Results of surgical treatment of unresolved Osgood-Schlatter disease in adults

Osgood-Schlatter is a common disease with most cases resolving spontaneously with skeletal maturity. Adults with continued symptoms may need surgical treatment if they fail to respond to conservative measures. The purpose of this study is to describe the pathological lesions, our surgical technique, and the results of our surgical treatment of Osgood Schlatter disease in adults. Thirty-five adult patients (37 knees) had surgery for unresolved Osgood-Schlatter disease. Three patients were lost for follow-up. An incision over the anterolateral aspect of the patellar tendon was used. Direct anterior incisions were avoided to decrease postoperative pain with kneeling. The patellar tendon was reflected medially, and the ossicle was removed from the posterior surface of the tendon. A tibial tuberosity reduction osteotomy was done in 29 cases (85%). A beak of the distal part of the tibial tubercle was found in 24 cases (71%) with impingement of the patellar ligament. Thirty-one knees (91%) had complete resolution of preoperative pain. There was one case of painful scar. This surgical technique for treatment of Osgood-Schlatter disease in adults is effective and safe especially for those who have the habit of frequent kneeling.     

Surgical treatment of unresolved Osgood-Schlatter disease: ossicle resection with tibial tubercleplasty

The mainstay of treatment of Osgood-Schlatter apophysitis is nonoperative. Surgical treatment has been described for patients who have failed nonoperative management of Osgood-Schlatter disease. The purpose of this study is to evaluate the functional outcome of ossicle excision and tibial tubercleplasty for unresolved Osgood-Schlatter disease that has failed nonoperative treatment. METHODS: A retrospective review was performed on 16 knees in 15 patients who underwent ossicle excision and tibial tubercleplasty for unresolved Osgood-Schlatter disease. Functional outcome was assessed using the International Knee Documentation Committee, the Lysholm Knee Scale, and Tegner Activity Score. RESULTS: Twelve patients (75%) returned to preoperative activities and sports, 2 patients (12.5%) partially returned, and 1 patient (6%) did not return. The mean postoperative Lysholm knee score was 76.5. Patients' individual scores ranged from 40 to 100. The mean International Knee Documentation Committee knee score was 75, ranging from 40 to 100. The mean Tegner activity level was 6.8 (range, 3-10). CONCLUSIONS: It is our recommendation that when patients fail extensive nonoperative management, surgery to remove the symptomatic ossicle should be offered after skeletal maturity. When this is the case, the addition of tubercleplasty should be performed.     

Ultrasonic features of the Osgood-Schlatter lesion

Ultrasound was used to compare the knees of 10 boys and four girls with typical clinical Osgood-Schlatter lesions with 27 symptomless knees. The normal sonographic changes of the tibial tubercle with advancing age are described. In all children with Osgood-Schlatter lesions, the distal patellar tendon thickened and became more echogenic than normal tendons, and an anechoic zone of edema was seen anterior to the tibial tuberosity. Four knees disclosed a thin shell-like elevated fragment of the tibial tuberosity seen as an echogenic surface. In 12 knees, single or multiple fragments of the tibial tuberosity were easily shown. Ultrasound is proposed as a simple, fast, and reliable method for the diagnosis of the Osgood-Schlatter lesion.     

Results of surgical treatment

In this chapter we report the results of the main papers of the international literature, but it is difficult to make an objective synopsis because only the best results are published and failure and complications remain confidential. Few papers describe "general complications" as thrombo phlebitis, wound infection, cardio respiratory insufficiency... which are probably as frequent as for all intracranial or spinal surgical procedures. The postoperative neurological status depends essentially on the location of the lesion. In non eloquent area, the postoperative neurological status is almost always excellent. But in a hemispheric functional area, basal ganglia and brain stem it is frequent to observe neurological sequellae; in the better series of the literature, 80% of the patients achieve a good outcome equivalent to or better than before the operation, but 20% are worsened. It is important to remember this fact before discussing the surgical indication. The risk of hemorrhage disappears after total surgical resection; and it is one of the benefits of the treatment, but this objective can be reached only when the lesion is unique. The risk persists in multiple forms and "de novo" cavernomas are always possible especially in familial forms. The main benefit is the treatment of epilepsy for seizure control. In case of good concordance between the location of the cavernoma and the clinical and electrical data, lesionectomy alone or lesionectomy with resection of the perilesional hemosiderin ring provide good results. In the event of severe epilepsy without good concordance between the site of the cavernoma and symptoms, the surgical approach may be functional and outcome less satisfactory.     

Surgical treatment of Osgood-Schlatter disease

18 patients (20 knee joints) were operated for Osgood-Schlatter disease. 12 patients (14 knee joints) had a follow-up of 2.4 years (0.5-13.5) after operation. The informations of the other patients were taken from our clinical data. 1 month (0.5-24) after operation 13 patients (15 knee joints) were painfree. In 5 cases there were still complaints, but 3 of them were improved by operation. One patient, who was operated on both knees, had no change after operation. The failures are analysed and interpreted concerning their pathogenesis. With help of our results the different operation methods of the literature are discussed.     

