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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 85-87

Solitary osteochondroma from interosseous border of distal tibia


Department of Orthopaedics, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India

Date of Submission17-Sep-2021
Date of Acceptance19-Sep-2021
Date of Web Publication27-Jan-2022

Correspondence Address:
John Ponnezhathu Sebastian
Department of Orthopaedics, Pushpagiri Institute of Medical Sciences and Research Centre, Tiruvalla - 689 101, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joasis.joasis_22_21

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  Abstract 


We present a 24-year-old man with an impending fracture of distal fibula, due to a solitary sessile osteochondroma arising from the lateral border of distal tibial metaphysis on the right side. He presented with a swelling on the anterolateral aspect of distal tibia causing mechanical limitation of dorsiflexion of ankle joint and with occasional mild pain. Imaging studies revealed a solitary sessile osteochondroma, abutting the distal epiphysis of tibia, and deforming the fibula. The swelling was excised and the histopathology was suggestive of osteochondroma.

Keywords: Distal tibia, excision, osteochondroma, solitary


How to cite this article:
John AM, Thomas V, Pillai MG, Theckanal JG, Sebastian JP. Solitary osteochondroma from interosseous border of distal tibia. J Orthop Assoc South Indian States 2021;18:85-7

How to cite this URL:
John AM, Thomas V, Pillai MG, Theckanal JG, Sebastian JP. Solitary osteochondroma from interosseous border of distal tibia. J Orthop Assoc South Indian States [serial online] 2021 [cited 2022 May 27];18:85-7. Available from: https://www.joasis.org/text.asp?2021/18/2/85/336653




  Introduction Top


Osteochondroma accounts for 12% of all bone tumors and about 45% of benign bone tumors.[1] Also known as exostosis, osteochondroma is a benign bone tumor consisting of a bony outgrowth covered by a cartilage cap. They are located commonly in the metaphysis of long bones and pelvis. Osteochondromas are mostly asymptomatic and can, therefore, be managed conservatively.[2],[3] These tumors are rarely localized in the foot and ankle, except in cases of Multiple Hereditary Osteochondromatosis. Osteochondroma or osteocartilaginous exostosis is a benign surface lesion of bone consisting of a bony outgrowth covered by a cartilage cap. It is considered the most common benign bone tumor, although the true incidence is unknown because most of the lesions are asymptomatic and never identified. Incidentally discovered osteochondromas in asymptomatic patients are managed with reassurance and periodic observation. The patient should be informed of the rare possibility of malignant change (<1%) and should return for evaluation if the lesion becomes larger or painful.[3],[4] The main symptoms are related to its size and location: irritation of nearby structures, bursitis due to chronic friction, or stalk fracture secondary to trauma.[5] Resection is indicated for patients with a symptomatic lesion secondary to irritation of the surrounding soft tissue, for a lesion in a location that is subjected to minor trauma, for a lesion causing a cosmetic deformity or potential damage to surrounding joints or neurovascular structures, and for a lesion that has characteristics of malignant transformation.[6],[7],[8],[9],[10] If possible, resection of an osteochondroma in a child should be postponed until skeletal maturity because the cartilage cap will become smaller and will be farther from the growth plate.[6]

Solitary osteochondromas around the ankle are very uncommon.[7] If they affect the ankle, they are occasionally found to be arising from the interosseous border. They very often deform distal tibia and fibula and appear before physeal fusion, as have been reported by Wani et al.[9] Plastic deformation of tibia and fibula, mechanical blocking of joint motion, syndesmotic problems (synostosis or diastasis), 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.[10],[11],[13] Hence, most of the authors prefer a surgical resection for osteochondromas in this location.[10],[11],[12],[13]

Surgical treatment of osteochondromas consists of extraperiosteal excision with a normal rim of bone around the base. Mirra reiterated the importance of complete resection of the cartilaginous cap to prevent recurrence.[4] Anterior, posterior, and transfibular approach has been described in the literature.[11] The anteriolateral approach used in this case is associated with the least amount of postoperative morbidity, as have been used by Wani et al.[9] There is still little information of the natural evolution after treatment of osteochondromas arising from the distal aspect of either the tibia or the fibula.[10],[13]


