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SA Orthopaedic Journal

On-line version ISSN 2309-8309
Print version ISSN 1681-150X

SA orthop. j. vol.17 n.1 Centurion Feb./Mar. 2018


Level of evidence: Level V (case report).

Key words: focal fibrocartilaginous dysplasia (FFCD), proximal femur, coxa vara




Focal fibrocartilaginous dysplasia (FFCD) is a rare developmental cause of unilateral angular deformity in long bones in childhood.1 A well-defined, cortical lesion that appears lytic on X-ray causes the deformity. The aetiology remains unclear and the natural history is poorly understood.

The disorder is most commonly recorded in the medial cortex of the proximal tibia and is associated with tibia vara. It has also been reported at several other sites. These include the distal femur, ulna, humerus, radius and phalanx, but never before in the proximal femur.

We report a unique case where FFCD in the postero-medial proximal femur was associated with coxa vara.


Materials and methods

Informed consent was obtained from the patient's parent for a case report and publication in a peer-reviewed journal. The patient's clinical and radiological data were retrieved and reviewed. A literature review using PubMed/Medline and Google Scholar was completed to identify previous publications on FFCD up to February 2015.


Case report

A 5-year-old girl child presented to our unit with a progressive, painless limp that was noticed at the start of walking (age 1 year). There was no relevant family history and no history of trauma.


Examination revealed a healthy child who was active and fit. She walked with a Trendelenburg gait associated with an increased, mobile lumbar lordosis and pelvic obliquity. Palpation revealed a high riding trochanter. Abduction was limited to 10 degrees. All other movements of the hip were normal. Shortening of 2.5 cm was noted in the right leg confined to the supratrochanteric region.


Pre-operative radiographs (Figure 1) confirmed a located hip with coxa vara. This was associated with an isolated lucent lesion in the medial cortex of the right proximal femur with surrounding sclerosis and cortical thickening extending distally. The site of lesion corresponded with the insertion of the psoas tendon. The neck-shaft angle measured 87° and the Hilgenreiner-epiphyseal angle 86°.



Blood investigations

Blood investigations included full blood count, erythrocyte sedimentation rate, C-reactive protein, urea and electrolytes, HIV testing, calcium, magnesium and phosphate and alkaline phosphatase. These were within normal limits.


The lesion in the medial neck correlated with the lesion seen on X-ray and showed hypo-intensity on T1W (Figure 2) and proton density (PD) (Figure 3) views. Minimal STIR hyper-intensity was seen surrounded the area of sclerosis (Figure 4). A small amount of fluid was seen in the iliopsoas bursa with inclusion of tendon in the area of abnormal signal in the medial neck of the femur (Figure 5). Coxa vara was confirmed. There was no evidence of avascular necrosis or slip of the femoral head. MRI concluded that FFCD was the likely diagnosis.










Observation for 6 months showed no improvement. A valgus osteotomy of the proximal femur was performed together with percutaneous adductor tenotomy. An incisional biopsy with curettage was taken. Stable fixation was achieved with a 130 degree paediatric LCP hip plate (Synthes GmBH Eimattstrasse 3 CH- 4436 Oberdorff).


Histological evaluation of specimens stained with haema-toxylin and eosin revealed dense fibrous tissue, fibrocar-tilage and bone (Figure 6) Areas of pale, hyalinised fibrocartilage were also present. These findings support a diagnosis of FFCD.1-3



The child made an uneventful recovery with union achieved and leg length restored to within 1 cm of the contralateral side. Follow-up X-rays at 8 months (Figure 7) demonstrated resolution of the lesion with metal-ware in situ. The neck-shaft angle was corrected to 120° (opposite side 145°) and the Hilgenreiner-epiphyseal angle measured 45°. Follow-up at 18 months showed maintenance of correction with complete resolution of the lesion.




The disorder was first described as a cause of tibia vara in three cases by Bell et al.1in 1985. Onset of deformity is generally early and a literature review shows the average age at presentation to be 24 months. Lesions in the lower limb were diagnosed earlier (91 cases; average 18 months) than upper limb lesions (22 cases; average 47 months). Children present with unilateral, painless limb bowing. Associated features may include mild shortening and rotation.

