REVIEW ARTICLE Resection and Reconstruction of an Osteochondroma of the Hallux: A Review of Benign Bone Tumors and a Description of an Unusual Case Molly Schnirring-Judge, DPM, FACFAS,1 and Jared Visser, DPM2 Osteochondroma, which is also known as exostosis, is the most common benign bone tumor. Although foot and hand surgeons frequently encounter the subungual exostosis, exostoses commonly localize to other areas of the skeleton as well. In this review, we describe the clinical and diagnostic imaging charac- teristics of benign bone tumors and, in particular, the osteochondroma and its surgical management. We also report the case of a patient who experienced an unusual pedal digital osteochondroma-like lesion. Level of Clinical Evidence: 4 (The Journal of Foot & Ankle Surgery 48(4):495–505, 2009) Key Words: chondroma, Codman’s triangle, foot, graft, juxtacortical, malignancy, periosteum The subject of bone tumors in the lower extremity has been Osteochondroma investigated by a number of authors who researched tumor types and their prevalence within the foot and ankle (1, 2). In 1891, Virchow (4) suggested that osteochondroma is Although the majority of these lesions are found to be benign, derived from the cartilaginous growth plate and, since that to gain further appreciation for neoplastic developments time, animal and human histopathological investigations within the lower extremity, large populations of tumors have supported Virchow’s understanding of the origin of have been studied. In 196 cases of tumor in the foot and this bone tumor (5–7). In essence, the excrescence results ankle, Ozdemir et al (1) found 171 (87.2%) of these lesions from new growth of normal tissue and is, therefore, regarded to be benign. Furthermore, they noted that of those cases as a hamartoma. The etiology is thought to be a defect in the studied, 136 (69.4%) originated from bone, whereas 60 perichondral node of Ranvier that allows exuberant develop- (30.6%) originated from soft tissue structures. In a smaller ment from the physeal growth center. In general, enchondral series, Chou and Malawar (2) reviewed 33 tumors of the ossification continues within these lesions until osseous matu- foot and ankle and reported that 21 (63.6%) of these were rity has been reached, and most of the growth halts with benign. Among the benign bone tumors that occur in the closure of the epiphyseal plate (7, 8). The exostosis is covered lower extremity, the osteochondroma is most common (3). with cartilaginous tissue, the thickness of which is variable In fact, osteochondroma, which is an osteocartilaginous with age and diminishes after skeletal maturity (9).The exostosis, is the most common tumor of bone (1, 2). majority of these lesions occur in long bones, and the femur, humerus, and tibia are most commonly affected. Other bony sites of involvement in the foot include the calcaneus and talus Address correspondence to: Molly S. Judge, DPM, FACFAS, 7581 Secor Rd, Lambertville, MI 48144. E-mail: [email protected]. (10–12). There are, moreover, reports of extraskeletal osteo- 1Director, Clerkship Programs, St. Vincent Charity Hospital, Cleveland, chondromas arising in the foot and ankle (13–15). Osteochon- Ohio; Faculty Graduate Medical Education, Mercy Hospital Health Systems, dromas are said to make up 36%-41% of all benign bone Toledo, Ohio. 2PGY-I, St. Vincent Charity Hospital, Cleveland, Ohio. tumors (16), and approximately 3%-5% of these occur in Financial Disclosure: None reported. the foot (1). The incidence of local recurrence after resection Conflict of Interest: None reported. is infrequent (17) and has been reported to be <2% (9). Copyright Ó 2009 by the American College of Foot and Ankle Surgeons 1067-2516/09/4804-0016$36.00/0 The initial presentation of osteochondroma can vary. doi:10.1053/j.jfas.2009.04.001 Although some osteochondromas develop in an idiopathic VOLUME 48, NUMBER 4, JULY/AUGUST 2009 495 fashion, it is not uncommon to have the lesion in association TABLE 1 Staging system for benign lesions as described by with trauma. The lesion has also been reported to develop Enneking after radiotherapy during the first decade of life (18). The Stage Description exostosis usually presents as a solitary lesion; however, multiple hereditary exostoses (MHE) have been well docu- 1 Static lesion that tends to heal spontaneously mented (19, 20). There is a slight male predominance, and 2 More aggressive radiographic appearance Less mature histologically approximately 75% of osteochondromas are identified before Evidence of continued growth the patient is 30 years of age (1). Early identification of dorsal 3 Locally aggressive lesion pedal lesions is usually the result of pressure on the thin Immature histologically dorsal skin from shoes, whereas