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Children's Orthopaedics: R. S. Lee, S. Weitzel, D. M. Eastwood, F. Monsell, J. Pringle, S. R. Cannon, and T. W. R. Briggs Osteofibrous dysplasia of the tibia: IS THERE A NEED FOR A RADICAL SURGICAL APPROACH? J Bone Joint Surg Br 2006; 88-B: 658-664 [Abstract] [Full text] [PDF]

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Authors' reply

Robert S. Lee, Stefan Weitzel, Deborah M. Eastwood, Fergal Monsell, Jean Pringle, Stephen R. Cannon, Timothy W.R. Briggs   (13 September 2006)

Conservative management of osteofibrous dysplasia

Robert J Grimer, Simon R. Carter, Roger M Tillman, Adesegun Abudu   (8 August 2006)

Authors' reply 13 September 2006
Robert S. Lee, Specialist Registrar Royal National Orthopaedic Hospital Stanmore, Stefan Weitzel, Deborah M. Eastwood, Fergal Monsell, Jean Pringle, Stephen R. Cannon, Timothy W.R. Briggs Send letter to journal: Re: Authors' reply leerobert9{at}hotmail.com Robert S. Lee, et al.	Sir, We were pleased to receive a communication from our colleagues, Messrs Grimer et al, in Birmingham. We fully acknowledge that the traditional treatment of osteofibrous dysplasia has been a conservative approach. However, not all results following a conservative approach are excellent. Often the healing of the tibia in particular can be extremely abnormal and the patient can suffer a shortened deformed bone in adolescence. Many patients and their parents are unhappy to undergo treatment of external support which may last up to ten years. The aim of our paper was really to emphasise two factors. The first factor is that if surgery is thought to be necessary due to increasing destruction of the bone and deformity, then we would recommend an extra periosteal radical type approach, rather than intra-lesional curettage, which in our experience nearly always leads to recurrence. The second aim of our paper, which does not seem to have been grasped, is the coincidental development of adamantinoma within osteofibrous dysplasia. As we can see, this occurred in three out of fifteen cases. Progressive osteofibrous dysplasia therefore may be hiding concomitant adamantinoma, which can of course be adequately treated at this early stage by complete en bloc excision. R.S. LEE, MRCS, S. WEITZEL, FRCS (Trauma & Orth), D.M. EASTWOOD, FRCS, F.MONSELL, FRCS, J. PRINGLE, FRCS, S.R. CANNON, FRCS, T.W.R. BRIGGS, FRCS.
Conservative management of osteofibrous dysplasia 8 August 2006
Robert J Grimer, Consultant Orthopaedic Surgeon Royal Orthopaedic Hospital, Birmingham, Simon R. Carter, Roger M Tillman, Adesegun Abudu Send letter to journal: Re: Conservative management of osteofibrous dysplasia rob.grimer{at}roh.nhs.uk Robert J Grimer, et al.	Sir, We are very concerned about the message given in the article by Lee et al on Osteofibrous Dysplasia (OFD). The authors have concluded on very weak evidence that "radical extraperiosteal excision is indicated in all cases of osteofibrous dysplasia". This goes against all the published evidence on this rare condition and is not supported at all by the authors' own evidence. The definitive book on diagnosis of bone tumours states “the natural history of osteofibrous dysplasia is that of gradual growth during the first decade of life followed by healing or spontaneous resolution”.1 The authors have included in their series of 16 patients, three who turned out not to have osteofibrous dysplasia on final histological review but had an adamantinoma and thus should not have been included in this paper. They have chosen to resect all of the involved bone electively in all patients that they treated and have not themselves considered any conservative surgery. The authors' own acceptance of the morbidity of the procedures they carried out is confirmed by the huge list of complications demonstrated in Table 1. We agree completely that diagnosing OFD and differentiating it from both adamantinoma and even fibrous dysplasia can be difficult, but careful radiological and histological analysis can almost always make a definite diagnosis. The benign nature of OFD is well established and the treatment philosophy in our unit has been to treat the symptoms, not the condition. We have had no case in the past 20 years where this treatment philosophy has failed. We believe that aggressive treatment for biopsy-proven osteofibrous dysplasia is not required and we would strongly recommend a conservative approach to this condition, but would agree that referral to a specialist musculoskeletal oncology unit should be considered in order to confirm diagnosis. R.J. GRIMER, Consultant Orthopaedic Surgeon, S.R. CARTER, R.M. TILLMAN, A. ABUDU, Royal Orthopaedic Hospital, Birmingham, UK. 1. Fletcher CD, Unni KK, Mertens F. Tumours of Soft Tissue and Bones. World Health Organization Classification of Tumours. Lyon: International Agency for Research on Cancer (IARC Press), 2002:343-4.