Knee Surg Sports Traumatol Arthrosc (2007) 15:431–435 DOI 10.1007/s00167-006-0180-0

KNEE

Multiple osteochondroses of bilateral knee joints: a case report Francesco Franceschi Æ Simona Angela Barnaba Æ Mario Rojas Æ Giancarlo Gualdi Æ Giacomo Rizzello Æ Rocco Papalia Æ Vincenzo Denaro

Received: 10 January 2006 / Accepted: 19 June 2006 / Published online: 9 September 2006 Ó Springer-Verlag 2006

Abstract Knee injuries in young athletes include not only the typical adult bone injuries, ligament and cartilage, but also the growth plate lesions. Osteochondroses are idiopathic, self-limited disturbance of enchondral ossification in which a rapid growth spurt is present. The patella could be affected by two different kinds of osteochondroses: Kohler syndrome and Sinding–Larsen–Johansson. Here we are reporting the first case of simultaneous location of ostechondroses of the two ossification centers of both patella. A 9-yearold boy, competitive skater, presented a history of anterior knee pain involving both knees. Standard X-rays, axial patellar view, MRI and arthro-MR were performed. In order to follow the natural history of the pathology and the evolution of the healing, examinations at 2 years were repeated. We proposed the young

F. Franceschi (&) Æ S. A. Barnaba Æ G. Rizzello Æ R. Papalia Æ V. Denaro Department of Orthopaedic surgery, University Campus Biomedico of Rome, via E. Longoni, N. 83, 00155 Rome, Italy e-mail: [email protected] S. A. Barnaba e-mail: [email protected] G. Rizzello e-mail: [email protected] R. Papalia e-mail: [email protected] V. Denaro e-mail: [email protected] M. Rojas Æ G. Gualdi Department of Radiology, Umberto I Hospital, Rome, Italy

skater a medical and a physiotherapeutic treatment based on unloading, isometric exercises, NSAID. As the symptoms improve a gradual return to competitive sports activity was allowed. The case mentioned above can be considered an atypical case because the patient suffered for a bilateral knee osteochondroses, involving simultaneously the primary ossification centre (Kohler syndrome) and the secondary ossification centre (Larsen syndrome) of the patella. Keywords Osteochondroses Æ Ossification Center Æ Patella Æ Arthro-Rm Æ Skating

Introduction Knee injuries in young athletes include not only the typical adult bone injuries, ligament and cartilage, but also the growth plate lesions [17]. Osteochondroses are idiopathic, self-limited disturbances of enchondral ossification. The incidence of this disease is 1.7% amongst general bone pathologies, with a higher occurrence in the lower limbs versus the upper ones. Kohler, in 1908 reported about osteochondroses of the tarsal navicular and the primary ossification center of the patella in the same subject [2]. The same pathology was observed by Pinar et al. involving both knees in the same patient. The patella could be affected by two different kinds of osteochondroses: Kohler syndrome and Sinding–Larsen– Johansson, which is the pathology of the secondary ossification center of the patella usually affecting the lower pole [5, 11, 13, 14]. In the first case we are facing an irregularity and sclerosis of the center part of the rotula; in the second

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Knee Surg Sports Traumatol Arthrosc (2007) 15:431–435

case, the same type of degeneration is localized upon the upper or lower pole of the rotula; the first, less frequent reveals between 5 and 7 years of age; the second, more frequent, between 9 and 11 years of age [5, 11, 13, 14]. Here we are reporting the first case of simultaneous location of osteochondroses of the two ossification centers of the patella.

Case report A 9-year-old boy, competitive skater, presented a history of anterior knee pain involving both knees. He referred that ascending the stairs, long-distance walking, running, and athletic activities (skating) worsened the pain. Clinical examination revealed normal patellar glide test, passive patellar tilt test, Q angle and tuberclesulcus angle. There was no effusion. Palpation, Zohlen and provocative tests were negative. Standard X-rays, axial patellar view, MRI and arthro-MR were performed. In order to follow the natural history of the pathology and the evolution of the healing, examinations at 2 years were repeated.

Fig. 1 a X-ray axial view showing fragmentation zones involving the whole patella, without patellar tilt or sub/luxation. b Healing at 2 years axial view

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Fig. 2 Lateral radiographs of bilateral knees: note the fragmentation of both patella

Imaging 1.

Axial patellar view: No evidence of patellar tilt or sub-luxation (Figs. 1a, 2). Follow-up at 2 years showing the radiological healing (Fig. 1b).

Fig. 3 a CT-scan showing the fragmentation phase of the whole patella. b CT control at 2 years follow-up showing the resolution of the fragmentation phase

Knee Surg Sports Traumatol Arthrosc (2007) 15:431–435

2.

3.

4.

CT-Scan: Shows fragmentation zones involving the entire patella with its structural lack of homogeneity (Fig. 3a). CT-Scan follow-up at 2 years showing the resolution of the fragmentation phase (Fig. 3b). MRI: Fragmentation of both ossification center of the patella, physis still open, no evidence of lesions or micro-crackings of the articular cartilage (Fig. 4a, b). Follow-up at 2 years demonstrating compaction of the bone morphology (Fig. 5a, b). Arthro-MR: No evidence of intra-articular bodies, traumatic cartilage lesions and osteochondral fractures (Fig. 6).

