ISSN 0972-978X 

  About COAA








Surgical Treatment Of Osgood–Schlatter Disease In Young Adults: Role Of The Mobile Osseous Fragment

Gabriel Nierenberg, Mazen Falah, Yaniv Keren, Mark Eidelman

Pediatric Orthopedic Surgery Unit
Orthopedic surgery A department
Rambam Health Care Campus
Haifa, Israel

Address for Correspondence:
Mark Eidelman
Pediatric Orthopedic Unit,
Meyer Children's Hospital
Rambam Health Care Campus
POB 9602
Haifa 31096 Israel

Phone : 972 4 8543-181
Fax     :
972 4 854-2030
E-mail :


Surgical treatment of Osgood-Schlatter disease is rarely indicated, as most patients become asymptomatic after skeletal maturity and fusion of the proximal tibial apophysis. Some patients with separated mobile ossicles have persistent pain with kneeling and direct pressure over the tibial tubercle. We describe the results of simple excision of the mobile ossicles in 22 patients with a mean age of 18 years after skeletal maturity. All but one were satisfied with the results of the surgery. An algorithm for treatment and surgical technique is presented.

J.Orthopaedics 2010;7(3)e12


Knee pain; Osgood-Schlatter disease; Tibial apophysis


Osgood-Schlatter disease (OSD) is a well known condition, characterized by pain over the tibial tubercle with subsequent tubercle prominence. The disease starts in the second decade of life and usually resolves spontaneously without sequelae by the time of skeletal maturity. Boys in the early second decade of life are predominantly affected. Less than one-quarter of patients develop pain over the tibial tubercles [1]. Initially, the tibial tubercle is painful following physical activity and gradually becomes prominent and constantly painful. Radiological examination demonstrates a round regular ossification over the tubercle. Treatment is symptomatic and includes modification of physical activity, ice, non steroidal anti inflammatory drugs, braces and pads. In the majority of the cases, symptoms resolve after physeal closure without the need for specific treatment and rarely do patients require surgical intervention. There are few reports in the literature about surgical treatment of OSD, usually due to the development of a painful ossicles in patients who did not respond to conservative treatment [2, 3]. We report our experience in OSD patients who were refractory to conservative treatment modalities, with clinically evident mobile ossicles and radiological confirmation of the presence of a free osseous fragment.

Materials and Methods:

Between January 2000 and May 2006, we treated surgically 23 knees in 22 patients with painful bursitis over the tibial tubercle (Table 1). Of these, 21 were males and one was a female. Patients had a documented history of OSD with recurrent pain for an average period of 22 months prior to surgery. Average age at surgery was 18 years, and the average follow up period was 38 month. All were treated in the acute phase by a conservative protocol that included three weeks of complete activity restriction, a course of topical and oral NSAID, and infra-patellar braces. Inclusion criteria were: age over 16 years, painful bursitis over the tibial tubercle after failure of initial conservative treatment of 3 months, radiological evidence of osseous fragment anterior to the tibial tubercle, and closure of growth plates.

Operative technique

Eighteen patients were operated under local anesthesia with Esracain 1% and Adrenalin 1:10.000, and four were under general anesthesia. A small longitudinal skin incision over the tibia tubercle was performed with exposure of the patellar tendon at the site of insertion to the tubercle. A longitudinal, as sparing as possible, fiber-splitting incision of the patellar tendon followed by subperiosteal undermining at either side of the osseous fragment was completed .The plain of cleavage between the bony bed and the mobile fragment was isolated by sharp dissection. Final removal of the osseous fragment from its bony bed was completed by delivery with a blunt instrument. Soft dressing was applied for the first few days. Patients were encouraged to resume daily activity immediately after surgery.

Results :

Surgical treatment is rarely indicated for OSD due to excellent pain relief after conservative treatment. Most patients become asymptomatic after naturally occurring fusion of the proximal tibial apophysis. Several studies showed that patients who did not respond to conservative treatment had a mobile osseous fragment which caused pain during direct pressure on the tubercle and upon kneeling [3-6].

Only rarely do some patients remain symptomatic. Approximately 10% of osseous fragments fail to unite with the tibia tubercle, and patients with this condition experience anterior knee pain even with mild activity but especially with kneeling [2,3,7]. Typically, their symptoms relate to the persistence of the separate mobile osseous fragment. These patients are the core of our study.

