|Year : 2023 | Volume
| Issue : 1 | Page : 86-90
Distal tibial interosseous osteochondroma with impending fracture of fibula, deformity and deep peroneal nerve entrapment neuropathy: A case report
Johney Juneja1, Gaurav Garg1, Nitin Andrews1, Ak Mehra1, Ramesh Sen2
1 Department of Orthopaedic, Rabindranath Tagore Medical College and Hospital, Udaipur, Rajasthan, India
2 Department of Joint Replacement and Joint Reconstruction, Max Superspeciality Hospital, Mohali, Punjab, India
|Date of Submission||17-Nov-2022|
|Date of Acceptance||28-Nov-2022|
|Date of Web Publication||20-Apr-2023|
Department of Orthopaedic, Rabindranath Tagore Medical College and Hospital, Udaipur 313001, Rajasthan
Source of Support: None, Conflict of Interest: None
Osteochondromas arising from the interosseous border of the distal tibia and involving distal fibula are uncommon. We present the case of a 34-year-old woman with an impending fracture, erosion, and weakness of the distal fibula, secondary to an osteochondroma arising from the distal tibia. Early excision of this deforming distal tibial osteochondroma avoided the future risk of pathological fracture of the distal fibula, ankle deformities, and syndesmotic complications.
Keywords: Deformity, neuropathy, osteochondroma
|How to cite this article:|
Juneja J, Garg G, Andrews N, Mehra A, Sen R. Distal tibial interosseous osteochondroma with impending fracture of fibula, deformity and deep peroneal nerve entrapment neuropathy: A case report. J Bone Joint Dis 2023;38:86-90
|How to cite this URL:|
Juneja J, Garg G, Andrews N, Mehra A, Sen R. Distal tibial interosseous osteochondroma with impending fracture of fibula, deformity and deep peroneal nerve entrapment neuropathy: A case report. J Bone Joint Dis [serial online] 2023 [cited 2023 Jun 7];38:86-90. Available from: http://www.jbjd.in/text.asp?2023/38/1/86/374427
| Introduction|| |
The largest group of benign bone tumors are the osteochondromas which are composed of spongy bone covered by a cartilaginous cap., Osteochondromas arising from the interosseous border, deforming distal tibia and fibula and occurring before physeal fusion are well reported in the literature. 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., Before skeletal maturity, a pathological fracture usually occurs if the osteochondroma is pedunculated. However, the progressive growth of a sessile lesion in the distal metaphyseal region of the leg can lead to pressure erosion and scalloping of the neighboring bone and a fracture may possibly ensue.,
| Case Presentation|| |
A 34-year-old woman presented to us with ankle swelling, exercise-induced pain, and numbness on the anterior aspect of the leg and great toe. On physical examination of ankle there fixed hard swelling over anteriolateral aspect of lower one third end of leg. Pain and numbness were exacerbated with foot dorsiflexion and great toe movements. The pain was continuous and the patient reported waking up at nights with intense pain. The patient also gave history of pain off and on. There was no history of difficulty in walking or restriction of movements at ankle. There was a globular swelling measuring 6 cm × 5 cm over lateral aspect of ankle on examination [Figure 1] and [Figure 2]. It was bony hard in consistency, smooth with ill-defined margins and nontender on palpation. There was no distal neurovascular deficit.
|Figure 1: (A and B) Radiological picture OD pedunculated osteochondroma marked pressure erosion of the distal fibula, (C) clinical picture of excised pedunculated osteochondroma after isolating superficial peroneal nerve|
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|Figure 2: (A) Osteochondroma which makes the fibula stringy, thinner, and deformed is observed on the fat-suppressed, T2-weighted coronal section. (B) The fibula, made springy and pushed laterally by the osteochondroma, is observed on the fat-suppressed, T2-weighted coronal section. (C) The increased signal is observed in the tibialis anterior muscle due to focal edema in sections traversing proximal to the osteochondroma. (D) Contrast uptake is observed at the area indicated by the arrow in fat-suppression, axial, postcontrast sections. Chronic-progressive compression affects the vasa nervorum supplying the nerve and cause contrast uptake by the nerve. The posterior peroneal nerve, normally very difficult to observe, is pushed to the anterolateral and becomes prominent due to contrast uptake (white arrow)|
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The patient was subjected to anteroposterior, lateral, and oblique radiography of leg with ankle. Radiography revealed a well-defined bony exostosis, arising from the interosseous border of distal tibial metaphysis with erosion and impending fracture of fibula on oblique view [Figure 3].
|Figure 3: In the pathologic specimen, the cartilaginous cap showing columnar array at the upper part lining the lesion, and the osteoid tissue beneath it are seen|
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The patient was initially put in an ankle foot orthosis. The nature and prognosis of the condition were discussed at length with the patient and his family, and an operative intervention was planned once an informed and written consent was obtained. An MRI scan was ordered once the decision was made to undertake operative intervention. It was consistent with a large, broad based benign osteochondroma arising from the lateral aspect of distal tibia with an uncalcified cartilaginous cap [Figure 1C]. This led to a marked pressure erosion of the distal fibula, which was only 5 mm thick at the narrowest point [Figure 1B].
The patient underwent excision of the osteochondroma through an anterior approach without fibular osteotomy. Intra-operatively, the fibula was found to be quite thin and weak. However, its outer cortical shell was intact. The inferior tibio-fibular joint was stable. Histology confirmed the clinical diagnosis of osteochondroma with no malignant transformation. Postoperatively, the patient was mobilized, non-weight bearing in a below knee plaster, for four weeks. Further mobilization was undertaken with a gradual transition from partial to full weight bearing. At one year follow-up, he had made a complete recovery with full return of ankle functions. The fibula had recovered the full thickness. There was no evidence of recurrence and he is still under follow-up.
