Fibrous dysplasia. Pathophysiology, evaluation, and treatment

First application of three-dimensional designing total hip arthroplasty with long uncemented stem for fibrous dysplasia patients combined with hip joint osteoarthritis

Background

In order to treat proximal femur fibrous dysplasia (FD) patients combined with hip joint osteoarthritis (OA), the three-dimensional (3D) designing osteotomy and implantation of femoral component was firstly used for deformity correction and total hip arthroplasty (THA). The purpose is to present the detailed design, perioperative management and evaluate short-term clinical outcomes of this novel therapeutic method.

Method

A retrospective study was performed in twelve FD patients combined with hip joint OA who were treated in our hospital between July 2013 and April 2015. Seven patients received 3D designing combined osteotomy and THA, and the other five patients underwent 3D designing THA only.

Results

All patients were followed-up with an average duration of 47 months (range, 35–56 months). There was no infection, dislocation, postoperative wound problems or mechanical failures. For the seven patients receiving 3D designing corrective osteotomy, the mean extremity lengthening was 2.8 (range, 1.5–4) cm. The average duration of bone union was 4.2 months. The average Harris Hip Score was improved from 46.08 (range, 13–67) points preoperatively to 93.72 (range, 83–100) points at the last follow-up. The average modified criteria of Guille was improved from 3.2 (range, 1–7) points preoperatively to 8.6 (range, 6–10) points at the last follow-up.

Conclusions

The 3D designing THA with long uncemented stem, including 3D designing corrective osteotomy and implantation of long prosthesis stem, seems to be a reliable method for FD patients combined with hip joint OA. Through preoperative 3D design, corrective osteotomy and implantation of long prosthesis stem can be precise to re-store alignment, uttermost preserve host bone, obtain primary stem stability and provide necessary condition for long-term stem survival, finally leading to better limb function. Besides, perioperative management should be abided strictly for late stability. Nevertheless, the outcomes of long-term follow-up and larger cases are still required.

Conservative treatment of Fibrous Dysplasia

Fibrous Dysplasia (FD) is a developmental disorder of bone that can affect one bone (monostotic type) or multiple bones (polyostotic type). The disease can be associated with hyperpigmentation and endocrinological disorders. In general, FD is found in teenagers, in the second decade of life. It often involves the long bones, craniofacial bones, ribs and pelvis. Approximately 30% of monostotic FD (MFD) lesions are found in the cranial, rather facial bones. It frequently appears in the posterior region of the jaw bone and is usually unilateral. The etiology of FD is not clear but even so genetic predisposition is suspected. The diagnosis is based on radiological and histopathological examination. We present an unusual case of symptomatic FD. A 15-year-old female patient was admitted to the clinic, complaining gradually increased swelling on her left side of the mandible one year ego with severe and unusual pain at related region. The bony enlargement was extending from median mandible to the crestal marginal level. Surgical shaving and recountering of mandible through the delicate preservation of the mental nerve in the left side of mandible was carried out. The aim of this report is to present the conservative treatment as sufficient treatment modality for the treatment of FD during puberty.

Surgical Treatment of Cervical Spine Fibrous Dysplasia: Case Report and Literature Review

Background

Fibrous dysplasia (FD) is an uncommon benign intramedullary fibro-osseous lesion. Cervical spine compromise is rare with only cases reported. Currently, the natural history of cervical FD is poorly understood, and its treatment remains controversial.

Methods

A review of the literature was performed to analyze and discuss the management of cervical FD through a case report and literature review.

Results

Cervical FD is a rare benign pathology. Clinical presentation is usually casual or only clinical pain. Computed tomography (CT)-guided percutaneous biopsy is a safe and effective technique for evaluation of spinal lesions; however, the accuracy of the preoperative biopsy findings has been disappointing. Although all treatments are valid, no one has been demonstrated to be better. Our proposed treatment, a corpectomy and fixation with a titanium mesh cage filled with allograft bone and an anterior cervical plate, showed good results.

Conclusions

The rarity of cervical FD and the lack of detailed reports with long-term follow-up periods complicate the research on the optimal treatment approach in these cases, but apparently all are valid for pain control. In our case, a corpectomy and fixation with a titanium mesh cage filled with allograft bone and an anterior cervical plate was carried out and showed good results. We submit this surgery option to be considered in these rare type of injuries.

Histological Diversity, Diagnostic Challenges, and Surgical Treatment Strategies of Fibrous Dysplasia of Upper and Mid-Thirds of the Craniomaxillofacial Complex

Background:

Owing to the overlapping clinical, radiographic and histopathological features among the diverse group of Fibro-osseous lesions, a precise and definitive diagnosis of Fibrous Dysplasia (FD) can be quite challenging. Moreover, FD itself may manifest with widely varying clinical presentations, radiographic appearances and histological pictures, depending upon the maturity of the lesion, and the relative quantum of its ‘fibrous’ and ‘osseous components’. Prompt and accurate diagnosis of Fibrous Dysplasia (FD) of the Craniomaxillofacial region is particularly important, as the condition is capable of causing considerable facial asymmetry or deformity leading even to marked disfigurement, which can have a profound psychosocial impact on the patient. Involvement of Maxillofacial bones by aggressive forms of FD, can produce serious functional debility as well, by compromising airway, breathing, vision, hearing, occlusion, mastication and mouth opening. Calvarial bone involvement can produce cranial asymmetry, and cranial base involvement can lead to persistent headaches, facial pain, numbness, and other neurological deficits owing to compression of cranial nerves.

Aims and Objectives:

To evaluate the importance of early and precise diagnosis, with prompt surgical management of these lesions, for a successful overall esthetic and functional outcome.

Materials and Methods:

A Case series of 15 patients, showcasing the principal variants of FD affecting the Craniomaxillofacial complex, namely, the Monostotic and Craniofacial forms have been described. Diversity in their Clinical, Radiographic and Histopathological presentations; their management modalities elucidating the various surgical approaches employed to access and excise these bone pathologies, have been provided along with a review of existing literature.

Results:

Various surgical approaches may be employed to access the lesions, depending upon their location, extent and involvement. Treatment protocols range from complete surgical excision to surgical shaving and recontouring, and must be decided upon on a case to case basis, with the aim to achieve the best possible esthetic and functional outcome with the least postoperative morbidity.

Conclusion:

Correlation of HPE with history, clinical features, biological behaviour, radiographic and CT appearance, laboratory findings, and intra-operative findings is imperative, so that they can be distinguished from other bony lesions and an appropriate, ideal and effective treatment modality can be instituted in time, so as to achieve the most favourable esthetic and functional outcome.

Co-administration of Systemic and Intralesional Zoledronic Acid in a Case of Fibrous Dysplasia: A Potentially Novel Therapy

Fibrous dysplasia (FD) is a benign bone lesion characterized by replacement of normal bone with abnormal fibrous tissue, clinically manifesting as deformities, bone pains, and pathological fractures. The standard medical management for FD includes systemic bisphosphonate therapy. The efficacy of systemic bisphosphonate is however limited with minimal functional improvement and pain relief. Keeping the above lacunae in mind, we have made a solitary attempt at treating FD with locally administered zoledronic acid. A 25-year-old gentleman had presented to our institute with swelling and pain involving the left thigh and left lower leg. He was diagnosed as having polyostotic FD, confirmed on bone histopathology. He was administered 4 mg of zoledronic acid intravenously while 1 mg of the drug was injected locally into the femoral lesion under ultrasound and fluoroscopy guidance. There were no peri-procedural complications. At 6 months follow-up, there was marked improvement in pain scores at the left thigh, while that at the left leg remained unchanged. In addition, repeat bone scintigraphy showed a 20.8% and 25.3% reduction in anterior and posterior uptake values, respectively, at the left femur while that at the left tibia remained unaltered.

