Multiple occurrence of osteochondromas in dysplasia epiphysealis hemimelica

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.

Diagnosis and surgical treatment of dysplasia epiphysealis hemimelica. A report of nine cases

BACKGROUND

Dysplasia epiphysealis hemimelica (DEH) is a rare developmental bone disorder with hemimelic involvement of one or more epiphysis. We report on nine new cases and discuss the clinical manifestations, the value of MRI, and the results of complete and early surgical resection of these lesions.

MATERIALS AND METHODS

In this retrospective study, nine patients with a diagnosis of DEH were evaluated. Age at presentation ranged from 1 year to 12 years. The main complaint at diagnosis was a swelling bony mass. Angular deformities were recorded in two patients. All patients were surgically treated and followed up clinically and by imaging. Eight patients underwent excision only.

RESULTS

The average follow-up was 5.6 years (range, 2-10.5 years). All patients had a good outcome without related symptoms. No epiphysiodesis, angular deformity or recurrence was observed. One patient with femoral lesion involving the distal medial part of the epiphysis developed, four months after surgical excision, a calcification outside the area of total excision. This calcification did not increase in size at two years follow-up. Another patient with lateral involvement of the proximal tibial epiphysis presented a postoperative nervous complication. Spontaneous nervous recovery occurred three months after surgery.

DISCUSSION

MRI was useful to find a potential plane of cleavage between the epiphysis and the pathological tissue. We recommend early removing ossifications when a cleavage plane is identified. Waiting a possible complication or increasing of size does not seem logical. Of course, the treatment will be not the same if no cleavage plane is found on MRI.

LEVEL OF EVIDENCE

IV.

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.

Hallux valgus interphalangeus deformity: A case series in the pediatric population

PURPOSE

The objective of this report is to describe three cases (four feet) of hallux valgus interphalangeus deformity in the pediatric population.

METHODS

A retrospective review was completed to identify three patients (four feet) with a deformity consistent with hallux valgus interphalangeus. Patients were followed at regular intervals for a minimum of 6 months. Treatment modalities and clinical results were reviewed for all patients for this relatively rare entity in the skeletally immature population.

RESULTS

All patients in this report had a deformity that was not consistent with a traumatic etiology. Case number 1 had a significantly symptomatic deformity that failed conservative treatment, and eventually necessitated full surgical correction of the deformity. Symptom free unrestricted activity was obtained post-operatively, however final follow-up radiographs have demonstrated early changes consistent with arthritis. Case numbers 2 & 3 were relatively asymptomatic throughout their course of treatment, and responded well to non-operative intervention.

CONCLUSION

Based on these findings excision of the exostosis and soft-tissue realignment appears to be a reliable option for symptom relief for patients who present with a painful symptomatic hallux valgus interphalangeus deformity. However, the risk of degenerative changes following spur removal must be entertained prior to the procedure. On the contrary a pain free deformity that does not impact functionality of toe, or impair shoe ware may be treated successfully with conservative measures.

Dysplasia epiphysealis hemimelica: a case report with novel pathophysiologic aspects

Dysplasia epiphysealis hemimelica (DEH) is a rare developmental disorder. The underlying pathophysiology is largely unclear. Its diagnosis is based on clinical findings and may be difficult due to its low incidence and close relationship to other disorders such as osteochondroma. We describe a 13-year-old boy who presented with a unilateral lesion of the left medial femoral condyle and left ankle. In addition to standard diagnostic tools such as radiographs and MRI, arthroscopy-guided biopsy was performed; histologic/immunohistochemical findings from cartilage-bone specimens confirmed the diagnosis and provided novel information toward a disease mechanism. The cellular phenotype of clustered chondrocytes exhibited characteristics of chondroprogenitor cells and terminally differentiated cells, suggesting dysregulation of resident progenitor cells. No other surgery was performed and during a 2 year period, we observed spontaneous ossification of the lesion associated with decreased joint impairment. Immunohistochemical analysis of the lesion provided a more accurate diagnosis and may contribute to unraveling potential novel mechanisms involved in its pathogenesis.

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.

Trevor's disease: the clinical manifestations and treatment of dysplasia epiphysealis hemimelica

Trevor's disease is a rare abnormality characterized by aberrant osteocartilaginous growth from an epiphysis. We describe six new cases from our institution. A patient with isolated tibial tuberosity involvement is described for the first time. Each patient was classified according to Azouz into localized (three), classical (two) and generalized (one) form. We recommend that parents be counseled regarding the progressive nature of this disorder owing to the chance of worsening deformity with surgical excision alone, and the need to be followed until skeletal maturity.

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.