A systematic review protocol of imaging findings in children and adolescents with Osgood-Schlatter Disease
Creators: name: Sørensen, Line
Publisher: name: Open Science Framework
Year: 2022
Subjects: subject: Medicine and Health Sciences
subject: Osgood schlatter disease

description: UPDATED DESCRIPTION: 3-6-2020: Changes are made from the original version (7-5-2020) and made while piloting the screening process Changes are referring to the study population: We will include participants (both sexes) in the study (no upper age limit) and not only kids and adolescents A SYSTEMATIC REVIEW PROTOCOL OF IMAGING FINDINGS IN PATIENTS WITH OSGOOD-SCHLATTER DISEASE Osgood Schlatter disease (OSD) is a common knee pain condition during adolescence that affects approximately 10% of this population group in the age range of 9-15 years (1). Mainly children and adolescents who are active in sports activities are at risk of obtaining OSD (2), and hence the condition is considered a sport-related complaint that is present during maturation of the tibial tubercle (3). The condition involves the developing anterior part of the tibial bone at the tendinous insertion and presents with swelling, tenderness, and localized pain at the tuberosity (4). Although the etiology remains unknown, OSD was originally described as a traction apophysitis due to repeated strain and overuse of the knee during the early cartilaginous stage of the tibial tuberosity and tendon attachment (5). The formation of avulsions of the secondary ossification center on the tibial tuberosity is suggested to enable the progression of this condition (6) and is generally supported by radiographic and imaging (7). However, an early imaging study also suggested that OSD resulted from patella tendinitis and soft tissue inflammation rather than a lesion of the tibial tubercle (8). Despite the clear clinical signs used to diagnose OSD, there is little information about disease etiology and progression of the pathology. Imaging examinations mainly based on ultrasonography (US) have been used to evaluate the developmental phase of the tibial tuberosity, and appears to be superior to conventional radiography for the assessment of soft-tissue structures and bony alterations such as the distal patellar thickening and fragmented tibial tuberosity (4,7,9). However, whether such changes are indicative of OSD or normal development are still questioned (10), and appropriate comparisons with either a healthy and asymptomatic knee, healthy controls, or follow-up are missing that can relate findings to OSD pathophysiology. De Flaviis et al. (4) classified OSD based on alterations of the secondary ossification center and a gradual change in the surrounding soft-tissue with a non-homogenous appearance and thickening of the distal patellar tendon, fluid collection, and presence of separate ossicles that have since been used in other US studies to characterize OSD. Furthermore, studies using magnetic resonance (MR) imaging show distinct differences between MR images and radiographic findings such as X-rays in the early and more progressive stages of OSD (11,12). Additionally, MR imaging is useful when evaluating soft-tissue changes such as bursitis and edema within the OSD knee joint and the quality of tendon structures that mainly presents as hypoechoic areas on US (11). However, there has been no systematic review detailing the potential characteristics or maturation status of the tibial tuberosity associated with OSD. Therefore, there is a need to evaluate and compare the different findings and classifications systematically based on imaging, which is currently lacking. Therefore, the aim of this study is to systematically review imaging findings related to soft tissue changes, bone alterations and morphological characteristics in participants/cases diagnosed with OSD compared with imaging findings on follow-up, asymptomatic control side on cases with unilateral OSD or healthy controls. Based on this, we will develop a new up to date scoring system to classify/characterize patients with OSD. METHODS Reporting guideline This protocol follows the PRISMA P statement (13) and the review will prospectively be uploaded on Open Science Framework (OSF). Literature search /search strategy A systematic search will be carried out in the following bibliographic databases (e.g. Embase, CINAHL, and PubMed) from the period between database inceptions to April 2020. A subsequent hand search, citation search of relevant articles, and forward citation tracking will follow to identify potentially relevant references that were not identified by our initial search. There will be no restrictions on dates and we will include publications in English, German, Spanish, French, Dutch, and Scandinavian languages. The following search strategy will include keywords and synonyms searched in both title and abstract for the following terms below. The full search strategy can be seen in