For the young skater we proposed a medical and a physiotherapeutic treatment based on using crutches to unload the involved knee for 2 months, isometric exercises, and NSAID. Two months post-op, partial weight bearing was increased to full weight bearing over a 3-week period. Physical therapy was carried out for about 6 months. For the following 2 months muscle strengthening and swimming (crawl and backstroke) were followed. As the symptoms improve a gradual return to competitive sports activity was allowed.

Discussion The case mentioned above can be considered an atypical case because the patient suffered for a bilat-

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eral knee osteochondroses, involving simultaneously the primary ossification centre (Kohler syndrome) and the secondary ossification center (Larsen syndrome) of the patella [5, 13, 16]. Pinar et al. in their case histories, show symptomatic patients; Keats shows almost asymptomatic cases and concludes that the irregular ossification of the knee could be a normal developmental variation, a variation that ranges from a serious X-ray presentation to an asymptomatic, individual, clinical presentation [14]. Our case was symptomatic, as is typically found in young people reporting anterior knee pain who are involved in intensive physical activity [3, 9, 15]. The overuse and the frequent microtraumatisms play a key role in causing the anterior knee pain [3, 9, 15]. X-Ray diagnostic examinations were used by all the authors. Through the standard radiographic exam, it is possible to highlight the typical phenomena of the three phases of osteochondroses, as the initial sclerosis of the ossification nucleus, the second phase of metallization and the beginning of the resolving phase. CT has a limited role: while it is more sensible than traditional radiology (X-rays), when compared to MRI proves to be better in the diagnosis of subchondral fractures [2]. On the base of the studies carried out over the years, we can say that MRI is the goldstandard in the diagnosis of the traumatic chondral lesions, of the dissecans osteochondrities and of the osteochondral fractures of the knee. With MRI we obtain a better spatial

Fig. 4 MRI sagittal (a) and axial (b) scans of bilateral knees showing the involvement of both patellar primary and secondary ossification center of patella

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Fig. 6 Arthro-MR FSE T1 fat-sat post gadolinium: contrast enhancement improve cartilage visualization, confirming the absence of cartilage fracture

Fig. 5 a–b Axial MRI T1-weight and sagittal follow-up at 2 years demonstrating the compaction of the bone morphology

resolution and the discrimination of the bone structure from the fleshy tissues so that we can analyze in a better way the conditions of the articular cartilages and in case of a suspected osteochondritis dissecans we can obtain the evidence of the interface between the ostochondral fragment and the bone portion [10]. Moreover, MRI is very useful in monitoring the response to both conservative and surgical therapy [7]. We can support the MRI with an MR-Arthrography after medium injected at the level of the articular cavity [17]. The arthro-MR not only allows the vision of any fragment on the point of dissection, but also the detection of micro-crackings of the articular cartilage and the micro-lesions of the osteochondral junctions and of the subchondral bone; therefore it remains a useful exam in order to highlight the hidden lesions of

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the subchondral bone and of the cartilage which can avoid the traditional exams, especially in case of OCD [12]. In our case, we have used the traditional instrumental diagnosis (X-ray and MRI) with an arthro-MR [6, 7, 10, 12, 17]. The diagnostic hypotheses we advanced were those, which belong to the common differential diagnoses of the anterior knee pain, namely overuse and traumarelated lesions [3, 9, 15]. Combining traditional diagnosis with an arthro-MR gives us an accurate diagnostic examination with which we were able to exclude most of these possibilities: Sinding–Larsen, OCD and osteochondritis dissecans [1]. Through the images of the arthro-MR, we were then able to differentiate between the two forms of the patella osteochondroses (the one of the primary ossification center and the one of the secondary ossification center) [1]. The ‘‘growth spurt’’ and the several micro-traumatisms of the knee due to the particular sports activity practiced by our young patient can have probably acted as a trigger for the pathology [18]. Actually, the typical skating load, have repercussions on those regions, which are mostly stressed by this kind of sport: knee, tibia and the hip region [4, 8]. The osteochondroses of the both ossification center of the patella is a self-limiting pathology with a benign course and a favorable prognosis; therefore the surgeon must not try to treat the pathology in a too aggressive way [10]. For these reasons, the young patient, underwent a conservative treatment, excluding any possible surgical procedure [10]. Besides the fundamental use of

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crutches to unloading the involved knee and isometric gym for the muscles of the quadriceps, the patient took NSAID.

Conclusions We report the first case of osteochondroses of the primary ossification center or Kohler syndrome and of the secondary one, Sinding–Larsen syndrome, which has been studied with new and close instrumental methods and treated with the most simple, less invasive but effective therapeutic aids (unloading, NSAID, isometric gym). The therapy resulted in a complete clinical and radiological recovery from the pathology and the return of our young athlete to competitive sport.

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