Osteochondromas are benign chondrogenic lesions arising on the external surface of the bone with aberrant cartilage (exostosis) from the perichondral ring that may contain a marrow cavity also. In a few cases, depending on the anatomical site affected, different degrees of edema, redness, paresthesia, or paresis can take place due to simple contact or friction. Also, depending on their closeness to neurovascular structures, the procedure of excision becomes crucial to avoid recurrence. We report a unique case of recurrent osteochondroma of the proximal humerus enclosing the brachial artery which makes for an important case and procedure to ensure that no relapse occurs. We report a unique case of a 13-year-old female who had presented with a history of pain and recurrent swelling for 5 years. The swelling size was 4.4 cm x 3.7 cm x 4 cm with a previous history of swelling at the same site operated in 2018. CT reports were suggestive of a large well defined broad-based exophytic diaphyseal lesion in the medial side of the proximal humerus extending posteriorly. Another similar morphological lesion measuring approximately 9 mm x 7 mm was noted involving the posterior humeral shaft. The minimal distance between the lesion and the brachial artery was 2 mm just anterior to the posterio-medial growth. Two intervals were made, first between the tumor and the neurovascular bundle and the other between the anterior tumor and brachial artery followed by exostosis and cauterization of the base. Proper curettage and excision of the tumor was done after dissecting and removing the soft tissue, blood vessels, and nerves so that there were very less chances of relapse. Post-operative X-ray was done and post 6 months of follow-up, there were no changes, and no relapse was observed. Thus, when presented with a case of recurrent osteochondroma of the proximal humerus, osteochondroma could also be in proximity to important vasculature as in this case enclosing the brachial artery. Thus, proper curettage and excision should be done in such cases to avoid recurrence

Aim: A case report: Symptomatic Osteochondroma of the Coracoid. Introduction: An osteochondroma is a common developmental tumour of bone characterized by abnormal periphyseal ectopic endochondral ossification. This results in a cartilage-capped subperiosteal bony projection. A solitary osteochondroma is encountered more frequently than are multiple hereditary osteochondromas. They are usually appreciated in the first decades of life and are most commonly located in the long bones, especially the femur, humerus and the tibia. Clinical presentations generally relate to the mass effect of the lesion. These lesions are said to grow to skeletal maturity. Continuous slow growth of the osteochondroma in adults should alert the clinician to the possibility of secondary malignant transformation, usually to a chondroma. Method: We present an unusual case of shoulder pain in a 36-year-old man with a painful solitary osteochondroma of the coracoid process. Plain radiographs, computed tomographic and magnetic resonance imaging of the lesion showed a solitary osteochondroma with a visible cartilage cap eroding the under surface of the clavicle. The lesion was surgically explored and excised. Histological examination showed a benign osteochondroma. Removal of the tumour resulted in resolution of all signs and symptoms. Conclusion: We are aware of no reported cases in the literature of osteochondroma of the coracoid process. This case was unusual in terms of age at clinical presentation and location, suggesting a continuous growth of the tumour beyond skeletal maturity

Osteochondromas occur are most commonly in the distal femur, proximal tibia and fibula and the proximal humerus. There are no large studies focusing on the clinical presentation, management and outcome of treatment for patients with an osteochondroma involving the proximal fibula. The purpose of this study is to specifically understand the manifestation of the proximal fibular osteochondroma on the preoperative peroneal nerve function, and how surgical management of the osteochondroma affects function immediately postoperatively and at long-term followup. This is an IRB-approved retrospective review of a consecutive series of patients with a proximal fibular osteochondroma (PFO) treated operatively at a single institution from 1990 to 2013. The medical record was carefully reviewed to identify demographic data, clinical data and especially the status of the peroneal function at various time points. There were 25 patients with 31 affected extremities who underwent surgical excision of the PFO at an average age of 12.4 years (range 3.0–17.9 years). There were 16 males and 9 females. The underlying diagnosis was isolated PFO in 2(8%) patients and multiple hereditary exostosis (MHE) in 23(92%) patients. Preoperatively, 9 (29%) had a foot drop and 22 (71%) did not. Those with preoperative foot drop underwent surgery at a younger age (9.1 vs 13.8 years) (p<0.004). Five of the nine (55.5%) had complete resolution, three (33.3%) had improvement, and one (11.1%) persisted postoperatively and required AFO. Of the 22 who were normal preoperatively, 5 (22.7%) developed a postoperative foot drop-three (60%) completely resolved, 1 (20%) improved, and 1 (20%) persisted and was found to have a transected nerve at exploration. In total, 23 of the 25 (92%) patients who had a PFO excision, had a normal or near-normal peroneal nerve function including those who had poor function preoperatively. A proximal fibular osteochondroma can result in a high incidence of peroneal nerve dysfunction prior to any treatment, but responds the majority of the time to surgical intervention with removal of the osteochondroma. For those who have normal preoperative function, 1 in 4 will develop a postoperative foot drop but nearly all improve spontaneously unless iatrogenic injured