appendix attached to the protocol. Osgood Schlatter Osteochondrosis Patella ligament Apophys* AND tibia* AND growth plate Magnetic resonance imaging Tomography, x-ray computed Ultrasonography AND ultrasound Radiography Radiological* X-ray Relevant studies will be screened by title and abstracts by two reviewers independently. Relevant studies will be saved and screened by full-text format by two reviewers. A third reviewer will be involved in case of any disagreements. Types of study to be included Study design We will include case series, cross-sectional, retrospective and prospective studies including participants (both sexes) with OSD. We will include controlled studies on OSD, providing they report on imaging findings. We will include studies if they report on a minimum of 10 participants diagnosed with OSD. There will be no restriction on endpoints for the prospective studies. Participants Diagnosis of OSD will be included providing they at a minimum describe pain localized to the tibial tuberosity or pain with palpation of the tibial tuberosity, regardless of whether imaging findings are used to confirm the diagnosis. Exposure All types of studies that include imaging (x-ray, CT, MRI, and Ultrasound) related to OSD or report on maturation status of the tibial tuberosity and presence of OSD will be considered eligible. Types of study to be excluded Studies including imaging techniques on other growth-related conditions, or types of non-traumatic anterior knee pain conditions will be excluded (such as patellofemoral pain, patellar tendinopathy, iliotibial band syndrome, Sinding-Larsen-Johansson syndrome). Studies that do not include any imaging outcomes will be excluded. Studies that report only the maturation status of the tibial tuberosity with no OSD cases included are not eligible to be included. Case studies and studies that include a small study sample (&lt;10) will be excluded. Moreover, other types of published literature such as letters or editorials will not be included. Imaging outcomes The main outcomes of interest from the different imaging techniques are morphological findings, and findings related to soft-tissues and alterations in bone structures associated with OSD. The outcomes related to potential pathological finding associated with OSD include (but is not limited to) changes in signal intensity in the tendon or tuberosity, description of bony changes, such as avulsion/ fragmentation/ irregularities of the secondary ossification center, inflammation of the patellar tendon insertion site, presence of edema, presence of ossicles, bone mineral density cartilage changes such as swelling, characteristics associated with tendon pathology including thickening of the patellar tendon, areas of increased Doppler flow on Power Doppler Ultrasound, hypoechoic areas on ultrasound, and non-homogenous appearance of the tendon, presence of bursitis/ distended bursa. Other outcomes include maturation status of the tibial tuberosity, and morphological characteristics such as the length and attachments of the patellar tendon, tendon thickness and apophysis length. Data extraction Data will be screened and independently extracted by two reviewers and cross-checked for comparisons and consistency between data. A third reviewer will resolve any uncertainties or discrepancies between the two reviewers in case agreement is not met. All eligible studies will be retrieved by full-text and saved before any data are extracted. Data to be extracted: - Study characteristics (authors, year of publication, journal, funding, study dates, study design and aims) - Participant characteristics (age, sex, number of participants, non-follow-ups, time to follow-up, pain characteristics including duration, intensity, frequency and uni versus bilateral knee pain, sport activity) - Primary outcome measures outlined above (imaging findings) - Imaging technique, equipment and methodology (imaging assessor(s), number of assessors, blinding of assessor(s), years of experience, background and qualification, training, type of imaging technique, type of equipment, - Secondary outcome measures (factors related with age and maturation of the tibial tuberosity) - Missing data (outcomes) Data syntheses All studies will be evaluated systematically and reported on the data extracted. Syntheses of the results will be based on a qualitative synthesis of the data and primary outcome measures will be compared between the different studies and imaging techniques and summarized in themes to give a collective meaning of the findings and interpretation of the data. The primary synthesis will compare participants with OSD to those without OSD, while secondary subgroup reporting will describe studies that only include cases with OSD with both unilateral and bilateral symptoms (with no comparison group) and changes over time. Based on data availability we will investigate the potential association between imaging findings, pain, age/maturation (including skeletal/time from peak height velocity and maturation of the tibial tuberosity), and sex. Quality assessment Data quality will be assessed and Downs and Black checklist and SIGN guidance and checklist will be used to evaluate the methodological quality and study validity. Type and methods of review Systematic review with qualitative synthesis. REFERENCES 1. De Lucena GL, Dos Santos Gomes C, Oliveira Guerra R. Prevalence and associated factors of osgood-schlatter syndrome in a population-based sample of brazilian adolescents. Am J Sports Med. 2011;39(2):415–20. 