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BACKGROUND: Patients with hereditary multiple exostosis (HME) usually present with forearm deformity with or without radial head dislocation. Ulna lengthening has been proposed to address this condition. Exostosis resection plus ulna lengthening has been adopted in our hospital since 2008, and patients with this condition were retrospectively reviewed. Herein, we aimed to investigate the optimal timing and clinical outcomes of this surgical approach. METHODS: In all, thirty-five patients (40 forearms), including 22 boys and 13 girls, were enrolled in our study from July 2014 to September 2020. We divided the patients into 4 groups based on the age when they received surgery and the status of the radial head. Pronation and supination of the forearm, flexion and extension of the elbow, wrist ulnar deviation and wrist radial deviation, and radiological parameters including ulnar length (UL), ulnar variance (UV), the percentage of radial bowing (RB/RL), radio articular angle (RAA) and carpal slip (CS), were assessed and recorded. RESULTS: The mean UL was significantly improved after surgery in four Groups (P<0.05). In patients with radial head dislocation, we found significant improvement in forearm, wrist function and elbow flexion (p < 0.05). For the patients with radial head dislocation, the juniors demonstrated better improvement in % RB and RAA (p<0.05, p = 0.003 and 0.031). CONCLUSION: Exostosis resection and ulna lengthening with unilateral external fixation can effectively improve the function and radiological parameters of forearm deformity in HME children. For patients with radial head dislocation, early surgery can achieve better results. For patients not associated with radial head dislocation, we recommend regular follow-up and surgical treatment after 10 years of age.

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INTRODUCTION: Hereditary multiple exostosis or hereditary multiple osteochondromas is a very rare clinical condition. Usually, these lesions tend to occur in the pediatric population, remaining silent until adulthood. Moreover, current studies show a small prevalence in the male population. The osteochondromas usually occur at sites with great bone activity and turnover, such as the diaphysis or metaphyseal plates (especially in children) of long bones. Their appearance in short bones (such as vertebrae) is very rare. CASE PRESENTATION: We present a case of familial HME in a 53-year-old female patient with a very uncommon clinical description of the disease. The patient presented at our hospital with Frankel D-type paraparesis, with multiple osteochondromas (located at the right humerus, bilateral femurs, right tibia, and hip joints, besides the numerous ones over the spinal column) and urinary incontinence. She was suffering from bilateral coxarthrosis and gonarthrosis, which limited severely the range of her movements. An early menopause status was brought into consideration by the patient, being installed circa 15 years before, at 38 years old. She was currently in treatment with bisphosphonates for her concomitant osteoporosis. CONCLUSIONS: Despite the relatively rare nature of the disease, it may be an important concern for the patient's quality of life. Intraspinal processes may trigger paraparesis or other neurological statuses, which may require a surgical treatment. The nature of the lesions is usually benign and do not require further radio- or chemotherapy.

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Introduction: Hereditary multiple exostoses (HME) Masada IIB has traditionally been treated by gradual ulnar lengthening with questionable efficacy in reducing the dislocated head. One-bone forearm (OBF) has been used as a reconstructive procedure in forearm deformities with very scarce literature for HME. The study aims to report short-term results of OBF as a definitive procedure for severe forearm deformities in Masada IIB patients with respect to clinical and radiological parameters. Materials and Methods: Four patients with HME Masada IIb were included in this retrospective study. All patients complained of forearm and wrist deformity with an abnormal bony protrusion restricting elbow motion. Indications for OBF were ulnar shortening > 3 cm, dysplastic proximal radius with convex radial head and restricted prono-supination. All patients were examined pre-operatively and post-operatively clinically and radiographically using the Peterson's outcome score. Results: The average age was 13 years (12-14 years). Pre-operative ulnar shortening, carpal slip percentage, and radial articular angle was 3.4 cm, 79.5%, and 47.5°, respectively. All radial heads were dislocated with convex articular surface restricting elbow extension and forearm prono-supination. At the latest follow-up, the mean elbow flexion was 110° with forearm in 10° supination. The mean carpal slip percentage, radial articular angle, and Peterson functional grade was 15%, 22.5°, and 8 points, respectively. The mean follow-up period was 30.25 months with no recurrence. Conclusion: We recommend one bone forearm as a definitive procedure in HME Masada IIB patients with severe forearm deformities with ulnar shortening > 3 cm and dysplastic proximal radius with a dislocated radial head, for faster return to function.