Midfacial degloving approach for management of the maxillary fibrous dysplasia: a case report

Background

Fibrous dysplasia (FD) is a benign bone lesion characterized by the progressive replacement of normal bone with fibro-osseous connective tissue. The maxilla is the most commonly affected area of facial bone, resulting in facial asymmetry and functional disorders. Surgery is an effective management option and involves removing the diseased bone via an intraoral approach: conservative bone shaving or radical excision and reconstruction.

Case presentation

This case report describes a monostotic fibrous dysplasia in which the patient’s right midface had a prominent appearance. The asymmetric maxillary area was surgically recontoured via the midfacial degloving approach under general anesthesia. Follow-up photography and radiographic imaging after surgery showed the structures were in a stable state without recurrence of the FD lesion. Furthermore, there were no visible scars or functional disability, and the patient reported no postoperative discomfort.

Conclusions

In conclusion, the midfacial degloving approach for treatment of maxillary fibrous dysplasia is a reliable and successful treatment option. Without visible scars and virtually free of postoperative functional disability, this approach offers good exposure of the middle third of the face for treatment of maxillary fibrous dysplasia with excellent cosmetic outcomes.

First two cases of craniomaxillofacial fibrous dysplasia from Nepal - case series

Fibrous dysplasia is a benign fibro-osseous disease of the bone, which is most commonly associated with congenital mutations in cAMP regulating protein Gsα coded by GNAS-1 gene. Often it is seen involving the craniofacial skeleton and can range from an asymptomatic monostotic form to polyostotic variant involving almost all the bones of the skull, thereby leading to functional and esthetic problems. This requires a continuous monitoring of the involved region throughout the life of the patient, even after the surgical interventions. We are presenting two cases of craniofacial form of fibrous dysplasia. One case shows monostotic form, while the other case shows features of polyostotic form of disease. To the best of our knowledge, these are the first two cases of craniomaxillofacial fibrous dysplasia from Nepal, which will be reported and published.

Giant monostotic osteofibrous dysplasia of the ilium: A case report and review of literature

BACKGROUND

Osteofibrous dysplasia (OFD) is a developmental skeletal disorder, and cases with a giant affected area in the pelvis are rare.

CASE SUMMARY

In this case report, a 48-year-old man presented with a large tumor in the right iliac region that turned out to be OFD. The patient had rebound tenderness in his right hip. After radiography examination, magnetic resonance imaging examinations and some physical examination, extensive bone destruction in the right ilium was confirmed. Moreover, changes in bone mineral density and peripheral cortical bone sclerosis with surrounding soft tissue swelling were observed. Thus, this patient was considered to have giant monostotic OFD of the ilium. The tumor-related area was removed completely by surgery, and the remaining cavity was filled by artificial bones from the opposite ilium. According to the results of follow-up, the patient had normal flexion and extension activities of the right hip joint, and there was no evidence of recurrence of the tumor.

CONCLUSION

Suture of iliopsoas and gluteus medius muscle following focus curettage and bone grafting is a promising and effective method to treat giant OFD of the ilium. It is a feasible way to fill a large cavity after removing a lesion like the one is this case.

Magnetic resonance imaging features of craniofacial fibrous dysplasia

Purpose

To assess the value of magnetic resonance imaging (MRI) in detecting craniofacial fibrous dysplasia (CFD) and diagnosing and differentiating it from intraosseous meningioma. Additionally, the MRI appearance of the typical computed tomography (CT) imaging feature, the ground glass phenomenon, was evaluated.

Material and methods

MRI datasets of 32 patients with CFD were analysed retrospectively. Detectability in MRI was assessed by analysis of 10 randomly selected patients with CFD and 10 normal controls by two blinded readers. Changes of affected bone, internal lesion structure, T1 and T2 signal intensity, and contrast enhancement of the lesion in general and ground glass areas in particular were assessed. Ten patients with intraosseous meningioma (one in each) served as differential diagnosis for CFD.

Results

All 10 CFD lesions were reliably detected in MRI. In 32 patients 36 CFD lesions were evaluated. In 66.7% CFD were iso- to hypointense in T1 and hyperintense in T2; this proportion was similar for ground glass areas (65.7%). Ground glass areas were more homogeneously structured than the whole CFD lesion in both T1 (100% vs. 56%, respectively) and T2 (91% vs. 61%, respectively). Contrast enhancement was found in 97% of complete CFD lesions and 93% of ground glass areas. The accuracy for CFD vs. intraosseous meningioma was 100% for 'no soft-tissue component' and 98% for 'bone broadening' in MRI.

Conclusions

Distinct morphological changes of CFD are reliably detected in MRI and allow differentiation from intraosseous meningioma. Areas with ground glass phenomenon in CT show a predominantly homogenous internal structure in MRI with contrast enhancement.

Percutaneous Treatments of Benign Bone Tumors

Benign bone tumors consist of a wide variety of neoplasms that do not metastasize but can still cause local complications. Historical management of these tumors has included surgical treatment for lesion resection and possible mechanical stabilization. Initial percutaneous ablation techniques were described for osteoid osteoma management. The successful experience from these resulted in further percutaneous image-guided techniques being attempted, and in other benign bone tumor types. In this article, we present the most common benign bone tumors and describe the available results for the percutaneous treatment of these lesions.

Treatment of the benign lytic lesions of the proximal femur with synthetic bone graft

BACKGROUND

Benign bone tumors and tumor-like conditions are commonly located in the proximal femur. The main indications for surgical treatment are lesions with impending or actual pathological fractures, or with aggressive or recurrent lesions. However, patients complaining of persistent pain, limping, or abnormal gait patterns are also considered for surgical treatment. In this study, we describe the outcomes of the surgical treatment of benign lytic lesions of the proximal femur by curettage followed by implantation of synthetic bone graft.

METHODS

This retrospective study included 27 patients (22 females and 5 males) with benign lytic lesions of the proximal femur. The average age was 25.5 years (6-65 years), and the mean follow-up period was 54.5 months (9-145 months). The histopathological diagnoses were fibrous dysplasia (8 patients), simple bone cyst (8 patients), chondroblastoma (7 patients), giant cell tumor (3 patients), and eosinophilic granuloma (1 patient). These lesions were managed with curettage followed by implantation of the bone defects with alpha tricalcium phosphate in 14 patients, beta tricalcium phosphate granules in 11 patients, hydroxyapatite granules in 1 patient, and combined beta tricalcium phosphate and hydroxyapatite granules in 1 patient. Internal fixation was performed in three patients.

RESULTS

The mean operative time was 143 min (80-245 min). Patients had regained normal unrestricted activity without pain at the operation site. Patients treated with beta tricalcium phosphate achieved radiographic consolidation of the bone defects within 1 year after the surgery, and those treated with alpha tricalcium phosphate or hydroxyapatite experienced no progression nor recurrence of the lesions. Local tumor recurrence was observed in one patient with giant cell tumor 5 years after the surgery. Post-operative pathological fracture was occurred in one patient with a simple bone cyst of the subtrochanteric region 1 month after surgery. No post-operative infection was observed.

CONCLUSION

We concluded that the treatment of benign lytic lesions of the proximal femur, either primary or recurrent, using synthetic bone graft is a safe and satisfactory method and the addition of internal fixation should be carefully planned.

