During the period from 2022-2023, three patients underwent surgical treatment involving curettage and bone grafting at our clinic (2 females and 1 male) due to hip pain. In two of them, a non-ossifying fibroma of the femoral neck and acetabulum was observed, while in the third patient, a bone cyst in the femoral neck was established. Due to possible fractures in these areas, the patients underwent surgery involving curettage and bone grafting with a synthetic bone substitute. Postoperatively, the patients had no pain and full range of motion

Alexandar Kostadinov

Georgi Georgiev

Ivelin Kostadinov

Kristian Nastev

Luben Lubenov  Stokov

Luben Stokov

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Article—Difficult-to-access benign bone tumors Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 27  Cases of difficult-to-access benign tumors with the potential risk for bone fracture  Luben Stokov1, Ivelin Kostadinov1, Georgi P. Georgiev2(), Kristian Nastev3,  L.L. Stokov4, Alexandar Kostadinov5 1Clinic of Orthopedics and Traumatology, UMHAT “St. Anna”, Sofia, Bulgaria 2Department of Orthopedics and Traumatology, University Hospital “Queen Giovanna - ISUL”, Medical University of Sofia, Sofa, Bulgaria 3MHAT, Skin Systems, Bulgaria 4Clinic of Orthopedics and Traumatology, MHAT “St. Sofia”, Sofia, Bulgaria 5MHAT Lyulin Hospital, Sofia, Bulgaria georgievgp@yahoo.com  DOI: https://doi.org/10.58542/jbota.v61i01.111  Abstract—During the period from 2022-2023, three patients underwent sur-gical treatment involving curettage and bone grafting at our clinic (2 females and 1 male) due to hip pain. In two of them, a non-ossifying fibroma of the femoral neck and acetabulum was observed, while in the third patient, a bone cyst in the femoral neck was established. Due to possible fractures in these areas, the pa-tients underwent surgery involving curettage and bone grafting with a synthetic bone substitute. Postoperatively, the patients had no pain and full range of mo-tion. Keywords—benign bone tumors, curettage, graft, operative treatment. 1 Introduction Bone lesions of benign origin include a diverse group of pathological conditions1,2. The benign bone lesions may be asymptomatic or being discover incidentally. When confirming the benign nature of the lesion, surgeons should assess the risk of fracture and determine the appropriate treatment1,3. In patients with benign lesions, pathologic fractures may occur even with minimal trauma1,4. Hence, preventing fractures becomes a priority in the management of these lesions1,5,6. The present strategies for managing benign bone lesions encompass a combination of conservative and surgical approaches, sparking ongoing debates among surgeons regarding the optimal treatment choice1,5,6.  2. Case series  Case 1 An 18-year-old female patient presented to our clinic with pain and an inability to fully support her right lower limb. The complaints gradually developed and progressed Article—Difficult-to-access benign bone tumors Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 28  over time. No history of previous trauma existed. Imaging studies (X-ray and CT) re-vealed disruption of the integrity of the medial contour of the femoral neck due to a non-ossifying fibroma, which was subsequently confirmed histologically (Fig. 1 and 2). With a limited lateral approach to the proximal femur under fluoroscopic control, the bone lesion was identified. Curettage and filling of the formed cavity with a syn-thetic bone substitute were performed. Postoperatively, the limb was completely non-weight bearing for a period of 3 months, followed by restricted weight bearing for an additional three months. After this period, complete recovery of the bone structure and the absence of pain during physical activity were observed (Fig.3).   Figure 1. Preoperative roentgenography  Figure 2. Preoperative CT Article—Difficult-to-access benign bone tumors Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 29     Figure 3. Postoperative roentgenography on the sixth month after operation.  Case 2 A 48-year-old female presented to our clinic with complaints of hip pain during walking, which started approximately two months ago without any preceding trauma. Imaging studies (X-ray and CT) revealed a lesion in the region of the iliac bone involv-ing the anterior-superior border of the acetabulum (Fig. 4 and 5). The lesion measured 2.5/1.5 cm in diameter. Using a modified anterior-lateral approach to the left hip joint, the anterior-superior portion of the acetabulum was reached. After opening a window two centimeters above the acetabulum, the bone lesion was accessed and curetted; the resulting cavity was filled with a synthetic bone graft. Histologically, a non-ossifying fibroma was confirmed. In the postoperative period, the limb was not weight-bearing for 3 months, followed by partial weight-bearing for an additional 2 months; subsequently, full weight-bearing was allowed with complete absence of pain during walking. Radiographically, good incorporation of the bone substitute was observed (Fig. 6).   