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BACKGROUND: Acquired hip deformities in patients affected by hereditary multiple exostosis (HME) may incur in early hip osteoarthritis and functional limitation requiring primary total hip arthroplasty (THA). Characteristic coxo-femoral joint dysmorphisms in HME may pose a challenge for the orthopaedic surgeon. Here we report our experience in a series of patients with HME treated in our hospital with THA. METHODS: With a mean follow-up of 5 years, 10 primary THAs were reviewed; proximal femur deformities, acetabular dysplasia and joint osteoarthritis has been assessed through x-rays and CT-scan evaluation. In all cases hemispheric press-fit cups were used; 4 stem had metaphyseal engagement, 5 had proximal diaphyseal engagement and 1, with anatomical geometry, had metaphyseal fixation. 2 cases required stem cementation, 3 modular neck and 1 lateralised. The clinical data, complications and clinical outcomes, were recorded and analysed. RESULTS: The mean Harris Hip Score (HHS) increased from 34 preoperative to 86 postoperative; preoperative mean neck shaft angle (NSA) was 150°, head/neck ratio 0.6, offset 31 mm; Wiberg angle 28°, Sharp angle 38°, 1 patient had subluxation grade 4 according to Crowe, 8 hips showed osteoarthritis (Tönnis grade ⩾2 ); 5 femurs were classified as Dorr type C, 2 as type B and 3 as type A. Perioperative complications were not observed. CONCLUSIONS: Primary THA in HME significantly improved clinical and functional outcomes. Press-fit cup fixation together with metaphyseal and proximal diaphyseal stem engagement on reliable bone quality femur, represents a valid option in HME patients with normal acetabular morphology, wide broaden neck and valgus NSA.

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BACKGROUND: Ulna distraction by monolateral external fixator (MEFix) is a good option for the treatment of Masada type I and IIb deformities in children with hereditary multiple exostoses (HMEs). However, there is no consensus regarding where to perform ulnar osteotomy. Our hypothesis is that osteotomy at the proximal third of the ulna and progressive distraction with MEFix can simultaneously correct elbow and wrist deformities in patients with HME. METHODS: We retrospectively reviewed patients with HME who underwent ulna distraction osteogenesis from June 2014 to March 2019. The carrying angle (CA), radial articular angle (RAA), ulnar variance (UV), radial variance (RV) and range of motion (ROM) of the affected forearm and elbow were clinically assessed before lengthening and at the last follow-up visit. The total ulna lengthening distance (LD) and radiographic outcome were also recorded. RESULTS: Nineteen patients (20 forearms) with HME aged 9.1 ± 2.4 years at the time of surgery were retrospectively reviewed. The mean follow-up period was 26.1 ± 5.6 months. There were 11 patients (12 forearms) with Masada type I deformities and eight patients (8 forearms) with Masada type IIb deformities. Patients with type IIb deformity had higher RV, lower CA values, less elbow flexion and forearm pronosupination than those with type I deformity (p < 0.05); RV was an independent risk factor for radial head dislocation, with the cut off at RV > 15.5 mm. The mean LDs in patients with type I and type IIb deformities were 33.6 ± 6.6 mm and 41.4 ± 5.4 mm, respectively. The mean CA, UV, RV, forearm pronation and ulna deviation at the wrist improved significantly following surgery in all patients. In particular, five of eight patients (62.5%) with type IIb deformities had concentric reduction of the radiocapitellar joint, while no radial head subluxation was detected in patients with type I deformities at the last follow-up. Three complications were recorded: two pin-track infections and one delayed union. CONCLUSIONS: Distraction osteogenesis at the proximal third of the ulna provides satisfactory clinical and radiological outcomes in patients with Masada type I and IIb deformities. Early treatment of Masada type I deformities is indicated before progression to more complex type IIb deformities.

