Osteochondropathy

A group of diseases with a long cyclical course, disruption of bone tissue nutrition and its subsequent aseptic necrosis is osteochondropathy.

This pathology has a dystrophic nature and is closely associated with genetic factors. According to the international classification of diseases ICD 10, it is included in group XIII Diseases of the musculoskeletal system and connective tissue (M00-M99):

M80-M94 Osteopathy and chondropathy:

• M80-M85 Disorders of bone density and structure.
• M86-M90 Other osteopathies.
• M91-M94 Chondropathy.

According to radiological manifestations and secondary clinical signs, the disease is associated with resorption and replacement of destroyed bone areas. Aseptic osteochondronecrosis is characterized by a cyclical change of the following processes:

• Non-inflammatory (aseptic) bone necrosis.
• Pathological fracture in the affected area.
• Resorption and rejection of necrotic parts of the bone.
• Repairing damage.

If the articular cartilage is involved in the pathological process, there are high risks of its function being impaired. The disease is characterized by a long, chronic course. With timely and adequate treatment, it has a favorable outcome.

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Epidemiology

According to medical statistics, many diseases of the musculoskeletal system are associated with a violation of the structure and density of bones and are most often found in elderly people. But with osteochondropathy, everything is the opposite, it manifests itself during the period of active growth of the body. It is diagnosed mainly in patients aged 10-18 years of athletic build. At the same time, most of the patients are young men.

The main area of damage is the bones and joints that are subject to increased muscle loads and microtraumas: knees, hip joints, feet. In adult patients with degenerative joint lesions, osteoarthrosis is diagnosed, which has a clinical picture similar to aseptic necrosis.

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Causes osteochondropathies

To date, the exact cause of the development of degenerative-necrotic lesions of certain bone sections has not been established. Studies indicate that osteochondropathy is associated with the following factors:

• Hereditary predisposition.
• Hormonal imbalance.
• Endocrine diseases.
• Metabolic disorders.
• Frequent injuries and microtraumas.
• Infectious diseases.
• Unbalanced diet.
• Violation of the interaction between bone tissue and blood vessels.
• Disruption of nervous trophism and regulation of blood flow.
• The limbs and spine are in an unnatural position for a long period of time.
• Atrophy of the thigh muscles.
• Long-term use of certain groups of medications.

During the diagnostic process, all of the above reasons are taken into account, and treatment is aimed at preventing them in the future.

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Risk factors

There are a number of factors that significantly increase the risk of bone nutrition disorders:

• Childhood and adolescence.
• Developed muscle mass.
• Overweight.
• Male gender.
• Genetic factor.
• Endocrine pathologies.
• Malnutrition.
• Disorders of vitamin and calcium metabolism.
• Excessive physical exertion, injuries.
• Systemic connective tissue disease.
• Use of corticosteroids.
• Neutrophic disorders.
• Age-related changes.
• Congenital anomalies in the development of organs and systems.
• Incorrectly selected shoes.

The more combinations of the above factors, the higher the risk of developing osteochondropathy.

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Pathogenesis

The mechanism of development of bone and joint damage is not fully understood. The pathogenesis of osteochondropathy is associated with excessive physical activity and injuries. There are also a number of other predisposing factors that may be associated with the development of the disease:

• Metabolic syndrome (disorder of metabolism of essential substances).
• Hormonal imbalance due to endocrine pathologies.
• Diseases of the pituitary gland, thyroid gland, ovaries, adrenal glands.
• Various infectious diseases.
• Deficiency of magnesium, calcium and other useful substances in the body.
• Disorder of blood supply to bone tissue.
• Obesity of any stage.
• Professional sports activities and frequent microtraumas.

The degenerative-dystrophic process in bones is closely related to hereditary factors. If one of the parents suffers from bone and joint damage, then under the influence of the above factors, the child can inherit this problem.

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Symptoms osteochondropathies

There are several types of osteochondropathy, each of which has its own symptoms.

Let's look at the symptoms of the most common pathologies:

1. Hip joint damage:

• Patients 4-9 years old.
• Limited movement in the joint.
• Muscle atrophy in the lower leg and thigh.
• Lesion of the femoral head.
• Severe pain in the injured area.
• Pain in the knee.
• Shortening of the affected limb by 1-2 cm.