Management of Fibrous Dysplasia of Proximal Femur by Internal Fixation Without Grafting: A Retrospective Study of 19 Patients

Introduction:

This paper assesses whether treating patients with fibrous dysplasia of proximal femur by internal fixation with correction of the deformity, if present, without grafting is enough or not.

Methods:

This study is a retrospective study using patient's medical records, including analysis of 19 patients with fibrous dysplasia of proximal femur treated by internal fixation only and followed up between 2000 and 2017 for at least 2 years. Epidemiologic data, clinical manifestations, radiologic and histologic investigations, surgery, functional outcomes, and complications in these patients were analyzed.

Results:

The study included 12 male patients and 7 female patients, with a mean age of 20.74 years. Of these, two patients presented with pathologic fractures, two presented with shepherd's crook deformity, and the remaining presented with hip pain and limping. Implants used for internal fixation were intramedullary nail in four patients, dynamic hip screw in eight patients, cannulated screws in four patients, broad dynamic compression plate in two patients, and narrow dynamic compression plate in one patient. The mean follow-up period was 53.58 months. Four patients had postoperative complications. The mean Musculoskeletal Tumor Society score was 27.63 points.

Discussion:

The optimal management option for fibrous dysplasia of proximal femur is debatable. We suggest that internal fixation without grafting has a good local control and satisfactory functional long-term outcome.

Advanced Unilateral Fibrous Dysplasia of the Scapula: A Rare Clinical Entity and Surgical Challenge

Introduction:

Fibrous dysplasia (FD) is an uncommon benign tumor of bone. Although FD can affect flat bones, it is rare for the scapula to be involved. In addition, little is known about the management of FD when it involves the scapula. We present possibly the first comprehensive case report of the management of advanced unilateral FD of the scapular region.

Case Report:

A 47-year-old male presented to us with pain and swelling over the left shoulder. The swelling was 11 cm × 15 cm × 8 cm and was hard and tender with rough texture. Radiograph showed large homogenous lesion with irregular but well-defined margins and a ground glass appearance. Magnetic resonance imaging scans showed well-defined borders with the expansion of the bone, with intact overlying cortices and endosteal scalloping. Biopsy confirmed the lesion to be FD. An innovative application of an existing surgical technique to minimize the impact of the residual deformity and dead space left after curettage of the scapula was done. The patient had good clinical and functional outcome at 6-month follow-up.

Conclusion:

Surgical exercise in FD is purely on symptomatic basis. In our case, the swelling was causing most discomfort, and we curettaged and compressed the bony swelling which resulted in excellent outcome in this patient.

Conservative surgical management of simple monostotic fibrous dysplasia of the proximal femur in a 19-year-old basketballer: a case report

Background

Fibrous dysplasia is a rare benign, intramedullary, fibro-osseous lesion. It is thought to be a developmental disorder of bone maturation where normal lamellar bone is replaced by irregular trabecular bone ensnared with fibrous dysplastic tissue that is unable to complete maturation resulting in significant loss of mechanical strength. This, together with the inability to mineralize sufficiently, leads to deformity, pain, and pathological fractures. It typically presents in young adults, with an equal representation in both genders. Surgical intervention is necessary in mild cases with chronic symptoms to prevent pathological fractures or to correct deformities.

Case presentation

A 19-year-old Chinese woman presented with non-traumatic, nonspecific left hip pain during basketball training. X-rays demonstrated a ground glass lesion, 10 cm in length, in her left femoral neck, which is a classic sign of fibrous dysplasia. No other deformities were noted. She was managed conservatively with analgesia for 6 months; however, her condition did not improve and a decision was made for surgical intervention. The lesion was a type 1 lesion according to the Ippolito radiological classification of fibrous dysplasia, which is a lesion with mild deformities. Therefore, we performed minimal curettage and insertion of a free autologous fibula strut harvested from her left leg, for structural stability. No implants were used. The operation was successful and her postoperative course was uneventful. Histology confirmed the diagnosis of fibrous dysplasia. She achieved partial weight bearing at 4 weeks postoperation, and full weight bearing at 8 weeks, and returned to basketball at 12 weeks. At 1-year follow-up, she returned to competitive basketball and remained pain free with no complications.

Conclusions

Fibrous dysplasia is a rare and benign fibrous tumor of the bone that presents mostly in a young patient population. From our case, we have shown that it is possible to treat young patients with uncomplicated Ippolito type 1 fibrous dysplasia with a minimally invasive approach of using a cortical bone graft for structural augmentation of the affected area, without the use of implants. They are able to fully return to an active and vigorous lifestyle without restriction of activities or long-term risks of orthopedic implant complications.

[Benign tumours and tumour-like lesions of the bone : General treatment principles]

BACKGROUND

Benign bone lesions are much more common than malignant lesions. Some benign bone tumors have a characteristic and typical radiographic appearance, while others are more challenging. Therapy of benign bone tumors differs greatly. While the majority of benign bone tumors do not require surgical therapy, other specific lesions, e. g. aneurysmal bone cysts or giant cell tumors (GCT) of the bone require surgery due to their locally aggressive behavior.

DIAGNOSTICS

The major challenge for the radiologist and/or pathologist is the differentiation between a benign and low-grade malignant lesion (e. g. enchondroma versus low-grade chondrosarcoma) for which all available clinical and radiographic information is mandatory. Therefore, surgical therapy is rather more often performed than necessary due to uncertainty in many cases.

THERAPY

Novel systemic therapies are available for fibrous dysplasia and GCT of the bone: Fibrous dysplasia can be treated with bisphosphonates, and GCT responds to denosumab. In fact, denosumab has been approved for the treatment of irresectable GCT. Osteoid osteoma is fairly easy to recognize and also to treat given the characteristic clinical presentation and rapid and effective response to local therapy (possible as percutaneous thermo-/laser ablation). In summary, several therapeutic options exist for benign bone tumors, and the choice depends upon the tendency/risk of local recurrence, the rate of surgical complications, options for defect reconstruction, postoperative functional deficits, and specific patient characteristics.

Fibrous dysplasia of the anterior mandible: A rare case report

Fibrous dysplasia (FD) is a rare bony disorder in which normal bone is replaced by abnormal fibro-osseous tissue. It often involves the long bones, craniofacial bones, ribs, and pelvis. Approximately 30% of monostotic FD (MFD) lesions are found in the cranial or facial bones. In general, FD is found in teenagers, and it usually becomes static after adulthood. FD involves the maxilla almost two times more often than the mandible. It frequently appears in the posterior region of the jaw bone and is usually unilateral. Here, we present an unusual case of symptomatic MFD affecting the anterior region of the mandible in a 43-year-old female with the clinical, radiographical, and histopathological features. The clinical examination showed both the labial and lingual bone expansion in the anterior mandible. The radiographic examination revealed a lesion with both radiopaque and radiolucent features showing a “ground-glass” appearance. The diagnosis was obtained after confirmatory intrabony biopsy with the histopathological examination, and it was diagnosed with benign FD. The patient preferred regular follow-up of MFD after discussion. During the regular follow-up, MFD lesion showed no obvious signs of progression or malignancy features.

A comprehensive review of the clivus: anatomy, embryology, variants, pathology, and surgical approaches

INTRODUCTION

The clivus is a bony structure formed by the fusion of the basioccipital and basispheniod bone at the sphenooccipital synchondrosis. This downward sloping structure from the dorsum sellae to the foramen magnum is derived from mesoderm and ectoderm properties.

