How should Osgood‑Schlatter disease presenting with an avulsed tibial tubercle fragment and reactive marrow changes be managed?

Treatment of Osgood-Schlatter Disease with Bone Fragment and Reactive Marrow

For Osgood-Schlatter disease presenting with an avulsed tibial tubercle fragment and reactive marrow changes, initial management should consist of activity modification, ice application, and NSAIDs for 3-6 months, with surgical excision of the mobile ossicle reserved for skeletally mature patients who fail conservative treatment and demonstrate a clearly separated fragment on lateral radiograph with clinical mobility on examination. 1, 2, 3

Initial Conservative Management

The ACR Appropriateness Criteria establish that MRI is useful for evaluating Osgood-Schlatter syndrome when bone fragments are present, as it can define the extent of cartilage injury and identify reactive marrow changes 4. However, the presence of a bone fragment and reactive marrow does not automatically mandate surgical intervention.

Conservative treatment should be the first-line approach for all patients, regardless of imaging findings, and includes:

• Activity restriction from jumping, running, climbing stairs, and kneeling until symptoms resolve, which may require several months 1, 2
• Ice application to reduce pain and swelling over the tibial tuberosity 1
• NSAIDs for pain control and anti-inflammatory effect 2
• Rehabilitation exercises once acute symptoms subside 2

Approximately 90% of patients respond well to this nonoperative approach 2. The condition is self-limiting and typically resolves completely with closure of the tibial growth plate at skeletal maturity 2, 5.

Indications for Surgical Intervention

Surgery should only be considered in skeletally mature patients who meet ALL of the following criteria:

• Persistent pain despite 3-6 months of conservative treatment 1, 3, 5
• Pain with kneeling or direct pressure that significantly impairs function 1, 3
• Lateral radiograph demonstrating a distinctly separated osseous fragment from the tibial tuberosity 3
• Positive clinical mobility test where the prominent tubercle can be firmly grasped and demonstrates sliding movement 3

The key surgical indication is the presence of a mobile ossicle that can be clearly visualized as separated on imaging and confirmed by physical examination 3. Reactive marrow changes on MRI alone do not constitute an indication for surgery.

Surgical Technique When Indicated

The surgical procedure consists of:

• Excision of the mobile osseous fragment via midline longitudinal incision 3
• Removal of surrounding bursa and any bony prominence 1, 3
• Subperiosteal dissection to clearly visualize and remove the separated fragment 3

Arthroscopic techniques are preferred over open procedures because they provide early postoperative recovery, avoid anterior incisional scars that cause kneeling discomfort, offer better cosmetic results, and allow treatment of concomitant intra-articular pathology 5.

Alternative surgical approaches for cases without a clearly mobile fragment include excision of a portion of the tibial tuberosity surface with multiple drill perforations to promote complete ossification and fusion with the tibial metaphysis 6.

Postoperative Management

• Soft dressing applied immediately after surgery 3
• Immediate resumption of daily activities encouraged 3
• Return to previous physical activity level expected within 12 weeks 3

Critical Pitfalls to Avoid

Do not operate on patients with open growth plates, as the condition will resolve spontaneously with skeletal maturity 2, 5. Surgery in skeletally immature patients is contraindicated.

Do not proceed with surgery if the lateral radiograph does not show a distinctly separated fragment, as this is associated with surgical failure 3. The presence of reactive marrow on MRI without a clearly mobile fragment does not warrant surgery.

Do not assume all bone fragments require removal, as many will fuse with the tibial tuberosity during normal skeletal maturation and become asymptomatic 1, 2.

Do not rush to surgery before completing an adequate trial of conservative treatment (minimum 3-6 months), as 90% of patients will respond without surgical intervention 2.

Expected Outcomes

The overall prognosis is excellent with conservative management 2, 5. For the minority requiring surgery, outcomes are uniformly good when proper inclusion criteria are followed, with patients becoming pain-free and returning to full activity 3. The only reported surgical failures occurred when patients were operated on without a clearly separated fragment visible on radiograph 3.

Some patients may experience residual discomfort with kneeling or require minor activity restrictions even after successful treatment, but this does not typically impair quality of life 2, 5.