2. Tuberous tibia:

• Patients 12-15 years old, male.
• Swelling in the affected area.
• Increased pain with intense movements.
• Dysfunction of the joint.

3. Metatarsal bone:

• Childhood age of patients.
• Systematic pain in the affected area.
• Swelling and redness of the skin on the back of the foot.
• Limitation of motor function.
• Shortening of the 2nd and 3rd fingers of the affected limb.

4. Lesions of the vertebrae and spine:

• Kyphosis of the mid-thoracic and lower thoracic spine.
• Discomfort in the back.
• Intervertebral neuralgia.
• Rapid back fatigue.
• Deformation of the affected segment.

The localization of the pain syndrome depends entirely on the affected area, and the severity of the pain depends on the severity of the pathological process. In all cases, discomfort increases with physical exertion, causing a number of additional symptoms.

There are a number of symptoms that indicate the development of aseptic necrosis. The first signs of the disease include:

• Physical activity causes an exacerbation of pain in the affected area.
• Swelling of the affected tissues.
• Joints crunch during movement.
• Limited motor function and lameness.
• Changes in structure and muscle atrophy.

It is unacceptable to ignore the above-mentioned signs. Without timely medical care, they begin to progress rapidly, causing acute pain and complications.

Stages

Degenerative necrotic disease of certain parts of the bones has several stages, each of which has certain symptoms:

1. Bone tissue necrosis – mild pain appears in the affected area with impaired limb function. Regional lymph nodes are normal, palpation does not reveal anything. There are no radiographic changes. It lasts from several months to six months.
2. Compression fracture – the bone sags and the damaged areas wedge into each other. On the X-ray there is a homogeneous darkening of the affected area and the absence of a structural pattern. This stage lasts from 2 to 6 months or more.
3. Fragmentation is the resorption of dead bone areas. The affected areas are replaced by granulation tissue and osteoclasts. X-rays show a decrease in bone height, as well as fragmentation of the affected areas with alternating dark and light zones. Duration is from six months to 2-4 years.
4. Recovery – gradual restoration of the shape and structure of the bone. Lasts from several months to several years.

The duration of all stages is 2-4 years. If the disease is left without medical assistance, the recovery process will proceed with residual deformation, which leads to the development of deforming arthrosis.

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Forms

Aseptic necrosis can occur in the spongy parts of any bone. The pathological condition is divided into several types, each of which has its own characteristics of the course and treatment.

1. Tubular bones (epiphysis):

• Femoral head - Legg-Calve-Perthes disease.
• Head of the I-III metatarsal bone, sternal end of the clavicle, fingers – Keller's disease II.

2. Short tubular bones:

• Navicular bone of the foot - Köhler I disease.
• Lunate bone in the hand - Kienbock's disease.
• Scaphoid carpal bone - Preiser's disease.
• Spinal body - Calve's disease.

3. Apophyses:

• Tibial tuberosity - Osgood-Schlatter disease.
• Tuberosity of the calcaneus - Haglund-Schinz disease.
• Apophyseal rings of the vertebrae - Scheuermann-Mau disease.

4. Joint surfaces - Koenig's disease.

Aseptic osteochondronecrosis is also divided into those that are treated with medication and those that require surgical intervention. The latter include:

• Koenig's disease (femoral condyles).
• Diaz's disease (talus).
• Legg-Calve-Perthes disease (femoral head).
• Larsen's disease (lower pole of the patella).
• Leuven's disease (articular surface of the patella).

The type of pathological condition determines the method of treatment and the prognosis for recovery.

The degenerative-dystrophic process in bones has several stages. Each stage has its own varieties and characteristic features.

Let's take a closer look at the classification of osteochondropathy:

1. Dystrophic and necrotic disorders in tubular bones (epiphysis). This category includes:
   • Head of the metatarsal bone.
   • The collarbone (a part of the bone in the thoracic spine).
   • Phalanges of the fingers of the upper limbs.
2. Lesions of short tubular bones:
   • Navicular bone of the foot.
   • Lunate bone of the hand.
   • Scaphoid bone of the wrist.
   • Vertebral body.
3. Pathological process in the apophyses:
   • Tuberosity of the tibia.
   • Heel tubercle.
   • Apophyseal rings of the spine.
4. Damage to the surface of the cuneiform and superficial joints:
   • Elbow joint.
   • Ankle.
   • Knee joint.