METHODS

This comprehensive review of the clivus will discuss its basic anatomy, embryology, pathological findings, and surgical implications. The clivus is an endochondral bone, formed under two processes; first, a cartilaginous base is developed, and it is secondly reabsorbed and replaced with bone. Knowledge of its embryological structure and growth of development will clarify the pathogenesis of anatomical variants and pathological findings of the clivus.

CONCLUSIONS

Understanding the anatomy including proximity to anatomical structures, adjacent neurovasculature properties, and anatomical variants will aid neurosurgeons in their surgical management when treating pathological findings around the clivus.

Computed Tomography and Magnetic Resonance Imaging Manifestations of Spinal Monostotic Fibrous Dysplasia

Aim:

The purpose of the study was to analyze and summarize the computed tomography (CT) and magnetic resonance imaging (MRI) findings of spinal monostotic fibrous dysplasia (MFD) as well as evaluate the clinical value of CT and MRI in MFD diagnosis.

Materials and Methods:

CT (n = 4) and MRI (n = 5) images of six patients with pathologically confirmed spinal MFD were examined. The assessed image features included location, shape, rib involvement, vertebral collapse, margin, attenuation, and sclerotic rim on CT, as well as signal intensity, dark signal rim, and enhancement pattern on MRI.

Results:

In total, four of six patients underwent CT scanning. The most common findings on CT scanning were expansile lesions (n = 4), sclerotic rims (n = 4), and ground-glass opacity (GGO) (n = 4). In total, five of six patients underwent MRI. The lesions were low-signal intensity (n = 2), low-to-isointense signal intensity (n = 1), and low-signal intensity with several isointense portions (n = 2) on T1-weighted imaging (T1WI). The lesions were low-signal intensity (n = 1), isointense to high intensity (n = 1), and isointense signal intensity with several high portions (n = 3) on T2WI. A dark signal rim was found in most cases on T1WI and T2WI (n = 4). The lesions (n = 2) showed obvious enhancement.

Conclusions:

The CT and MRI manifestations of spinal MFD have the following characteristics: expansile lesion, GGO, sclerotic rim, and no obvious soft-tissue mass. The combined use of CT and MRI examinations is necessary for patients with suspected spinal MFD.

Concomittant fibrous dysplasia with aneurysmal bone cyst formation within the skull, humerus and rib

Polyostotic fibrous dysplasia (FD) is a rare pathology characterized by the abnormal and gradual replacement of normal bone (calcium hydroxylapatite of osteoid matrix) with fibrous connective tissue. Aneurysmal bone cyst (ABC) is a tumor-like benign lesion with blood-filled cavities that can affect virtually any bone in the body. We report on a 20-year-old male presenting with an extremely rare pathology of FD with ABC formation of the skull, fourth rib and humerus. Our case report represents a novel literary addition to rare FD with ABC pathologies. Optimal diagnosis of this rare pathology can be achieved by a full body evaluation for clinical and radiographic FD with or without ABC, and optimal treatment for this rare pathology is the maximum surgical excision of the tumor and/or soft tissue.

Fibrous dysplasia of bone: Surgical management options and outcomes of 22 cases

The surgical treatment for fibrous dysplasia (FD) of bone is problematic due to its variable clinical courses. And multifarious surgical treatment options have been reported while no consistent view can be reached. Therefore, we reviewed a series of 22 patients (11 males and 11 females; mean age 28.4 years, range 15-48 years) with FD between December 2011 and July 2015. Fourteen patients had monostotic fibrous dysplasia (MFD) and eight patients had polyostotic fibrous dysplasia (PFD) with nine lesions. All patients were followed up from 15 to 58 months with an average of 26.0 months. Functional and radiographic outcomes were recorded. In the MFD group, four patients were treated with curettage and bone grafting without internal fixation and nine were treated with curettage and bone grafting with internal fixations. Osteotomy and intramedullary (IM) nail was applied in one patient with serious deformity. In the PFD group, three deformity lesions were treated with osteotomy and proximal femoral nail anti-rotation (PFNA). IM were also applied in six large lesions to treat fracture or prevent deformity. One lesion in tibia were treated with only curettage and bone graft. No complication was observed in MFD group and satisfactory union and functional outcomes acquired during follow-up period. In the PFD group, the spiral blade cutting out from femoral head in PFNA was observed in one patient and treated with revision surgery. No other complication occurred, and satisfactory radiological and functional outcome were observed. The severity of both MFD and PFD are related to size, site and of the lesion. The goal of the surgery is to eliminate pain, correct deformity and treat pathological fracture. Curettage, bone grafting with internal fixation is recommended for treating large lesions with deformity or high pathological fracture risk. PFNA or IM nail is prior in osteotomy with better clinical outcome.

Expression of an active Gαs mutant in skeletal stem cells is sufficient and necessary for fibrous dysplasia initiation and maintenance

Fibrous dysplasia (FD) is a disease caused by postzygotic activating mutations of GNAS (R201C and R201H) that encode the α-subunit of the Gs stimulatory protein. FD is characterized by the development of areas of abnormal fibroosseous tissue in the bones, resulting in skeletal deformities, fractures, and pain. Despite the well-defined genetic alterations underlying FD, whether GNAS activation is sufficient for FD initiation and the molecular and cellular consequences of GNAS mutations remains largely unresolved, and there are no currently available targeted therapeutic options for FD. Here, we have developed a conditional tetracycline (Tet)-inducible animal model expressing the GαsR201C in the skeletal stem cell (SSC) lineage (Tet-GαsR201C/Prrx1-Cre/LSL-rtTA-IRES-GFP mice), which develops typical FD bone lesions in both embryos and adult mice in less than 2 weeks following doxycycline (Dox) administration. Conditional GαsR201C expression promoted PKA activation and proliferation of SSCs along the osteogenic lineage but halted their differentiation to mature osteoblasts. Rather, as is seen clinically, areas of woven bone admixed with fibrous tissue were formed. GαsR201C caused the concomitant expression of receptor activator of nuclear factor kappa-B ligand (Rankl) that led to marked osteoclastogenesis and bone resorption. GαsR201C expression ablation by Dox withdrawal resulted in FD-like lesion regression, supporting the rationale for Gαs-targeted drugs to attempt FD cure. This model, which develops FD-like lesions that can form rapidly and revert on cessation of mutant Gαs expression, provides an opportunity to identify the molecular mechanism underlying FD initiation and progression and accelerate the development of new treatment options.

Illness Perceptions are Associated with Quality of Life in Patients with Fibrous Dysplasia

Fibrous dysplasia (FD) is a rare bone disorder in which normal bone is replaced by fibrous tissue resulting in pain, deformities, pathological fractures or asymptomatic disease. Illness perceptions are patients' cognitions and emotions about their illness and its treatment, which may impact on Quality of Life (QoL). Here, we explore illness perceptions in patients with FD compared to other disorders, identify factors associated with illness perceptions and evaluate their relationship with QoL. Ninety-seven out of 138 eligible patients from the LUMC FD cohort completed the Illness Perception Questionnaire-Revised (IPQ-R) and the Short Form-36 (SF-36). Age, Gender, Skeletal Burden Score (SBS), FGF-23 levels, type of FD and SF-36 scores were analysed for an association with illness perceptions. We observed significant (p < 0.01) differences in patients' illness perceptions between FD subtypes in the domains: identity, timeline acute/chronic and consequences. Patients with craniofacial FD reported to perceive more consequences (p = 0.022). High SBS was associated with perceiving more negative consequences and attributing the cause of FD to psychological factors (p < 0.01), and high FGF-23 levels with attributing more symptoms to the disease and perceiving more consequences (p < 0.01). The IPQ-R domain identity, timeline acute/chronic, timeline cyclical, consequences, emotional representations and treatment control were significantly associated with impairments in QoL. Illness perceptions in patients with FD relate to QoL, differ from those in patients with other disorders, and are associated with disease severity. Identifying and addressing maladaptive illness perceptions may improve quality of life in patients with FD.

