Vascular complication of osteochondroma: case report

Abstracts

Osteocondromas ou exostoses são os tumores benignos mais comuns do tecido ósseo. Eles surgem durante o período de crescimento e, raramente, são responsáveis por complicações vasculares. No presente relato, reportamos um caso de paciente com osteocondroma no membro inferior e complicação vascular provocada pela compressão da artéria poplítea. O paciente apresentava queixas de dor em membro inferior direito quando foi investigado com angiografia e radiografia, que identificaram a lesão vascular e a tumoração óssea. Os tratamentos cirúrgicos simultâneos de ambas as lesões foram realizados com boa evolução pós-operatória.

Osteocondromas; complicações vasculares; oclusão arterial

CASE REPORT

Vascular complication of osteochondroma: case report

Fábio André Tornquist^I; Carlos César Leopardo^II; Tibiriçá Cecim Segala^III; Ali Juma Abdalla Abel Hamid^IV

^I

^IIAssociate member, SBACV – Regional RS. Vascular surgeon, Hospital Ana Nery, Santa Cruz do Sul, RS, Brazil

^IIIMember, Brazilian Society of Orthopedics and Traumatology. Orthopedist, Hospital Ana Nery, Santa Cruz do Sul, RS, Brazil

^IVMember, Brazilian Society of Orthopedics and Traumatology. Orthopedist, Hospital Ana Nery, Santa Cruz do Sul, RS, Brazil

^{Correspondence}

ABSTRACT

Osteochondromas or exostoses are the most common benign tumors of the bone. They occur during the growth period and are rarely responsible for vascular complications. We report a case of a patient with osteochondroma in the lower limb and vascular complication caused by compression of the popliteal artery. The patient complained of pain at the right lower limb during angiography and radiography screening, which identified the vascular lesion and the bone tumor. A simultaneous surgical treatment of both lesions was performed with good postoperative evolution.

Keywords: Osteochondromas, vascular complications, arterial occlusion.

Introduction

Osteochondromas or exostoses, despite being the most common benign tumors, rarely present vascular complications.¹ The involvement of vascular structures occurs when the exostosis grows near vessels, which may cause arterial (pseudoaneurysm, arterial occlusion) and venous (venous thrombosis) lesions.^2.3 We report a case of extrinsic compression of the popliteal artery caused by an osteochondroma located at the tibia, resulting in arterial thrombosis.

Case report

Clinical data

A 45–year–old male patient, with complaint of pain for 7 days, was admitted to our hospital. The patient reported pain at rest at the right lower limb, as well as reduction in temperature and pallor. He reported pain in the right calf to walk long distances for 3 years, evolving to pain at rest 7 days ago. The patient did not present comorbid conditions neither family history. He denied smoking. On vascular clinical examination, he presented pain at rest at the right lower limb, pallor, reduction in temperature, absence of peripheral (popliteal and tibial) pulses and solid, fixed and nonpulsatile mass in the popliteal fossa.

Complementary tests

Diagnostic intervention using angiography showed complete occlusion of the popliteal artery (Figure 1). Due to the presence of mass identified in the popliteal fossa during physical examination, a simple radiography of the bone tissues was performed at the end of angiography. It showed presence of bone mass in the posterior aspect of the tibia, compatible with exostosis (osteochondroma).

Surgical treatment

The patient was submitted to surgical treatment using a posterior approach in the popliteal fossa, with a Z incision. The vascular and nervous bundle and the osteochondroma were dissected. Initially, the bone mass was resected (Figure 2) and then a longitudinal arteriotomy was performed in the popliteal artery and the thrombus was successfully removed using a Fogarty 4F catheter. The popliteal artery did not present lesions in its wall such as aneurysmal degenerations, rupture of the intimal layer or sclerosing atherosclerotic plaques. The popliteal artery was then closed with patch (graft) of the short saphenous vein with the aim of reducing the incidence of recurrent stenosis by manipulating the vessel.

Histological examination

The anatomopathological examination of the excised tumoral bone mass confirmed the osteochondroma, with no histological evidence of malignization.

Clinical evolution

Postoperative recovery was good, with limb reperfusion and remission of the pain. The patient was discharged on the 5th postoperative day. Six months after the surgery, the patient was assessed using arterial color–flow Doppler ultrasonography of the lower limb for control, which demonstrated functioning revascularization with no evidence of vascular lesions (Figure 3).

Discussion

Osteochondromas, also known as exostoses, are the most common bone masses, seen in 1–2% of the population.^3.4 These lesions are essentially the result of a misguided growth of the epiphyseal bone, producing bone projections capped by cartilage of the lateral contours of endochondral bones. Osteochondromas can occur in all bones, but are more frequently identified in the ends of long bones (tibia, femur and humerus) in metaphyses close to the epiphyseal region. They occasionally affect the pelvis, shoulder, clavicle, costal arch and vertebra.^3–5 Osteochondromas can occur alone or in multiple masses. When multiple, they represent a hereditary, dominant, autosomal disease and present a frequency of malignant degeneration in more than 10% of cases.^3.6 Osteochondromas are rarely found before the second childhood or adolescence, maybe reflecting the time needed for their development. The lesion growth is usually interrupted due to epiphyseal closure.