Since Bell's initial description, 110 additional patients with the condition have been reported in the literature. It has been most commonly recorded in the medial cortex of the proximal tibia and associated with tibia vara (68 cases).1,3-22

Three cases of a lateral tibial lesion causing tibial valgus have also been reported.16,23,24 It has also been reported at several other sites. This includes the distal femur (18 cases),25-31 ulna (16 cases),3,32-36 humerus (four cases),32,37radius (two cases)33 and phalanx (two cases),33 but never in the proximal femur.

The typical radiological appearance of FFCD is a well-defined, lytic lesion situated in the cortex of a long bone with surrounding sclerosis.19,20 Sclerosis and cortical thickening extend distally in proximal lesions and proximally in distal lesions.3 It does not involve the physis. The lesion is associated with bowing of the long bone.

Magnetic image resonance images typically show a lesion that is cortically based which is hypo-intense on T1W images and does not show increased uptake of contrast.12

Histology reveals a variety of findings: from dense, fibrous and tendon-like tissue to benign fibrocartilaginous tissue.2,3 Individual specimens show regional variation in cellularity with dense fibrous areas being pauci-cellular and more cellular areas of fibrocartilage. Areas of hyalinised fibrocartilage have also been described.2,3Prominent areas of osteoblastic and osteoclastic activity in and around some lesions support the theory of active remodelling. Kim et al.2suggest, after analysing specimens from the femur and the tibia, that this variation represents a transition from fibrocartilage to dense fibrous tissue during the evolution of the disorder.

Bell et al.1first described the aetiopathogenesis. They postulate that abnormal mesenchymal differentiation at the site of insertion of the pes anserine is responsible for disordered growth on the medial aspect of the proximal tibia. In our case MRI demonstrated inclusion of the psoas tendon insertion within the lesion. In our estimation this corresponds to the abnormal insertion of the pes anserine in the proximal tibia, supporting the abnormal periosteal anchor aetiological theory. Jouve et al.19describe the effect of the abnormal insertion of the pes anserine in the proximal tibia further. They believe the entity represents an abnormal anchor of the pes anserine causing an 'epiphyseodesis-like' effect on the adjacent physis. For this reason they prefer the term 'fibrous periosteal inclusion'. Other authors describe non-anatomical fibrous bands inserted in a subperiosteal cortical defect to be associated with angular deformities.15-24-35-36 Choi et al.3and Poul and Straka16 describe an isolated subperiosteal fibrous cortical inclusion without any abnormal tendon or fibrous band in their cases. We agree with Jouve et al.19that an abnormal periosteal anchor causes an epiphyseodesis-like effect during growth and resultant angular deformity. They also postulate that smaller lesions may rupture spontaneously, resulting in deformity correction. Larger lesions may persist, causing progressive deformity. These lesions would likely require surgical correction.

The natural history is variable depending on the site of the lesion. Spontaneous resolution of FFCD of the tibia vara was first reported by Bell et al. 1 in one of their three

cases, and Dusabe et al.17reported that a varus deformity of the tibia of up to 30 degrees should correct spontaneously. Choi et al.3report that up to 45% of tibial lesions are likely to undergo spontaneous recovery. Initial treatment should be observation,1-3-19 with surgery indicated in progressive or biomechanically and cosmetically unacceptable lesions.19

Most femoral lesions were found to be progressive and reported treatment has mostly included deformity correction with osteotomies. Later reports indicate that timeous curettage and / or fibrous band excision (or hemi-circumferential periosteal release) may prevent the need for osteotomy.13,16,29 There is only one case report of a femoral lesion spontaneously correcting (over a 7-year period).31

In the upper limb the most common site described is the ulna. Ulnar bowing in these cases may be associated with radial head dislocation, and early treatment is advised to prevent this complication.15 Four cases in the proximal humerus have been described to be progressive without spontaneous correction.32,37

