Calcaneal Bone Tumors.

Bone tumors of the foot are an uncommon finding. Most tumors are found incidentally on imaging and are benign. Care must be taken although due to the aggressive nature of malignant bone tumors that can occur in the calcaneus. Malignant lesions will more commonly present with symptoms of pain and swelling. Often misdiagnosed as soft tissue injuries, it is critical to be able to diagnose and treat these lesions early. Imaging plays an important role with plain films and advanced imaging. Surgical treatments can range from curettage with grafting to amputation for more aggressive lesions.

Manejo expectante de osteocondroma solitario interóseo de la tibia distal: reporte de un caso y revisión de la literatura / Non-surgical management of an interosseous solitary osteochondroma of the distal tibia: a case report and review of the literature

La localización del osteocondroma en la tibia distal es poco frecuente y su crecimiento con compromiso y deformidad del peroné distal es aún más raro, haciéndolo una condición más sintomática que en otras ubicaciones. Factores como la severidad de los síntomas, deformidad progresiva del tobillo, complicaciones sindesmóticas, riesgo de fractura patológica o transformación maligna, junto con nuevas y mejores técnicas quirúrgicas, han llevado a que el manejo expectante de esas lesiones sea excepcional y escasamente reportado. Presentamos el caso de un joven de 17 años con osteocondroma solitario interóseo tibio distal sintomático y compromiso fibular, que fue exitosamente manejado en forma expectante. A los 5 años de seguimiento clínico-radiológico no presenta complicaciones y la lesión se mantiene estable.

Osteochondromas located in the distal tibia are a rare condition, and the involvement of the distal fibula with deformity is even more uncommon. Factors such as the severity of symptoms, progressive deformity of the ankle, syndesmotic complications, the risk of pathological fracture or malignant transformation, together with new and safer surgical techniques, have led to scarce reports of non-surgical management. We present a case report of a 17-year-old male with a symptomatic interosseous solitary osteochondroma in the distal tibia with fibular involvement, which was successfully managed non surgically. After 5 years of clinical and radiological follow-up, he has no complications, and the lesion remains stable.

Osteocondromas del extremo proximal del húmero. Manejo diagnóstico y terapéutico / Osteochondromas of the Proximal Humerus. Diagnostic and Therapeutic Management

Objetivo: 1) Recordar la epidemiología y semiología de los osteocondromas del extremo proximal del húmero (EPH); 2) determinar las indicaciones de su tratamiento y 3) hacer recomendaciones relativas al tratamiento quirúrgico en ese asiento. Material y método: Estudio retrospectivo observacional y longitudinal de 20 osteocondromas solitarios y 12 múltiples del EPH. Se analizaron las características epidemiológicas, clínicas y de imagen de los pacientes de la serie, y los resultados del tratamiento, con un tiempo medio de seguimiento de los casos intervenidos de 45 meses. Resultados: Los osteocondromas solitarios correspondieron a 11 hombres (55%) y 9 mujeres (45%), con una edad media de 21 años. Doce (60%) fueron intervenidos a una edad media de 23 años por ser sintomáticos o, en un caso, por sospecharse malignización. Dos casos solitarios no intervenidos pudieron haber involucionado espontáneamente. Las formas múltiples ocurrieron en 11 hombres (92%) y una mujer (8%) y 3 fueron intervenidos. No hubo complicaciones ni recidivas y el resultado funcional fue excelente en todos los pacientes. Discusión: Los osteocondromas del EPH son relativamente frecuentes, aunque la mayoría de las publicaciones son de casos clínicos aislados o de series cortas. Conclusiones: Los osteocondromas del EPH no difieren de los de otra localización. Los casos sintomáticos y en los que se sospecha malignización serían intervenidos, aquellos mejor con el crecimiento finalizado. El tratamiento quirúrgico se resume en la planificación del abordaje mediante TC o RM, resección en bloque extraperióstica y una eventual reconstrucción ósea, idealmente con homoinjerto

