Foot and Ankle Surgery 20 (2014) e51–e55
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Valgus toe deformity of fourth proximal phalanx due to osteochondroma treated with closing wedge osteotomy Toshinori Kurashige MD*, Seiichi Suzuki MD Department of 1st Orthopaedic Surgery, Mito Red Cross Hospital, 3-12-48, Sannomaru, Mito City, Ibaraki 310-0011, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 April 2014 Received in revised form 29 April 2014 Accepted 27 June 2014
Osteochondroma is the most common benign tumor of all benign and primary bone tumors. It rarely occurs in the proximal phalanx of the lesser toe. The treatment of osteochondroma usually consists of simple resection. However, if other deformities remain, added procedures may be considered. We report a case of a valgus toe deformity of the fourth proximal phalanx due to osteochondroma. The patient was a 21-year-old man who noticed a valgus deformity of his fourth toe over 10 years earlier. He began to experience pain in his fifth toe because of crossover of the fourth toe when wearing formal shoes. Although resection of osteochondroma was performed, the valgus deformity was not sufficiently corrected. Therefore, closing wedge osteotomy of the proximal phalanx was performed at the same time. A good outcome was achieved for this patient. ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Osteochondroma Proximal phalanx Valgus deformity Closing wedge osteotomy Side-cutting burr
1. Introduction Osteochondroma is the most common benign tumor of all benign and primary bone tumors [1,2]. It arises from the periphery of the cartilaginous growth plate and occurs most often around the long tubular bones and rarely in the small bones of the foot [2–4]. Most frequently involved sites are distal femur, proximal humerus, proximal tibia and ilium. Unni et al. [2] reported only one case of phalange in their 884 series of solitary osteochondromas. Osteochondroma rarely occurs in the proximal phalanx of the lesser toe. Only a few related reports have been published [3,5,6]. Malignant transformations to chondrosarcoma have been most commonly reported in patients with hereditary multiple lesions, but such change occurs in fewer than 1% [2]. Malignant transformation of a solitary lesion is extremely rare. Symptoms are usually caused by mechanical factors. Therefore, the treatment of osteochondroma usually consists of simple resection [2,3,5,6]. However, if other deformities remain, added procedures may be considered [7,8]. We report a case of a valgus toe deformity of the fourth proximal phalanx due to osteochondroma. To our knowledge, there are only two previous case reports in the
* Corresponding author. Tel.: +81 29 221 5177; fax: +81 29 227 0819. E-mail addresses: [email protected], [email protected] (T. Kurashige), [email protected] (S. Suzuki).
English literature about osteochondroma of the proximal phalanx of the lesser toe in which resection was performed [5,6]. We also believe that this is the first case in which closing wedge osteotomy was performed for a valgus toe deformity of the proximal phalanx due to osteochondroma. 2. Case report The patient was a 21-year-old man who noticed a valgus deformity of the left fourth toe over 10 years earlier. He had no history of trauma or surgery to the foot. He had never visited a hospital because he had experienced no restriction in his activities of daily living and recreational sports. He became a college student and began to wear formal shoes for job interviews. He had no complaints regarding his fourth toe; however, he began to experience pain in the fifth toe due to crossover of the fourth toe when wearing these shoes. Therefore, he was referred to our department. On physical examination, the fourth toe had a valgus deformity and crossed over the fifth toe (Fig. 1a). There was no pain or numbness in the fourth toe; however, a painful callus had formed beneath the tip of the fifth toe (Fig. 1b). Palpation revealed a bony hard mass on the dorsal side of the third web. Flexibility of the toe was normal. There was no other apparent deformity in his feet or body and no family history of congenital or developmental skeletal deformities.
http://dx.doi.org/10.1016/j.fas.2014.06.005 1268-7731/ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
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T. Kurashige, S. Suzuki / Foot and Ankle Surgery 20 (2014) e51–e55
Fig. 1. Macroscopic findings. (a) The fourth toe with a valgus deformity is shown; the fourth toe has crossed over the fifth toe. (b) A painful callus is present beneath the tip of the fifth toe.
