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.     

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 extra-articular osteoid osteoma of the calcaneus following military training

Osteoid osteoma is a benign bone tumor that causes localized pain that typically increases during the night and is relieved by NSAIDs [1]. It most commonly occurs in the femur and tibia. Only 8% of osteoid osteoma is found in the foot [2]. For that reason, if osteoid osteoma develops in the foot, there may be a delay in diagnosis as it often mimics other, more frequent pathologies. Moreover, if the patient has a history of injury, the initial diagnosis of osteoid ostoema is even more difficult to make [3] as it is natural for the physician to attribute the symptoms to the trauma.     

Osteoid osteoma of the carpal bones

Osteoid osteoma is a benign bone tumor that rarely localizes in the hand or the carpal bones. We report two cases of osteoid osteoma localized in two different carpal bones. Unremitting wrist pain was a major clinical symptom. Surgical treatment including excision of the nidus was dramatically curative. In young patients, osteoid osteoma should be considered in the differential diagnosis of chronic wrist pain. Received: 21 May 1999     

The diagnostic dilemma created by osteoid osteoma that presents as knee pain

Purpose: Osteoid osteoma is a rare benign bone lesion with a high incidence in adolescents and young people. The objective of our study was to illustrate the difficulties in diagnosis of osteoid osteoma in patients presenting with atypical knee pain. Type of Study: Retrospective case series. Methods: In 10 patients who presented to our department with atypical knee pain between 1984 and 1999, the diagnosis of an osteoid osteoma was delayed. Retrospective review of these 10 cases was performed using interviews and re-evaluation of medical histories, radiographs, computed tomography (CT) scans, isotope bone scan, and magnetic resonance imaging (MRI). Results: Initial radiographs showed features of osteiod osteoma in only 2 cases. In addition, in 1 case, not only initial but also repeated radiographs of the knee joint were still normal 10 months after the delineation of the nidus using MRI. Four unnecessary arthroscopies were performed on 4 of the 10 patients and the final diagnosis was established using MRI, CT, and isotope bone scan. The mean time interval between arthroscopy and osteiod osteoma diagnosis was 11.5 months. Conclusions: Osteoid osteoma must be included in the differential diagnosis of persistent unexplained knee pain, especially when objective findings of the knee are vague. The presence of the lesion juxta-articular to the knee joint or in the midshaft or upper end of the femur may be referred as pain to a nearby joint. Plain radiographs have a low diagnostic value in the detection of the lesion whereas isotope bone scan and MRI are reliable imaging techniques. The evaluation of the ipsilateral hip joint should not be overlooked.     

Osteoid osteoma

Osteoid osteoma is a relatively frequent benign bone tumour, consisting of osteoid and woven bone, and surrounded by a halo of reactive sclerotic bone, with an average size of the nidus less than 1.5 cm. It is a condition of late childhood, adolescence and young adult age. It usually occurs in the appendicular skeleton and the spine, and is generally localised in or near the cortex. The lesion causes pain, especially at night, but can cause joint pain with synovitis and joint effusion if located in the vicinity of chondral structures, or painful scoliosis if located in the spine. Osteoid osteoma may have an unpredictable course, and may require treatment or resolve spontaneously. In some cases, the diagnostic approach is challenging; there are different treatment methods, some of which have been recently introduced, with promising results. We review the literature about the natural history, clinical presentation, diagnostic approach and classical or modern treatment modalities of osteoid osteoma.     

Osteoid osteoma in the medial malleolus

A case of osteoid osteoma in an unusual location is reported. The osteoma was diagnosed, and the nidus was localized to the anterior colliculus of the medial malleolus based on the clinical symptoms and on the findings in radionuclide bone scanning, tomography, and computerized tomographic (CT) scanning. After precise radiographic localization of the nidus, it was determined that the lesion could be excised surgically without compromising the ankle joint. The tumor was removed by en block excision and curettage. At 10 months follow-up, the patient was free of pain without impairment of function.     

