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Hip Arthroscopy for Excision of Osteoid Osteoma of Femoral Neck
Hip Arthroscopy for Excision of Osteoid Osteoma of Femoral Neck Hatem Galal Said, M.D., AbdulRahman Abdulla Babaqi, M.B.B.S., M.Sc., and Maher AbdelSalam El-Assal, M.D.
Abstract: Osteoid osteoma (OO) is the most commonly seen benign bone-forming lesion. It can occur anywhere, including the metaphyseal regions of small and large bones. We present 2 cases that underwent an arthroscopic technique for removal of OO of the femoral neck. The diagnosis was confirmed by computed tomography in addition to magnetic resonance imaging. The lesions were accessed arthroscopically and excised by unroofing and curettage. The clinical and radiographic findings are presented, along with the surgical management. The patients improved dramatically postoperatively. OO of the femoral neck should be included in the differential diagnosis of hip pain in young patients. Arthroscopic excision and curettage provide a good choice for management, with low morbidity and rapid recovery.
O
steoid osteoma (OO) was first described in 1935 by Jaffe, who also coined the term.1,2 It is the most commonly seen benign bone-forming lesion, accounting for 10% to 12% of all benign bone tumors and 3% of all primary bone tumors.3,4 This lesion most commonly occurs in persons aged 5 to 25 years, with a male-female ratio of 2:1.5,6 Although any bone can be affected, at least 50% of lesions are reported in the lower extremity.7 The proximal femur is involved in 25% to 27% of OOs.8,9 OOs are intra-articular in location in 5% to 12% of cases.8,9 Gaeta et al.8 cited a study by Cohen et al. noting that the most common location of intra-articular OO of the hip was the cortex of the medial femoral neck. We present our technique of arthroscopic excision by unroofing and curettage of OO of the femoral neck and describe 2 cases.
From the Assiut Arthroscopy & Sports Injuries Unit, Orthopaedic & Traumatology Department, Assiut University, Assiut, Egypt. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received July 27, 2013; accepted September 19, 2013. Address correspondence to AbdulRahman Abdulla Babaqi, M.B.B.S., M.Sc., Faculty of Medicine, Assiut University, 71515, Assiut, Egypt. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/13523/$36.00 http://dx.doi.org/10.1016/j.eats.2013.09.011
Case Descriptions
The first case was an 18-year-old man who presented to our institute with the chief complaint of right hip pain, increasing mainly at night, that was dull and nonradiating. The pain started insidiously 2 months earlier. It became worse with walking and exercise. The pain did not affect his activities of daily living. It was often partially relieved by nonsteroidal anti-inflammatory drugs. On examination, the findings of all the hip tests were positive (impingement, labral stress, resisted straight-leg raise, and
Fig 1. Cam lesion of right femoral neck (yellow arrow) with osteolytic lesion on inferior part of neck (red arrow).
Arthroscopy Techniques, Vol 3, No 1 (February), 2014: pp e145-e148
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Fig 2. Magnetic resonance images showing hyperintense nidus as well as surrounding bone edema and joint effusion.