3. Imaging findings Radiography revealed a bone tumor on the medial side of the fourth proximal phalanx. The phalanx had a valgus deformity (Fig. 2a). Computed tomography (CT) revealed that the bone tumor had a wide base that was continuous with the proximal phalanx (Fig. 2b). Coronal T2-weighted fat suppression magnetic resonance imaging (MRI) revealed that the lesion was in continuity with the medulla of the proximal phalanx and had a thin cartilage cap (Fig. 3). 4. Operative technique The patient was placed in the supine position. A pneumatic tourniquet was used. The bone tumor was exposed through a longitudinal incision at the dorsal medial aspect of the fourth proximal phalanx. The bone tumor was resected from its base at
the proximal phalanx. The fourth toe remained in valgus after tumor resection (Fig. 4a). Fluoroscopic images revealed that the proximal phalanx had a valgus deformity in the anteroposterior view (Fig. 4b) but had neither flexion nor extension deformity in the lateral view (Fig. 4c). Therefore, closing wedge osteotomy of the proximal phalanx was performed at the same time. After removing the dorsal and plantar periosteum, a side-cutting burr 2 mm in diameter and 5 mm in length was inserted from the medial aspect of the proximal phalanx at the apex of the deformity. Care was taken not to penetrate the lateral cortex. Wedge osteotomy was performed using a sweeping motion of the burr keeping the lateral cortex intact. The osteotomy site was closed with gentle finger pressure; however, a fracture of the lateral cortex occurred. Therefore, 1.2-mm Kirshner wire fixation was percutaneously performed (Fig. 5). Pathological examination identified the tumor as an osteochondroma.
Fig. 2. Preoperative images. (a) Radiograph showing the bone tumor at the medial side of the fourth proximal phalanx. The bone has a valgus deformity. (b) Computed tomographic image showing that the bone tumor has a wide base continuous with the proximal phalanx.
T. Kurashige, S. Suzuki / Foot and Ankle Surgery 20 (2014) e51–e55
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5. Postoperative course Weight bearing on the heel was immediately permitted. The wire was removed, and range of motion exercise of the toe was started 4 weeks after the operation. Union was achieved 2 months postoperatively. Good cosmetic and functional outcomes were achieved, and the patient could wear formal shoes with no complaints (Fig. 6a, b). Flexibility and mobility of the fourth toe were normal (Fig. 6c and d). No floating toe was observed. Radiographs revealed the union of the fourth proximal phalanx and no recurrence of the bone tumor 6 months after the operation (Fig. 7). 6. Discussion Fig. 3. Magnetic resonance imaging (MRI) findings. Coronal T2-weighted fatsuppression MRI showing that the lesion is in continuity with the medulla of the proximal phalanx and has a thin cartilage cap (arrow).
Osteochondroma is the most common benign tumor of all benign and primary bone tumors [1,2]. This tumor arises from the periphery of the cartilaginous growth plate and is composed of a cartilage cap and bone stalk. Growth usually stops with closure of the physeal plates. Osteochondroma usually presents as a solitary lesion; however, approximately 15% of osteochondromas occur as
Fig. 4. Intraoperative findings. (a) Shown is the fourth toe remaining in valgus after resection of the bone tumor. (b) Fluoroscopic images showing that the proximal phalanx has a valgus deformity in the anteroposterior view. (c) The proximal phalanx shows neither flexion nor extension deformity in the lateral view.
Fig. 5. Postoperative findings. A Kirshner wire is used to fix the osteotomy site.
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T. Kurashige, S. Suzuki / Foot and Ankle Surgery 20 (2014) e51–e55
Fig. 6. Most recent follow-up images. (a) and (b) A good cosmetic result is shown. (c) and (d) Both extension and flexion of the fourth toe are normal.