An osteochondroma is a benign tumour and multiple hereditary osteochondromatosis [MHO] is an auto-somal dominant skeletal disorder in which there are numerous cartilage-capped excrescences. The true incidence of malignant change of osteochondromas is not known, as many osteochondromas, especially solitary lesions, are asymptomatic and usually not reported. Between the years 1995 to 2002, 11 patients with a secondary chondrosarcoma developing in osteochon-droma were found, out of 300 cases of musculoskeletal tumours treated at our institution. All the patients were treated surgically, The mean follow up of the patients was approximately 2 years [range from 3 months to 4 years]. In radiographs, evidence of malignant change was seen in all the cases. In the cases where MRI was carried out [6 out of 11 cases], the average cartilage cap thickness was 5.0 cm [ranging from 2 to 12 cm]. It is important to recognize the features suggesting malignant change, namely pain, continued growth of the lesion after skeletal maturity, thick bulky cartilaginous cap, and soft tissue mass with or without calcifications. Six of our cases had Grade I chondrosarcoma. High-grade chondrosarcomas occur with greater frequency in patients of multiple hereditary osteochondromatosis. Grading of chondrosarcoma is considered to have prognostic significance. However, the rate of local recurrence is primarily dependent on the adequacy of the primary surgical therapy, rather than the histological grade. In our series we had 3 cases wih local recurrence. In 2 of these cases, intralesional debulking had been done and in 1 case of marginal excision was done. Therefore primary resection [with a cuff of normal tissue] or radical excision appears to be the treatment of choice for these lesions

The purpose of this study was to determine the surgical risks and recurrence rate associated with the excision of osteochondroma from the long bones most frequently operated on in our institution; the femur, tibia, humerus and fibula. Two hundred and twenty four osteochondromata were excised in total between July 1992 and January 2001. The medical records and radiographs of 126 patients who had 147 osteochondromata excised from the femur, tibia, humerus and fibula were reviewed. Of these, 30 patients presented with multiple osteochondromata, accounting for 48 of the 147. Fifty three involved the femur (2 proximal), 55 the tibia (16 distal), 12 the fibula (2 distal) and 27 the proximal humerus. The mean age at excision was 12.5 years (2–18 years) and the mean follow-up was five years (1 to 10 years). There were 15 surgical complications (10% of excisions) including one compartment syndrome, five superficial wound infections, two haematoma formations which required evacuation, one partial wound dehiscence, one deep infection with sinus formation which required excision, one sural nerve and one saphenous nerve neuropraxia, one cutaneous nerve entrapment and two hypertophic scar/keloid formations. The patient with the compartment syndrome had excision of a distal femoral, proximal tibial and fibular osteochondroma during the same procedure and was diagnosed to have won Willebrand disease after the surgery. There were eight recurrences involving five patients with multiple osteochondromata and three in whom the excision was incomplete due to the proximity to neurovascular structures. Surgical risks related to excision of osteochondroma are relatively frequent and must not be underestimated. Excision should therefore only be performed if strongly indicated. The recurrence rate (5.5%) seems to be higher than previously reported in the literature (2%) and generally affects patients with multiple osteochondromata. Incomplete excision resulted in recurrence in all our cases