These masses are usually asymptomatic and can be diagnosed during radiological examinations incidentally. Complications occur in 4% of osteochondromas, with neurological involvement, growth abnormality, malignant degeneration (fibrosarcoma, osteosarcoma or chondrosarcoma) or vascular lesions.⁷

Vascular complication is an unusual form of diagnosing osteochondroma. Symptoms depend on tumor location, size and type of vascular impairment. The types of complications reported are: pseudoaneurysm, arterial thrombosis, venous thrombosis and bleeding. Osteochondromas usually compress neighboring tissues, veins and arteries, resulting in vascular lesion.

Arterial complications are the most common, with incidence of 91%.⁷ Popliteal vessels are the most affected, due to higher incidence in the lower limbs (femur, tibia and fibula).^8–14 Pseudoaneurysms are the most commonly described arterial lesion, occurring in 64% of cases. They can be manifested with the association of a pulsatile mass at the knee and distal ischemia as the result of peripheral embolism.^10.15–18 The mechanism of the arterial lesion is due to repeated trauma, caused by movement of the knee, presence of an osteochondroma spike or direct trauma and fracture of the tumors that generated vessel lesion.^8,11,16

Hemorrhagic complications caused by osteochondromas in costal archs are reported. In two cases, there were pulmonary and pericardial–phrenic lesions, which caused hemothorax treated with risk of life.³

Popliteal artery thrombosis due to osteochondroma compression was reported in 1979 by Lowell et al.¹⁹ Osteochondromas have an effect of direct mass on the vessel, obstructing the flow and generating arterial thrombosis.^19–23 The popliteal artery is more affected in cases of arterial occlusion, but other locations, such as femur and radius, have been reported.^4,6,24–26 This case report refers to a complete arterial occlusion of the popliteal artery, in which the patient presented with clinical status of lower limb ischemia, caused by extrinsic compression by a tibial osteochondroma.

Impairment of the deep venous system by exostosis, which occurs in 5% of vascular complications, is caused by obstruction of the venous flow. Such complication has been described in association or not with arterial lesion.^3,10,22

The diagnostic of osteochondroma is always performed using radiography of the affected area. As to the vascular lesion, it can be diagnosed by angiography or color–flow Doppler ultrasonography.²⁷ Angiography can fail to show presence of pseudoaneurysm, especially in cases of associated arterial occlusion. This can also occur in cases of pseudoaneurysms in which the image of the vessel lumen remains intact due to mural thrombus, and may go unnoticed in the diagnosis.^3,17,24,28 Color–flow Doppler ultrasonography can simultaneously diagnose arterial thrombosis, venous thrombosis and presence of pseudoaneurysm.^17.26 Computed tomography and magnetic resonance are useful in these cases, since they can concomitantly demonstrate bone, vascular and soft tissue lesions.^2,4,16

Treatment of bone and vascular lesions is performed simultaneously. After osteochondroma resection, repair of the arterial lesion is performed according to lesion size and type. In pseudoaneurysm reconstruction, graft interposition may be needed, and preference should always be given to saphenous vein graft. Terminoterminal anastomosis of the arterial lesion should be performed whenever possible. In cases of arterial thrombosis, we can perform the treatment using thrombectomy or saphenous vein bypass (bypass).³ In our case, thrombectomy with short saphenous vein graft was successfully performed.

The surgical treatment of vascular complications of osteochondromas is recommended as an emergency procedure to avoid irreversible lesions such as occlusion of distal vessels or venous thrombosis with risk of pulmonary embolism.

Opinions about the need of prophylactic resection of all osteochondromas in case of multiple hereditary osteochondromas are controversial. However, surgical resection of osteochondromas seems to be indicated if there is proximity of vessels, risk of interference in the articulation, osteochondroma fracture and suspicion of malignant change of the osteochondroma.

Conclusion

Intermittent claudication in young patients is unusual and unlikely to occur due to atherosclerotic cause. Different causes of vascular disease should be explored in this population. Arterial insufficiency can be a consequence of popliteal artery entrapment syndrome, popliteal cyst and obliterating thromboangiitis (Buerger's disease). Diagnosis is traditionally clinical and confirmed by complementary tests. Simple radiography should be systematically performed to dismiss hypothesis of osteochondroma, whereas color–flow Doppler ultrasonography and angiography assess possible vascular lesions. The present case stresses the need of early investigation of any venous or arterial disorder in young and healthy individuals. Preventive surgery should be discussed in all cases of exostoses with risk of vessel impairment due to the potential severity of vascular complications.

References

Manuscript received July 14, 2006, accepted January 30, 2007.

This study was carried out at the Vascular Surgery and Orthopedic Service, Hospital Ana Nery, Santa Cruz do Sul, RS, Brazil, and was presented as a free paper at XXXIV Congresso Brasileiro de Angiologia e Cirurgia Vascular.

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Publication Dates

• Publication in this collection
  19 July 2007
• Date of issue
  Mar 2007

History

• Accepted
  30 Jan 2007
• Received
  14 July 2006