Osteochondroma, also called osteochondral exostosis, is the most common benign tumor of the skeleton. It is a bone growth on the mother bone, covered on the outside with a cartilaginous cap. The size of the tumor varies widely and can reach 12 cm or more.
Osteochondromas account for about 20% of all bone tumors, and the knee joint is most often affected. The disease can be completely asymptomatic, in other cases it leads to pain or even neurological complications. This raises the question of surgically removing exostosis of the knee.
Exostosis of the knee joint in children and adults
Exostosis of the knee joint is most common in children. In most cases, the disease is diagnosed before the age of 20, although it can also be detected in adulthood.
The knee is the second largest joint in the human body and is formed by the epiphyses (heads) of the femur and tibia, as well as the patella. In children, immediately behind the epiphyses there are so-called growth plates or epiphyseal plates. They are formed by cartilage tissue, the cells of which are in the process of constant division. Due to this, the femur and tibia, like many other bones, lengthen as the child grows. The resulting cells gradually ossify, thereby forming the metaphysis (neck) of the bone.
Exostosis of the knee in a child most often forms as a result of displacement of part of the epiphyseal plate from its normal position. This may be a consequence of dysembryogenesis, hereditary predisposition, radiation therapy in early childhood, or trauma. Although the exact reasons for the development of osteochondroma in children have not been established.
The growth zone continues to produce cells that subsequently ossify. As a result, an osteochondral growth is formed on the femur or tibia, which has a single cortical wall and bone marrow space with it. It may have a thin stem or a wider base. Initially, the neoplasm is entirely represented by cartilaginous tissue, but as the child grows older, it gradually ossifies and acquires the density characteristic of bone. But the cartilaginous cap is preserved, although its thickness gradually decreases as they grow older.
Exostosis of the femur accounts for 30% of all cases of osteochondroma formation, and on the bones of the leg - 15-20%.
Osteochondral exostosis of the knee joint can be either the only neoplasm of this kind in the body or one of the manifestations of multiple exostosis. In the latter case, osteochondromas will be found in other bones of the skeleton, in particular in the upper limbs, feet, spine, etc. Multiple exostotic disease is inherited in an autosomal dominant manner and is usually diagnosed in childhood.
In adults, exostosis of the knee joint can also be detected. It can become an accidental finding and be undiagnosed in childhood as osteochondroma or develop subsequently as a result of trauma.
But do not confuse osteochondral exostosis with osteophytes of the knee joint. The consequence is also bone growths on the surface of the articular surfaces of the tibia and shin bones. But unlike osteochondroma, they are not integral with the maternal bone, but arise as a result of the development of degenerative changes in the knee, for example, with arthrosis.
What is exostosis
Exostosis is a bone or bone and cartilaginous growth of a non-tumor type on the surface of bones (a type of linear, spherical and other formation).
Exostosis in its structure consists of cartilaginous tissue (ossified in its similarity to normal cartilage tissue) and therefore the name “cartilaginous” exostosis does not accurately indicate the essence of the entire process. The process of ossification during exostosis is usually accompanied by transformation into spongy bone, enclosed on the outside in a thin and dense bone shell. The surface of the bone exostosis is a layer covered with hyaline cartilage, the thickness of which is only a few millimeters. From such a cartilaginous head the growth of the entire exostosis subsequently results.
Symptoms and complications
Often the disease is asymptomatic, especially when the osteochondroma is small. It usually grows at a rate directly proportional to skeletal growth. At a certain location, it can be palpated: it is a dense, immobile formation, usually painless on palpation.
When it reaches a large size, it can stick out and create a cosmetic defect. Also in such cases, symptoms such as:
- pain, especially with physical activity or wearing high-heeled shoes;
- knee deformity;
- swelling of the soft tissues around the knee;
- limitation of joint mobility;
- numbness of the limb.