Double localization of osteoid osteoma of the tibia--case report]

Osteoid osteoma is a common, benign lesion of bone. Most patients who have osteoid osteoma have a history of pain in a limb, that is characteristically worse at night and is relieved dramatically by salicylates. There is general agreement in the literature that complete excision is the treatment of choice and that incomplete removal of the nidus leads to recurrence of symptoms. Usually, the affected bone is easily accessible to the surgeon, and it is not difficult to excise the lesion en bloc or, less commonly, to perform cortical shaving and curettage of the cavity of the nidus. The case nine years old boy of double nidus localization of osteoid osteoma of the tibia is presented. No reports on patients who were treated with double nidus localization have been published, to our knowledge.     

Treatment of osteoid osteoma by computed tomography guided excision in the pediatric patient

An osteoid osteoma is a benign lesion that can occur in any bone. Controversy exists regarding treatment of this condition. This study demonstrates that the nidus of an osteoid osteoma can be disrupted and removed by use of the CORB biopsy system guided by computed tomography (CT) scan. Of nine patients followed for an average of 42.5 months (range 18-76 months), seven have had complete resolution of their pain after this procedure. The technique failed in two patients, who each required two separate en bloc excisions with bone grafting to resolve each lesion. CT-directed CORB appears to be useful in localization and removal of the nidus of an osteoid osteoma.     

Radiofrequency ablation for treatment for osteoid osteoma of the scapula using a new three-dimensional fluoroscopic navigation system

Osteoid osteoma is a relatively common benign skeletal tumor. The traditional standard treatment has been surgical resection of the nidus. Recently, computed tomography (CT)-guided radiofrequency ablation (RFA) has gained favor as a more precise alternative due to potentially less bone destruction. However, CT-guided RFA is limited in treatment for osteoid osteoma involving complex anatomic structures such as cervical spine, pelvis, or scapula because of difficulty in approach and proximity to neurovascular structures. To solve this problem, we investigated RFA using a new real-time three-dimensional fluoroscopic navigation system. We report its technical procedure and use in a rare case of osteoid osteoma of the scapula.     

Osteoid osteoma of the great toe

Osteoid osteoma is a relatively common osteoblastic lesion of benign skeletal neoplasms and occurs most commonly in the cortex of long bones, especially the femur and the tibia. Radiological characteristics are a nidus that appears as a small, relatively radiolucent zone within an area of extensive reactive sclerosis. Clinically, the lesion presents with increasing pain, is worse at night, and is relived by nonsteroidal anti-inflammatory drugs (NSAIDs). Osteoid osteomas involving the phalanges of the toes are uncommon, and its accurate preoperative diagnosis is difficult due to the unique clinical and radiological features. The features in the phalanx of the toe are soft tissue swelling and a nidus frequently located in the cancellous without osteosclerosis. This article presents a case of a 22-year-old man with osteoid osteoma in his distal phalanx of the hallux. A needle biopsy of his great toe revealed a small number of bacteria, so he was initially treated for osteomyelitis but with unsatisfactory results. The particular characteristics of clinical and imaging findings supported a diagnosis of osteoid osteoma in the distal phalanx of the hallux. After surgical removal of the tumor, his symptoms resolved. The pathological examination confirmed the suspected diagnosis. In a patient with chronic foot pain that changes to become nocturnal and disappears with NSAID administration, it is important to include osteoid osteoma as a differential diagnosis. A detailed assessment of both clinical and radiological features can lead to the correct diagnosis, which must be confirmed with histopathological examination to ensure adequate excision.     

Intraarticular epiphyseal osteoid osteoma of the distal femur

A 9-year-old boy had pain in the medial side of the right knee with limited range of motion and limping. Roentgenography showed a small sclerotic shadow (8 X 8 mm2) in the medial femoral condyle, where bone scintigraphy revealed a high uptake area and angiography showed a nidus. Five months after initial presentation, en bloc excision was done through the posteromedial approach. Histological examination showed a network of osteoid trabeculae, differentiated osteoblasts, and multinucleated giant cells in this nidus, which were compatible with those of osteoid osteoma. Complete relief of pain was obtained at follow-up 1 year after the operation.     