Our case had a typical clinical presentation, except for the proximal femoral location of the lesion, which corresponded with the insertion of the psoas tendon. The differential diagnosis is described in Table I. Coxa vara is bilateral in skeletal dysplasia. Proximal focal femoral deficiency (PFFD) and congenital short femur have significant associated shortening. The absence of a Fairbank's triangle excludes developmental coxa vara. There is no osteopaenia nor a lytic lesion as seen in 'soft bone' conditions such as osteogenesis imperfecta, rickets and fibrous dysplasia. There was no history of trauma. Cortical lesions such as fibrous cortical defect, osteoid osteoma and periosteal chondroma were excluded clinically, radiologi-cally and histologically. We propose that FFCD be added as an acquired cause due to a pathological bone condition.



In the proximal tibia clinical appearance and radiography should be adequate for a diagnosis of FFCD, with MRI used only for doubtful cases.20 In our case (due to the atypical location) radiographs alone were inadequate for a diagnosis. MRI was considered mandatory, while the biopsy confirmed the diagnosis.

A clear history of a deterioration of limp with persistent deformity (coxa vara) under observation for 6 months were our indications for surgery. We cannot state whether spontaneous correction is likely to occur with a FFCD in the proximal femur, but we treated this patient on clinical and radiological grounds, as for any child with a coxa vara deformity.



This is the first report of focal fibrocartilaginous dysplasia in the proximal femur. FFCD should be considered in the differential diagnosis of a cortically based lytic lesion associated with bony deformity in growing bone. Further research is needed to define the aetiopathogenesis and natural history of the disorder. Treatment guidelines are needed for atypical locations.

Compliance with Ethics Guidelines

Drs PH Maré and DM Thompson have no conflict of interest to declare.

The content of the article is the original work of the authors. No benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of the article.

Informed consent was obtained from the patient's parent for a case report and publication in a peer-reviewed journal.



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2. Kim CJ, Choi IH, Cho TJ, Chung CY, Chi JG. The histological spectrum of subperiosteal fibrocartilaginous pseudotumor of long bone (focal fibrocartilaginous dysplasia). Pathol Int 1999 Nov;49(11):1000-1006.         [ Links ]

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10. Zayer M. Tibia vara in focal fibrocartilaginous dysplasia. A report of 2 cases. Acta Orthop Scand 1992 Jun;63(3):353-55.         [ Links ]

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12. Meyer JS, Davidson RS, Hubbard AM, Conard KA. MRI of focal fibrocartilaginous dysplasia. J Pediatr Orthop 1995 May-Jun;15(3):304-306.         [ Links ]

13. Albinana J, Cuervo M, Certucha JA, Gonzalez-Mediero I, Abril JC. Five additional cases of local fibrocartilaginous dysplasia. J Pediatr Orthop Part B 1997 Jan;6(1):52-55.         [ Links ]

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15. Postovsky S, Militianu D, Bialik V, Vlodavsky E, Elhasid R, Peled M, et al. Concomitant focal fibrocartilaginous dysplasia of the tibia and eosinophilic granuloma of the jaw in a child. J Pediatr Orthop Part B 2002 Apr;11(2): 172-75.         [ Links ]

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18. Bakman M, Monu JU. Focal fibrocartilaginous dysplasia (FFCD). Pediatr Radiol 2007 Jan;37(1):107.         [ Links ]

19. Jouve JL, Kohler R, Mubarak SJ, Nelson SC, Dohin B, Bollini G. Focal fibrocartilaginous dysplasia ('fibrous periosteal inclusion'): an additional series of eleven cases and literature review. J Pediatric Orthop 2007 Jan- Feb;27(1):75-84.         [ Links ]

20. Ringe KI, Schirg E, Rosenthal H, Berendonk H, Galanski M. Unilateral tibia vara in a toddler caused by focal fibrocartilaginous dysplasia. J Radiol Case Rep 2009;3(9):14-17.         [ Links ]