Results of the surgical treatment of hypertension due to a bilateral lesion of the renal arteries

The paper analyzes experience of the surgical treatment of bilateral lesions of the renal arteries in 52 patients who were subjected to 64 operations. The authors have shown that lesions of the both renal arteries in patients with renovascular hypertension can be observed in 28,9% of cases. In most cases atherosclerosis and aorto-arteritis are responsible for such lesions. The authors support the two-step operations in bilateral lesions of the renal arteries. Late results of such operations are favourable in 82% of cases.     

Insulinoma. Results of surgical treatment

The insulinoma is the most common pancreas tumour with endocrine activity, with more than 2,000 cases being described in the literature worldwide. The first successful extirpation was performed by Graham in 1928. Clinical appearance is characterized by severe paroxysmal hypoglycaemia together with inadequately increased serum insulin levels. Surgery is indicated in such situations because of limited effectiveness of medicamentous therapy. Surgical approach and long-time results are discussed in this paper, with reference being made to 13 cases of the authors.     

Results following surgical treatment of hyperthyroidism

In the years 1965–1978, 1,222 patients with different types of thyrotoxicosis underwent surgical treatment at the 1st Department of Surgery, University of Vienna. Wherever possible a psaring selective surgical appraoch was considered preferable: autonomous adenoma (45%) enucleartion resection or subtotal uni-lateral resection; multinodular toxic goiter (35%) and Graves disease (5%) uni- or bilateral subtotal resection. The remaining 5% were rather rare types of goiter (recurrent goiter, thyroidits, adenocarcinoma). Overall mortality due was 0.7%. One-hundred and seven patients (8.76%) were over 70 years old at the time of the operation. Post-operative death occurred in the group of patients with toxic adenomas (2.7%). Four-hundred and ninety-five patients were followed up from 3–13 years postoperatively: the rate of recurrent thyrotoxicosis was 4.4%, 4.8% of the patients with hypothyroidism. In this paper the significance of the rapid effect of surgery in, cases of hyperthyroidism is discussed and the results are compared with findings in other studies.     

Results of surgical treatment of ischemic colitis

Between January 1984 and December 1989, 13 patients, aged 39 to 89 (median 63), underwent surgery for histologically proven ischemic colitis. Most suffered from pre-existing cardiovascular conditions (2 shortly after surgery for aortic aneurysm). One patient developed ischemia after the traumatic avulsion of the ileocolic artery and another after the spontaneous reduction of a strangled inguinal hernia. Diagnosis of ischemic colitis was made prior to operation in 4 instances only. The left colon was affected 5 times and the right colon 8 times (with the terminal coil of ileum 3 times). Treatment always consisted in segmental colectomy; laparotomy was used in 3 patients (2 to 7 reoperations). Colon anastomosis was performed directly 5 times, while 4 patients had secondary stomy closures; 2 patients still have their original stomy. Two patients died (15%), one of sepsis and the other following broncho-aspiration. The prognosis of ischemic colitis is rather favorable, even at the stage of transmural necrosis, provided all ischemic zones are resected. This is in contrast with the severe mortality of mesenteric infarcts, when extensive small bowel necrosis is found in association with colonic ischemia.     

Results of surgical treatment of proximal hypospadias

Eighteen patients of proximal hypospadia underwent operations by our two-stage method. First stage operation was done by exaggerated Nesbit's method. The foreskin was transposed to the ventral surface of the penis as a flap that is long enough to be brought to the top of the glans. The second-stage procedure was done after a minimum of 6 months. The urethral tube was formed around the Foley catheter with a flap, its peripheral end being one to two centimeters proximal to the sulcus. For one to two centimeters the distal flap was freed. The tubularization was done by a continuous 4-0 nylon suture, which was removed after ten days. The tube was passed to the top of the glans through the tunnel and sutured to the glans with 5-0 nylon. Urinary diversion was not performed. In one case the new urethral orifice receded and reoperation was done. The operations in the other 17 cases were successful without stricture or fistula formation.     

Results of surgical treatment of chronic pancreatitis

On the basis of a group of 67 patients studied by the authors, the various techniques for the surgical treatment of chronic pancreatitis are discussed. The average age of the patients covered by this study was 45.7 years, and the male:female ratio was 2.9:1. In more than 82% of the cases a history of chronic alcohol abuse was definitely established. For the drainage operations performed the preferred operative techniques were the pancreaticojejunal anastomosis and, where pancreatic pseudocysts were present, the cystojejunostomy. Resection of the pancreas was performed in a total of 18 patients, the clinical mortality here being 5.6%. In our study also the long-term prognosis for patients with chronic pancreatitis depended, on the whole, less upon the operative technique chosen than upon the subsequent degree of alcoholism.