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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 58-60

Approach to the management of solitary osteochondroma of the body of the pubis


1 Department of Orthopaedics, U.C.M.S and G.T.B Hospital, Delhi, India
2 Department of Orthopaedics, Trauma Centre, Motihari, Bihar, India

Date of Submission14-Oct-2019
Date of Decision30-Oct-2019
Date of Acceptance13-Nov-2019
Date of Web Publication23-Dec-2019

Correspondence Address:
Saurabh Kumar
Department of Orthopaedics, U.C.M.S and G.T.B Hospital, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODP.JODP_15_19

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  Abstract 


Osteochondroma is considered the most common benign tumor of the bone (20%–50% of all benign tumors); some consider them arising from small cartilaginous nodules present in the periosteum. They are developmental malformation or true neoplasm. Their growth usually ceases when skeletal maturity is reached. Pelvic osteochondroma is uncommon (5% of all osteochondromas). Osteochondroma of the pubic ramus is a rare entity, and the actual incidence is not known. We present the case of an 18-year-old female, who came with a swelling in the right groin for 5 years which was diagnosed to be osteochondroma on X-ray and three-dimensional computed tomography (3D-CT) scan. En bloc excision was done as the patient wanted it to be removed for a cosmetic purpose and confirmed it to be nonmalignant osteochondroma. There has been no recurrence even after 1 year of follow-up. Treating doctor should be well versed with various approaches and 3D-CT scan is required for planning surgical excision. Pelvic osteochondromas should be considered in the differential diagnosis of any bony mass in the pubic region.

Keywords: En bloc excision, osteochondroma, pubic ramus, three-dimensional computed tomography scan


How to cite this article:
Kumar R, Kumar S, Vijay T, Verma D. Approach to the management of solitary osteochondroma of the body of the pubis. J Orthop Dis Traumatol 2019;2:58-60

How to cite this URL:
Kumar R, Kumar S, Vijay T, Verma D. Approach to the management of solitary osteochondroma of the body of the pubis. J Orthop Dis Traumatol [serial online] 2019 [cited 2020 Jan 21];2:58-60. Available from: http://www.jodt.org/text.asp?2019/2/3/58/273884




  Introduction Top


Osteochondroma is considered the most common benign tumor of the bone (20%–50% of all benign tumors); some consider them arising from small cartilaginous nodules present in the periosteum.[1] They are developmental malformation or true neoplasm. They are found to exist of solitary form or multiple, pedunculated or sessile form. Solitary osteochondromas develop as a bony projection with the cartilaginous cap. The typical osteochondroma develops from the metaphyseal region of long bones and is slow-growing. Their growth usually ceases when skeletal maturity is reached. The site of osteochondroma is the axial skeleton, flat bones of skull, and facial bones.[1] It is often found on the distal femur, proximal tibia, and proximal humerus. Pelvic osteochondromas are uncommon (5% of all osteochondromas).[1] Osteochondroma of the pubic ramus is a rare entity, and the actual incidence is not known. It can present as a solitary lesion or as a part of multiple hereditary exostosis. We report a case of solitary osteochondroma in the body of the right pubic bone, and we will discuss how to approach in cases of osteochondroma of the pubic bone.


  Case Report Top


An 18-year-old female reported to the outpatient department with complaints of painless swelling in the right groin for 5 years [Figure 1]. The swelling was small in size initially and slowly progressed to the present size and was static for the last 2 years. The patient came for medical help due to cosmetic reasons. On examination, there was a bony hard swelling of 6 cm × 5 cm in size in the groin at parasymphyseal area of the right pubis. It was fixed to the underlying bone. The skin over the swelling was free and mobile. The patient did not have any similar swellings elsewhere in the body. There was no involvement of any neurovascular bundle. Any involvement of the urinary tract was also ruled out plain X-ray of the pelvis antero-posterior (AP) view, and computed tomography (CT) imaging [Figure 2] showed bony growth of 66 mm × 39 mm × 55 mm in size in transverse, craniocaudal, and AP dimensions. It was arising from the right superior pubic ramus at the level of pubic tubercle and located anterior to the pubis (extrapelvic). The patient was taken up for excisional biopsy. A Pfannenstiel incision using the Stoppa's approach [Figure 3] was used for the excision of the tumor. The rectus abdominis muscle was cut from its attachment at the pubis instead of placing Homan's retractor anteriorly to retract the muscle (modification from the classical Stoppa's approach) to remain extraperiosteal for excision. The en bloc removal of tumor was done [Figure 4]. The rectus abdominis was reattached to its stump, and the abdomen was closed in layers. Cosmetic closure of the skin was done. Histopathology confirmed it to be benign osteochondroma without any undifferentiated cells. The postoperative radiograph [Figure 5] confirmed the complete removal of tumor. Since then, there has been no recurrence even after 1-year of follow-up.
Figure 1: Bony swelling in the right groin

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Figure 2: Three-dimensional computed tomography scan of the pelvis

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Figure 3: Pfannenstiel incision

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Figure 4: Excised tumor

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Figure 5: Postoperative X-ray of the pelvis – Antero-posterior view

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  Discussion Top


The observed finding of osteochondroma on the body of the pubic bone is incidental and is of academic interest. The incidence of pubic bone osteochondroma is very rare (5% of all osteochondromas) and is seldom reported in literature. Hence, we hereby discuss our experience with such case stresses on the surgical approach used in the management of this case.