Fig. 7. Most recent radiographic images. Radiographic images showing union and remodeling 6 months postoperatively. A slight callus formation is observed at the resection site of the osteochondroma.
multiple lesions known as hereditary multiple exostoses, an autosomal dominant disorder [2]. In our case, there was no family history of congenital or developmental skeletal deformities and no other apparent deformity of his body. We did not take whole body radiography; however, preoperative radiography of chest and lumbar spine, which were taken routinely to select anesthetic procedure, revealed no other apparent bone tumor of ribs,
shoulders, lumber spines and iliums. Therefore, we considered the tumor as a solitary lesion. Osteochondromas occur most often around the long tubular bones and rarely in the small bones of the foot [2–4]. Most frequently involved sites are distal femur, proximal humerus, proximal tibia and ilium. Subungual exostoses of the distal phalanx, particularly of the great toe, are not defined as
T. Kurashige, S. Suzuki / Foot and Ankle Surgery 20 (2014) e51–e55
osteochondromas because they are almost a form of heterotopic ossification [2,3]. Malignant transformation of a solitary lesion to a chondrosarcoma is extremely rare. Such transformations have been most commonly reported in patients with hereditary multiple lesions, but occurs in fewer than 1% [2,3]. Identification of malignant transformation is suggested by the presence of a thick cartilaginous cap (more than 1–2 cm in width) that continues to grow after bone maturity has been reached [2]. In our case, the patient had a thin cartilaginous cap, and pathological examination revealed no malignancy. Osteochondroma usually presents as a painless bony mass localized at the metaphysis of a long bone. Symptoms are usually caused by mechanical irritation [2,3]. Our patient had a painful callus beneath the tip of the fifth toe caused by crossover of the fourth toe. The characteristic radiographic appearance of osteochondroma is the presence of a medullary bone continuous with the stalk and the underlying cortical bone [1–3]. CT and MRI are helpful for demonstrating continuity between the osteochondroma and underlying bone and to show the thickness of the cartilage cap [2]. In this case, these characteristics were preoperatively identified. In the foot, osteochondroma is commonly located in the distal phalanx and metatarsal bones. The occurrence of osteochondroma in the proximal phalanx is extremely rare [1,3,5,6]. Unni et al. [2] reported a case of phalange in 884 series of osteochondromas; however, there was no record of the precise location of the tumor. Murari et al. [4] reported 255 bone tumors of the foot. In their series, there were 13 osteochondromas and 1 case involving the phalange; however, the precise location of the tumor was unknown. Coughlin et al. [3] reported a case of osteochondroma of the third proximal phalanx; however, it was in a patient with multiple hereditary lesions. Schnirring-Judge et al. [1] reported a case involving the proximal phalanx of the hallux. To our knowledge, there are only two previous case reports in the English literature about osteochondroma of the proximal phalanx of the lesser toe in which resection was performed. Cohen et al. [5] reported one case of osteochondroma of the third proximal phalanx. The patient had noticed the mass in the second web 4 years earlier and had undergone tumor resection because it began to interfere with his ability to wear shoes. Greenberg et al. [6] reported another case of osteochondroma of the third proximal phalanx. The patient had noticed the mass on the bottom of his third toe several years ago. He had undergone tumor resection because of increasing difficulty to wear shoes and apparent rapid growth. Asymptomatic lesions require no treatment. Lesions that are suspected to be malignant because of rapid growth or sudden onset of pain should be removed. Symptoms are usually caused by mechanical factors. Therefore, the treatment of osteochondroma generally consists of simple resection. Previous two patients reported by Cohen et al. [5] and Greenberg et al. [6] underwent simple resection of an osteochondroma of the third proximal phalanx. However, if some deformities