- Email: [email protected]
Arthroscopic Excision of Osteoid Osteoma of the Elbow
Arthroscopic Excision of Osteoid Osteoma of the Elbow Deepak N. Bhatia, M.S.(Orth.), D.N.B.(Orth.)
Abstract: Osteoid osteoma has been reported infrequently around the elbow joint, and is usually treated with radiofrequency ablation or open excision. Elbow arthroscopy is useful for excision of accessible lesions, and the accompanying elbow stiffness can be treated concurrently. This report describes an arthroscopic excision of an osteoid osteoma located in the juxta-articular distal humeral bone. An initial adhesiolysis and capsulectomy is performed to gain access to the region above the capitellar articular margin. A 70 arthroscope is necessary to visualize this region via the anteromedial portal. An accessory lateral portal is used to detach the capsule from the distal humerus; the scar tissue overlying the lesion is debrided and the circumferential lesion is visualized and probed for identification of its extent. A biopsy is performed, and thereafter the lesion is excised piecemeal. The sclerotic margins are curetted, and radiofrequency ablation is performed. The technique is cosmetic and minimally invasive, and can be performed in revision scenarios involving recurrences after open surgery or needle radiofrequency thermal ablation. Early rehabilitation restores range of motion and strength. Technical tips for identification and curettage of the lesion are presented.
O
steoid osteoma is a painful bone tumor, and has been infrequently described at various locations within the elbow joint.1-4 The lesion is usually associated with disabling pain and occasionally may result in progressive stiffness of the elbow.5 Radiofrequency ablation is usually the treatment of choice; however, arthroscopic excision has been described as an alternate management option and can be combined with arthroscopic elbow adhesiolysis for restoration of motion.6-10 Arthroscopic identification of the lesion is difficult, and inadequate excision may result in persistence of symptoms and stiffness. The purpose of this report is to describe an arthroscopic technique for excision of an osteoid osteoma situated in the distal humerus. Elbow arthroscopy is
From Seth GS Medical College, and King Edward VII Memorial Hospital, Mumbai, India. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received October 15, 2016; accepted November 30, 2016. Address correspondence to Deepak N. Bhatia, M.S.(Orth.), D.N.B.(Orth.), Department of Orthopaedic Surgery, Seth GS Medical College, and King Edward VII Memorial Hospital, Parel, Mumbai, 400012 Maharashtra, India. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/161005/$36.00 http://dx.doi.org/10.1016/j.eats.2016.11.014
used to perform adhesiolysis, and intraoperative arthroscopic appearance of the osteoid osteoma is described for accurate identification. Guidelines for systematic exposure and biopsy of the lesion are described, and steps for complete excision of the lesion are presented.
Technique The preoperative imaging is studied, and the position of the osteoid osteoma is noted (Fig 1 A and B). The procedure is performed with the patient in the lateral decubitus position; the shoulder is flexed to 90 , and the elbow flexed 90 . The upper arm is placed on an elbow support, and an upper limb tourniquet is used at a pressure of 220 mm Hg. Standard anteromedial (AM) and anterolateral (AL) elbow arthroscopy portals are marked, and a 30 arthroscope (2.9 mm 160 mm, ConMed Linvatec, Largo, FL) is used for diagnostic arthroscopy (Fig 2). The key steps and surgical pearls of the technique are summarized in Tables 1 and 2, and the steps are shown in Video 1. Step 1: Diagnostic Elbow Arthroscopy The elbow joint is insufflated with saline via a needle placed through the posterolateral “soft spot.” An anteromedial portal is placed approximately 1 cm anterior and proximal to the medial epicondyle, and is the
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Fig 1. (A) Magnetic resonance imaging of the left elbow shows a well-defined lytic lesion (0.5 0.5 0.7 cm) in the lower end of the humerus. The lesion (OS) is lateral to the coronoid fossa and is proximal to the articular margin of the capitellum (right image, coronal image). The overlying anterior cortex is thin (black arrow, left image axial view), and the associated synovitis (SY) is noted. (B) Computed tomographic scan of the left elbow shows a central lytic zone surrounded by a peripheral sclerotic rim in the lower end of the humerus (right image, coronal view). The overlying anterior cortex is thinned out (white arrow, central image axial view), and a probably osseous reactive tissue is noted proximal to the lesion (white arrow, left image, sagittal view). (A, anterior; C, capitellum; E, lateral epicondyle; L, lateral; LE, lateral epicondyle; M, medial; ME, medial epicondyle; OL, olecranon; P, posterior; R, radial head; T, trochlea; U, proximal ulna.)
