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Bone Pathology

Foot bone pathology: benign cysts, giant cell tumors, chondrosarcoma, osteosarcoma—diagnosis, staging, and surgical considerations.

Overview

Bone pathology in the hand encompasses a diverse spectrum of lesions requiring distinct management strategies. For enchondromata, simple curettage without bone grafting yields excellent radiographic and functional outcomes with no local recurrence [2]. In contrast, giant cell tumours of the bone in the hand may be managed with either curettage or resection/amputation [79], with decisions individualized based on the site and extent of disease to minimize morbidity while maximizing control [79]. Management of unicameral bone cysts remains controversial with no single standard of care, though new minimally invasive techniques involving cyst decompression with bone grafting and instrumentation have shown promising results with low complication and recurrence rates [22].

Specific pathologies present unique diagnostic and prognostic challenges. Osseous Rosai-Dorfman disease often follows a long, complicated clinical course due to diagnostic difficulties, with bone involvement potentially requiring intervention and carrying a worse prognosis than other forms [3]. Parosteal osteosarcoma diagnosis allows for focal or appreciable medullary involvement provided the overall histology remains consistent [28]. Symptomatic monostotic Paget disease of the hand should initially be treated with bisphosphonates before considering surgical options [30]. Conversely, bone grafting in polyostotic fibrous dysplasia carries a high probability of graft resorption and return of fibrous dysplasia characteristics, particularly in younger patients [72].

Definitive treatment parameters for several conditions remain undefined or require further investigation. The absolute indications for vascularized bone graft have yet to be defined by high-quality studies [20]. While studies establish baseline survival figures for osteogenic sarcoma subclasses treated by radical ablative surgery and compare these with irradiation or other therapies, prospective clinical trials are still needed for unicameral bone cyst management [21, 22]. Reviews currently encompass the classifications and treatment options of bone loss in the hand [7], while histologic features such as viable chondrocytes, functional matrix preservation, and complete host bone replacement are associated with long-term allograft survival [5].

Anatomy & Pathophysiology

Osseous and Articular Pathology

Multiple, various-stage bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults [4]. Osteochondral lesions of the talus are usually late sequelae of ankle trauma [24], a condition complicated by the talus's limited capacity for repair [24]. Hallux rigidus is characterized by restriction of motion at the first metatarsophalangeal joint [34] and is often associated with mechanical block from periarticular osteophytes [34]. Osteoid osteoma of the ankle joint exhibits a progressive course [91] and is difficult to diagnose at an early stage [91]. Surgical management for low-grade chondrosarcomas of the hands and feet should aim to preserve function [92], whereas Grade 2 and high-grade chondrosarcomas of the hands and feet require more aggressive surgical approaches [92]. Complete resection and correction osteotomy in patients with functional impairment or remarkable deformity from Trevor's disease can lead to restoration of normal anatomy [94] and result in good function without local recurrence [94].

Kinematics and Biomechanics

Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway [83]. A high medial longitudinal arch may contribute to increased load on the lateral side of the foot [84]. Elbow valgus torque increases contact pressure in the radiocapitellar joint [95]. Removal of the vastus lateralis and vastus intermedius results in better gait performance and a more physiological knee-loading pattern compared to removal of the vastus medialis [86].

Forefoot and Soft Tissue Pathology

Plantar plate pathology is associated with erosive disease in the painful forefoot of patients with rheumatoid arthritis [89]. Ray resection results in the best cosmetic and functional outcomes in feet with involvement of the lesser toes [97], while involvement of the great toe in macrodactyly often yields only fair results requiring repeated soft-tissue debulking [97]. Nonvascularized autogenous bone grafting is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss [96].

Vascular and Neural Considerations

Removal of a vascularized portion of the fibula is associated with a low prevalence of motor weakness and sensory deficits in the foot [90].

Classification

General Pathology: The incidence of bone metastases is increasing gradually [1], presenting with serious clinical symptoms [1] and exhibiting complex pathogenesis [1] with diverse clinical treatment options [1]. Metabolic diseases-associated bone lesions require a comprehensive diagnosis of multiple inspection items [14]. Bone islands are common benign lesions that may be difficult to distinguish from more important lesions without biopsy [17]. Multiple, various-stage bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults [4]. Reviews encompass the classifications and treatment options of bone loss in the hand [7].

Constitutional Disorders: A nomenclature was developed to standardize terms used in medical publications for constitutional disorders of bone [46], though this nomenclature is not a classification and is subject to revision as knowledge progresses [46]. The third edition of Tumors of Bone presents a review justifying original classifications for entities such as benign giant-cell tumor, chondroblastoma, and chondrosarcoma [48]. A radiographic classification of fibrous dysplasia is reproducible and useful for describing and assessing this disease [19].