remain after tumor resection, added procedures may be considered. Some cases of large osteochondroma of distal tibia needed distal tibiofibular fusion or correction of ankle valgus deformity [7,8]. In our case, the valgus deformity remained after resection of the bone tumor; therefore, closing wedge osteotomy of the proximal phalanx was performed at the same time. This procedure is usually performed for correction of the valgus deformity of the second toe. Kilmartin et al. [9] reported a good result after using closing wedge osteotomy of the second toe. They did not use internal fixation; however, the second toe was buddy strapped to the first toe. Davis et al. [10] reported a multiple perforation
e55
technique using a small awl to perform closing wedge osteotomy of the second and third proximal phalanxes. They performed internal fixation using a percutaneous Kirshner wire if the osteotomy site was unstable. In our case, we used a sidecutting burr to perform osteotomy because it was difficult to perform osteotomy safely using a micro bone saw in a small incision and we wanted to prevent breakage of the lateral cortex of the fourth proximal phalanx, which is smaller than the second and third proximal phalanxes. Care was taken to leave the lateral cortex intact; however, a fracture of the lateral cortex occurred when closing the osteotomy site. The bone may have been fragile after resection of the bone tumor or too much angulation may have been required to correct the valgus deformity. A 1.2-mm percutaneous Kirshner wire fixation technique was used to stabilize osteotomy. Union was achieved 2 months postoperatively without complication. The patient was satisfied with the cosmetic and functional outcomes. To our knowledge, this is the third case report in the English literature about osteochondroma of the proximal phalanx of the lesser toe in which resection was performed. We also believe that this is the first case in which closing wedge osteotomy was performed for the valgus toe deformity of the proximal phalanx due to osteochondroma. Summary We report an extremely rare case of a valgus toe deformity of the fourth proximal phalanx due to osteochondroma. Tumor resection and concurrent closing wedge osteotomy were performed to correct the valgus deformity. We believe that closing wedge osteotomy is an effective procedure when a proximal phalanx has a severe valgus deformity. This work has been approved by the appropriate ethical committees related to the institution where it was performed, and informed consent was obtained from the subject. Conflict of interest The authors declare that there are no conflict of interests. Funding The authors received no financial support for the research, authorship, and/or publication of this article. References [1] Schnirring-Judge M, Visser J. Resection and reconstruction of an osteochondroma of the hallux: a review of benign bone tumors and a description of an unusual case. J Foot Ankle Surg 2009;48:495–505. [2] Unni KK, Inwards CY. Dahlin’s bone tumors 6th edition: general aspect and data on 10,165 cases. Philadelphia: LWW; 2010. p. 9–21. [3] Coughlin M, Saltzman C, Anderson R. Surgery of the foot and ankle. 9th ed. Philadelphia: Elsevier; 2013. 846. [4] Murari TM, Callaghan JJ, Berrey Jr BH, Sweet DE. Primary benign and malignant osseous neoplasms of the foot. Foot Ankle Int 1989;10:68–80. [5] Cohen I, Chechick A, Heim M. Special feature: pathological case of the month osteochondroma (exostosis). Arch Pediatr Adolesc Med 2000;154:1163–4. [6] Greenberg D, Lenet MD, Sherman M. A large osteochondroma of the third toe. J Am Podiatry Assoc 1983;73:208–11. [7] Ciampolini J, Gargan MF, Newman JH. Arthrodesis of the distal tibiofibular joint for a large osteochondroma in an adult. Foot Ankle Int 1999;20:657–8. [8] Shawen SB, McHale KA, Temple HT. Correction of ankle valgus deformity secondary to multiple hereditary osteochondral exostoses with llizarov. Foot Ankle Int 2000;21:1019–22. [9] Kilmartin T, O’Kane C. Correction of valgus second toe by closing wedge osteotomy of the proximal phalanx. Foot Ankle Int 2007;28:1260–4. [10] Davis WH, Anderson RB, Thompson FM, Hamilton WG. Proximal basilar osteotomy for resistant angulation of the lesser toes. Foot Ankle Int 1997;18:103–4.