primary viewing portal throughout the procedure.7 Additional AL and direct lateral (accessory AL) portals are created for instrumentation.8,9 Gravity fluid inflow is used to achieve adequate distension. Intra-articular adhesions are documented, and articular surfaces of the radial head and capitellum are inspected if possible.
Step 2: Capsulotomy and Adhesiolysis A 4-mm tapered shaver blade (Torpedo; Arthrex, Naples, FL) is introduced into the elbow joint via the AL portal and is used to excise ulnotrochlear and radiocapitellar adhesions (Fig 3). Next, anterior capsulectomy is performed to improve access to the radiocapitellar region and to the proximal aspect of distal humerus. Then the capsule is detached from the distal humeral attachment, above the capitellar articular margin, and the region of the osteoid osteoma is visualized. Further proximal visualization via the anteromedial portal is inadequate for complete exposure, and a 70 arthroscope is necessary. Step 3: 70 View and Working Access to the Distal Humerus The arthroscope is changed to a 70 lens and is positioned to view the region superior to the capitellar articular margin. An accessory AL (direct lateral) portal is Table 1. Key Steps of the Procedure
Fig 2. Elbow position and portals used in the technique are shown (left elbow, lateral decubitus position). A standard anterolateral portal (AL) is created approximately 1 cm proximal and anterior to the lateral epicondyle (LE). An accessory anterolateral portal (AC) is created approximately 1 cm anterior and directly lateral to the lateral epicondyle. An old surgical scar (dotted line) from a previous open surgery is seen along the lateral aspect of the elbow. (INF, inferior; LAT, lateral; MED, medial; OL, olecranon; R, radial head, SUP, superior.)
Arthroscopic viewing is performed through a 30 lens initially, and is later shifted to a 70 view. The 30 view permits an adequate intraarticular adhesiolysis for subsequent steps. The 70 view provides access to the more proximal region of the distal humerus for accurate identification of the osteoid osteoma. Two anterolateral working portals are used. The AL portal is useful for initial adhesiolysis, and is later used to retract the superior and anterior capsules for a better view. The AC portal is used in conjunction with curved instruments for biopsy and excision of the lesion. Biopsy is necessary to confirm and document the lesion. Arthroscopic biopsy material is obtained from the central and peripheral zones of the lesion. Excision of the lesion is performed using curved instruments via the AC portal. The AC portal must be more anterior than usual, to provide access to the distal humerus. Radiofrequency ablation must be used to extend margins of excision. Short pulses are used for 10-15 minutes. Early rehabilitation is started to regain most of range of motion. AC, accessory anterolateral portal; AL, standard anterolateral portal.
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Table 2. Technical Pearls for Key Steps of the Procedure Steps
Pearls
Adequate arthroscopic visualization
A thorough adhesiolysis is necessary to provide working and viewing space. Adhesions are excised, and a capsulotomy is performed to improve range. Fluid inflow is restricted after capsular resection to prevent extravasation and swelling. The adhesions are thick and fibrotic, and a shaver should be used for rapid resection. A 70 view is necessary for visualization of the region proximal to the articular margins of the capitellum and trochlea. View from the anteromedial portal with a 70 lens. Use the anterolateral portal for capsular retraction via a Wissinger rod. Make the accessory anterolateral portal slightly anterior to its usual position so that instruments may pass across the capitellar curve and up to the extra-articular distal humerus. Use instruments with a 15 -20 angled tip to adequately reach the deeper regions of the lesion. Obtain biopsy material from the central and peripheral zones. The chisel is useful to elevate chunks of tissue, and a biter can then excise these piecemeal. The chisel may also be used along with a ring curette to excise sclerotic peripheral and deeper bone. The deeper curettage is performed cautiously to prevent spillage into posterior compartments. Radiofrequency ablation is useful to extend margins of excision.
