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In a normal limb, the injured joint is protected from further trauma by pain. In the absence of pain and proprioceptive sensation, however, the joint continues to be active and is repeatedly injured.

Synovial effusion and hemarthrosis are aggravated and, together with the abnormal stresses on the joint, cause extreme stretching and weakening of the capsule and supportive ligaments.

Local hyperemia causes bone atrophy and resorption.

Cartilage destruction, bone erosion, and minute fractures soon follow. Reparative response results in the formation of callus and metaplastic changes in surrounding traumatized soft tissues. With repeated injury, the joint becomes totally disorganized, subluxation ensues, and severe degenerative changes take place.

The affected joints are boggy, tense, swollen, nontender, and have an excessively abnormal range of motion on clinical examinaion. The local triad of swelling, instability, and absence of pain is nearly always suggestive of Charcot joint.

Radiographic Findings

The joint will show varying degrees of destructive and hypertrophic changes. There is loss of articular cartilage, fragmentation and absorption of subchondral bone, and osseous proliferation of the articular margins.

The bone overgrowth may be enormous, bizarre in configuration, and so great as to surround the joint as a spongy mass. The periarticular soft tissues are thickened and contain scattered calcifications.

Pathologic fractures involving the articular surface are common, as are irregular loose bodies within the joint.

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* Congenital insensitivity to pain
* Peripheral nerve injuries
* Diabetic neuropathy
* Chronic diseases of the spinal cord that lead to sensory disturbances of the limbs.

In myelomeningocele, absence of pain sensation is associated with flaccid paralysis and marked limitation of physical activity; thus, owing to associated severe osteoporosis, the bone and joint changes present a different picture.

The joints involved vary with the different etiologic conditions.

In congenital insensitivity to pain and diabetic neuropathy, the destructive changes occur primarily in the tarsal and metatarsal joints, less commonly in the ankle, and rarely in the knee.

In syringomyelia, the joints involved are those of the shoulder and elbow. In tabes dorsalis, the knee, hip, ankle, and thoracolumbar spine are frequent sites of the disease.

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This condition was described by Charcot, in 1868. He described it as a bizarre destruction of the knee joints with indolent swelling and instability in patients of tabes dorsalis. He proposed that the disease resulted from traumatization of a joint deprived of sensation.

Later Steindler classified the condition into the condition into the destructive, atrophic and hypertrophic proliferative forms.

Charcot-like changes in joints are seen in patients who have absence or depression of pain and proprioceptive sensation and who take part in extended continuous physical activity.

As a consequence their joints sustain repeated trauma.

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Osteochondritis dissecans is a condition in which a segment of articular cartilage with its underlying subchondral bone graudually separates from the surrounding osteocartilaginous tissue.

The separation of the fragment may be partial or complete.

The osteochondral segment may remain in situ, it may become partially detached, or it may become completely detached and lodge in the contiguous joint as a loose body. It is important to differentiate the word dissecans from dessicans, the latter being derived from desiccare, “to dry up”.

The disease was first described in 1870 by Sir James Paget and the term osteochondritis dissecans was given in 1887 by Konig.

During the early part of this century various modalities of treatment of osteochondritis dissecans were recommended like

* Simple observation
* Restriction of physical activity
* Non-weight-bearing by crutch protection
* Immobilization
* Surgery

Various surgeries recommended wer drilling, transfixing with pins, bone grafting, and removal of the partially or completely detached osteochondral fragment.

However in osteochondritis dissecans children, the healing is excellent.

The advent of arthroscopic surgery has opened new vistas in management of osteochondritis dissecans.

Various options available are

* Direct visualization of the lesion.
* Drilling of the base of the osteochondral fragment.
* Stabilization of partially separated fragments.
* Atraumatic removal of loose bodies.

Causes of Osteochondritis Dissecans

Etiology

The exact cause of osteochondritis dissecans is not known yet. There are various theories that try to explain the causation. There appears multiple factor that decide this conditionThe etiology is most probably multifactorial.

Predisposition

Multiple joint involvement in the same patient are known in osteochondritis dissecans, indicating a constitutional factor in its etiology. Diseaseslike Legg-Calve-Perthes disease and tibia vara also associated with this condition.

Ischemia

Interruption in the blood supply to an area of subchondral bone has been proposed as the cause

Trauma

Injury plays a principal role in the causation of osteochondritis dissecans. A direct relationship between injury and the development of osteochondritis dissecans has been noted.

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Women who fail to respond to, or stop taking, their medication to fight the bone-thinning condition osteoporosis are at high risk of suffering a bone fracture, a new study suggests.

British researchers found that among nearly 2,000 older women with an “inadequate response” to osteoporosis medication, 9 percent suffered a fracture over the next year.

Those who’d had a fracture in the past were at particular risk, according to findings published in the journal Osteoporosis International.