Objective: 1) To recall the epidemiology and signs of osteochondromas of the proximal humerus (OPH); 2) determine treatment indications; 3) and make recommendations for surgical treatment. Methods: Retrospective, observational and longitudinal study of 20 solitary and 12 multiple osteochondromas of the proximal humerus. We analyzed the epidemiological, clinical and imaging characteristics and treatment results with an average time of follow-up of the operated cases of 45 months.Results: Eleven (55%) males and 9(45%) females with an average age of 21 years presented solitary osteochondromas. Twelve (60%) cases were operated on at a mean age of 23 years because they were symptomatic or, in one case, malignancy was suspected. Two solitary osteochondromas could have spontaneously regressed. Multiple osteochondromas were found in 11(92%) males and one (8%) female of whom 3required surgery. There were no complications or recurrences. Functional outcome was excellent in all patients. Discussion: Osteochondromas of the proximal humerus are relatively common, although most publications are case reports or short series. Conclusions: Osteochondromas of the proximal humerus do not differ from those in other locations. Symptomatic cases and those in which malignancy is suspected would be operated, the former preferably at the end of growth. The surgical treatment is summarized in planning the approach, using CT and/or MRI, extraperiosteal en bloc resection, and eventual bone reconstruction, ideally with allograft

Comparison of the clinical effects of treatment of osteochondroma by two types of vertical ramus osteotomy.

The purpose of this retrospective study was to evaluate 10 patients with osteochondroma of the mandibular condyle who were treated by vertical ramus osteotomy. Three patients had resection of the condyle and reconstruction with free vertical ramus osteotomy grafts (free graft group) and seven had pedicled vertical sliding ramus osteotomy grafts (pedicled graft group). The mean (range) observation period was 30 months. All patients had satisfactory clinical outcomes, and facial symmetry and good occlusion were achieved during the first 10 months. However, slight facial asymmetry was observed in patients treated by free grafts at 11 months, as the mandible deviated to the operated side when the mouth was opened. Postoperative radiographs showed varying degrees of neocondylar resorption and reduction in height. Patients treated with pedicled grafts did not develop these symptoms, and had no bony resorption to speak of on radiographs taken during the follow-up period. In conclusion, the advantages of the pedicled graft over the free graft include less bony resorption and better long-term clinical outcomes.

[A motorcyclist with hematomas and tingling in his leg]. / Motorrijder met hematomen en tintelingen in het been.

A 30-year-old man presented with recurrent hematomas and tingling in his left leg, caused by a large femoral neck osteochondroma that induced multiple muscle ruptures and compressed the ischiadic nerve. There were no radiological signs of malignant transformation and symptoms disappeared without intervention. Hence, we chose a 'wait and see' approach instead of surgical removal of the osteochondroma.

Hereditary multiple exostoses and solitary osteochondroma associated with growth hormone deficiency: to treat or not to treat?

BACKGROUND: Osteochondroma generally occurs as a single lesion and it is not a heritable disease. When two or more osteochondroma are present, this condition represents a genetic disorder named hereditary multiple exostoses (HME). Growth hormone deficiency (GHD) has rarely been found in HME patients and a few data about growth therapy (GH) therapy effects in development/growth of solitary or multiple exostoses have been reported. CASE PRESENTATION: We describe the clinical features of 2 patients (one with osteochondroma and one with HME) evaluated before and after GH therapy. In the first patient, the single osteochondroma was noticed after the start of treatment; the other patient showed no evidence of significant increase in size or number of lesions related to GH therapy. CONCLUSION: It is necessary to investigate GH secretion in patients with osteochondroma or HME and short stature because they could benefit from GH replacement therapy. Moreover, careful clinical and imaging follow-up of exostoses is mandatory.

Characterization of a biodegradable coralline hydroxyapatite/calcium carbonate composite and its clinical implementation.