21. Jibri Z, Chakraverty J, Thomas P, Kamath S. Focal fibrocartilaginous dysplasia and spontaneously resolving bowing of the leg. J Pediatr 2013 Nov;163(5):1527 e1.         [ Links ]

22. Pavone V, Testa G, Riccioli M, Sessa A, Evola FR, Avondo S. The natural history of focal fibrocartilaginous dysplasia in the young child with tibia vara. Eur J Orthop Surg Traumatol 2014 May;24(4):579-86.         [ Links ]

23. Santos M, Valente E, Almada A, Neves J. Tibia valga due to focal fibrocartilaginous dysplasia: case report. J Pediatr Orthop Part B 2002 Apr;11(2):167-71.         [ Links ]

24. Mooney JF, Slone HS. Two unusual presentations of focal fibrocartilaginous dysplasia. J Pediatr Orthop Part B 2013 Jul;22(4):367-71.         [ Links ]

25. Beaty JH, Barrett IR. Unilateral angular deformity of the distal end of the femur secondary to a focal fibrous tether. A report of four cases. J Bone Joint Surg (Am) 1989 Mar;71(3):440-45.         [ Links ]

26. Vallcanera Calatayud A, Sanguesa Nebot C, Martinez Fernandez M, Cortina Orts H. Varus deformity of the distal end of the femur secondary to a focal fibrous lesion. Pediatr Radiol 1994;24(1):74-75.         [ Links ]

27. Amillo S, Mora G, Leniz P. Progressive genu valgum secondary to a fibrous tether at the distal aspect of the femur. A case report. J Bone Joint Surg (Am) 1998 Mar;80(3):424-27.         [ Links ]

28. Macnicol MF. Focal fibrocartilaginous dysplasia of the femur. J Pediatr Orthop Part B 1999 Jan;8(1):61-63.         [ Links ]

29. Ruchelsman DE, Madan SS, Feldman DS. Genu valgum secondary to focal fibrocartilaginous dysplasia of the distal femur. J Pediatr Orthop 2004 Jul-Aug;24(4):408-13.         [ Links ]

30. Ando A, Hatori M, Hosaka M, Hagiwara Y, Kita A, Ochiai T, et al. A patient with focal fibrocartilaginous dysplasia in the distal femur and review of the literature. The Tohoku journal of experimental medicine. 2008 Aug;215(4):307-12.         [ Links ]

31. Thabet AM, Belthur MV, Herzenberg JE. Spontaneous resolution of angular deformity of the distal femur in focal fibrocartilaginous dysplasia: a case report. J Pediatr Orthop Part B 2010 Mar;19(2):161-63.         [ Links ]

32. Lincoln TL, Birch JG. Focal fibrocartilaginous dysplasia in the upper extremity. J Pediatric Orthop 1997 Jul- Aug;17(4):528-32.         [ Links ]

33. Smith NC, Carter PR, Ezaki M. Focal fibrocartilaginous dysplasia in the upper limb: seven additional cases. J Pediatric Orthop 2004 Nov-Dec;24(6):700-705.         [ Links ]

34. Kazuki K, Hiroshima K, Kawahara K. Ulnar focal cortical indentation: a previously unrecognised form of ulnar dysplasia. J Bone Joint Surg (Br) 2005 Apr;87(4):540-43.         [ Links ]

35. Gottschalk HP, Light TR, Smith P. Focal fibrocartilaginous dysplasia in the ulna: report on 3 cases. J Hand Surg 2012 Nov;37(ll):2300-3003.         [ Links ]

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37. Eren A, Cakar M, Erol B, Ozkurt A, Guven M. Focal fibrocartilaginous dysplasia in the humerus. J Pediatr Orthop Part B 2006 Nov;15(6):449-52.         [ Links ]



