Surgical management of symptomatic solitary osteochondroma of femur neck in an adult: A case report

Arpan Nag

doi:10.4103/jbjd.jbjd_37_22

CASE REPORT

Year : 2022 | Volume : 37 | Issue : 3 | Page : 183-187

Surgical management of symptomatic solitary osteochondroma of femur neck in an adult: A case report

Arpan Nag
Senior Resident, Department of Orthopaedics, Esic Medical College and Hospital, Faridabad, Haryana, India

Date of Submission	06-Nov-2022
Date of Acceptance	09-Nov-2022
Date of Web Publication	15-Dec-2022

Correspondence Address:
Arpan Nag
K15/13 DLF Phase 2, Gurugram, Haryana
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_37_22

Abstract

Osteochondromas are the common benign bone tumors of the long bones, usually asymptomatic and mostly found incidentally in children and adolescents on radiographs. Osteochondromas are usually present as sessile and pedunculated swelling arising from the metaphyseal region of long bone ends. We reported a 35-year-old woman, who presented with a hard painful mass in the left gluteal region and decreased hip movements. Radiological examination showed a tumor arising from the base of femur neck. The appropriate surgical approach wasused for the complete resection of bone swelling, cartilage cap, and surrounding bursa without hampering surrounding structures as they are at risk of injury during surgical resection of the tumor. Histopathology confirmed the diagnosis of an osteochondroma. Proximal femur or neck of the femur is an unusual site for ostechondroma to occur; the risk of sarcomatous degeneration and malignant transformation of such swelling presenting late is more. Complete resection of such bone tumors keeping in mind the risk associated is the foremost aim.

Keywords: Benign, osteochondroma, pedunculated

How to cite this article:
Nag A. Surgical management of symptomatic solitary osteochondroma of femur neck in an adult: A case report. J Bone Joint Dis 2022;37:183-7

How to cite this URL:
Nag A. Surgical management of symptomatic solitary osteochondroma of femur neck in an adult: A case report. J Bone Joint Dis [serial online] 2022 [cited 2023 Feb 6];37:183-7. Available from: http://www.jbjd.in/text.asp?2022/37/3/183/363859

Introduction

Osteochondromas (OCs) are hamartomatous growth of both, bone and cartilage that are thought to arise from trapped growth-plate cartilage, extend through the cortex, and grow via endochondral ossification beneath the periosteum.^[1]

Osteochondroma involves long bones such as the distal femur, the proximal tibia, and the proximal humerus.^[2] Typically, osteochondroma arises within the first three decades of life and affects children and adolescents. The majority of OCs are asymptomatic and are found incidentally.^[3],[4] The femur accounts for the majority of the cases, which is approximately 30% of the total and most of them are distal lesions.^[5]The main purpose of this study is to illustrate a rare case of osteochondroma at the base of the neck of the femur and its management.

Case Report

This report presents a case of a 35-year-old woman, who was referred to the Department of Orthopaedic Surgery in the ESIC Hospital and Medical College, complaining of left gluteal region pain and feeling of a hard mass since the past 2.5 years. The pain was insidious and increased over time, which was exacerbated on walking but relieved with rest and there was no night pain. She also reported a progressive limitation of right hip extension which significantly interfered with her daily activities.

Before presenting to us, the patient consulted a few general physicians for her gluteal pain, but she was managed by analgesics and physiotherapy. Pain and her complaints did not subside with them. The patient was assessed clinically by us and on deep palpation, an unusually hard swelling was palpable on the left gluteal region. On physical examination, there was tenderness in the gluteal area and over the greater trochanter, with a restricted passive and active extension of the left hip joint, but there was no weakness and symmetric power 5/5 was present in both lower limbs. All clinical findings were consistent with a bony hard swelling. A pelvic radiograph showed an osseous mass related to the left proximal femur [Figure 1].

Figure 1: Pelvic radiograph showing osseous mass at the left proximal femur

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The results of the laboratory tests (complete blood count, erythrocyte sedimentation rate, C-reactive protein, kidney function test, and electrolyte) were within normal limits.

The patient was advised a computed tomography (CT) scan and magnetic resonance imaging (MRI) for further evaluation. CT scan was ordered and showed a right femoral neck posterior-inferior osseous mass with cortical and medullary continuity on the axial view [Figure 2] and [Figure 3].

Figure 2: MRI

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Figure 3: CT scan: proximal femoral bony growth arising from the posterior aspect of the base of the femur neck, having a stalk and communicating with the medulla

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The plan was to excise the mass, and the intra-operative risk of a femur neck fracture, sciatic nerve injury, and incomplete resection was discussed with the patient. The operation was in a lateral position through a lateral approach to the hip. The hip capsule was intact and the mass was extracapsular in posterior relation to the femur neck with a stalk. A bursa-like tissue surrounding the swelling was found, which was carefully dissected and removed [Figure 4]. Swelling was removed as close as possible to the femur neck using the saw and osteotome. It was completely removed without a fracture to the femur neck [Figure 5]. The mass was sent for histopathology evaluation [Figure 6], which confirmed the diagnosis of OC. The patient started full weight bearing and hip range of motion immediately on the next day of the surgery. After 2 months of follow-up, the patient reported a significant improvement in her hip extension and a complete resolution of her gluteal pain.

Figure 4: Bursa-like tissue surrounding the bony swelling

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Figure 5: Bursa along with the swelling completely removed

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Figure 6: (A) Excised specimen sent for histopathological examination. (B and C) In histopathological examination, it is diagnosed as osteochondroma

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Discussion

OCs are common benign bone tumors although they are more correctly thought to be a developmental anomaly.^[6] They present as solitary (in 85% of cases) or multiple lesions in the context of hereditary multiple exostoses (in 15% of cases), and commonly it has an autosomal dominant inheritance.^[7] Femoral neck OC is relatively rare. It could be associated with snapping hip,^[8] trochanteric bursitis, sciatic nerve compression,^[9],[10] and femoroacetabular impingement^[11]

Exostoses are generally asymptomatic until they compress some adjacent neurovascular lar structure or undergo malignant change. The incidence of malignant transformation or sarcomatous change in the proximal femur or pelvis osteochondroma is significantly higher in adolescents.^{[12],[13],[14]} This makes it necessary to follow up with these patients keenly and early resection should be considered. Although osteochondroma of the proximal femur and acetabulum are mainly followed up because of the risk of malignant change, a peri-acetabular osteochondroma may cause acetabular dysplasia and a proximal femoral osteochondroma may cause coxa-valga and overgrowth of the femoral neck.^[15] Due to the risk of malignant transformation of these lesions, it is important to consider surgery in patients with radiographic or imaging evidence of malignant change, however minimal.

The choice of the proper surgical approach to femoral neck OC is often difficult, as it should reflect a balance between complete excision and the risk of neurovascular injury or intraoperative fracture. The surgeon can choose the most effective approach to help in removing the tumor safely without complications. In our patient, we used the postero-lateral approach. The OC was in posterior relation to the femur neck and it was pedunculated with a high risk for intra-operative fracture. We used the saw and osteotomes to remove it completely and as close as possible to the femur neck.

Conclusion

OC of the femoral neck is a rare case that needs careful evaluation and treatment as a risk of femoral neck fracture and neurovascular compromise, the malignant transformation needs a detailed radiological workup to determine its size and site in relation to the femoral neck accurately.

Femoral neck OC can present with restricted hip motion, a feeling of a hard mass on one side, and gluteal pain that may interfere with daily activities. In this case, early surgical excision was carried out for removing any questions and doubts related to future complications related to the tumor.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

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.

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