Adequate working access
Arthroscopic excision and biopsy
Step 4: Identification of the Osteoid Osteoma The osteoid osteoma is visible arthroscopically as a purplish-colored region of soft trabecular bone, and is
surrounded by denser, whitish-colored bone circumferentially. This appearance can be clearly recognized under arthroscopic magnification after excision of overlying adhesions. The lesion is palpated using a blunt probe; the soft trabecular bone is easily indented, and traces of blood are seen oozing from it under pressure. The deeper region of the lesion can be observed after procurement of biopsy tissue, and appears reddish and bleeds with reduction of intraarticular fluid pressure (Fig 5).
Fig 3. Arthroscopic image of the left elbow is shown via a 30 view (anteromedial portal). A thorough adhesiolysis is performed to visualize the radial head (R) and capitellum (C). An accessory anterolateral portal (AC) is made using an outside-in technique via a needle and is used to access the scar tissue (ST, white arrows) overlying the osteoid osteoma. (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
Fig 4. Arthroscopic image of the left elbow is shown via a 70 view (anteromedial portal). A shaver blade (SH) is introduced via the accessory anterolateral portal (AC) and is used to debride the thick scar tissue (ST) overlying the osteoid osteoma (OS). (INF, inferior; LAT, lateral; MED, medial; SUP, superior; TR, trochlear articular margin.)
established slightly inferior and anterior to the AL portal; an outside-in technique is used to ascertain the trajectory, so that the portal can provide working access to the osteoid osteoma. A shaver (Torpedo; Arthrex) is used to further excise the overlying soft tissue adhesions and scarring, and the osteoid osteoma is visualized circumferentially (Fig 4).
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Fig 5. Arthroscopic appearance of an osteoid osteoma (left elbow) is shown via a 70 view (anteromedial portal). The right image shows a purplish central region of soft trabecular bone (white arrow), and this is surrounded by a peripheral zone of dense sclerotic bone (black arrows). The left image shows the deeper region of the lesion and is seen after obtaining a biopsy. The deeper aspect shows red discoloration and oozing from bleeding bone (white arrows), and the surrounding rim (black arrows) appears avascular. (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
Step 5: Arthroscopic Biopsy of the Osteoid Osteoma A 5.5-mm metal cannula is inserted through the accessory AL portal, and a curved-tip chisel is used to elevate the central region of the lesion. An angled arthroscopic biter (Acufex; Smith & Nephew, Andover, MA) is then passed through the cannula and is used to excise chunks of the elevated tissue as biopsy material (Fig 6).
present for several years, or in revision scenarios, progressive relief is observed over several weeks after the procedure. Range of motion exercises are started immediately. Isometric strengthening is initiated in the second week, and progressive strengthening is continued for 6 to 8 weeks Achievement of full range is
Step 6: Intralesional Curettage and Excision of Sclerotic Zone of the Lesion Excision of the lesion is performed by using an angled biter for piecemeal removal of the soft central region. The peripheral sclerotic zone is excised using a curved ring curette, and the chisel may be used in addition. The curettage is continued until the entire lesion is removed, and a curved shaver blade (4-mm dissector; Arthrex) is used to remove the debris from the joint (Fig 7 A-C). The margins may be further extended using radiofrequency ablation, as described below. Step 7: Radiofrequency Ablation of the Lesion A radiofrequency probe (Super Turbovac 90; ArthroCare, Austin, TX) with a 90 probe angle is introduced into the joint via the accessory AL portal. The probe tip is brought into contact with the lesion, and radiofrequency is administered in short pulses for approximately 10 minutes (Fig 8 A and B). The arm is kept in a sling for comfort, and the sling is discarded on the third or fourth postoperative day. Most patients report significant relief in pain in the first week itself. In chronic cases, where symptoms have been
Fig 6. Arthroscopic technique of obtaining a biopsy is shown (left elbow) via a 70 view (anteromedial portal). An angled biter is used via the accessory anterolateral portal and provides access to the distal lateral humerus. The upper jaw (PU) is inserted deep into the osteoid osteoma (OS), and the jaws are closed to obtain a chunk of tissue under direct visualization. (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
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Fig 7. Arthroscopic technique of excision and curettage of an osteoid osteoma (left elbow) is shown via a 70 view (anteromedial portal). (A) An angled chisel (CH) is used via the accessory anterolateral portal and provides access to deeper region of the lesion (OS). The angled tip reaches proximal to the articular margins of the capitellum (C) and trochlea (TR). An angled biter is used in conjunction, and the lesion is excised piecemeal. (B) A ring curette (CU) is used to further excise the peripheral sclerotic region of the lesion (OS). (C) The debris and bone flakes from the lesion and finally debrided using an angled shaver blade (SH). (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
dependent on the initial severity of the stiffness, and may vary from 4 to 8 months. Light work is permitted immediately, and return to heavy work is permitted after 4 weeks.