  Case Report Top


A young adult aged 24 years presented to our outpatient service with pain over the outer aspect of right ankle. He gave a history of repeated sprains while playing football. There was no history of any constitutional symptoms. Recently, he has noticed a mild swelling on the outer aspect of the ankle. Any history of recent increase in the size of the swelling was absent. Clinical examination revealed a nontender, bony swelling arising from the anterolateral aspect of distal tibia very close to the ankle joint and extending on to the fibula. The exact size of the swelling could not be made out. The lower fibula was showing an outward bending deformity. The fingers could not be insinuated under the swelling, and there was considerable limitation of dorsiflexion of the ankle joint. There were no effusion in the ankle, no distal neurovascular deficit, no ankle deformities, and the soft tissues around the ankle including skin were normal.

The radiological examination revealed a sessile, solitary osteochondroma arising from the interosseous border of distal tibial metaphysis sitting close to the physeal line distally and pushing the fibula laterally to produce a lateral bending deformity. There were scalloping and erosion of the interosseous border of the fibula so as to leave only the thinned out and bowed outer cortex of fibula [Figure 1].
Figure 1: X-ray of the angle showing the osteochondroma from the lateral border of distal tibia

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MRI findings were consistent with osteochondroma arising from the lateral border of distal tibia producing pressure erosion of the distal fibula. The cartilaginous cap was 9-mm thick. The swelling was excised through an anterolateral approach. The anteroinferior tibiofibular ligament and the deep peroneal nerve were intact. There was no instability and the lateral cortex of fibula was intact. The histopathology report was consistent with osteochondroma, and the patient was mobilized with below the knee walking cast. On recent follow-up, he is asymptomatic and has regained full range of ankle movements.


  Discussion Top


Osteochondromas are considered to be the most common benign tumor of bone. Osteochondroma or osteocartilaginous exostosis is a benign lesion of bone consisting of a bony outgrowth covered by a cartilage cap.[1],[2],[3] It is usually located in an area of active metaphyseal growth in long tubular bones near the epiphyseal plate[1],[4],[5],[6] and most typically occurs in the distal femur and proximal tibia.[5],[7] Osteochondromas around the ankle are very uncommon except in cases of multiple hereditary exostoses.[8] If they affect the ankle, they may arise rarely from the interosseous border, deforming distal fibula. Although the osteochondromas are asymptomatic benign tumors and are identified incidently, there is always a rare possibility of malignant transformation. The onset of malignancy is suspected if the size of the swelling increases rapidly after skeletal maturity. Usual indication for excision of osteochondroma is onset of malignancy, pressure effects, neurovascular compression, mechanical limitation of joint mobility and for cosmesis. Early excision is recommended in distal tibial and fibular osteochondromas, even if they are asymptomatic, to prevent complications such as limitation of ankle movements, ankle instability, tibiofibular diastasis, and pressure erosions leading to fracture of fibula.

We are reporting a very unusual case of solitary osteochondroma, arising from the interosseous border of distal tibia, producing pressure erosion, bending and an impending fracture of distal fibula, and abutting the distal tibial epiphysis without producing any significant ankle deformity in a skeletally mature patient. Solitary osteochondroma around the ankle is very rarely reported, even though involvement of distal tibia and fibula is not uncommon in hereditary multiple osteochondromatosis. Osteochondroma arising from the interosseous border of the distal tibia is extremely rare.[14] Osteochondroma abutting the distal epiphysis of tibia is also a very unusual feature noticed in this case.[15] Usually, the metaphyseal osteochondroma gets displaced toward the diaphysis and becomes either metaphysio-diaphyseal or even diaphyseal during longitudinal growth of the bone as the child grows. Epiphyseal osteochondroma or dysplasia epiphysealis hemimelica is primarily located in the epiphysis and will produce early ankle deformities due to growth arrest of the one half of the distal tibial physis. The absence of ankle deformity and the sparing of epiphyseal area in this case have excluded the possibility of dysplasia epiphysealis hemimelica.[16],[17] Early excision will avoid pathological fracture of distal fibula, ankle deformities, syndesmotic complications, and mechanical limitation of ankle joint mobility.