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In this study, the effect of heterozygous germline mutations in the heparan sulfate (HS) glycosaminoglycan chain co-polymerases EXT1 and EXT2 on glomerular barrier function and the endothelial glycocalyx in humans is investigated. Heparan sulfate (HS) glycosaminoglycans are deemed essential to the glomerular filtration barrier, including the glomerular endothelial glycocalyx. Animal studies have shown that loss of HS results in a thinner glycocalyx. Also, decreased glomerular HS expression is observed in various proteinuric renal diseases in humans. A case report of a patient with an EXT1 mutation indicated that this could result in a specific renal phenotype. This patient suffered from multiple osteochondromas, an autosomal dominant disease caused by mono-allelic germline mutations in the EXT1 or EXT2 gene. These studies imply that HS is indeed essential to the glomerular filtration barrier. However, loss of HS did not lead to proteinuria in various animal models. We demonstrate that multiple osteochondroma patients do not have more microalbuminuria or altered glycocalyx properties compared to age-matched controls (n = 19). A search for all Dutch patients registered with both osteochondroma and kidney biopsy (n = 39) showed that an EXT1 or EXT2 mutation does not necessarily lead to specific glomerular morphological phenotypic changes. In conclusion, this study shows that a heterozygous mutation in the HS backbone elongating enzymes EXT1 and EXT2 in humans does not result in (micro)albuminuria, a specific renal phenotype or changes to the endothelial glycocalyx, adding to the growing knowledge on the role of EXT1 and EXT2 genes in pathophysiology.

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BACKGROUND: Hereditary multiple exostosis (HME) is an autosomal dominant skeletal disorder characterized by the development of multiple cartilage-covered tumors on the external surfaces of bones (osteochondromas). Most of HME cases result from heterozygous loss-of-function mutations in EXT1 or EXT2 gene. METHODS: Clinical examination was performed to diagnose the patients: Whole exome sequencing (WES) was used to identify pathogenic mutations in the proband, which is confirmed by Sanger sequencing and co-segregation analysis: qRT-PCR was performed to identify the mRNA expression level of EXT1 in patient peripheral blood samples: minigene splicing assay was performed to mimic the splicing process of EXT1 variants in vitro. RESULTS: We evaluated the pathogenicity of EXT1 c.1056 + 1G > T in a Chinese family with HME. The clinical, phenotypic, and genetic characterization of patients in this family were described. The variant was detected by whole-exome sequencing (WES) and confirmed by Sanger sequencing. Sequencing of the RT-PCR products from the patient's blood sample identified a large deletion (94 nucleotides), which is the whole exome 2 of the EXT1 cDNA. Splicing assay indicated that the mutated minigene produced alternatively spliced transcripts, which cause a frameshift resulting in an early termination of protein expression. CONCLUSIONS: Our study establishes the pathogenesis of the splicing mutation EXT1 c.1056 + 1G > T to HME and provides scientific foundation for accurate diagnosis and precise medical intervention for HME.

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AIMS: Chondrosarcoma is the second most common primary sarcoma of bone: conventional chondrosarcoma accounts for 85% of all cases. Conventional chondrosarcoma may be central or peripheral. Most studies group central and peripheral chondrosarcomas together, although there is growing evidence that their clinical behaviour and prognosis differ. The aims of this study were to analyze any differences in characteristics between central and peripheral chondrosarcomas and to investigate the incidence and role of different syndromes. METHODS: Data from two international tertiary referral sarcoma centres between January 1995 and December 2018 were retrospectively reviewed. The study population consisted of 714 patients with surgically treated conventional chondrosarcoma of the pelvis and limbs. RESULTS: In patients with Ollier's disease and Mafucci's syndrome, 12/20 (60%) and 2/5 (60%) of malignancies, respectively, were in the limbs, most frequently in the proximal humerus, proximal tibia, and in the hands and feet. In patients with hereditary multiple exostosis (HME), 20/29 (69.0%) of chondrosarcomas were in the pelvis and scapula, specifically in the ilium in 13/29 (44.8%) and the scapula in 3/29 (10.3%). In central chondrosarcoma, survival of patients with Ollier's disease and non-syndromic patients was the same (p = 0.805). In peripheral chondrosarcoma, survival among HME patients was similar (p = 0.676) in patients with tumours of the pelvis and limbs. CONCLUSION: Both central and peripheral chondrosarcoma have specific characteristics. HME is frequently seen in patients with a peripheral chondrosarcoma, in whom tumours are commonly located in the ilium and scapula. The incidence of Ollier's disease is uncommon in patients with a central chondrosarcoma. Disease-specific survival is equal in different subtypes after adjustment for histological grade. The local recurrence-free survival is the same for different locations and subtypes after adjustment for surgical margin. Cite this article: Bone Joint J 2021;103-B(5):984-990.

