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

Dysplasia Epiphysealis Hemimelica (Trevor Disease) of the Patella: A Case Report

CASE

We report a rare case of dysplasia epiphysealis hemimelica in an 11-year-old male child involving the patella. The patient noticed swelling in the right knee 6 months before presentation. On evaluation, there was a mass lesion originating from superior pole of the patella extending into the suprapatellar pouch. On opening the knee joint, it was found to be mainly cartilaginous in nature. Surgical excision of the mass was carried out.

CONCLUSION

Trevor disease should be considered in the differential diagnosis of a mass originating from the patella in children. The recommended treatment is complete excision of the mass.

Dysplasia Epiphysealis Hemimelica Can Be Controlled by Growth Modulation: A Case Report

CASE

Dysplasia epiphysealis hemimelica (DEH), or Trevor disease, is an abnormal nonmalignant overgrowth of the epiphysis on one side of the body, often confined to one half of a joint of a limb. There is no known etiology or treatment for it. We are reporting the case of a 4.5-year-old boy with osteochondral-like growths on one side of the knee and ankle that could not be controlled by repeated excision. He underwent epiphyseal stapling at the knee and ankle. The regrowth was halted in both locations and has lasted for over 8 years.

CONCLUSION

Modulation of physeal growth by stapling can halt the uncontrollable overgrowth of lesions in DEH.

Trevor's disease: up-to-date review of the literature with case series

Trevor's disease, also known as dysplasia epiphysealis hemimelica, is a rare nonhereditary skeletal development disorder that affects epiphyses. This type of dysplastic lesion was first reported by Mouchet and Berlot in 1926 under the name 'tarsomegaly'. The main aim of this study is to raise awareness of Trevor's disease among orthopedic surgeons and underline some important aspects of treatment by a detailed presentation of four different possible manifestations of the disease. Four different treatment methods were used on four different patients (three localized in hindfoot ankle region and one classic Trevor's disease case). Treatment methods, localization of the sides involved, different characteristics of entire lower extremity, asymetry, distal femoral lateral epiphysis involvement, and hip involvement were analyzed thoroughly and the results were compared with those found in the most recent literature. Of our four patients, three were localized (hind foot ankle) cases and one was a classic dysplasia epiphysealis hemimelica with hemimelic distribution of the entire lower extremity. We used arthroscopic resection, observation, excision, and temporary hemiepiphysiodesis treatment methods in each of our cases. Clinical follow-up results were reported to be between good and excellent. In sum, our opinion is that the treatment for this condition should be customized according to lesion localization and lesion size. Majority of cases with ankle involvement show good prognosis following excision. Observation is also an alternative in patients who refuse surgery. If an intra-articular lesion is present, the surgeon should perform an arthroscopy for assessment of lesion surface. If the lesion is adapted to the joint curvature, it should be left alone and hemiepiphysiodesis should be considered for correction. The most risky involvements that are related to deformities and limb-length discrepancies are the hip and the knee. This is usually the result of corrective osteotomy targeted at the supracondylar femoral area in immature skeletons. Hemiepiphysiodesis might be a more feasible option in those cases as it provides the surgeon with the choice to remove the staples when necessary.

Assessment of the Pediatric Foot Mass

Masses in the pediatric foot are relatively uncommon and can present a diagnostic challenge. The literature lacks a comprehensive overview of these types of lesions. Most are benign soft-tissue lesions that can be diagnosed on the basis of history and physical examination. However, some rare malignant neoplasms can mimic benign masses. It is imperative to recognize these lesions because the consequences of a delayed or missed diagnosis can be substantial. A thorough history and physical examination of all pediatric patients with foot lesions are crucial to ensure that any lesion not readily identified as benign is appropriately managed.

Trevor's Disease: Management Difficulties and Proposed Classification

Dysplasia epiphysealis hemimelica, also known as Trevor's disease, is a rare developmental disorder with osteocartilagenous overgrowth of the epiphysis or epiphyseal equivalent. The condition bears similarities to osteochondroma in terms of its radiographic appearance, but differs in its pathobiology and geographic occurrence. Unlike the metaphyseal occurrence of osteochondromata, it arises from the epiphysis. The clinical presentation is wide and varied, but mechanical symptoms and deformities predominate. Early reports of the condition suggested involvement of the lower limbs only. However, since then, numerous reports have indicated a more generalized distribution. Difficulties in management and recurrence rates seem to hinge on whether its origin is intra-articular or extra-articular. A new classification system to include these parameters is discussed. [Orthopedics.2016; 39(5):e967-e969.].

Dysplasia epiphysealis hemimelica of the knee: an unusual presentation with intra-articular loose bodies and literature review

Dysplasia epiphysealis hemimelica (DEH) is a rare disease characterized by the formation of osteochondromas asymmetrically at the epiphysis of extremities, typically involving the ankle and the knee. It progresses during childhood and presents with limited range of motion, swelling, and angular deformities. A 9-year-old boy with a 7-year history of DEH and previous removal of ankle osteochondromas presented with acute knee pain, swelling, and limited range of motion. A clinical, radiographic, and literature review of this case was conducted to better describe this occurrence. On the basis of clinical and radiographic analyses, loose bodies were found to be originating from intra-articular osteochondromas. Because of the patient's symptoms, an exploratory arthroscopy was performed to further assess the formations, and the loose bodies were removed. After the procedure, the patient's function and symptoms improved. To the best of our knowledge, this is the first report of a case that identifies a complication of DEH to be loose bodies with a clear etiology and acute progression of symptoms. The possibility of loose bodies should be considered when examining a patient diagnosed with DEH with acute progression of symptoms. Level of evidence level IV, case report.