plantar pressure areas are Evidence of progressive growth realized during weight-bearing stance and gait. Osteochon- Not limited by natural barriers dromas, moreover, vary in regard to the portion of the bone that is involved, and they may result from aberrant outgrowth of the physeal plate, periosteum, cortex, or medullary canal. make an accurate diagnosis. Enneking has devised useful staging systems for both benign and malignant tumors (25), Clinical Findings Associated with which have been adopted by The Musculoskeletal Tumor Osteochondroma Society (Alexandria, Virginia, http://msts.org/) (26),and these are depicted in Table 1. An osteochondroma usually presents as a painless excres- cence localized to the metaphysis of a long bone. In general, Radiological Findings symptomatic lesions are the result of local mechanical irrita- tion at the area of tumor protrusion. Large lesions or lesions in an area of repetitive contact or external pressure can be Plain radiology continues to be the mainstay of diagnosis problematic, and dysfunction secondary to such bony prom- for bone tumors. The pathognomonic feature of the osteo- inences is common. Presentation on the proximal aspect of chondroma is the presence of medullary bone contiguous the anterior tibia, for example, can interfere with the ability with the stalk of the exostoses and the underlying cortical to kneel or crawl, whereas a pedal prominence may result bone (9, 27). These lesions often are pedunculated with the in friction and overlying cutaneous irritation in association stalk cortex histologically identical to that of the underlying with shoe wear (11, 21). When an osteochondroma infringes bone. Normal periosteum is uninterrupted along the lesion on adjacent soft tissue structures or neurovascular elements, and its associated cortex, and calcified cartilage is often noted symptoms such as pain and paresthesia may develop (22). on plain films as small, radiodense foci. Although these Vascular complications such as arterial thrombosis, arterio- lesions are usually pedunculated, they can also be attached venous fistula formation, pseudoaneurysm, claudication, directly to bone by a broad, sessile base. acute ischemia, and arterial rupture can also develop if the Radionuclide scans in general are not necessary in the degree of friction and pressure is sufficient (23, 24). Attention presence of positive plain radiographs. They can be useful, to the clinical history may help delineate the onset of bony however, for identification of occult lesions in the face of protrusion in association with the development of neural or negative plain films, and exostoses usually demonstrate vascular complaints, and may explain the cause of an associ- increased uptake of radiotracer for years after skeletal matu- ated nerve entrapment or vascular defect. rity (27). Great care should be taken when interpreting these films, however, because synovitis and unrecognized trauma can cause associated increased areas of activity, and false Tumor Staging positives can lead to unnecessary workup and biopsy. Cross-sectional analysis of bone tumors can be accom- The practice of tumor staging has utility in the periopera- plished through more sophisticated methods. Radionuclide tive management of both benign and malignant tumors. Ob- imaging can be acquired in 3-dimensional fashion for local- taining information regarding the tumor type, location, and izing lesions with single-emission computed tomography, extent of invasiveness is obligatory in the surgical candidate which can provide more meaningful information as and can be achieved through various imaging techniques, compared with the 1-dimensional imaging of the routine although the standard for bone tumors remains plain radiog- bone scan with 99mTc-methylene diphosphonate (99mTc- raphy. Most benign bone tumors are associated with charac- MDP). Computerized axial tomography (CAT) is a very teristic radiographic and histological findings that allow useful method for evaluation of osseous elements in cross- differentiation and aid in making a specific diagnosis. sectional views. In fact, contrast CAT can provide excellent Consultations in radiology, pathology, and oncology are soft tissue detail as well as delineate bone marrow involvement often necessary to correlate with clinical findings, and to when it is present. Alternately, magnetic resonance imaging 496 THE JOURNAL OF FOOT & ANKLE SURGERY (MRI) provides superior evaluation of adjacent soft tissue structures in cross-sectional analysis. The contiguous nature of the osteochondroma with that of the medullary bone can easily be identified with these 3-dimensional technologies. Despite the fact that the aforementioned 3-dimensional imaging methods can be very useful, it is important