Anterior cruciate ligament reconstruction in athletes with an ossicle associated with Osgood-Schlatter's disease

Anterior Cruciate Ligament Reconstruction in Athletes With an Ossicle Associated With Osgood-Schlatter's Disease

J o h n R. M c C a r r o l l , M . D . , K. D o n a l d S h e l b o u r n e , M . D . ,

a n d D i p a k V. Pa t e l , M . D . , M . S . , M . S c . Or th . , F . C . P , S . Or th .

Summary: We report a series of 20 athletes with an ossicle associated with Osgood-Schlatter's disease (OSD) who underwent anterior cruciate ligament (ACL) reconstruction using autogenous, central-10-mm patellar-tendon graft. All patients had an Osgood-Schlatter's lesion with an ossicle as seen on a plain radiograph. The patients were reviewed at an average follow-up of 44 months (range, 24 to 108 months). The postoperative assessment included clinical examination, KT-1000 testing, isokinetic testing, and subjective score (using the modified Noyes' questionnaire). At the time of latest review, all 20 patients had a stable knee. The average side-to-side difference on manual maximum KT-1000 assessment was 1.9 mm (range, 0 to 5 mm). Average time to return to full sporting activities was 5.2 months (range, 2.6 to 8.9 months). All patients returned to their previous level of activity. The mean modified Noyes' knee score was 96 (range, 89 to 100). To date, no graft failure has occurred. Based on the results of this study, we believe that ACL reconstruction using the autogenous bone-patellar tendon-bone graft can be safely undertaken in athletes with an ossicle associated with OSD without compromising the final knee function. Key Words: Anterior cruciate ligament-- Reconstruction-- Ossicle-- Osgood-Schlatter' s disease.

T he central one third of the patellar tendon is popu- lar as an autogenous graft source for anterior cru-

ciate ligament (ACL) reconstruction. J Various authors have reported excellent clinical results with ACL reconstruction using autogenous bone-patel lar tendon- bone graft. 2-5

Osgood-Schlatter 's disease (OSD) is an apophysitis of the tibial tubercle that commonly affects children during their adolescent growth spurts. 6'7 Krause et al. 8 reported the natural history of untreated OSD in 50 patients (69 knees). In their series, at an average follow-up of 9 years (range, 3 to 30 years), 76% of the patients believed they had no limitation of activity,

From the Methodist Sports Medicine Center, Indianapolis, Indiana, U.S.A. Address correspondence and reprint requests to John R. McCarroll,

M.D., Methodist Sports Medicine Center, 1815 N Capitol Ave, Suite 530, Indianapolis, IN 46202, U.S.A.

© 1996 by the Arthroscopy Association of North America 0749-8063/96/1205-136353.00/0

although 60% of the patients still could not kneel without discomfort. A specific series reporting the results of ACL reconstruction using an autogenous patellar-tendon graft in athletes with OSD has previously not been reported. Cosgarea et al. 9 stated in a single case report that if structural abnormalities of the patellar tendon secondary to OSD are identified, the surgeon must be prepared to consider other treatment options including the use of alternative graft sources because of compromised strength of the patellar tendon graft. However, we have consistently used an autogenous patellar-tendon graft for reconstruction of the ACL even in athletes with an ossicle associated with OSD.

For patients with an associated Osgood-Schlatter 's lesion, there remains some concern whether the patellar tendon graft is in fact strong enough, or if it is compromised in some way. The purpose of this article is to address this issue and to report our technique and results of ACL reconstruction using a patellar-

556 Arthroscopy: The Journal o f Arthroscopic and Related Surgery, Vol 12, No 5 (October), 1996: pp 556-560

ACL RECONSTRUCTION AND OSD-ASSOCIATED OSSICLE 557

'J#----PATELLA

~SICLE

l

t

FIG 1. (A) Lateral radiograph showing a separated ossicle near the insertion of the patellar tendon to the tibial tuberosity in a patient with OSD. (B) Corresponding diagram showing the ossicle.

tendon autograft in athletes with an associated OSD ossicle.

MATERIALS AND METHODS

Between January 1987 and July 1993, 20 athletes (18 men and 2 women) with functionally unstable ACL-deficient knees and an ossicle associated with OSD underwent ACL reconstruction using autogenous bone-patellar tendon-bone graft. All patients reported a history of OSD with presence of an easily identified ossicle on initial plain radiographs (Fig 1). None of the patients had active symptomatic OSD at the time of ACL reconstruction; they all had "burnt out" OSD. The mean age of the patients at surgery was 22 years (range, 12 to 35 years). The average postoperative follow-up was 44 months (range, 24 to 108 months).