Induced GnasR201H expression from the endogenous Gnas locus causes fibrous dysplasia by up-regulating Wnt/β-catenin signaling

Fibrous dysplasia (FD; Online Mendelian Inheritance in Man no. 174800) is a crippling skeletal disease caused by activating mutations of the GNAS gene, which encodes the stimulatory G protein Gα_s FD can lead to severe adverse conditions such as bone deformity, fracture, and severe pain, leading to functional impairment and wheelchair confinement. So far there is no cure, as the underlying molecular and cellular mechanisms remain largely unknown and the lack of appropriate animal models has severely hampered FD research. Here we have investigated the cellular and molecular mechanisms underlying FD and tested its potential treatment by establishing a mouse model in which the human FD mutation (R201H) has been conditionally knocked into the corresponding mouse Gnas locus. We found that the germ-line FD mutant was embryonic lethal, and Cre-induced Gnas FD mutant expression in early osteochondral progenitors, osteoblast cells, or bone marrow stromal cells (BMSCs) recapitulated FD features. In addition, mosaic expression of FD mutant Gα_s in BMSCs induced bone marrow fibrosis both cell autonomously and non-cell autonomously. Furthermore, Wnt/β-catenin signaling was up-regulated in FD mutant mouse bone and BMSCs undergoing osteogenic differentiation, as we have found in FD human tissue previously. Reduction of Wnt/β-catenin signaling by removing one Lrp6 copy in an FD mutant line significantly rescued the phenotypes. We demonstrate that induced expression of the FD Gα_s mutant from the mouse endogenous Gnas locus exhibits human FD phenotypes in vivo, and that inhibitors of Wnt/β-catenin signaling may be repurposed for treating FD and other bone diseases caused by Gα_s activation.

Natural history of cranial fibrous dysplasia revealed during long-term follow-up: Case report and literature review

BACKGROUND

Fibrous dysplasia (FD) is a rare developmental disease characterized by the replacement of bone marrow with proliferating fibro-osseous tissue. There exist three forms of FD-monostotic, polyostotic, and that associated with McCune-Albright syndrome. The disease can present in different locations and with a variety of symptoms. One of the more common locations of FD occurrence is the craniofacial region. Treatment of asymptomatic FD often involves conservative management with serial imaging. Medical management with bisphosphonates is an option, though long-term efficacy data are lacking. Surgical resection is usually reserved for very large or symptomatic lesions.

CASE DESCRIPTION

We discuss the most unusual case of a 52-year-old male found to have a left pterional mass while being worked up for sinus headaches. The patient elected to follow this lesion conservatively, and imaging several years later showed obvious growth which accelerated in the last 4 years during an 18-year observational period. He ultimately underwent successful resection of an extradural and intradural FD.

CONCLUSIONS

The significant growth potential of these lesions was revealed in this patient, in whom conservative management had been adopted. Despite optimal surgical resection and outcome in this case, the importance of surveillance imaging and perhaps earlier intervention cannot be underestimated when managing cranial FD.

Post-traumatic fibrous dysplasia of the parietal bone: A rare entity

Fibrous dysplasia (FD) is a rare fibro-osseous lesion in which normal bone is replaced by abnormal fibrous tissue. Although a congenital disorder, a single case report of traumatic etiology had been described in the literature. We report a case of monostotic FD of the parietal calvarium in a 21-year-old female patient who presented to us with a single swelling in the parietal region been noticed after head injury sustained at the age of 7 years. After imaging investigations, the lesion was excised via craniotomy followed by cranioplasty in the same sitting. The histopathological evidence was suggestive of FD. To the best of our knowledge, this is the second case of a posttraumatic cranial FD and the first case describing the growing mass in the parietal bone secondary to head injury.

The value of 99mTc-methylene diphosphonate single photon emission computed tomography/computed tomography in diagnosis of fibrous dysplasia

Background

Fibrous dysplasia (FD) is a rare benign bone disorder in which the normal bone is replaced by immature fibro-osseous tissue. However, some case reports have reported that FD showed significantly increased ^99mTc-methylene diphosphonate (^99mTc-MDP) uptake on whole-body bone scintigraphy (WBS), which may mimic bone metastasis or skeletal involvement of the patients with known cancer. Thus, the purpose of present study is to observe the reliable characteristics and usefulness of single photon emission computed tomography/computed tomography (SPECT/CT) for the diagnosis of FD.

Methods

This was a retrospective review of 21 patients with FD (14 males and 7 females, mean age 51.2 ± 12.5 years) who were referred to have WBS to determine whether there was any osseous metastasis. WBS and SPECT/CT images were independently interpreted by two experienced nuclear medicine physician together with a diagnostic radiologist. In cases of discrepancy, consensus was obtained by a joint reading. The final diagnosis was based on biopsy proof and radiologic follow-up over at least 1 year.

Results

The lesions of FD were most frequently found in craniofacial region (15/21). Eighteen of the 21 (85.7%) cases showed moderate and high metabolism on WBS (compared to sternum). On CT imaging, GGO and expansion were the most common finding, were noted in 90.5% and 85.7% of the patients. Lytic lesions were present in 61.9% of the patients, and sclerosis was present in 38.1% of the patients. Cortical disruption was not seen in any patient.

Conclusions

FD has certain characteristic appearance on SPECT/CT. It should be enrolled in the differential diagnoses when lesions show elevated ^99mTc-MDP uptake on WBS. For SPECT/CT, the CT features of GGO and expansion in the areas of abnormal radiotracer uptake are helpful for the diagnosis of FD.

Bilateral Avascular Necrosis of the Femoral Head in Fibrous Dysplasia

Fibrous dysplasia (FD) is an uncommon benign skeletal disorder, characterized by bone pain, deformities, and the development of pathological fractures. It is caused by osteoblastic lineage differentiation defects, leading to the replacement of normal bone with benign disorganized fibrous connective tissue. Avascular necrosis (AVN) of the femoral head is an insidious condition that can often be challenging to diagnose in its early stages. The pathogenesis of AVN is not well understood; however, it causes femoral head ischemia and collapse, often requiring hip arthroplasty. We report the first case of FD and bilateral AVN of the femoral head in the absence of an antecedent fracture. We postulate several mechanisms to explain how FD may result in AVN; however, further research is required to understand its pathophysiology and thus to guide clinical practice. © 2017 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

What Is the Role of Allogeneic Cortical Strut Grafts in the Treatment of Fibrous Dysplasia of the Proximal Femur?

BACKGROUND

Fibrous dysplasia of the proximal femur is a progressive, often recurrent condition of bone that can cause skeletal deformity, fractures, and pain [corrected]. Allogeneic cortical strut grafting to minimize the risk of fracture or as part of fracture treatment is a promising treatment option, but evidence is scarce on the intermediate- to long-term results of this procedure and there are no data on factors associated with graft failure.

QUESTIONS/PURPOSES

The purposes of this study were (1) to evaluate the revision-free survivorship; (2) radiographic findings; (3) factors associated with failure; and (4) complications associated with cortical strut allograft to prevent or treat fractures of the proximal femur in patients with fibrous dysplasia.

