OSTEOCHONDROPATHY [osteochondropathia (grech, osteon bone + chondros cartilage + pathos suffering, disease); synonym: aseptic necrosis of bones, osteochondrolysis, epifizeonekroz] — a number of the diseases of the bone and joint device which are found preferential at children's and youthful age, stadiyno proceeding and shown an aseptic necrosis nek-ry subkhondralno the located most loaded sites of a skeleton, their compression and fragmentation.
Essence of a disease consists in local disturbance of blood circulation of a bone and development of sites of an aseptic necrosis. An epiphysis of long and short bones, bodies of vertebras and other spongy bones are surprised generally.
All O. can conditionally be divided into 4 groups: The lake of an epiphysis of tubular bones — humeral (Hass's disease), metacarpal bones, phalanxes of fingers of a brush (Timann's disease), a head of a femur (see. Pertesa disease ), heads of II, are more rare than III, plusnevy bones (see. Köhler of a disease ); The lake of short spongy bones — bodies of vertebrae (see. to Kalva disease ), a semi-lunar bone (see. Kinbeka disease ), a navicular of a brush (Prayzer's disease), a navicular of foot (see. Köhler of a disease ); The lake of apophyses (apophysites) — a youthful apophysitis of vertebrae (see. Sheyermanna — Mau a disease ), an apophysitis of haunch bones, a tibial bone (see. Osgood — Shlattera a disease ), a stifle joint — Larsen's disease — Yukhanssona (see. Patella ), a calcaneus (see. Haglunda — Shintsa a disease ), apophysitis of the V plusnevy bone (Izlen's disease); partial wedge-shaped necroses of the joint ends of bones (the cutting osteochondrosis) — heads of a humeral bone, a distal epiphysis of a humeral bone, a distal epiphysis of a femur (see. Keniga disease ), bodies of an astragalus (Haglund's disease — the North).
As for the first time allocated an independent disease of O. in 1923 Mr. G. Axhausen, then this pathology was described by E. Bergmann in 1927. However even earlier, in 1910, the aseptic necrosis of a head of a femur was described by A. Legg, and in 1924 Per a yew.
According to M. V. Volkov (1974), among all orthopedic pathology of O. makes 2,7%. In this group, according to N. S. Co-sinskaya, in the field of a hip joint 34%, knee — 8,5%, elbow — 14,9%, a radiocarpal joint and a wrist — 42,6% are the share of an aseptic necrosis. Damage of joints and bones of an upper extremity is observed in 57,5%, the lower extremity — 42,5% of cases.
The etiology and a pathogeny
Origins of O. are not found out. Believe that the injury, an infection, inborn factors, dysfunction of closed glands, disturbances of metabolism, etc. matter. Most of researchers consider the basic etiol, a factor a chronic or acute injury in combination with disturbance of blood circulation. M. V. Volkov (1974) believes that changes in a skeleton at O. are a consequence of an osteodystrophy of angionevrogenny character.
At all types of O. pathoanatomical changes are identical. They consist of dystrophic-nekrotiche-skikh changes of a joint cartilage, circulatory disturbances in a zone of an epiphysis and in subchondral departments, various sizes and a form of the centers of a necrosis and microfractures of bone crossbeams of a spongy bone, and also the reparative reaction of osteoarticular elements which is combined with reorganization of these elements. Macroscopically changes come to light in the accruing deformation of an epiphysis of bones, development of the deforming arthrosis, in emergence of free joint bodies owing to sequestration of nekrotizovanny subchondral fragments. Patomorfol. features are defined by local anatomic conditions and degree of mechanical load of the damaged bone bodies.
Microscopically in subchondral departments note the disorder arrangement of the bone crossbeams and their fragments which are partially soldered by an endosteal callosity. Many bone fragments are deprived of osteocytes and are represented nekro-tizirovanny, standing out against the background of the centers of fibrosis, hemorrhages, glybok fibrin and multicellular neogenic bone substance clearly, a cut was not exposed to a mineralization and reorganization yet. The hyaline cartilage of joint surfaces is exposed to focal homogenization, calcification and disintegration owing to what there is «stripping» of joint surfaces to the subsequent closing of defects with fibrous fabric. Dynamics morfol, changes of a head of a femur is rather in detail studied at Pertes's disease. Primary aseptic heart attack of subchondral departments of the verkhnenaruzhny, most loaded departments of a head of a hip is the cornerstone of these changes. The centers of a necrosis have the flat, cone-shaped and rounded form. Depth of a necrosis at prescription of a disease in 2 — 3 years from 1 to 3,5 cm. In a circle of the centers of a necrosis in these terms there is a peculiar demarcation zone presented by the skeletogenous or fibrocartilage fabric rich with vessels (fig. 1). At the same time the intensive rassasyvaniye of dead bone material osteoclasts and substitution by his neogenic bone is noticeable, however the complete recovery is observed only at rather limited defeats. Knaruzhi from a zone of demarcation is marked out preceding a necrosis osteoporosis (see), traces of accrete microfractures, detrital structures (fig. 2), the centers of fibrosis and eburnation, secondary necroses, to-rye quite often come to an end with formation of a bone cyst. Sequestration of nekrotizirovanny fragments with formation of free intra joint bodies is possible (see. Joint mouse ), more characteristic of O. of a knee joint (disease of Keniga). It is very indicative that both in the centers of a necrosis, and in free intra joint bodies the nekrotizirovanny bone does not lose the very tectonics. Feature of a disease of Keniga — the free intra joint body representing the bone tissue covered with a hyaline cartilage. And only in a zone of the former demarcation traces of microfractures, growths of chondroid fabric and the created switching plate (fig. 3) are visible. Similar changes demonstrate traumatic genesis of joint mice at a disease of Keniga. Lack of the centers of a necrosis is characteristic also of O. of tuberosity of a tibial bone — Osgood's diseases — Shlattera. Primary necrotic changes the bones inherent to Pertes's disease are characteristic of all other kinds of O.