Surface Osteosarcomas: Osteosarcomas arising on the surfaces of long bones are subdivided into three categories with distinct histological features and prognoses [57]. Parosteal osteosarcoma: has the best prognosis among surface osteosarcomas [57]. Periosteal osteosarcoma: has an intermediate prognosis among surface osteosarcomas [57]. High-grade surface osteosarcoma: has a poor prognosis among surface osteosarcomas [57]. Modified diagnostic criteria allow for focal or appreciable medullary involvement in parosteal osteosarcoma as long as the overall histology remains consistent with parosteal osteosarcoma [28].

Angiomatous Lesions: A general classification of angiomatous lesions of the extremities is established based on clinical and pathological features [53]. Transitional features exist between groups in the classification of angiomatous lesions of the extremities [53].

Giant Cell Tumors: The division of osteogenic sarcomata into three major types based on histological production emphasizes variation in microscopic pattern [60]. Osteogenic sarcomata types share similar skeletal localization, age distribution, and tendency for early hematogenous metastasis [60]. Tumors penetrating through the bone cortex were more aggressive than those located entirely within bone in giant-cell tumors [58]. Histopathological grading was of no prognostic value in giant-cell tumors [58]. The classification of 'simple fracture' and 'complex fracture' could guide decisions regarding the best surgical method for giant cell tumours around the knee with different degrees of fracture [55].

Other Considerations: Differentiation for surgical treatment of pathological fractures of the long bones should be based on the expected survival [63], the type and extent of the tumour [63], and the location of the fracture [63].

Clinical Presentation

The incidence of bone metastases is increasing gradually, presenting with serious clinical symptoms despite complex pathogenesis and diverse treatment options [1]. Similarly, osteoporosis is a common bone disorder with a rising incidence [16]. In contrast, primary bone lymphoma is a rare entity that can present as a pathological fracture but is often misdiagnosed initially [41]. Malignant hemangioendothelioma of bone is also a rare lesion, frequently misdiagnosed initially and associated with a poor prognosis [43].

Diagnostic challenges are prevalent across various pathologies. The clinical course of osseous Rosai–Dorfman disease is often long and complicated due to inherent difficulties with diagnosis, and bone involvement may require intervention; this form may carry a worse prognosis compared to other variants [3]. Diagnosis of bizarre parosteal osteochondromatous proliferation (Nora lesion) in pediatric phalanges is challenging due to presenting symptoms and radiographic findings [10]. Osteoid osteoma presents as a diagnostic challenge when atypical clinical features are present [11], while intra-articular variants often have ambiguous symptomatic and radiographic presentations that lead to significant delays in diagnosis [12]. Specific challenges for intra-articular osteoid osteoma include atypical symptomatology and a lack of characteristic imaging findings [13]. Skeletal abnormalities mainly develop in intra-/juxta-articular osteoid osteoma and may lead to permanent skeletal sequelae [6].

Metabolic and systemic conditions further complicate clinical assessment. Metabolic diseases-associated bone lesions require a comprehensive diagnosis of multiple inspection items [14]. Diagnosing sarcoidosis is difficult when presenting as pathological fractures of long bones from clinical, radiographic, and pathological standpoints [15]. Bone islands are common benign lesions but may be difficult to distinguish from more important lesions without biopsy [17]. Bone disease is a diagnosis of exclusion in the differential diagnosis of child abuse [38].

Specific presentations and patterns guide the physical examination. Multiple, various-stage bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults [4]. Presentation and prognosis of Panner's disease and osteochondritis dissecans are dependent primarily on age at onset, as these conditions likely represent a continuum of disordered endochondral ossification [18]. Extraskeletal cartilaginous tumors can arise at unusual anatomic sites, requiring an integrated clinical-pathologic diagnosis to clarify their nature [42]. Osteofibrous dysplasia has specific clinical signs, diagnosis methods, and treatment options [39].

Surgeons should utilize information regarding clinical presentation, pathophysiology, diagnosis, and treatment of COVID-associated osteonecrosis to screen and manage patients appropriately [40]. Multifocal osteoid osteoma should be considered when dealing with multifocal lytic lesions of the bone or when there is pain persistence after treatment [44].

Investigations

Plain radiography: Simple curettage without bone grafting for enchondromata of the hand yields excellent radiographic and functional outcomes with no local recurrence [2]. Calcified medullary defects appear as asymptomatic, unilateral, irregular, radio-opaque lesions in routine roentgenographic studies, most commonly at the ends of long bones [32]. A radiographic classification of fibrous dysplasia is reproducible and useful for describing and assessing this disease [19]. Further radiographs prior to surgical treatment for resection of a giant cell tumour of the proximal phalanx are unnecessary [68]. However, plain radiographs may fail to show a peripheral rim of ossification in soft-tissue recurrences of giant-cell tumor, necessitating thorough physical examination and magnetic resonance imaging [66]. Skeletal abnormalities mainly develop in intra-/juxta-articular osteoid osteoma and may lead to permanent skeletal sequelae [6]. Multiple, various-stage bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults [4]. Diagnosing sarcoidosis presenting as pathological fractures of long bones is difficult from clinical, radiographic, and pathological standpoints [15]. Histological and roentgenographic findings in a child with metaphyseal dysostosis disprove previous diagnoses of rickets and osteogenesis imperfecta [76].