Removal of osteoid osteoma of the tibia using two-portal posterior ankle arthroscopy

The case of a 30-year-old male with a history of pain in his left ankle is presented. The pain was described as predominantly nocturnal and frequently relieved by the use of nonsteroidal anti-inflammatory drugs. Computed tomography indicated a diagnosis of an osteoid osteoma in the posteromedial portion of the tibia. The patient underwent excision of the tumor using 2-portal posterior ankle arthroscopy. A clearly visualized nidus was removed using a combination of a cochlea and shaver. Histopathologic analysis of the resected tissue confirmed the diagnosis of an osteoid osteoma. The patient reported immediate relief of the pain and was rapidly allowed to bear weight on the foot. During regular follow-up, he had no pain recurrence and his joint mobility was normal. To our knowledge, this is the first report of the removal of an osteoid osteoma of the ankle using 2-portal posterior ankle arthroscopy.     

Osteoid osteoma of the dens axis

An osteoid osteoma of the dens axis was diagnosed by computed tomography and bone scintigraphy in a 14-year-old girl with a 1.5-year history of pain. No case of an osteoid osteoma of the dens axis has been published in the literature yet. Regarding its clinical and radiological appearance, this osteoid osteoma was essentially similar to osteoid osteomas in other locations, i.e., it had an osteolytic nidus surrounded by sclerosis, associated with nocturnal pain and a positive aspirin test.

     

Case Report: Curetting Osteoid Osteoma of the Spine Using Combined Video-assisted Thoracoscopic Surgery and Navigation

Background

A spinal osteoid osteoma is a rare benign tumor. The usual treatment involves complete curettage including the nidus. In the thoracic spine, conventional open surgical treatment usually carries relatively high surgical risks because of the close anatomic relationship to the spinal cord, nerve roots, and thoracic vessels, and pulmonary complications and postoperative pain.

Case Report

We report the case of a 16-year-old girl with a symptomatic osteoid osteoma at the T9 level whose lesion was currettaged using video-assisted thoracoscopic surgery (VATS) guided by a navigation system (VATS-NAV). There were no complications and the patient had immediate relief of the characteristic pain after surgery and was asymptomatic at 5 months’ followup.

Literature Review

Progressive advances in the technology of spinal surgery have evolved to offer greater safety and less morbidity for patients. The advent of minimally invasive surgery has expanded the indications for VATS for anterior spinal disorders. Spinal navigation systems have become useful tools allowing localization and excision of the nidus of osteoid osteomas with minimal bone resection and without radiation exposure.

Clinical Relevance

The VATS-NAV combination in our patient allowed accurate localization and guidance for complete excision of a spinal osteoid osteoma through a minimally invasive approach without compromising spinal stability.     

Osteoid osteoma causing subtalar joint arthralgia: A case report

The authors describe a juvenile patient with an osteoid osteoma in the foot-a relatively rare location for this type of lesion. The appearance of this lesion in a juxtaarticular location is even more rare. An 11-year-old boy with a 6-month history of limping secondary to subtalar joint pain presented with a juxtaarticular osteoid osteoma located within the calcaneus. The lesion was present beneath the sinus tarsi and the subtalar joint region. Plain radiographs showed equivocal changes; however, magnetic resonance imaging clearly showed a central nidus. The lateral aspect and midbody of the calcaneus showed a spherical focus of diminished signal on both the T1- and T2-weighted images. This focus had a surrounding rim of significantly diminished signal on all sequences. Thus, findings were most consistent with an osteoid osteoma, although a Brodie abscess could not be ruled out. Surgical excision was performed and led to complete resolution of pain and limping. The pathology report confirmed the diagnosis of osteoid osteoma.     

Classical surgical resection of osteoid osteoma of the cervical spine

Osteoid osteoma is a benign primary skeletal neoplasm occurring mainly in the cortex of long bones, but also in the spine. It occurs most often in young adult males and causes pain in the affected area. It presents as a nidus surrounded by reactive osteosclerosis or less often as a cancellous lesion with only a slight osteosclerosis. Osteoid osteoma may occur in basically any bone of the body, but the strategy of treatment has to be considered carefully, especially when it occurs in the spine. We report about a 38 year old female diagnosed with an osteoid osteoma located in the posterior element of the 5th cervical vertebra. She presented with persisting neck pain over one and a half years. An MRI and CT scan was performed. Due to the vicinity seen in the MRI imaging to neural structures and the slim rest of cortex in this area we decided to use the classical surgical excision through a minimal invasive approach to resect the lesion. Histological examination revealed the typical structures for osteoid osteoma. The patient was immediately free of symptoms and still is nine months after treatment. Surgical excision of an osteoid osteoma is still a good alternative to percutaneous radiofrequency ablation when treating osteoid osteoma located in close vicinity to neural structures.     