METHODS

Between 1980 and 2013 we performed cortical strut allografting in 30 patients for impending or actual fractures of the proximal femur, of whom 28 (93%) were available for followup at a minimum of 2 years (mean, 13 years; range, 4-37 years) and of whom 22 (73%) had also been evaluated within the last 5 years. During that time, the indications for cortical strut allografting were an impending fracture of the proximal femur, persistent pain, or an actual nondisplaced femoral fracture. In patients who presented with a diaphyseal fracture, a fracture with severe dislocation of severe varus deformity, which required an osteotomy, placement of a blade plate was instead performed and these patients are not included here. During that time, for patients with diaphyseal fractures, and in patients with a displaced femoral fracture of the proximal femur, placement of a blade plate without strut grafting was instead performed; these patients are not included here. The primary outcome was the success rate of allogeneic cortical strut grafting surgery as assessed by the absence of revision surgery for a newly sustained fracture, resorption of the graft, or progressive deformity of the proximal femur. The association of possible contributing factors to graft failure such as gender, age at surgery, preoperative fracture, and anchoring distances of the graft in healthy bone was also evaluated using Cox regression analysis.

RESULTS

Revision surgery was performed in 13 patients, resulting in a mean survival time of 13 years (Kaplan-Meier 95% confidence interval [CI], 10-16). Radiological resorption of the graft was observed in 15 of 28 patients (54%). However, revision surgery was not performed in all patients who developed graft resorption, because of the absence of a risk for fracture on the basis of the anatomical site of resorption. Identified risk factors for graft failure included preoperative fractures (hazard ratio [HR], 4.5; 95% CI, 1.2-17.2; p = 0.028) and insufficient proximal anchoring of the graft in healthy bone (HR, 6.02; 95% CI, 1.3-27; p = 0.02). One patient sustained a refracture after surgery resulting from an in-hospital fall. The fracture was treated without further surgery, and it healed.

CONCLUSIONS

Our findings from this study suggest that cortical strut allografting may be a viable option for treatment of fibrous dysplasia of the proximal femur a without previous pathological fracture. Surgeons should pay particular attention to the proximal fixation point of the allograft to decrease the risk of failure. Patients with a fracture have an increased risk of failure and reoperation and so should be treated with an osteosynthesis.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Fibrous Dysplasia in the Epiphysis of the Distal Femur

Fibrous dysplasia is a common benign skeletal lesion that may involve a single bone or multiple bones. Although fibrous dysplasia can affect any bone, monostotic fibrous dysplasia of the long bone typically occurs in the diaphysis or metaphysis. We report a very rare case of monostotic fibrous dysplasia involving the epiphysis of the distal femur in a young man.

Monostotic fibrous dysplasia of the metacarpal: a case report

Fibrous dysplasia is a bone disease characterized by abnormal differentiation of fibrous tissue in the bones; it is often asymptomatic. It may affect one bone (monostotic) or several bones (polyostotic). The monostotic form primarily affects the ribs, but hardly ever affects the hand. It is important to make the differential diagnosis with malignant bone tumors. This article describes the treatment and outcome of a rare case of a patient admitted with a history of tumor growth in the right hand, diagnosed as fibrous dysplasia of the right second metacarpal. Male patient, 14 years of age, admitted to the Sarah Hospital with lesion on the dorsum of the right hand without pain complaints, previous history of trauma, nor local signs of inflammation. Physical examination revealed swelling on the dorsum of the second metacarpal, painless, with unaltered mobility and sensitivity. Radiography, computed tomography, and magnetic resonance imaging indicated the involvement of the entire length of the second metacarpal: only the distal epiphysis was preserved, with areas of bone lysis. After biopsy confirmation, the patient underwent surgery, using a long cortical graft for reconstructing the metacarpal. During the follow-up period of five years there were no signs of recurrence, and proper digital growth and functionality of the operated hand were observed.

Functional and radiological outcomes of a minimally invasive surgical approach to monostotic fibrous dysplasia

Background

Reports showing high recurrence rates for intralesional curettage and bone grafting have made the current treatment principle for fibrous dysplasia controversial. This study aimed to report the postoperative clinical outcomes from three minimally invasive surgical strategies we use for monostotic fibrous dysplasia (MFD).

Patients and methods

Twelve patients with MFD presenting with no pathologic fracture or deformity and treated with one of three surgical strategies—plain open biopsy, plain alpha-tricalcium phosphate (ATP) reconstruction, and prophylactic bridge plating—were included. There were nine men and three women, with median age of 38 years. Mean follow-up was 88 weeks. Five cases involved the proximal femur, two each involved the femoral and tibial diaphyses, and one each involved the distal humerus, radial diaphysis, and proximal tibia. All cases were reviewed for functional and radiological outcomes.

Results

Median time to full activity was 1 day (range 1 to 3) for the plain open biopsy group, while the prophylactic bridge-plating and plain ATP reconstruction groups had longer median recovery times (59 days, range 3 to 143, and 52 days, range 11 to 192, respectively). Musculoskeletal Tumor Society scores at last follow-up were excellent for all the cases (mean 29.6, range 25 to 30). Radiological analysis using Gaski et al.’s criteria showed plain open biopsy resulted in partial resolution of proximal femoral lesions, while ATP reconstruction and prophylactic plating resulted in no change and progression in this lesion site, respectively. For femoral diaphyseal lesions, prophylactic plating resulted in partial resolution, while ATP reconstruction resulted in no change. In the tibial diaphysis, prophylactic plating resulted in partial resolution, while plain open biopsy resulted in no change. For the lesions involving the distal humerus and the proximal tibia, plain open biopsy resulted in partial resolution, while for the radial diaphyseal lesion, ATP reconstruction resulted in no change. Radiological progression was limited in 11 (92%) cases, and none had postoperative complications.

Conclusion

Plain open biopsies for asymptomatic lesions; prophylactic bridge plating for symptomatic, large diaphyseal lytic lesions; and plain ATP reconstructions for both small and large nondiaphyseal symptomatic lytic lesions may be acceptable alternatives to curettage-incorporating procedures for MFD.

Image Findings of Polyostotic Fibrous Dysplasia Mimicking Metastasis in F-18 FDG Positron Emission Tomography/Computed Tomography

Fibrous dysplasia (FD) of the bone is characterized by the medullary cavity of bones becoming filled with fibrous tissue, and its etiology remains unknown. It is usually asymptomatic and found incidentally on imaging studies that are performed for other purposes. FD may closely mimic the appearance of bony metastatic disease on radiological examinations. We report the case of a 45-year-old female patient, which appeared to have multiple bone lesions on initial workup images. Subsequently, the bone lesions that showed increased FDG uptake on PET/CT in right femur and tibia were identified as FD. The present case is a useful addition to the current body of literature of false positive F-18 FDG PET/CT due to a benign skeletal pathology and underscores the importance of high index of suspicion and careful correlation, whenever one comes across such an unusual PET/CT finding.

Hypothyroidism in McCune-Albright Syndrome and Role of Bone Scan in Management of Fibrous Dysplasia: An Unusual Case Scenario with Review of Literature

The McCune–Albright syndrome (MAS) is a triad of café-au-lait skin pigmentation, precocious puberty (PP), and polyostotic fibrous dysplasia of bone (FD). In general, FD seems to be the most common component of MAS but very rarely precocious puberty can be found in association with café-au-lait skin pigmentation in the absence of FD (about 1% of the cases). Therefore, a more clinically relevant definition of MAS is fibrous dysplasia of bone (FD) and at least one of the typical hyperfunctioning endocrinopathy and/or café-au-lait spots, with almost any combination possible. Bone scan can be the modality of choice to look for bone disease burden of fibrous dysplasia in most patients of MAS and may change the management accordingly. Most of the cases of MAS reported worldwide are associated with hyperthyroidism, up to best of our knowledge on the basis of literature search in pubmed and Google; no case was reported with hypothyroidism. Herein, we report a 12-year-old girl diagnosed with MAS and associated hypothyroidism. We have also reviewed the MAS related literature.