MRI: Clinico-radiological surveillance can identify growing cartilage lesions, with MRI as the modality of choice [47]. MRI reliably diagnosed osteolysis with 100% agreement with arthroscopy in osteolytic lesions of the greater tuberosity associated with calcific tendinitis of the shoulder [56]. Magnetic resonance imaging is recommended in any case of an osteolytic, expanding lesion, particularly in cases that are clinically and radiologically not obviously an intraosseous epidermoid cyst [67]. A soft-tissue recurrence of giant-cell tumor may not be recognized if MRI studies are not carried out, as plain radiographs may not show a peripheral rim of ossification [66]. MRI may help in the diagnosis of intravascular papillary endothelial hyperplasia of the digit as it is difficult to diagnose based only on clinical features [74]. Distinct imaging features of multiple plexiform schwannomas in the plantar aspect of the foot may facilitate the diagnosis process [62].

Other Considerations: The diagnosis of bizarre parosteal osteochondromatous proliferation (Nora lesion) in pediatric phalanges can be challenging due to presenting symptoms and radiographic findings [10]. Osteoid osteoma can be a diagnostic challenge when presented with atypical clinical features [11]. Intra-articular osteoid osteomas often have ambiguous symptomatic and radiographic presentations, which can lead to significant delays in diagnosis [12]. Diagnosis of intra-articular osteoid osteoma may be challenging due to atypical symptomatology and lack of characteristic imaging findings [13]. A high index of suspicion and thorough evaluation including radiographs and biopsy are essential to avoid misdiagnosis in patients with known metastatic disease presenting with metastatic prostate cancer to the distal phalanx [71]. Low-grade myofibroblastic sarcoma demonstrates unique radiological and pathological features depending on its site of origin [75].

Treatment

Non-Operative

Conservative management is the primary strategy for several bone pathologies. Early, stable lesions of osteochondritis dissecans of the capitellum can heal with prompt recognition and nonoperative treatment [9]. Symptomatic patients with monostotic Paget disease of the hand should initially receive bisphosphonate therapy before considering surgical options [30]. Asymptomatic patients with diffuse pigmented villonodular synovitis of the foot and ankle can be successfully managed nonoperatively [59]. No operative intervention is required for Salmonella spondylitis in the absence of neurological impairment or osseous instability, as satisfactory antibiotic therapy and brace immobilization yield good long-term results [73]. Initial management of spontaneous and postarthroscopic osteonecrosis of the knee is typically nonsurgical, involving observation for progression [77]. Surgery has not proven superior to conservative clinical and radiological observation for enchondromas and atypical cartilaginous tumors of the long bones [80].

Operative

Indications: Surgical intervention is indicated for patients with unstable lesions of osteochondritis dissecans of the capitellum or those failing nonoperative therapy [9]. Early surgical intervention is recommended for secondary osteonecrosis of the knee [77]. Complete resection is indicated to improve overall survival in patients with bone metastasis [45].

Surgical Approach / Technique: Simple curettage without bone grafting for enchondromata of the hand results in excellent radiographic and functional outcomes with no local recurrence [2]. En-bloc resection of the entire fifth metacarpal bone with Y-shaped bone fusion to the fourth metacarpal can be performed without anatomical reconstruction, yielding almost complete function without signs of inferior bone quality or fracture risk [29]. Surgical debridement in conjunction with autologous bone grafting can yield favorable outcomes for osteomyelitis of the cuboid [52].

Adjuncts: New minimally invasive techniques involving cyst decompression with bone grafting and instrumentation for unicameral bone cysts have yielded promising results with low rates of complications and recurrence [22]. For active unicameral bone cysts, minimally invasive treatment is feasible to control cyst progression and then cure it without sequelae [69].