In most cases, degenerative necrotic disease occurs in children and adolescents, affecting bones and joints. All forms of the disease are characterized by a benign chronic course with a favorable outcome.

Leuven's osteochondropathy

Patellar articular surface lesion is a degenerative-necrotic disease of Leuven. It is based on aseptic necrosis of the patella and cartilage damage. The pathology occurs in patients aged 12-14 years and is unilateral. It develops due to chronic microtrauma in the patella area, dislocations, and disruption of the biomechanics of the quadriceps muscle.

Symptoms are manifested by intermittent moderate pain in the knee joint. Their occurrence is not always associated with physical activity. At the same time, movement in the joint is painless and fully preserved.

Diagnostics consists of collecting anamnesis, a set of laboratory and instrumental methods. The most informative include CT, MRI and radiography. Arthroscopy is performed to establish a final diagnosis. Treatment is conservative. The doctor prescribes a course of medication, physiotherapy, and exercise therapy. With timely treatment, the disease has a favorable prognosis.

Complications and consequences

Among the possible complications and consequences of osteochondropathy, patients most often encounter the following problems:

• Dysfunction of joints.
• Modification of bone structure.
• Restriction in the joint of the injured limb.
• Dystrophic processes in the joints.
• Slow destruction of bone tissue.

To prevent complications, you should seek medical help in a timely manner and fully comply with medical prescriptions.

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Diagnostics osteochondropathies

If a degenerative-necrotic disease of certain parts of the bones is suspected, a set of laboratory and instrumental methods is carried out, as well as a differential approach.

Osteochondropathy diagnostics begins with anamnesis and clinical picture examination. Blood tests and rheumatic tests are then prescribed. Particular attention is paid to radiography.

At the initial stage of the disease, the X-ray picture is not very informative, so MRI and CT are performed to detect the slightest changes in the bone structure. Diagnostic examinations are also indicated during the treatment to determine its effectiveness.

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Tests

Laboratory diagnostics in aseptic necrosis are necessary to determine the level of minerals in the blood, markers of bone formation and bone resorption in biological fluids. General blood and urine tests are not informative in degenerative processes in bones, but are carried out to assess the general condition of the body and identify inflammatory processes.

1. Analysis to determine minerals in the blood.
   1. Calcium is the main component of bone and is involved in the construction of the skeleton. Its norm in venous blood is 2.15-2.65 mmol/l. If the values are below the norm, the mineral deficiency is compensated by leaching from the bones. This leads to gradual destruction of bone and is not reflected in the visible health of the body.
   2. Phosphorus and magnesium interact with calcium, improving its penetration into bone tissue. With an increased phosphorus value, calcium is washed out of the body. The normal calcium and phosphorus ratio is 2:1. The phosphorus norm in the blood is from 0.81 to 1.45 mmol/l, the magnesium norm is from 0.73 to 1.2 mmol/l. If there is a disorder in the growth zone of spongy bones, their values may decrease or remain within the normal range.
2. Biochemical indicators of bone tissue destruction

The protein collagen, which provides strength and elasticity to bone tissue, is the main material of the interosseous substance, which is located between the bone plates. When bones are damaged, the protein, like collagen, is destroyed, breaking down into several markers. The substances enter the blood and are excreted unchanged in urine.

The main markers of aseptic necrosis include: deoxypyridonoline (DPID), pyridinoline and Cross-Laps. The latter is 8 amino acids that make up collagen and are involved in building proteins.

Also during diagnostics, indicators of bone formation enhancement are analyzed. The most informative is osteocalcin. This substance is produced by osteoblasts during bone tissue formation and partially penetrates into the systemic bloodstream. When bones are damaged, its level increases.

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Instrumental diagnostics

A mandatory component of diagnostics in case of suspected osteochondropathy is a set of instrumental examinations. Hardware methods have a number of indications for implementation:

• Recent injuries.
• Acute, chronic pain radiating to other parts of the body.
• Monitoring the effectiveness of the treatment.
• Preparing for surgery.
• Assessment of bone and vascular condition.

