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.     

Effect of rofecoxib on pain caused by osteoid osteoma

In a prospective study, nine patients with osteoid osteoma were treated with a selective cyclooxygenase-2 inhibitor (rofecoxib). Patient pain perception with no treatment, with conventional nonsteroidal anti-inflammatory drug (NSAID) treatment, and with rofecoxib therapy was compared using a visual analog scale. Tumor response was also monitored by radiographs, computed tomography, and bone scintigraphy. In all cases, pain diminished on administration of rofecoxiib in comparison to conventional NSAIDs (P < .05). Four patients underwent surgery whereas in the remaining five patients, bone scintigraphy showed reduced uptake after 6 months. In four patients who were retested at 12 months,scintigraphy values were normal. These four patients are currently asymptomatic and are not receiving any treatment, whereas the fifth patient is still receiving therapy.     

Chronic persistent knee pain after repeated diagnostic arthroscopy: osteoid osteoma, a primarily overlooked diagnosis in a young woman

We report a case of osteoid osteoma of the distal femur in an adolescent female patient that was primarily overlooked and led to repeated diagnostic arthroscopy of the knee. A thorough history and physical examination of the joint as well as adequate roentgenographic studies could have spared this patient two unnecessary arthroscopies and indicated the correct therapy. Received: 20 February 1997     

Painful and tender toe,osteoid osteoma of the distal phalanx of toe,a diagnostic dilemma

Osteoid osteoma rarely involves the phalanges of the toes. Basically osteoid osteoma is often a diagnostic dilemma in musculoskeletal practice especially in the foot and ankle. Its presentation is confusing and this may result in delayed diagnosis. We have reported a case of osteoid osteoma of the distal phalanx of the second toe which was treated successfully with surgical excision and reviewed the literature.     

Intra- and juxta-articular osteoid osteoma: a diagnostic challenge

Osteoid osteoma is a benign tumour in young adults. The clinical manifestations are generally typical nocturnal pain that prevents sleep and that is alleviated with aspirin. When the typical clinical and radiological features are present, diagnosis is not difficult. Problems in the differential diagnosis may arise in connection with an unusual location. We report on the clinical features, radiographic and histopathological findings, treatment, and results of four patients who were managed for an intra- or juxta-articular osteoid osteoma at our medical centre between 2000 and 2002 and in whom the initial diagnosis was erroneous and delayed from 1 to 10 years. In order to remove these lesions, we performed a CT-guided en block retrograde resection under arthroscopic control for juxta-articular osteoid osteomas (knee) and an arthroscopy-assisted en block antegrade resection in two cases of intra-articular osteoid osteoma (elbow and shoulder). None of the osteoid osteomas recurred in the follow-up period, and each patient got relief from pain.     

Interesting clinical presentation of anterior knee pain causing diagnostic dilemma

A diverse variety of lesions may occasionally occur in the patella. In this case report, we are presenting an interesting case of anterior knee pain in middle aged gentleman. Initial investigations including Magnetic Resonance Imaging not showed any abnormality. Due to prolonged continued pain he had bone scan and MRI, which confirmed the diagnosis of Brodie’s abscess. We are presenting this case of Brodie’s abscess of the patella causing diagnostic dilemma because of its rarity.     

Arthroscopic excision of an intra-articular osteoid osteoma at the knee

Osteoid osteoma at the knee is a rare condition. The literature is reviewed, and a patient is reported in whom a lesion communicating with the knee joint was removed arthroscopically. The diagnosis was made histologically and review of the radiographs revealed the lesion.     