Introduction and Objectives: Osteochondroma is the most common tumour of the bone. Treatment is necessary only in the case of pain, compression of adjacent structures, for aesthetic reasons, or in cases of suspected malignancy. Materials and Methods: This study reviews a series of 119 patients with solitary osteochondroma tracked in our centre since 1975. Location, gender, reason for consultation, tumour and treatment-related complications, type of treatment, recurrence and malignant transformation, and final status of patients were tracked for a minimum of one year. Results: Of the 119 patients in this study, 75 required surgical intervention, with tumor recurrence being the most common complication (15 cases). Seven patients suffered malignant transformation all of which resolved after surgical intervention. Discussion and Conclusions: In our experience, simple resection is a satisfactory treatment for osteochon-droma in most cases. Periodic follow-up is necessary in these cases as they have the potential to become malignant

Aim: This study describes the clinical features and treatment of 94 patients with skeletal osteochondroma during the last 20 years. Materials-methods: A retrospective review of various size solitary osteochondroma was evaluated. There were 51 males and 44 females with mean age 21 years. The mean follow-up was 8 years (1–12). There were 40 lesions in the distal femur, 6 in the greater trochanter, 19 in the proximal tibia, 1 in the proximal fibula, 1 in the calcaneus, 3 in the lateral malleolus, 1 in the medial malleolus, 3 in the talus, 2 in the tarsus, 3 in the metatarsals, 3 in the scapula, 4 in the humerus, 1 in the elbow,1 in the radius, 6 in the fingers. The lesions were diagnosed by history and plain radiographs. In two patients with large lesions around the knee an angiography was done. Results: Pain and local tenderness were the main symptoms. The treatment was en bloc excision of the tumor. There were no recurrence. Two patients had wound infection which was dealt with antibiotic. Conclusion: The site and the results of this study are similar with the literature. The radiologic image is pathognomic for the tumor. The treatment consisted of en bloc excision. There is high possibility of recurrence in case of insufficient excision

Intracapsular and para-articular osteochondromas are a rare subtype of soft tissue chondroma occurring in and around joints. We report a giant 5.5cm × 5.5cm × 3.0cm mass occurring in the knee of a 45 years old lady and examine previous cases to update our understanding of para-articular soft tissue osteochondromas. Clinicopathological data were obtained from medical records for the case report whilst a multi-database literature search was conduction for the literature review. 27 articles containing 39 cases were identified in the English literature under our strict inclusion criteria. Along with our data, 40 cases were collated and analysed to provide a set of reference characteristics. These included: age, male-female ratio, spatial location, time of onset, tumour size, clinical symptoms, mechanism of injury, investigations used, treatment received, histopathology features, follow-up and recurrence characteristics. Statistical analysis was performed on data to elicit any discernable pattern of tumour formation. Median age of patients was 50 years old with a male to female ratio of 1:1.11. Most commonly occurs in the 40s, 50s and 60s accounting for two-thirds of all cases. Majority of tumours were located within or adjacent to a fat pad structure. 33 were located in the infra-patellar region, 3 in the suprapatella/pre-femoral region and 4 in other para-articular locations. Average time of onset to diagnosis was 5.81 yrs with a mean volume of 87.5 cubic centimetres. No discernable correlation between time of onset to diagnosis and tumour size was found (spearman correlation co-efficient 0.534, p=0.007). The main symptom reported was pain in 29 cases, whilst 5 were pain free, 6 cases were unspecified. X-Rays, CT and MRI have become the core imaging modalities in investigation. En bloc excision is the choice of treatment, whilst arthroscopic techniques have also been used with similar success. Histologically, 35 cases had a typical description of a cartilage capped lesion with central trabecular bone and areas of endochondral ossification. 3 cases had a histological appearance of predominantly bone whilst 2 cases had predominantly cartilage. All tumours analysed were benign. No recurrences were reported with an average follow up period of 1.91 years. We have provided the latest set of data for the characterisation of para-articular and intracapsular soft tissue osteochondromas. These tumours are benign entity with an invariably good outcome following simple excision. Recognition of this entity is important to prevent over investigation and the performance unnecessarily invasive and radical procedures