A partially converted, biodegradable coralline hydroxyapatite/calcium carbonate (CHACC) composite comprising a coral calcium carbonate scaffold enveloped by a thin layer of hydroxyapatite was used in the present study. The CHACC was characterized using powder x-ray diffraction, scanning electron microscopy and energy dispersive x-ray spectroscopy. The ability of the CHACC to promote conductive osteogenesis was assessed in vitro using human mesenchymal stem cells (hMSCs) and in vivo using an immunodeficient mouse model. The clinical performance of CHACC as a bone substitute to fill voids caused by excision of bone tumours was also observed in 16 patients. The CHACC was found to consist of two overlapping layers both morphologically and chemically. Hydroxyapatite formed a thin layer of nanocrystals on the surface and a thick rough crystal layer of around 30 µm in thickness enveloping the rock-like core calcium carbonate exoskeletal architecture. hMSCs cultured on CHACC in osteogenic medium demonstrated significant osteogenic differentiation. After subcutaneous implantation of CHACC incorporating osteogenically differentiated hMSCs and an anti-resorptive agent, risedronate, into an immunodeficient mouse model, bone formation was observed on the surface of the implants. Clinical application of CHACC alone in 16 patients for bone augmentation after tumour removal showed that after implantation, visible callus formation was observed at one month and clinical bone healing achieved at four months. The majority of the implanted CHACC was degraded in 18-24 months. In conclusion, CHACC appears to be an excellent biodegradable bone graft material. It biointegrates with the host, is osteoconductive, biodegradable and can be an attractive alternative to autogenous grafts.

Benign tumors of the spine.

Benign tumors in the spine include osteoid osteoma, osteoblastoma, aneurysmal bone cyst, osteochondroma, neurofibroma, giant cell tumor of bone, eosinophilic granuloma, and hemangioma. Although some are incidental findings, some cause local pain, radicular symptoms, neurologic compromise, spinal instability, and deformity. The evaluation of spinal tumors includes a thorough history and physical examination, imaging, sometimes laboratory evaluation, and biopsy when indicated. Appropriate treatment may be observational (eg, eosinophilic granuloma) or ablative (eg, osteoid osteoma, neurofibroma, hemangioma), but generally is surgical, depending on the level of pain, instability, neurologic compromise, and natural history of the lesion. Knowledge of the epidemiology, common presentation, imaging, and treatment of benign bone tumors is essential for successful management of these lesions.

Estabilidade sagital da condiloplastia associada à cirurgia ortognática para o tratamento do osteocondroma mandibular / Post surgical stability of conservative condylectomy for treatment of osteochondroma of the mandibular condyle

O propósito deste estudo foi avaliar alterações das estruturas esqueléticas,dentárias e a estabilidade da técnica da condiloplastia, reposicionamento do disco articular e cirurgia ortognática como tratamento integral do paciente portador de osteocondroma condilar. Foram analisadas telerradiografias laterais de 15 pacientes (12 femininos, três masculinos), idade média de 32,3 anos (entre, 13 e 56 anos), com osteocondroma condilar ativo unilateral consecutivamente tratado. Os pacientes foram submetidos à condiloplastia,reposicionamento do disco articular e cirurgia ortognática simultânea. O acompanhamento pós-cirúrgico foi de 19 meses em média. As telerradiografias da amostra foram tomadas em três intervalos: pré-cirúrgico (T1). pós-cirúrgico imediato (T2) e pós-cirúrgico tardio (T3) e avaliadas por meio da análise cefalométrica. No pós-cirúrgico imediato observou-se diminuição da inclinação do plano oclusal em -2,85° ± 4,53°, o complexo maxilomandibulargirou no sentido anti-horário com avanço do ponto Me em 5,32 ± 5,58 mm, pogonio 4,99 ± 5,15 mm, ponto B 3,41 ± 4,18 mm e ponto A 1,00 ± 1,54 mm. O acompanhamento em longo prazo mostrou que houve pequenas mudanças na sobremordida (-0,56 ± 0,51mm) e no ângulo SNGoMe (0,93° ± 1,53°). O ponto Me mostrou instabilidade horizontal de -1,21 ± 1,94 mm e o ponto ENP apresentou instabilidade vertical de -1,48 ± 1,67 mm. A proservação em longo prazo mostrou sólida estabilidade dentoesquelética na maioria dasáreas estudadas com instabilidade isolada horizontal do ponto Me e vertical do ponto ENP que não foram relacionadas com a recidiva do tumor.