2. Dupuis CS, Westra SJ, Makris J, Wallace EC. Injuries and Conditions of the Extensor Mechanism of the Pediatric Knee. RadioGraphics. 2009 May 1;29(3):877–86. 3. Rejeb A, Johnson A, Vaeyens R, Horobeanu C, Farooq A, Witvrouw E. Compelling overuse injury incidence in youth multisport athletes. Eur J Sport Sci. 2017 Apr 21;17(4):495–502. 4. Flaviis L De, Nessi R, Scaglione P, Balconi G, Albisetti W, Derchi LE, et al. Ultrasonic diagnosis of Osgood-Schlatter and Sinding-Larsen-Johansson diseases of the knee. Skeletal Radiol. 1989;193–7. 5. Osgood RB. Lesions of the tibial tubercle occurring during adolescence. In: Clinical Orthopaedics and Related Research. 1993. p. 4–9. 6. Ogden JA, Southwick WO. Osgood Schlatter’s disease and tibial tuberosity development. Clin Orthop Relat Res. 1976;no.116:180–9. 7. Lanning P, Heikkinen E. Ultrasonic features of the osgood-schlatter lesion. J Prosthetics Orthot 1991;11(4):538–40. 8. Beltran J, Lehman B, Cheung Y, Grant D. Lesion : Fracture. 1992;853–8. 9. Blankstein A, Cohen I, Heim M, Diamant L, Salai M, Chechick A, et al. Ultrasonography as a diagnostic modality in Osgood-Schlatter disease. A clinical study and review of the literature. Arch Orthop Trauma Surg. 2001;121(9):536–9. 10. Ducher G, Cook J, Lammers G, Coombs P, Ptazsnik R, Black J, et al. The ultrasound appearance of the patellar tendon attachment to the tibia in young athletes is conditional on gender and pubertal stage. J Sci Med Sport. 2010;13(1):20–3. 11. Rosenberg ZS, Kawelblum M, Cheung YY, Beltran J, Lehman WB, Grant AD. Osgood-Schlatter lesion: Fracture or tendinitis? Scintigraphic, CT, and MR imaging features. Radiology. 1992;185(3):853–8. 12. Hirano A, Fukubayashi T, Ishii T, Ochiai N. Magnetic resonance imaging of Osgood-Schlatter disease: The course of the disease. Skeletal Radiol. 2002;31(6):334–42. 13. Moher D, Shamseer L, Clarke M, Ghersi D, Liberatî A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Vol. 4. 2015 Search strategy A systematic review of imaging findings in children and adolescents with Osgood-Schlatter Disease A systematic search will be carried out in the following bibliographic databases (e.g. Embase, CINAHL, and Medline via Pubmed) Pubmed: Search (((((((("Magnetic Resonance Imaging"[Mesh] OR "Ultrasonography"[Mesh] OR "Tomography, X-Ray Computed"[Mesh] OR "Tomography Scanners, X-Ray Computed"[Mesh] OR "Tomography, Emission-Computed"[Mesh] OR magnetic resonance imaging[Title/Abstract] OR ultrasonography[Title/Abstract] OR radiograph[Title/Abstract]) OR radiography[Title/Abstract] OR X-ray[Title/Abstract] OR tomography scanners[Title/Abstract] OR ultrasound[Title/Abstract] OR CT[Title/Abstract]))) OR Radiologic* OR radiographic)) AND ((((((((((("Osteochondrosis"[Mesh:NoExp]) OR "Patellar Ligament"[Mesh]) OR "Growth Plate"[Mesh]) OR osgood schlatter*[Title/Abstract]) OR patellar ligament[Title/Abstract]) OR (tibia*[Title/Abstract] AND injur*[Title/Abstract] AND growth plate[Title/Abstract])) OR (apophys* AND tibia*)))))))) EMBASE: ('osgood schlatter disease' OR 'osgood schlatter'/exp OR 'osteochondrosis'/exp OR 'apophysis'/exp OR 'apophysis' OR 'apophysitis' OR 'apophyseal injury'/exp OR 'apophyseal injury' OR 'patellar ligament'/mj OR 'osgood schlatter disease':ti,ab OR 'osgood schlatter':ti,ab OR 'osteochondrosis':ti,ab OR 'growth plate':ti,ab OR (tibia*:ti,ab AND injur*:ti,ab AND 'growth plate':ti,ab) OR (apophys* AND tibia*)) AND ('nuclear magnetic resonance imaging'/exp OR 'nuclear magnetic resonance imaging' OR 'ultrasound'/exp OR 'ultrasound' OR 'x-ray computed tomography'/exp OR 'x-ray computed tomography' OR 'radiography'/exp OR 'radiography' OR radiologic* OR 'radiograph' OR 'radiography' OR 'computed tomography scanner':ti,ab) AND [humans]/lim CINAHL: 1# (MH "Osteochondrosis") 2# (MH "Patellar Ligament") 3# "growth plate" 4# "osgood schlatter" 5# "patellar ligament" 6# "osteochondrosis" 7# ("tibia* AND injur* AND growth plate") 8# ("tibia* AND apophys*") 9# (S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8) 10# (MH "Magnetic Resonance Imaging") 11# (MH "Tomography, X-Ray Computed") 12# (MH "Ultrasonography") 13# "magnetic resonance imaging" 14# "mri" 15# "ultrasonography" 16#" ultrasound" 17# "x-ray" 18# "CT" 19# "radiograph" 20# "radiography" 21# "radiographic" 22# "radiologic*" 23# S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 24# S9 AND S22