The researchers considered two groups of women as having an inadequate response to drug therapy: those who, before the study period, had suffered a bone break despite being on osteoporosis medication for at least one year; and those who had stopped taking their medication because of side effects or difficulty sticking with the regimen.

While some women in each group suffered a bone break over the next year, the risk was nearly twice as high among women with a past fracture.

Suffering a new fracture took a toll on the women’s quality of life, with many reporting pain, discomfort and problems with their normal daily activities.

In general, health-related quality of life among all women who suffered a fracture was far lower than the norm for women their age, according to the researchers, led by Dr. Cyrus Cooper of Southampton General Hospital in the UK.

Women who don’t benefit from osteoporosis treatment, or who stop taking the medication, need to be aware of their fracture risk and get further evaluation and treatment, Cooper told Reuters Health.

Past studies have found that up to half of women on osteoporosis medication stop taking the drugs within one year, often because of side effects.

Side effects depend on the type of medication. With the group of drugs known as bisphosphonates the more common side effects include stomach upset, heartburn, and joint, muscle or abdominal pain.

The drug raloxifene, can cause hot flashes and raise the risk of blood clots in the legs. Enhancing better compliance is key to the effectiveness of preventive strategies against fractures.

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In osteoporosis patients with spinal fractures, vertebroplasty provides significant pain relief and helps decrease disability, according to a new study.

Vertebroplasty is a procedure that involves injection of medical-grade bone cement into a fractured vertebra to shore up the fracture and provide pain relief. It’s used to treat painful vertebral compression fractures that don’t respond to conventional medical therapy with analgesics or narcotics.

The study followed 884 patients for five years who were assessed before and after vertebroplasty. Their average pre-treatment pain score on an 11-point scale decreased from 7.9 (+/- 1.5) before treatment to an average of 1.3 (+/- 1.8) after treatment.

The patients’ ability to manage everyday tasks such as washing and dressing was measured using the Oswestry Disability Questionnaire. The patients’ scores went from an average of 69.3 percent (+/-13.5) a month before treatment to 18.8 percent (+/- 6.9) a month after treatment.

“These data provide good news for physicians and osteoporosis patients. Many osteoporosis patients with compression fractures are in terrible pain and have a greatly diminished ability to perform basic daily activities, such as dressing themselves,” Dr. Giovanni C. Anselmetti, an interventional radiologist at the Institute for Cancer Research and Treatment in Turin, Italy, said in a prepared statement.

The study also found that vertebroplasty didn’t increase the risk of fracture in nearby vertebra.

“Vertebroplasty is already known to be a safe and effective treatment for osteoporotic vertebral fractures. Osteoporosis patients remain susceptible to new fractures, which often occur in the contiguous vertebra to an existing fracture. Our large-scale study shows that vertebroplasty does not increase the risk of fracture in the level contiguous to previously treated vertebra and that these new fractures occur at the same rate as they would in osteoporosis patients who did not have vertebroplasty,” Anselmetti said.

The study was to be presented Tuesday at the annual scientific meeting of the Society of International Radiology.

Osteoporosis affects about 10 million Americans and causes about 1.5 million vertebral fractures each year, according to the U.S. National Institutes of Health. Multiple vertebral fractures can cause chronic pain, disability, loss of independence, stooped posture, and compression of the lungs and stomach.

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The usual presenting complaints are

* Intermittent pain in the joint on strenuous physical activity
* Stiffness
* Swelling
* Clicking and locking of the joint
* Limp

When the knee joint is involved, “giving way” of the knee is a frequent complaint.

Physical Findings

These depend on the joint involved, the duration of the disease, and whether or not the fragment has become detached.

An important finding is localized tenderness over the lesoinal area.

In knee it iis usually over the lateral surface of the medial femoral condyle and is best elicited by deep pressure over the lesion with the knee acutely flexed.

When the medial femoral condyle is the site of the lesion, the patient will toe out; lateral rotation of the tibia prevents the tibial spine from impinging on the lateral surface of the medial femoral condyle.

Wilson’s sign

With the patient in supine position, the affected knee is flexed to a right angle, the leg is medially rotated fully, and then the knee is gradually extended. At 30 degrees of flexion, the patient will complain of pain over the anterior aspect of the medial femoral condyle. The pain is relieved on lateral rotation of the leg.

Atrophy of the controlling muscles, synovial thickening, hydrarthrosis, and limited joint motion are common. One may be able to palpate the loose body may be palpated.

When ankle is involved, there is intermittent pain on weight-bearing aggravated by strenuous physical activity such as running and sports. Limp is common. At times, the condition is asymptomatic.

Physical findings include localized tenderness which can be detected by markedly plantar-flexing the ankle joint and palpating the medial and lateral corners of the dome of the talus.

