Giant Osteochondroma on Pubic Ramus:

A Case Report

Mujaddid Idulhaq*, Pamudji Utomo *, Bayu Sakti Jiwandono**, Muhammad Qathar

Email: [email protected]
Office: Prof. Dr. Soeharso Orthopaedic Hospital Surakarta, Orthopaedic and Traumatology
Department, Jl. A. Yani No.157, Mendungan, Pabelan, Kec. Kartasura, Kabupaten
Sukoharjo, Surakarta, Central Java 57162

ABSTRACT
Introduction
Osteochondroma is the most common benign tumor of bone. Osteochondroma is a
developmental malformation rather than true neoplasms. It usually affects bones that
develop by endochondral ossification and rarely originate from bones that develop by
intramembranous ossification such as pubic rami, scapula, clavicle, and ribs.
Objective
This paper was intended to present a rare case of pubic osteochondroma and evaluate the
outcome after wide excision.
Case
A man 34 years old with a lump on his right groin area complained for 10 years. At our
hospital he underwent challenging wide excision of the right pubic ramus, in which many
dangerous structures have to be avoided. We obtained the whole tumor tissue with a
diameter of 12 centimeters. According to Clinicopathological Conference the tumor was
concluded as osteochondroma. The tumor site and clinical presentation were rare. He had
no visceral nor vascular involvement though the lesion was very close to many vital
structures on superior pubic ramus.
Results
After 1 year of evaluation, the patient's clinical condition is good. He does not feel any
complaints, no sign of recurrence, and there are no complications on the surgical wound.

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Conclusions
We have performed extensive excision of the tumor in the pubic ramus of a 34-year-old man.
Histopathological examination results were in accordance with the description of
osteochondroma. Osteochondroma which arise from the pelvic is an unusual presentation
that should be kept in mind as a differential diagnosis when evaluating patient with mass on
th pelvis.

Key words : Osteochondroma, wide excision, pubic ramus, bone tumor

ABSTRAK
Pendahuluan
Osteokondroma adalah tumor tulang jinak yang paling umum. Osteokondroma adalah
malformasi perkembangan daripada neoplasma sejati. Ini biasanya mempengaruhi tulang
yang berkembang oleh osifikasi endokondral dan jarang berasal dari tulang yang
berkembang secara osifikasi intramembran seperti tulang rami pubis, skapula, klavikula, dan
tulang rusuk.
Objektif
Makalah ini dimaksudkan untuk menyajikan kasus osteokondroma pubis yang jarang terjadi
dan mengevaluasi hasil setelah eksisi luas.
Kasus
Seorang pria 34 tahun dengan benjolan di daerah selangkangan kanan mengeluh selama
10 tahun. Di rumah sakit kami, dia menjalani eksisi lebar ramus pubis kanan, di mana
banyak struktur berbahaya yang harus dihindari. Kami mendapatkan seluruh jaringan tumor
dengan diameter 12 sentimeter. Menurut Konferensi Klinikopatologi tumor disimpulkan
sebagai osteokondroma. Lokasi tumor dan presentasi klinis jarang terjadi. Tumor ini tidak
memiliki keterlibatan viseral atau vaskular meskipun lesi tersebut sangat dekat dengan
banyak struktur vital pada ramus pubis superior.
Hasil
Setelah 1 tahun evaluasi, kondisi klinis pasien baik. Ia tidak merasakan keluhan apapun,
tidak ada tanda-tanda kambuh, dan tidak ada komplikasi pada luka operasi.
Kesimpulan
Kami telah melakukan eksisi ekstensif tumor di ramus pubis pria berusia 34 tahun. Hasil
pemeriksaan histopatologi sesuai dengan gambaran osteokondroma. Osteokondroma yang
muncul dari panggul adalah presentasi yang tidak biasa yang harus diingat sebagai
diagnosis banding saat mengevaluasi pasien dengan massa di panggul.

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BACKGROUNDS
Osteochondroma is a hamartomatous
proliferation of bone and cartilage that is
thought to arise from growth cartilage, and
grows through endochondral ossification
under the periosteum. This process of
developing osteochondroma can explain its
tendency to involve long bones, such as the
distal femur, proximal tibia, and proximal
humerus. Generally, osteochondroma
appears in the first three decades of life and Figure 1. Patient clinical picture

affects the age of children and adolescents. Source: Internal database

The majority of osteochondroma are Pelvic radiograph shows an osseous

asymptomatic and are found accidentally.(1) mass of about 11 cm x 12 cm attached to the

The main objective of this study is to superior ramus aspect of the right pubic.

describe the profile of osteochondroma Pelvic CT scan shows that the mass was very

patients on pubic ramus and how this case is close to major vascular structures, hence

treated. Given this case is quite rare and quite makes the surgery was technically

difficult technically because of the many challenging.

important structures around the pubic ramus. During the surgery, excision of the

Case mass was carried out through the anterior

A man, 34 years old, with a complain approach in the supine position of the patient.

of a lump on the right side of the groin area An incision was made by deepened the layer

since 10 years ago. Accompanied by a by layer until the tumor tissue was visible.

palpable mass in the anterior aspect of the During the surgery we identified many

right pubic which has been enlarged since 5 vascular structures adjacent to tumor tissue.

years. Physical examination of the patient Wide excision and osteotomy were performed

showed an immobile mass measuring around to the healthy border of the pubic bone. The

10 cm x 10 cm. The mass was non-tender, condition of the pubic ramus was examined

non-mobile, and fixed to underlying bone but after excision and there was no fracture or

not adherent to skin or the overlying tissue. defect.