计算机导航辅助骨样骨瘤的外科治疗

目的 探讨计算机导航技术在骨样骨瘤外科治疗中的意义.方法 回顾性分析2008年1月至2009年12月应用计算机导航辅助切除骨样骨瘤手术26例患者的临床资料,其中男性23例,女性3例,平均年龄18岁(7～35岁).26例患者肿瘤位于股骨干9例、股骨粗隆部4例、股骨颈2例、胫骨干5例、胫骨近端干骺端1例、髋臼2例、耻骨1例、脊柱附件1例、桡骨干1例.术前均经局部X线及CT扫描明确诊断.其中4例采用CT数据导航,22例采用Iso-C 3D C型臂术中实时导航.术中导航指引定位,精确切除瘤巢.结果 全部病例均完成导航手术,其中行开窗刮除12例、整块切除14例;植骨21例、未植骨5例.26例患者均经术中肉眼判定、术中导航指引器确认、术后X线和(或)CT扫描确认瘤巢去除充分.全部病例均经组织病理学确诊为骨样骨瘤,术后疼痛即刻缓解.全部病例均获随访,平均随访20.6个月(12～35个月),未见肿瘤复发和疼痛复发.结论 将计算机导航技术应用于骨样骨瘤的外科治疗,不仅使术中瘤巢定位更精确,而且对于复杂部位瘤巢的切除可以达到骨结构微创治疗的目的.对于骨干部位的骨样骨瘤,Iso-C 3D C型臂术中实时导航较CT数据导航更有帮助.

Abstract：

Objective To report the experience for the precision osteoid osteoma resection using computer navigation system. Methods Between January 2008 and December 2009, 26 surgical resections were performed for 26 patients who had osteoid osteoma with computer navigation system. There were 23 males and 3 females with an average age of 18 years (7 to 35). Tumors were located at femoral shaft 9,femoral trochanter 4, femoral neck 2, tibial shaft 5, metaphysic of proximal tibia 1, acetabulum 2, pubis 1,vertebral appendix 1 and radial shaft 1. Pre-operative X-ray and CT of each patient was performed to confirm the diagnosis. It was carried out intraoperatively the process of CT-based navigation in 4 cases and intraoperative Iso-C three-dimensional navigation in 22 cases. The Navigation System software was Spine Navigation 1.2 in all cases. The Pointer was helpful to localize the lesion and precisely resected the lesion without removal of any excess bone. Results All the navigation operations were finished successfully with curettage for 12 and En Bloc resection for 14. Bone grafting was made in 21 cases and none in 3 cases. The completely clearance of nidus by intraoperative visual inspection and Pointer confirmation, postoperative X-ray and (or) CT scan was performed in all cases. All cases had histopathology diagnosis of osteoid osteoma and immediate pain relief after surgery. All cases were followed up for 20. 6 months averagely (12 to 35 months). No local recurrence and pain relapse occurred. Conclusions The navigation system is very helpful for the precision tumor resection of nidus. Especially for the patients with osteoid osteoma located at diaphysis, Intraoperative Iso-C three-dimensional navigation is more useful.     

Results of surgical treatment of osteoid osteoma of the spine

Ten percent of all osteoid osteomas are located in the spine; they represent the most common cause of painful scoliosis in adolescents. The recommended treatment is surgical excision of the nidus. Nine patients with osteoid osteoma of the spine underwent surgical treatment between 1996 and 2002. Complete nidus removal was performed in all patients and the diagnosis was made by frozen sections intraoperatively. The follow-up period was 27 months. Scoliosis was present in five of the cases (55.5%). All deformities improved during the postoperative follow-up period. All nine patients with the diagnosis of osteoid osteoma who had operations had histological confirmation. All patients had immediate and complete relief of pain after surgery. There were no complications and no local recurrences after a follow-up of two years. In the authors' opinion, removal of the nidus by open surgical technique remains a valid method of treatment for osteoid osteoma of the spine.