OSTEO-ARTHRITIS OSTEO-ARTHRITIS

BY PROF.

DEFORMANS DEFORMANS
F. J.
LANG, INNSBRUCK,

CONTRASTED JUVENILIS
AUSTRIA

WITH
*

Professor

of Pathology Institute

and of the study

Director University the

of is a

of the

Pathological-A

natonucal

of Innsbruck and
the disease. non-infectious, proliferative

The
arthritis changes

comparative
deformans present must. in the

of
based types

adult
upon this chronic

juvenile

types
and

of

osteo-

be two

anatomical

histological

Osteo-arthritis

deformans

inflammation The especial

of The arthritis exostoses const.itute

that importance
deformans. the decisive arise

leads and for the

to presence

a deformity of marginal
marginal for t.he

of the as well
diagnosis

joint. as the
of

structures have
are this

(Fig. been diagnosis

1). of
and

development

exostoses
exostoses

always

anatomical
These

histological
characteristic disease ossification

feature as the result

(Fig. which,

2).

of vascularization

and

beginning calcified
This and follow ticity cartilage prise diagnostic the

in the cartilage.
vascularizat ossification the of first loss the and features

subchondral
ion

marrow

spaces,

invade

the

overlying

non-

of elasjoint comdefinite of

arthritis (Pommer)
These exostoses

deformans (Fig. 3).

marginal are not.
F

ossified (\rolkmann),
ost.eal or

excrescences or penpenichonor (Nichols or

drial
and
(Kimnura,

proliferat.ions Richardson),

osteophytes

periosteal
they are (as

lippings Ziegler);
Pommer bone
FIG.1

maintains)

formations,
arising
*

that,
from the the College
Lecture).

lesions.

Arthritis

(Maccrated

deformans

specimen.)

of a hip

joint,

showing

characteristic

Read
Newbold

before

of Physicians 563

of Philadelphia,

November

4, 1931

) Mary

Scott

564

F.

J.

LANG

FIG.

2 with marginal exostoses. (Microscopic

Head section.

of the

femur

in art hritis

deformans

subchondra.l possess

marrow a laminated

t.issue, structure,

grow

out

into

the

joint

cartilage.

They

are

usually

covered

with

new

are united cartilage.

to

the

spongiosa

(Fig.

2),

and

,.\,%,,i.

FIG.

3 basal cartilage

Vascularization superficial layers

and
of

ossification

of the

the

joint

cartilage.

(Hip

joint

of

following alterations a fifty-three-year-old

of the man.)

OSTEO-ARTHRITIS

DEFORMANS

565

The
presents ations,

joint.
various chief

cartilage
alteramong

which
in ciated of stance alterations damage of These the the

are
consistency with (Fig. the

alterations
assoa splitting ground 3). disturb elasticity in cartilage. subThese and
ft

alterations

the
tural the

physical
normal first. sites of into those

and

strucof

characteristics articular appear of normal hyaline fibrous Anatom-

cartilage at transition cartilage cartilage.

ically, the mon locations

changes margins are of

most for
about the

comthese
the fovea

and

at

the

junction Separated joint cartilage

giosa. (Arthritis deformans three-year-old man.

FIG

of the femoral head and neck (Lang, 1924). A stnikmng sequel

.

lying
of the

deep
hip

within
joint

the sponof a fifty-

to thus

the

vascularizat.ion

and

the

ossification of the
are mark

of the The
found site of

cartilage portions
to the lie deep original does

is the
within

underthe

mining
spongiosa

of the
separated and

deeper
by in this

portions
undermining position

cartilage.
often the

of cartilage
boundary not in take the any more

between
As part. by in newly

cartilage
previously the formation

and

bone
of the

(Figs.
the marginal

3 and
peniosteum

4).
in general exostoses. However,

mentioned,

advanced The

cases

of arthritis

deformans,

peniosteal

bone

proliferat

ions

covered

formed cartilage synovial membrane the

of subchondral against in the arthritis the t.hat changes basal the bone functional overlying deformans of functional

can l)e seen at the insertion of the tendons. may also be the site of proliferative changes.
in the cartilage surface layer zone compact. mechanical (Pommer). for its circumstances. cartilage is and dependent. anatomical and of the rarely of the The cartilage, take joint damage vascularization place. cartilage subchondral in Hence, development spite it The is very bone of cause broad, is thus the loss the and for

Despite ossification this or of that is either the

calcification is very

protected elasticity

is obvious upon

combination

566 The layer away and

to

F.