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Introduction: Hereditary multiple exostoses (HME) disease is hallmarked by cartilaginous osteochondromas secondary to an autosomal dominant mutation within the exostosin gene family. These outgrowths predominantly occur around the long bone physis. An associated disease is dysplasia epiphysealis hemimelica also known as Trevor's disease. Trevor's disease is hallmarked by intra-articular osteochondromas. While the two diseases are similar, they are not genetically related and often have differing patient presentations. Case Report: We report on a case of a 7-year-old female with a familial history significant for HME that presented with an isolated chief complaint of elbow extension block secondary to osteochondromas found both intra-articular and at the olecranon fossa. We present what could be one of the first cases of coexisting HME and Trevor's disease of the upper extremity. Conclusion: Our patient's unique presentation of an intra-articular osteochondroma speculated to be a result of Trevor's disease, in the presence of an established HME diagnosis. Management for this patient did not deviate heavily from the established approach for HME which entails conservative observation until symptomatic. Due to the substantial loss of range of motion (ROM), surgical intervention took place in the form of exostoses removal and necessary reconstruction of the fossa. The patient's ROM subsequently was restored to near normal.

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Osteoid osteoma is a benign bony pathology. It presents either as a solitary lesion or as multiple lesions with a genetic predisposition. Reported more often in teenagers with thrice more common incidence among boys than in girls, it has a predilection for long bones of lower limbs. Less commonly arising from iliac crest or ribs; it is seen to be further rare to have originated from vertebrae or tarsal/carpal bones. Cranial osteomas are detected either incidentally on imaging or present as a bony hard swelling arising from the skull. Spinal intracanal osteomas are extremely rare to encounter in clinical practice. Cervical intracanal lesion in a case of hereditary multiple exostoses (HME) presenting with myelopathy is further rare. Less than thirty such cases have been reported so far. We present here a rare case of HME in a 16-year-old boy with compressive myelopathy secondary to intracanal cervical osteoma at C4 Lamina and spinous process. He had a phenotypical expression of hereditary multiple osteomas with a strong family history of inheritance of trait among first-degree male relatives favoring genetic transmission of disease with variable penetrance. All reported cases, to date, are discussed in a tabulated form.

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OBJECTIVES: Hereditary multiple exostosis (HME) often involves forearm deformities. The aim of this study was to present the clinical results of 37 children who underwent ulnar lengthening with two different types of unilateral external fixators and to investigate the risk factors of complications. METHODS: We evaluated 37 children with forearm deformities caused by HME treated in our hospital from January 2008 to July 2019. The surgical procedures included resection of exostosis, osteotomy of the ulna, and gradual lengthening of the ulna with a unilateral external fixator. According to the type of fixator they received, the children were divided into two groups: group A received monorail fixators and group B received multi-joint fixators. Radiographic and functional parameters were assessed. Complications were recorded. RESULTS: All patients were followed-up for an average of 4.6 years (3.0 to 6.5). In both group A and group B, the ulna shortening (US), radial articular angle (RAA), carpal slip (CS), elbow flexion, forearm pronation, supination, and Mayo Elbow Performance Score (MEPS) values improved significantly from preoperatively to postoperatively (p < 0.05). However, the ulnar deviation was observed in 4 cases in group B and no cases in group A. According to logistic regression, the difference was only related to age (p < 0.05) and the type of external fixator (p < 0.05). CONCLUSIONS: Ulnar lengthening with unilateral external fixation is a safe and effective procedure for the treatment of HME. Regarding complications, deviation of the ulna axis was more likely to occur in older children with multi-joint external fixators.

