Solitary Osteochondroma Treatment & Management
- Author: Ian D Dickey, MD, FRCSC; Chief Editor: Harris Gellman, MD more...
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.
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. Magnetic resonance imaging (MRI) is useful in assessing cartilage cap thickness.
In skeletally immature patients, care must be taken to avoid damage to the growth plate during exposure and resection of the lesion. In a small study evaluating surgical outcomes of pediatric patients with digital osteochondroma (average age, 3.6 years), early surgical treatment was recommended for those with nonepiphyseal metaphysis of the bone to improve motion and prevent further finger deformity; tumor excision, potentially including part of the articular surface, was recommended for laterally oriented tumors that included less than one third of the joint surface.[28, 29]
Local anatomic constraints must be considered carefully so that the approach and resection do not damage nearby structures. Computed tomography (CT) 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.
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. If needed, a surgical drain can be placed, ideally exiting in line with the wound.
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.
The local recurrence rate after resection of osteochondroma is about 1.8%. 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.
Complications after surgical resection of osteochondromas are rare. Considerations include physeal disturbance or growth arrest, fracture, recurrence, incorrect diagnosis, and hematoma formation.
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%.[32, 33, 34, 35] 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.[36, 37, 38, 39, 40, 41, 42]
Florez et al performed a retrospective study of 113 solitary osteochondromas (most frequently located in the distal femur) that were treated between 1970 and 2002. Six patients had a recurrence after treatment, and in two patients, the lesions became malignant and developed into chondrosarcoma. The authors noted that relapse of the exostosis is rare, occurring in approximately 2% of resections, and that growth of an osteochondroma or the presence of pain in older patients suggests a possible malignancy.
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.[8, 9] Research is in the early stages, and further investigation is needed.[10, 11, 12, 13] Biologic therapies for osteochondromas may be possible in the future.
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