J.

LANG

worn
rise

of cartilage the underlying polished surfaces

covering bone

large marginal be exposed and

exostoses made smooth, in have degree function

bone

may be giving various become of irritaof the

resorption

areas exposed tion

part

a hard, highly of the polished

surface (Fig. small portions and the

understood

5). Frequently of the marrow When mechanical the

by and

mechanical resulting by side

irritation from increased

it is easily

wear. impaired
why

trauma side

is considered,

increased

is found

with

new the

bone

formation. of one the can

In

this

union

of opposite deformities In the

phenomena is found of the joints in arthritis more advanced cases bone resorptive of the and

explanation deformans. of this disease,

characteristic find, especially

in the subchondral bone, callus and arises as a result cartilage. of porosity

specimen.

along the junction tissue proliferations. splitting and cracking processes that make is so

between cartilage and This callus formation of the bone and of the the in striking picture the macerated

These and

reactive condensation

clear obvious

Microscopic cysts are likewise found in the exposed subchondral marrow spaces (Fig. 5). These cysts are either the result of encapsulation of hemorrhages or of areas of detritus. Thus is disproved the theory of Kimura and Ziegler that the cause of arthritis deformans lies in regressive changes in the subchondral bone (Pommer). In far advanced arthritis deformans, the so called cartilage in the marrow spaces of the surface. According to Pommer can originate tures, and, transported
where progressive atrophy, they

nodules are observed ; these are situated spongy bone beneath the polished joint and Lang (1924), the cartilage nodules as callus of joint capillaries local origin
occurs

in two ways : first, second, as fragments as emboli lodge. the knowledge

changes in age

resulting cartilage and

from that lymph

microscopic are broken vessels and reactive

understood time that

fracoff and grow and

how these

along

the

With

of the
arthritis and

of the
it at can the

various
be same

deformans,

caused

by

inactivity,

other
polished distinction

changes
areas Considering

are
are between

taking
observed. the above the

place.
described atrophic

Thus,

not
findings

only

sclerotic
and their

but

also

atrophic
the the

explanations, or between

and

the

hypertrophic

degenerative necessary. According

and

the

hyperplastic and Beitzke,

types the

of

arthritis

deformans of arthritis

is not deformans

to Pommer

varieties

present no distinctive differences; they are but gradations of a process that is uniform as regards its origin. Naturally, in the explanation of these differences, individual variations must be considered. These variations have their origin in the anatomical structure, in the functional requirements, and in the effacement of the part by use (Lang, 1924). A distinction
deformans is also

between
unnecessary.

the

chondral
For, in the

and final

osseous analysis,

forms

of

arthritis damage

it is the

OSTEO-ARTHRITIS

DEFORMAXS

567

FIG.

5 in the underlying man.) spongiosa.

Polished (Arthritis

articular deformans

bone surface of the hip

with

cyst
of

joint

formation a fifty-three-year-old

.,

. --.4

FIG.

6 juvenilis. Note

Head the loss

of the femur of substance

of a nine-year-old in the articular

girl with arthritis (leformans surface of the cartilage.

56S

F.

J.

LANG

FIG.

7 in a nine-year-old of the femoral head. girl with forma-

Arthritis tion

deformans exostoses

juvenilis and

(Leggs mushrooming

disease)

of marginal

to for
as

the

cartilage

with

its

resultant

loss

of

elasticity

that

is

responsible

the In
to the

origin spite
nature

of the of the

disease numerous
origin,

(Lang,
arthritis

1931). and
deformans

anatomical

pathological
has more

investigations
recently been

of its

called,
Sis of
.