flexioneabductioneexternal rotation tests), with some limitation of range of motion. Radiographs of the hip showed a cam lesion of the right head, which was more visible on the lateral view, with a small osteolytic lesion on the inferior part of the neck. The alpha angle was 65 (Fig 1). Magnetic resonance images showed extensive fluid signal in the region of the neck on the coronal short tau inversion recovery view; this differs from the appearance of a pincer divot, which presents with smaller fluid signal. On the radial magnetic resonance angiography cuts, a hyperintense nidus was observed, along with surrounding bone edema and joint effusion (Fig 2). Multislice computed tomography (CT) showed
the cam lesion and the osteolytic lesion with a central nidus. Hip arthroscopy was performed, and after cam osteoplasty with an arthroscopic burr (Smith & Nephew Dyonics, Andover, MA), the location of the OO was identified and excision and curettage were performed with a curette (Karl Storz, Tuttlingen, Germany) (Video 1). Histopathologic assessment confirmed the diagnosis of OO. The patient improved dramatically on the third day postoperatively. An evaluation performed at 4 months postoperatively showed that the patient’s Harris Hip Score and Oxford Hip Score improved from 54 to 100 and from 19 to 48, respectively. However, the fact that the patient’s improvement was dramatic and occurred within a few days suggests that the OO was more responsible for his symptoms than the cam lesion. The second case was a 35-year-old man who presented with a similar clinical picture for 6 months, but in addition, he had wasting of the quadriceps. The result of the flexioneabductioneexternal rotation test was positive, with double the distance of the knee to the bed compared with other side. Radiographs did not show any significant lesion, but on coronal magnetic resonance imaging, the short tau inversion recovery view showed extensive fluid signal in the region of the femoral neck (Fig 3). Multislice CT showed a welldemarcated nidus overlying the right femoral neck (subperiosteal OO) (Figs 4 and 5). Hip arthroscopy was performed through the peripheral compartment, and the lesion was removed with an arthroscopic grasper (Smith & Nephew) (Video 1). Biopsy confirmed the diagnosis of OO. The patient improved dramatically postoperatively. At the 2-week follow-up evaluation, the Harris Hip Score and Oxford Hip Score improved from 56 to 100 and from 24 to 48, respectively.
Surgical Technique We perform hip arthroscopy by starting in the peripheral compartment using the anatomic surface landmarks without an intraoperative image intensifier.10 Proximal and distal anterolateral portals are used and are sufficient for this procedure.
Discussion OO can present as a cause of hip pain with or without radiologic findings of impingement. The clinical picture of continuous hip pain, worse at night, should alert the surgeon to this possibility. The extensive fluid reaction of the femoral neck seen on magnetic resonance imaging is a telltale sign and should not be mistaken for a pincer divot. If one is in
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Fig 3. Magnetic resonance images showing hyperintense signal over right femoral neck.
Fig 4. Multislice CT scan showing well-demarcated nidus overlying right femoral neck (arrow).
Fig 5. Subperiosteal OO overlying femoral neck before excision.
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doubt, multislice CT will confirm the diagnosis. Hip arthroscopy of the peripheral compartment was performed to excise both lesions in our patients with excellent outcomes and rapid recovery.
References 1. Kransdorf MJ, Stull MA, Gilkey FW, Moser RP Jr. Osteoid osteoma. Radiographics 1991;11:671-696. 2. Jaffe HL. Osteoid osteoma: A benign osteoblastic tumor composed of osteoid and atypical bone. Arch Surg 1935;31: 709-728. 3. Eggel Y, Theumann N, Luthi F. Intra-articular osteoid osteoma of the knee: Clinical and therapeutical particularities. Joint Bone Spine 2007;74:379-381. 4. Greenspan A. Benign bone-forming lesions: Osteoma, osteoid osteoma, and osteoblastoma. Clinical, imaging, pathologic, and differential considerations. Skeletal Radiol 1993;22:485-500.
5. Peyser A, Applbaum Y, Simanovsky N, Safran O, Lamdan R. CT-guided radiofrequency ablation of pediatric osteoid osteoma utilizing a water-cooled tip. Ann Surg Oncol 2009;16:2856-2861. 6. Cerase A, Priolo F. Skeletal benign bone-forming lesions. Eur J Radiol 1998;27(suppl 1):S91-S97. 7. Cohen MD, Harrington TM, Ginsburg WW. Osteoid Osteoma: 95 cases and a review of the literature. Semin Arthritis Rheum 1983;12:265-281. 8. Gaeta M, Minutoli F, Pandolfo I, Vinci S, D’Andrea L, Blandino A. Magnetic resonance imaging findings of osteoid osteoma of the proximal femur. Eur Radiol 2004;14: 1582-1589. 9. Toni A, Calderoni P. Intracapsular metaphyseal osteoid osteoma of the femoral neck. Ital J Orthop Traumatol 1983;9:501-506. 10. Masoud MA, Said HG. Intra-articular hip injection using anatomic surface landmarks. Arthrosc Tech 2013;2: e147-e149.