Other Considerations: The absolute indications for vascularized bone graft as borne out by high-quality studies have yet to be defined [20]. The role of denosumab in the management of osteoblastoma in achieving local tumor control is yet to be determined and may warrant further investigation [54]. A thorough medical history and the exclusion of other causes of osteonecrosis are mandatory to initiate appropriate treatment for bilateral idiopathic osteonecrosis of the major tubercle of the humerus [31]. All differential diagnoses for soft-tissue masses should be considered when planning surgical management for synovial sarcoma presenting as an intra-articular mass in a pediatric patient [78]. The physician should maintain a high degree of suspicion to rule out the possibility of organic material causing reaction in bone and consider it in the roentgenographic differential diagnosis of bone neoplasia [82]. Reviews encompass the classifications and treatment options of bone loss in the hand [7]. Baseline survival figures for various subclasses of osteogenic sarcoma treated by radical ablative surgery have been established and compared with patients receiving irradiation or other therapies [21]. Management of unicameral bone cysts remains controversial with no single method emerging as the standard of care, necessitating prospective clinical trials [22]. Osteochondral lesions of the talus are usually late sequelae of ankle trauma, making correct early diagnosis important due to the functional significance of the talus and its limited capacity for repair [24]. The authors recommend screening the hips of patients with osteonecrosis of the talus [81]. Histologic features associated with long-term allograft survival include viable chondrocytes, functional preservation of matrix, and complete replacement of the graft bone with the host bone [5]. The incidence of bone metastases is increasing gradually, presenting with serious clinical symptoms, complex pathogenesis, and diverse clinical treatment options [1]. A short-course of preoperative denosumab (three or fewer doses) is associated with no differences in clinical scores, histological and radiological response, or local recurrence-free survivorship compared with longer-course denosumab for giant cell tumor of bone [8]. However, the use of Denosumab for joint salvage in patients with giant cell tumour of bone was associated with a higher than expected rate of local recurrence at 44% [50]. Zoledronate treatment is more likely to be effective in male patients with early-stage osteonecrosis (ARCO I–II), whereas advanced-stage osteonecrosis (ARCO III–IV) may not respond well to zoledronate treatment [49]. Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes [34].

Complications

Other Considerations: The incidence of bone metastases is increasing gradually [1], presenting with serious clinical symptoms [1] and complex pathogenesis [1] that exhibit diverse clinical treatment options [1]. Osseous Rosai–Dorfman disease follows a long and complicated clinical course, often due to inherent diagnostic difficulties [3], where bone involvement may require intervention and carries a worse prognosis compared to other disease forms [3]. Skeletal abnormalities primarily develop in intra-/juxta-articular osteoid osteoma [6] and may lead to permanent skeletal sequelae [6]. The natural history of melorheostosis can include marked progression over nineteen years [33], while Paget's disease in the tibia may involve a purely lytic lesion over twelve years with faster longitudinal growth during the first six years before slowing [35]. Osteopetrosis is associated with sparse long-term follow-up data [61] but can include progressive fragmentation of femoral heads and disappearance of femoral necks over 24 years [61].

Other Considerations: Simple curettage without bone grafting for enchondromata of the hand yields excellent radiographic [2] and functional outcomes [2] with no local recurrence [2]. For osteochondritis dissecans of the capitellum, prompt recognition and nonoperative treatment of early, stable lesions can result in healing [9], whereas unstable lesions or those failing nonoperative therapy require operative intervention [9]. Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy in childhood coxa vara [37], while moderate nonprogressive deformity often does not require surgery [37]. Osteoporosis is a common bone disorder with increasing incidence [16]; its treatment pillars include early recognition [16], medical management [16], and fracture prevention [16].

Other Considerations: Histologic features associated with long-term allograft survival include viable chondrocytes [5], functional preservation of matrix [5], and complete replacement of the graft bone with the host bone [5]. A short-course of preoperative denosumab (three or fewer doses) shows no differences in clinical scores [8], histological response [8], radiological response [8], or local recurrence-free survivorship compared with longer-course denosumab [8]. Calcified medullary defects are asymptomatic [32], unilateral [32], irregular radio-opaque lesions found in routine roentgenographic studies [32], most commonly located in the ends of long bones [32]. There is no evidence that skeletal sequelae persist after prostaglandin therapy [23]. The term osteonecrosis more accurately reflects the multifactorial nature of this condition compared to avascular necrosis [25]. An aneurysmal bone cyst may be a manifestation of a reactive process of normal bone initiated by fracture trauma [26], which results in an arteriovenous fistula in the involved bone [26].

Other Considerations: Follow-up after operation proved the successful treatment of extensive bone defect of the femur caused by secondary syphilis by total hip arthroplasty [27]. A thorough medical history is mandatory to initiate appropriate treatment for bilateral idiopathic osteonecrosis of the major tubercle of the humerus [31], as is the exclusion of other causes of osteonecrosis [31]. The natural course of osteoid osteoma involves the central nidus increasing in size through bone destruction [36], spontaneous healing where the osteoid bone changes to normal bone [36], and clinical symptoms disappearing [36]. Medical history and clinical examination can be misleading in cases of apparent bone destruction [70], necessitating that a malignancy must always be excluded prior to treatment [70].

Recovery

Light activity (weeks): Evidence does not specify a discrete week range for light activity initiation across the provided pathology cohorts. However, prompt recognition and nonoperative treatment for early, stable lesions of osteochondritis dissecans of the capitellum can result in healing, while unstable lesions or those failing nonoperative therapy require operative intervention [9]. Similarly, simple curettage without bone grafting for enchondromata of the hand resulted in excellent functional outcomes and no local recurrence [2].

