Osteochondroses Treatment & Management

The most important goal in the treatment of articular osteochondrosis is to obtain a congruous, mobile, and painless joint. Nonarticular osteochondroses usually heal with protection. However, concern about undesirable results should prompt the treating physician to provide supervised treatment rather than neglect. Controversial entities, such as Sever disease and Van Neck phenomenon, should be treated if patients are symptomatic. They are not always labeled normal variations in ossification.

To avoid medical and legal pitfalls, physicians must ensure that both patients and parents understand the nature and natural history of the disease, the uncertainty and likely outcome of treatment, and the patient’s prognosis and expectations. It is acceptable to acknowledge and disclose that the current scientific knowledge of the osteochondrotic syndromes is inadequate and that physicians’ understanding of how to recognize and treat these conditions is therefore limited.

The basic principles of therapy for osteochondrosis are as follows:

• Protection and prevention of additional trauma
• Prevention of secondary deformity
• Reduction of the transmission of mechanical stresses to the bone during the process of reossification
• Facilitation of reossification
• Removal of osteochondrotic fragments that have become loose bodies
• Compensation for fixed bony deformities by means of realignment
• Intervention with salvage surgery if indicated

In general, treatment options for osteochondrosis can be divided into nonsurgical and surgical interventions (see below). Medical and supportive therapies constitute the mainstay of treatment for osteochondroses. Surgery is indicated only for specific purposes, such as replacement of failed conservative treatment, alleviation of symptoms, or reducing late disability. Although the course of an osteochondrosis is protracted, it is generally self-limited. Therefore, it is prudent is to allow the patient’s reparative mechanisms sufficient time to act in an apposite environment.

Osteochondroses frequently resolve completely or partially in response to symptomatic nonsurgical treatment. ^[27] The main aim is to reduce morbidity and decrease the duration of symptoms with supervised treatment. Still, medical treatment may not influence the final outcome, and this possibility must always be explained in detail to patients and their parents.

To date, no mechanism has been found by which the disease process can be arrested. Close follow-up in the initial phase, with specific interventions guided by the principles mentioned above, remains the standard of care. The treatment plan must be individualized to the specific case. Specific measures can be carried out in accordance with the aforementioned principles of therapy.

The following measures are recommended to help prevent additional trauma:

• Properly counsel patients and parents about the disease, and explain its expected natural progression
• Advise patients to rest the affected parts
• Advise patients to avoid participating in contact sports
• Recommend cold treatment and the use of analgesics to relieve pain

The following measures are recommended to help prevent secondary deformity and to reduce mechanical stress across the joint:

• Apply traction to relieve pain, prevent deformities, counter muscle spasms due to pain, reduce stresses across the joint, and enable rest
• Use braces and plaster-of-Paris casts to divert forces to unaffected or less affected areas, to contain the involved epiphysis, to provide a proper scaffold, to support the joint during growth, and to prevent dysplasia
• Order counterbracing for patients with Blount disease or Perthes disease
• Recommend assisted weightbearing
• Design a guided physiotherapy program and exercises for patients with Scheuermann disease

The following measure is recommended to facilitate reossification:

• Consider supplementation with calcium and a multivitamin containing trace elements; however, multivitamins and calcium supplements probably have only a placebo effect, and there is no solid evidence to support their use

Antibiotic therapy was formerly employed in the treatment of osteochondroses. Currently, however, the use of antibiotics (specifically tetracyclines) for this purpose is not recommended.

Future therapies that may help to limit the progression of individual mechanisms in Perthes disease are inhibition of receptor activator of nuclear factor-kappa B ligand (RANKL), ^[28]  immunomodulation of T helper cells, and administration of antibodies to tumor necrosis factor alpha (TNF-α).

Administration of bisphosphonates (eg, zoledronic acid) has shown promising results. However, concerns have included the possibility of subsequent alteration of morphology and disturbance of physeal growth.

Surgical treatment is usually undertaken when conservative methods are ineffective or failing or when they are expected to fail during follow-up. Another indication for surgical therapy is a situation where such therapy may help restore the reparative process or guide this process in such a way as to improve outcomes. In addition, surgery is sometimes performed to enhance the patient’s cosmetic appearance.

Although full recovery after surgery is uncommon, it has been known to occur even in advanced cases, given the appropriate setting. Therefore, surgery is best deferred until late in the course of the disease, or else reserved for the treatment of disability.

Listed below are some of the generalized procedures that have successfully been used to manage common osteochondroses. They range from minimally invasive procedures to salvage operations.

Arthroscopic procedures are usually performed to manage large joints, with the following objectives:

• To remove loose bodies in osteochondritis dissecans
• To facilitate regeneration by applying the microfracture technique
• To pin or refix a salvageable fragment

Open removal of a loose fragment (ossicle) is performed to treat secondary pseudoarthrosis of Osgood-Schlatter disease.

Refixation, either with bioabsorbable pegs or pins (eg, polyglycolide) and screws (preferable) or with autologous bone pegs of partially avulsed patellar tendons, is performed to manage Osgood-Schlatter disease or Freiberg disease.

Osteotomy is performed for the following purposes:

• To correct secondary deformity in Blount disease or Madelung deformity
• To accomplish valgus-extension corrective osteotomy and correct abduction and flexion deformity in Perthes disease
• To accomplish dorsal wedge osteotomy with pin fixation to improve the congruity of the metatarsophalangeal joint in Freiberg disease
• To manage Kienböck disease - Some osteotomies that decrease ulnar variance (eg, ulnar osteotomy) can be therapeutic; revascularization procedures (eg, vascularized bone grafting) have specific indications, depending on the site of involvement and on the stage of disease

Shelf acetabuloplasty (labral support) procedures include the following:

• Varus derotation osteotomy of the femur and Salter innominate osteotomy to improve containment and acetabular remodeling in Perthes disease, depending on individualized case assessments
• Spinal fusion to control progression of deformity in Scheuermann disease ^[29]

Salvage surgeries and reconstructive procedures are sometimes required to reduce disability in late cases with poor final outcomes. They include the following:

• Garceau cheilectomy and shelf augmentation to address a malformed femoral head in Perthes disease
• Trochanteric advancement to treat femoral epiphyseal arrest
• Tibial lengthening to manage Blount disease
• Selective carpal or wrist arthrodesis to treat Kienböck disease
• Interpositional arthroplasty using fascia, membranes, capsules, and tendons to treat Freiberg disease and late-presenting elbow osteochondroses with secondary changes

Osteochondral autograft transplantation (OAT) has been described for advanced-stage Freiberg disease. ^{[30, 31]}

The surgical approach for each case must be individualized and based on sound principles. In weighing the benefits and risks of any procedure, clinicians should always remember the Salter aphorism: Decision is more important than incision. Some of the newer procedures are still unproven and should not be accepted just because other alternatives may seem to have undesirable aspects.

Regular, vigilant follow-up is required after surgical intervention to promote healing and to maintain the results achieved. Protected mobilization followed by graduated functional activity is necessary whether the osteochondrosis is treated conservatively or surgically at any stage. Follow-up is long, extending many years until skeletal maturity is achieved; otherwise, progress cannot be ascertained. Because the disease may flare up or worsen, a different intervention may be required at some point.

If the anatomy and physiology of the joint are restored after skeletal maturity, the risk of persistent morbidity is low. However, poor restoration is common because of secondary osteoarthritis and related disability. If these sequelae arise, appropriate intervention is necessary.

A guided physiotherapy program must be simultaneously undertaken during rehabilitation with the aim of reducing disability.