Abstract

Case Report Journal of Bone and Joint Diseases | May-Aug 2020 | 35(2): 50-52

IntroductionChondromas are benign cartilaginous tumours. Most of them are enchondromas, which develop within the bone marrow [1]. Periosteal chondroma, on the other hand, is relatively rare (<2% of all benign bone tumours) [2] less common, slow-growing benign cartilaginous tumor which arises within or under the periosteum. It induces cortical erosion and periosteal reaction under constant pressure [3]. �is gives it a characteristic radiologic appearance of a single cartilaginous mass in the metaphyseal region with well-de�ned depression or "saucerization" of the adjacent cortex. Radiologically it is o�en confused with so�-tissue tumors compressing bone (like sub-periosteal haemangioma and sub-periosteal ganglion), �brous cortical defect, aneurysmal bone cyst, chondromyxoid �broma and periosteal chondrosarcoma or osteosarcoma [2,4,5]. At times, especially when it is large, it may even mimic osteochondroma [6]. Histologically, it shows hypercellularity, plump nuclei, and binucleation, which makes it difficult to differentiate from chondrosarcoma. Evidence of invasion is the major parameter to differentiate between the two [7]. �e management remains surgical excision which can range from intralesional/marginal resection to en-bloc excision. Recurrence rate has been reported to be 3.6% [3]. �is case report highlights the difficulties encountered in

surgical excision of a giant periosteal chondroma (size in greatest dimension >5 cm) of proximal humerus especially with regards to preservation of axillary nerve and the newer surgical approach through shoulder strap incision[8], which to the best of our knowledge has never been reported in a case of periosteal chondroma excision.

Case reportWe are reporting a case of 22 year old male, student by occupation who presented to us with a slow growing (>2 years duration), mildly painful swelling over the lateral aspect of le� proximal humerus. It was not quite obvious on inspection but there was presence of local tenderness, bony hard mass with irregular surface of size around 6cm X 4cm on palpation. �ere were no clinical features suggestive of involvement of axillary nerve. We got the X-ray and MRI done. Considering the age of the patient and insidious onset of symptoms, based on X-ray, we were suspecting some benign tumour. �e differential diagnosis included sessile osteochodroma, periosteal chondroma, �brous cortical defect, chondromyxoid �broma, etc. MRI was done and that revealed a lobulated lesion, appearing predominantly hypointense on T1W, hyperintense on T2W, arising from the lateral cortex of le� proximal humerus with suspected areas of cortical breach medially.

Neurovascular bundles were found to be free and no de�nite extra osseous so� tissue component was seen. �e lesion showed heterogenous post-contrast enhancement. �e size of the lesion was 30mm (AP) X 26mm(Transverse) X 52mm (craniocaudal). �e radiological features were consistent with a diagnosis of Periosteal Chondroma.

¹Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences,Rae Bareli road, Vrindavan Yojna, Lucknow, U.P.

Address of Correspondence:Dr. Kumar Keshav,Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences,Rae Bareli road, Vrindavan Yojna, Lucknow, U.P., PIN- 226029E-mail: keshav4700@yahoo.co.in

Dr. Kumar Keshav

Periosteal chondromas are relatively rare (<2%) amongst the benign bone tumours and giant periosteal chondromas (size in largest dimension >5 cm) are rarer still. It is o�en confused radiologically with more aggressive malignant tumours of bone. �is case report is about a giant periosteal chondroma of the le� proximal humerus in a 22 year old male wherein axillary nerve was passing through almost the mid of the lesion. Deltoid split approach via Edinburgh Shoulder strap incision was used to access the tumour which was then removed by marginal excision and intralesional cure�age. Axillary nerve was preserved. Histopathologically, there was no signs of malignancy and the diagnosis of periosteal chondroma was con�rmed. At 9 months of follow-up, clinico radiologically there are no signs of recurrence, patient is asymptomatic and performing his normal routine activities.Keywords: Giant periosteal chondroma, Shoulder strap incision, Axillary nerve

Kumar Keshav¹

Giant periosteal chondroma of proximal humerus extending on both sides of axillary nerve managed by surgical excision through deltoid split approach via

shoulder strap incision : A case report

50 | | | | | Journal of Bone and Joint Diseases Volume 35 Issue 2 May-Aug 2020 Page 50-52

© 2020 by Journal of Bone and Joint Diseases | Available on www.jbjdonline.com | doi- 10.13107/jbjd.2020.v35i02.022 �is is an Open Access article distributed under the terms of the Creative Commons A�ribution Non-Commercial License (h�p://c reativecommons.org/licenses/by-nc/3.0)

which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Informed consent for operative intervention a�er explaining all the risks especially with regards to chances of axillary nerve palsy, recurrence, pathological fracture and possibility of the lesion coming out to be malignant was taken. Consent was also taken for publication in a scienti�c journal without revealing the identity of the patient. We went in with the operation through direct lateral approach to the proximal humerus via a shoulder strap incision [8]. We tried performing margin excision but we had no choice but to take out the tumour in two pieces due to the presence of axillary nerve straddling through the tumour mass. While trying to isolate the axillary nerve, when we were passing a haemostat under it, the capsule got breached despite our utmost gentleness. Once the major tumour mass was excised, we also cure�ed the area of the bone from where we had removed the tumour. Post operatively there was no evidence of axillary nerve palsy. �e biopsy specimen was sent for histopathology where it was con�rmed to be periosteal chondroma with no evidence of any malignancy. �e limb had to be kept in bag arm pouch for around 3 months to prevent chances of any pathological fracture. Only when some sclerosis could be seen on the X-ray and patient was absolutely pain-free did we allow him for normal routine activities. Nine months down the line, the patient is still asymptomatic and is able to perform his normal routine activities. Latest X-rays showed no evidence of recurrence.

