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.

Bifocal Avulsion of the Patellar Tendon From the Distal Patella and Tibial Tuberosity in a Skeletally Immature Patient: A Case Report.

CASE: A 13-year-old boy suffered a sports injury of the right knee. The clinical examination showed swelling, inability to bear weight, and pain involving the inferior apex of the patella and the anterior tibial tuberosity. Imaging studies showed an avulsion fracture, sleeve-like, from the patella apex and avulsion of the tibial tuberosity. The patient underwent open reduction and internal fixation. At the 24-month follow-up, no pain, limitation, or complication was reported. CONCLUSIONS: Bifocal patellar tendon avulsion in a skeletally immature patient is an extremely rare injury, and to our knowledge, only one case is reported.

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.

Pediatric Pain Syndromes and Noninflammatory Musculoskeletal Pain.

Chronic musculoskeletal pain (CMP) is one of the main reasons for referral to a pediatric rheumatologist and is the third most common cause of chronic pain in children and adolescents. Causes of CMP include amplified musculoskeletal pain, benign limb pain of childhood, hypermobility, overuse syndromes, and back pain. CMP can negatively affect physical, social, academic, and psychological function so it is essential that clinicians know how to diagnose and treat these conditions. This article provides an overview of the epidemiology and impact of CMP, the steps in a comprehensive pain assessment, and the management of the most common CMPs.

Enfermedad de Osgood-Schlatter en un adolescente deportista: Caso clínico / Osgood-Schlatter disease in adolescent athlete: Case report

El dolor de rodilla es uno de los síntomas musculoesqueléticos más frecuentes en jóvenes físicamente activos y aparece, sobre todo, en adolescentes varones. Dentro del diagnóstico diferencial, hay que considerar entidades habituales de diagnóstico clínico, como la osteocondrosis apofisaria, y también otras en las que se precisan estudios complementarios. Se presenta el caso de un varón deportista de 12 años con dolor continuo en la rodilla derecha que se intensificaba con la actividad física y la presión directa. Se hizo el diagnóstico de enfermedad de Osgood-Schlatter mediante los datos exploratorios, reproducción del dolor ante la palpación a punta de dedo sobre la tuberosidad tibial anterior, y se confirmó mediante radiología. Se describe esta entidad y otras derivadas de la sobreutilización en la actividad física con las que hacer diagnóstico diferencial; se insiste en las medidas preventivas en cuanto a una correcta orientación en la actividad deportiva.

Knee pain is one of the most frequent musculoskeletal symptoms in young physically active males. Common entities of clinical diagnosis as osteochondritis/apophysitis and others that need complementary studies should be considered in the differential diagnosis. We present the case of a 12-year-old male athlete with continuous pain in his right knee that intensifies with physical activity and with direct pressure. Diagnosis of Osgood-Schlatter disease is made by exploratory data, pain-to-finger palpation on the anterior tibial tuberosity, and is confirmed by radiology. This entity is described as well as the main pathologies derived from overuse to make differential diagnosis and to stress preventive measures regarding a correct orientation in the sport activity.

[Osgood-Schlatter disease in adolescent athlete. Case report]. / Enfermedad de Osgood-Schlatter en un adolescente deportista. Caso clínico.

Knee pain is one of the most frequent musculoskeletal symptoms in young physically active males. Common entities of clinical diagnosis as osteochondritis/apophysitis and others that need complementary studies should be considered in the differential diagnosis. We present the case of a 12-year-old male athlete with continuous pain in his right knee that intensifies with physical activity and with direct pressure. Diagnosis of Osgood-Schlatter disease is made by exploratory data, pain-to-finger palpation on the anterior tibial tuberosity, and is confirmed by radiology. This entity is described as well as the main pathologies derived from overuse to make differential diagnosis and to stress preventive measures regarding a correct orientation in the sport activity.

El dolor de rodilla es uno de los síntomas musculoesqueléticos más frecuentes en jóvenes físicamente activos y aparece, sobre todo, en adolescentes varones. Dentro del diagnóstico diferencial, hay que considerar entidades habituales de diagnóstico clínico, como la osteocondrosis apofisaria, y también otras en las que se precisan estudios complementarios. Se presenta el caso de un varón deportista de 12 años con dolor continuo en la rodilla derecha que se intensificaba con la actividad física y la presión directa. Se hizo el diagnóstico de enfermedad de Osgood-Schlatter mediante los datos exploratorios, reproducción del dolor ante la palpación a punta de dedo sobre la tuberosidad tibial anterior, y se confirmó mediante radiología. Se describe esta entidad y otras derivadas de la sobreutilización en la actividad física con las que hacer diagnóstico diferencial; se insiste en las medidas preventivas en cuanto a una correcta orientación en la actividad deportiva.

[Ischiopubic osteochondrosis revealed by an atypical "acute transient synovitis of the hip": A case report]. / Un cas d'ostéochondrose ischiopubienne révélée par une « synovite aiguë transitoire de hanche ¼ atypique.