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.

Dysplasia epiphysealis hemimelica: a huge articular mass with unpredictable surgical results

Dysplasia epiphysealis hemimelica or Trevor's disease is a rare disorder of localised osteochondral overgrowth affecting the epiphysis of extremities. This paper reports a 12-year-old boy presenting with a large bony mass at the left ankle diagnosed as dysplasia epiphysealis hemimelica. The articular surface of the ankle joint of the patient was evaluated with preoperative and postoperative MRIs. The 2-year postoperative MRI showed early osteoarthritis of the ankle, therefore demonstrating the importance of early excision avoiding more complex resections of intra-articular lesions.

Imaging of dysplasia epiphysealis hemimelica (Trevor's disease)

Dysplasia epiphysealis hemimelica (DEH; synonyms; Trevor's or Trevor Fairbank disease) is a rare developmental disorder of the skeleton characterized by asymmetric osteochondral overgrowth of the cartilage of a medial or lateral epiphysis or epiphyseal equivalent. Imaging plays an important role in the diagnosis and management of DEH and in assessing the need for biopsy to differentiate it from more sinister diseases. There is no recent comprehensive review of the imaging of DEH and the purpose of this article is to describe the modern radiological manifestations of DEH.

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.

Bony island within the articular cartilage of the knee in a child: a rare condition for early osteoarthritis

Articular cartilage is a specific type of connective tissue composed of hydrated proteoglycans within a matrix of collagen fibrils. In the elderly population, it shows degenerative changes that may results in osteoarthritis. The more severe form of osteoarthritis occasionally demonstrates bone formation within the cartilage, which is designated as a bony protuberance, however, such lesions are rare in children. This report presents the case of a 10-year-old boy with a bony protuberance within the articular cartilage of the knee. The patient initially complained of knee pain and he subsequently developed flexion contracture. Radiological and arthroscopic examinations revealed a bony protuberance in the articular cartilage and degenerative changes of the cartilage above it. He was successfully treated by the removal of the bony protuberance and osteochondral grafting. The bony protuberance may have caused cartilage degradation since the thickness of the cartilage above it was thinner than that around the lesion. The bony protuberance within the articular cartilage formed in the younger population may be a possible cause of osteoarthritis. This case is a noteworthy with regard to the pathogenesis of osteoarthritis.

Bony island within the articular cartilage of the knee in a child: a rare condition for early osteoarthritis

Articular cartilage is a specific type of connective tissue composed of hydrated proteoglycans within a matrix of collagen fibrils. In the elderly population, it shows degenerative changes that may results in osteoarthritis. The more severe form of osteoarthritis occasionally demonstrates bone formation within the cartilage, which is designated as a bony protuberance, however, such lesions are rare in children. This report presents the case of a 10-year-old boy with a bony protuberance within the articular cartilage of the knee. The patient initially complained of knee pain and he subsequently developed flexion contracture. Radiological and arthroscopic examinations revealed a bony protuberance in the articular cartilage and degenerative changes of the cartilage above it. He was successfully treated by the removal of the bony protuberance and osteochondral grafting. The bony protuberance may have caused cartilage degradation since the thickness of the cartilage above it was thinner than that around the lesion. The bony protuberance within the articular cartilage formed in the younger population may be a possible cause of osteoarthritis. This case is a noteworthy with regard to the pathogenesis of osteoarthritis.

Trevor's disease (dysplasia epiphysealis hemimelica) located at the hand: case report and review of the literature

Trevor's disease, also known as dysplasia epiphysealis hemimelica (DEH), is a rare developmental bone dysplasia, characterized by benign osteocartilaginous overgrowth. The lesion arises from an epiphysis. Its localization may be different, and it mostly occurs unilateral. In this report, we present a 40 years old woman suffering from Trevor's disease with unusual localization at the hand. Because of significant symptoms surgical excision was chosen.

Glycobiology and the growth plate: current concepts in multiple hereditary exostoses

BACKGROUND

Multiple hereditary exostoses, also termed as multiple osteochondromas, is a heritable disorder of connective tissue with primarily orthopaedic clinical manifestations. Understanding of its biological underpinnings has been advanced on a variety of fronts in recent years.

METHODS

The multifaceted literature regarding osteochondromagenesis and the major clinical challenges in patients with multiple osteochondromas were reviewed.

RESULTS

Consideration of recent advances in molecular biology, biochemistry, and animal modeling of osteochondroma pathogenesis yields a unified model.

CONCLUSIONS

Mechanistic details and therapeutic targets have yet to be elucidated, but the general biology of osteochondroma formation is increasingly clear, as well as its implications in the orthopaedic clinical setting.

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: 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.

Generalized dysplasia epiphysealis hemimelica with contralateral sacro-iliac joint involvement

Dysplasia epiphysealis hemimelica (or Trevor's disease) is a rare developmental bone dysplasia characterized by benign osteocartilaginous overgrowth involving one or multiple epiphyses, usually of a single lower extremity. It is classified as localized form, classical form (most common), and generalized form. In this report we describe a case of generalized form of dysplasia epiphysealis hemimelica with involvement of the contralateral sacroiliac joint, which is an extremely rare presentation.