Similar manifestations occur when a neoplasm mechanically compresses the neurovascular bundle. Their occurrence is a reason to consult an orthopedist-traumatologist in the near future.
Sometimes exostosis of the knee joint injures soft tissues, which provokes the development of tendinitis, i.e. inflammation of the tendons, and bursitis, inflammation of the synovial capsule of the knee. This is accompanied by:
- pain of varying degrees of intensity, which tends to intensify with load on the joint, which causes a forced limitation of mobility;
- redness, swelling of soft tissues;
- local increase in body temperature.
Exostosis can affect the epiphyseal plates of the femur or tibia. This can cause disruption of their growth and shortening in relation to a healthy limb.
Also, osteochondroma, especially large ones, can provoke deformation of the femur, tibia or fibula. This will cause the leg to bend and also increases the risk of a pathological fracture. Such changes are extremely undesirable, as they not only significantly reduce the child’s quality of life, but also negatively affect his mental and emotional state.
But the most dangerous complication of tumors of this kind is the potential for malignant transformation. With single exostoses of the knee joint, this occurs in less than 1% of cases, but with multiple exostoses, the risk of malignancy increases to 10%.
Diagnostic measures
If a person experiences knee discomfort, it is important to contact a medical facility as soon as possible. It is impossible to diagnose the disease at home. At the appointment, the doctor asks the patient how long ago the discomfort began and whether there are additional symptoms. The patient is then sent for an X-ray examination. The disadvantage of radiography is that it is impossible to accurately determine the size of the tumor. However, the results of the X-ray image show the shape of the tumor and its location. Before making a diagnosis, it is important to make sure that the patient has formed a bone growth and not a malignant neoplasm. To do this, they resort to magnetic resonance imaging.
Diagnostics
If a protrusion in the knee area or other symptoms is detected, you should consult an orthopedic traumatologist. The main way to diagnose osteochondromas is x-ray. In the image, the tumor has the appearance of a “cauliflower”, having a thin stalk or a wide base. A typical sign of exostosis is the cortical walls and medullary space that are unified with the maternal bone.
But x-rays do not allow us to assess the structure and size of the cartilaginous cap, especially in children, since the formation of foci of mineralization in it usually occurs in adulthood. The width of the cartilaginous cap is an important diagnostic feature that allows one to detect signs of malignant degeneration. Therefore, to exclude this, an MRI of the knee joint is performed. Detection of cartilage tissue thickness of more than 1.5-2 cm is considered as a sign of malignancy. Additionally, MRI provides comprehensive data on the condition and location of the neurovascular bundle, as well as the hyaline cartilage covering the epiphyses of the femur and tibia. But since malignancy of osteochondromas, especially single ones, occurs extremely rarely, MRI is often not performed until indications for removal of exostosis of the knee joint arise.
Clinical picture
Clinically, osteochondroma manifests itself in the form of formations of various sizes with bone density, which are located in the metaphysis of long tubular or flat bones. There may be several or one, they can range in size from 1 cm to several, but are usually motionlessly attached to the bone and do not cause pain.
If the growth is large enough, it can limit the mobility of a nearby joint or several. Most often, osteochondroma manifests itself in adolescence and young adulthood, and does not depend on gender. The formation grows slowly, and as already mentioned, its growth is synchronous with the entire skeleton of the body. The clinical size of osteochondroma usually does not differ much from that determined using x-rays, since it consists mainly of bone tissue, which is clearly visible on x-rays. Often the outgrowths are localized in the metaphysis of the humerus, spine or scapula.
The x-ray gives a clear picture: the changed shape of the bone due to a growth that is attached to it through a thin or thick bone pedicle. The formation has an indistinct contour in the distal region, and may also contain inclusions of mineral substances. Sometimes osteochondroma causes displacement of soft tissues, organs and muscle fibers. This method of analysis, together with a clear clinical picture, leaves no doubt about the accuracy of the diagnosis, so differential diagnosis is usually not required.