Cases of distal tibial osteochondroma causing fibular fracture have been reported in the literature; however, we did not encounter any cases of osteochondroma causing entrapment neuropathy of the deep peroneal nerve. In distal tibial fractures, deep peroneal nerve injury and entrapment syndrome have been reported, similar to our case. However, vascular injury accompanies neural damage in these cases. In conclusion, entrapment neuropathy is characterized by pain and numbness at the region innervated by the compressed nerve and may occur at different sites in the upper and lower extremities. Deep peroneal nerve entrapment neuropathy is a rare clinical entity. Differential diagnosis must include entrapment neuropathy in cases where there is no history of severe trauma to the edematous muscle and pain and numbness are present in [Figure 3]. In the pathologic specimen, the cartilaginous cap showing columnar array at the upper part lining the lesion, and the osteoid tissue beneath it are seen. [Color figure can be viewed in the online issue, which is available at www.aott.org.tr] 466 Acta Orthop Traumatol Turc night. Magnetic resonance imaging shows muscular edema and allows tracking of the neural course. In this way, the region where the nerve has been compressed can be located and timely therapy can be instituted before nerve-muscle atrophy occurs. Our patient’s complaints were relieved following resection of the osteochondroma, supporting the diagnosis of entrapment neuropathy.
| Discussion|| |
Osteochondromas are considered developmental lesions rather than neoplasm. They commonly originate from the metaphysis of the tubular bones and grow in the opposite direction of the nearest joint. Hereditary multiple exostosis (HME) is an autosomal dominant syndrome characterized with multiple osteochondromas. Although, the risk of malignant transformation of osteochondromas is very low, it is three times greater in HME cases than solitary lesions. The lesion in our case was one-sided. The tumor may cause deformation of the bone in which it is located or in the neighboring bone, as well as compressive signs in the adjacent neurovascular structures., Rarely, it can form a swelling at the ankle by tapering the fibula and making it springy if it is located at the distal tibial metaphysis. Lesions grow quite slowly and almost stop growing once the epiphysis plate has been closed. Therefore, treatment is recommended at a stage after the epiphysis plate has been closed. However, treatment should be commenced as early as possible in cases involving fracture risk of the neighboring bone, severe compression of neural structures, vascular compression, or syndesmosis. Complete resection must be performed whenever possible to prevent recurrences.,,
Osteochondromas are the most common benign bone tumors (40% of all benign, 10% of all primary skeletal tumors). They present most often in the second decade of life. The metaphyses of proximal tibia, distal femur, distal tibia, distal fibula, proximal femur, and proximal humerus are the most commonly affected sites., Osteochondromas arising from the tibial interosseous border and causing fibular erosion with imminent fractures after skeletal maturity are rare.
Osteochondromas usually follow a predictable course. The lesion slowly increases in size until physeal fusion. After skeletal maturity, the growth of this tumor slows down and eventually ceases in virtually all the cases. The main symptom is a mass or bony lump. Progressive enlargement of osteochondromata may cause nerve compression or skeletal deformity resulting in pressure symptoms. Malignant transformation to chondrosarcoma is rare (less than 1%) and should be suspected in the presence of increasing pain and sudden increase in the size of lesion in patients presenting after skeletal maturity.
The decision to treat distal tibial osteochondromas non-operatively carries the risk of persistence of symptoms and ankle deformity. Mirra reiterated the importance of complete resection of the cartilaginous cap to prevent recurrence. In the previously published literature, anterior, posterior, and trans-fibular approaches with fibular reconstruction are described, although anterior approach without fibular osteotomy is associated with the least postoperative morbidity and was successfully used in this case.
| Conclusion|| |
This case highlighted the need for early excision of the osteochondromas deforming the distal aspect of tibia and fibula to prevent ankle deformities and syndesmotic complications and thereby obviated the need for complex reconstructive surgery.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Jaffe HL Hereditary multiple exostoses. Arch Pathol 1943;36:335.
Schramm G Pathogenesis of cartilaginous exostoses and enchondromas. Arch Orthop 1929;27:421.
Chin KR, Kharazzi FD, Miller BS, Mankin HJ, Gebhardt MC Osteochondromas of distal aspect of tibia and fibula. Natural history and treatment. J Bone Joint Surg Am 2000;82:1269-78.
Spatz DK, Guille JT, Kumar SJ Distal tibiofibular diastasis secondary to osteochondroma in a child. Clin Orthop 1997;345:195-7.
Davids JR, Glancy GL, Eilert RE Fracture through the stalk of pedunculated osteochondromas. A report of three cases. Clin Orth Related Res 1991;271:258-64.
Danielsson LG, El-Haddad I, Quadros O Distal tibial osteochondroma deforming the fibula. Acta Orthop Scand. 1990;61:469-70.
Southerland JT Osteochondroma of distal tibia. A case study. J Am Podiatr Med Assoc 1995;85:542-5.
Krieg JC, Buckwalter JA, Peterson KK, El-Khoury GY, Robinson RA Extensive growth of an osteochondroma in a skeletally mature patient. A case report. J Bone Joint Surg Am 1995;77:269-73.
Mirra JM Bone tumours, clinical, radiologic and pathologic correlation. Philadelphia, Lea and Febiger 1989;2:1626-60.
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.
[Figure 1], [Figure 2], [Figure 3]