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Kohler’s Disease

Kohler’s Disease (Navicular Osteochondrosis) is an avascular necrosis of the navicular bone of the foot. It was first described by Alban Köhler in 1908 1.

The disease is characterized by pain in the midfoot accompanied by radiographic changes consisting of sclerosis, flattening, and irregular radiolucency of the tarsal navicular.

The word Navicular in Latin means a little ship.

  • Kohler’s Disease mostly occurs in young children at the age of 5 years (4-7 years).
  • It’s More common in male that female.
  • Bilateral cases represent in 25% of cases.
See Also: Osgood Schlatter Disease
  • Navicular bone is the most medial tarsal bone, it lies between the talus and the cuneiforms bone.
  • Proximally: the surface is oval and concave for its articulation with the head of the talus.
  • Distally: the navicular has three articular surfaces, one for each of the cuneiforms.
  • Medial plantar projection serves as the insertion for the posterior tibial tendon.
  • Ossification centers of the navicular appear between the ages of 1.5 and 2 years in girls and 2.5 and 3 years in boys.
See Also: Foot Anatomy

Blood is supplied to the navicular bone by a dense perichondrial network of vessels on the nonarticular surfaces. As a child matures, one or more penetrating arteries appear, and ossification begins around these vessels. When more than one vessel penetrates, there will be more than one ossification center.

At maturity the Navicular bone blood supply comes mainly from two sources: dorsalis pedis artery and posterior tibial artery:

  • The dorsalis pedis artery supply the dorsal part, while the medial plantar branch of posterior tibial artery supply the plantar part of the navicular.
  • These branches enter the bone through the numerous vascular foramina found on the surface of the bone.
  • the navicular tuberosity receives its blood supply from the anastomosis between the branches of dorsalis pedis and posterior tibial artery.
  • The arterial branches enter at the small “waist” of cortical bone and gets distributed to supply the medial and lateral thirds leaving the central one third as area of relative avascularity.

The development of the ossific nucleus was associated most frequently with a single artery, but the incorporation of other penetrating vessels as part of the vascular supply varied; occasionally a single vessel is the sole supply until the age of 4 to 6 years.

Pathophysiology

  • The delay of ossification of the navicular subjects it to more pressure than the bony structures can withstand.
  • Abnormal ossification may be a response of the unprotected, growing nucleus to normal stresses of weight bearing.
  • If osseous vessels are compressed as they pass through the junction between cartilage and bone, ischemia results and leads to reactive hyperemia and pain.
  • Avascularity of the central one third of navicular also play a rule in Kohler’s Disease pathophysilogy.
  • The navicular becomes distorted and sclerotic, the head of the talus becomes flattened, the articular surfaces of the two bones become fibrillated, and osteophytes form along the margin of the articular surfaces.

Kohler’s Disease Symptoms

The diagnosis of Köhler’s disease is a clinical one requiring the presence of pain and tenderness in the area of the tarsal navicular.

Children with Köhler bone disease typically walk with an antalgic gait on the lateral border of the foot.

Physical signs include tenderness, swelling, and sometimes redness over the dorsum of the foot (occasionally this clinical picture has been mistaken for an infection). The foot is generally held in pronation. Occasionally, however, it will be in supination as the child walks on the lateral side of the foot to relieve stress on the painful medial arch.

Symptoms resolve spontaneously within 6 to 15 months. The navicular reconstitutes over 6 to 48 months with No residual deformity or disability occurs in adulthood.

Persistence of symptoms into adulthood is extremely rare.

Kohler’s Disease Radiology

Radiology include AP and lateral views of the foot.

The radiographic changes may include:

  1. Sclerosis .
  2. Fragmentation.
  3. Diminished size of the navicular bone.

These changes gradually disappear over a period of several years, with the radiographic appearance of the navicular ultimately returning to normal.

The appearance of multiple ossification centers without an increase in density should not be confused with kohler’s disease, and radiographic findings similar to kohler’s disease in an asymptomatic foot should be considered an irregularity of ossification.

CT and MRI imaging are not required for diagnosis, but they may become necessary if the patient’s symptoms do not improve with treatment.

Kohler's Disease
Kohler Bone Disease Radiology

Kohler’s Disease Treatment

Kohler’s Disease is a self-limiting condition, and operative treatment rarely is indicated.

Non-operative Treatment:

  • Cast immobilization for 4 to 8 weeks with a short-leg walking cast has been reported to produce quicker resolution of symptoms.
  • A short course of NSAIDs for symptoms relief.

Operative Treatment:

Surgery is indicated when disabling symptoms persist.

Arthrodesis is the only operation of value, and the calcaneocuboid joint is included because most of its function is lost when the talonavicular joint is fused.

  • The midtarsal joints (talonavicular and calcaneocuboid) can be arthrodesed by a technique similar to that used for deformities in poliomyelitis.
  • The results of this operation usually are excellent; most patients become symptom free but may notice loss of lateral movements of the foot.
  • When symptoms arise from the naviculocuneiform joints also, these joints should be included in the fusion.

Q & A for Patients

What causes Kohler’s bone disease?

The cause of Kohler disease is unknown till now, but the navicular delay of ossification and its vessels passage that can be compromised make it predispose to Avascularity and therefor a Kohler’s bone disease.

Is Kohler’s disease hereditary?

No, Kohler disease is not hereditary as there is many factors can cause it.

Can Kohler’s disease heal completely?

If Kohler’s bone disease treated properly, it’s completely healed without any complication.

References

  1. Köhler A: Über eine haüfige bisher anscheinend’-unbekannte Erkrankung einzelner kindlicher Knochen, Münch Med Wochenschr 45:1923, 1908.
  2. Prathapamchandra V, Ravichandran P, Shanmugasundaram J, Jayaraman A, Salem RS. Vascular foramina of navicular bone: a morphometric study. Anat Cell Biol. 2017 Jun;50(2):93-98. doi: 10.5115/acb.2017.50.2.93. Epub 2017 Jun 27. PMID: 28713611; PMCID: PMC5509905.
  3. van Langelaan EJ. A kinematical analysis of the tarsal joints. An X-ray photogrammetric study. Acta Orthop Scand Suppl. 1983;204:1-269. PMID: 6582753.
  4. Trammell AP, Davis DD, Scott AT. Kohler Disease. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507831/
  5. Sharp RJ, Calder JDF, Saxby TS: Osteochondritis of the navicular: a case report, Foot Ankle Int 24:509, 2003.
  6. Waugh W: The ossification and vascularisation of the tarsal navicular and their relation to Köhler’s disease, J Bone Joint Surg Br 40:765, 1958.
  7. Borges JL, Guille JT, Bowen JR: Köhler’s bone disease of the tarsal navicular, J Pediatr Orthop 15:596, 1995.
  8. Karp M: Kohlers disease of the tarsal scaphoid, J Bone Joint Surg 19:84, 1937.
  9. Kidner F, Muro F: Kohler’s disease of the tarsal scaphoid or os navicular pedis retardatum, JAMA 83:650, 1924.
  10. Williams GA. Cowell HR: Köhler’s disease of the tarsal navicular, Clin Orthop Relat Res 158:53, 1981.
  11. Millers Review of Orthopaedics, 7th Edition Book.
  12. Campbel’s Operative Orthopaedics 13th edition book.
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