Osteoidosteom

Background

In recent years, osteoid osteomas have been treated more frequently by means of percutaneous procedures. The main disadvantage in patients with suspected osteoid osteoma is the lack of histological verification. Our study presents the results that we obtained using a minimally invasive diamond bone-cutting system allowing histologic verification.

Materials and methods

Six patients (age 10–20 years) with osteoid osteoma in the lower extremities were subjected to resection of the nidus using a minimally invasive water-cooled diamond bone-cutting system. All specimens were histologically processed and diagnosed.

Results

In all patients the nidus was resected successfully, and the diagnosis was histologically confirmed. The mean operating time was 22.8 min. All patients were allowed full weight-bearing immediately, and hospitalization was a maximum of 2 days. All patients were free of pain and relapse-free during the entire 2-year postoperative follow-up.

Conclusion

In selected localizations with a clearly visible nidus, the minimally invasive diamond bone-cutting system presented here offers an alternative to the established surgical and percutaneous procedures for treating osteoid osteomas. This procedure combines the advantages of a minimally invasive technique with the option of histological verification of the diagnosis and correct nidus ablation.     

Osteoidosteom

Background

The CT-guided therapy of osteoid osteoma instead of older methods such as open resection has the advantage of exact localization of the nidus intraoperatively and exact documentation of its ablation. Another advantage is the less invasive approach.

Patients and methods

A total of 52 patients with osteoid osteoma were treated in our institution between 1996 and 2005 either by radiofrequency ablation (n=11) or by percutaneous resection under CT guidance (n=41). Their age was between 7 and 48 years, mean age was 22.3 years, and follow-up was 31.3 months.

Results

In all patients (n=52) the osteoid osteoma was successfully treated. In 50 patients the first treatment resulted in long-term success. In two patients the nidus was first missed; they were successfully treated with another operation using the same technique.

Conclusion

The CT-guided operation of osteoid osteoma made the therapy much easier because of the exact localization and the less invasive approach. This technique can be used analogously to tumor biopsy. The advantage is the exact documentation of the biopsy path and the possibility to take specimens.     

A comparison of percutaneous trephine excision and open surgery in the treatment of osteoid osteoma

Purpose

The aim of this study was to compare CT-assisted percutaneous excision, which is a closed, economic method and a more cosmetic approach, and open surgery in the treatment of osteoid osteoma.

Materials and methods

Fifty-three patients (12 female and 41 male patients) who had percutaneous excision (n?=?24) and open surgery (n?=?29) were evaluated retrospectively. The mean age was 16.6 years and the mean duration of follow-up was 53.5 months. During percutaneous excision, a trephine was advanced through the labeling wire and the site, including the nidus, was excised en-bloc and the incision walls were curetted. During the open surgery, the localization of the nidus was marked using c-arm X-ray and the nidus was accessed by lifting the cortical bone, layer-by-layer, using burr. The nidus was excised and its cavity curetted.

Results

The result was successful in 22 and a failure in three patients who had closed excision. The result was successful in 20 and a failure in nine patients who had open surgery. The mean duration of operation was 44.37 minutes in the percutaneous excision group and 80.6 minutes in the open surgery group. There was no difference in the pre-operative VAS values between the two groups, whereas the post-operative VAS values were statistically significantly different. There was also a statistically significant difference in the duration of the operation and the length of the hospital stay between the groups.

Conclusion

Percutaneous excision with trephine is a more successful, effective, minimally invasive, safe and a better cosmetic approach in the treatment of osteoid osteoma. This method is also a cheap method that does not require expensive equipment.

     

Percutaneous computed tomography-guided resection of non-spinal osteoid osteomas in 54 patients and review of the literature

Background

Osteoid osteoma is a benign osteoblastic tumor with a nidus of <20 mm in maximum diameter. There are several treatment options, all of them aiming either to resect or to eliminate the nidus.

Purpose

To report and to describe the benefits of treating non-spinal osteoid osteoma by percutaneous computed tomography-guided resection, according to our experience.

Study design

Retrospective case series

Methods

Between 1992 and 2008, 54 patients with non-spinal osteoid osteoma underwent primary treatment with percutaneous CT-guided resection. In all cases, the materials obtained were processed for pathology and microbiology.