There is no consensus about definitive treatment of residual OSD. Trail [1] compared two groups of patients with symptomatic OSD over a 4-5 year follow-up period. One group was treated by tibial sequestrectomy and one group was treated conservatively. Sequestrectomy did not offer significant benefit over conservative treatment and a significant complication rate was reported. Ferciot and Thompson described excision of the ossicles without excision of the tibia tubercle prominence [8,9]. Flowers and Bhadreshwar reported results of a modified Ferciot procedure in 35 patients [3].They achieved pain relief in 95% of patients and reduction of the prominence in 85% with minimal complications. Orava et al [5] summarized their experience with 70 operations on 67 patients with late unresolved OSD. Mean age of their patients was 19.6 years. Excision was performed in 62 cases. The reported outcome was excellent or good in 56 cases, moderate in 9, poor in 3 and unknown in 2 patients. Binazzi et al [4] described surgical treatment of 15 patients with OSD. There was one fair and no poor result. The authors concluded that removal of all loose intratendinous ossicles associated with prominent tibial tubercles is the procedure of choice, both from the functional and cosmetic points of view. Mital et al [2] reviewed a cohort of 118 patients with OSD. Fourteen patients (fifteen knees) had a distinct and separate ossicle at the proximal aspect of the tibial tubercle. Resection of the ossicles brought relief of symptoms. The authors concluded that unresolved OSD patients suffered from avulsion of the proximal cartilaginous part of the tibia tubercle and should be treated by surgical excision.

We describe the results of treatment in 22 young adult patients with known OSD treated by simple excision of mobile ossicles. All our patients suffered from pain with kneeling and direct pressure over the ossicles. All patients were mature or at the end of skeletal maturity according to their physis appearance. Sixteen patients had a clinically mobile ossicle and all but one showed clear separation of the ossicles from the tibial tubercle (Fig. 1). Based on our experience, we have devised a treatment algorithm (Fig. 2). We believe that the key factors for successful surgical treatment are clear visualization of separation on lateral knee x-ray view and a clinical mobility positive test (firm grasping of the prominent part of the tubercle and its sliding movement). Our results are uniformly good; the only one failure related to mistaken inclusion criteria where the lateral x-ray did not show clear ossicle separation.

Discussion :

Figure 1: Appearance of free ossicle and spiky deformity of the underlying apophysis

Figure 2:Treatment algorithm



  1. Trail IA (1988) Tibial sequestrectomy in the management of Osgood-Schlatter disease. J Pediatr Orthop 8:554-557

  2. Mital MA, Matza RA, Cohen J (1980) The so-called unresolved Osgood-Schlatter lesion: a concept based on fifteen surgically treated lesions. J Bone Joint Surg Am 62:732-739

  3. Flowers MJ, Bhadreshwar DR (1995) Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop 15:292-297

  4. Binazzi R, Felli L, Vaccari V, Borelli P (1993) Surgical treatment of unresolved Osgood-Schlatter lesion. Clin Orthop Relat Res 289:202-204

  5. Orava S, Malinen L, Karpakka J, Kvist M, Leppilahti J, Rantanen J, Kujala UM (2000) Results of surgical treatment of unresolved Osgood–Schlatter lesion. Ann Chir Gynaecol 89:298-302

  6. Robertsen K, Kristensen O, Sommer J (1996) Pseudoarthrosis between a patellar tendon ossicle and the tibial tuberosity in Osgood-Schlatter's disease. Scan J Med Sci Sports 6:57-59

  7. Lynch MC, Walsh HP (1991) Tibia recurvatum as a complication of Osgood-Schlatter's disease: a report of two cases. J Pediatr Orthop 11:543-544

  8. Ferciot CF (1995) Surgical management of anterior tibial epiphysis. Clin Orthop 5:204-206

  9. Thompson JEM (1956) Operative treatment of osteochondritis of the tibial tubercle. J Bone Joint Surg Am 38:142-148


This is a peer reviewed paper 

Please cite as: Gabriel Nierenberg: Surgical Treatment Of Osgood–Schlatter Disease In Young Adults: Role Of The Mobile Osseous Fragment

J.Orthopaedics 2010;7(3)e12





Arthrocon 2011

Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044



Powered by



© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.