An analysis of indications for surgical excision and complications in 116 consecutive cases of osteochondroma

Malignant transformation of osteochondroma to chondrosarcoma: a challenging case

A 50-year-old female presented with a large palpable mass in the right buttock and proximal thigh, accompanied by sciatic paresthesia. She reported intermittent thigh and knee pain for 5 years, worsening over the previous 6 months. Plain radiography images revealed a pedunculated osteochondroma on the posterolateral aspect of the femur with extensive soft tissue involvement and soft tissue calcifications. A computed tomography (CT) scan showed an osteochondroma with a large adjacent bursa containing multiple foci of calcifications with a "snowstorm" appearance. A diagnostic dilemma arose regarding whether the condition represented reactive bursitis secondary to osteochondroma or a malignant transformation to chondrosarcoma with intra-bursal invasion. Magnetic resonance imaging (MRI) indicated a thick cartilage cap of osteochondroma measuring 53 mm and multiple cartilage nodules in the bursa along with heterogeneous enhancement in cartilage islands. Moreover, evidence of adjacent muscle invasion and sciatic nerve encasement was noted. These findings suggested an unusual diagnosis of malignant transformation of the osteochondroma to chondrosarcoma with intra-bursal invasion. The patient underwent wide-margin resection of the proximal femur and tumoral soft tissue, reconstructed with a proximal femoral mega prosthesis. Histologic evaluation confirmed a well-differentiated chondrosarcoma with intra-bursal invasion. This case highlights the critical role of diagnostic imaging in differentiating between benign and malignant complications associated with osteochondroma.

Osteochondroma of tibial tuberosity in a young soccer player mimicking an Osgood-Schlatter disease: A case report and literature review

We report a case of a 9-year-old male with anterior knee pain and swelling associated with physical activity. The orthopedic surgeon suspected Osgood-Schlatter's disease. X-ray and MRI showed an osteochondroma of the tibial tuberosity. The patellar tendon partially inserted on the osteochondroma and the tibial tubercle, causing pain associated with physical activity. We chose a conservative management with temporary rest, local application of ice and NSAIDs. After a few weeks, the boy returned to regular training without pain and our final recommendation was only radiological monitoring of the lesion over the time.

Hereditary multiple exostoses: an educational review

Hereditary multiple exostoses (HME), an autosomal dominant disorder with an incidence of 1:50,000 to 1:100,000, is characterised by the formation of multiple osteochondromas arising from the metaphyses of long and flat bones. These osteochondromas often present as painless palpable lumps, though some cases are symptomatic due to mechanical compression or bursitis. Diagnosis of HME is typically clinical and radiological. WHO diagnostic criteria include ≥ 2 radiological osteochondromas in the juxta-epiphyseal region of the long bones. Genetic testing is reserved for ambiguous cases. HME is associated with mutations in the EXT-1 (exostosin-1) and EXT-2 (exostosin-2) genes. Imaging techniques, including conventional radiography, CT, MRI, ultrasound, and nuclear medicine, play a crucial role in diagnosing and assessing HME, with each modality offering distinct advantages in visualising the lesions and associated complications. Common complications include skeletal deformities, fractures, bursitis, as well as neural and vascular abnormalities. Notably, there is a 10% risk of malignant transformation into secondary chondrosarcoma in HME patients, compared to only a 1% risk in those with solitary osteochondromas. Malignant transformation should be suspected in patients with new-onset pain or specific imaging features in an osteochondroma, such as growth of de cartilaginous cap. In these cases, an MRI should be performed to assess the cartilage cap thickness. Advances in imaging techniques and genetic understanding have improved the management and prognosis of HME. Follow-up is essential to rule out malignant transformation. This review summarises current knowledge on the clinical presentation, pathogenesis, imaging characteristics, complications, and treatment of HME. CRITICAL RELEVANCE STATEMENT: HME is a disorder characterised by the formation of osteochondromas arising from long and flat bones. Multi-modality imaging characteristics, clinical presentation, complications, and treatment are highlighted to familiarise the readers with this entity and offer optimal patient care. KEY POINTS: HME is characterised by multiple osteochondromas on long and flat bones. Imaging for HME includes radiography, CT, MRI, ultrasound, and nuclear medicine studies. Complications include non-malignant complications, such as bone deformities and malignant transformation. Cartilage-cap measurement with MRI or US is key to exclude malignancy. Follow-up is essential to rule out malignant transformation of the osteochondromas.