Results

Fifty-four patients with a mean age of 22.7 years (range 10–47), of whom 46 were males (85.2 %) and 8 were females (14.8 %). The lesion size ranged between 5 and 15 mm with an average size of 6.9 mm. The resection was considered complete by the CT study in all 54 cases. Of all the specimens sent to pathology, the histological diagnosis was achieved in 41 (75.9 %). Cure was obtained in 50 patients (92.6 %) and the other four patients required a second surgery using the same technique, after which all of them achieved clinical and radiological improvement (100 %).

Conclusion

Percutaneous computed tomography-guided resection of non-spinal osteoid osteomas provides good results, similar to other surgical techniques, with the advantages of being a simple, mini invasive, safe and economic procedure without the need for specific materials. Level of evidence, IV.     

Computer-Assisted Navigation Full Visualization Spinal Endoscopic Surgery for Lumbar Vertebral Osteoid Osteoma

Background

Osteoid osteoma is a benign osteogenic tumor that occurs mostly in the femoral stem, while osteoid osteoma occurring in the lumbar vertebral body is a relatively rare case. To minimize treatment-related complications, a computer-assisted navigation fully visualized spinal endoscopy was used. Ultimately, the pathology was diagnosed as osteoid osteoma.

Case Presentation

We report a 19-year-old adult male with low back pain that worsened at night and CT, MRI imaging showed an abnormal signal shadow at the posterior margin of the lumbar vertebral body. Due to the proximity of the lesion to the spinal canal and adjacent to the nerve roots, it was difficult to precisely localize the lesion by purely endoscopic or open procedures, and if necessary, the resection of surrounding tissues had to be expanded, causing unnecessary damage to the surrounding tissues. Therefore, we choose computer-assisted navigation fully visualized spinal endoscopy to perform the treatment.

Conclusion

In this case, we report an osteoid osteoma that occurs less frequently in the lumbar vertebral body. Using computer-assisted navigation with fully visualized spinal endoscopy, we successfully resected the osteoid osteoma at the posterior margin of the L3 vertebral body preoperatively by computer-planned path with intraoperative visualization endoscopy, minimizing the damage to spinal stability. Computer-assisted navigation with visualization endoscopy provides a more precise and minimally invasive approach to the treatment of osteoid osteoma of the spine.     

Die CT-gesteuerte Entfernung eines Osteoidosteoms im Schenkelhals

Objective Removal of the nidus of an osteoid osteoma through a minimally invasive procedure to eliminate pain and to restore function. Histologic examination of biopsy material. Indications Osteoid osteomas irrespective of localization as long as they can be directly reached percutaneously. Contraindications Nerves, vessels or other important structures precluding a direct percutaneous approach. Sugical Technique Placement of guide wire in soft tissues. CT check. Stab incision. Insertion of threaded Kirschner wire into bone 1 cm paallel to the projected approach. Advancement of Kirschner wire mounted on a drill under CT control up to the nidus. Insertion of a cannulated drill bit over the Kirschner wire and drilling of cortex and subcortical bone. A special trephine mounted on a hand-held Jacob's chuck is advanced into the nidus under CT control. Removal of the Kirschner wire and change for a drilling system with extraction forceps. Overdrilling of the nidus. Advancement of extraction forceps and extraction of nidus. If needed, removal of remaining material with curette or rongeur. Final CT check. Results Between March 9, 1998 and January 25, 2000 we operated five women and twelve men, average age 22 (16–57) years. Femoral neck, tibia and femur were mostly involved. All patients were pain-free and without limitation of function immediately after surgery and at time of follow-up done at an average of 8.4 (1–22) months. No important complications. Through a technical error the nidus was lost in the soft tissues together with the extraction device. Only the metal part could be retrieved, subsequent encapsulation of the nidus in the soft tissues without causing symptoms. A superficial wound healing disturbance was noted in another patient.     

Robotic-assisted minimally invasive vs. thoracoscopic lung lobectomy: comparison of perioperative results in a learning curve setting

Purpose

Minimally invasive lung lobectomy was introduced in the late 1990s. Since that time, various different approaches have been described. At our institution, two different minimally invasive approaches, a robotic and a conventional thoracoscopic one, were performed for pulmonary lobectomies. This study compares perioperative outcome of the two different techniques in a learning curve setting.

Methods

Between 2001 and 2008, 26 patients underwent lung lobectomy with a robotic-assisted thoracoscopic surgery (RATS) technique. In 2009, the minimally invasive approach was changed to a conventional video-assisted thoracoscopic surgery (VATS) technique. Perioperative results of the first 26 VATS patients were compared to the results of the robotic group.

