Solitary Osteochondroma Causing Sural Nerve Entrapment Neuropathy

Distal Fibular Osteochondroma Resulting in Tarsal Tunnel Syndrome: Case Report and Literature Review

BACKGROUND

Osteochondromas are benign osseous tumors encountered most routinely by physicians responsible for diagnosing musculoskeletal disorders. Often, these osseous lesions are identified following symptoms related to their impingement on adjacent soft tissue or bone.

METHODS

This article presents a unique case of an asymptomatic osteochondroma of the distal fibula in a 29-year-old Caucasian woman that manifested clinically as an impingement on the tibial nerve.

RESULTS

After resection of the osteochondroma, the patient's tarsal tunnel syndrome symptoms resolved.

CONCLUSIONS

This case report demonstrates a never-before-described osteochondroma of the distal fibula traversing posterior to the ankle joint and impinging on the tibial nerve. After resection, the patient's symptoms resolved.

Symptomatic os talus secundarius: a case report and review of the literature

Os talus secundarius is an extremely rare accessory ossicle located at the lateral aspect of the talus just anterior to the fibula. Although rarely seen, it may cause lateral-sided chronic ankle pain. Only a few cases of symptomatic os talus secundarius have been reported to date. Herein, a 42-year-old male patient with symptomatic os talus secundarius is presented, and its imaging findings, differential diagnosis, and treatment are discussed.

LEVEL OF EVIDENCE

Level IV.

Solitary osteochondroma of the sinus tarsi

Tumors are a rare cause of ankle-region pain. Osteochondroma is one of the most common benign bone tumors, but is rarely localized to the foot bones. Here, we describe a case of a solitary osteochondroma of the sinus tarsi presenting in an 8-year-old boy with a history of recurrent ankle sprains and limited range-of-motion of the subtalar joint. Treatment was surgical excision of the tumor, and the patient is now symptom free. Clinical presentation, treatment, pathoanatomy, localization, and complication of this benign form of tumor are discussed and all previously reported cases are reviewed to provide a more comprehensive picture of osteochondroma of talus.

Percutaneous Ultrasound-Guided Hydrodissection of a Symptomatic Sural Neuroma

Symptomatic neuromas of the sural nerve are a rare but significant cause of pain and debilitation in athletes. Presentation is usually in the form of chronic pain and dysesthesias or paresthesias of the lateral foot and ankle. Treatment traditionally ranges from conservative measures, such as removing all external compressive forces, to administration of nonsteroidal anti-inflammatory drugs, vitamin B6, tricyclic antidepressants, antiepileptics, or topical anesthetics. This article reports a case of sural nerve entrapment in a 34-year-old male triathlete with a history of recurrent training-induced right-sided gastrocnemius strains. The patient presented with numbness in the right lateral foot and ankle that had persisted for 3 months, after he was treated unsuccessfully with extensive nonoperative measures, including anti-inflammatory drugs, activity modification, and a dedicated physical therapy program of stretching and strengthening. Orthopedic assessment showed worsening pain with forced passive dorsiflexion and manual pressure applied over the distal aspect of the gastrocnemius. Plain radiographs showed normal findings, but in-office ultrasound imaging showed evidence of sural nerve entrapment with edema and neuromatous scar formation in the absence of gastrocnemius or soleus pathology. Percutaneous ultrasound-guided hydrodissection of the sural nerve at the area of symptomatic neuroma and neural edema was performed the same day. The patient had complete relief of symptoms and full return to the preinjury level of participation in competitive sports. This case report shows that hydrodissection, when performed by an experienced physician, can be an effective, minimally invasive technique for neurolysis in the setting of sural nerve entrapment, resulting in improvement in clinical symptoms.

Retrofibular osteochondroma with peroneal tendon subluxation

Osteochondroma of the bone can cause a range of complications involving tendons, joints and neurovascular structures. Distal fibular osteochondroma and non-traumatic peroneal tendon subluxation are both rare. In this case report, we describe an unusual case of distal retrofibular osteochondroma in a 36-year old male causing peroneal tendon subluxation. He presented with pain and instability around his ankle, but with no history of trauma. He successfully underwent osteochondroma excision, peroneal groove deepening and a Brostrom-Gould type reconstruction for the lateral ankle ligament insufficiency. Complete resolution of the symptoms of instability and subluxation was noted upon 6-month follow up.