Range of motion (ROM) of the knee was recorded as a/b/c, where " a " represents the degree of hyperex- tension, " b " represents the degree of flexion short of

0 ° and " c " represents the degree of flexion in the knee. The mean preoperative ROM was 4°/0°/133 ° (range, 2°/0°/128 ° to 7°/0°/146°). The average preoperative side-to-side difference on manual maximum KT-1000 (MEDMetric Corp, San Diego, CA) testing was 6.6 mm (range, 5 to 11 mm). On isokinetic testing (Cybex, Lumex Inc, Ronkonkoma, NY) at 180°/s speed, the mean quadriceps strength score was 74% (range, 56% to 92%) and the average hamstrings strength score was 88% (range, 72% to 116%) compared with the opposite normal knee.

The patients' postoperative assessment included a physical examination including the ROM, Lachman and pivot shift tests, KT-1000 manual maximum side- to-side difference, and isokinetic muscle strength testing at 180°/s speed. Postoperative KT-1000 and isokinetic evaluations were performed at 5 weeks, 3 months, 6 months, 1 year, and yearly thereafter. A modified Noyes' questionnaire 4 was used for subjective evaluation.

558 J. R. McCARROLL ET AL.

OSSICLE

PATELLA ~ , TIBIA

FIG 2. The ossicle is excised.

The ACL reconstruction was performed using a miniarthrotomy technique ~° in 11 patients and a "through the patellar-tendon defect" technique H in 9 patients. The details of these techniques have been published previously.

Before ACL surgery, radiographs were evaluated to assess the size, number, and location of any Osgood- Schlatter ossicles. Several technical points in the operative technique are important to graft harvesting in patients with OSD. While harvesting the central 10- mm patellar-tendon graft, it is important to differenti- ate the ossicle from the tibial insertion of the patellar tendon. If the ossicle is not thus identified preoperatively, it may be mistakenly assumed to be the tibial insertion of the patellar tendon. The tibial attachment being distal to the ossicle makes the tibial bone cut somewhat difficult. We use separate medial and lateral cuts for harvesting the graft following the line of the patellar tendon fibers because they may splay out over the ossicle making the patellar tendon look wider in this region. Failure to appreciate this may lead to harvesting a narrower graft. The average length of the patellar tendon was measured intraoperatively and was found to be 49.5 mm (range, 37 to 63 mm).

Once the graft is harvested, the ossicle is removed by careful dissection with either a No. 15 or 11 blade (Fig 2). After removal of the ossicle, the patellar tendon in the region of the ossicle is flatter than rest of the tendon but does not cause a problem with graft place- ment. After graft harvest, any bony protuberances of the tibial tubercle may be smoothed with a rongeur.

If the harvested graft looks thinner from where the bony fragment was excised, reinforcing sutures can be taken (Fig 3). We were able to harvest a tibial bone plug (average size, 10 × 25 mm) in all cases. No

fixation problems of the bone-patellar tendon-bone graft were encountered using our suture and button or staple and button techniques.

RESULTS

At the time of latest review, all knees were stable on clinical examination as assessed by Lachman and pivot shift tests. The average ROM was 6°/0°/136 ° (range, 2°/0°/125 ° to 10°/0°/148°). The mean side-to- side difference on manual maximum KT-1000 assessment was 1.9 mm (range, 0 to 5 mm). Nineteen patients had KT-1000 manual maximum value of less than 3 mm. One patient had a KT-1000 manual maximum value of 5 mm with a trace Lachman with a good endpoint and no pivot shift•

On isokinetic testing, the mean quadriceps strength score was 86% (range, 68% to 108%) compared with the quadriceps strength in the opposite extremity and the average hamstrings strength score was 95% (range, 78% to 127%) compared with the hamstrings strength in the opposite limb. All patients returned to their pre- injury activity level. The average time to return to full sports was 5.2 months (range, 2.6 to 8.9 months). The mean modified Noyes' score was 96 (range, 89 to 100).

None of the patients in this series had persistent anterior knee pain (patellofemoral or in the area of the excised ossicle) postoperatively. No intraoperative or postoperative complications were encountered in our series. To date, no graft failure has occurred.

DISCUSSION

OSD commonly affects adolescents near the age of puberty and is seen more often in adolescent athletes

~ ~ ~ ~ ~ . ~ . ~ -.z~,:.,, ,%~e.~,_'~,

F IG 3. Sutures can be taken to reinforce the thinner portion of the patellar tendon.

ACL RECONSTRUCTION AND OSD-ASSOCIATED OSSICLE 559

participating in sports involving kicking, jumping, and squatting. 7 0 S D is generally considered to be a rela- tively benign condition without any significant long- term sequelae. 12 Rare complications of OSD include genu recurvatum secondary to premature fusion of the anterior portion of the proximal tibial epiphysis, 13 and patellar tendon avulsion. J4 The most common late complication following OSD is the presence of a symptomatic, ununited ossicle at or near the insertion of the patellar tendon to the tibial tuberosity, ~4 resulting in discomfort on kneeling. In most cases, Osgood-Schlat- ter 's lesion heals with a resultant enlarged, prominent tibial tuberosity.