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Valgus toe deformity of fourth proximal phalanx due to osteochondroma treated with closing wedge osteotomy Toshinori Kurashige MD*, Seiichi Suzuki MD Department of 1st Orthopaedic Surgery, Mito Red Cross Hospital, 3-12-48, Sannomaru, Mito City, Ibaraki 310-0011, Japan
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 April 2014 Received in revised form 29 April 2014 Accepted 27 June 2014
Osteochondroma is the most common benign tumor of all benign and primary bone tumors. It rarely occurs in the proximal phalanx of the lesser toe. The treatment of osteochondroma usually consists of simple resection. However, if other deformities remain, added procedures may be considered. We report a case of a valgus toe deformity of the fourth proximal phalanx due to osteochondroma. The patient was a 21-year-old man who noticed a valgus deformity of his fourth toe over 10 years earlier. He began to experience pain in his fifth toe because of crossover of the fourth toe when wearing formal shoes. Although resection of osteochondroma was performed, the valgus deformity was not sufficiently corrected. Therefore, closing wedge osteotomy of the proximal phalanx was performed at the same time. A good outcome was achieved for this patient. ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Osteochondroma Proximal phalanx Valgus deformity Closing wedge osteotomy Side-cutting burr
1. Introduction Osteochondroma is the most common benign tumor of all benign and primary bone tumors [1,2]. It arises from the periphery of the cartilaginous growth plate and occurs most often around the long tubular bones and rarely in the small bones of the foot [2–4]. Most frequently involved sites are distal femur, proximal humerus, proximal tibia and ilium. Unni et al. [2] reported only one case of phalange in their 884 series of solitary osteochondromas. Osteochondroma rarely occurs in the proximal phalanx of the lesser toe. Only a few related reports have been published [3,5,6]. Malignant transformations to chondrosarcoma have been most commonly reported in patients with hereditary multiple lesions, but such change occurs in fewer than 1% [2]. Malignant transformation of a solitary lesion is extremely rare. Symptoms are usually caused by mechanical factors. Therefore, the treatment of osteochondroma usually consists of simple resection [2,3,5,6]. However, if other deformities remain, added procedures may be considered [7,8]. We report a case of a valgus toe deformity of the fourth proximal phalanx due to osteochondroma. To our knowledge, there are only two previous case reports in the
* Corresponding author. Tel.: +81 29 221 5177; fax: +81 29 227 0819. E-mail addresses: [email protected], [email protected] (T. Kurashige), [email protected] (S. Suzuki).
English literature about osteochondroma of the proximal phalanx of the lesser toe in which resection was performed [5,6]. We also believe that this is the first case in which closing wedge osteotomy was performed for a valgus toe deformity of the proximal phalanx due to osteochondroma. 2. Case report The patient was a 21-year-old man who noticed a valgus deformity of the left fourth toe over 10 years earlier. He had no history of trauma or surgery to the foot. He had never visited a hospital because he had experienced no restriction in his activities of daily living and recreational sports. He became a college student and began to wear formal shoes for job interviews. He had no complaints regarding his fourth toe; however, he began to experience pain in the fifth toe due to crossover of the fourth toe when wearing these shoes. Therefore, he was referred to our department. On physical examination, the fourth toe had a valgus deformity and crossed over the fifth toe (Fig. 1a). There was no pain or numbness in the fourth toe; however, a painful callus had formed beneath the tip of the fifth toe (Fig. 1b). Palpation revealed a bony hard mass on the dorsal side of the third web. Flexibility of the toe was normal. There was no other apparent deformity in his feet or body and no family history of congenital or developmental skeletal deformities.
http://dx.doi.org/10.1016/j.fas.2014.06.005 1268-7731/ß 2014 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
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T. Kurashige, S. Suzuki / Foot and Ankle Surgery 20 (2014) e51–e55
Fig. 1. Macroscopic findings. (a) The fourth toe with a valgus deformity is shown; the fourth toe has crossed over the fifth toe. (b) A painful callus is present beneath the tip of the fifth toe.