Effect of Solitary Osteochondroma on Alignment and Length in the Lower Extremities

BACKGROUND

There is a lack of information about the effects of untreated solitary osteochondroma (SO) on longitudinal growth of the lower extremities in children and adolescents. This study aimed to assess the coronal alignment and length of the lower extremity in patients with SO around the knee and to identify the factors related to the development of deformities.

METHODS

We retrospectively reviewed 111 patients diagnosed with SO around the knee. The patients were classified into 2 groups depending on the location of the SO: 51 in the distal femur and 60 in the proximal tibia. Characteristics of the lesions, such as type, location, size, and distance from the joint line, were determined. Radiographic analysis of the lower limbs included mechanical lateral distal femoral angle, mechanical medial proximal tibial angle, whole-leg length, femoral length, and tibial length.

RESULTS

The mean age at the time of diagnosis was 12.3±3.4 years. No statistically significant differences were found between the affected and contralateral sides for mechanical lateral distal femoral angle and mechanical medial proximal tibial angle in either the distal femur or the proximal tibia groups. In patients with femoral lesions, the femoral and whole-leg lengths were significantly shorter on the affected side than on the unaffected side ( P <0.001 and 0.002, respectively), and the mean differences were 2.1±3.6 and 2.1±4.4 mm, respectively. Univariate logistic regression analysis did not reveal any factors associated with limb length discrepancy (LLD). In patients with tibial lesions, no statistically significant differences were found in LLD.

CONCLUSIONS

SOs around the knee did not cause clinically significant deformity of the lower extremity. However, in contrast to proximal tibia lesions, SO in the distal femur was associated with the shortening of the affected limb. Consideration should be given to the development of LLD in skeletally immature children with SO in the distal femur.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Solitary Osteochondroma at Unusual Sites: A Case Report and Literature Review

Osteochondromas (OCs) are bone lesions composed of cartilaginous and medullary bone capped with hyaline cartilage. OCs result from the separation of epiphyseal growth plate cartilage, pushing through the periosteal bone cuff. They commonly appear as pedunculated or sessile masses in the metaphysis of long bones and are the most common benign bone tumors. While rare in the scapula, OCs can occur there. Symptoms may arise from fractures, osseous abnormalities, or potential malignant transformation, especially in the presence of hereditary multiple exostoses (HME). The estimated rate of malignant transformation in solitary lesions is 1%, whereas in hereditary multiple OCs, it can reach up to 3-5%. We report a case of a 10-year-old female who presented with a gradually progressive swelling on the back of her right scapula. This progressive growth has been observed over the course of the past two years accompanied by mild pain. The pain was intermittent and did not affect her daily activities. On examination, a hard, tender, non-mobile swelling of approximately 2 × 2 cm was found over the right scapula. The patient had a normal range of motion in the shoulder and scapulothoracic regions. In conclusion, since solitary scapular OCs are extremely rare, they are quite common when associated with HME. This study aimed to increase awareness of the unusual site of OCs. Furthermore, we have included a full account of the surgical therapy we administered to this patient in order to assist future surgeons who may come across similar conditions.

Osteochondroma of the Scapula: A Case Report and Literature Review

Osteochondromas are bone lesions composed of medullary and cartilaginous bone covered by a cap of hyaline cartilage. The presence of medullary and cortical bone with the continuity of the tumor is pathognomonic for osteochondroma and aid in establishing the diagnosis. We report a case of a two-year-old girl who presented to our clinic following her mother noticing a palpable, growing, and painful mass on her left scapula. There was no limitation in the range of motion. A clear-cut mass was seen on the dorsal aspect and palpated measuring around 2.5x3 cm. Surgical excision of the mass followed by histologic examination confirmed osteochondroma. Upon follow-up, the patient had no pain and had a full range of left shoulder motion without discomfort or pain. In conclusion, scapular exostoses are very rare and more so when they present dorsally. Symptomatic lesions can be managed effectively with surgical excision of exostosis.