  Conclusion Top


It is universally agreed that most of the osteochondromas in children should be treated conservatively until skeletal maturity. However, those affecting the distal tibia or fibula should be treated with surgical excision quite early even if they are asymptomatic, to prevent ankle deformity, syndesmotic lesions or even fracture due to the expanding nature of this benign tumor.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Derk FF, Nardozza AJ. Osteochondroma of the subtalar joint. J Foot Ankle Surg 1993;33:448-54.  Back to cited text no. 1
    
2.
Spatz DK, Guille JT, Kumar SJ. Distal tibiofibular diastasis secondary to osteochondroma in a child. Clin Orthop Relat Res 1997;345:195-7.  Back to cited text no. 2
    
3.
Davids JR, Glancy GL, Eilert RE. Fracture through the stalk of pedunculated osteochondromas. A report of three cases. Clin Orthop Relat Res 1991;271:258-64.  Back to cited text no. 3
    
4.
Banks AS. Bone tumors of the foot and ankle. In: Banks AS, Downey MS, Martin D, SJ Miller SJ, editors. McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. 3rd ed. Baltimore, MD: Lippincott, Williams, and Wilkins; 2001. p. 1392-4.  Back to cited text no. 4
    
5.
Berquist TH. Bone and soft tissue tumors and tumor-like conditions. In: Thomas H, Berquist TH, editors. Radiology of the Foot and Ankle. 2nd ed. Baltimore, MD: Lippincott, Williams, and Wilkins; 2000. p. 328-30.  Back to cited text no. 5
    
6.
Day FN, Ruggieri C, Britton C. Recurrent osteochondroma. J Foot Ankle Surg 1998;37:162-4.  Back to cited text no. 6
    
7.
Erler K, Oguz E, Komurcu M, Atesalp S, Basbozkurt M. Ankle swelling in a 6-year-old boy with unusual presentation: Report of a rare case. J Foot Ankle Surg 2003;42:235-9.  Back to cited text no. 7
    
8.
Takikawa K, Haga N, Tanaka H, Okada K. Characteristic factors of ankle valgus with multiple cartilaginous exostoses. J Pediatr Orthop 2008;28:761-5.  Back to cited text no. 8
    
9.
Wani IH, Sharma S, Malik FH, Singh M, Shiekh I, Salaria AQ. Distal tibial interosseous osteochondroma with impending fracture of fibula-A case report and review of literature. Cases J 2009;2:115.  Back to cited text no. 9
    
10.
Skyrme AD, Chana R, Selmon GP, Butler-Manuel A. Osteochondroma of the distal tibia leading to deformity and stress fracture of the fibula. Foot Ankle Surg 2003;9:129-30.  Back to cited text no. 10
    
11.
Ismail BE, Kissel CG, Husain ZS, Entwistle T. Osteochondroma of the distal tibia in an adolescent: A case report. J Foot Ankle Surg 2008;47:554-8.  Back to cited text no. 11
    
12.
Galasso O, Mariconda M, Milano C. An enlarging distal tibia osteochondroma in the adult patient. J Am Podiatr Med Assoc 2009;99:157-61.  Back to cited text no. 12
    
13.
Matsumoto K, Sumi H, Shimizu K. Tibial osteochondroma causing foot pain mimicking tarsal tunnel syndrome: A case report. J Foot Ankle Surg 2005;44:159-62.  Back to cited text no. 13
    
14.
Chin KR, Kharrazi FD, Miller BS, Mankin HJ, Gebhardt MC. Osteochondromas of the distal aspect of the tibia or fibula. Natural history and treatment. J Bone Joint Surg Am 2000;82:1269-78.  Back to cited text no. 14
    
15.
Gupte CM, Dasgupta R, Beverly MC. The transfibular approach for distal tibial osteochondroma: An alternative technique for excision. J Foot Ankle Surg 2003;42:95-8.  Back to cited text no. 15
    
16.
Danielsson LG, el-Haddad I, Quadros O. Distal tibial osteochondroma deforming the fibula. Acta Orthop Scand 1990;61:469-70.  Back to cited text no. 16
    
17.
Mirra JM. Bone Tumors Clinical, Radiological and Pathologic Correlation. Vol. 2. Philadel-phia: Lea and Febiger; 1989. p. 1626-60.  Back to cited text no. 17
    


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