3. Imaging findings Radiography revealed a bone tumor on the medial side of the fourth proximal phalanx. The phalanx had a valgus deformity (Fig. 2a). Computed tomography (CT) revealed that the bone tumor had a wide base that was continuous with the proximal phalanx (Fig. 2b). Coronal T2-weighted fat suppression magnetic resonance imaging (MRI) revealed that the lesion was in continuity with the medulla of the proximal phalanx and had a thin cartilage cap (Fig. 3). 4. Operative technique The patient was placed in the supine position. A pneumatic tourniquet was used. The bone tumor was exposed through a longitudinal incision at the dorsal medial aspect of the fourth proximal phalanx. The bone tumor was resected from its base at
the proximal phalanx. The fourth toe remained in valgus after tumor resection (Fig. 4a). Fluoroscopic images revealed that the proximal phalanx had a valgus deformity in the anteroposterior view (Fig. 4b) but had neither flexion nor extension deformity in the lateral view (Fig. 4c). Therefore, closing wedge osteotomy of the proximal phalanx was performed at the same time. After removing the dorsal and plantar periosteum, a side-cutting burr 2 mm in diameter and 5 mm in length was inserted from the medial aspect of the proximal phalanx at the apex of the deformity. Care was taken not to penetrate the lateral cortex. Wedge osteotomy was performed using a sweeping motion of the burr keeping the lateral cortex intact. The osteotomy site was closed with gentle finger pressure; however, a fracture of the lateral cortex occurred. Therefore, 1.2-mm Kirshner wire fixation was percutaneously performed (Fig. 5). Pathological examination identified the tumor as an osteochondroma.
Fig. 2. Preoperative images. (a) Radiograph showing the bone tumor at the medial side of the fourth proximal phalanx. The bone has a valgus deformity. (b) Computed tomographic image showing that the bone tumor has a wide base continuous with the proximal phalanx.
T. Kurashige, S. Suzuki / Foot and Ankle Surgery 20 (2014) e51–e55
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5. Postoperative course Weight bearing on the heel was immediately permitted. The wire was removed, and range of motion exercise of the toe was started 4 weeks after the operation. Union was achieved 2 months postoperatively. Good cosmetic and functional outcomes were achieved, and the patient could wear formal shoes with no complaints (Fig. 6a, b). Flexibility and mobility of the fourth toe were normal (Fig. 6c and d). No floating toe was observed. Radiographs revealed the union of the fourth proximal phalanx and no recurrence of the bone tumor 6 months after the operation (Fig. 7). 6. Discussion Fig. 3. Magnetic resonance imaging (MRI) findings. Coronal T2-weighted fatsuppression MRI showing that the lesion is in continuity with the medulla of the proximal phalanx and has a thin cartilage cap (arrow).
Osteochondroma is the most common benign tumor of all benign and primary bone tumors [1,2]. This tumor arises from the periphery of the cartilaginous growth plate and is composed of a cartilage cap and bone stalk. Growth usually stops with closure of the physeal plates. Osteochondroma usually presents as a solitary lesion; however, approximately 15% of osteochondromas occur as
Fig. 4. Intraoperative findings. (a) Shown is the fourth toe remaining in valgus after resection of the bone tumor. (b) Fluoroscopic images showing that the proximal phalanx has a valgus deformity in the anteroposterior view. (c) The proximal phalanx shows neither flexion nor extension deformity in the lateral view.
Fig. 5. Postoperative findings. A Kirshner wire is used to fix the osteotomy site.
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T. Kurashige, S. Suzuki / Foot and Ankle Surgery 20 (2014) e51–e55
Fig. 6. Most recent follow-up images. (a) and (b) A good cosmetic result is shown. (c) and (d) Both extension and flexion of the fourth toe are normal.
