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Long-Term Outcome After Surgical Treatment of Unresolved OsgoodSchlatter Disease in Young Men Surgical Technique By Harri K. Pihlajamäki, MD, PhD, and Tuomo I. Visuri, MD, PhD Investigation performed at the Research Department, Centre for Military Medicine and Department of Orthopaedic Surgery, Central Military Hospital, Helsinki, Finland The original scientific article in which the surgical technique was presented was published in JBJS Vol. 91-A, pp. 2350-8, October 2009

ABSTRACT FROM THE ORIGINAL ARTICLE BACKGROUND: Surgical treatment of Osgood-Schlatter disease is occasionally warranted, but its long-term prognosis remains poorly investigated. We studied the rate of occurrence of surgical treatment of unresolved Osgood-Schlatter disease as well as the clinical course, radiographic characteristics, and long-term outcomes after that treatment in a large population of military recruits. METHODS: During a thirteen-year period, 178 consecutive recruits underwent surgery for unresolved Osgood-Schlatter disease, and 107 of them (117 knees) who met the inclusion criteria participated in a follow-up examination. We obtained data from the original medical records and radiographs as well as follow-up information from physical and radiographic examinations, interviews, and questionnaires to determine functional outcomes. RESULTS: The rate of occurrence of surgically treated unresolved Osgood-Schlatter disease was forty-two per 100,000 military recruits. The median age at the onset of symptoms was fifteen years. After a median duration of follow-up of ten years after the surgery, ninety-three patients (87%) reported no restrictions in everyday activities or at work and eighty (75%) had returned to their preoperative level of sports activity. The median modified Kujala score was 95 points, and the median visual analog score for pain was 7 mm. Forty-one patients (38%) reported a complete absence of pain when kneeling. Six patients had experienced minor postoperative complications, and two had undergone a reoperation for the treatment of the OsgoodSchlatter disease. After resection, the mean tibial tuberosity thickness decreased by 47%. The mean Insall-Salvati index was 1.0 preoperatively and 1.09 postoperatively (p = 0.003), and the corresponding mean Blackburne-Peel indexes were 0.85 and 0.95 (p = 0.003). With the numbers studied, the symptom duration, surgical methods, and radiographic indexes were not found to have an effect on the outcome of surgery. CONCLUSIONS: In the great majority of young adults, the functional outcome of surgical treatment of unresolved OsgoodSchlatter disease is excellent or good, the residual pain intensity is low, and postoperative complications or subsequent reoperations are rare. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION: “Long-Term Outcome After Surgical Treatment of Unresolved Osgood-Schlatter Disease in Young Men” (2009;91:2350-8).

DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Surg Am. 2010;92 Suppl 1 (Part 2):258-264 • doi:10.2106/JBJS.J.00450

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Fig. 1-A

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Fig. 1-B

Figs. 1-A through 1-E First method. Fig. 1-A Skin incision. Figs. 1-B and 1-C The patellar tendon is split and retracted to expose the tibial tuberosity.

Fig. 1-C

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Fig. 1-D

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Fig. 1-E

Figs. 1-D and 1-E The ossicles have been removed and the prominent area of the tibial tuberosity has been excised.

INTRODUCTION Surgical treatment of OsgoodSchlatter disease is occasionally warranted. In the great majority of young adults with unresolved Osgood-Schlatter disease, the long-term functional outcome of surgical treatment is excellent or good, residual pain intensity is low, and postoperative complications or the need for subsequent reoperations are rare1. In the previous literature, excision of the ossicle(s), with or without resection of the tibial tuberosity

prominence, has been shown to yield better results than other methods (drilling, bone-grafting, or refixation of the ossicle)2-4. The tibial tuberosity prominence can be measured using the tibial tuberosity index5. The aim of surgical treatment is to remove the harmful knee prominence and to restore the anatomy of the knee region. SURGICAL TECHNIQUES We describe two approaches for surgical treatment of Osgood-

Schlatter disease. In the first approach (Figs. 1-A through 1-E), the patient is placed on the operating table in a supine position. A vertical 5-cm incision is made over the center of the distal part of the patellar tendon, 1 cm proximal to the tibial tuberosity. The longitudinal incision is continued over the center of the tibial tuberosity. The distal patellar tendon is divided longitudinally. The tendon is elevated laterally and medially to expose the superior part of the tibial tuberosity.