Results

There were significantly more patients with clinical stage >IB in the VATS group than in the robotic-assisted group (23.1 vs. 0 %). Otherwise, demographic data were equal between the groups. Operative time was significantly longer in the robotic group (215 vs. 183 min, p?=?0.0362). Median difference between preoperative hemoglobin levels and levels on postoperative day 1 was higher in the RATS group, suggesting a higher blood loss. No difference was found in conversion rate, acute phase protein levels (C-reactive protein), chest drain duration, postoperative morbidity and mortality, and length of hospital stay. Procedural costs were higher for the robotic approach (difference, 770.55?€, i.e., 44.4 %).

Conclusions

Shorter operative times, a lower drop of postoperative hemoglobin levels indicating less blood loss, and lower procedural costs suggest a benefit of the VATS approach over the robotic approach for minimally invasive lung lobectomy.     

Osteoid osteoma of the shoulder and elbow: from diagnosis to minimally invasive removal

Purpose

Musculoskeletal tumours are rare in the daily practice of an orthopaedic surgeon or even a shoulder and elbow specialist. Patient complaints are often related to secondary changes to the underlying disease making the correct diagnosis challenging. The goal of this study is to identify key symptoms and findings which should give rise to suspicion of an osteoid osteoma.

Methods

This retrospective study analyses the diagnostic pathway, surgical treatment and clinical outcome of six patients who underwent resection of an osteoid osteoma of the shoulder or elbow joint.

Results

Average follow-up was 24 months (range 16–36 months). The neoplasm was often associated with synovitis mimicking a frozen joint causing marked delay in tumour identification. Misdiagnosis led to surgery without addressing the tumour in two cases, making further surgical intervention necessary. Once the tumour was identified and removed the pain resolved rapidly.

Conclusions

In cases of chronic shoulder or elbow pain without an adequate clinical history an underlying cause including rarities such as an osteoid osteoma or other musculoskeletal tumours should be taken into consideration. Particularly in young patients, a magnetic resonance imaging (MRI)-proven hot spot of unknown origin should prompt a computed tomography examination to further clarify the source of pain and stiffness.

Level of evidence

IV, case series     

Atypical location of an osteoid osteoma with atypical anterior knee pain

INTRODUCTION

An osteoid osteoma is a painful tumor that most commonly affects the extra-articular parts of the long bones. An intra-articular location of an osteoid osteoma is rare. Various differential diagnoses may arise in connection with such an unusual location because it causes atypical clinical signs.

PRESENTATION OF CASE

A 24-year-old male developed pain in the central region of the right knee. Magnetic resonance imaging (MRI) showed no clear pathology in the knee joint. A technetium bone scan and computed tomography (CT) were then ordered and confirmed the presence of an osteoid osteoma in the knee joint. The patient was treated through an anteromedial approach to the knee, and the lesion was removed by excisional biopsy under fluoroscopy.

DISCUSSION

The diagnosis of intra-articular osteoid osteoma is challenging because the clinical presentation can be misleading. MRI is often requested as the first imaging method when dealing with knee symptoms, and radiologists are often unaware of the clinical presentation. Edema seen on MRI can be misleading with respect to the location of the nidus. CT is considered to be the best imaging method because it usually allows for clear visualization of the nidus. Different treatments have been proposed, ranging from open excision to arthroscopic resection.

CONCLUSION

Osteoid osteoma should be considered in young adult patients with chronic knee pain and no history of trauma.     

Laparoscopic radical cholecystectomy and Roux-en-Y choledochojejunostomy for gallbladder cancer

Background

Although laparoscopic cholecystectomy was one of the first laparoscopic procedures, gallbladder cancer has been one of the last malignancies tackled with minimally invasive techniques. This video reviews the minimally invasive approaches to preoperatively suspected gallbladder cancer.

Methods

Like the standard laparoscopic cholecystectomy, the minimally invasive procedure is performed with four trocars. The surgeon operates with the patient in the French position. A totally laparoscopic radical cholecystectomy including wedge resections of segments IVB and V is undertaken with hepatoduodenal lymphadenectomy and common bile duct excision. The biliary system is reconstructed via a laparoscopic choledochojejunostomy.

