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 "doubledensity 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.

13. 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.

14. 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.

15. 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.

16. 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.

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

18. 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.

24. • 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.

59. Post op – after drilling

60. 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.

61. 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.

62. 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%.

63. 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%.

64. 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
• naneria@yahoo.com