Jakob et al. 15 reported that OSD can lead to elongation of the patellar tendon and a slight patella alta. However, we did not find any significant lengthening of the patellar tendon in the 20 athletes in our series. We measured the patellar tendon intraoperatively and found that the average length was 49.5 mm (range, 37 to 63 mm). Since 1992, we have measured the patellar tendon length on preoperative radiographs and intraoperatively of 551 patients and have found that the average length is 49 mm (range, 34 to 67 mm). Comparing these figures with the present series, we found that elongation of the patellar tendon was not present in an:y of the patients.

Various studies have reported on the presence of ossicles in association with OSD. 8'16'17 There is an anecdotal concern regarding the use of bone-patellar tendon- bone graft for ACL reconstruction in athletes with OSD. Cosgarea et al. 9 reported a case of 20-year-old male collegiate soccer player with a ruptured ACL who had OSD during adolescence. They believed that ACL reconstruction using autogenous bone-patellar tendon- bone graft was contraindicated in the presence of a free- floating ossicle in the patellar tendon because of the concern of the graft strength and, therefore, ACL reconstruction with an allograft was performed in their patient.

Avulsion fracture of the tibial tubercle in adolescents with preexisting OSD has been reported. ~s'~9 Avulsion of the patellar tendon as a complication of OSD has also been reported in a 13-year-old male athlete by Bowers. 74 Although these reports provide indirect clinical evidence suggesting that the function of the b o n e - patellar tendon-bone unit may be compromised in the setting of concurrent or previous OSD, our clinical experience has shown that, with careful operative technique, excellent successful results following ACL reconstruction can be obtained in athletes with an ossicle associated with OSD.

Histological evidence of structural incontinuity of the patellar tendon 2° raises the question whether the

integrity of the patellar tendon-tibial bone block unit may be compromised. LaZerte and Rapp 2° studied the histology in 9 specimens from the tibial tuberosities in 7 patients with OSD. In all cases, a defect in the anterior cortical bone of the tibial tuberosity was found. This defect was filled and surrounded by a zone of proliferating connective tissue with differentiation into irregularly arranged osteoid tissue, and occasionally cartilage. In some of the cases with free ossicles in the patellar tendon, a cleft resembling a pseudarthrosis was found in the fibrocartilagenous tissue between the tuberosity and the ossicle, or between two ossicles. The tendinous tissue about the ossicle frequently showed increased vascularity and occasionally contained foci of mucoid degeneration.

Mital et al. 17 excised 15 free ossicles in patients with persistent OSD who had conservative treatment for an average of 3.8 years. Histological study of the specimens showed no evidence of avascularity. All ossicles were attached to the distal part of the undersurface of the ligamentum patellae, and were separated from the tibial tubercle by a bursa (13 knees) or scar tissue (2 knees). All patients in our series had an ossicle in the patellar tendon near its insertion to the tibial tuberosity as seen on plain radiographs. These ossicles were excised at surgery and, although the remaining patellar tendon after the excision of ossicle was thinner than the rest of the patellar tendon, to date, no long-term problems concerning the knee stability have been seen. The flattened area of the tendon can be left as it is or be made into a tubular form using a suture depending on the surgeon's preference with equally good long- term results.

The importance of recognizing the presence of an Osgood-Schlatter ossicle in the patellar tendon when undertaking a patellar tendon ACL reconstruction is twofold: (1) to recognize the ossicle preoperatively on radiographs so that during the graft harvest, the ossicle is not mistakenly identified as the tibial insertion of the patellar tendon, which can result in an error in the harvest of the tibial attachment of the patellar tendon; and (2) excision of the ossicle is required to harvest a graft of the correct size to be placed in the 10-mm tunnels. The ossicle is not "free floating" and needs to be excised with a No. 15 or 11 surgical blade after the graft harvest. Awareness of the presence of the ossicle allows us to widen the borders of the tendon cuts at the time of graft harvest. Although the graft over the ossicle is thinner after ossicle removal, the tendon can be left as it is or can be made into a tubular structure, still providing a graft of adequate strength and an ultimate optimal functional result.