Application of allograft and absorbable screws in the reconstruction of a massive bone defect following resection of giant osteochondroma: A retrospective study

Background

This study aims to introduce a reconstruction method of applying allografts and absorbable screws to repair large bone defects caused by the resection of giant osteochondroma.

Methods

A retrospective study of a series of patients who underwent the resection of giant osteochondroma reconstructed by allografts and absorbable screws was conducted from February 2020 to September 2021. Their demographic data, location site, area of bone defect, and pertinent operative details were recorded. The reconstruction modality of allografts was elaborated on. In the follow-up, radiographic images were utilized to determine bone union, and the Musculoskeletal Tumor Society score was used to evaluate postoperative limb function.

Results

A total of seven patients were included, including three males and four females with an average age of 16.6 ± 6.5 years. Among them, three cases of tumors occurred in the humerus and four cases occurred in the femur. The average follow-up time was 11.3 ± 3.0 months. The average area of bone defect was 25.9 ± 8.3 cm². No complications such as infection, nonunion, and allograft bone fracture were found during the follow-up period. Six months after the operation, the average Musculoskeletal Tumor Society score was 26.4 ± 1.6, with acceptable postoperative function.

Conclusions

The cooperative application of absorbable screw fixation and allografts including mixed cortical bone and cancellous bone, which yielded satisfactory functional outcomes and acceptable postoperative complications, is an effective reconstruction method for a massive bone defect after the resection of giant osteochondroma.

Osteochondroma of the Tibial Tubercle Masquerading as Osgood-Shlatter Disease: A Case Report

Background:

Osteochondromas are a relatively common primary bone tumor, which may share common clinical features with Osgood-Schlatter disease (OSD). A limited number of cases have described tumors misdiagnosed as OSD.

Case Presentation:

We report the case of an 11-year-old male with a sessile osteochondroma of the tibial tubercle and concomitant involvement of the distal extension and attachment of the patellar tendon into the tibial periosteum. A prior diagnosis OSD had been made. The lesion was resected and repair of the extensor mechanism was required at the time of surgery. The patient was followed for 20 months postoperatively and had restoration of knee function with minimal pain, as demonstrated by a PEDI-IKDC score of 94.6 at 19-month.

Conclusion:

This is a rarely reported case of benign tumor masquerading as OSD requiring excisional biopsy with extensor mechanism repair.

Hereditary multiple exostoses: A case report and literature review

Osteochondroma is the most common bone tumor representing 20%–50% of all benign bone tumors and 10%–15% of all bone tumors. Osteochondroma has similar radiological appearance in both solitary and multiple forms; the latter is an autosomal dominant disorder termed hereditary multiple exostoses. Associated complications of osteochondroma include deformity, fracture, neurovascular compromise, bursa formation, and malignant transformation. Measurement of the cartilage cap thickness is an important index suggesting secondary malignancy of osteochondroma. The upper limit of cap thickness after skeletal maturation is 1.5 cm which can be reliably measured on ultrasound or magnetic resonance imaging. Hereditary multiple exostoses are linked to the mutations of different exostoses genes located on chromosome 8, 11, and 19. We reported cases of two siblings presented with multiple osteochondromas managed by surgical excision. We evaluated their clinical and radiological presentation, genetic correlations and compared with the literature.

Unusual location of osteochondroma in the temporal region in a patient with functional pituitary adenoma

Osteochondromas are common in the long bones and relatively rare in the head and neck regions. We herein report a case of a solitary temporal bone osteochondroma associated with a functional pituitary adenoma hypersecreting prolactin. The patient was a 48-year-old man with progressive, painless temporal swelling associated with gradual visual loss, gynaecomastia, erectile dysfunction, and loss of libido. A brain computed tomography scan with bone windows showed right temporal sessile bony expansion and a pituitary tumour. A pituitary function test revealed hyperprolactinaemia. His symptoms resolved with medical management, and excisional biopsy of the temporal tumour confirmed an osteochondroma. To the best of our knowledge, this is the first reported case of a solitary temporal bone osteochondroma with a functional pituitary adenoma hypersecreting prolactin.