Full activity (months): The timeline for full activity is variable and pathology-dependent. Patients with non-anatomical reconstruction of the entire fifth metacarpal bone regained almost complete function despite the lack of anatomical restoration [29]. Mid-term results of talonavicular-cuneiform arthrodesis for the treatment of Müller-Weiss were maintained until mid-term follow-up [65]. In contrast, the natural history of melorheostosis can include marked progression over nineteen years [33], and the progression of Paget's disease in the tibia involved a purely lytic lesion over twelve years [35].

Complete recovery / outcome plateau (months): Recovery trajectories vary significantly by disease etiology. The natural course of osteoid osteoma involves spontaneous healing where the osteoid bone changes to normal bone and clinical symptoms disappear [36]. Conversely, the clinical course of osseous Rosai–Dorfman disease is often long and complicated, with bone involvement potentially carrying a worse prognosis compared to other forms of the disease [3]. For Paget's disease of the tibia, faster longitudinal growth occurred during the first six years before slowing, with the disease eventually extending to involve the entire bone over time [35].

Rehabilitation protocol: Specific rehabilitation protocols, including PT phasing, immobilisation duration, or weight-bearing progression, are not detailed in the provided evidence. Management is dictated by lesion stability and pathology; for instance, aneurysmal bone cysts may be a manifestation of a reactive process initiated by fracture trauma [26], and bone involvement in osseous Rosai–Dorfman disease may require intervention [3]. Histologic features associated with long-term allograft survival include viable chondrocytes, functional preservation of matrix, and complete replacement of the graft bone with the host bone [5].

Functional milestones: Functional outcomes are generally favorable for specific benign conditions. Simple curettage without bone grafting for enchondromata of the hand resulted in excellent radiographic and functional outcomes [2]. Despite non-anatomical reconstruction of the entire fifth metacarpal bone, no signs of inferior bone quality or risk of fracture developed, and the patient regained almost complete function [29]. Follow-up after operation proved successful treatment of extensive bone defect of the femur caused by secondary syphilis by total hip arthroplasty [27].

Other Considerations: Several factors influence long-term outcomes and disease course. The incidence of bone metastases is increasing gradually, presenting with serious clinical symptoms and complex pathogenesis requiring diverse clinical treatment [1]. A short-course of preoperative denosumab (three or fewer doses) was associated with no differences in clinical scores, histological response, radiological response, or local recurrence-free survivorship compared with longer-course denosumab [8]. Presentation and prognosis of Panner's disease and osteochondritis dissecans are dependent primarily on age at onset, with both likely representing a continuum of disordered endochondral ossification [18]. Further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time for autologous matrix-induced chondrogenesis [64]. The term osteonecrosis more accurately reflects the multifactorial nature of this condition compared to avascular necrosis [25]. There is no evidence to suggest that skeletal sequelae persist after prostaglandin therapy [23]. While it is exceedingly unusual for a patient with myeloma of bone with multiple involvement to survive for nine years, a case report documents a patient who lived for nine years and five months after diagnosis [88]. The benign clinical course of chondromyxoid fibroma makes differentiation from chondrosarcoma important [87], and the non-ossifying fibroma follows a characteristic radiomorphological course with variable duration of each stage [85]. An aneurysmal bone cyst may result in an arteriovenous fistula in the involved bone [26].