Intra-articular osteoid osteoma of the lower extremity: diagnostic problems

We report five cases of intra-articular osteoid osteoma. Physical findings of osteoid osteoma vary with the site of the tumor. Juxta- and intra-articular osteoid osteomas present various atypical and nonspecific features. They are recorded both for their rarity and for the unusual clinical and roentgenographic findings that may delay diagnosis or induce misdiagnosis. Specialized imaging techniques may hasten diagnosis, but only an accurate clinical history, with a high index of suspicion, can allow for a proper diagnosis. When the diagnosis is suspected, we suggest that the most sensitive test is a "three-phase" technetium-99m bone-scan followed by computerized tomographic-scanning. Detailed evaluation of the suspected area, using thin sections is required to prevent misinterpretation, especially in a diagnosis involving first sprain of an ankle. The following cases of intra-articular osteoid osteoma illustrate the problems encountered in their diagnosis.     

Cyclooxygenase-2 inhibitor for pain management in osteoid osteoma.

Thirteen patients with osteoid osteoma were enrolled in a prospective trial to test whether rofecoxib, a selective cyclooxygenase-2 inhibitor, is as effective for pain control as acetylsalicylic acid. Each patient documented the pain level using a visual analog scale, with 0 being no pain and 10 being unbearable pain, during 2 days of no pain medication, 4 days of 500 mg acetylsalicylic acid three times a day, and 10 days of 25 mg rofecoxib once a day. Oral administration of 500 mg acetylsalicylic acid three times a day led to a significant decrease in pain at night, pain at rest, and pain induced by exercise. Twenty-five milligrams rofecoxib given once a day at midday showed the same remarkable improvement in pain at night, pain at rest, and pain induced by exercise. Rofecoxib in comparison with acetylsalicylic acid showed a trend toward lower pain levels in all categories. Rofecoxib offered a significantly better reduction in pain at rest during the day than did acetylsalicylic acid. Results of the current study suggest that pain induction in osteoid osteoma is related to cyclooxygenase-2, an enzyme that is blocked by acetylsalicylic acid and rofecoxib. Conservative medical treatment with rofecoxib for osteoid osteoma is recommended when percutaneous intervention is associated with significant morbidity.     

Intra-articular osteoid osteoma of the knee: clinical and therapeutical particularities

The intra-articular osteoid osteoma (10-13% of the cases) is often difficult to identify. They present frequent atypical clinical signs and radiological images that eventually lead to inadequate treatment. For example, it has been observed that this pathology leads to inappropriate arthroscopies (up to 40%). Meniscal tear and then osteochondritis were initially suspected on a patient with an intra-articular osteoid osteoma at the tibia level. For the treatment, any damage of the cartilage has to be avoided. Thermoablation with radiofrequency is the treatment of choice.     

Subtalar arthralgia caused by juxtaarticular osteoid osteoma

Juxtaarticular osteoid osteomas in the ankle are frequently misdiagnosed because their symptoms mimic arthritis and may precede roentgenographic findings. In addition, these tumors are rare compared to arthritis and other sources of ankle pain. Four cases of osteoid osteoma of the talus or calcaneus are reported, indicating some of the problems encountered with their identification, and suggestions are made for appropriate investigations to aid in the early and correct diagnosis. The use of plain tomograms, thin-section computed tomograms, and radionuclide scans aid an early and correct diagnosis. Arthroscopy and arthrotomy are often inappropriate.     

Limited posterolateral surgical approach to the knee for excision of osteoid osteoma

An 18-year-old man suffered four years of undiagnosed knee pain until a CAT scan revealed an epiphyseal osteoid osteoma of the tibia located subchondrally, just medial to the proximal tibiofibular joint. A nidus in this location is not easily accessible, and its proximity to the joint surface raised concerns about damage to the tibial plateau. To facilitate excision of the tumor, cadaveric dissections were performed to develop a limited posterior approach to the proximal, lateral portion of the tibia. The CAT scan was used to calculate the precise dimensions of the tumor and its relation to the posterior tibial cortex and the proximal tibiofibular joint. With the use of the exposure developed in the laboratory and the calculations derived from the CAT scan, the tumor could be excised by removing a single block of bone 15 mm3. Intraoperative radiographs confirmed the presence of the nidus within the excised block of bone. This case report reaffirms the frequent difficulties and tardiness in diagnosing osteoid osteomas and the need to include these tumors in the differential diagnosis of knee pain and epiphyseal lesions. Before CAT scans were used, the working diagnoses were torn meniscus, juvenile rheumatoid arthritis, and bone hemangiomatosis.     