560 J. R. M c C A R R O L L E T AL.

All 20 patients in the present series had "burn t ou t" OSD and none had symptoms of OSD at the time of

their ACL reconstruction. In the early postoperative

period, activity-related, intermittent patellar tendon

soreness was noted in most athletes and this subsided

within 12 months. All patients achieved a stable knee

with a full ROM at an average follow-up of 44 months

postoperatively, signifying that graft function was not

compromised. By careful attention to the technical de-

tails (as described previously) of graft harvesting, ACL

reconstruction can be safely undertaken in athletes with

an ossicle associated with OSD. All patients were able to return to full competitive

or recreational sports at an average of 5.2 months post-

operatively. To date, no clinical or arthrometric evi-

dence of graft laxity has been seen. We believe that ACL reconstruction can be safely performed using au-

togenous bone-pa te l l a r t e n d o n - b o n e graft in patients

who have OSD with free ossicles with careful attention

to details of dissection of loose ossicles and graft place-

ment. Based on our clinical experience, the b o n e - p a -

tellar t e n d o n - b o n e graft can be used for ACL recon-

struction in athletes with OSD, without compromising

graft function and knee stability. We have been able to achieve consistent, predictable, excellent clinical re-

suits in these patients without associated morbidity or

sequelae.

R E F E R E N C E S

1. Johnson RJ, Beynnon BD, Nichols CE, Renstrom P. Current concepts review: The treatment of injuries of the anterior cruciate ligament. J Bone Joint Surg Am 1992;74:140-151.

2. Clancy WG Jr, Nelson DA, Reider B, Narechania RG. Anterior cruciate ligament reconstruction using one-third of the patellar ligament, augmented by extra-articular tendon transfers. J Bone Joint Surg Am 1982;64:352-359.

3. Johnson ILl, Eriksson E, Haggmark T, Pope MH. Five- to ten-

year follow-up evaluation alter reconstruction of the anterior cruciate ligament. Clin Orthop Rel Res 1984; 183:122-140.

4. Shelbourne KD, Whitaker HJ, McCarroll JR, Rettig AC, Hirsch- man LD. Anterior cruciate ligament injury: Evaluation of intra- articular reconstruction of acute tears without repair: Two to seven year follow-up of 155 athletes. Am J Sports Med 1990; 18:484-489.

5. Aglietti P, Buzzi R, D'Andria S, Zaccherotti G. Long-term study of anterior cruciate ligament reconstruction for chronic instabil- ity using the central one-third patellar tendon and a lateral extra- articular tenodesis. Am J Sports Med 1992; 20:38-45.

6. D'Ambrosia RD, MacDonald GL. Pitfalls in the diagnosis of Osgood-Schlatter disease. Clin Orthop Rel Res 1975; 110:206- 209.

7. Kujala UM, Kvist M, Heinonen O. Osgood-Schlatter's disease in adolescent athletes: Retrospective study of incidence and du- ration. Am J Sports Med 1985; 13:236-241.

8. Krause BL, Williams JPR, Catterall A. Natural history of Os- good-Schlatter disease. J Pediatr Orthop 1990; 10:65-68.

9. Cosgarea AJ, Weng MS, Andrews M. Osgood-Schlatter's disease complicating anterior cruciate ligament reconstruction. Arthroscopy 1993;9:700-703.

10. Shelbourne KD, Klootwyk TE. The miniarthrotomy technique for anterior cruciate ligament reconstruction. Oper Tech Sports Med 1993; 1:26-39.

11. Van Meter CD, Sallay P, McCarroll JR. Anterior cruciate ligament reconstruction through the patellar tendon defect. Oper Tech Sports Med 1993; 1:40-44.

12. Ehrenborg G. The Osgood-Schlatter lesion: A clinical study of 170 cases. Acta Chir Scand 1962; 124:89-105.

13. Jeffreys TE. Genu recurvatum after Osgood-Schlatter's disease: Report of a case. J Bone Joint Surg Br 1965;47:298-299.

14. Bowers KD Jr. Patellar tendon avulsion as a complication of Osgood-Schlatter's disease. Am J Sports Med 1981;9:356-359.

15. Jakob RP, Von Gumppenberg S, Engelhardt P. Does Osgood- Schlatter's disease influence the position of the patella? J Bone Joint Surg Br 1981;63:579-582.

16. Woolfrey BF, Chandler EF. Manifestations of Osgood-Schlat- ter's disease in late teen age and early adulthood. J Bone Joint Surg Am 1960;42:327-332.

17. Mital MA, Matza RA, Cohen J. The so-called unresolved Os- good-Schlatter lesion: A concept based on fifteen surgically treated lesions. J Bone Joint Surg Am 1980;62:732-739.

18. Hand WL, Hand CR, Dunn AW. Avulsion fractures of the tibial tubercle. J Bone Joint Surg Am 1971;53:1579-1583.

19. Levi JH, Coleman CR. Fracture of the tibial tubercle. Am J Sports Med 1976;4:254-263.

20. LaZerte GD, Rapp IH. Pathogenesis of Osgood-Schlatter's disease. Am J Pathol 1958;34:803-815.

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Anterior cruciate ligament reconstruction in athletes with an ossicle associated with Osgood-Schlatter's disease