Discussion Arthroscopic excision of an elbow osteoid osteoma is a minimally invasive and reliable option for definitive treatment of this lesion. The technique is difficult
in the presence of severe intra-articular adhesions that are a result of previous interventions or chronicity; cautious dissection is necessary to prevent iatrogenic neurovascular injury and extravasation of fluid. Our technique presents a step-by-step approach for identification and biopsy of the lesion, and for meticulous resection of the lesion under direct visualization. The technique is safe and ensures complete excision and symptomatic resolution. The overall
Fig 8. (A) Arthroscopic step of radiofrequency ablation of the osteoid osteoma (left elbow) is shown via a 70 view (anteromedial portal). A radiofrequency probe (RF) is passed via the accessory anterolateral portal (AC), and the 90 angled tip is approximated to the lesion. (B) Ablation is performed in short pulses for approximately 5-10 minutes. Note that the depth of the lesion is sufficiently ablated; the reddish bleeding tissue is no longer visible (white arrows), and the peripheral sclerotic bone is excised (black arrows). (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
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Table 3. Advantages and Pitfalls of the Technique Advantages The arthroscopic technique avoids the need for an open surgical approach and its subsequent morbidity. There is minimal blood loss, and the procedure is better accepted by patients. Simultaneous adhesiolysis is performed in stiff elbows in long-standing cases. Arthroscopic approach ensures an adequate adhesiolysis, and this facilitates a rapid gain in range of motion Biopsy is obtained under vision, and both central and peripheral regions may be accessed adequately. Excision is performed under vision. Radiofrequency ablation is applied safely and without any potential danger to the neurovascular structures. Pitfalls Extravasation of fluid after capsulotomy may result in elevation of compartment pressures. Inadequate resection is possible, and results in persistent stiffness and pain. Neurovascular injury is possible; this may occur during capsulotomy and adhesiolysis. Proximal debridement and capsulotomy may add to the risk of neurovascular injury, and the risk may be minimized by limiting the proximal debridement close to the distal humerus bone. Surgeon inexperience is a contraindication for the procedure. Excessive resection may weaken the articular region of the distal humerus. The instruments must be passed carefully over the articular cartilage to prevent iatrogenic damage. Early initiation of range is necessary to prevent reformation of adhesions and recurrent stiffness.
advantages and pitfalls of the technique are outlined in Table 3.