The aim of this study was to evaluate the stability of the conservative condylectomy technique and articular disc repositioning as the surgical treatment approach for management of mandibular condylar osteochondroma, with appropriate Orthognathicsurgery. Fifteen patients (12 females and 3 males), average age of 32.3 years (range, 13 to 56 yeers), with unilateral active osteochondroma of the mandibular condyle were analyzed. All patients underwent conserva tive condylectomy, recontouring of the remaining condylarneck stump and articular disc repositioned and indicated orthognatic surgical procedures. Average post surgical follow-up was 19 months. Each patient's lateral cephalograms weretraced at 3intervals (presurgery, immediate post surgery and long-term follow-up). Immediate after surgery the oclusal plane angle decreased -2.8 ± 4.50, the maxillomandibular complexrotated counter-clockwise with advancement at menton 5.3 ± 5.6 mm, pogonion 5.0 ± 5.1 mm, B point 3.4 ± 4.2 mm and A point 1.0 ± 1.5 mm. The long-term follow-up showedsigniticant changes in overbite (-0.6 ± 0.5 mm) and SNGoMe (0,93° ± 1,53°). Horizontally and vertically small instabilities occurred in Me (-1.21 s: 1.94 mm) and PNS (-1.48 ± 1.67mm) respectively. The treatment protocol studied produced counterclockwise rotation andmaxillofacial mandibular advancement. The long-term follow-up showed solid dental and skeletal stability with horizontal instability of Me and PNS in the vertical direction.

Cervical spine osteochondroma: rare presentation of a common lesion.

OBJECTIVE: This case report describes the rare presentation of an osteochondroma arising from the anterior body of C4. This is the first known reported case of an osteochondroma arising from the anterior vertebral body of C4. CLINICAL FEATURES: A 24-year-old male sought consultation with his primary care physician for neck pain. The patient was then referred for cervical radiography and for chiropractic evaluation and treatment. An osseous lesion was noted arising from the C4 vertebra. Osteochondroma was suspected; however, chondrosarcoma could not be ruled out. After orthopedic consultation, osteochondroma was the confirmed diagnosis with the lesion likely incidental to the chief complaint. INTERVENTION AND OUTCOME: The patient underwent 12 chiropractic treatments for 8 weeks including thoracic and cervical high-velocity, low-amplitude spinal manipulation, interferential current, therapeutic ultrasound, stretching, and therapeutic exercise of the paraspinal musculature. Reevaluation revealed the patient experienced no pain with occupational duties, activities of daily living, and improved sleep quality. He was discharged with a home stretching and strengthening regimen targeting the thoracic and cervical paraspinal musculature. Follow-up at 6 months revealed no return of symptoms. CONCLUSION: We described the first case of an osteochondroma arising from the anterior aspect of the C4 vertebral body. The clinical evaluation, differential diagnosis, imaging workup, and treatment are addressed. This case also demonstrates that an asymptomatic osteochondroma of the cervical spine may be a relative, not an absolute, contraindication for high-velocity, low-amplitude spinal manipulation.

