Dysplasia epiphysealis hemimelica of the scaphoid bone

Dysplasia epiphysealis hemimelica: a histological comparative study with osteochondromas

PURPOSE

Dysplasia epiphysealis hemimelica (DEH) is a rare developmental disorder resulting in epiphyseal overgrowth. Based on histological appearance, it is often described as an osteochondroma or osteochondroma-like lesion, although clinical differences exist between DEH and osteochondromas. The aim of this study was to test whether DEH and osteochondromas are histologically identical diseases.

METHODS

Tissue samples of two age- and gender-matched cases with DEH and hereditary multiple exostoses were histologically compared. Sections were stained with Safranin-O for detection of proteoglycans and immunohistochemistry was performed for detection of collagen type II, collagen type X as a marker of hypertrophic chondrocytes and Sox9 as a marker of proliferative chondrocytes. Due to the rarity, descriptions of the included DEH patients were outlined.

RESULTS

Histologically, chondrocyte clusters in a fibrillary matrix, a thick disorganised cartilage cap and ossification centres with small amounts of unabsorbed cartilage, were observed in DEH. In contrast, cartilage organisation of osteochondromas displays characteristics of the normal growth plate. Collagen type II was clearly detected in the cartilaginous extracellular matrix in osteochondromas, while weak expression was observed in DEH. Collagen type X was not detected in DEH, while expressed in the matrix surrounding hypertrophic chondrocytes in osteochondromas. Sox9 staining was positive in hypertrophic chondrocytes in osteochondromas, while expressed in nuclei of chondrocyte clusters in DEH.

CONCLUSION

Both morphological and immunohistological differences were observed in histological sections of DEH and osteochondromas. These results support the previously identified clinical, radiological and genetic differences and imply a different aetiology between DEH and osteochondroma formation.

Epiphyseal osteochondromas of the upper limb: a report of 7 cases

BACKGROUND

Originally described as osteochondromatous lesions arising from the tarsal bones, osteochondromas arising from the epiphysis or carpal/tarsal bones are less common than those arising from the metaphysis. Histologically, all osteochondromas are indistinguishable regardless of the location from which they arise. Few case reports and case series exist describing these lesions in the upper limb.

METHODS

We review 7 cases of osteochondromas arising from epiphyses and ossicles in the upper limb treated at 3 institutions. Patients were followed for an average of 5.7 years. The average patient age at the presentation was 7.8 years.

RESULTS

We identified 25 lesions: 5 distal radial epiphyseal, 3 distal radial metaphyseal, 4 scaphoid, 4 lunate, 4 trapezial, 2 accessory ossicles adjacent to the trapezium, 2 trapezoid, and 1 metacarpal lesion. Three patients presented with pain, 5 with decreased motion, and 3 with angular deformity. In 1 case, the lesion presented as an incidental finding. Four patients underwent a total of 7 procedures: 2 open biopsies, 2 distal radial epiphyseal lesion excisions, 2 revisions, and 1 excision of all lesions with a scaphoid osteotomy.

CONCLUSIONS

Intra-articular and transosseous lesions are more likely to result in angular deformities and loss of motion at the joints, whereas juxtaphyseal and transphyseal lesions are more likely to result in growth disturbances and angular deformities at the physis.

LEVEL OF EVIDENCE

Case series, level IV.

Treatment of dysplasia epiphysealis hemimelica: a systematic review of published reports and a report of seven patients

Dysplasia epiphysealis hemimelica is a rare entity. It is characterized by cartilage overgrowth in the epiphyses and is considered to be an epiphyseal osteochondroma. It usually presents during childhood and can cause pain and functional limitations. The aim of the present study was to describe the entity through our cases and published data and to present the results of our suggested treatment. A systematic search was performed to retrieve and describe all studies on dysplasia epiphysealis hemimelica. Studies were included if sufficient information on the patient characteristics, lesion location, treatment, and outcomes were described. In addition, we report on 7 of our patients. In our review, 48 studies were found, of which 42 could be included. Owing to the large heterogeneity in the studies, no pooling of data was performed. The studies included 138 patients with 255 lesions. Approximately 27% were female patients. The age at presentation ranged from 3 months to 66 years; however, in most, the entity was discovered before 8 years of age. No apparent guidelines were presented concerning the treatment strategy; however, most investigators performed resection because of pain or limitations in the range of motion. Most lesions were located in the ankle or foot (139 of 255). In our own cases, 5 of 7 patients experienced pain, limited range of motion, or activity restriction. The mean follow-up period was 4 years. Dysplasia epiphysealis hemimelica is a rare entity, occurring predominantly in the lower extremity of in young male patients. Its aggressive growth warrants aggressive treatment in the case of pain or functional or range of motion limitations.

Solitary intra-articular osteochondroma of the finger

BACKGROUND

A solitary osteochondroma of the finger occasionally occurs intra-articularly and may cause clinical symptoms, including limited motion and deformity. The present report describes the clinical features and the results of operative treatment for a series of patients who had a solitary intra-articular osteochondroma of the finger.