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INTRODUCTION: Combined achondroplasia and hereditary multiple exostosis (HME) syndrome is a rare autosomal dominant inherited skeletal dysplasia. We report, for the 1sttime, a complex primary hip arthroplasty in a patient with combined achondroplasia and HME syndrome. We emphasize to the femoral and acetabular surgical concerns and difficulties of the surgical exposure and soft tissue balancing for this complex procedure. CASE REPORT: An ambulatory 66-year-old female Caucasian with achondroplasia and HME presented with the left hip pain, progressive walk disability and limited range of hip motion due to severe hip osteoarthritis. Full cemented primary total hip arthroplasty (THA) with an impaction grafting technique was performed; posterior lip augmentation device was implanted to improve stability. At 5 years follow-up, the patient remains ambulatory and pain-free with improved range of hip motion. No signs of aseptic loosening are present. CONCLUSIONS: Cemented THA could be an efficient option to reconstruct the complex hip anatomy in patients with skeletal dysplasia.

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RESUMEN Introducción: la osteocondromatosis múltiple hereditaria, entidad autosómica dominante, que se caracteriza por el crecimiento de múltiples tumores benignos llamados osteocondromas. Presentación del caso: paciente femenina de 12 años de edad, que acude a consulta refiriendo dolor constante en rodilla derecha, más acentuado con la marcha. Examen físico SOMA: Aumento de volumen de rodilla derecha hacia sus caras externas e internas con dolor a la palpación, se palpa masa dura, no movible, de bordes irregulares. También se constatan tumoraciones de similares características en ambos hombros y rodillas. Discusión: se le realizan radiografías, observando lesiones óseas en la metáfisis proximal de ambos húmeros a predominio derecho. Exostosis a nivel de metáfisis proximal y distal de ambos fémures, en tibia y peroné bilateral. En rodilla derecha se observa crecimiento hacia la línea media de la tumoración del peroné desplazando en valgo la metáfisis proximal de la tibia. Conclusiones: se plantea una exostosis múltiple como diagnóstico. Se realizó tratamiento quirúrgico escisión tumoral del extremo proximal del peroné de la rodilla derecha y de la cara interna de la metáfisis proximal de la tibia y biopsia que confirmó el diagnóstico.

ABSTRACT Introduction: hereditary multiple osteochondromatosis, an autosomal dominant entity, characterized by the growth of multiple benign tumors called osteochondromas. Case presentation: 12-year-old female patient, who comes to the consultation referring to constant pain in the right knee, more accentuated with the gait. PHYSICAL exam SOMA: Increase of volume of right knee towards their outer and inner faces with pain to palpation, it palps hard mass, not movable, of irregular edges. Tumors of similar characteristics are also found in both shoulders and knees. Discussion: X-rays are performed, observing bone lesions in the proximal metaphysis of both humeruses to right predominance. Exostosis at the level of proximal and distal metaphysis of both femurs, in tibia and bilateral fibula. In the right knee, growth is observed towards the midline of the fibula tumor displacing the proximal metaphysis of the tibia in valgo. Conclusions: Multiple exostosis is raised as a diagnosis. Surgical treatment was performed tumor excision of the proximal end of the fibula of the right knee and the inner face of the proximal metaphysis of the tibia and biopsy that confirmed the diagnosis.