Peripheral nerve injuries due to osteochondromas: analysis of 20 cases and review of the literature

Object

Nerve compressions due to osteochondromas are extremely rare. The aim of this retrospective study was to investigate the mechanisms, diagnostic evaluations, and treatment of nerve lesions due to osteochondromas, and to review the literature.

Methods

The authors retrospectively reviewed their clinic data archive from 1998 through 2008, and 20 patients who were operated on due to peripheral nerve injuries caused by osseous growth were enrolled in the study. Patients' age, duration of symptoms, localizations, intraoperative findings, and modified British Medical Research Council (MRC) and electromyography data obtained from hospital records were evaluated. The literature on this topic available in PubMed was also reviewed. All 20 patients underwent surgery, which consisted of tumor excision performed by orthopedic surgeons and nerve decompression performed by neurosurgeons.

Results

There were 17 men and 3 women included in the study, with a mean age of 21 years (range 18–25 years). Three patients had multiple hereditary exostoses, and 17 had a solitary exostosis. All of the patients underwent en bloc resection. The most common lesion site was the distal femur (45%). The peroneal and posterior tibial nerves were the structures that were affected the most frequently. The mean follow-up was 3.9 years (range 2–7 years). After the surgery, all patients (100%) experienced good sensory recovery (modified MRC Grade S4 or S5).

Conclusions

To the authors' knowledge, no large series have reported peripheral nerve compression due to exostoses. The authors have several recommendations as a result of their findings. First, all patients with peripheral nerve compression due to an osteochondroma should undergo surgery. Second, preoperative electromyographic examinations and radiographic evaluation, consisting of MRI and CT to provide optimal information about the lesion, are crucially important. Third, immediate treatment is mandatory to regain the best possible recovery. And fourth, performing nerve decompression first and en bloc resection of osteochondroma consecutively in a multidisciplinary fashion is strongly recommended to avoid peripheral nerve injury.

Peripheral nerve entrapments

Peripheral nerve entrapment is a rare, but important, cause of foot and ankle pain that often is underdiagnosed and mistreated. A peripheral nerve may become entrapped anywhere along its course, but certain anatomic locations are characteristic. Clinically,nerve entrapment is divided into three stages: in stage I patients feel rest pain and intermittent paresthesias which are worse at night; in stage II, continued nerve compression leads to paresthesias, numbness, and, occasionally, muscle weakness that does not disappear during the day, and in stage III, patients describe constant pain, muscle atrophy, and permanent sensory loss. Diagnostic confusion abounds because of the multiple etiologies of peripheral nerve entrapments and their complex physical and temporal relation. A thorough understanding of the causes of peripheral nerve entrapments, the anatomic course and variation of the peripheral nerves, the diagnostic modalities, and the treatment options can simplify this complex problem.

Sural nerve entrapment after injury to the gastrocnemius: a case report

A 43-year-old man developed progressive calf pain and paresthesias after a strain of the right gastrocnemius muscle. Physical examination revealed sensory loss in the distribution of the sural nerve with a positive Tinel's sign in the posterior calf in the region of his previous injury. Electrodiagnostic studies revealed prolongation of the sural distal latency with reduction of the sensory nerve action potential amplitude. Magnetic resonance imaging of the lower right leg demonstrated abnormal signal in the right medial gastrocnemius consistent with a subacute hematoma. Surgical exploration revealed entrapment of the sural nerve in scar tissue beneath the deep fascia of the gastrocnemius. Surgical release of the nerve resulted in complete resolution of symptoms and full return of sensation by the 3-month follow-up point. A brief review of the literature is presented.

[Osteochondromas of the spine. A diagnosis to consider in spinal cord compression syndromes]

The authors reviewed 312 cases of solitary and multiple osteochondromas seen in SARAH Hospital for the Locomotor System during a period of 13 years-from 1982 to 1994. They selected six cases of patients with osteochondromas of the spine, corresponding to 1.92% of the total number of diagnosed cases of this entity. The selected cases were submitted to roentgenographic examination that comprised plain roentgenograms, myelography, computerized tomography and, in one of them, magnetic resonance imaging. They were submitted to decompressive surgical procedures (including laminectomy) with exeresis of the lesions and posterior histopathological examination which confirmed the initial diagnostic hypothesis. This study also includes a review of the possible mechanisms implicated in the pathogenesis of the disease.