Osteochondromas: An Updated Review of Epidemiology, Pathogenesis, Clinical Presentation, Radiological Features and Treatment Options

Osteochondroma, the most common benign bone tumor, is a projection on the external surface of the bone, which can be sessile or pedunculated. 85% of osteochondromas present as solitary lesions, while 15% occur in the context of hereditary multiple exostoses (HME), a genetic disorder that is inherited in an autosomal dominant manner. Although often asymptomatic, symptoms may eventuate from compression of adjacent vessels or nerves, fractures, osseous deformities, bursa formation, or malignant transformation. Cartilage cap thickness >2 cm in adults or >3 cm in children as well as new onset of pain or growth, or rapid growth of the lesion, especially after the closure of the growth plate, might reflect cancerous transformation. Surgical resection is indicated for symptomatic lesions, complications, cosmetic reasons or malignant transformation. Excision of the tumor with free margin is the treatment of choice. Local recurrence is less than 2% if complete resection is achieved.

Distal Clavicle Osteochondroma Causing Supraspinatus Tendinopathy

Shoulder pain is a very common symptom especially in young and active population. Rotator cuff tendinopathies are believed to be the most common cause of shoulder pain up to 86%. Tumors around the shoulder area can cause pain or joint stiffness when expanding in the subacromial space. We present a rare case of a distal clavicle osteochondroma. It is a benign tumor which in this area causes supraspinatus tendinopathy and every physician should suspect this kind of diseases during the diagnostic approach of a shoulder pain. In this case, early diagnosis and appropriate treatment with excision of the lesion gave us a very good outcome with fully relief of the symptoms.

An Unusual Location of Osteochondroma: Temporal Bone

Osteochondromas are the most common benign tumor of the bones which are cartilage-capped exophytic lesions that arises from the bone cortex. They usually seen in the axial skeleton, especially around the metaphysis of long bone but seldom in the head and neck region. The majority of patients in the head and neck region affect the mandibular area. To our knowledge, this is the first reported patient with an osteochondroma of the temporal bone in the English literature. A patient with temporal bone osteochondroma and its surgical treatment are here described.

[Management of popliteal artery pseudoaneurysms as a result of limb trauma and orthopedic surgery or associated with osteochondromas]

Most published articles regarding popliteal artery pseudoaneurysms (PAPs) are case reports and in English language literature. In this context, no study with robust data was previously published. The exact epidemiology of these APs is not well-known and their management is not yet codified. We wanted to summarize the current knowledge on diagnostic and therapeutic features of PAPs as a result of limb trauma and orthopedic surgery or associated with osteochondromas. An electronic research on MEDLINE and EMBASE between 1953 and March 2015 was performed; using the key words "popliteal pseudoaneurysm". The referenced articles were selectively read and this systematic review included 116 articles. Patient demographics; clinical presentations; diagnostic and therapeutic features were reviewed. In sum, 122 cases were analyzed. Overall young adult (average age=30.48±21.25 years old) represented the majority of the affected population with a masculine preponderance (79%). The main etiologies included femoral exostosis (63%), followed by the orthopedic surgery (25%) and direct trauma into the knee (10%). Painful swelling (44%) and/or pulsatile mass (39%) represented the most commonly presenting symptoms. The commonest radiological investigations used included arteriography (49%) and CTA (27%). The treatment was open surgical repair (85%) or endovascular stenting graft (14%). Post-therapeutic courses were often uneventful (98%). The morbidity rate was low at about 2%. The treatment of direct post-traumatic PAPs was usually open surgical repair (83%) with saphenous vein grafting. Endovascular stenting may be an ideal option for managing PAPs following orthopedic surgery (88%). Open surgery for vascular repair and maximum exostectomy must be undertaken concomitantly in the setting of APs associated with osteochondromas.

Surgical hip dislocation according to Ganz for excision of osteochondromas in patients with multiple hereditary exostoses

AIMS

We report a prospective cohort study of the midterm results of surgical dislocation of the hip (according to Ganz) to perform resection of osteochondromas involving the femoral neck in patients with multiple hereditary exostoses (MHE).