The transformation of single osteochondromas into malignant tumors occurs in 1-2% of cases, while for multiple growths this figure is 5-10%. This process is most typical when located in the pelvis or scapula.
Degeneration can be determined by a noticeable increase in the size of the growth and the appearance of pain. An x-ray will show blurred contours, and the dimensions themselves are much larger than x-rays. This confirms that tumor formation occurs due to cartilage tissue, which is not visible to x-rays. In such cases, treatment is carried out in the same way as for chondrosarcoma.
Treatment of exostosis of the knee joint
In asymptomatic cases, exostosis of the knee joint is not treated. Patients are prescribed only follow-up examinations and x-rays. If the neoplasm provokes pain, NSAIDs and, less commonly, corticosteroids may be prescribed. But the only effective treatment is surgery.
It is indicated for:
- active growth of the tumor, the appearance of signs of malignancy;
- fracture of the pedicle of the neoplasm;
- deformations of the femur, tibia, fibula, and the knee joint itself;
- persistent pain that prevents the patient from leading an active lifestyle;
- vascular and neurological complications.
The main method for removing osteochondral exostosis of the knee is marginal resection. The operation is performed under general anesthesia and consists of removing the tumor along with the cartilage capsule using special instruments within healthy tissue. If after resection a large defect of the maternal bone is formed, it is closed by introducing a synthetic material or a graft taken from the patient's bone.
If there is severe deformation of the osteochondromic bone, a corrective osteotomy can be performed. During the operation, the exostosis of the knee joint is removed along with a fragment of the parent bone. The resulting fragments are fixed in an anatomically correct position using titanium plates and screws.
Treatment of osteophytes
Treatment of osteophytes of the knee joint, spine or any other location always begins with treatment of the underlying disease due to which they appeared. The fight against the bone outgrowths itself is carried out in several directions:
- drug therapy to relieve pain and inflammation, restore tissue trophism and prevent further joint destruction (anti-inflammatory drugs, angio- and chondroprotectors);
- therapeutic exercises (relieve muscle spasms and reduce the load on sore joints, improve metabolism in tissues);
- physiotherapeutic treatment (the doctor chooses the method taking into account the location and type of osteophytes);
- maintaining a healthy lifestyle and daily activity (patients should give up bad habits, walk as much as possible, swim, choose active types of recreation);
- massage and self-massage, as well as the use of orthoses (collars, corsets, walking aids);
- following a non-strict diet (foods rich in calcium and magnesium are recommended, such as fish, seafood, nuts and seeds, spinach and other greens, legumes and dairy products - in the absence of contraindications due to metabolic diseases). Patients should avoid sweet, smoked and highly salty foods, as well as any semi-finished products (except homemade preparations) and fast food. Overweight people need to lose weight to successfully treat osteophytes.
Although osteophytes cannot always be completely eliminated with conservative treatment alone, it can reduce their size and completely stop the progression of the pathology. In advanced cases, surgical removal of osteophytes and part or all of the joint is performed.
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Physiotherapy
Taking courses of physiotherapy helps stop the growth of osteophytes, support joints and significantly alleviate the patient’s condition. To combat the problem, methods such as:
- shock wave therapy
; - electrophoresis
(especially with medications - glucocorticoids, lithium, sulfur, zinc); - phonophoresis with analgesics
; - diadynamic therapy
; - galvanization with caripain
; - massotherapy;
- balneotherapy
(radon, turpentine baths),
mud therapy
; - kinesiotherapy and therapeutic exercises.
Most physiotherapeutic procedures are contraindicated in the presence of cancer and cardiovascular diseases.
Drug treatment
Local drug treatment of osteophytes is carried out in the early stages of the disease and consists of rubbing in warming, anti-inflammatory, locally irritating compounds (ointments, gels, creams and balms). Patients can also do baths and compresses. In all other cases, you need to take pills, and sometimes even injections.