Dr PH Maré
PO Box 351
3231 Msunduzi
Tel: +27 33 897 3050
Cell: +27 83 294 8375

^rND^sBell^nSN^rND^sCampbell^nPE^rND^sCole^nWG^rND^sMenelaus^nMB^rND^sKim^nCJ^rND^sChoi^nIH^rND^sCho^nTJ^rND^sChung^nCY^rND^sChi^nJG^rND^sChoi^nIH^rND^sKim^nCJ^rND^sCho^nTJ^rND^sChung^nCY^rND^sSong^nKS^rND^sHwang^nJK^rND^sBradish^nCF^rND^sDavies^nSJ^rND^sMalone^nM^rND^sHusien^nAM^rND^sKale^nVR^rND^sHerman^nTE^rND^sSiegel^nMJ^rND^sMcAlister^nWH^rND^sOlney^nBW^rND^sCole^nWG^rND^sMenelaus^nMB^rND^sKariya^nY^rND^sTaniguchi^nK^rND^sYagisawa^nH^rND^sOoi^nY^rND^sLandreau-Jolivet^nI^rND^sPilliard^nD^rND^sTaussig^nG^rND^sZayer^nM^rND^sCockshott^nWP^rND^sMartin^nR^rND^sFriedman^nL^rND^sYuen^nM^rND^sMeyer^nJS^rND^sDavidson^nRS^rND^sHubbard^nAM^rND^sConard^nKA^rND^sAlbinana^nJ^rND^sCuervo^nM^rND^sCertucha^nJA^rND^sGonzalez-Mediero^nI^rND^sAbril^nJC^rND^sKhanna^nG^rND^sSundaram^nM^rND^sEl-Khoury^nGY^rND^sMerkel^nK^rND^sPostovsky^nS^rND^sMilitianu^nD^rND^sBialik^nV^rND^sVlodavsky^nE^rND^sElhasid^nR^rND^sPeled^nM^rND^sPoul^nJ^rND^sStraka^nM^rND^sDusabe^nJP^rND^sDocquier^nPL^rND^sMousny^nM^rND^sRombouts^nJJ^rND^sBakman^nM^rND^sMonu^nJU^rND^sJouve^nJL^rND^sKohler^nR^rND^sMubarak^nSJ^rND^sNelson^nSC^rND^sDohin^nB^rND^sBollini^nG^rND^sRinge^nKI^rND^sSchirg^nE^rND^sRosenthal^nH^rND^sBerendonk^nH^rND^sGalanski^nM^rND^sJibri^nZ^rND^sChakraverty^nJ^rND^sThomas^nP^rND^sKamath^nS^rND^sPavone^nV^rND^sTesta^nG^rND^sRiccioli^nM^rND^sSessa^nA^rND^sEvola^nFR^rND^sAvondo^nS^rND^sSantos^nM^rND^sValente^nE^rND^sAlmada^nA^rND^sNeves^nJ^rND^sMooney^nJF^rND^sSlone^nHS^rND^sBeaty^nJH^rND^sBarrett^nIR^rND^sVallcanera Calatayud^nA^rND^sSanguesa Nebot^nC^rND^sMartinez Fernandez^nM^rND^sCortina Orts^nH^rND^sAmillo^nS^rND^sMora^nG^rND^sLeniz^nP^rND^sMacnicol^nMF^rND^sRuchelsman^nDE^rND^sMadan^nSS^rND^sFeldman^nDS^rND^sAndo^nA^rND^sHatori^nM^rND^sHosaka^nM^rND^sHagiwara^nY^rND^sKita^nA^rND^sOchiai^nT^rND^sThabet^nAM^rND^sBelthur^nMV^rND^sHerzenberg^nJE^rND^sLincoln^nTL^rND^sBirch^nJG^rND^sSmith^nNC^rND^sCarter^nPR^rND^sEzaki^nM^rND^sKazuki^nK^rND^sHiroshima^nK^rND^sKawahara^nK^rND^sGottschalk^nHP^rND^sLight^nTR^rND^sSmith^nP^rND^sVerhoeven^nN^rND^sDe Smet^nL^rND^sEren^nA^rND^sCakar^nM^rND^sErol^nB^rND^sOzkurt^nA^rND^sGuven^nM^rND^1A01^nRS^sRangongo^rND^1A02^nMV^sNgcelwane^rND^1A03^nFE^sSuleman^rND^1A01^nRS^sRangongo^rND^1A02^nMV^sNgcelwane^rND^1A03^nFE^sSuleman^rND^1A01^nRS^sRangongo^rND^1A02^nMV^sNgcelwane^rND^1A03^nFE^sSuleman



