Solitary Osteochondroma Treatment & Management

Updated: Aug 12, 2019
  • Author: Ian D Dickey, MD, FRCSC, LMCC; Chief Editor: Harris Gellman, MD  more...
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Treatment

Approach Considerations

Asymptomatic lesions require no treatment and can be monitored initially with radiographs and subsequently by clinical examination. Further investigation is indicated if the patient presents with a painful lesion or develops pain or an increase in size of a preexisting lesion. Such changes may represent either a new mechanical symptom or malignant degeneration. Magnetic resonance imaging (MRI) is very useful for investigating these changes. The most common causes of pain are bursa formation, impingement, fracture of the stalk, and malignant degeneration. [45, 46, 47]

Excision is the treatment of choice for symptomatic lesions. As with all lesions of muscle and bone, the physician must be confident of the diagnosis and well versed in the care of tumors, should the lesion in fact be malignant. If the surgeon has any doubt about the diagnosis of the lesion or the management of a potential malignancy, patient referral is the most appropriate course of action.

In excising the lesion, it is important to avoid leaving any remnants of cartilage from the cap or any perichondrium, because this can allow recurrence. The reported rate of local recurrence is less than 2-5%. [48, 49]  The risk of recurrence is thought by some to be higher in the skeletally immature; therefore, resection might best be delayed until skeletal maturity is reached. Great care must be exercised with lesions close to the physeal plate in the immature patient, because of the risk of growth plate arrest and subsequent deformity.

No frank contraindications for removal exist, but the surgeon should be aware that a large osteochondroma may in fact be a chondrosarcoma and should therefore exercise appropriate caution. Removal by a surgeon who is not well versed in dealing with orthopedic malignancies may be a relative contraindication.

Biologic therapies for osteochondromas may be possible in the future.

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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 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. [50, 51]

Preparation for surgery

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. [52]

Operative 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. If needed, a surgical drain can be placed, ideally exiting in line with the wound.

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Postoperative Care

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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Complications

Complications after surgical resection of osteochondromas are rare. Considerations include the following:

  • Physeal disturbance or growth arrest
  • Fracture
  • Recurrence
  • Incorrect diagnosis
  • Hematoma formation
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Long-Term Monitoring

The local recurrence rate after resection of osteochondroma is about 1.8%. [53]  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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