Eight children developed osteochondroma (OS) at a mean of 88 months, after hematopoietic stem cell transplantation (HSCT). The mean age at HSCT was 56 months (12-84). This represents a cumulative incidence of 20% among patients less than 18 years of age transplanted from 1981 to 1997. These eight patients underwent allogeneic (n=2) of autologous (n=6) transplantation for either acute leukemia (n=6) or neuroblastoma (n=2) after a conditioning regimen including total body irradiation (n=7) or a combination of Busulfan and Cyclophosphamide.Multiple OS were indentified in seven patients and a solitary OS in one. Locations included: clavicle (2), ribs (2), superior iliac epiphysis (1), metaphy-sis of the distal femur (2), distal (2) and proximal (1) tibia, proximal humerus (1), distal radii (3), scapula (3), proximal metaphysis of the proximal phalanges of the fingers (2) and parietal bone (1). OS were asymptomatic in four children. Eight lesions in five patients were resected and all were benign. No recurrence occured.Four children received growth hormone before diagnosis of OS, but there was no clinical, radiological or histological difference between those who did not. Univariate analysis showed an increased rate associated only with autolo-gous HSCT, with a 31,7% probability of a new OS et 12 years after HSCT.Ostoechondroma should be added to the other adverse effects of HSCT in children

Dysplasia Epiphysealis Hemimelica (DEH) also known as Trevor's Disease is a rare developmental disorder resulting in cartilaginous overgrowth of the epiphysis of long bones. DEH is usually diagnosed in children between two and eight years old and it is three times more often diagnosed in boys. The most reported complaints are pain, limitation in range of motion, and deformity or swelling of the affected joint. Treatment of symptomatic lesions consists of surgical resection of the lesion, resulting in good long-term results. Based on histological evaluation, DEH is often described as an osteochondroma or an osteochondroma-like lesion, although there are clinical, radiological and genetic differences between DEH and osteochondromas. To investigate the hypothesis that DEH and osteochondromas are histologically identical, two cases of DEH and two cases of osteochondromas in patients with Hereditary Multiple Osteochondroma (HMO) are compared at histological level. Tissue samples from patients with a histopathologically confirmed diagnosis of DEH were compared with two age and gender matched patients diagnosed with HMO. After tissue sampling and processing, (immuno)histological stainings were performed for Collagen type II, Collagen type X, Sox-9 and Safranin-O. Histologically, clumping of chondrocytes in a fibrillar matrix, a thick disorganized cartilage cap and ossification centres with small amounts of unresorbed cartilage were observed in DEH. In contrast, chondrocyte organisation in cartilage of osteochondromas displays characteristics of the normal growth plate. In addition, differences in expression of collagen type II, collagen type X and Sox9 were observed. Collagen type II was expressed in the extracellular matrix surrounding proliferative and hypertrophic chondrocytes in osteochondromas, while weak expression was observed in the entire cartilage cap in DEH. Collagen type X was not expressed in DEH, while expressed in the pericellular matrix surrounding hypertrophic chondrocytes in osteochondromas. Staining for Sox9 was positive in the hypertrophic chondrocytes in osteochondromas, while expressed in the nuclei of all chondrocyte clusters in DEH. Both morphological and immunohistological differences were observed in histological sections of DEH and osteochondromas. These findings reject our hypothesis, and supports the earlier observed clinical, radiological and genetic differences and implies a different aetiology between DEH and osteochondroma formation in HMO

Aim: The pelvis is a rare location for osteochondromas and differentiation from chondrosarcomas can be difficult. We aim to aid this differentiation using tends and demographics of treated cases. Methods and Results: Patients referred to a supra-regional bone tumour centre with pelvic tumours, consequently diagnosed as osteochondromas were studied to determine the clinico-pathological features that differentiate them from chondrosarcoma. Treatment outcome was also reviewed. 30 patients were studied with a mean follow-up of 32 months. The mean age at diagnosis was 34yrs (range 19–79). The male to female ratio was 1:1. The most common location was the ilium (19 patients), with the pubis and ischium accounting for a third of patients. Only 1 patient had an acetabular osteochondroma. Median duration of symptoms prior to referral was 6 months (1–79). Pain without a lump was the main presenting symptom (16 patients), followed by lump with pain (6), and lump alone (6). Two patients presented with obstructive labour requiring emergency procedures. The lesions were solitary in 24 and associated with hereditary multiple exostosis (HME) in 6 patients. 1 patient had a radiation induced lesion. The lesions showed increased uptake on bone scans and the cartilage cap was less than 10mm in all but 2 patients. Treatment was surgical excision in 21 patients and observation with serial radiographs in 9. Histological examination confirmed osteochondroma in all patients, however 1 patient with HME had areas of Grade I malignancy. Significant surgical complications occurred in 1 patient who developed pulmonary embolism. Conclusion: We conclude that symptoms from osteochondromas of the pelvis are similar to those with chondrosarcomas and increased uptake on bone scans is seen in both. However, a tumour with a cartilage cap larger than 10mm or arising from the acetabulum is unlikely to be an osteochondroma