References 1. Ditsios K, Papadakis N, Theodoroudis I, et al. A misguiding osteoid osteoma in the bicipital tuberosity of the radius. Case Rep Orthop 2016;2016:6428137. 2. Challawar NS, Shah HH. Intra-articular osteoid osteoma of the distal humerus: a diagnostic challenge [published online March 6, 2014]. BMJ Case Rep. doi: 10.1136/bcr-2013-202943. 3. Kraus G, Fortes S, Vazquez J, Renfree KJ. Intra-articular osteoid osteoma of the proximal ulna. Orthopedics 2014;37:e214-e217. 4. Mnif H, Kammoun MH, Zrig M, Koubaa M, Abid A. Osteoid osteoma of the coronoid process tip. J Shoulder Elbow Surg 2009;18:e9-e12. 5. Ebrahimzadeh MH, Choghadeh MF, Moradi A, Kalati HH, Jafarian AH. Elbow stiffness secondary to elbow joint osteoid osteoma, a diagnostic dilemma. Arch Bone Jt Surg 2015;3:144-147. 6. Trebse R, Poberaj B, Cör A, Levasic V. Arthroscopic removal of an osteoid osteoma in the radial head: A case report. Arthroscopy 2007;23:1361.e1-1361.e3. 7. Nourissat G, Kakuda C, Dumontier C. Arthroscopic excision of osteoid osteoma of the elbow. Arthroscopy 2007;23: 799.e1-799.e4. 8. Zupanc O, Sarabon N, Strazar K. Arthroscopic removal of juxtaarticular osteoid osteoma of the elbow. Knee Surg Sports Traumatol Arthrosc 2007;15:1240-1243. 9. Albisinni U, Bazzocchi A, Bettelli G, et al. Treatment of osteoid osteoma of the elbow by radiofrequency thermal ablation. J Shoulder Elbow Surg 2014;23:e1-e7. 10. Miyazaki M, Arai Y, Myoui A, et al. Phase I/II MultiInstitutional Study of Percutaneous Radiofrequency Ablation for Painful Osteoid Osteoma (JIVROSG-0704). Cardiovasc Intervent Radiol 2016;39:1464-1470.
Abstract: Osteoid osteoma has been reported infrequently around the elbow joint, and is usually treated with radiofrequency ablation or open excision. Elbow arthroscopy is useful for excision of accessible lesions, and the accompanying elbow stiffness can be treated concurrently. This report describes an arthroscopic excision of an osteoid osteoma located in the juxta-articular distal humeral bone. An initial adhesiolysis and capsulectomy is performed to gain access to the region above the capitellar articular margin. A 70 arthroscope is necessary to visualize this region via the anteromedial portal. An accessory lateral portal is used to detach the capsule from the distal humerus; the scar tissue overlying the lesion is debrided and the circumferential lesion is visualized and probed for identification of its extent. A biopsy is performed, and thereafter the lesion is excised piecemeal. The sclerotic margins are curetted, and radiofrequency ablation is performed. The technique is cosmetic and minimally invasive, and can be performed in revision scenarios involving recurrences after open surgery or needle radiofrequency thermal ablation. Early rehabilitation restores range of motion and strength. Technical tips for identification and curettage of the lesion are presented.
O
steoid osteoma is a painful bone tumor, and has been infrequently described at various locations within the elbow joint.1-4 The lesion is usually associated with disabling pain and occasionally may result in progressive stiffness of the elbow.5 Radiofrequency ablation is usually the treatment of choice; however, arthroscopic excision has been described as an alternate management option and can be combined with arthroscopic elbow adhesiolysis for restoration of motion.6-10 Arthroscopic identification of the lesion is difficult, and inadequate excision may result in persistence of symptoms and stiffness. The purpose of this report is to describe an arthroscopic technique for excision of an osteoid osteoma situated in the distal humerus. Elbow arthroscopy is
From Seth GS Medical College, and King Edward VII Memorial Hospital, Mumbai, India. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received October 15, 2016; accepted November 30, 2016. Address correspondence to Deepak N. Bhatia, M.S.(Orth.), D.N.B.(Orth.), Department of Orthopaedic Surgery, Seth GS Medical College, and King Edward VII Memorial Hospital, Parel, Mumbai, 400012 Maharashtra, India. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/161005/$36.00 http://dx.doi.org/10.1016/j.eats.2016.11.014
used to perform adhesiolysis, and intraoperative arthroscopic appearance of the osteoid osteoma is described for accurate identification. Guidelines for systematic exposure and biopsy of the lesion are described, and steps for complete excision of the lesion are presented.