Tratamento dos defeitos osteocondrais do joelho / Treatment of the knee osteochondral defects

Os defeitos osteocondrais do joelho acometem toda a espessura da cartilagem e são geralmente de origem traumática, podendo ocorrer isoladamente ou em conjunto com lesões ligamentares ou meniscais. O diagnóstico definitivo geralmente é feito por ressonância magnética, apesar da história e exame físico darem indícios do diagnóstico. As lesões osteocondrais sintomáticas necessitam de tratamento cirúrgico e a escolha da técnica cirúrgica depende de alguns fatores como tamanho da lesão, local da lesão, atividade e idade do paciente. Técnicas, como abrasão e drilling são pouco usadas atualmente. A microfratura é largamente usada e geralmente é a primeira escolha no tratamento de defeitos osteocondrais de 1 a 2,5 cm2. A mosaicoplastia também pode ser usada para lesões desta magnitude, mas em pacientes mais ativos que necessitam um retorno mais rápido às atividades esportivas. Pode também ser usadas em defeitos maiores, porém o transplante autólogo de condrócitos (TAC) aparece como uma boa opção para lesões maiores. A primeira geração do TAC transplanta condrócitos os quais ficam contidos no defeito devido a uma cobertura de periósteo, já a segunda geração de TAC apresenta os condrócitos embebidos em uma matriz e evita o uso da cobertura com periósteo. O transplante alógeno osteocondral também é uma opção para defeitos maiores que 4 cm2. Novas tecnologias estão sendo desenvolvidas, porém ainda sem aplicabilidade clínica.

Costal chondrosarcoma. Report of five cases.

We report five cases of coastal chondrosarcoma (CS) in four women and one man between 28 and 49 years of age. In four cases, the tumor had spread and infiltrated the adjacent structures (soft tissues, thoracic vertebrae, mediastinum, etc.). CS was diagnosed based either on wide surgical resection specimens in three patients, or on tumor biopsies in two cases. The CS was grade I in one patient, grade II in three cases, and grade III in one case. Wide surgical resection which was performed in three patients was associated in one case with adjuvant radiotherapy and chemotherapy. In the three cases, the disease natural history appeared favorable after a follow-up duration ranging from 1 month to 4 years. Two patients died, one after radiotherapy and chemotherapy done immediately after diagnosis as a result of the large size and invasive nature of the tumor. Coastal CS is characterized by a distinct potential for locoregional and distant metastasis. Diagnosis remains anatomopathological. Wide surgical resection is the only demonstrated curative treatment, even for high-grade CS.

Lesiones vasculares de la extremidad inferior causados por osteocondromas / Vascular lesions in the lower limbs caused by osteochondromas

Introducción. El tumor óseo más frecuente de la población es el osteocondroma (OC). Se puede encontrar deforma esporádica o múltiple, y característicamente afecta a los huesos largos de la extremidad inferior durante la etapade crecimiento. Suele ser asintomático, pero en su crecimiento puede lesionar estructuras vasculares, originando roturay formación de pseudoaneurismas. En la bibliografía médica hasta hoy, la serie más numerosa refiere seis pacientes conlesión vascular por este tumor. Objetivo. Presentar y analizar nuestra experiencia sobre cuatro casos de este tipo de complicacionesvasculares originadas por OC. Pacientes y métodos. En todos se vio afectada la arteria poplítea. Caso 1: varón,16 años, OC múltiple y rotura arterial de cinco días de evolución; caso 2: varón, 9 años, OC esporádico y pseudoaneurismade un mes de evolución; caso 3: varón, 17 años, OC esporádico y pseudoaneurisma gigante de mes y mediode evolución; caso 4: mujer, 19 años, OC múltiple y pseudoaneurisma de once meses de evolución. La reconstrucción arterialfue con parche venoso en tres casos y sutura directa en uno. Resultados. No hubo recidivas de los OC en los casos1 y 2, de prolongado seguimiento. El análisis anatomopatológico confirmó la benignidad en todos. Curso postoperatoriofavorable y alta hospitalaria precoz. Conclusión. Es necesario descartar este cuadro ante dolor en extremidades inferioresen adolescentes debido a la frecuencia de estos tumores, especialmente si se conoce la existencia previa de OC. Es importanteel estudio de imagen con reconstrucción arterial antes de la cirugía. Es necesario resecar de modo preventivolos OC de crecimiento hacia trayectos vasculares, aun siendo asintomáticos