Aim. Multiple (hereditary) osteochondroma (MO) is a rare autosomal dominant disease. Previous reports show that the risk of a malignant degeneration varies between 5-25%, but these are often combined with data on other cartilaginous diseases. The aim of this study was to establish clinical and radiological parameters that could identify a group of MO patients who are at risk for peripheral chondrosarcoma. Methods. A database of 64 MO patients surgically treated between 1980-2009 was established. For 24 patients full radiological (including MRI), surgical and pathological records were complete. This group contained 14 osteochondroma patients and 10 chondrosarcoma patients. Non-parametric tests and Kaplan-Meier survival analysis were used to establish a cartilage-cap thickness cut off point and a volume cut off point. Results. A total of 450 osteochondromas were seen in 64 patients, most common sites were the distal femur (14%) and the proximal tibia (12%). Eighteen patients developed a chondrosarcoma (28%), the most common sites were the ribs (22%) and the proximal femur (17%). Between osteochondromas and chondrosarcomas there was no significant difference in clinical symptoms like pain (10% vs 29% p=0,472) and growth (25% vs 30% p=0,669). The median cartilage-cap thickness was 5mm (range 1-12) for benign and the median cartilage-cap thickness was 40mm (range 15-130) malignant lesions, with a cut-off point at 8mm. Chondrosarcomas had a larger median volume of 227cm3 (range 2-147) compared to 51cm3 (range 37-545) in the osteochondroma group, with a cut-off point at 175cm3. Conclusion. Clinical symptoms (pain and growth) are non-reliable indicators for malignancy. In MO patients a cartilage-cap thickness larger than 8mm or a tumour-volume larger than 175cm3 should be considered malignant. Lower thickness of the cartilage cap than earlier reported and volume measurement both based on MRI, are indicators for malignant degeneration and should be implemented in screening protocols

To identify if disease severity and cancer-risk might depend on genotype in Hereditary Multiple Exostoses (HME). The discovery that the EXT family of tumour suppressor genes is responsible for Hereditary Multiple Exostoses (HME) now enables correlation of clinical features with genetic defects. Genetic epidemiological studies, such as this, may provide additional data of use to the clinician. In most population-based HME cohorts, the incidence of sarcomatous degeneration has been estimated as 1–5%. This is not high, but occurs at a younger age (on average 2–3 decades younger) than chondrosarcoma in the general population. Genetic stratification might allow a very high-risk subgroup to be identified, within which surveillance for neoplastic change in osteochondromas could be concentrated. In a pilot study, 29 affected individuals from 17 families with HME were screened for EXT mutation, with mutations identified in 12 families. Pedigrees were obtained and a complete assessment of disease severity made. We have since expanded this cohort; a further 71 affected individuals from 34 families with HME have provided detailed pedigree data and undergone a simple clinical examination to assess number of palpable osteo-chondromas. EXT mutation was assessed by means of fluorescent single-strand conformational polymorphism (f-SSCP) screening, followed by sequencing analysis. Validation of clinical examination : In those who underwent radiographic examination for clinical purposes, number of palpable osteochondromas correlated strongly with number seen on radiographs at 146 anatomical sites (r= 0.814, p< 0.001), validating the usefulness of clinical examination in a population analysis, and negating the need for a radiographic skeletal survey in individuals at risk from malignant change. EXT mutation : EXT mutation detection rates for f-SSCP were calculated to be 93%. As suggested in the pilot study, most (84%) were loss-of-function mutations. 60% had not previously been reported in the literature. There were 42 individuals with EXT1 and 29 with EXT2 mutations. Disease severity and EXT mutation: In the pilot study, median number of palpable osteochondromas were about twice as frequent in the 7 families with EXT1 mutation than in the 5 families with EXT2 mutation (p< 0.05). This was also reflected in overall disease severity scores. In the larger follow-up study, individuals with EXT1 mutation had a median number of 32 osteochondromas, compared with 16 osteochondromas in those with EXT2 mutation (Wilcoxon rank sum test p< 0.0005). Cancer risk: Six chondrosarcomas occurred, and were only found in individuals with EXT1 mutation. The observation that osteochondromas are more frequent in patients with EXT1 than EXT2 mutations is an important message in genetic counselling. If disease severity and cancer risk is greater in individuals with EXT1 mutation, screening for neoplastic change might be targeted on this group, in which lifetime risk of malignant change in osteochondromas could be increased to between 5% and 10%