1. Radiography – gives a general idea of the condition of the affected bone. Does not reveal circulatory disorders. As a rule, images are taken in several projections for a more accurate analysis.
2. Computer tomography is a layer-by-layer study of bones and soft tissues. It determines the structure of the affected bone and the condition of the vessels using a contrast agent.
3. Magnetic resonance imaging – reveals pathological changes at early stages. Electromagnetic waves are used to visualize the affected area.
4. Scintigraphy – detects abnormal processes in the bone at early stages, before they appear on X-ray. Most often used as an additional method to MRI or CT. Rarely used in pediatric practice.
5. Arthroscopy – allows you to assess the condition of the knee joint as accurately as possible and develop further treatment tactics. Combines diagnostic and therapeutic functions. Most often used to diagnose Koenig's disease, that is, damage to the femoral condyles.

Osteochondropathies on X-ray

Radiography is the gold standard of examination when degenerative-necrotic bone disease is suspected. Let's consider the main signs of osteochondropathy of any localization on radiography:

1. Necrosis of spongy bone and bone marrow. Articular cartilage is not subject to necrosis.
2. Pathological fracture – necrotic bone tissue is not functional, trabeculae of spongy substance cannot withstand the load exerted on them. X-ray shows signs of bone deformation, its shortening, compaction. This stage lasts about six months.
3. Stage of resorption of necrotic masses by lysis. On the radiograph, necrotic masses surrounded by osteoclasts. The epiphysis has a non-uniform structure, signs of hemorrhage with subsequent calcification, cystic changes are possible.
4. At the stage of reparation, that is, restoration of the bone structure, the radiograph shows areas of enlightenment in the newly created bone tissue caused by cystic changes.

To determine the stage of the disease, the results of radiography are compared with the clinical symptoms of the disease.

Differential diagnosis

When making a final diagnosis, osteochondropathy is differentiated from other diseases with similar symptoms. The symptom complex of the disease is compared with the following pathologies:

• Deforming arthrosis.
• Tuberculosis of bones.
• Arthritis.
• Atherosclerosis.
• Degenerative-proliferative changes in bones.
• New growths.
• Infectious and inflammatory diseases.
• Compression syndromes and entrapment of peripheral nerves.

When conducting differential diagnostics, a set of laboratory and instrumental examinations is analyzed, and the stage of aseptic necrosis is also determined.

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Treatment osteochondropathies

Based on the results of the diagnostics, the orthopedist draws up a treatment plan for aseptic necrosis. First of all, patients are prescribed a course of medications, which includes the following drugs:

• Painkillers.
• Nonsteroidal anti-inflammatory drugs.
• To improve blood circulation.
• Vitamin complexes.

Prevention

Prevention of disorders in the growth zone of spongy bones consists of a set of methods aimed at general strengthening of the body, increasing the protective properties of the immune system, and supplying useful micro and macroelements.

Prevention of osteochondropathy consists of the following recommendations:

• Balanced physical activity to create and strengthen the muscular corset.
• Limit increased physical activity.
• Avoiding injury.
• Rational nutrition.
• Taking vitamin and mineral complexes.
• Timely treatment of viral, infectious and other diseases of the body.
• Wearing properly fitted shoes with orthopedic insoles.
• Regular check-ups with your doctor.

Preventive measures also include regular massage of the limbs and other parts of the body. At the first pain in the bones and joints, you should seek medical help to diagnose the causes of the painful condition and eliminate them.

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Forecast

With timely diagnosis and treatment, osteochondropathy has a favorable prognosis. Severe forms of aseptic necrosis are difficult to correct, so they can have an unfavorable outcome. The prognosis worsens significantly with the development of complications of the disease.

Osteochondropathy and the army

Degenerative necrotic disease of certain bone sections is not an exemption from military service. In order to avoid military service, it is necessary to undergo a military medical examination, which will confirm the presence of functional disorders that prevent service.

The list of pathologies that may be a ban for military service includes diseases of the skeletal system and their complications:

• Congenital curvature of the spine of a fixed type.
• Severe chest wall deformity with severe respiratory failure.
• Acquired curvatures of the spine with rotation of the vertebrae.
• Inability to maintain an upright position due to skeletal deformities.
• Instability of spinal column segments.
• Muscle weakness of the limbs, muscle paresis with decompensation.
• Disorders of motor functions.

In the presence of the above-mentioned diseases, the conscript is sent to undergo a series of examinations that will confirm pathological changes: CT, MRI, X-ray, radioisotope scanning. Based on the results of the studies and the conclusion of the medical advisory commission, the conscript is exempted from military service due to osteochondropathy or its complications.

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