Key Evidence

  • [L4] The incidence of bone metastases is increasing gradually, with serious clinical symptoms, complex pathogenesis and diverse clinical treatment. (10.3389/fonc.2022.1105745)
  • [L4] Simple curettage without bone grafting resulted in excellent radiographic and functional outcomes with no local recurrence. (10.1054/jhsb.2002.0843)
  • [L4] The clinical course of osseous Rosai-Dorfman disease is often long and complicated due to inherent difficulties with diagnosis, and bone involvement may require intervention with a potentially worse prognosis compared to other forms of the disease. (10.1016/j.jhsa.2018.03.019)
  • [L4] Multiple, various-stage bone stress injuries of the ankle and foot may occur simultaneously in physically active young adults. (10.1177/0363546506295701)
  • [L4] Skeletal abnormalities mainly develop in intra-/juxta-articular osteoid osteoma, and these may lead to permanent skeletal sequelae. (10.1186/s12891-015-0456-y)
  • [L5] This review encompasses the classifications and treatment options of bone loss in the hand. (10.1016/j.jhsa.2013.02.026)
  • [L3] A short-course of preoperative denosumab (three or fewer doses) was associated with no differences in clinical scores, histological and radiological response, or local recurrence-free survivorship compared with longer-course denosumab. (10.1097/corr.0000000000001285)
  • [L5] Prompt recognition and nonoperative treatment for early, stable lesions can result in healing, while patients with unstable lesions or those failing nonoperative therapy require operative intervention. (10.1177/0363546509354969)
  • [L4] The diagnosis in pediatric cases can be challenging due to presenting symptoms and radiographic findings. (10.1016/j.jhsa.2020.05.002)
  • [Case_report] Osteoid osteoma can be a diagnostic challenge when presented with atypical clinical features. (10.1007/s00167-005-0653-6)
  • [L4] Intra-articular osteoid osteomas often have ambiguous symptomatic and radiographic presentations, which can lead to significant delays in diagnosis. (10.1177/0363546507307865)
  • [Case_report] Diagnosis of intra-articular osteoid osteoma may be challenging due to atypical symptomatology and lack of characteristic imaging findings. (10.1136/jisakos-2020-000598)
  • [Case_report] Metabolic diseases-associated bone lesions require a comprehensive diagnosis of multiple inspection items. (10.1186/s12891-022-05274-0)
  • [Case_report] The case illustrates the difficulty in diagnosing sarcoidosis from clinical, radiographic, and pathological standpoints when presenting as pathological fractures of long bones. (10.2106/00004623-199503000-00014)
  • [Case_report] Bone islands are common benign lesions that may be difficult to distinguish from more important lesions without biopsy. (10.2106/00004623-198567050-00021)
  • [L5] Panner's disease and osteochondritis dissecans likely represent a continuum of disordered endochondral ossification with presentation and prognosis dependent primarily on age at onset. (10.5435/00124635-200407000-00005)
  • [L4] This radiographic classification of fibrous dysplasia is reproducible and useful for describing and assessing this disease. (10.1186/s13018-015-0313-6)
  • [L4] The absolute indications for vascularized bone graft as borne out by high-quality studies have yet to be defined. (10.2106/jbjs.rvw.16.00125)
  • [L4] The study establishes baseline survival figures for various subclasses of osteogenic sarcoma treated by radical ablative surgery and compares them with patients receiving irradiation or other therapies. (10.2106/00004623-196648010-00001)
  • [L5] Management of unicameral bone cysts remains controversial with no single method emerging as the standard of care; new minimally invasive techniques involving cyst decompression with bone grafting and instrumentation have yielded promising results with low rates of complications and recurrence, though prospective clinical trials are needed. (10.5435/jaaos-22-05-295)
  • [Case_report] There is no evidence to suggest that skeletal sequelae persist after prostaglandin therapy. (10.2106/00004623-199506000-00014)
  • [L4] Osteochondral lesions of the talus are usually late sequelae of ankle trauma; correct early diagnosis is important due to the functional significance of the talus and its limited capacity for repair. (10.5435/00124635-201010000-00005)
  • [L5] The term osteonecrosis more accurately reflects the multifactorial nature of this condition compared to avascular necrosis. (10.1016/j.arth.2025.05.064)
  • [L4] The case histories support the concept that an aneurysmal bone cyst may be a manifestation of a reactive process of normal bone initiated by the trauma of a fracture, resulting in an arteriovenous fistula in the involved bone. (10.2106/00004623-198264040-00021)
  • [Case_report] Follow-up after the operation proved the successful treatment of the extensive bone defect of femur by total hip arthroplasty. (10.1186/s12891-018-2152-1)
  • [Case_report] The authors propose modified diagnostic criteria that allow for focal or appreciable medullary involvement as long as the overall histology remains consistent with parosteal osteosarcoma. (10.2106/00004623-198769010-00020)
  • [Case_report] Despite the non-anatomical reconstruction, no signs of inferior bone quality or risk of fracture developed, and the patient regained almost complete function. (10.1177/1753193417701061)
  • [L4] Symptomatic patients should be treated initially with a bisphosphonate before surgical options are considered. (10.1016/j.jhsa.2015.04.022)
  • [L5] A thorough medical history and the exclusion of other causes of osteonecrosis are mandatory to initiate appropriate treatment. (10.1007/s00167-012-2025-3)
  • [L5] Hallux rigidus is a common disorder characterized by restriction of motion at the first metatarsophalangeal joint, often associated with mechanical block from periarticular osteophytes. (10.2106/00004623-199806000-00015)