Introduction: In hereditary multiple exostosis (HME) the synthesis of the polysaccharide heparan sulphate (HS) is disrupted. HS-proteoglycans are low affinity receptors involved in fibroblast growth factor signaling. Activation of FGF receptor 3 (FGFr3) on mature chondrocytes leads to growth attenuation rather than stimulation. We tested the hypothesis that in HME chondrocytes with absent or reduced HS-PG synthesis there is impaired response to the FGFr3 ligand and loss of control of chondrocyte proliferation. Materials and methods: Chondrocytes were harvested from normal growth plate (epiphyseodesis) or HME osteochondroma cartilage cap obtained as surgical discard and cultured to 70% confluence in growth media. Cells were re-plated for experimentation. Growth curves were obtained for cells over a period of 5 days. In addition proliferative responses of healthy and HME chondrocytes were determined after low serum synchronization followed by challenge with FGF 9 (10 and 100ng/ml) and incorporation of BrdU for 2hours every two hours over a twenty eight hour period. Using these techniques it is possible to describe in detail the time dependent entry of cells into S-phase of the cell cycle and compare cell lines and treatment. Results: Significant differences were observed in the growth characteristics over a five-day period (p< 0.05). Under baseline growing conditions the chondrocytes derived from osteochondroma had a more rapid doubling time when compared with the normal growth plate chondrocyte (2.6+/− 0.6 vs 4.9+/−1.0, p< 0.05). In response to incubation with FGF-9 cells from normal growth plate have a lower peak proportion of cells entering the s-phase than with media alone (7% vs 25%). This inhibition is not observed in chondrocytes from osteochondroma. Conclusions: It would appear that osteochondroma chondrocytes are resistant to the normal regulatory effect of FGF-9 on cell proliferation. The differential response to FGF may be responsible for the growth differences observed both in-vitro and in-vivo

To determine whether the spectrum of genetic mutation in Hereditary Multiple Exostoses supports a neoplastic aetiology for this condition. Historically, experts have been cautious in attributing neoplastic qualities to the osteochondroma. Solomon states ‘[osteochondromas] are not neoplastic in the ordinary sense of the word’; Morton that it ‘is not a tumour but a growth-aberration; Peterson that the ‘osteochondroma is not a true neoplasm’; and Schmale that ‘exostoses are the result of dysplasia of the lateral apect of the growth-plate’. There are, however, several features of osteochondroma behaviour common to other neoplasms which suggest a neoplastic aetiology:. the existence of an autosomal dominant inherited multiple form, in which lesions are histologically identical to the solitary form. lesions which are distributed randomly and perhaps asymmetrically at ‘high-risk’ anatomical sites (usually adjacent to those physes with greatest growth potential). evidence of behavioural or cellular disorder. a potential for malignant transformation. Recent genetic data has supported a fresh look at the neoplastic nature of osteochondromas. EXT1 and EXT2 genes are responsible for Hereditary Multiple Exostoses (HME). EXT1 codes for a protein which alters the synthesis and display of cell-surface heparan sulphate glycosaminoglycans; molecules which affect cellular growth, differentiation, motility and adhesion. Loss-of-function of such a gene may initiate a neoplastic pathogenesis in osteochondromas. From 1996–1999, 51 families with HME were screened for EXT mutation, with mutations identified in 41 families. EXT mutation was assessed by means of fluorescent single-strand conformational polymorphism (f-SSCP) screening, followed by sequencing analysis. Results : All missense mutations had previously been reported in the literature. In contrast, only 9 of 34 loss-of function mutations (frame-shift, splice-site and nonsense) had previously been reported. All frame-shift, splice-site and nonsense mutations are loss-of-function. Missense mutations may result in partial or complete dysfunction if a crucial folding or binding site is involved. Since no missense mutations were new, this suggested their mutation sites are important, and may effectively result in loss-of-function. These data strongly support a tumour suppressor gene function for EXT genes, and a neoplastic pathogenesis for HME