Pressure can be exerted on the dome of the talus by rotating the leg inward and outward while the foot remains on the floor in plantar flexion and inversion, then in dorsiflexion and eversion.

Atrophy of the calf is common.

Radiography

The radiograph shows a well-circumscribed fragment of subchondral bone is demarcated from the surrounding femoral condyle or affected bone by a radiolucent saucer or crescent-shaped line. The affected bone may appear denser than the surrounding parent bone.

As the fragment separates, a  depression is seen at the site of separation. However the  detached loose body in the joint continues to grow deriving its nutrition from synovial fluid. Osteochondritic fragment becomes radiopaque is due to subchondral bone with articular cartilage, secondary calcification in degenerating articular cartilage and  new bone formation following revascularization.

Special views may be necessary to visualize the lesion.

Computed Tomography

The CT scan makes possible a definitive diagnosis and determines the precise location and true extent of the lesion. It also reveals whether the fragment is detached completely or partially.

Bone Scanning with Technetium-99m shows localized increased activity at the site of the lesion

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Treatment of  Osteochondritis Dissecans in children under 12 years of age is nonoperative. Arthroscopy is reserved for the cases in which the fragment has become detached.

If the lesion is in a non-weight bearing area or it involved only a portion of the weight-bearing area of a joint it is observed with serial radiograms made every six to eight weeks to determine its natural course.

Protection from weight-bearing is not required unless the lesion begins to separate and symptoms persist.

In case the weight bearing is prohibited, it is resumed gradually with aid of crutches providing partial support. Generally, a period of three months is required for healing of the lesion.

In case of suspected seapration of fragment, bone imaging with technetium-99m and computed tomographic studies should be carried out.

If osteochondritis dissecans in a child fails to respond to nonsurgical management, arthroscopic examination and drilling of the osteochondritic lesion are recommended.

Indications of arthroscopy

Arthroscopy  directly visualizes the involved area and determines its exact location and size, and the degree of articular cartilage separation.

Arthroscopy is indicated in osteochondritis dissecans in patients 12 years of age and older in whom the weight-bearing area is involved with a lesion over 1 cm. in diameter. Arthroscopic examination is also indicated in case of late diagnosis.

In children under 12 years of age arthroscopy should be done when, there is no radiographic or clinical evidence of improvement after a reasonable period of non operative treatment, or if the lesion becomes partially or completely detached.

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The menisci in the knee joint are required for

* Compensation of incongruity between the femur and tibia
* In the distribution of joint pressure
* Shock absorber, for stabilization of the knee, in provision of rotation, in spreading of synovial fluid, and in nutrition of articular cartilage.

An intact meniscus transmits 70 to 90 percent of the total load across the knee joint. Therefore, it is desirable to preserve the meniscus whenever possible.

A conservative nonoperative method of management is recommended In the treatment of discoid meniscus  if pain and functional disability are minimal.

SIlent discoid menisci  require no treatment. however, they should be kept under observation.

Conservative measures

* Immobilization of the knee
* Restriction of physical activity
* Progressive exercises for the quadriceps.

Operative Measures

If the knee locking persists their is functional disability or pain partial or complete excision of the discoid meniscus is indicated.

Diagnostic arthroscopy is carried out to know the pathologic changes and the type of discoid meniscus.

Partial resection of the discoid meniscus is preferred when it is of the complete or incomplete type with minimal tearing and slight degeneration

Excision of the entire meniscus is performed when it is of the Wrisberg type  or when it is torn and there is marked degenerations.

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There are two categories of risk factors associated with back pain: extrinsic and intrinsic.

Extrinsic risks include

* Heavy physical labor
* Frequent bending and twisting
* Frequent lifting and forceful movements
* Repetitive work
* Vibration
* Sedentary office work
* Smoking.

Intrinsic risk factors for include

* Spinal abnormalities
* Genetic predisposition
* Weight and height

Occupational Risk Factors

Heavy physical labor often is associated with low back pain.

However, there is a positive relationship between sedentary occupation s and low-back pain.

There is a strong correlation between disc prolapse and long-distance driving. This increased risk of back disorders in driver has been attributed both to posture and vibration.

Nonoccupational Risk Factors

There is a positive association between low-back pain and participation in sports such as golf, gymnastics, rowing, and bowling.

Good muscle strength and good overall fitness is suggested for reducing the risk of low-back pain and disc herniation.

Studies have implicated smoking as a risk factor for back pain.

A magnetic resonance imaging (MRI) study of smoking and nonsmoking identical twins found that those who smoked had an increased frequency of disc degeneration throughout the entire lumbar spine.Body Habitus

Both increased height and increased body mass are associated with an increased risk of disc prolapse.

Genetic Predisposition

Certain congenital spinal abnormalities such as asymmetric facet orientation and a small vertebral canal hypothetically predispose certain individuals to symptomatic disc herniations.

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