  • [Case_report] The report documents the progression of a purely lytic lesion in Paget's disease of the tibia over twelve years, noting that faster longitudinal growth occurred during the first six years before slowing as the disease extended to involve the entire bone. (10.2106/00004623-197658060-00023)
  • [L4] The natural course of osteoid osteoma involves the central nidus increasing in size through bone destruction, followed by spontaneous healing where the osteoid bone changes to normal bone and clinical symptoms disappear. (10.2106/00004623-195133010-00015)
  • [L5] Surgical management is indicated for progressive, painful, unilateral deformity or leg-length discrepancy, while moderate nonprogressive deformity often does not require surgery. (10.5435/00124635-199803000-00003)
  • [L4] Bone disease is a diagnosis of exclusion in the differential diagnosis of child abuse. (10.1007/s11999-010-1578-z)
  • [L5] This narrative review discusses clinical signs, diagnosis methods, and treatment options of osteofibrous dysplasia to improve understanding, which is helpful for accurate diagnosis and appropriate treatment. (10.1186/s13018-024-04682-3)
  • [L4] For patients inoculated with the COVID-19 virus, it is important for surgeons to use information regarding clinical presentation, pathophysiology, diagnosis, and treatment of COVID-associated osteonecrosis to screen and manage patients appropriately. (10.1016/j.arth.2025.06.015)
  • [Case_report] Primary bone lymphoma is a rare entity that can present as a pathological fracture and is often misdiagnosed initially; early diagnosis and multimodal treatment including chemotherapy, radiotherapy, and surgical reconstruction can lead to complete remission and functional recovery. (10.1016/j.xrrt.2023.12.008)
  • [L4] An integrated clinical-pathologic diagnosis helps to clarify the nature of extraskeletal cartilaginous tumors that can arise at unusual anatomic site. (10.1186/1471-2474-7-57)
  • [L4] Malignant hemangioendothelioma of bone is a rare lesion that is often misdiagnosed initially; the authors report two cases to highlight the difficulty in diagnosis and the poor prognosis associated with the disease. (10.2106/00004623-197860050-00020)
  • [Case_report] The case highlights the importance of considering a diagnosis of multifocal osteoid osteoma when dealing with multifocal lytic lesions of the bone and with pain persistence after treatment. (10.1186/s12891-019-2552-x)
  • [Case_report] Overall survival of patients with bone metastasis is improved by complete resection. (10.1186/s12891-015-0748-2)
  • [L5] The nomenclature developed is intended to standardize terms used in medical publications for constitutional disorders of bone, though it is not a classification and is subject to revision as knowledge progresses. (10.2106/00004623-197153050-00012)
  • [L3] Clinico-radiological surveillance can identify growing cartilage lesions, with MRI as the modality of choice. (10.1302/0301-620x.98b11.37864)
  • [L5] This third edition presents an even more complete review of all available material on tumors of bone, with follow-up reports justifying original classifications for entities such as benign giant-cell tumor, chondroblastoma, and chondrosarcoma. (10.2106/00004623-195032010-00029)
  • [L3] Zoledronate treatment is more likely to be effective in male patients with early-stage osteonecrosis (ARCO I–II), whereas advanced-stage disease (ARCO III–IV) may not respond well. (10.1186/s13018-025-06647-6)
  • [L3] The use of Denosumab for joint salvage was associated with a higher than expected rate of local recurrence at 44%. (10.1302/0301-620x.103b1.bjj-2020-0274.r1)
  • [Case_report] Surgical debridement in conjunction with autologous bone grafting can yield favorable outcomes. (10.1186/s12891-025-08929-w)
  • [L4] The study establishes a general classification of angiomatous lesions of the extremities based on clinical and pathological features, noting that while each group has distinctive characteristics, transitional features exist between groups. (10.2106/00004623-196244050-00001)
  • [L4] The role of denosumab in the management of osteoblastoma in achieving local tumor control is yet to be determined and may warrant further investigation. (10.1016/j.jhsa.2019.02.001)
  • [L3] The classification of 'simple fracture' and 'complex fracture' could guide decisions regarding the best surgical method for lesions in patients who have giant cell tumour around the knee with different degrees of fracture. (10.1186/s12891-022-06005-1)
  • [L2] MRI reliably diagnosed osteolysis with 100% agreement with arthroscopy. (10.1016/j.jse.2008.09.016)
  • [L4] Osteosarcomas arising on the surfaces of long bones are subdivided into three categories with distinct histological features and prognoses: parosteal osteosarcoma (best prognosis), periosteal osteosarcoma (intermediate prognosis), and high-grade surface osteosarcoma (poor prognosis). (10.2106/00004623-198870040-00012)
  • [L4] Tumors penetrating through the bone cortex were more aggressive than those located entirely within bone, and histopathological grading was of no prognostic value. (10.2106/00004623-197557020-00007)
  • [L4] Asymptomatic patients can be successfully managed nonoperatively. (10.1302/0301-620x.95b3.30192)
  • [L4] The division of osteogenic sarcomata into three major types based on histological production emphasizes variation in microscopic pattern while noting similar skeletal localization, age distribution, and tendency for early hematogenous metastasis. (10.2106/00004623-195739040-00002)
  • [Case_report] The distinct imaging features presented may facilitate the diagnosis process in the future. (10.1186/1471-2474-15-342)
  • [L4] This differentiation should be based on the expected survival, the type and extent of the tumour, and the location of the fracture. (10.1302/0301-620x.100b10.bjj-2018-0239.r1)
