outcome vary considerably between the different localizations. Physicians should therefore be informed about the etiology, clinical presentation and treatment options for osteochondroses of the growing foot.

[Osteochondrosis as a possible cause of pharyngeal dysphagia].

Dysphageal complaints in a 65-year-old woman were regarded as a manifestation of mental illness. The autopsy of the patient weighing 32 kg who died from bilateral pneumonia revealed 9-mm osteophytes on the anterior surface of the cervical spine as the cause of dysphagia. Twenty-nine cases of cervical osteochondrosis-induced dysphagia, published in the literature, were analyzed.

[Epidural pharmacotherapy in the treatment of the pain syndrome in osteochondrosis complicated by intervertebral discs protrusion of lumbar part of the vertebral column].

Experience of application of intralaminar epidural pharmacotherapy for the treatment of the pain syndrome in the patients, suffering osteochondrosis of lumbar portion of vertebral column, complicated by intervertebral discs protrusion, was summarized. The method introduction permits to escape the operative intervention performance for complicated osteochondrosis.