The following groups of drugs are used to treat osteophytes in the spine and joints:
- Non-steroidal anti-inflammatory drugs.
- Glucocorticoids.
- Chondroprotectors (Artracam)
are the only group of drugs that can prevent the destruction of cartilage and joint tissue, as well as start the processes of its regeneration. Other medications are usually used for symptomatic relief. - Muscle relaxants.
- Vitamin and mineral preparations.
In case of severe pain, when it is not possible to urgently consult a doctor, temporary use of simple analgesics is allowed (taking into account their side effects).
Surgery
Surgical treatment of osteophytes of the spine and joints is carried out at the 4th stage of the disease, in which the patient suffers from chronic pain that is not amenable to drug therapy. Such cases include late stages of spondylosis with ring-shaped osteophytes and other severe conditions. A timely operation allows you to save the nervous tissue from irreversible changes and eliminate pain
, and in some cases, even return a certain range of movements.
Minimally invasive operations with a short recovery period are performed in situations where bone spurs pose a serious threat to blood flow and nerve endings and entail severe symptoms, as well as interfere with the patient’s movement and are accompanied by severe pain.
Surgical treatment of spinal osteophytes is carried out in the case of massive growths that disrupt the functions of tissues in the places of occurrence.
In case of degenerative joint diseases, not only the osteophyte is removed, but also excess bone tissue. In the case of knee, elbow and some other joints, joint replacement is indicated.
Please note that gentle arthroscopic operations do not relieve the patient of responsibility for his joints
: after removal of osteophytes, new ones may grow in their place if the patient is not concerned about his health.
Take care of yourself and be happy!
Rehabilitation
The duration and complexity of the recovery period depend on the type of surgical intervention performed and the individual characteristics of the patient. When performing marginal resection, discharge from the hospital is usually carried out after 3 days. In this case, no serious restrictions are required. And after 7-10 days, patients can return to everyday activities. With corrective osteotomy, rehabilitation is more complex and lengthy. Patients are required to undergo exercise therapy, physiotherapy, and wear orthoses.
Thus, osteochondroma or exostosis of the knee is a relatively harmless tumor, but sometimes it can reduce the quality of life of patients and lead to complications. In such situations, surgical removal is indicated, since there are no other effective methods of treating the disease.
Causes of exostosis
The causes of the formation of exostosis can be an inflammatory process, bruise, pinching, abnormalities of the periosteum and cartilage, infectious diseases such as syphilis, insufficiency of the functions of the endocrine system or its individual glands. Exostosis is presented, in general, as a persistent formation, however, there are cases when the process of formation of exostosis decreases over time and the exostosis disappears forever.
Often, slowly increasing and not causing pain, exostosis is not marked by clinical symptoms, remaining invisible to both the patient and the doctor. Exostosis is detected by X-ray examination, or by palpation of seals that are already visible during examination.
A large number of scientific works are devoted to elucidating the causes of exostosis; their attention is directed to the study of heredity in this disease . However, even the presence in certain cases of family exostoses, which are inherited, does not yet provide any basis for explaining the occurrence of this disease.
How to detect osteochondral exostosis
It is difficult to say how often such formations develop: according to one estimate, it is 1-2% of the population. But very often osteochondroma does not give any symptoms - and remains undetected for a long time. Some exostoses become an incidental finding on an x-ray taken for another reason. Some can only be detected when pain, numbness and functional impairment of the limbs occur due to compression of blood vessels, tendons, nerve trunks, and muscles.
Symptoms usually appear when the osteochondroma reaches a sufficient size, in which case it must be removed. At one time, our patient had no idea that a tumor was growing on the bone until it began to affect movement: the man limped, walked with difficulty, and could not squat down.
Not a single musculoskeletal system goes through life without injury, deformation and damage. But modern traumatology is already capable of a lot: and some of its successes are so minimally invasive and delicate that they remain invisible.