METHODS

Ten patients with a solitary intra-articular osteochondroma of a phalanx of a finger were managed surgically. Eight patients were male, and two were female. The average age at the time of surgery was fourteen years. Treatment consisted of mass excision for three patients and mass excision with corrective osteotomy for six. One additional patient had a boutonniere deformity and underwent extensor tendon reconstruction combined with mass excision. The average duration of follow-up was forty-four months.

RESULTS

The proximal phalanx was affected in six patients, and the middle phalanx was affected in four. All tumors involved the distal epiphysis. All patients had postoperative improvement in terms of deformity and/or limitation of motion. Six patients had a preoperative mean coronal plane deformity of 29 degrees, which improved to 4 degrees after surgery. The preoperative mean arc of flexion-extension improved from 54 degrees to 78 degrees in four patients who had a motion deficit at the proximal interphalangeal joint and from 60 degrees to 80 degrees in one patient who had a motion deficit at the distal interphalangeal joint. Two patients had a residual flexion contracture, one with preexisting osteoarthritis and one with a longstanding progressive boutonniere deformity. There were no other complications or recurrences.

CONCLUSIONS

Isolated intra-articular osteochondroma of the finger can cause deformity and/or motion limitation. Early mass excision and corrective osteotomy when indicated are recommended to restore full range of motion and to prevent osteoarthritis and secondary deformity.

Dysplasia epiphysealis hemimelica of the distal ulna: a case report and review of the literature

Dysplasia epiphysealis hemimelica (DEH) or Trevor's Disease is a very rare disease with an estimated incidence of one in 1.000.000. The majority of cases reported affect the lower limb and only 25 case reports of 33 cases with affection of the upper limb have been published. Here we present a case of DEH affecting the distal ulnar epiphysis and the lunate in an eleven-year-old girl, a DEH location described extremely rarely before. We firstly do not only present clinical and radiological findings (plane radiographs, CT, MRI), but also the surgical approach and the histopathological results of DEH in this uncommon location. Although extremely rare, DEH should be considered also in non-typical locations.

Dysplasia epiphysealis hemimelica (Trevor's disease): 7 of our own cases and a review of the literature

BACKGROUND AND PURPOSE

Dysplasia epiphysealis hemimelica is characterized by irregular overgrowth of cartilage in the epiphysis, usually affecting the knee and ankle. We treated 7 children by surgery between 1980 and 2005. After reporting one child case, we summarize our cases and the cases described in the literature.

METHOD

We discuss the diagnosis of this dysplasia, especially the role of radiography. We describe the suggested treatment, which could be surgical or non-surgical depending on the location and the symptoms.

RESULTS

After reviewing 57 cases, we found that this dysplasia occurs twice as often in males as in females. The medial side of the epiphysis is affected twice as often as the lateral side. In two-thirds of the cases, more than one epiphysis was affected. If the location of the exostosis suggests that it might lead to joint deformity, early surgical excision is recommended.

INTERPRETATION

Since there is often involvement of more than one epiphysis, we emphasize the importance of a skeletal survey once this dysplasia is diagnosed.

Acetabular dysplasia with hip subluxation in Trevor's disease of the hip

Dysplasia epiphysealis hemimelica (Trevor's disease) is a rare developmental bone disorder characterized by single or multiple epiphyseal intraarticular lesions that are usually unilateral and restricted to one side of the limb. Although the process often is limited to the lower extremity, hip involvement is not common. When it occurs it is more commonly limited to the femoral side. We report a 14-year-old boy with Trevor's disease involving the hip, femoral and acetabular sides, and with progressive dysplasia. We describe a new surgical approach to this rare condition using a two-stage procedure consisting of intraarticular resection of the lesion followed by a modified shelf acetabuloplasty in a second stage to prevent compromise of the proximal femur vasculature, and to allow preservation and improvement of range of motion of the hip. At 36 months followup the patient is pain-free, has full range of motion, improved gait, and no signs of recurrence. Although technically challenging, the two-stage approach to Trevor's disease seems a reasonable and safe method.

Early loss of hip containment in a child with dysplasia epiphysealis hemimelica

Progressive loss of hip containment attributable to dysplasia epiphysealis hemimelica of the right proximal femur and macrodactyly of the right second toe was diagnosed and monitored by radiographs and magnetic resonance imaging in a 7-year-old boy. The patient had early surgical correction including shortening osteotomy of the hypertrophic toe and partial resection of the involved superolateral femoral head-neck junction combined with a Pemberton-like acetabuloplasty. This treatment restored containment and function. At 4 years followup, the femoral head remained contained and the patient was participating fully in the activities of daily life for his age-group. A review of the literature suggests monitoring the hip with magnetic resonance imaging may allow early identification of a hip at risk for loss of containment. This treatment may save the hip from severe deformity and early secondary osteoarthritis.

Dysplasia epiphysealis hemimelica of the hand: two cases at the proximal interphalangeal joint

We report two cases of dysplasia epiphysealis hemimelica (Trevor's disease) at the PIP level of the finger. In one girl the first radiographic signs were seen at the age of 4 years, and progressive clinodactyly required treatment at the age of 7 years. She underwent an osteotomy. The second girl was seen with a clinodactyly and the accessory growth center was present already at the age of 5 years. The intra-articular exostosis was removed. Both had a complete correlation and a full range of motion.