In general, the solitary osteochondromas are male predominant (male: female ratio: 1.74:1) found in the bones that are formed by the endochondral ossification,[2] but in our case, the patient was female. They usually affect long tubular bones (60%).[3] The osteochondromas are rarely seen in the axial skeleton, flat bones of the skull, and facial bones.[1] The flat bones are prone for osteochondroma, for example, in the scapula along the inner border, the ilium along the iliac crest, and around the acetabulum.[2] The incidence of pelvic osteochondroma is documented to be 5% of all osteochondromas.[3] Kumar et al.[4] have reported a case of osteochondroma on the ileum bone. The osteochondroma of the pubic symphysis may cause sexual disturbances.[5] Buzon[6] has reported two cases of osteochondroma in the os pubis presenting as a bony lump projecting from the anterior surface of the right pubis (in a 29-year-old male) and on the superior ramus of the left pubic bone in another case.[7] Herode et al. reported an osteochondroma arising from the pubic ramus of the right pelvis in an 18-year-old young female.[8] No evidence of recurrence was noted in the above two case series after excision.

In the present case, the osteochondroma was arising from the right side superior pubic ramus anteriorly, and the patient presented with a lump in the right groin. The X-ray pelvis AP view was not of much help either for diagnostic or surgical planning purpose due to complex orientations and overlap of the pelvic bones. CT scan with three-dimensional (3D) reconstruction was done to confirm and evaluate the site, size, and orientation of the tumor. The CT scan fairly confirmed the diagnosis of osteochondroma by showing continuity of the medullary cavity of tumor to the parent bone [Figure 6]. It also showed the tumor to be arising from the pubic tubercle and parasymphyseal region of the right pubis and lying anterior to the pubis. Due to more medial location of the tumor, surgical excision was planned with Stoppa's approach (less extensive and cosmetic than ilioinguinal approach). The other authors used extended ilioinguinal approach and transverse for excision.[7],[8]
Figure 6: Axial computed tomography image showing continuity of the medullary cavity of tumor to the parent bone

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To use either of the two common approaches (Stoppa's approach and ilioinguinal approach) for osteochondroma of the superior pubic ramus or to use femoribus internus–perineal approach for inferior pubic ramus depends on the location of the tumor.[9] For tumor of the superior pubic bone arising from the posterior surface or anteriorly located tumor placed more medially, i.e., around pubic tubercle can be safely approached with Stoppa's approach. The ilioinguinal approach should be used in cases where tumor is placed more laterally and anteriorly. Hence, it is important to get CT scan with 3D reconstruction for better surgical planning.

The complications of tumor depend on its location. If the tumor is located anterior to pubic ramus, the patient may have difficulty in micturition due to pressure on the urethra and sexual dysfunction. If tumor is located posterior to the ramus, the patient may have bladder compression, leading to frequent micturition and birth canal obstruction due to decrease in the size of the pelvic cavity. If tumor is placed lateral to the pubic tubercle, it may lead to pseudoaneurysm, arterial or venous thrombosis, or symptoms due to femoral nerve irritation.


  Conclusion Top


  1. Treating doctor should be well versed with various approaches and its modification when dealing with osteochondroma of this region
  2. The surgical approach is decided on the basis of location of tumor which is assisted by 3D CT scan; hence, we think 3D CT scan is required for planning surgical excision
  3. Pelvic osteochondromas should be considered in the differential diagnosis of any bony mass in the pubic region.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Murphey MD, Choi JJ, Kransdorf MJ, Flemming DJ, Gannon FH. Imaging of osteochondroma: Variants and complications with radiologic-pathologic correlation. Radiographics 2000;20:1407-34.  Back to cited text no. 1
    
2.
Price CH. Primary bone-forming tumours and their relationship to skeletal growth. J Bone Joint Surg Br 1958;40-B:574-93.  Back to cited text no. 2
    
3.
Strange FG. Excision of the superior ramus of the pubis for large osteochondroma. Br J Surg 1954;41:377-9.  Back to cited text no. 3
    
4.
Kumar S, Shah AK, Patel AM, Shah UA. CT and MR images of flat bone osteochondromata from head to foot: A pictorial essay. Indian J Radiol Imaging 2006;16:589-96.  Back to cited text no. 4
  [Full text]  
5.
Hoshimoto K, Mitsuya K, Ohkura T. Osteochondroma of the pubic symphysis associated with sexual disturbance. Gynecol Obstet Invest 2000;50:70-2.  Back to cited text no. 5
    
6.
Buzon MR. Two cases of pelvic osteochondroma in New Kingdom Nubia. Int J Osteoarchaeol 2005;15:377-82.  Back to cited text no. 6
    
7.
Mnif H, Zrig M, Koubaa M, Zammel N, Abid A. An unusual complication of pubic exostosis. Orthop Traumatol Surg Res 2009;95:151-3.  Back to cited text no. 7
    
8.
Herode P, Shroff A, Patel P, Aggarwal P, Mandlewala V. A rare case of pubic ramus osteochondroma. J Orthop Case Rep 2015;5:51-3.  Back to cited text no. 8
    
9.
He X, Hu YC, Yu XC, Yuan BB. Resection of inferior pubic ramus tumors through a femoribus internus-perineal approach. Orthop Surg 2014;6:65-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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