Distal tibial interosseous osteochondroma with impending fracture of fibula – a case report and review of literature
- Iftikhar H Wani†1, 2Email author,
- Siddhartha Sharma†1, 2,
- Farid H Malik†1, 2,
- Manjeet Singh†1, 2,
- Irfan Shiekh†1, 2 and
- Abdul Q Salaria†1, 2
© Wani et al; licensee BioMed Central Ltd. 2009
Received: 05 January 2009
Accepted: 02 February 2009
Published: 02 February 2009
Osteochondromas arising from the interosseous border of the distal tibia and involving distal fibula are uncommon. We present a 16 year old young boy 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.
The largest group of benign bone tumours are the osteochondromas which are composed of spongy bone covered by a cartilaginous cap[1, 2]. Osteochondromas arising from the interosseous border, deforming distal tibia and fibula and occurring prior to 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 [3, 4]. Prior to 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 neighbouring bone and a fracture may possibly ensue [6, 7].
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. Post-operatively, the patient was mobilised, non-weight bearing in a below knee plaster, for four weeks. Further mobilisation 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.
Osteochondromas are the most common benign bone tumours (40% of all benign, 10% of all primary skeletal tumours). 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 [3, 4]. 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 tumour 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 (1989) reiterated the importance of complete resection of the cartilaginous cap to prevent recurrence . In the previously published literature, anterior , posterior  and trans-fibular approach 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.
This case highlights 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 obviates the need for complex reconstructive surgery.
"Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal."
- Jaffe HL: Hereditary multiple exostoses. Arch Pathol. 1943, 36: 335.Google Scholar
- Schramm G: Pathogenesis of cartilaginous exostoses and enchondromas. Arch orthop. 1929, 27: 421-10.1007/BF02629048.View ArticleGoogle Scholar
- 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 (9): 1269-78.PubMedGoogle Scholar
- Spatz DK, Guille JT, Kumar SJ: Distal tibiofibular diastasis secondary to osteochondroma in a child. Clin Orthop. 1997, 345: 195-7.View ArticlePubMedGoogle Scholar
- Davids JR, Glancy GL, Eilert RE: Fracture through the stalk of pedunculated osteochondromas. A report of three cases. Clin Orth Related Res. 1991, 271: 258-264.Google Scholar
- Danielsson LG, El-Haddad I, Quadros O: Distal tibial osteochondroma deforming the fibula. Acta orthop Scand. 1990, 61 (5): 469-470.View ArticlePubMedGoogle Scholar
- Southerland JT: Osteochondroma of distal tibia. A case study). J Am Podiatr Med Assoc. 1995, 85 (10): 542-5.View ArticlePubMedGoogle Scholar
- 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 (2): 269-73.PubMedGoogle Scholar
- Mirra JM: Bone tumours, clinical, radiologic and pathologic correlation. Philadelphia, Lea and Febiger. 1989, 2: 1626-1660.Google Scholar
- Gupte CM, DasGupta R, Beverly MC: The transfibular approach for distal tibial osteochondroma: An alternative technique for excision. The Journal of Foot & Ankle Surgery. 2003, 42 (2): 95-98. 10.1016/S1067-2516(03)70008-8.View ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.