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E-ISSN: 2395-1958

P-ISSN: 2706-6630

IJOS 2020; 6(4): 73-76

© 2020 IJOS



Received: 30-07-2020

Accepted: 06-09-2020

Dr. Tashi Galen Khonglah

Room no. 3, OPD Complex,

The North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India

Wanlamkupar Khongwir

Department of Orthopaedics & Trauma, The North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, Meghalaya, India

Corresponding Author:

Dr. Tashi Galen Khonglah

Room no. 3, OPD Complex,

The North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Mawdiangdiang, Shillong, Meghalaya, India

Bulky fibular osteochondromas causing joint impingement in adults: A case series with review of literature

Tashi G Khonglah and Wanlamkupar Khongwir

DOI:

Abstract

Introduction: Osteochondromas are the most common benign bone tumors and represent 20-50% of all benign bone tumors and 10-15% of all bone tumors. The incidence of primary bone tumor in the fibula is 2.5%. Most osteochondromas are asymptomatic and are seen incidentally during radiographic examination. The most common symptom related to osteochondroma is a nontender, painless cosmetic deformity related to the slowly enlarging exophytic mass. Additional complications that cause symptoms include osseous deformity, fracture, vascular compromise, neurologic sequelae, overlying bursa formation, and malignant transformation.

Case Series: In a series of two cases, we document the occurrence of osteochondromas involving the fibula in two adult males. While, these benign tumors were located at either ends of the bone, both patients had similar symptoms of swelling with restriction of joint movement and pain. Neither had neurovascular involvement in either limbs and there was no joint instability on examination. They both improved dramatically following surgical resection of these tumors without any recurrences.

Conclusion: The two cases of fibular osteochondromas reported here illustrate their rare and atypical locations at the same time coincidentally possessing similar presentations of impingement due to their bulky sizes.

Keywords: Benign bone tumors, osteochondroma, fibula, joint impingement

Introduction

Osteochondromas are the most common benign bone tumors and represent 20-50% of all benign bone tumors and 10-15% of all bone tumors. The long bones of the lower extremity are twice more commonly involved than those of the upper extremities. Tibial osteochondromas account for 15% - 20% of cases and most commonly occurring in the proximal location. The incidence of primary bone tumor in the fibula is 2.5% [1]. They are rarely localized in the foot and ankle, except in cases of Multiple Hereditary Exostosis [2]. Most osteochondromas are asymptomatic and are seen incidentally during radiographic examination. The authors report two cases of unusual presentations of bulky fibular osteochondromas illustrating their peculiar locations in the knee and ankle joints.

Case 1

A 22-year-old male footballer presented with a swelling on his left knee. He was unable to recall the duration of the swelling. On clinical examination, this swelling was located on the posterolateral aspect of the knee adjacent to the fibular head. The swelling was firm, irregular in appearance and immobile. His knee movement was however restricted on terminal flexion and was accompanied by pain. There was no neurovascular deficit on the involved limb. All other extremities were examined to rule out exostosis.

On plain radiography of the left knee, there was a large pedunculated exostosis arising from the head of the fibula. (Fig.1) There were no signs of any fracture. A CT scan depicted a large bony outgrowth arising from the posterior aspect of the fibular head showing cortico-medullary continuation with the parent bone. (Fig.2) A 3-D reconstruction of the same confirmed its precise location. (Fig.3) The adjacent soft tissues appeared normal.

After a thorough evaluation, the patient was operated in a right lateral decubitus position. Through a posterior approach, the tumour was excised from its attachment at the head of the

fibula. (Fig.4) Macroscopically, a lobulated, pink bony mass was seen attached through a stalk from the head of the fibula. (Fig. 5) Postoperatively, the limb was immobilized for two weeks in mild flexion in an above knee plaster slab following which, full weight bearing was allowed. Histology confirmed the growth to be an osteochondroma with no evidence of any malignant transformation. The patient recovered uneventfully without any neurovascular deficit or knee instability.

At 1 year of follow up, the patient was asymptomatic, his knee range of motion returned to normal and there was no evidence of any recurrence.

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Fig 1: X-ray of the knee showing a large pedunculated exostosis arising from the head of the fibular head.

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Fig 2: CT scan showing a large bony outgrowth arising from the posterior aspect of the fibular head showing cortico-medullary continuation with the parent bone.

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Fig 3: A CT 3-D reconstruction demonstrating the lesion arising from the fibular head.

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Fig 4: Intraoperative findings: posterior approach showing osteochondroma projecting from the fibular head.

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Fig 5: Macroscopic specimen of the excised bone.

Case 2

A 25-year-old male belonging to the armed forces came with the complaint of a palpable lump on his right ankle. On physical examination, there was restriction of ankle movement in dorsiflexion and inversion, which was also painful. An irregular swelling over the anterolateral aspect of the ankle was noted. It was non-tender, immobile, hard in consistency without neurovascular impairment. There was no ankle instability and the syndesmosis was normal on examination. A thorough examination of the patient’s other extremities were performed in order to rule out any exostosis.

A radiograph of the ankle revealed a well-defined bulky exostosis arising from the anterolateral aspect on the distal fibula. (Fig.6) The CT scan depicted a cauliflower shaped bony outgrowth arising from the ventral aspect of the distal of the fibula with cortico-medullary continuity with the parent bone. (Fig.7&8) The MRI of the involved joint revealed the lesion causing displacement of the overlying tibialis anterior muscle.

