Solitary Osteochondroma Treatment & Management

  • Author: Ian D Dickey, MD, FRCSC; Chief Editor: Harris Gellman, MD   more...
 
Updated: Apr 29, 2011
 

Medical Therapy

No medical therapy currently exists for osteochondromas. The mainstay of nonoperative treatment is observation because most lesions are asymptomatic. Lesions found incidentally can be observed, and the patient can be reassured.

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Surgical Therapy

The treatment for symptomatic osteochondromas is resection. Care must be taken to ensure that none of the cartilage cap or perichondrium is left in the resection bed; otherwise, there may be a recurrence. Ideally, the line of resection should be through the base of the stalk; thus, the entire lesion is removed en bloc with its fibrous covering. Atypical or very large lesions should be investigated fully to exclude the remote possibility of malignancy. MRI is useful in assessing cartilage cap thickness.

In the skeletally immature patient, care must be taken to avoid damage to the growth plate during the exposure and resection of the lesion. One small study evaluated surgical outcomes of pediatric patients with osteochondroma of the digits; average age at surgery was 3.6 years. The study recommends early surgical treatment for patients with nonepiphyseal metaphysis of the bone to improve motion and to prevent further finger deformity. However, tumor excision, which may include part of the articular surface, is recommended when tumors are laterally oriented and include less than one third of the joint surface.[28]

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Preoperative Details

Local anatomic constraints must be considered carefully so that the approach and resection do not damage nearby structures. CT scanning and MRI can be useful for lesions that arise from flat bones or that are located in difficult areas, such as lesions around the hip or scapula.[29]

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Intraoperative Details

Once the osteochondroma is exposed, dissection is limited to the base of the lesion so that an osteotome can be used to shear off the base at the level of the host bone cortex. Care is required to ensure that the resection neither violates normal host cortex by straying too deep nor leaves residual lesion by staying too shallow. The overlying bursa should be left intact, and the loose adhesive tissue should be dissected away so that the lesion and the bursa are removed en bloc.

The resected surface of the host bone can be rasped smooth, and if needed, bone wax can be packed on the cut surface to stop bleeding.

Once the specimen is removed and pathologic confirmation is received, the wound should be irrigated well and a surgical drain can be placed if needed. The drain should exit in line with the wound.

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Postoperative Details

Most osteochondromas allow the patient to return to activity as tolerated. However, after resection of a large sessile lesion, restriction of activities should be considered because the stress riser created by the violation of the cortex may increase the risk of fracture.

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Follow-up

The local recurrence rate after resection of osteochondroma is about 1.8%.[30] Once the wound is healed, follow-up on an as-needed basis is reasonable if no associated bone deformity or potential growth-arrest concerns exist.

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Complications

Complications after surgical resection of osteochondromas are rare. Considerations include physeal disturbance or growth arrest, fracture, recurrence, incorrect diagnosis, and hematoma formation.

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Outcome and Prognosis

For solitary osteochondromas, the outcome and prognosis after surgery are excellent, with excellent local control and a local recurrence rate of less than 2%.[31, 5] The process is a benign one; thus, the prognosis is usually one of complete recovery. Poorer outcomes usually are related to the morbidity associated with the exposure required to remove the lesion or associated with secondary bone deformity, but the latter is usually observed in the multiple hereditary form of the disease.[32, 33, 34, 35, 36, 37, 38]

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Future and Controversies

Genetic karyotyping suggests that reproducible genetic abnormalities are associated with these benign growths and that they may represent a true neoplastic process, not a reactive one.[10, 11] Research is in the early stages, and further investigation is needed.[12, 13, 14, 15] Biologic therapies for osteochondromas may be possible in the future.

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Contributor Information and Disclosures
Author

Ian D Dickey, MD, FRCSC  Adjunct Professor, Department of Chemical and Biological Engineering, University of Maine; Consulting Staff, Adult Reconstruction, Orthopedic Oncology, Department of Orthopedics, Eastern Maine Medical Center

Ian D Dickey, MD, FRCSC is a member of the following medical societies: American Academy of Orthopaedic Surgeons, British Columbia Medical Association, Canadian Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Stryker Orthopaedics Consulting fee Consulting; Cadence Honoraria Speaking and teaching

Specialty Editor Board

Lynn A Crosby, MD, FACS  Chief of Shoulder Division, Professor, Department of Orthopedic Surgery, Wright State University School of Medicine

Lynn A Crosby, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American College of Surgeons, American Fracture Association, American Medical Association, American Medical Tennis Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Arthroscopy Association of North America, Mid-America Orthopaedic Association, and Orthopaedic Research Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Sean P Scully, MD, PhD  Professor, Department of Orthopedics, University of Miami

Sean P Scully, MD, PhD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, International Society on Thrombosis and Haemostasis, and Society of Surgical Oncology

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD  Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

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Solitary osteochondroma. Anteroposterior radiograph of a pedunculated osteochondroma of the distal femur.
Solitary osteochondroma. Lateral radiograph of a pedunculated osteochondroma of the distal femur. Orientation is away from the growth plate, and medullary continuity is clear.
Solitary osteochondroma. Lateral radiograph of a sessile osteochondroma of the distal femur.
Solitary osteochondroma. Anatomic and age distribution of solitary osteochondromas.
Solitary osteochondroma. CT scan of the pelvis depicting a massive solitary osteochondroma.
Solitary osteochondroma. Anteroposterior radiograph of sessile osteochondroma of the humerus.
Solitary osteochondroma. CT scan of the same sessile osteochondroma of the humerus as in Image 6.
Solitary osteochondroma. MRI of sessile osteochondroma of the femur demonstrating the thickness of the cartilage cap.
Solitary osteochondroma. Gross osteochondroma specimen at the time of resection. Bone stalk and overlying membrane on cartilage cap.
Solitary osteochondroma. Cut surface of surgical osteochondroma specimen. Cartilage cap and underlying bone with medullary continuity.
Solitary osteochondroma. Histology of cut osteochondroma specimen. Cartilage cap and orientation of enchondral bone formation.
Solitary osteochondroma. High-power view of benign cartilage cells arranged in vertical growth plate pattern.
Solitary osteochondroma. Radiograph demonstrating the deformation of the distal tibiofibular joint in a patient with a solitary osteochondroma.
 
 
 
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