We report here the case of a 3-year-old patient, who presented a left limp and a total refusal of walking, without any traumatism. Clinical examination revealed a significant pain in the left leg with a limit to the limiting mobilization. Acute phase reactants were slightly elevated. Based on the hip ultrasound, acute transient synovitis of the hip was diagnosed. Following persistent complaints, a hip plain radiography was performed, showing a discreet reshuffle at the right ischiopubic branch. The MRI of the hip revealed a discrete T2 high intensity centered on the right ischiopubic synchondrosis (IPS), corresponding to a Van Neck-Odelberg osteochondrosis. Non-steroidal anti-inflammatory drugs and limited weight bearing enabled significant clinical improvement. The ischiopubic osteochondrosis is a physiological phenomenon, frequent and mostly asymptomatic. However, when associated with pain, it could easily be mistaken for another musculoskeletal or rheumatological disorder. Therefore, it is important to continue investigating more thoroughly any limping that does not have a typical evolution from the presumed diagnosis.

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.

Evaluation of the external fixator TrueLok Hexapod System for tibial deformity correction in children.

BACKGROUND: Tibial deformities are common in paediatric orthopaedic practice. Correcting multiplanar tibial deformities associated with lower limb length discrepancy can be challenging. Hexapod external fixation with gradual correction has been proven effective in this situation. OBJECTIVE: To assess clinical and radiological outcomes of gradual tibial deformity correction using the external fixator TL-HEX™ (Orthofix) in children. HYPOTHESIS: TL-HEX™ is effective in correcting tibial deformities in children. PATIENTS AND METHODS: This multicentre retrospective study collected data from the medical files of 26 patients with 31 tibial deformities treated by gradual correction using TL-HEX™. The tibial deformities were due to congenital defects in 11 (35%) cases, Blount's disease in 9 (29%) cases, pseudo-achondroplasia in 4 (13%) cases, and other causes in 7 (23%) cases. Mean age at surgery was 11.9 years. In each patient, antero-posterior long leg radiographs obtained pre-operatively and at last follow-up were used to measure parameters including the mechanical axis deviation (MAD), medial proximal tibia angle (MPTA), and leg length discrepancy (LLD). RESULTS: The mean healing index was 39.3 days/cm (range, 32-58 days/cm). The overall complication rate was 61%, with 11 unplanned visits. Superficial pin tract infection was the most common complication. Significant decreases between the pre-operative and post-operative assessments occurred in mean MAD (from 32.1mm to 10.2mm, P<0.001) and mean LLD (from 36.8mm to 9.1mm, P<0.001). Patients who underwent proximal tibial osteotomy had a significant improvement in MPTA, from 80.6° to 88.5° (P=0.006). DISCUSSION: This is the first clinical study specifically designed to assess outcomes of TL-HEX™ limb lengthening and deformity correction. MAD, MPTA, and LLD were significantly improved at last follow-up. MAD was greater than 10mm at last follow-up in only 11patients. The complication rate was similar to those reported with other external fixators. TL-HEX™ is effective in the management of tibial deformities in children. LEVEL OF EVIDENCE: IV (retrospective study).

Response of cattle with clinical osteochondrosis to mineral supplementation.

Since 1982, farmers in the North West province and other parts of South Africa have noticed an increase in the incidence of lameness in cattle. Macro- and microscopical lesions of joints resembled osteochondrosis. Pre-trial data indicated that cattle with osteochondrotic lesions recovered almost completely when fed a supplement containing bio-available micro- and macrominerals of high quality. In the present trial, 43 clinically affected cattle of varying ages (1-5 years) and sexes were randomly divided into three groups. Each group was fed the same commercial supplement base with differing micro- and macromineral concentrations to determine the effect of mineral concentrations on the recovery from osteochondrosis. Both supplements 1 and 2 contained 25% of the recommended National Research Council (NRC) mineral values. Additional phosphate was added to supplement 2. Supplement 3, containing 80% of the NRC mineral values, was used as the control. Results from all three groups indicated no recovery from osteochondrosis. Urine pH of a small sample of the test cattle showed aciduria (pH < 6). Supplement analysis revealed addition of ammonium sulphate that contributed sulphate and nitrogen to the supplement. Supplementary dietary cation anion difference (DCAD) values were negative at -411 mEq/kg, -466 mEq/kg and -467 mEq/kg for supplements 1, 2 and 3, respectively, whereas the pre-trial supplement was calculated at +19.87 mEq/kg. It was hypothesised that feeding a low (negative) DCAD diet will predispose growing cattle to the development of osteochondrosis or exacerbate subclinical or clinical osteochondrosis in cattle.

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.

[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.

[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.

Complete Closing Wedge Osteotomy for Correction of Blount Disease (Tibia Vara): A Technique.

Treatment of Blount disease (tibia vara) can be daunting in adolescents because of their obesity. The goals in performing osteotomy for Blount disease are to correct the deformity, restore joint alignment, preserve leg length, and prevent recurrent deformity and other complications, such as neurovascular injury, nonunion, and infection. In this article, we report on our treatment of 9 limbs in 8 patients (age range, 13-17 years) with Blount disease. In each case, we performed an oblique complete closing wedge osteotomy of the tibia fixed with a compression plate with oblique screw and a fibular osteotomy. Mean body mass index was 38. In 2 patients, an external fixator (instead of a cast) was used after surgery to increase stability. Mean correction was 26°. The cast was removed at 6 weeks. A hinged knee brace was worn for another 6 weeks. Return to normal activities was allowed after 4 months. The described method, using a closing wedge tibial osteotomy and an oblique fibular osteotomy, is practical and safe and has reproducible results.