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Feedback from You: Hypertrophic
Bone Formation
Thank you to all who provided feedback and offered your suggestions
on last week’s topic of “Hypertrophic Bone Re-Growth”. I still find
this problem to be quite troubling and without a good explanation in
the literature. However, one area that I have come across more and
more research is renal osteodystrophy. This is a metabolic disorder
commonly seen in dialysis patients in which systemic calcium and
phosphorus levels are improperly regulated. While renal
osteodystrophy typically results in bone mineral density loss, I
would venture to say that further research in this area is very much
needed. In fact, many (if not most) of the patients in my practice
with post amputation hypertrophic bone growth also have some degree
of renal compromise.
Here are some of the comments I received from RI readers:
I believe that boney regeneration often occurs
because of residual periosteum that was not excised during
amputation procedures. In osteomyelitis, the periosteum lifts
away making it more difficult to remove. It's from the inner
cambium layer that new cells arise. I have found less boney
regeneration in arthroplasty procedures when power
instrumentation is used as opposed to bone forceps.
Jay Lieberman, DPM
jlieberman@podiatry.com
Causes- multifactorial- in probable order of
experienced cases
1. Motion (w/ respect to osteotomies) a) inadequate fixation b)
inadequate immobilization
2. Poor site selection i.e. areas of active bone growth/turnover
i.e. metaphyseal bone
3. Excessive ground reactive forces i.e. The equinus foot, cavus
foot
4. Sites exposed to repetitive shoe trauma i.e. toes, dorsum of
foot
5. Manual bone cutting instrumentation use i.e. intra-operative
bone splintering
6. Inherent disorders affecting Ca++, collagen and/or
coagulation metabolism
Prevention-
1. Reduce motion through adequate fixation/immobilization
2. Proper osteotomy site selection
3. Pre-surgical recognition and subsequent control of ground
reactive forces a. equinus repair b. non-weightbearing
immediately post op during the acute inflammatory wound healing
phase c. functional orthotics when indicated
4. Strict intraoperative hemostasis
5. Bone wax use over exposed metaphyseal bone - occasionally
Prediction- Afro-Americans are more prone to hypertrophic bone
formation, presumably from inherent differences in collagen
makeup with respect to caucasians. I have not been able to
predict- I leave that to Kreskin and the other psychics of the
world
Sites other than metatarsals-
1. phalangeal heads post arthroplasty
2. dorsum of Lisfranc's joint following exostosis removal
3. Distal aspects of toes i.e. Durlacher corn repair through
Winograd procedures
Barry Mullen, DPM
YAZY630@aol.com
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S. Steinberg, DPM
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