from The
as degenerative

the clinical designation

the termination nature. change in that

and roent.genological of arthritis deformans

osis Thus, the kidney, constitutional deformans, arthritis. are organ influences and the or can, outcome necessary to what is used for and example, nephritis, influences and, This

points as

of vinw, arthrosis
to indicate

an

arthrois

to

be
any

avoi(led, a (legenerative
eSS.

in pathology nephrosis an have therefore, argument,

changes proc-

indicates to the be

inflammatory designation

It. is asserted development These regardless Constitutional the 1931). is not

considered
is not inflamtype, process histological t.he

in t.he a.rthrosis sound. process, mnation. intensity, (Lang, distinction (listinction

of arthrit.is considerations of extension, It

is preferable

however,

important
structure nevert.heless, of to keep

for
is the an

every
site affect inflammatory

inflammatory
of the the the

is absolutely

in mind

between processes

inflammatory
superfluous and

and
is of value

degenerative
since

processes.
inflammatory and 1931).

This
de-

generat.ive all conditions, non-infectious

designation

frequently

occur of arthritis of the joint

is arthritis

side and,
.

by

side

(Lang, is a chronic, the

Under justifiable

the character inflammation

of this process

deformans

proliferative, only

t.herefore,

OSTEO-ARTHRITIS

DEFORMANS

569 it must first of all be

Regarding admitted certain sclerosis, changes secondary as occur no proof

the

causes

of

arthritis

deformans, between changes,

that a direct relationship systemic diseases. But are that not the main are sometimes inflammation

can exist vascular

arthritic changes and especially arteriovessel of or such there cause is of

cause of arthritis seen are generally or localized

deformans. The either independent disturbances,

to the

circulatory

in the advanced cases of arthritis deformans. Likewise, that under natural and non-experimental conditions the is due confirmation subchondral to

primary arthritis deformans Furthermore, there is no atrophic changes of the development The the cartilage,
marrow

necrotic changes of the cartilage. of the view that regressive and bone are of importance in the for arthritis the Following deformans presupposes subchondral
jarrings,

only

of this disease. satisfactory explanation theory of Pommer. its

irregular,

is found that bone to the the and

and

in joint its
pres-

functional
from

This protects
effects

theory

through
the

elasticity,
localized

of impacts,

sures

arising

from

normal

function.

damage

joint of

cartilage, with subsequent loss of its elasticity, the mechanical effects normal joint function become more or less localized and are transmitted unmodified to the joint structure resulting in a reactive vascularization and ossification The damage of the cartilage. to the joint strains, in tabes
-

cartilage

arises

: first,

from

unequally

disposture, is lost; through

tributed or violent or of those occurring second, through

for example, of heavy dorsalis in which the of the joint cartilage

labor, of bent pain sensibility itself; third, and the endocrine

diseases

diseases of the joint capsule, bone ; and, fourth, through (Lang, The joint 1931). recognition as the of the

the synovial membrane, endogenous metabolic and functional covering and mechanical of the

subchondral influences of the (Roux)

importance bone

cartilage

protective

subchondral

demands that the mechanical and functional damages to the joint cartilage be adjudged the most important. factor, not only for t.he pathogenesis, but also as the etiological factor of arthritis deformans. An especial confirmation for t.he functional theory of arthritis deformans is the fact that this disease is frequently found in certain for this statement is given in the literature.
occupations. Sufficient proof

R. Beneke
changes. in which traumatic
substantiated:

has pointed

out the possible

sequelae

of old traumatic

I was able to confirm his idea I found evidences of the end changes (Lang, 1922, 1924).
that arthritis deformans

by my studies of juvenile joints, results of more or less extensive By these studies, this theory is
is already initiated in the early

years quence the

of life and, of trauma effects

therefore, carried of trauma

the disease has to be considered over from childhood and adolescence. in early life are considered, it becomes oft-repeated of the adult functional traumata (Lang, 1931).

as a conseWhen evident lies the

after

that in the sequelae etiology of arthrit.is

of chronic, deformans

570

F. J. LAN(;

FIG.