Technique The preoperative imaging is studied, and the position of the osteoid osteoma is noted (Fig 1 A and B). The procedure is performed with the patient in the lateral decubitus position; the shoulder is flexed to 90 , and the elbow flexed 90 . The upper arm is placed on an elbow support, and an upper limb tourniquet is used at a pressure of 220 mm Hg. Standard anteromedial (AM) and anterolateral (AL) elbow arthroscopy portals are marked, and a 30 arthroscope (2.9 mm 160 mm, ConMed Linvatec, Largo, FL) is used for diagnostic arthroscopy (Fig 2). The key steps and surgical pearls of the technique are summarized in Tables 1 and 2, and the steps are shown in Video 1. Step 1: Diagnostic Elbow Arthroscopy The elbow joint is insufflated with saline via a needle placed through the posterolateral “soft spot.” An anteromedial portal is placed approximately 1 cm anterior and proximal to the medial epicondyle, and is the
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Fig 1. (A) Magnetic resonance imaging of the left elbow shows a well-defined lytic lesion (0.5 0.5 0.7 cm) in the lower end of the humerus. The lesion (OS) is lateral to the coronoid fossa and is proximal to the articular margin of the capitellum (right image, coronal image). The overlying anterior cortex is thin (black arrow, left image axial view), and the associated synovitis (SY) is noted. (B) Computed tomographic scan of the left elbow shows a central lytic zone surrounded by a peripheral sclerotic rim in the lower end of the humerus (right image, coronal view). The overlying anterior cortex is thinned out (white arrow, central image axial view), and a probably osseous reactive tissue is noted proximal to the lesion (white arrow, left image, sagittal view). (A, anterior; C, capitellum; E, lateral epicondyle; L, lateral; LE, lateral epicondyle; M, medial; ME, medial epicondyle; OL, olecranon; P, posterior; R, radial head; T, trochlea; U, proximal ulna.)
primary viewing portal throughout the procedure.7 Additional AL and direct lateral (accessory AL) portals are created for instrumentation.8,9 Gravity fluid inflow is used to achieve adequate distension. Intra-articular adhesions are documented, and articular surfaces of the radial head and capitellum are inspected if possible.
Step 2: Capsulotomy and Adhesiolysis A 4-mm tapered shaver blade (Torpedo; Arthrex, Naples, FL) is introduced into the elbow joint via the AL portal and is used to excise ulnotrochlear and radiocapitellar adhesions (Fig 3). Next, anterior capsulectomy is performed to improve access to the radiocapitellar region and to the proximal aspect of distal humerus. Then the capsule is detached from the distal humeral attachment, above the capitellar articular margin, and the region of the osteoid osteoma is visualized. Further proximal visualization via the anteromedial portal is inadequate for complete exposure, and a 70 arthroscope is necessary. Step 3: 70 View and Working Access to the Distal Humerus The arthroscope is changed to a 70 lens and is positioned to view the region superior to the capitellar articular margin. An accessory AL (direct lateral) portal is Table 1. Key Steps of the Procedure
Fig 2. Elbow position and portals used in the technique are shown (left elbow, lateral decubitus position). A standard anterolateral portal (AL) is created approximately 1 cm proximal and anterior to the lateral epicondyle (LE). An accessory anterolateral portal (AC) is created approximately 1 cm anterior and directly lateral to the lateral epicondyle. An old surgical scar (dotted line) from a previous open surgery is seen along the lateral aspect of the elbow. (INF, inferior; LAT, lateral; MED, medial; OL, olecranon; R, radial head, SUP, superior.)
Arthroscopic viewing is performed through a 30 lens initially, and is later shifted to a 70 view. The 30 view permits an adequate intraarticular adhesiolysis for subsequent steps. The 70 view provides access to the more proximal region of the distal humerus for accurate identification of the osteoid osteoma. Two anterolateral working portals are used. The AL portal is useful for initial adhesiolysis, and is later used to retract the superior and anterior capsules for a better view. The AC portal is used in conjunction with curved instruments for biopsy and excision of the lesion. Biopsy is necessary to confirm and document the lesion. Arthroscopic biopsy material is obtained from the central and peripheral zones of the lesion. Excision of the lesion is performed using curved instruments via the AC portal. The AC portal must be more anterior than usual, to provide access to the distal humerus. Radiofrequency ablation must be used to extend margins of excision. Short pulses are used for 10-15 minutes. Early rehabilitation is started to regain most of range of motion. AC, accessory anterolateral portal; AL, standard anterolateral portal.
