Osteoid osteoma

benign bone tumor, percutaneous drilling, CT localization, Bone scan

1. Osteoid Osteoma Vinod Naneria Girish Yeotikar Arjun Wadhwani Choithram Hospital & Research Centre, Indore India

2. Osteoid Osteoma Benign neoplasm most often seen in young males. Found in the first three decades of life, occasionally reported in older patients. Incidence is 13.5% in all benign tumors of bones. M/F ratio is 4:1. Bergstrand -first described in 1930. Jaffe in 1935 - first to recognize it as a unique entity.

3. Osteoid Osteoma Any bone can be involved, There is a predilection for the lower extremity, with half the cases involving the femur or tibia. The tumor may be found in cortical or cancellous bone, producing a distinct x-ray appearance of cortical sclerosis. 5% of tumors are subperiosteal .

4. Osteoid Osteoma Multicentric foci have been reported. No malignant change has ever been documented. The typical patient has pain that is worse at night and relieved by aspirin.

5. Osteoid Osteoma When the lesion is near a joint, swelling, stiffness, and contracture may occur. When in a vertebra, scoliosis may occur. Occasionally, osteoid osteoma occurs with minimal pain. In children, overgrowth and angular deformities may occur .

6. Osteoid Osteoma - Diagnosis Routine roentgenograms often are diagnostic, but bone scans or CT are often required to localize the lesion accurately.

7. Osteoid Osteoma CT may detect the nidus, whereas roentgenograms show only sclerosis.

8. Osteoid Osteoma - CT CT is more accurate than MRI. CT helped in confirming the diagnosis of osteoid osteoma in 74% of cases. Szendroi et al reported accuracies of about 66% in the diagnosis of intra- articular lesions and 90% in extra- articular lesions. To date, CT scanning is the primary investigational tool for the definitive diagnosis of osteoid osteoma.

9. Osteoid Osteoma – Bone scan To date, no negative bone-scan findings have been reported in patients with osteoid osteoma. Bone scanning is currently the most accurate means of localizing the tumour. Wells et al noted that the sensitivity of skeletal bone scan for osteoid osteoma is 100%.

10. Osteoid Osteoma – Bone scan A bone scan is helpful in detecting the "double-density sign," which is a focal area of increased activity with a second smaller area of increased uptake superimposed on it, is said to be diagnostic of osteoid osteoma .

11. Osteoid Osteoma - MRI MRI has not been useful in the diagnosis of osteoid osteoma. MRI is reserved for equivocal cases because it can suggest the diagnosis of osteoid osteoma. MRI interpretation may result in errors in diagnosis, most often confusion with malignancies.

12. Natural History The literature suggests a history of resolving pain and healing of the lesions. The course of this disease is unpredictable and protracted, with intervals of resolution of pain that sometimes last 6-15 years.

13. Natural History - Stages Atar et al (1992) described 2 stages of the disease.   The first is an acutely painful stage that lasts 18-36 months, during which patients require steady use of analgesics. The second is the recovery stage, which includes healing of the nidus and which usually takes 3-7 years.

14. Natural History Barei et al noted that healing involves ossification of the untreated nidus, which cannot be readily distinguished from surrounding bone and which resembles a localized zone of cortical hypertrophy.

15. Osteoid Osteoma - Tx En bloc resection The entire nidus must be removed. Block resection of the nidus. Unroofing and curettage An alternative method - shave the reactive bone with a sharp osteotome until the nidus is encountered, then curettage of the exposed nidus.

16. Osteoid Osteoma - Tx Intraoperative localization of the nidus is possible with preoperatively injected technetium-labeled methylene diphosphonate and a sterile, wrapped Geiger counter.

17. Osteoid Osteoma - Tx Excision of the osteoid osteoma nidus using CT–assisted localization, a Kirschner wire inserted into the nidus, and a biopsy punch inserted over the Kirschner wire into the bone. They recommend using a trephine 2 mm larger than the lesion for complete removal. Recurrence after apparently complete excision has been reported but is rare.

18. A CT guided needle was passed to localize the lesion. Through an anterior "Hernia" approach the lesion was approached and excised. The Follow-up CT Scanning done to reveal complete removal of lesion. A biopsy confirmed it later.

19. Post op – after drilling

20. CT – Guided Drilling OPD procedure, Localization of the nidus in CT Scan, Local anesthesia, K-wire passed into nidus , Transferred to OT, Short GA, Drilling of the nidus by a cannulated drill, Complete relief of pain.

21. Referrence CT-guided percutaneous drilling is a safe and reliable method of treating osteoid osteomas - Edgard Eduard Engel, Nelson Fabrício Gava , Marcello Henrique Nogueira-Barbosa , Filipe Almeida Botter doi:10.1186/2193-1801-2-34 Engel et al.: CT-guided percutaneous drilling is a safe and reliable method of treating osteoid osteomas . SpringerPlus 2013 2:34.

22. Summary Traditional open surgical treatment consists of en bloc resection and unroofing and curettage, which is the treatment of choice. The rate of primary cure is approximately 100%. Disadvantages include perioperative morbidity, extended hospital stay, perioperative fractures, a need for bone grafts or internal fixation, periarticular stiffness, and delayed functional recovery. The recurrence rate is 9-28%.

23. Summary Minimally invasive surgical treatments include radionuclide-guided excision, CT-guided percutaneous excision, percutaneous laser photocoagulation, percutaneous radiofrequency coagulation, and computer-assisted surgery. Success rates can reach approximately 100%. Disadvantages include incomplete resection in 35% of patients, persistence of symptoms in 23%, and recurrence in 12%.

24. DISCLAIMER Information contained and transmitted by this presentation is based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 34 years. It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification . Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. For any correction or suggestion please contact [email protected]