Post traumatic osteoid osteoma in the talar neck: A diagnostic challenge

We report a case of juxta-articular osteoid osteoma of the talus that defied diagnosis for 2 years. The patient had a history of trauma to her left ankle, which was treated as a chronically painful sprained ankle without resolution of symptoms. The patient had complete symptomatic relief after resection of the tumour and repair of the lateral ligamentous complex. A high index of suspicion and appropriate imaging studies are important in making an early diagnosis.     

Unusual knee swelling: a diagnostic dilemma

Haemangioma is a common benign soft tissue tumour. Intramuscular haemangiomas are rare but pose quite a diagnostic challenge. An intramuscular haemangioma can be confused with other soft tissue swellings including abscess. We present a case report of swelling around the knee in an adolescent patient, which was ultimately diagnosed and treated as intramuscular haemangioma of the quadriceps muscle.     

Open resection of osteoid osteoma guided by a gamma-probe

Osteoid osteoma is the third most common type of bone tumour. Radiofrequency ablation and other percutaneous procedures are the treatment of choice. However, in some sites these methods are difficult or dangerous. Our objective of this study was to evaluate whether open resection and intraoperative nidus detection with a hand-held gamma probe is an efficient method for treating this type of tumour. Fifty-three patients with osteoid osteomas were submitted to surgical treatment. The first group (gamma group) consisted of 34 patients submitted to open nidus resection guided by a hand-held gamma probe. The control group consisted of 19 patients operated on by conventional technique. In the postoperative period, histopathology, imaging studies, and clinical outcome were evaluated. The gamma group patients were followed up for an average 26.2 months; the control group patients were followed up for an average 38 months. There was no difference with regard to pain relief and histopathology findings between the two groups. However, in the postoperative imaging studies, there was significantly less nidus present in the gamma group (p = 0.01).The gamma probe helped to locate the osteoid osteoma nidus more precisely, as demonstrated by the postoperative imaging studies.     

A pathologic fracture of an intracortical chondroma masking as an osteoid osteoma

The differential diagnosis of a tibial intracortical diaphyseal lesion includes osteoid osteoma, periosteal chondroma, nonossifying fibroma, osteofibrous dysplasia, and adamantinoma. While osteoid osteomas represent 5% of all primary bone tumors, little is understood about intracortical chondromas. Intracortical chondroma was first described in 1990 and 7 reported cases have since been published. This article presents the first reported case of a pathologic fracture of an intracortical lesion in a child that shared radiographic and clinical features similar to those of osteoid osteoma, but on histopathologic examination revealed an intracortical chondroma. Our patient exhibited radiographic features of a poorly circumscribed cortical bone sclerosis, a centralized radiolucent nidus on computed tomography, and a hot bone scan of a lesion <1 cm in size that was consistent with an osteoid osteoma. An excision of the bone lesion was performed. The histopathology of the lesion revealed nodules of benign hyaline cartilage in cortical bone, consistent with an intracortical chondroma. Demarcated by cortical bone with mature Haversian systems rather than periosteum or cancellous bone, intracortical chondroma differs from the other 2 chondroma variants, periosteal chondroma and enchondroma, by its relationship to the surrounding bone. Enchondromas are characteristically understood to be asymptomatic. Intracortical chondromas along with periosteal chondromas have been found to present as painful lesions. The similarities with osteoid osteoma and intracortical chondroma in our patient make it circumspect in regards to ablating lesions (ie, needle radiofrequency ablation) without acquiring a biopsy in pediatric patients that both clinically and radiographically are presumably an osteoid osteoma.