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Table 2. Technical Pearls for Key Steps of the Procedure Steps
Pearls
Adequate arthroscopic visualization
A thorough adhesiolysis is necessary to provide working and viewing space. Adhesions are excised, and a capsulotomy is performed to improve range. Fluid inflow is restricted after capsular resection to prevent extravasation and swelling. The adhesions are thick and fibrotic, and a shaver should be used for rapid resection. A 70 view is necessary for visualization of the region proximal to the articular margins of the capitellum and trochlea. View from the anteromedial portal with a 70 lens. Use the anterolateral portal for capsular retraction via a Wissinger rod. Make the accessory anterolateral portal slightly anterior to its usual position so that instruments may pass across the capitellar curve and up to the extra-articular distal humerus. Use instruments with a 15 -20 angled tip to adequately reach the deeper regions of the lesion. Obtain biopsy material from the central and peripheral zones. The chisel is useful to elevate chunks of tissue, and a biter can then excise these piecemeal. The chisel may also be used along with a ring curette to excise sclerotic peripheral and deeper bone. The deeper curettage is performed cautiously to prevent spillage into posterior compartments. Radiofrequency ablation is useful to extend margins of excision.
Adequate working access
Arthroscopic excision and biopsy
Step 4: Identification of the Osteoid Osteoma The osteoid osteoma is visible arthroscopically as a purplish-colored region of soft trabecular bone, and is
surrounded by denser, whitish-colored bone circumferentially. This appearance can be clearly recognized under arthroscopic magnification after excision of overlying adhesions. The lesion is palpated using a blunt probe; the soft trabecular bone is easily indented, and traces of blood are seen oozing from it under pressure. The deeper region of the lesion can be observed after procurement of biopsy tissue, and appears reddish and bleeds with reduction of intraarticular fluid pressure (Fig 5).
Fig 3. Arthroscopic image of the left elbow is shown via a 30 view (anteromedial portal). A thorough adhesiolysis is performed to visualize the radial head (R) and capitellum (C). An accessory anterolateral portal (AC) is made using an outside-in technique via a needle and is used to access the scar tissue (ST, white arrows) overlying the osteoid osteoma. (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
Fig 4. Arthroscopic image of the left elbow is shown via a 70 view (anteromedial portal). A shaver blade (SH) is introduced via the accessory anterolateral portal (AC) and is used to debride the thick scar tissue (ST) overlying the osteoid osteoma (OS). (INF, inferior; LAT, lateral; MED, medial; SUP, superior; TR, trochlear articular margin.)
established slightly inferior and anterior to the AL portal; an outside-in technique is used to ascertain the trajectory, so that the portal can provide working access to the osteoid osteoma. A shaver (Torpedo; Arthrex) is used to further excise the overlying soft tissue adhesions and scarring, and the osteoid osteoma is visualized circumferentially (Fig 4).
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Fig 5. Arthroscopic appearance of an osteoid osteoma (left elbow) is shown via a 70 view (anteromedial portal). The right image shows a purplish central region of soft trabecular bone (white arrow), and this is surrounded by a peripheral zone of dense sclerotic bone (black arrows). The left image shows the deeper region of the lesion and is seen after obtaining a biopsy. The deeper aspect shows red discoloration and oozing from bleeding bone (white arrows), and the surrounding rim (black arrows) appears avascular. (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
Step 5: Arthroscopic Biopsy of the Osteoid Osteoma A 5.5-mm metal cannula is inserted through the accessory AL portal, and a curved-tip chisel is used to elevate the central region of the lesion. An angled arthroscopic biter (Acufex; Smith & Nephew, Andover, MA) is then passed through the cannula and is used to excise chunks of the elevated tissue as biopsy material (Fig 6).