  • [L4] However, further studies with long-term follow-up are needed to determine whether the grafted area will maintain structural and functional integrity over time. (10.1007/s00167-010-1042-3)
  • [L4] These results were maintained until mid-term follow-up. (10.1186/s12891-023-06293-1)
  • [L4] A soft-tissue recurrence of giant-cell tumor may not be recognized if a thorough physical examination is not performed and magnetic resonance imaging studies are not carried out, as plain radiographs may not show a peripheral rim of ossification. (10.2106/00004623-199905000-00012)
  • [L4] Magnetic resonance imaging is recommended in any case of an osteolytic, expanding lesion, particularly in cases that are clinically and radiologically not obviously an intraosseous epidermoid cyst. (10.1177/1753193411401987)
  • [L4] Further radiographs prior to surgical treatment are unnecessary. (10.1177/1753193408097859)
  • [L4] For active unicameral bone cysts, minimally invasive treatment is feasible to control cyst progression and then cure it without sequelae. (10.1186/s13018-019-1326-3)
  • [Case_report] This report emphasizes that medical history and clinical examination can be misleading in cases of apparent bone destruction, and that a malignancy must always be excluded prior to treatment. (10.1186/1749-799x-5-36)
  • [Case_report] A high index of suspicion and thorough evaluation including radiographs and biopsy are essential to avoid misdiagnosis in patients with known metastatic disease. (10.1177/15589447211028922)
  • [L4] The expectations of patients and surgeons should include the high probability of graft resorption over time with return of bone characteristics of fibrous dysplasia, particularly in younger patients. (10.2106/jbjs.o.00547)
  • [L4] No operative treatment is needed in the absence of neurological impairment or osseous instability, and a good long-term result should be expected after satisfactory antibiotic therapy and immobilization in a brace. (10.2106/00004623-198870030-00025)
  • [L4] MRI may help in the diagnosis of this condition as it is difficult to diagnose based only on clinical features. (10.1177/1753193412453541)
  • [Case_report] LGMS demonstrates unique radiological and pathological features depending on its site of origin. (10.1186/s12891-025-08565-4)
  • [L4] Histological and roentgenographic findings in a child with metaphyseal dysostosis disprove previous diagnoses of rickets and osteogenesis imperfecta. (10.2106/00004623-197355030-00021)
  • [L5] Early surgical intervention is recommended for secondary ON, while initial management of spontaneous and postarthroscopic ON is typically nonsurgical with observation for progression. (10.5435/00124635-201108000-00004)
  • [Case_report] We strongly recommend considering all differential diagnoses for soft-tissue masses when planning surgical management. (10.1186/s12891-020-03312-3)
  • [L4] Both curettage and resection/amputation are acceptable treatment options for the rare condition of giant cell tumour of bone in the hand, with a need to individualize treatment decisions based on the site and extent of disease to minimize treatment morbidity while maximizing disease control. (10.1177/17531934211007820)
  • [L3] Surgery did not prove superior compared to conservative clinical and radiological observation. (10.1186/s12891-019-2502-7)
  • [L4] The authors also recommend screening the hips of patients with osteonecrosis of the talus. (10.2106/00004623-199804000-00009)
  • [L4] Hallux valgus deformity and its severity were positively associated with the magnitude of the anteroposterior postural sway. (10.1186/s12891-021-04385-4)
  • [L3] In addition, high medial longitudinal arch may contribute to increased load on the lateral side of the foot. (10.1177/0363546519893365)
  • [L4] The non-ossifying fibroma follows a characteristic radiomorphological course with variable duration of each stage. (10.1186/s12891-016-1004-0)
  • [L3] Patients in whom the vastus lateralis and vastus intermedius were removed had better gait performance and a more physiological knee-loading pattern than did patients in whom the vastus medialis was removed. (10.2106/00004623-200011000-00016)
  • [L3] Longitudinal follow-up is required to determine the mechanism and presentation of plantar plate pathology in the painful forefoot of patients with RA. (10.1186/s12891-017-1668-0)
  • [L3] Removal of a vascularized portion of the fibula is associated with a low prevalence of motor weakness and sensory deficits in the foot. (10.2106/00004623-199602000-00006)
  • [Case_report] OO of the ankle joint exhibits a progressive course and is difficult to diagnose at an early stage. (10.1186/s12891-017-1413-8)
  • [L3] For low-grade CSs of the hands and feet, surgical management should aim to preserve function, while grade 2 and high-grade tumours require more aggressive approaches. (10.1302/0301-620x.103b3.bjj-2020-1337.r1)
  • [L4] Complete resection and correction osteotomy in patients with functional impairment or remarkable deformity can lead to restoration of normal anatomy and result in good function without local recurrence. (10.1016/j.jse.2012.10.031)
  • [L5] Elbow valgus torque increases contact pressure in the radiocapitellar joint. (10.1177/0363546513490652)
  • [Case_report] The technique is capable of restoring good hand function in severe injuries with substantial phalangeal bone loss. (10.1016/j.jhsa.2008.04.025)
  • [L4] Ray resection results in the best cosmetic and functional outcomes in feet with involvement of the lesser toes, while involvement of the great toe often yields only fair results requiring repeated soft-tissue debulking. (10.2106/00004623-200207000-00015)

See Also

References

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b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.