Introduction. The most common bone tumour is osteochondroma (OC). It may be found in both sporadicsolitary or multiple forms, and characteristically affects the long bones of the lower limbs while the individual is stillgrowing. It is usually asymptomatic but as it grows it may injure vascular structures, giving rise to ruptures and theformation of pseudoaneurysms. In the medical literature to date, the most numerous series consisted of six patients withvascular lesions due to this kind of tumour. Aim. To report and analyse our experience on four cases of this sort ofvascular complications produced by OC. Patients and methods. In all cases the popliteal artery was involved. Case 1:male, 16 years old, multiple OC and a five-day history of arterial rupture; case 2: male, 9 years old, sporadic OC and aone-month history of pseudoaneurysm; case 3: male, 17 years old, sporadic OC and a one-month history of giantpseudoaneurysm; case 4: female, 19 years old, sporadic OC and an 11-months’ history of pseudoaneurysm. Arterialreconstruction was performed with a vein patch in three cases and direct suturing in one case. Results. There were norecurrences of OC in cases 1 and 2, which were subject to long follow-ups. Pathological analysis confirmed the tumourswere benign in all cases. Post-operative progress was favourable and patients were soon discharged from hospital.Conclusions. This condition needs to be ruled out when dealing with pain in the lower limbs in teenagers, due to thefrequency of these tumours, especially if OC is known to have existed previously. An imaging study is important witharterial reconstruction before surgery. OCs growing towards vascular pathways must be excised as a preventivemeasure, even though they are asymptomatic

Osteochondromas: review of the clinical, radiological and pathological features.

Osteochondroma is the most common benign bone tumor and usually occurs in the metaphyseal region of the long bones. This tumor takes the form of a cartilage-capped bony outgrowth on the surface of the bone. The vast majority (85%) of osteochondromas present as solitary, nonhereditary lesions. Approximately 15% of osteochondromas occur as multiple lesions in the context of hereditary multiple osteochondromas (HMOs), a disorder that is inherited in an autosomal dominant manner. Most lesions appear in children and adolescents as painless, slow-growing masses. However, depending on the location of the osteochondroma, significant symptoms may occur as a result of complications such as fracture, bony deformity, mechanical joint problems and vascular or neurologic compromise. Malignant transformation of osteochondromas can occur later in adulthood but rarely metastasize. The treatment of choice for osteochondroma is surgical unless the skeleton is still immature. Pathogenetic analysis showed that HMOs are caused by mutations in either of two genes: exostosis (multiple)-1 (EXT1), which is located on chromosome 8q24.11-q24.13 or exostosis (multiple)-2 (EXT2), which is located on chromosome 11p11-12. Recently, biallelic inactivation of the EXT1 locus was described in nonhereditary osteochondromas. The EXT1 and EXT2 proteins function in the biosynthesis of heparin sulfate proteoglycans (HSPGs) which are multifunctional proteins involved in several growth signaling pathways in the normal epiphyseal growth plate. Reduced EXT1 or EXT2 expression in osteochondromas is associated with disordered cellular distribution of HSPGs, resulting in defective endochondral ossification which is likely to be involved in the formation of osteochondromas. Here the clinical, radiological, pathological and pathogenetic features and the treatment modalities of osteochondroma are reviewed.

Pseudoaneurysm and deep vein thrombosis complicating femoral osteochondroma: multimodality imaging.

A case of a femoral osteochondroma complicated by pseudoaneurysm and deep venous thrombosis is presented. Multimodality imaging contributed crucial information to allow successful diagnosis and preoperative planning.

Radiology-pathology conference: osteosarcoma in a cartilaginous exostosis of the femur.

Osteochondromas are common lesions in the metaphyseal segments of the long bones and are known to be able to degenerate into chondrosarcoma. We present the case of a 20-year-old patient with an osteosarcoma at the base of a cartilaginous exostosis and discuss the causal relationship between the two lesions on the basis of the radiologic and pathologic findings.