RESUMO Introdução: osteocondromatose múltipla hereditária, uma entidade autossômica dominante, caracterizada pelo crescimento de múltiplos tumores benignos chamados osteochondromas. Apresentação do caso: paciente do sexo feminino de 12 anos, que chega à consulta referindo-se a dores constantes no joelho direito, mais acentuadas com a marcha. Exame FÍSICO SOMA: Aumento do volume do joelho direito em direção aos seus rostos externos e internos com dor à palpação, palpa massa dura, não móvel, de bordas irregulares. Tumores de características semelhantes também são encontrados em ambos os ombros e joelhos. Discussão: São realizados raios-X, observando lesões ósseas na metafise proximal de ambos os úmeros à predominância direita. Exostose ao nível de metafísica proximal e distal de ambos os fêmures, natíbia e fíbula bilateral. No joelho direito, observa-se crescimento para a linha média do tumor de fíbula deslocando a metafísica proximal da tíbia em valgo. Conclusões: A exostose múltipla é levantada como diagnóstico. Foi realizado tratamento cirúrgico excisão tumoral da extremidade proximal da fíbula do joelho direito e da face interna da metafise proximal da tíbia e biópsia que confirmou o diagnóstico.

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INTRODUCTION: Hereditary multiple exostosis (HME) is an autosomal dominant disorder affecting the skeletal system, which is characterized by multiple osteochondromas in bones arising from osteochondral ossification and leading to skeletal deformities, short stature, soft tissue, and neurovascular compressive symptoms. CASE REPORT: A 10-year-old female a case of HME presented with painless multiple swelling around knees, wrist, and painful varus deformity in the lower third of the right leg. The large exostosis of the right distal tibia was symptomatic and indenting the fibula which required excision along with the segment of the fibula of about 2.5 cm above the syndesmosis adjacent to the exostosis as the mass was adherent to the fibula. CONCLUSION: Although distal tibia osteochondromas are rare, they can lead to deformity of the ankle and loss of function if not managed early and properly. Hence, early detection, proper planning, and management of periarticular distal tibia osteochondromas are essential to prevent the development or progression of the deformity. Segmental fibulectomy is required to remove the adherent osteochondromas completely and to prevent the recurrence and secondary surgical procedures. It is very essential to follow up the patient till the skeletal maturity to identify the delayed presentation and late progression of the ankle deformities.

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BACKGROUND: The most serious complication of hereditary multiple exostoses(HME) is chondrosarcoma transformation. Numerous authors have suggested that screening might allow early chondrosarcoma detection. However, literature-quoted incidences of malignant transformation are highly variable. METHODS: A systematic review of malignant transformation by sex, exostosin-1 mutation(EXT1), age and site was conducted searching Medline, Embase and CINHAL. Three HME screening strategies were then developed and compared using cost per life-year gained and incremental cost-effectiveness ratio (ICER). RESULTS: Systematic review: 18 papers with 852 chondrosarcomas were identified. The incidence of chondrosarcoma transformation averaged 4%, 75.2% occurring between ages 20-40 and 56.2% at the pelvis and proximal femur. Screening model: In the general HME population, plain radiographs provided cost per life-year gain of £19,013 compared to £53,392 in MRIs. ICER in MRIs compared to X-rays was £80,218. However, for every generation of HME patients screened over 20 years, X-ray radiation induced 0.65 cancers. Psychological effects of false-positives were marginal. Screening only higher-risk groups (males or EXT1) reduced cost but benefited fewer patients. CONCLUSIONS: Our results suggest that annual MRI screening for all HME patients between age 20-40 may be of value. However, the extent of anatomical imaging is subject to debate; it is possible that focused imaging protocols which scan from cervical spine to proximal femur may improve cost-effectiveness.

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Osteochondroma or hereditary multiple exostoses is the most common benign bone tumor and is usually found in young patients. Osteochondromata of the proximal femur or hip have been reported in 30% to 90% of patients with hereditary multiple exostoses. This article presents a 25-year-old-male referred to our orthopedic clinic with a complaint of pain in both groins for the last four years which has deteriorated in the past 6 months by limitation of range of motion. Radiographic findings were consistent with huge hip osteochondroma and a histopathological report confirmed the diagnosis. This was a case of a huge bilateral osteochondroma of the hip originating from the posterior of the hips to the neck of the femur and hip joints and part of proximal of femur, that underwent one-stage surgical excision of the tumor with posterior approach and tumor resection. As we know, this case of bilateral huge hip osteochondromas has rarely been presented previously by someone who has undergone one-stage surgery treatment of a tumor this size. Bilateral hip osteochondroma is a rare condition and we showed that one-stage excision can be performed successfully.