Forearm lengthening in children is controversial. Paley (1990) and Peterson (1994) advocate aggressive treatment of the deformity for cosmetic and functional reasons. Scoenecker (1997) has shown that mature patients are comfortable with their appearance and functional deficit. We reviewed 8 forearm lengthenings performed in 8 children in the 14 year period from 1991 to 2004. Five patients had ulnar shortening (osteochondromata = 4, growth arrest due to trauma = 1). Of the three patients with radial shortening, one was due to a congenital short radius and two following growth arrest (post trauma and meningococcal septicemia). The shortening resulted in a cosmetically unacceptable ulnar or radial tilt with absent radial or ulnar deviation of the wrist and decreased supination and/or pronation. One patient with a proximal ulnar osteochondroma had a dislocation of the radial head with cubitus varus. Excision of the osteochondroma was done 6 months prior to lengthening. Lengthening was accomplished with two Ilizarov rings and a distal corticotomy for radial and proximal for ulnar shortening. Reduction of the dislocated radial head was achieved with an olive wire. Associated procedures were: hemiepiphyseal stapling of the distal radius for an increased radial articular angle in 3 patients with osteochondroma, and corrective osteotomy of the distal radius in 1 patient with growth arrest. The average lengthening obtained was 23 mm (range 13–40 mm) with an average lengthening index of 1.45 months per cm. At an average follow-up of six years (range 2–15 years; 7 to maturity) all patients were satisfied with the cosmetic improvement and had full radial and ulnar deviation. Except for two patients the supination/pronation was improved. We concluded the forearm lengthening is warranted for cosmetic and functional reasons

Aim. To review the natural history of upper limb osteochondromas and assess their functional effect. Materials. We performed a retrospective casenote review of a consecutive patient cohort presenting between 1997–2012 with upper limb osteochondromas. Indications for surgical intervention were noted and considered to be cosmetic, functional (including pain relief) and ‘prophylactic’ in terms of deformity prevention. All patients were invited to complete questionnaires for the PODCI, DASH, OSS and MHS scores. Results. We identified 102 patients (62 male: 40 female; mean age = 13.3 years; range 3–31 years). 84 patients had multiple exostoses whilst 18 had a solitary lesion. 52 patients had shoulder girdle involvement (scapula, clavicle and proximal humerus), 51 forearm (Masada I (n=31) Masada II (n=9) Masada III (n=11)), and 38 hand involvement. 46/102 patients had concurrent lower limb lesions. 56 operative procedures were performed primarily for functional benefit. Shoulder girdle procedures (n=21) improved pressure related pain, scapular pseudowinging/dyskinesia and cuff impingement. Forearm procedures (n=35) were performed for functional and prophylactic reasons and involved excision with ulnar lengthening and radial deformity correction (n=15, Masada I), realignment osteotomy or radial head excision for subluxation (n=7, Masada II) and excision with internal fixation of concomitant osteotomy (n=13, Masada I/III). No hand surgery was performed. Radial head dislocations are associated with large ulnar lesions causing shortening > 0.15 total ulnar length. Osteochondromas of the upper limb are generally well tolerated: functional effects were most commonly present in lesions involving the forearm but significant patient benefit was noted following shoulder girdle procedures. The scoring systems used failed to discriminate well between the various procedures used and the perceived benefit. Conclusion:. Patient outcomes are related to surgical indications. Currently available PROMs are either inappropriate Qs (DASH) and/or non-validated (OSS, MHS) and/or non-specific (PODCI*) only 8 parameters for the upper extremity. Better-validated measures may be required. Level of evidence: IV