Due to the restricted ankle movement and discomfort triggered by wearing combat boots during duty hours, the patient was keen to undergo surgery. The excision of the swelling was performed using the anterolateral approach. (Fig.9) Intraoperatively, we discovered a sessile exostosis resembling a cauliflower measuring 5.5cm×3cm. (Fig.10) Histological examination confirmed the clinical and radiological diagnosis. The excised specimen showed no evidence of a malignant transformation. Following the operation, the patient’s ankle was immobilized in a below knee plaster boot for 6 weeks during which he was permitted toe touch weight bearing using axillary crutches. After removal of the plaster boot, ankle physiotherapy was also initiated with partial weight bearing for the next 2 weeks followed by full weight bearing.

At 1 year of follow up, the patient was asymptomatic, and his ankle range of motion returned to normal.

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Fig 6: Radiograph of the ankle revealed a well-defined bulky exostosis arising from the anterolateral aspect on the distal fibula.

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Fig 7: CT scan showing a growth arising from the ventral aspect of the distal of the fibula with cortico-medullary continuity with the parent bone.

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Fig 8: A CT 3-D reconstruction demonstrating the lesion on the ventral aspect of the fibula.

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Fig 9: Intraoperative finding: a large sessile exostosis attached to the fibula.

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Fig 10: Macroscopic specimen of the excised bone.

Discussion

Osteochondroma are the most common benign tumor or tumor-like lesion of bone. They can be considered more of developmental lesions rather than true neoplasms and result from the separation of a fragment of epiphyseal growth plate cartilage, which subsequently herniates through the periosteal bone cuff that normally surrounds the growth plate [3-6]. Solitary osteochondromas constitute 20% - 50% of benign bone tumors and 10% - 15% of all bone tumors. A vast majority of osteochondromas are found incidentally and remain asymptomatic. 75% - 80% of symptomatic lesion are found before the age of 20 years with solitary osteochondromas having a male predilection, ranging from 1.6-3.4 to 1 [7, 8].

The most common symptom related to osteochondroma is a nontender, painless cosmetic deformity related to the slowly enlarging exophytic mass. Additional complications that cause symptoms include osseous deformity, fracture, vascular compromise, neurologic sequelae, overlying bursa formation, and malignant transformation [9].

Osteochondromas can arise from any bone that develop from enchondral ossification and their growth usually ceases at skeletal maturity. The long bones of the lower extremity are twice more commonly involved than those of the upper extremities. In 40% of cases, osteochondromas occur about the knee and of these 30% mostly affect the femur with distal involvement 3 times more frequent than the proximal. Tibial osteochondromas account for 15% - 20% of cases and most commonly occurring in the proximal location. Long bone lesions frequently effect the metaphysis, with the diaphysis being a rare location. Another frequent site for osteochondroma is the humerus (10%-20%). The unusual location of osteochondroma include small bones of the hand and feet (10%), scapula (4%), pelvis (5%), and the spine (2%) [5, 7].

The incidence of primary bone tumor in the fibula is 2.5%. The most common tumors found in the proximal fibula are osteochondromas, giant cell tumors, osteosarcomas, and Ewing’s tumor. A plain radiograph is often enough to diagnose an osteochondroma. Computed tomography and MRI can be useful for identifying any mass effect over neurovascular structures due to this slowly growing tumor. Most cases of solitary osteochondroma are observed over time and surgical excision is required if neurovascular involvement occurs [10, 11].

A fibular head osteochondroma may alter the normal anatomical course of nerves and vessels, the common peroneal nerve being most vulnerable as it winds around the neck of the fibula. Many reasons for entrapment neuropathy involving the common peroneal nerve have been mentioned in literature, but that caused by a fibular head osteochondroma is rare [12, 13]. Though our patient had no neurological involvement, his main concern was the difficulty encountered while bending his knee.

Osteochondromas around the ankle are very uncommon except in cases of Multiple Hereditary Exostoses [14]. Osteochondromas that effect the ankle are mostly found arising from the interosseus border, deforming the distal tibia and fibula and occur prior to physeal fusion. Plastic deformation of the tibia and fibula, mechanical blocking of joint motion, syndesmotic issues, varus or valgus deformities of the ankle and subsequent degenerative changes in the ankle joint are some of the documented complications in the neglected cases [2]. Malignant transformation, the most feared sequelae of osteochondroma is said to occur in approximately 1% of solitary lesions even though this complication was higher with hereditary multiple exostosis by 25% [5].

Treatment of osteochondroma is individualized, with small asymptomatic or minimally symptomatic lesions followed up and only supportive care provided. Larger symptomatic lesions may be resected at their base where there is continuity with the underlying bone. Pedunculated lesions are more easily removed. The overall recurrence after surgical excision has been estimated to be 2% [15]. Therefore, it is important to entirely resect the overlying perichondrium because inadequate excision of this tissue significantly increases the risk of recurrence [4].

Conclusion

Osteochondromas represent the most common bone tumor and the radiographic appearance of a lesion is often pathognomonic. Though most osteochondromas may be treated conservatively, lesion about the knee and ankle are treated with surgical resection in order to prevent the numerous associated complications. The growing potential of osteochondromas usually ends by the time of closure of growth plate, and if the growth continues into adulthood as in our patients, it should alarm the surgeon for possible malignancy. Treatment for symptomatic osteochondromas of the fibula is surgical excision of the mass. The prognosis is mostly good following excision; recurrence may, however, occur, if the excision is incomplete.

References

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International Journal of Orthopaedics Sciences 2020; 6(4): 73-76

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International Journal of Orthopaedics Sciences

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