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PURPOSE: This study attempted to evaluate a series of patients with hereditary multiple exostoses (HME) who could not be categorized according to the widely accepted Masada classification and to identify radiographic variables such as radial bowing, ulnar shortening, ulnar variance, radial articular angle, and carpal slip predictive of deformity. METHODS: We retrospectively reviewed data on 102 upper limbs of 53 pediatric patients with HME. Demographics, site of forearm involvement, and radiographic parameters were documented. Patients with exostoses of the forearms were categorized into 6 groups based on location of the exostoses and presence or absence of a dislocated radial head. Proportional ulnar shortening was calculated as the ratio of ulnar length to radial length. RESULTS: According to the Masada classification, 4 limbs were normal, 10 were type I, 2 were type II, and 24 were type III. Sixty-six limbs were unclassifiable. We classified those 66 limbs using a modification of the Masada classification. Of the 106 limbs, 11 (10.3%) had a dislocated radial head. Based on the radiographic analysis, patients with proportional ulnar shortening of less than 0.9 had a higher risk of radial head dislocation than did those with proportional ulnar shortening of 0.9 or greater. Patients with radial bowing greater than 8.1% showed a higher frequency of radial head dislocation than did those with radial bowing of 8.1% or less. Exostoses of both the distal radius and ulna tended to increase the rate of radial head dislocation. A greater amount of negative ulnar variance caused more radial bowing and a greater radioarticular angle. CONCLUSIONS: We propose a new comprehensive forearm classification for patients with HME. Proportional ulnar shortening less than 0.9 and radial bowing 8.1% or greater can be used to predict the risk of radial head dislocation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

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INTRODUCTION: The giant cell tumor, in which BCL-2 gene was expressed only in its malignant transformation, is a benign, primary skeletal neoplasm with variable biologic aggressiveness. The is of the giant cell tumor. A coexistence with hereditary multiple exostosis with expression of EXT-1 is very rare. The correlation between giant cell tumor in hereditary multiple exostosis is still not clearly determined. PRESENTATION OF CASE: A 31-years-old female presented with pain and lump on her left wrist and a coexistence of non tender multiple lump in the right and left knee. A wide excision of the tumor and reconstruction using non vascularized fibular graft was performed, followed by histopathology and immunohistochemistry of EXT-1 and BCL-2. DISCUSSION: In this case, the tumor showed negative BCL-2 and positive EXT-1 gene expression. Giant cell tumor and hereditary multiple exostosis also demonstrated associations of chromosomes 11 with a different pathological process. CONCLUSION: Giant cell tumor in hereditary multiple exostosis revealed positive EXT-1 without BCL-2 expression. It still need more investigation to confirm the relationship between these tumors.

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Hereditary multiple exostosis (HME) is an autosomal dominant disorder characterized by two or more benign growing, cartilage capped tumors of long bones called osteochondromas. If abnormal growth and clinical symptoms of osteochondromas newly appear in adults, malignant transformation of the usually benign growing tumors should be suspected and diagnostic testing should be initiated. Against the background of hypothesized higher malignant transformation of osteochondromas into chondrosarcoma in individuals with shoulder exostoses, we report a case of bilateral scapulothoracic osteochondromas in a patient suffering from HME. A 60-year-old female with HME complained of chest pain while being hospitalized for bilateral femoral fractures. A computed tomography scan of the chest was performed to rule out pulmonary embolism. However, bilateral osteochondromas in the scapulothoracic spaces were detected. Due to absence of radiographic evidences for malignant transformation in the patient, invasive diagnostic procedures such as biopsy and histological examination were recommended in order to exclude malignant transformation of both osteochondromas. Physicians should be aware that patients with HME who present with shoulder pain should be examined for osteochondromas in the scapulothoracic space. Due to possible sarcomatous transformation, regular follow-ups are necessary for adolescents and adults.