What is the treatment for nonossifying fibroma?

Treatment of Nonossifying Fibroma

Observation is the primary treatment for nonossifying fibroma, with surgical intervention reserved only for symptomatic lesions, those at high risk for pathological fracture (>50% cortical involvement), or lesions causing functional impairment.

Initial Management Strategy

Most nonossifying fibromas require no treatment and will spontaneously resolve with skeletal maturity. 1 The natural history of NOF is benign, with gradual ossification and disappearance as the child ages. 1

Observation Protocol

For asymptomatic NOF discovered incidentally:

• Serial radiographic monitoring every 3-6 months initially, then annually until skeletal maturity 2
• No activity restrictions are needed for small lesions (<50% cortical involvement) 2
• Patient and family education about the benign nature and expected spontaneous resolution 1

Indications for Surgical Intervention

Surgery should be considered when:

• Lesions involve >50% of bone diameter (high fracture risk) 3
• Symptomatic lesions causing persistent pain that limits daily activities or sports 4, 2
• Pathological fracture has occurred 5
• Large, aggressive-appearing lesions (>5 cm) in weight-bearing bones 4, 2
• Lesions showing progressive expansion on serial imaging 4

Surgical Treatment Approach

Standard Technique

The gold standard surgical treatment is curettage with bone grafting: 3, 4, 2

• Intralesional curettage of the fibrous tissue 2
• Chemical cauterization of bone walls (does not interfere with graft integration) 2
• Bone grafting options include:
  • Calcium sulfate pellets (safe, cheap, convenient alternative to autograft with excellent incorporation) 2
  • Autologous bone graft 4
  • Allograft bone 4

Special Circumstances

For challenging locations (femoral neck, subtrochanteric region) or failed previous surgery:

• Curettage followed by vascularized fibular graft provides structural support 3
• Internal fixation with locking plates may be necessary for pathological fractures in proximal femur 5

For large lesions with significant bone loss:

• External fixation may be required in addition to curettage and grafting 4

Internal Fixation Considerations

• Most cases do not require internal fixation after curettage and grafting 2
• Fixation is reserved for pathological fractures or lesions with severe cortical thinning 5

Expected Outcomes

Surgical treatment yields excellent results with:

• Complete graft incorporation typically achieved within 2 years 2
• Full return to sports and daily activities 2
• No growth disturbances or deformities when properly managed 2
• Very low recurrence rates after adequate curettage 4, 2

Critical Pitfalls to Avoid

• Do not perform prophylactic surgery on small, asymptomatic lesions - these will resolve spontaneously 1
• Do not miss the 50% cortical involvement threshold - this significantly increases fracture risk and warrants prophylactic treatment 3
• Do not confuse NOF with fibrous cortical defect - the latter is smaller and almost never requires treatment 1
• Consider Jaffe-Campanacci syndrome in patients with multiple NOFs - these patients have systemic findings and require different management 1
• Ensure adequate curettage of all fibrous tissue - incomplete removal may lead to recurrence 4