Figure 4. Preoperative roentgenography Article—Difficult-to-access benign bone tumors Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 30   Figure 5. Preoperative CT   Figure 6. Postoperative roentgenography on the third month after operation  Article—Difficult-to-access benign bone tumors Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 31   Case 3 A 60-year-old male presented to the clinic with pain upon loading in the area of the right hip joint for approximately three months, with no history of trauma in the region. Imaging data (X-ray and CT) revealed the presence of a cystic, rounded lesion with a diameter of approximately 2/2 cm at the base of the right femoral neck (Fig. 7 and 8). Using a limited anterior-lateral approach under fluoroscopic control, the bone lesion was reached. After opening a small window at the base of the femoral neck, the bone lesion was accessed and curetted; the resulting cavity was filled with a synthetic bone graft. Histologically, a simple bone cyst was established. During the postoperative period, the limb was not weight-bearing for 3 months. Sub-sequently, with full weight-bearing, there was no pain in the area of the right hip joint. Radiographically, partial integration of the bone substitute was observed (Fig. 9).   Figure 7. Preoperative roentgenography   Figure 8. Preoperative CT   Article—Difficult-to-access benign bone tumors Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 32   Figure 9. Postoperative roentgenography on the third month after operation   3. Discussion and Conclusion  Benign bone tumors, such as non-ossifying fibroma and simple bone cysts, are often discovered incidentally, usually during rentgenography after trauma or due to imaging studies for unclear pain in the affected region. Usually, after incidental discovery, most patients are only observed via periodical roentgenographies; if there are signs of pro-gression of these lesions with potential risk of impending fracture, surgical treatment is indicated. In the described cases, the presence of osteolysis in the cortex of the femoral neck and the upper edge of the acetabulum, along with pain and a weakened bone structure around the cyst, serves as an indicator of an impending fracture. In such cases, there is an indication for surgical treatment involving curettage of the bone lesions and restora-tion of the integrity and quality of the affected bone with different bone grafts.    4. References  1. Li HB, Ye WS, Shu Q. Fracture risk assessment in children with benign bone lesions of long bones. World J Clin Cases. 2021;9(24):7053-7061. doi: 10.12998/wjcc.v9.i24.7053. 2. Woertler K. Benign bone tumors and tumor-like lesions: value of cross-sectional imag-ing. Eur Radiol. 2003;13(8):1820-35. doi: 10.1007/s00330-003-1902-z. 3. Tomaszewski R, Rutz E, Mayr J, Dajka J. Surgical treatment of benign lesions and path-ologic fractures of the proximal femur in children. Arch Orthop Trauma Surg. 2022;142(4):615-624. doi: 10.1007/s00402-020-03687-x. Article—Difficult-to-access benign bone tumors Journal of The Bulgarian Orthopedic and Trauma Association, Vol.61/1-2024,                ISSN 2815-3715 33  4. Erol B, Topkar MO, Aydemir AN, Okay E, Caliskan E, Sofulu O. A treatment strategy for proximal femoral benign bone lesions in children and recommended surgical proce-dures: retrospective analysis of 62 patients. Arch Orthop Trauma Surg. 2016;136(8):1051-61. doi: 10.1007/s00402-016-2486-9. 5. Canavese F, Samba A, Rousset M. Pathological fractures in children: Diagnosis and treat-ment options. Orthop Traumatol Surg Res. 2016;102 (1 Suppl):S149-59. doi: 10.1016/j.otsr.2015.05.010. 6. Slavchev SA, Georgiev GP. A Non-ossifying Fibroma and a Stress Fracture of the Femur Mimicking Bone Malignancy in a Child. Cureus. 2020;12(4):e7652. doi: 10.7759/cu-reus.7652.   Authors Luben Stokov, M.D., Ph.D. is a member of the Bulgarian Orthopedic and Trau-matology Association (BOTA). He works as an ortopaedic surgeon at Clinic of Or-thopedics and Traumatology, UMHAT “St. Anna”, Sofia, Bulgaria. He is professor at the Department of Orthopedics and Traumatology, Medical University of Sofia, Sofia, Bulgaria. He is a member of the Editorial Board of the Journal of the Bulgarian Ortho-paedics and Trauma Association (JBOTA). Ivelin Kostadinov, M.D. is member of the Bulgarian Orthopedic and Trauma-tology Association (BOTA). He works as an ortopaedic surgeon at Clinic of Orthope-dics and Traumatology, UMHAT “St. Anna”, Sofia, Bulgaria. Georgi P. Georgiev, M.D., Ph.D., D.Sc. is member of the Bulgarian Orthopedic and Traumatology Association (BOTA). He works as an orthopaedic surgeon at the Department of Orthopedics and Traumatology, University Hospital “Queen Giovanna - ISUL”, Medical University of Sofia, Bulgaria. He is Assistant Professor at the De-partment of Orthopedics and Traumatology, Medical University of Sofia, Bulgaria. He is a member of the Editorial board of BMC Musculoskeletal Disorders and Clinical Anatomy. Kristian Nastev, M.D. is member of the Bulgarian Orthopedic and Traumatol-ogy Association (BOTA). He works as an ortopaedic surgeon at MHAT, Skin Systems, Bulgaria. Luben Lubenov Stokov, is a member of the Bulgarian Orthopedic and Trauma-tology Association (BOTA). He works as volunteer at Clinic of Orthopedics and Trau-matology, MHAT “St. Sofia”, Sofia, Bulgaria. He is medical student, Medical Univer-sity of Sofia, Sofia, Bulgaria. Alexandar Kostadinov, M.D. is member of the Bulgarian Orthopedic and Trau-matology Association (BOTA). He works as an ortopaedic surgeon at MHAT Lyulin Hospital, Sofia, Bulgaria.  

Cases of difficult-to-access benign tumors with the potential risk for bone fracture

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Cases of difficult-to-access benign tumors with the potential risk for bone fracture

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