METHODS

Hip range of movement (ROM) was assessed pre- and post-operatively. Patients' judgment of post-operative reduction of pain, symptoms, the Rand 36-item Health Survey (RAND-36) and complications were analysed.

RESULTS

Symptomatic osteochondromas of the femoral neck were removed in 20 hips (17 patients) between 2007 and 2012. There were nine men and eight women with a mean age at the time of surgery of 29 years (11 to 47). Mean follow-up was 46 months (26 to 73). At latest follow-up, mean ROM was significantly increased in all directions. Post-operatively the pain associated with the lesion was either significantly decreased or non-existent. There was a significant improvement in seven RAND-36 sub-domains. Encountered complications in four patients were pseudoarthrosis of the trochanteric osteotomy, traumatic separation of the trochanteric osteotomy, a pertrochanteric femoral fracture and avasvular necrosis. Histological analysis revealed osteochondromas in all hips.

DISCUSSION

This study confirms the Ganz trochanteric flip osteotomy provided a reliable approach to osteochondromas of the femoral neck that are otherwise difficult to access for surgical resection. The procedure offered significant improvement in the quality of life, although one should be aware of the serious complications can arise despite the relatively safe procedure.

TAKE HOME MESSAGE

When daily function and activities are affected, resection of osteochondromas of the proximal femur according to Ganz is indicated to significantly improve quality of life.

Management of extremity arterial pseudoaneurysms associated with osteochondromas

Arterial pseudoaneurysms associated with osteochondromas are rare and most publications on this topic are case reports. The management of this double entity is not standardized. We wanted to update it. Literature searches on MEDLINE and EMBASE were performed using the keywords "artery pseudoaneurysm" and "osteochondroma". Patient demographics, clinical presentations, diagnostic and therapeutic modalities were reviewed. In sum, 101 cases were analyzed. Overall, young adults represented the majority of the affected population with a masculine preponderancy (86%). Painful swelling (51%) was the most commonly physical finding. Distal femur was the most common site of the osteochondroma (86%). Multiple hereditary exostosis was seldom reported (36%). Diagnostic confirmation was dominated by arteriography (55%). Popliteal artery (77%) was the most commonly injured vessel. The treatment was open surgery with vascular repair and optimal exostectomy. Arterial repair was performed with saphenous vein grafting (40%) or lateral suture (39%). Postoperative courses were often uneventful (97%). Arterial pseudoaneurysms resulted from osteochondromas were dominated by those involving the popliteal artery. The use of arteriography to confirm the diagnosis may be limited to the benefit of non-invasive radiological methods because endovascular treatment is not relevant in the setting of osteochondroma-induced arterial pseudoaneurysm.

Management of a case of ruptured pseudoaneurysm and stenosis of femoral artery caused by femoral osteochondroma

We present a rare case of ruptured pseudoaneurysm of distal femoral artery due to osteochondroma in a 21-year- old male. The patient was initially treated for osteochondroma as ruptured pseudoaneurysm was not suspected. Diagnosis of ruptured pseudoaneurysm could only be made intraoperatively when rent in the femoral artery was found along with surrounding hematoma and obstruction in the distal femoral artery. Patient underwent multiple surgeries (resection of osteochondroma and femoro-popliteal bypass) and recovered well with palpable pulsations in the operated limb.

Small sharp exostosis tip in solitary osteochondroma causing intermittent knee pain due to pseudoaneurysm

BACKGROUND

Complications of solitary or multiple osteochondromas are rare but have been reported in recent literature. Most reported complications arose in patients with multiple and/or sizable osteochondromas.

CASE PRESENTATION

A 22-year-old, female, Caucasian patient with obesity presented with intermittent knee pain and hematoma of the right calf. The MRI depicted a small, sharp exostosis tip of the dorsal distal femur with a surrounding soft-tissue mass. After profuse bleeding occurred during biopsy of the soft tissue mass, angiography revealed a pseudoaneurysm of the right popliteal artery. In a second-stage surgery the exostosis tip and pseudoaneurysm were resected.

CONCLUSION

Complications can also arise in small, seemingly harmless osteochondromas. Surgical resection should be considered as a preventive measure when exostoses form sharp tips close to neurovascular structures regardless of total osteochondroma size.