Fibrous dysplasia of the maxilla in an elderly female: Case report on a 14-year quiescent phase

Fibrous dysplasia (FD) is an uncommon skeletal disorder in which normal bone is replaced by abnormal fibro-osseous tissue. Mainly, FD is found in children, and by adulthood it usually becomes quiescent. Our case showed FD of more than 14-year duration in the left maxilla. Our evaluation was that growth ceased in adulthood and had achieved the static stage. Because FD cases in elderly patients are rarely reported, we hereby present a monostotic FD case in a 65-year-old female. We presented sequential radiographic images and scintigraphic images of this case, and combined them with a literature review that emphasized the progression of the disease.

"Well Digging" Subcraniotomy Strategy with Navigation for Optic Nerve Decompression in Frontoorbital Fibrous Dysplasia: Preliminary Experience

Background:

During the past decades, surgical intervention has been the primary treatment modality for frontoorbital fibrous dysplasia involving optic nerve. However, controversy has surrounded the role of optic nerve decompression in a number of ways. Herein, we describe 3 patients with frontoorbital fibrous dysplasia involving optic nerve, who underwent a “well digging” subcraniotomy strategy with navigation for intraorbital unit optic nerve decompression.

Methods:

From 2013 to 2015, 3 patients with frontoorbital fibrous dysplasia were investigated in a retrospective manner. They underwent unilateral intraorbital optic nerve decompression with the help of “well digging” strategy and navigation. The key procedures comprise preoperative software simulation, frontoorbital subcraniotomy (like digging a well), expanding cone-shaped surgical field, intraorbital unit optic nerve decompression with navigation, correcting frontal-orbital dystopias, and deformities.

Results:

Both at the immediate postoperative period and during the 3–12 months follow-up, 2 cases showed improvement of visual acuity in the affected eye and 1 case showed no deterioration. Other ocular examinations including eye movement were stable. Subsequent reconstruction yielded a satisfactory cosmetic result. No postoperative complications happened.

Conclusions:

In our philosophy, surgical management should be tailored to each patient, which is based on the most possible potential etiology. We consider that the intraorbital optic nerve decompression may be more feasible and safer with the help of “well digging” strategy and navigation, especially for those with exophthalmos, orbital volume decreasing, and nonacute visual loss.

Odontogenic Sinusitis Caused by an Inflammation of a Dentigerous Cyst and Subsequent Finding of a Fibrous Dysplasia. A Case Report

We report the case of a 38-year old male patient with sinusitis caused by an infected follicular cyst due to an ectopic impacted third molar in the right maxillary sinus. A 10-day antibiotherapy regimen was administered; subsequently, the cyst and the third molar were removed achieving complete recovery. Fibrous dysplasia was diagnosed at follow-up examination (occupation of the maxillary sinus by bone tissue was observed in a radiographic examination) and confirmed by biopsy. In cases of odontogenic sinusitis, thorough examination is crucial, as evidenced by the case reported in this study. A Literature review was performed in order to identify the diagnostic methods currently available and the clinical features, complications and treatment for both, odontogenic maxillary sinusitis and fibrous dysplasia.

Fibrous dysplasia of the middle nasal turbinate: imaging and clinical significance

Two cases of fibrous dysplasia involving the middle nasal turbinate are presented. Fibrous dysplasia is a common benign fibro-osseous disease involving the flat bones, often affecting the bony structures of the skull and facial skeleton. Primary occurrence or secondary involvement of the nasal turbinate is not a common manifestation of the disease. Involvement of the inferior turbinate generally does not have specific management-related issues; however, involvement of the middle turbinate, especially the lateral lamella, can predispose to surgical morbidity during endoscopic surgical management. Clinical presentation, management and features of the disease on CT imaging are presented.

[Place of the microscopic examination in the diagnosis of costal fibrous dysplasia]

BACKGROUND

Fibrous dysplasia of bone is a rare benign lesion characterized by the coexistence of a fibrous tissue and an immature osteogenesis. Costal localization is rare and may be monostotic or polyostotic. The diagnosis may be suspected based on clinical and radiological findings. Facing the development of radiological investigations, we tried to highlight the diagnostic role of the microscopic examination through the experience of our department.

METHODS

We describe a retrospective study about 12 costal fibrous dysplasias diagnosed over a 17-year-period. Clinical records were retrieved from the department of thoracic surgery of the same hospital.

RESULTS

Costal fibrous dysplasia is equally observed in men and women with predominance in the third and fourth decades. Clinical symptoms consist mainly in chest pain. Physical examination was normal in almost all cases. Based on the radiological findings, the diagnosis was suspected in 33% of the cases. Microscopic examination highlighted the diagnosis in all cases but it was challenging in one case and necessitated a multi-disciplinary approach. The difficulties encountered were due to artifact decalcification.

CONCLUSION

Costal fibrous dysplasia is a benign lesion which diagnosis is based on microscopic features. Radiologic investigations show nonspecific features but allow to rule out a malignant tumor. The outcome of the patients is generally good except in rare cases with a malignant transformation.

Two-Stage Surgical Treatment of Complex Femoral Deformities with Severe Coxa Vara in Polyostotic Fibrous Dysplasia

Introduction

For complex femoral deformities in patients affected by polyostotic fibrous dysplasia and coxa vara associated with shepherd's crook deformity of the femoral shaft, the correct treatment is stabilization with an interlocking cervicodiaphyseal nail after correction of all of the femoral deformities.

Indications & Contraindications

Step 1 The First-Stage Procedure—Intertrochanteric Valgus Osteotomy and Fixation with a Hip Blade-Plate Preoperative Planning

Evaluate the patient radiographically and select the hardware.

Step 2 Patient Preparation

Position the patient on the traction table.

Step 3 Preparation of the Lateral Aspect of the Proximal Part of the Femur and Marking the Position for Both the Osteotomy and the Hip Blade-Plate

Expose the lateral aspect of the proximal part of the femur and mark the position of both the blade-plate and the osteotomy.

Step 4 Blade-Plate Positioning Osteotomy and Osteotomy Fixation

Prepare the slot for the blade, perform the osteotomy, and correct the valgus alignment of the proximal part of the femur.

Step 5 Postoperative Management

Check postoperative bleeding, provide blood transfusions if needed, and have the patient resume walking.

Step 6 The Second-Stage Procedure—Hip Plate Removal Osteotomy of the Femoral Shaft to Correct the Shepherd’s Crook Deformity and Stabilization with a Cervicodiaphyseal Nail Preoperative Planning

Study the patient radiographically, simulate the osteotomies, perform another assessment of lower-limb length, and select the hardware.

Step 7 Patient Preparation Plate Removal and Drilling of Kirschner Wires to Mark the Site of the Planned Osteotomies

Position the patient on the traction table and expose the lateral aspect of the femur from the tip of the greater trochanter to the level of the most distal planned osteotomy.

Step 8 Perform All of the Osteotomies and Drill a Medullary Canal in the Osteotomy Fragments

All of the osteotomies are performed, and a medullary canal is drilled in each femoral fragment.