Fig. 7. Most recent radiographic images. Radiographic images showing union and remodeling 6 months postoperatively. A slight callus formation is observed at the resection site of the osteochondroma.
multiple lesions known as hereditary multiple exostoses, an autosomal dominant disorder [2]. In our case, there was no family history of congenital or developmental skeletal deformities and no other apparent deformity of his body. We did not take whole body radiography; however, preoperative radiography of chest and lumbar spine, which were taken routinely to select anesthetic procedure, revealed no other apparent bone tumor of ribs,
shoulders, lumber spines and iliums. Therefore, we considered the tumor as a solitary lesion. Osteochondromas occur most often around the long tubular bones and rarely in the small bones of the foot [2–4]. Most frequently involved sites are distal femur, proximal humerus, proximal tibia and ilium. Subungual exostoses of the distal phalanx, particularly of the great toe, are not defined as
T. Kurashige, S. Suzuki / Foot and Ankle Surgery 20 (2014) e51–e55
osteochondromas because they are almost a form of heterotopic ossification [2,3]. Malignant transformation of a solitary lesion to a chondrosarcoma is extremely rare. Such transformations have been most commonly reported in patients with hereditary multiple lesions, but occurs in fewer than 1% [2,3]. Identification of malignant transformation is suggested by the presence of a thick cartilaginous cap (more than 1–2 cm in width) that continues to grow after bone maturity has been reached [2]. In our case, the patient had a thin cartilaginous cap, and pathological examination revealed no malignancy. Osteochondroma usually presents as a painless bony mass localized at the metaphysis of a long bone. Symptoms are usually caused by mechanical irritation [2,3]. Our patient had a painful callus beneath the tip of the fifth toe caused by crossover of the fourth toe. The characteristic radiographic appearance of osteochondroma is the presence of a medullary bone continuous with the stalk and the underlying cortical bone [1–3]. CT and MRI are helpful for demonstrating continuity between the osteochondroma and underlying bone and to show the thickness of the cartilage cap [2]. In this case, these characteristics were preoperatively identified. In the foot, osteochondroma is commonly located in the distal phalanx and metatarsal bones. The occurrence of osteochondroma in the proximal phalanx is extremely rare [1,3,5,6]. Unni et al. [2] reported a case of phalange in 884 series of osteochondromas; however, there was no record of the precise location of the tumor. Murari et al. [4] reported 255 bone tumors of the foot. In their series, there were 13 osteochondromas and 1 case involving the phalange; however, the precise location of the tumor was unknown. Coughlin et al. [3] reported a case of osteochondroma of the third proximal phalanx; however, it was in a patient with multiple hereditary lesions. Schnirring-Judge et al. [1] reported a case involving the proximal phalanx of the hallux. To our knowledge, there are only two previous case reports in the English literature about osteochondroma of the proximal phalanx of the lesser toe in which resection was performed. Cohen et al. [5] reported one case of osteochondroma of the third proximal phalanx. The patient had noticed the mass in the second web 4 years earlier and had undergone tumor resection because it began to interfere with his ability to wear shoes. Greenberg et al. [6] reported another case of osteochondroma of the third proximal phalanx. The patient had noticed the mass on the bottom of his third toe several years ago. He had undergone tumor resection because of increasing difficulty to wear shoes and apparent rapid growth. Asymptomatic lesions require no treatment. Lesions that are suspected to be malignant because of rapid growth or sudden onset of pain should be removed. Symptoms are usually caused by mechanical factors. Therefore, the treatment of osteochondroma generally consists of simple resection. Previous two patients reported by Cohen et al. [5] and Greenberg et al. [6] underwent simple resection of an osteochondroma of the third proximal phalanx. However, if some deformities