present for several years, or in revision scenarios, progressive relief is observed over several weeks after the procedure. Range of motion exercises are started immediately. Isometric strengthening is initiated in the second week, and progressive strengthening is continued for 6 to 8 weeks Achievement of full range is
Step 6: Intralesional Curettage and Excision of Sclerotic Zone of the Lesion Excision of the lesion is performed by using an angled biter for piecemeal removal of the soft central region. The peripheral sclerotic zone is excised using a curved ring curette, and the chisel may be used in addition. The curettage is continued until the entire lesion is removed, and a curved shaver blade (4-mm dissector; Arthrex) is used to remove the debris from the joint (Fig 7 A-C). The margins may be further extended using radiofrequency ablation, as described below. Step 7: Radiofrequency Ablation of the Lesion A radiofrequency probe (Super Turbovac 90; ArthroCare, Austin, TX) with a 90 probe angle is introduced into the joint via the accessory AL portal. The probe tip is brought into contact with the lesion, and radiofrequency is administered in short pulses for approximately 10 minutes (Fig 8 A and B). The arm is kept in a sling for comfort, and the sling is discarded on the third or fourth postoperative day. Most patients report significant relief in pain in the first week itself. In chronic cases, where symptoms have been
Fig 6. Arthroscopic technique of obtaining a biopsy is shown (left elbow) via a 70 view (anteromedial portal). An angled biter is used via the accessory anterolateral portal and provides access to the distal lateral humerus. The upper jaw (PU) is inserted deep into the osteoid osteoma (OS), and the jaws are closed to obtain a chunk of tissue under direct visualization. (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
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Fig 7. Arthroscopic technique of excision and curettage of an osteoid osteoma (left elbow) is shown via a 70 view (anteromedial portal). (A) An angled chisel (CH) is used via the accessory anterolateral portal and provides access to deeper region of the lesion (OS). The angled tip reaches proximal to the articular margins of the capitellum (C) and trochlea (TR). An angled biter is used in conjunction, and the lesion is excised piecemeal. (B) A ring curette (CU) is used to further excise the peripheral sclerotic region of the lesion (OS). (C) The debris and bone flakes from the lesion and finally debrided using an angled shaver blade (SH). (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
dependent on the initial severity of the stiffness, and may vary from 4 to 8 months. Light work is permitted immediately, and return to heavy work is permitted after 4 weeks.
Discussion Arthroscopic excision of an elbow osteoid osteoma is a minimally invasive and reliable option for definitive treatment of this lesion. The technique is difficult
in the presence of severe intra-articular adhesions that are a result of previous interventions or chronicity; cautious dissection is necessary to prevent iatrogenic neurovascular injury and extravasation of fluid. Our technique presents a step-by-step approach for identification and biopsy of the lesion, and for meticulous resection of the lesion under direct visualization. The technique is safe and ensures complete excision and symptomatic resolution. The overall
Fig 8. (A) Arthroscopic step of radiofrequency ablation of the osteoid osteoma (left elbow) is shown via a 70 view (anteromedial portal). A radiofrequency probe (RF) is passed via the accessory anterolateral portal (AC), and the 90 angled tip is approximated to the lesion. (B) Ablation is performed in short pulses for approximately 5-10 minutes. Note that the depth of the lesion is sufficiently ablated; the reddish bleeding tissue is no longer visible (white arrows), and the peripheral sclerotic bone is excised (black arrows). (INF, inferior; LAT, lateral; MED, medial; SUP, superior.)
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D. N. BHATIA
Table 3. Advantages and Pitfalls of the Technique Advantages The arthroscopic technique avoids the need for an open surgical approach and its subsequent morbidity. There is minimal blood loss, and the procedure is better accepted by patients. Simultaneous adhesiolysis is performed in stiff elbows in long-standing cases. Arthroscopic approach ensures an adequate adhesiolysis, and this facilitates a rapid gain in range of motion Biopsy is obtained under vision, and both central and peripheral regions may be accessed adequately. Excision is performed under vision. Radiofrequency ablation is applied safely and without any potential danger to the neurovascular structures. Pitfalls Extravasation of fluid after capsulotomy may result in elevation of compartment pressures. Inadequate resection is possible, and results in persistent stiffness and pain. Neurovascular injury is possible; this may occur during capsulotomy and adhesiolysis. Proximal debridement and capsulotomy may add to the risk of neurovascular injury, and the risk may be minimized by limiting the proximal debridement close to the distal humerus bone. Surgeon inexperience is a contraindication for the procedure. Excessive resection may weaken the articular region of the distal humerus. The instruments must be passed carefully over the articular cartilage to prevent iatrogenic damage. Early initiation of range is necessary to prevent reformation of adhesions and recurrent stiffness.
advantages and pitfalls of the technique are outlined in Table 3.
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