Step 9 Nail and Spiral Blade Insertion Stabilization of Osteotomies and Closure

Introduce the nail into the osteotomy fragments and insert the spiral blade and distal locking screws.

Step 10 Postoperative Management

Check postoperative bleeding, which is usually marked; administer blood transfusions as needed; and have the patient resume walking.

Results

We performed this surgery on 13 femora in 11 patients.

Pitfalls & Challenges

A Rare Cause of Shoulder Pain: Monostotic Fibrous Dysplasia

Fibrous dysplasia is a rare bone disease which has a wide spectrum of symptoms depending on the involvement area such as pain, deformity, fracture, dyspnea or visual loss. One of the rare involvement areas is the bones around the shoulder. Fibrous dysplasia presents in two forms named monostotic or polyostotic. In this article, we present a case with monostotic fibrous dysplasia of the humeral head who admitted to our clinic with shoulder pain.

Central Cemento-Ossifying Fibroma: Primary Odontogenic or Osseous Neoplasm?

Currently, central cemento-ossifying fibroma is classified by the World Health Organization as a primary bone-forming tumor of the jaws. However, histopathologically, it is often indistinguishable from cemento-osseous dysplasias in that it forms osteoid and cementicles (cementum droplets) in varying proportions. It is believed that pluripotent cells within the periodontal membrane can be stimulated to produce either osteoid or woven bone and cementicles when stimulated. If this is true, cemento-ossifying fibroma would be better classified as a primary odontogenic neoplasm arising from the periodontal ligament. Cemento-ossifying fibromas also do not occur in the long bones. The present report compares several entities that fall within the diagnostic realm of benign fibro-osseous lesions and reviews the evidence for reclassifying central cemento-ossifying fibroma as a primary odontogenic neoplasm.

McCune-Albright syndrome with craniofacial dysplasia: Clinical review and surgical management

BACKGROUND

Fibrous dysplasia (FD) is a benign fibro-osseous lesion related to an abnormal bone development and replacement by fibrous tissue. FD has three clinical patterns namely monostotic, polyostotic, and the McCune-Albright syndrome (MAS). MAS is a rare genetic disorder (about 3% of all FD's) that comprises a triad of polyostotic FD, café-au-lait skin macules, and precocious puberty. MAS can involve the orbit region and cause stenosis in the optic canal, leading the patient to a progressive visual loss.

METHODS

We reported a case of craniofacial FD in MAS in a 9-year-old male with progressive visual loss, submitted to optic nerve decompression by fronto-orbito-zygomatic approach, with total recovery. A research was made at Bireme, PubMed, Cochrane, LILACS, and MEDLINE with the keywords: FD/craniofacial/McCune-Albright/Optic compression for the clinical review.

RESULTS

A clinical review of the disease was made, the multiple, clinical, and surgical management options were presented, and the case report was reported.

CONCLUSION

MAS is a rare disease with a progressive polyostotic FD. Whenever it affects the orbit region, the optic canal, and it is associated with a progressive visual loss, the urgent optic nerve decompression is mandatory, either manually or with a rapid drill. It is known that aggressive approach is associated with less recurrence; it is also associated with worsening of the visual loss in optic nerve decompression. In MAS cases, multiple and less aggressive surgeries seem to be more suitable.

Imaging of focal calvarial lesions

Focal calvarial lesions may present as a visible, palpable, or symptomatic lump; however, with increasing use of cross-sectional imaging they are often encountered as an incidental finding. Knowledge of the possible disease entities along with a structured approach to imaging is required to suggest an appropriate diagnosis and assist in management planning. Abnormalities range from common neoplastic lesions to rarer congenital conditions, benign pathologies, and calvarial defects that can mimic lesions. The aim of this article is to demonstrate the salient imaging features that may help to limit the differential diagnosis of a focal calvarial lesion.

Fibrocartilaginous Dysplasia of the Bone: A Rare Variant of Fibrous Dysplasia

Fibrocartilaginous dysplasia (FCD) is a rare variant of fibrous dysplasia (FD) which frequently involves the long bones, and the proximal femur is the most commonly affected site. This benign, lytic, and expansile bone lesion causes progressive deformity in the bones and may lead to pathological fracture. Radiologically, this lesion may mimic cartilaginous benign and malignant bone tumors. Therefore, histopathological differentiation of FCD from other cartilaginous tumors is of the utmost importance. The treatment is often surgical, in the form of curettage and bone grafting or corrective osteotomy, to treat progressive deformity in the long bones. The risk of pathological fracture is high in FCD with bony deformity and often requires surgery.

A Rare Case of Monostotic Spinal Fibrous Dysplasia Mimicking Solitary Metastatic Lesion of Thyroid Carcinoma

Monostotic fibrous dysplasia of the vertebra is a rare entity. A case of a 53-year-old lady who presented with an 8 months history of pain in the thoracic spine region with paraparesis is discussed. She had a history of papillary thyroid carcinoma and had undergone total thyroidectomy one year prior to her current problem. Magnetic resonance imaging revealed isolated osteolytic lesion over the posterior element of the T12 vertebra with narrowing of the spinal canal causing compression of the cord. The diagnosis of fibrous dysplasia was made histologically. Fibrous dysplasia rarely occurs in axial bones compared with peripheral bones. This case illustrates that osteolytic lesion of the vertebrae should be evaluated with detailed radiological and histopathological examination before an empirical diagnosis of spinal metastasis is made in an adult with a background history of primary malignancy well-known to spread to the bone.

Radiographic classification and treatment of fibrous dysplasia of the proximal femur: 227 femurs with a mean follow-up of 6 years

BACKGROUND

Research into the optimal treatment of fibrous dysplasia has been limited by the lack of an established classification system for the disease. The purposes of this study were to develop a radiographic classification for fibrous dysplasia of the proximal femur and to test this classification's intra- and interobserver reliability as well as the effectiveness of our treatments.

METHODS

We retrospectively reviewed radiographs and computed tomography (CT) of 227 femurs from 206 patients with fibrous dysplasia. The radiographs were evaluated in the coronal plane for neck-shaft angle, varus deformity in the proximal femoral shaft, and distal juxtaarticular valgus deformity. CT was evaluated in the axial plane for destruction of cortex. Reduction of bone strength was defined as the thickness of the remaining cortex less than 50 % of the original on axial CT. Two senior orthopedists evaluated each radiograph and CT twice at 8-week intervals. Intra- and interobserver reliability testing was performed using the kappa statistic. Treatments were assessed through mid-term follow-up.

RESULTS

The 227 femurs were classified into five reproducible types: type 1 (33 %), normal bone strength without angular deformity; type 2 (30 %), decreased bone strength without angular deformity; type 3 (12 %), isolated coxa vara with neck-shaft angle <120°; type 4 (11 %), isolated varus deformity in the proximal femoral shaft; and type 5 (14 %), coxa vara with varus deformity in the proximal femoral shaft. Intra- and interobserver kappa values were excellent, ranging from 0.85 to 0.88. Good clinical outcomes were achieved.

CONCLUSIONS

This radiographic classification of fibrous dysplasia is reproducible and useful for describing and assessing this disease. The treatments based on this classification were effective.

CT-guided percutaneous skull biopsy using a drill-assisted system: Technical report of two cases

The OnControl coaxial biopsy system (Vidacare Corporation, Shavano Park, TX) includes an inner diamond-tipped access needle and hollow biopsy needle that engage with a battery-powered hand drill. Herein, we report the use of this novel device to perform two CT-guided percutaneous skull biopsies. Both procedures were performed without complication and facilitated a pathologic diagnosis.