remain after tumor resection, added procedures may be considered. Some cases of large osteochondroma of distal tibia needed distal tibiofibular fusion or correction of ankle valgus deformity [7,8]. In our case, the valgus deformity remained after resection of the bone tumor; therefore, closing wedge osteotomy of the proximal phalanx was performed at the same time. This procedure is usually performed for correction of the valgus deformity of the second toe. Kilmartin et al. [9] reported a good result after using closing wedge osteotomy of the second toe. They did not use internal fixation; however, the second toe was buddy strapped to the first toe. Davis et al. [10] reported a multiple perforation
e55
technique using a small awl to perform closing wedge osteotomy of the second and third proximal phalanxes. They performed internal fixation using a percutaneous Kirshner wire if the osteotomy site was unstable. In our case, we used a sidecutting burr to perform osteotomy because it was difficult to perform osteotomy safely using a micro bone saw in a small incision and we wanted to prevent breakage of the lateral cortex of the fourth proximal phalanx, which is smaller than the second and third proximal phalanxes. Care was taken to leave the lateral cortex intact; however, a fracture of the lateral cortex occurred when closing the osteotomy site. The bone may have been fragile after resection of the bone tumor or too much angulation may have been required to correct the valgus deformity. A 1.2-mm percutaneous Kirshner wire fixation technique was used to stabilize osteotomy. Union was achieved 2 months postoperatively without complication. The patient was satisfied with the cosmetic and functional outcomes. To our knowledge, this is the third case report in the English literature about osteochondroma of the proximal phalanx of the lesser toe in which resection was performed. We also believe that this is the first case in which closing wedge osteotomy was performed for the valgus toe deformity of the proximal phalanx due to osteochondroma. Summary We report an extremely rare case of a valgus toe deformity of the fourth proximal phalanx due to osteochondroma. Tumor resection and concurrent closing wedge osteotomy were performed to correct the valgus deformity. We believe that closing wedge osteotomy is an effective procedure when a proximal phalanx has a severe valgus deformity. This work has been approved by the appropriate ethical committees related to the institution where it was performed, and informed consent was obtained from the subject. Conflict of interest The authors declare that there are no conflict of interests. Funding The authors received no financial support for the research, authorship, and/or publication of this article. References [1] Schnirring-Judge M, Visser J. Resection and reconstruction of an osteochondroma of the hallux: a review of benign bone tumors and a description of an unusual case. J Foot Ankle Surg 2009;48:495–505. [2] Unni KK, Inwards CY. Dahlin’s bone tumors 6th edition: general aspect and data on 10,165 cases. Philadelphia: LWW; 2010. p. 9–21. [3] Coughlin M, Saltzman C, Anderson R. Surgery of the foot and ankle. 9th ed. Philadelphia: Elsevier; 2013. 846. [4] Murari TM, Callaghan JJ, Berrey Jr BH, Sweet DE. Primary benign and malignant osseous neoplasms of the foot. Foot Ankle Int 1989;10:68–80. [5] Cohen I, Chechick A, Heim M. Special feature: pathological case of the month osteochondroma (exostosis). Arch Pediatr Adolesc Med 2000;154:1163–4. [6] Greenberg D, Lenet MD, Sherman M. A large osteochondroma of the third toe. J Am Podiatry Assoc 1983;73:208–11. [7] Ciampolini J, Gargan MF, Newman JH. Arthrodesis of the distal tibiofibular joint for a large osteochondroma in an adult. Foot Ankle Int 1999;20:657–8. [8] Shawen SB, McHale KA, Temple HT. Correction of ankle valgus deformity secondary to multiple hereditary osteochondral exostoses with llizarov. Foot Ankle Int 2000;21:1019–22. [9] Kilmartin T, O’Kane C. Correction of valgus second toe by closing wedge osteotomy of the proximal phalanx. Foot Ankle Int 2007;28:1260–4. [10] Davis WH, Anderson RB, Thompson FM, Hamilton WG. Proximal basilar osteotomy for resistant angulation of the lesser toes. Foot Ankle Int 1997;18:103–4.