The range of right hip movement was normal.

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 DISCUSSIONS
Skeletal osteochondroma is
considered by some authors to be a tumor
and by others as a growth or developmental
disruption resulting from the separation of a
fragment from the epiphyseal growth plate,
which is then herniated through the periosteal
bone cuff that usually surrounds the growth
plate (encoche of Ranvier). An
osteochondroma can arise in any bone that
Figure 2. Patient Pelvis Xray. develops from endochondral ossification.(1)
Source: Internal database
Histopathological examination results
showed that the microscopic picture of this
tumor was in accordance with
osteochondroma, with a cartilaginous sheath.
Postoperatively, the patient reported an
improvement in pain at the location of the
operation. On the 1 year follow-up, the patient
stated no symptom and sign of recurrence. Figure 4. Tumor tissue. Source:
Pelvic radiographic examination showed no Internal database
evidence of new mass formation. Although the exact etiology of this
growth is unknown, it is thought that some
peripheral physis is thought to undergo
herniation of the growth plate. This herniation
may be idiopathic or a result from trauma or
deficiency of the perichondrial ring. Whatever
the cause, the result is an abnormal extension
of the metaplastic cartilage that responds to
factors that stimulate the growth plate and
Figure 3. Pelvis CT-scan and 3D thus produce growth exostosis.(2)
reconstruction. Source: Internal database

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 Figure 6. Tumor histopathology with marked
compact bone surrounded by cartilage. There
is no sign of malignancy . Source: Internal
database
Osteochondroma was thought to arise
through a progressive hardening process in
the growth plate deviant cartilage as a
consequence of congenital defect or trauma.
Osteochondroma is present as sessile bones
Figure 5. Post operative xray and clinical
or pedunculated lesions with the periosteum
pictures.
and cortex which are continuous with that of
Source: Internal documentation.
the host bone. They manifest in two different
Cartilage islets organize into
patterns, solitary lesions without genetic
structures similar to epiphyses. Because
abnormality or multiple lesions known as
metaplastic cartilage is stimulated,
hereditary multiple exostoses. Longer bones
endochondral bone formation occurs,
of the lower extremities are most commonly
developing a bony stalk. This theory is
affected (50% of cases) and
thought to explain the classic findings of
more frequently involved than the upper limb
osteochondroma associated with growth
by a ratio of 2 to 1.(3)
plates and growing away from the physis
Osteochondroma located in the pelvis
while still within their medullary. This theory is
is unusual. Kimt et al presents a case of
also thought to explain the clinical state of
pelvic osteochondroma with spinal nerve root
exostosis growing only until the skeleton
compressions An exostotic bony projection
reaches maturity.(2)

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composed of dense calcification of the or as palpable masses that may or may not
cartilaginous cap arose from the iliac crest, be painful. Asymptomatic presentations of
which was located just lateral to the right solitary osteochondromas can occur
sacroiliac joint in the paravertebral area, L5 conservatively because of low levels of
level. The L5 nerve root was focally malignancy transformation. Tumor that cause
compressed and thinned. En bloc excision, pain or neurological complications due to
the treatment of choice of symptomatic compression should be underwent surgical
osteochondroma, was performed. The patient procedures. Complete excision with wide
had complete resolution of symptoms excision is the main goal, because of an
postoperatively, and other neurologic incomplete removal of the cartilaginous cap
symptoms may be expected to improve over may precipitate tumor recurrence.(5)
time.(6) Conclusions
Our patient is reported as 34 years old Treatment of osteochondroma is
male with visible mass on his right groin. Here generally conservative unless symptoms such
in our case the mass near his private part was as pain, or the lesion develops progressively,
the cause for him to seek medical help. There the tumor enlarges after skeletal maturation,
were no compressive symptoms either on or the alleged transformation becomes
vessels or on urinary tract. A similar case was malignant.(5)
reported by Qaisrani GH and associates A long follow-up period is needed to
which was also present osteochondroma on ensure recurrence. In conclusion, we report a
superior pubic ramus and was removed for rare case of osteochondroma on pubic ramus
(7)
cosmetic deformity. in a man who was treated with wide excision
Clinical manifestations are greatly with good post-operative follow-up results.
varies. Tumors can be present as painful sites

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