Abstract: Osteoid osteoma (OO) is the most commonly seen benign bone-forming lesion. It can occur anywhere, including the metaphyseal regions of small and large bones. We present 2 cases that underwent an arthroscopic technique for removal of OO of the femoral neck. The diagnosis was confirmed by computed tomography in addition to magnetic resonance imaging. The lesions were accessed arthroscopically and excised by unroofing and curettage. The clinical and radiographic findings are presented, along with the surgical management. The patients improved dramatically postoperatively. OO of the femoral neck should be included in the differential diagnosis of hip pain in young patients. Arthroscopic excision and curettage provide a good choice for management, with low morbidity and rapid recovery.
O
steoid osteoma (OO) was first described in 1935 by Jaffe, who also coined the term.1,2 It is the most commonly seen benign bone-forming lesion, accounting for 10% to 12% of all benign bone tumors and 3% of all primary bone tumors.3,4 This lesion most commonly occurs in persons aged 5 to 25 years, with a male-female ratio of 2:1.5,6 Although any bone can be affected, at least 50% of lesions are reported in the lower extremity.7 The proximal femur is involved in 25% to 27% of OOs.8,9 OOs are intra-articular in location in 5% to 12% of cases.8,9 Gaeta et al.8 cited a study by Cohen et al. noting that the most common location of intra-articular OO of the hip was the cortex of the medial femoral neck. We present our technique of arthroscopic excision by unroofing and curettage of OO of the femoral neck and describe 2 cases.
From the Assiut Arthroscopy & Sports Injuries Unit, Orthopaedic & Traumatology Department, Assiut University, Assiut, Egypt. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received July 27, 2013; accepted September 19, 2013. Address correspondence to AbdulRahman Abdulla Babaqi, M.B.B.S., M.Sc., Faculty of Medicine, Assiut University, 71515, Assiut, Egypt. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 2212-6287/13523/$36.00 http://dx.doi.org/10.1016/j.eats.2013.09.011
Case Descriptions
The first case was an 18-year-old man who presented to our institute with the chief complaint of right hip pain, increasing mainly at night, that was dull and nonradiating. The pain started insidiously 2 months earlier. It became worse with walking and exercise. The pain did not affect his activities of daily living. It was often partially relieved by nonsteroidal anti-inflammatory drugs. On examination, the findings of all the hip tests were positive (impingement, labral stress, resisted straight-leg raise, and
Fig 1. Cam lesion of right femoral neck (yellow arrow) with osteolytic lesion on inferior part of neck (red arrow).
Arthroscopy Techniques, Vol 3, No 1 (February), 2014: pp e145-e148
e145
e146
H. G. SAID ET AL.
Fig 2. Magnetic resonance images showing hyperintense nidus as well as surrounding bone edema and joint effusion.