S epiphyseal line. (Leggs disease, nine-

Fissure year-old

formation girl.

in the

cartilage

of the

I was
Ilfl(l SeCond

able

to investigate
disease bones,

the
of the and

juvenile
hip other joint,

form
so

of arthritis
K#{246}hlers disease called aseptic

deformans
of the necroses first

in

Perthes-Legg-Calv#{233}s metatarsal

(Lang, features
joint marginal In presents

1922, 1924, of arthritis

(artilage, exostoses the juvenile changes to these of are the found of along formation of the

1931).
deforinans vascularization (Figs. type typical changes, striking cartilage, epiphyseal the the with of

In

these
were and 7). arthritis

diseases
ossification

the

characteristic
changes of the occurs the

diagnostic
of the and zone of in the arthritis splintering adults. cartilage, epiphyseal

present,-namely:

6 and of those

ileformans in arthritis of ossification cases fissure (Fig. of 8). new juncture; The of bone, These cartilage

found In the of subehondral line

defornians juvenile and of changes and their lines bone and

As a sequel portion

cessation line. examples of

involved
deforand bone stimulate so charfissuraand

epiphyseal

mans
cartilage callus acteristic tions are in

formations,

fragmentation

the

production bone cartilage

juvenile
along parallel

arthritis with of the

of

deformuans. in part at right zone

and

splintering

are
part

found

of direction

an(l

angles
the size,

to the
position,

lines

of strains
and struewhether

(Fig.
ture tion

8. The
of of

behavior
the the epiphyseal vibrations

epiphyseal
bone determine impacts

and
whether jarrings

adjustment are possible

and or

distribu-

OSTEO-ARTHRITIS

DEFORMANS

571

.-sc
-

CI)

=
C

ct

bL bL

C,2

-C

CC

572 splintering
occur

F. J. LANG

and fragmentation with displacement of the fragments will 1931). More or less extensive hemorrhage with subsequent hemosiderin deposits and blood-cyst formation complete the picture of previous trauma. From my studies it is evident that functional traumata are delermin(Lang,
of

ing factors
effects

for the origin of juvenile this trauma are responsible deformans. following two cases of

arthritis for the Pert.hes

deformans. insidious disease are

The character illustrative

continuous of juvenile of this

arthritis The point.. The

injuring chanteric

first

patient

was

a normal

twenty-two-year-old

male

who

fell

from

a ladder,

his right fracture.

thigh. After

X-ray examination six weeks in a plaster

showed an oblique, incomplete, cast the patient was discharged

subtrowith the
Two years

x-ray
later

examination
a pronounced
and a half limitation

at this

time

showing

complete

healing

of

the

fracture.

three
and

flattening of the years after the injury,

of motion, the joint

femur head was roentgenologically was far advanced. At this time,

was opened

removed. This what is especially

quent invisible with picture islands

case is clarified important-fissure

only

by postulating formations
equilibrium, were processes lined by

which, of pain and a mushroom-shaped femoral head damages to the joint cartilage andin the subchondral hone with a consedamages to continued areas which were, functional The final of osteitis of course,

visible because

disturbance in the first six shows weeks tiny a resulting of splintered

of the structural two x-ray films. of rest these areas of the

After

subjected new cartilage,

traumata microscopic fibrosa with

disturbance pseudarthroses and

of reconstruction.

all the The following

characteristic

pulverized bone, cysts signs of arthritis deformans.

containing

hemorrhages

and

debris,

and

second patient was a fifteen-year-old boy who developed Perthes disease a gunshot wound of the soft parts about his right hip. Neither hone nor joint structures were involved. X-rays were taken immediately and at periods of nine and eleven months after the injury (Just). The first roentgenological examination failed to show any damage to bone or joint. In the examination made nine months after injury there existed well advanced changes in the femoral head characteristic of Legg-Perthes disease. These changes were more marked in the last x-ray. Here, as a result of a
relatively mild localized indirect trauma (as compared with the first case cited), there

developed

a characteristic

deformation

of the femoral

head.

from: direct.

These first, trauma.

The

two cases are severe direct

bilateral, symmetrical

representative trauma and,

type of

of latent second,
Leggs

bone from disease

changes relatively of t.he hip

resulting mild injoint is

exceptional. When the disease is bilateral it is usually found that there existed a developmental malformation of both femoral epiphyses. It is well recognized that a developmental malformation of an epiphysis predisposes that structure to damage by relatively mild functional and actual The
formans

traumata (Fig. importance

is in no wise

9). of trauma
lessened because

for

the
no

origin
history

of

juvenile
can

arthritis

dein severe

of injuries

be elicited.