Nek-roye complication morfol, pictures is observed at O. of apophyses of vertebrae (Sheyermann's disease — May), at a cut along with the changes of a spongy bone described above note disturbance of ossification of epiphyseal plates, dystrophy of intervertebral disks with formation of gryzhevidny protrusions of a cartilage in marrowy spaces (Shmorl's hernia). Characteristic of a disease to Kalva flattening of a body of a vertebra is caused by strength loss of frame structures against the background of the proceeding mechanical loading.
Pathoanatomical researches demonstrate that O. of any localization can have various nature. In favor of an embolic (vascular) origin of the centers of an aseptic necrosis their development at the compressed-air disease described at fishermen-nyryalytsikov testifies. I. V. Shumada et al. (1980) showed in an experiment that the aseptic necrosis of a bone arises at the distsir-kulyatorny frustration which are combined with raised funkts, load of a bone. Numerous messages on an aseptic necrosis of the bones arising in connection with disturbances of metabolism at the long use of corticosteroids, napr after transplantation of kidneys are published. In this case also the nephrogenic osteopathy caused hron, a disease of kidneys matters (see. Osteopathy nephrogenic ).
O.'s Current, as a rule, long (2 — 3 years). D. G. Rokhlin (1952) distinguishes 3 phases a wedge, currents of an aseptic necrosis: phase of a necrosis, degenerativnoproduktivny phase, or phase of fragmentation, and phase of an outcome. In the first phase of the patient complains of fatigue, not clear painful feelings; appear small funkts, disturbances, local pain, lameness (at damage of the lower extremities), then there is a compression nekrotizirovavshegosya the site of a bone. In the second phase of pain amplify, the patient spares the affected extremity. By the outcome of the second phase of pain can disappear, but function of an extremity is not recovered. In the third phase process of recovery or development of the deforming arthrosis with resuming of pains is observed.
At children in a growth period the aseptic necrosis leads to disturbance of bone formation — to braking of enchondral ossification. At development of secondary ischemic disturbances premature closing of region of growth and deformation of the joint end of a bone is observed.
plays the Crucial role in diagnosis rentgenol, a research. As a rule, make a X-ray analysis of the struck segment in standard projections, and if necessary and tomography (see). Radiological in O.'s development it is conditionally possible to allocate 5 phases, or stages. In the I stage — a subcartilaginous necrosis — rentgenol, the picture of a bone can be not changed, despite existence of symptoms of a disease; at the end of a stage weak limited consolidation of bone substance in a zone of a necrosis appears. In the II stage — a stage of a compression change — in a zone of a necrosis on the roentgenogram the site of consolidation of a bone of homogeneous or uneven character is visible. The joint crack is expanded. I and II stages correspond to a phase of a necrosis. In the III stage — a stage of a rassasyvaniye — the affected area represents several dense unstructured fragments of irregular shape (a phase of fragmentation). The IV stage — a stage of regeneration — is characterized by gradual normalization rentgenol, structures of a bone, sometimes with development of cystic cavities. In a final, V stage of O. occurs or a complete recovery of structure and a shape of a bone, or signs of deforming develop arthrosis (see), IV and V stages correspond to a phase of an outcome. Intervals between the next rentgenol, researches depend on stages of a disease and average from one to several months in the II stages, from 0,5 to 1 years, and sometimes and more, in III and IV stages.
Treatment of an aseptic necrosis of an epiphysis of bones children in connection with high reparative opportunities in a growth period shall have a conservative treatment and the Forecast, with unloading of the affected extremity and use of physiotherapeutic procedures. If O. at children and adults ended with deformation of the joint end, in some cases an operative measure is shown: corrective osteotomies (see), arthroplasty (see), etc.
The forecast for life favorable. O.'s forecast concerning recovery of function of an extremity is defined by timeliness of the begun treatment. Self-healing is observed seldom. Usually does not happen because of late begun or irrational treatment of a complete recovery of a shape of a bone and function of an extremity — there are effects in the form of arthrosis.
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E. P. Mezhenina; H. K. Permyakov (stalemate. An.), V. V. Kitayev (rents.).