The relationship of the size of the footprint of the fibular graft to the surface area of the vertebral endplate in the reconstruction of the anterior column of the spine



Dr RS RangongoI; Prof MV NgcelwaneII; Dr FE SulemanIII

IBSc, MBChB(Medunsa), MMed(Orth)(UP); Department of Orthopaedics, 1 Military Hospital, University of Pretoria
IIMBChB(Natal), FCS(SA)Orth, MSc(Orth)(London); Head: Department of Orthopaedics, Steve Biko Academic Hospital, University of Pretoria
IIIMBChB, FCRad(D)SA, MMedRad(D)(UL); Clinical Head of Unit: Department of Radiology, Steve Biko Academic Hospital, University of Pretoria





INTRODUCTION: The anterior column of the spine is often destroyed by trauma, infection or tumours. It is reconstructed by using an autograft, allograft or synthetic cages. The fibular autograft provides good strength, incorporates quickly and has less risk of disease transmission, which is a big advantage in communities with a high incidence of HIV.
Various authors cite that its major drawback is the size of its footprint because of the possibility of subsidence. We could not, however, find any literature that measures its size.
AIM: To measure the size of the footprint of the fibular graft in relation to the surface area of the vertebral endplate. The clinical relevance is that it may guide the surgeon in deciding how many struts of the fibular graft to use in reconstructing the anterior column, and also quantifies the statement that the fibular strut has a small footprint.
Material and method: CT angiograms are done frequently for peripheral vascular diseases. These angiograms show CT scan images of the lumbar and thoracic vertebrae, and fibulae of the same patient. We retrospectively examined 60 scans done during the years 2012 and 2013. From the CT scans, we measured the surface area of the endplates of the vertebral bodies of T6, 8, 12, L2, and the surface area of the cut surface of the proximal 10 cm, 20 cm and 30 cm of the fibular graft, all in square millimetres (mm2). We then compared the areas of the vertebral measurements to the area of the fibular graft measurements.
RESULTS: The middle third of the fibular graft had the biggest axial surface area. The ratio of the fibular graft surface area to that of the thoracic vertebral endplate is 1:3-6. These ratios suggest that more than one fibular strut graft is required to reconstruct the anterior column in the thoracic spine.
CONCLUSION: The results show that the fibular graft is better suited for reconstruction in the upper thoracic spine. Below that more than two struts are required.

Key words: vertebral body reconstruction, autograft, fibular graft




The anterior column of the spine is often destroyed by malignancy, infection, trauma and congenital abnormalities. The gold standard for the reconstruction of the anterior column is the use of autologous bone graft.1,2 Over the years other materials such as allograft and metallic cages have become more popular.

Allograft is often preferred in the reconstruction of a destroyed anterior column of the spine. The bones often used are the humerus, femur, tibia or a fibula. The grafts are processed under strict conditions to minimise the risk of disease transmission and immuno-incompatibility.3Allografts are acquired through the bone bank and the quantity is therefore only limited if there are financial constraints or delivery problems. Allografts are procured either from living donors or from human cadavers. Their potential morbidity arises mainly from the possible transmission of pathogens, particularly viruses. However, processing of the grafts removes blood and bone marrow in which the viral agents reside.3 Mechanical performance of the allograft is weakened by the negative effects of tissue processing, fatigue and post-operative fatigue.4Few guidelines exist regarding donor eligibility as to mechanical integrity of the structural allograft. The principal advantage of the allograft is the avoidance of graft harvest morbidity, and its availability in various shapes and sizes.4 Current regulations address disease transmission and tissue contamination so that they are minimised.4 Choosing between an allograft and autograft on the basis of economic cost is controversial because studies directly comparing these costs are lacking.2 The cost of allografts increases in direct proportion to their processing.

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