In orthopaedic oncology surgical precision is important and intraoperative imaging is often necessary. CAS may enhance precision and provide continuous 3D imaging without radiation. The goal of this work is to report our experience with CAS. Since 2006 we used CAS (Stryker) in 26 patients with a bone tumour: 11 chondrosarcomas, three osteosarcomas, seven osteochondromas and five miscellaneous. Twelve lesions were located in the femur, six in the pelvis, five in the lower leg and three in the upper extremity. In 18 cases a tumour was excised, in six of these a prosthesis was placed. In eight cases a curettage was done. In 23 cases the navigation was image-based (CT and/or MRI based) and in three cases image-less (no image-preparation necessary preoperatively). CAS was successfully employed in 23 cases. In three cases the procedure was aborted. In two cases, both in the ulna, we were unable to reconstruct the exact dimensions and in one case (image-less) the tracker was to far away from the work-field. There were no complications related to CAS. Mean precision is 0.5 mm. The time CAS takes is about 15 minutes during the procedure (7–60). In the eight curettages it proved helpful. We did not measure radiation time. In the six resections were tumour-prostheses were placed it was really helpful in rotation and length determination. In three of these, image-less navigation was performed (all distal femur). In osteochondroma resections it is helpful in four of seven cases. All surgical margins were adequate in the resections; after curettage, all MRI controls at three months did not show residual tumour. Oncology follow-up is too short yet; there was one local recurrence after two years in a parosteal osteosarcoma. We conclude that CAS can be our navigator in orthopaedic oncology; it is successful in providing precision and continuous 3D imaging. The indication area needs further study

Introduction: In the management of patients with bone neoplasm, we are confronted with various status which is difficult to treat. External fixation is useful for such status, and result in succes. The purpose of this study is to report that patients of bone neoplasms were treated with external fixation. Materials and methods: Fifteen patients with bone neoplasm who had treated by external fixation are an objective of this study, between 1989 and 2000. Clinical and pathological diagnosis is osteosarcoma in 7, giant cell tumor in 4, Ewing’s sarcoma in 1, chondrosarcoma in1, osteochondroma in 1, enchondroma in 1. Patients were divided into 4 groups depends on difference of indication of external fixation. Result. Group 1. Immobilization of pathological fracture. Two patients with osteosarcoma of femur and one patient with GCT of humerus were treated by external fixation for their pathological fracture. Group 2. Bone lengthening or correction for bone defect or deformity. We performed external fixation with Ilizarov fixator for bone lengthening following bone defect after tumor excision in 4 patients. Mean length of bone defect was 83.5 (22–150) mm. Two in 4 cases were stopped bone lengthening owing to local recurrence and progression of disease. And in 2 patients, we performed correction with external fixation for bone deformity arised by enchondroma of humerus and osteochondroma of ulna. Group 3. Stabilization for vascularized bone graft. We performed vascularized fibular graft after wide resection and stabilized with external fixator in 2 patients with humeral sarcoma. Group 4. Salvage of infected prosthesis. There were 4 patients with infected prosthesis. Three of them were treated by bone lengthening technique after removal of prosthesis. Mean length of bone defect was 264 (220–330) mm and mean term of fitting external fixator was 583.7 (442–726) days. Discussion: Advantages of treatment with external fixation for bone defect, bone deformity and pathological fracture arise from bone neoplasm are mentioned as follows. It could immobilize pathological fracture that is difficult for plaster cast immobilization. It could compensate for bone defect following tumor resection. It is useful method for salvage of the infected prosthesis. Disadvantages of using of external fixation are mentioned as follows. In case of bone lengthening, it is need to perform a complete tumor control. Treatment term is longer. It is need pin site management. Treatment with external fixation is one of the useful method for pathological fracture, bone deformity, shortening, bone defect and infected prosthesis arise from bone neoplasm

Aims

Autologous chondrocyte implantation (ACI) is a promising treatment for articular cartilage degeneration and injury; however, it requires a large number of human hyaline chondrocytes, which often undergo dedifferentiation during in vitro expansion. This study aimed to investigate the effect of suramin on chondrocyte differentiation and its underlying mechanism.