Discussion Periosteal chondromas are one of the rare kinds of benign tumours that has been reported in numerous papers. But, giant periosteal chondroma, which are more than 5 cm in length have been very rarely reported [6,9]. Imura et al reported giant periosteal chondroma of the right distal femur in a 17 year old male, which was treated with intralesional resection and intensive cure�age. �ey reported a novel application of a

bioresorbable plate in the management of the large bone defect a�er resection of a benign bone tumor [9]. �e difficulties encountered in excising such a mass because of the presence of axillary nerve has not been stressed upon in any of the papers. It becomes a question of weighing between two options (1) Radical Excision of the tumour along with the i n t e r v e n i n g a x i l l a r y n e r v e a n d ( 2 ) M a r g i n a l excision/cure�age and preserving the axillary nerve. We went with the la�er considering the benign nature of the lesion and the recurrence rate being low at around 3.6 % [3]. As the axillary nerve was passing through the tumour, it was a bit difficult for us to delineate the nerve from the tumour. We isolated the nerve along with some �bres of deltoid. Shoulder strap incision was used because of the following reasons:- (1) �e incision is parallel to the Langer’s lines and thus heals cosmetically. (2) It gives be�er view of the surgical �eld. (3) Although not done in our case but we could have split deltoid at more than one place if required, which would not have been possible with direct lateral approach [8]. Unlike the case of Imuraet al [9], we did not feel the need to apply any plate to protect the bone because of the fact that humerus is a non-weight bearing bone and that there was more than 3/5��� of the circumference of humerus that was still intact. But, nevertheless application of a biodegradable or even conventional plate is an option if one suspects the chances of pathological fracture.

ConclusionGiant periosteal chondroma, due to its large size is one of the differential diagnosis of benign tumours of bone which must be distinguished from radiologically similar malignant neoplasms like periosteal chondrosarcoma or osteosarcoma. Although the de�nitive diagnosis can be done only on histopathology, MRI is helpful to see whether it is well localised or in�ltrating the surrounding tissues. As the chances of recurrence is very low, radical surgery should be avoided and a�empt should be made to preserve the vital structures, if possible. Deltoid spli�ing approach by shoulder strap incision which is cosmetically be�er and provides wide exposure can be used in cases of periosteal chondroma or any other benign bony tumour excision.

Keshav K et al www.jbjdonline.com

51 | | | | | Journal of Bone and Joint Diseases Volume 35 Issue 2 May-Aug 2020 Page 50-52

Figure : 1. (a)X-ray and (b)MRI of the patient showing the tumour2. Intraoperative picture (a) showing the isolated axillary nerve and the tumour in situ (b) Surgical area a�er

tumour excision (c)Half of the excised and cure�ed tumour mass 3. Post-operative Radiograph (a)Immediate Post-operative (b) 9 months later

4. Clinical pictures showing excellent functional outcome and cosmetically superior scar

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Keshav K et al www.jbjdonline.com

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2. Bauer TW, Dorfman HD, LathamJr JT. Periosteal chondroma. A clinicopathologic study of 23 cases. Am J Surg Pathol 1982;6(7):631–7.

3. Lewis MM1, Kenan S, Yabut SM, Norman A, Steiner G. Periosteal chondroma. A report of ten cases and review of the literature. Clin OrthopRelat Res. 1990;256:185-92.

4. Kenan S, Abdelwahab IF, Klein MJ, Lewis MM. Case report 837: Juxtacortical (periosteal) chondromyxoid fibroma of the proximal tibia. Skeletal Radiol 1994;23(3):237-39.

5. Durr HR, Lienemann A, Nerlich A, Stumpenhausen B, Refior HJ. Chondromyxoid fibroma of bone. Arch Orthop Trauma Surg 2000;120(1-2):42-47.

6. Kesavan A, Surendran D, Augustine J, Puthoor DK, Davis D. Giant Periosteal Chondroma: Report of a Rare Case. Journal of Clinical and Diagnostic Research 2019;13(10):ED15-ED17.

7. Nojima T, Unni KK, McLeod RA, Pritchard DJ. Periosteal chondroma and periosteal chondrosarcoma. American Journal of Surgical Pathology. 1985;9(9):666–677.

8. Robinson CM, Murray IR: The extended deltoid-splitting approach to the proximal humerus: Variations and extensions. J Bone Joint Surg Br 2011;93:387-392.

9. Imura Y, Shigi A, Outani H, et al. A giant periosteal chondroma of the distal femur successfully reconstructed with synthetic bone grafts and a bioresorbable plate: a case report. World J Surg Oncol. 2014;12:354.

Con�ict of Interest: Nil. Source of Support: None

How to Cite this ArticleKeshav K Giant periosteal chondroma of proximal humerus extending |

on both sides of axillary nerve managed by surgical excision through deltoid split approach via shoulder strap incision : A case report Journal |

of Bone and Joint Diseases May-Aug 2020;35(2):50-52.|

References