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The prominent tibial tuberosity is removed with use of an osteo­ tome and rongeurs, and, if present, the posterior intratendinous ossicles are excised. The ossicle may be firmly attached to the patellar tendon, and the surgeon should ensure that all fragments are removed. The most common operative technique used with this approach is to remove the osteocartilaginous fragments with or without resecting the tibial tuberosity prominence (Figs. 2-A and 2-B). The tibial tuberosity is resected down to

Fig. 2-A

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the insertion of the tendon and smoothed with a file. No drilling is performed. The peripheral and distal margins of the insertion of the patellar tendon should not be disturbed. Finally, the wound is closed in layers (patellar tendon and then skin) and a light compression dressing is applied to the whole limb. In the alternative method (Figs. 3-A through 3-E), a transverse 5-cm incision is centered over a point 1 cm proximal to the tibial tuberosity. With use of this approach, the lateral

soft-tissue attachments of the patellar tendon are released longitudinally, leaving the patellar tendon intact. The tendon is elevated, and the intratendinous osteocartilaginous fragments are removed. The tibial tuberosity is resected down to the insertion of the tendon with an osteotome and smoothed with a file. The lateral and distal margins of the insertion of the patellar tendon should not be disturbed. Finally, the wound is closed in layers and a light compression dressing is applied to the whole limb.

Fig. 2-B

Fig. 2-A Lateral radiograph of the knee reveals Osgood-Schlatter disease in a twenty-year-old man who had pain in the region of a prominence on the anterior aspect of the proximal part of the tibia when kneeling. Fig. 2-B Several years after surgery, the osseous tibial tuberosity prominence can be seen clearly diminished.

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Fig. 3-A

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Fig. 3-B

Figs. 3-A through 3-E Alternative method. Fig. 3-A Skin incision. Figs. 3-B and 3-C A longitudinal incision is made in the lateral soft-tissue attachments of the patellar tendon, and the tendon is elevated to expose the tibial tuberosity.

Fig. 3-C

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Fig. 3-E

Figs. 3-D and 3-E The ossicles have been removed and the osseous prominence has been excised. Fig. 3-D

POSTOPERATIVE CARE Quadriceps-setting exercises are started on the first postoperative day. Postoperative mobiliza-

tion should be supervised by a physiotherapist. Crutches may be prescribed for a short period postoperatively. Although regain-

ing adequate quadriceps function should be emphasized, all strenuous physical activity should be avoided for six to twelve weeks.

CRITICAL CONCEPTS INDICATIONS: • Radiographic and clinical evidence of Osgood-Schlatter disease • Symptoms localized to the prominent tibial tuberosity region • Symptoms impact sport activities or everyday life • Conservative treatment has proven to be ineffective over the long term • The patient is unable to kneel or squat without persistent pain continued

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CRITICAL CONCEPTS (CONTINUED) CONTRAINDICATIONS: • No clinical or radiographic evidence of Osgood-Schlatter disease • Symptoms and clinical signs do not confirm the diagnosis despite radiographic findings of a prominent tibial tuberosity • Symptom duration has been short-term (a couple of months) • Conservative treatment has not been adequate • Kneeling and squatting do not cause pain PITFALLS: • Insufficient ossicle removal and excision of the osseous prominence may fail to resolve the clinical symptoms. • The patellar tendon may become damaged or disrupted if the peripheral and distal margins of the insertion of the tendon are disturbed during the surgical procedure. AUTHOR UPDATE: These procedures have remained the same since the time of publication of our original paper.

Harri K. Pihlajamäki, MD, PhD Tuomo I. Visuri, MD, PhD Research Department, Centre for Military Medicine, P.O. Box 50, FIN 00301 Helsinki, Finland. E-mail address for H.K. Pihlajamäki: harri.pihlajamaki@ helsinki.fi. E-mail address for T.I. Visuri: tuomo. [email protected] The line drawings in this article are the work of Jennifer Fairman ([email protected]).

REFERENCES

1. Pihlajamäki HK, Mattila VM, Parviainen M, Kiuru MJ, Visuri TI. Long-term outcome after surgical treatment of unresolved OsgoodSchlatter disease in young men. J Bone Joint Surg Am. 2009;91:2350-8. 2. Flowers MJ, Bhadreshwar DR. Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop. 1995;15:292-7. 3. Glynn MK, Regan BF. Surgical treatment of

Osgood-Schlatter’s disease. J Pediatr Orthop. 1983;3:216-9. 4. Binazzi R, Felli L, Vaccari V, Borelli P. Surgical treatment of unresolved OsgoodSchlatter lesion. Clin Orthop Relat Res. 1993;289:202-4. 5. Visuri T, Pihlajamäki HK, Mattila VM, Kiuru M. Elongated patellae at the final stage of Osgood-Schlatter disease: a radiographic study. Knee. 2007;14:198-203.