Results

Six patients have undergone laparoscopic radical cholecystectomy. Three of these patients were found to have gallbladder cancer according to the final pathology. All the final surgical margins were negative, and the average lymph node retrieval was 3 (range, 1–6).

Conclusion

The minimally invasive approach to gallbladder cancer is feasible and safe. It should currently be performed in high-volume centers with expertise in both hepatobiliary and minimally invasive surgery. Larger trials are needed to determine whether either the open or laparoscopic approach offers any advantage.     

Importance of preoperative imaging with 64-row three-dimensional multidetector computed tomography for safer video-assisted thoracic surgery in lung cancer

Purpose

Video-assisted thoracic surgery (VATS) has recently been adopted for complicated anatomical lung resections. During these thoracoscopic procedures, surgeons view the operative field on a two-dimensional (2-D) video monitor and cannot palpate the organ directly, thus frequently encountering anatomical difficulties. This study aimed to estimate the usefulness of preoperative three-dimensional (3-D) imaging of thoracic organs.

Methods

We compared the preoperative 64-row three-dimensional multidetector computed tomography (3DMDCT) findings of lung cancer-affected thoracic organs to the operative findings.

Results

In comparison to the operative findings, the branches of pulmonary arteries, veins, and bronchi were well defined in the 3D-MDCT images of 27 patients.

Conclusion

3D-MDCT imaging is useful for preoperatively understanding the individual thoracic anatomy in lung cancer surgery. This modality can therefore contribute to safer anatomical pulmonary operations, especially in VATS.     

Local treatment of pulmonary metastases: from open resection to minimally invasive approach? Less morbidity, comparable local control

Background

The level of evidence for efficacy of local treatment of pulmonary metastases is low; therefore, complication rates should be minimized. Minimally invasive techniques may have the potential to reduce morbidity but potentially lead to more local and/or ipsilateral recurrences. The objective of this study was to evaluate the introduction of a new treatment strategy incorporating the increased use of video-assisted thoracic surgery (VATS) and radiofrequency ablation (RFA), weighing complications against recurrence rates.

Methods

We retrospectively reviewed results of all local treatment of pulmonary metastases in the Netherlands Cancer Institute from 2002 to 2007. Each of 158 identified interventions was analyzed separately to retrieve procedure-related data. Overall survival data were analyzed per patient. To evaluate the introduction of a strategy incorporating minimally invasive techniques, the study period was split in two (before and after the introduction of this strategy in July 2004).

Results

In Strategy I, 47 interventions (2 VATS, no RFA) were performed in 37 patients; in Strategy II 111 interventions (51 VATS and RFA) in 86 patients. Metastases of a variety of primary tumors were treated. Median hospital stay was shorter (5 vs. 7 days) and procedure-related morbidity was less with Strategy II (p < 0.01). Time-to-recurrence rates were comparable (p = 0.18), as were local and ipsilateral recurrence rates within 3 years (p = 0.72). Estimated overall 3-year survival was 59% for patients treated with Strategy I and 54% with Strategy II.

Conclusions

Increased use of minimally invasive techniques for local treatment of pulmonary metastatic disease is associated with low morbidity, without apparent reduction in (local) disease control.     

Oblique paraspinal approach for thoracic disc herniations using tubular retractor with robotic holder: a technical note

Introduction

Symptomatic thoracic disc herniations (TDHs) are uncommon and can be surgically treated. Although transthoracic decompression is considered the gold standard, it is associated with significant comorbidities. In particular, approach via a posterior laminectomy has been associated with poor results. Several strategies have been developed for the resection of TDHs without manipulating the spinal cord. We describe a minimally invasive technique by using 3-D navigation and tubular retractors with the aid of a robotic holder via an oblique paraspinal approach.

Materials and Methods

The 20-mm working tube via an oblique trajectory through the fascia provides a good surgical field for thoracic discectomy through a microscope. We present our first five patients with TDHs operated using this minimally invasive approach.

Results

Neurological symptoms were improved postoperatively, and there were no surgical complications. There was no instability or recurrence during the follow-up period.

Conclusion

The oblique paraspinal approach may offer an alternative surgical option for treating TDHs.     

Minimally invasive hip surgery: the approach did not make the difference

Background

We hypothesized that minimally invasive surgery was superior to conventional surgery for total hip arthroplasty procedure.