flexioneabductioneexternal rotation tests), with some limitation of range of motion. Radiographs of the hip showed a cam lesion of the right head, which was more visible on the lateral view, with a small osteolytic lesion on the inferior part of the neck. The alpha angle was 65 (Fig 1). Magnetic resonance images showed extensive fluid signal in the region of the neck on the coronal short tau inversion recovery view; this differs from the appearance of a pincer divot, which presents with smaller fluid signal. On the radial magnetic resonance angiography cuts, a hyperintense nidus was observed, along with surrounding bone edema and joint effusion (Fig 2). Multislice computed tomography (CT) showed
the cam lesion and the osteolytic lesion with a central nidus. Hip arthroscopy was performed, and after cam osteoplasty with an arthroscopic burr (Smith & Nephew Dyonics, Andover, MA), the location of the OO was identified and excision and curettage were performed with a curette (Karl Storz, Tuttlingen, Germany) (Video 1). Histopathologic assessment confirmed the diagnosis of OO. The patient improved dramatically on the third day postoperatively. An evaluation performed at 4 months postoperatively showed that the patient’s Harris Hip Score and Oxford Hip Score improved from 54 to 100 and from 19 to 48, respectively. However, the fact that the patient’s improvement was dramatic and occurred within a few days suggests that the OO was more responsible for his symptoms than the cam lesion. The second case was a 35-year-old man who presented with a similar clinical picture for 6 months, but in addition, he had wasting of the quadriceps. The result of the flexioneabductioneexternal rotation test was positive, with double the distance of the knee to the bed compared with other side. Radiographs did not show any significant lesion, but on coronal magnetic resonance imaging, the short tau inversion recovery view showed extensive fluid signal in the region of the femoral neck (Fig 3). Multislice CT showed a welldemarcated nidus overlying the right femoral neck (subperiosteal OO) (Figs 4 and 5). Hip arthroscopy was performed through the peripheral compartment, and the lesion was removed with an arthroscopic grasper (Smith & Nephew) (Video 1). Biopsy confirmed the diagnosis of OO. The patient improved dramatically postoperatively. At the 2-week follow-up evaluation, the Harris Hip Score and Oxford Hip Score improved from 56 to 100 and from 24 to 48, respectively.
Surgical Technique We perform hip arthroscopy by starting in the peripheral compartment using the anatomic surface landmarks without an intraoperative image intensifier.10 Proximal and distal anterolateral portals are used and are sufficient for this procedure.
Discussion OO can present as a cause of hip pain with or without radiologic findings of impingement. The clinical picture of continuous hip pain, worse at night, should alert the surgeon to this possibility. The extensive fluid reaction of the femoral neck seen on magnetic resonance imaging is a telltale sign and should not be mistaken for a pincer divot. If one is in
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Fig 3. Magnetic resonance images showing hyperintense signal over right femoral neck.
Fig 4. Multislice CT scan showing well-demarcated nidus overlying right femoral neck (arrow).
Fig 5. Subperiosteal OO overlying femoral neck before excision.
e148
H. G. SAID ET AL.
doubt, multislice CT will confirm the diagnosis. Hip arthroscopy of the peripheral compartment was performed to excise both lesions in our patients with excellent outcomes and rapid recovery.
References 1. Kransdorf MJ, Stull MA, Gilkey FW, Moser RP Jr. Osteoid osteoma. Radiographics 1991;11:671-696. 2. Jaffe HL. Osteoid osteoma: A benign osteoblastic tumor composed of osteoid and atypical bone. Arch Surg 1935;31: 709-728. 3. Eggel Y, Theumann N, Luthi F. Intra-articular osteoid osteoma of the knee: Clinical and therapeutical particularities. Joint Bone Spine 2007;74:379-381. 4. Greenspan A. Benign bone-forming lesions: Osteoma, osteoid osteoma, and osteoblastoma. Clinical, imaging, pathologic, and differential considerations. Skeletal Radiol 1993;22:485-500.
5. Peyser A, Applbaum Y, Simanovsky N, Safran O, Lamdan R. CT-guided radiofrequency ablation of pediatric osteoid osteoma utilizing a water-cooled tip. Ann Surg Oncol 2009;16:2856-2861. 6. Cerase A, Priolo F. Skeletal benign bone-forming lesions. Eur J Radiol 1998;27(suppl 1):S91-S97. 7. Cohen MD, Harrington TM, Ginsburg WW. Osteoid Osteoma: 95 cases and a review of the literature. Semin Arthritis Rheum 1983;12:265-281. 8. Gaeta M, Minutoli F, Pandolfo I, Vinci S, D’Andrea L, Blandino A. Magnetic resonance imaging findings of osteoid osteoma of the proximal femur. Eur Radiol 2004;14: 1582-1589. 9. Toni A, Calderoni P. Intracapsular metaphyseal osteoid osteoma of the femoral neck. Ital J Orthop Traumatol 1983;9:501-506. 10. Masoud MA, Said HG. Intra-articular hip injection using anatomic surface landmarks. Arthrosc Tech 2013;2: e147-e149.