How are bone spurs and hypertrophy of bone managed?

Management of Bone Spurs and Bone Hypertrophy

Bone spurs and bone hypertrophy should be managed through a multimodal approach based on location, symptoms, and underlying cause, with treatment options including conservative measures, medications, and surgical interventions when necessary. 1

Types and Causes

• Bone spurs include both osteophytes (forming around joint lines) and enthesophytes (forming at insertion sites of tendons or ligaments) 1
• Bone hypertrophy can result from athletic training, causing increased cortical thickness, bony spurs at tendon insertions, and increased bone density 2
• Pathological bone hypertrophy may occur in metastatic disease, leading to skeletal-related events (SRE) including pain, fractures, and neurological complications 3

Assessment and Diagnosis

• Evaluation should include assessment of pain, neurological risk, and bone instability 3
• CT scan is the first-line investigation for bone abnormalities, with MRI recommended when neurological complications are suspected 3
• For spinal lesions, the Spinal Instability Neoplastic Score (SINS) helps determine instability risk, classifying lesions as stable (≤6), potentially unstable (7-12), or unstable (≥13) 3
• For long bones, the Mirels' score helps assess fracture risk, with scores ≥9 indicating high risk 3

Conservative Management

• First-line treatment for most bone spurs includes:
  • Pain management with appropriate analgesics 3
  • Physical therapy to improve strength, function, and fitness 3
  • Activity modification to reduce stress on affected areas 1
• For plantar fasciitis with bone spurs, conservative treatment should be attempted before considering surgical options 4

Pharmacological Management

• For bone metastases with hypertrophy:
  • Antiresorptive treatments (bisphosphonates or denosumab) may be indicated to prevent skeletal-related events 3
  • Systemic oncological treatments based on primary tumor type 3
• For inflammatory conditions causing bone hypertrophy:
  • Anti-inflammatory medications to control underlying disease activity 5

Surgical Management

Indications for Surgery

• Persistent pain despite conservative treatment 3
• Mechanical instability or high fracture risk 3
• Neurological compromise 3
• Functional limitation affecting quality of life 4

Surgical Approaches

• For bone spurs causing tendon ruptures:

  • Removal of the causative bone spur is imperative to prevent further damage 5
  • Early tenosynovectomy may be indicated to prevent tendon ruptures 5

• For plantar fasciitis with bone spurs:

  • A four-step surgical approach including plantar fascia release, calcaneal spur grinding, inflammatory tissue removal, and calcaneal burr decompression has shown significant improvement in pain and function 4

• For bone metastases with hypertrophy:

  • Surgical stabilization for unstable lesions or those at high risk of fracture 3
  • Prophylactic stabilization of impending fractures is preferred over fixation after fracture 3
  • Surgical approach depends on location:
    • For proximal femur and humerus: long-stem cemented or modular tumor endoprosthesis 3
    • For diaphysis of long bones: plate, intramedullary nail, or prosthesis 3
    • For short-term life expectancies: minimally-invasive intramedullary nailing with locking screws 3

• For turbinate hypertrophy:

  • Outfracture procedure repositions the turbinate laterally by fracturing the turbinate bone, creating more space in the nasal passage 6
  • Should be reserved for patients who have failed medical therapy 6

Radiotherapy and Other Interventions

• Radiotherapy may be beneficial for bone metastases causing pain or at risk of fracture 3
• Cementoplasty for spine metastases provides rapid analgesic effect (within 24-48 hours) 3
• Radiofrequency ablation, often paired with cementoplasty, can provide significant pain relief 3

Special Considerations

• Enthesophyte fractures should be treated conservatively with focus on increasing range of motion, progressive resistance exercises, and eccentric loading 1
• Prevention of tendon ruptures from bone spurs should be a priority through early intervention 5
• For bone metastases, treatment should be guided by a multidisciplinary tumor board 3

Monitoring and Follow-up

• Regular assessment of pain control and functional status 4
• Imaging to evaluate progression or resolution of bone abnormalities 4
• Monitoring for complications of treatment, particularly with surgical interventions 3