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Surgical management and recurrence risk in bizarre parosteal osteochondromatous proliferation: a systematic review and pooled observational analysis
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DOI：10.1186/s40001-026-04978-6.png)
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Abstract
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Bizarre parosteal osteochondromatous proliferation (BPOP), or Nora’s lesion, is a rare, benign, surface-based bone lesion. While cortical preservation is a traditional diagnostic hallmark, recent evidence suggests cortical erosion may occur, potentially leading to diagnostic confusion with malignancy. We conducted a systematic review and pooled observational analysis of 323 cases (322 from 74 published studies plus one illustrative institutional index case) following PRISMA 2020 guidelines. Methodological quality and risk of bias were formally appraised for all 74 included studies using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. Using a random-effects model with the Hartung–Knapp–Sidik–Jonkman (HKSJ) adjustment, we compared local recurrence rates between simple excision (n = 200) and en-bloc resection with adjuvant high-speed burr curettage (n = 123). BPOP exhibited local aggressiveness, with an overall recurrence rate of 43.3% in this pooled cohort. Cortical erosion was identified in a subset of cases ($$14.5\%$$), mimicking features of osteosarcoma or parosteal osteosarcoma. Pooled analysis suggested that simple excision is associated with a higher risk of recurrence compared to en-bloc resection with an adjuvant high-speed burr (OR: 8.39; 95% CI 5.60–12.55; $$P<0.01$$). Statistical heterogeneity was low ($${I}^{2}=0\%$$). Quality appraisal indicated that while the evidence base is primarily retrospective, it maintains high diagnostic and outcome-reporting standards. This pooled observational analysis suggests a significant reduction in recurrence risk associated with en-bloc resection and high-speed burr adjuvant therapy. Furthermore, the presence of cortical erosion should not reflexively trigger a diagnosis of malignancy. These findings support consideration of a refined diagnostic–surgical approach emphasizing marginal resection with cortical burring to minimize recurrence while optimizing functional outcomes.
Keywords:
Bizarre parosteal osteochondromatous proliferation
Nora’s lesion
Cortical erosion
Systematic review and pooled analysis
Surgical recurrence
High-speed burr curettage
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