In comparative many cases traumatic

giving

studies, I was able a negative history with their sequelae

t.o demonstrate for trauma, (Lang, 1924)

more (Fig.

histologically, or less 10).

changes

OSTEO-ARTHRITIS

DEFORMANS

573 or must by and until objective consider of this collapse some time that is of K#{252}mmell.

When symptoms the the This the

after

there being that may

is a history of trauma without present immediately after the may lead be found of at the a later vertebrae not become date. atrophy but

subjective injury, one An described

sequelae post-traumatic atrophy body

example

to almost it does

complete

disappearance evident there can

of a vertebra

the original In estimating

injury. the importance

of trauma,

be no doubt activity

mechanical life, will In between Both cartilage the against

As

damage to a joint, due lead to arthritis deformans conclusion, arthritis of the with functional
a causative

to excessive athletic (Lang, 1931).

in early differences deformans. and joint bone to to removes

it is evident that there are no fundamental deformans of the adult and juvenile arthritis disease the and
agent

types protection

originate loss normal mechanical

for arthritis

after cartilage influences.

damage This affords

deformans

to the loss to the

articular of elasticity subchondral the

subsequent that

of its elasticity.

in adults,

damage importance. damages

the cartilage, In juvenile the cartilage responsible.

of arthritis

resulting from arthritis deformans,

excessive direct

strains, is of primary and indirect traumatic

and, especially, to the osteochondral The decisive factor for the progressive
deformans is the of constant

junction are held course of both types

acting character

as a source

action of the functional requirements which, irritation, forms the basis for the progressive

of the disease.
REFERENCES

BEITZKE

H. : tber
215,

die Sogen.
1911-12.

Arthritis

Deformans

Atrophica.
Beitr. Arzte, Juvenilis

Ztschr.
z. Wiss.

f. KIm. Med.
vom Wiener

Med.,

LXXIV,
BENEKE,

R. : Zur Lehre von der Spondylitis Deformans. d. LXIX. Vers. Deutscher Naturforscher und Braunschweig, Staatsministerium, p. 109, 1897.
E.: Zur Aetiologie XLIV, der 889, und 225, Osteochondritis 1931. Untersuchungen Arthritis 591, Befunde 1900. bei Juveniler Coxae Wchnschr.,

Festschr.
Herzogl. Klin. Folgen, u. z.

Dangehoten Deformans. und Beitr. z. Path. Deformans.

JUST;

KIMURA,

Coxa
Allg. LANG,

K.: Histologische Vara, Ostitis

#{252}berKnochenatrophie

Deren Anat.

Deformans.

Zieglers Arthritis

Path.,
f. Path.

XXVII,

F. J.:

Mikroskopische

Virchows Deformans.

Arch.
Virchows

Anat.

CCXXXIX, Anat.,

76, 1922.

Zur Kenntnis
Arch.

der Veranderungen
CCLII,

der HUftpfanne
578, 1924.

bei

Arthritis

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Die
1931.
NIcHoLS, (New

Osteo-Arthritis
RICHARDSON,

Deformans.
F. L.: Arthritis 1909.
Befunde bei Krankheiten Pt. 2. Erlangen, Arthritis Klasse,

Wiener

Kim.

Wchnschr., J. Med.
Denkschr. 65, 1914.

XLIV, Research,
der Handhuch bei Arthritis 502,

861, XXI
Kaiser!. der De-

E. H. AND Series G.: d. Wiss. R.: Spec. tber

Deformans.
Deformans. LXXXIX, der 1865. der Bewegungsorgane.

XVI), Wien. Chirurgie, die

149,

POMMER,
Akad.

Mikroskopische Verletzungen

Math. und II, Subchondralen

Naturw.

VOLKMANN,
Allg.
ZIEGLER,

u.
E.:

Veranderungen

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formans

und

#{252}ber Knochencysten.

Virchows

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