Purpose

To compare the results of total hip replacement (THR) made by minimally invasive lateral approach with the results of THR made by conventional lateral approach.

Materials and methods

Prospective, randomized trial. Fifty patients were selected and then divided into two groups based on utilized approach.

Data collected

Perioperative bleeding, postoperative pain, time of recovery, components orientation, complications and functional results. Five-year follow-up.

Results

No differences were found in blood loss, postoperative pain, surgical time, components orientation, rate of complications or functional result. Minimally invasive lateral approach produced faster recovery with less hospital stay and earlier walking start.

Conclusion

Our results suggested that minimally invasive lateral approach has not provided significant benefits over conventional lateral approach for the implantation of a total hip arthroplasty.     

Extreme Lateral Interbody Fusion (XLIF) in the Thoracic and Thoracolumbar Spine: Technical Report and Early Outcomes

Background

Previous studies have demonstrated the distinct advantages of thoracoscopically assisted spinal fusion compared to traditional open thoracotomy. However, these techniques are limited by a steep learning curve, prolonged operative time, and lack of three-dimensional visualization of the surgical field.

Objective

The objective of this study was to describe our initial experience with an adaptation of the extreme lateral interbody fusion (XLIF) technique allowing access to the anterior aspect of the thoracic and thoracolumbar spine with specific reference to (1) early pulmonary complications, (2) non-pulmonary complications, and (3) ability of this technique to successfully achieve spinal decompression and fusion at the operative level.

Methods

Clinical and radiographic data were reviewed for the entire perioperative period. A total of 18 patients (72% females; mean age, 56.8 years) underwent a thoracic XLIF procedure for spinal pathologies including disc herniation, fracture, tumor, pseudoarthrosis, and proximal junctional kyphosis. A total of 32 levels were treated, with the majority located at the thoracolumbar junction. Twelve of the procedures were done as part of a combined anterior/posterior surgery.

Results

The mean estimated blood loss was 577 ml and the mean length of stay was 12 days. At a mean follow-up of 14 months, all patients except for one (who died of widely metastatic disease) had achieved radiographic evidence of fusion. Two patients developed pulmonary effusions requiring medical intervention. Six patients had seven non-pulmonary complications: incidental durotomy (two), infection (one), instrumentation pullout (one), cardiac arrhythmia (two), and death from metastatic disease (one).

Conclusions

The XLIF technique can be utilized for access to the anterior column of the thoracic and thoracolumbar spine. The advantages of this minimally invasive technique include avoidance of the need for an access surgeon and for lung deflation during surgery as well as excellent visualization of the spinal pathology.     

Percutaneous CT-guided radio-frequency ablation of osteoid osteoma of the foot and ankle

Introduction

Percutaneous radiofrequency ablation (RFA) has been considered, in recent years, the standard treatment for osteoid osteoma (OO) of the appendicular skeleton. The variable clinical presentations in the foot and ankle pose problems in diagnosis, localization and thus treatment. The aim of this study was to assess the efficacy of RFA for patients with osteoid osteoma of the foot and ankle.

Materials and methods

A total of 29 patients (22 males, 7 females; mean age 16.7?years; range 8?C44?years) with OO of the foot and ankle (distal tibia, n?=?17; distal fibula, n?=?6; talus, n?=?3; calcaneus, n?=?3) were enrolled in the study. A CT-guided RFA was performed, using a cool-tip electrode without the cooling system, heating the lesion up to 90?°C for 4?C5?min. Clinical success, assessed at a minimum follow-up of 1?year, was defined as complete or partial pain relief after RFA. Pain and clinical outcomes were scored pre-operatively and at the follow-up with a visual analogue scale (VAS) and with the American Orthopaedic Foot and Ankle Society (AOFAS) score. Complications and local recurrences were also recorded.

Results

Clinical success was achieved in 26 patients (89.6?%). After RFA, mean VAS and AOFAS score significantly improved from 8?±?1 to 2?±?1 (p?<?0.05) and from 60.7?±?12.7 to 89.6?±?7.1 (p?<?0.05), respectively. Two patients experienced partial relief of pain and underwent a second successful ablation. Local recurrences were found in three patients, always associated with pain. These underwent conventional excision through open surgery. No early or late complications were detected after RFA.

Conclusion

CT-guided RFA of foot and ankle osteoid osteoma is a safe and effective procedure, showing similar results for the rest of the appendicular skeleton.