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Osteoid osteoma of the great toe: A case report
Foot and Ankle Surgery 16 (2010) e12–e15
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Osteoid osteoma of the great toe: A case report Charlie R.J. Jowett MBBS, BSc(Hons.), MRCS*, Dishan Singh FRCS(Orth.)1 Royal National Orthopaedic Hospital, Stanmore, Flat 84 Garand Court, Hornsey Street, London, N7 8EB, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 December 2007 Received in revised form 6 April 2009 Accepted 14 April 2009
Osteoid osteoma of the great toe is an uncommon finding and usually treated with radiofrequency ablation. We present a case that is more appropriately treated with surgical excision. ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Osteoid osteoma Great toe Radiofrequency ablation Surgical excision
1. Introduction
2. Case report
Osteoid osteoma is a tumour of bone first described in 1935 by Jaffe [1]. It is a benign osteoblastic lesion characterised by a well demarcated core of usually less than 1 cm, and by a distinctive surrounding zone of reactive bone formation [2]. The characteristic features are of pain and an increase in local temperature. The pain is usually relieved with non-steroidal anti-inflammatory drugs. The pain caused by these tumours results from production of large amounts of prostaglandins, thus NSAIDS are typically effective for analgesia in these patients [3] It most commonly affects adolescents and young adults, occurring more commonly in males [4]. Osteoid osteomatas are most often found in the long bones of the legs and arms, particularly the femur. Several studies have indicated that the talus is the most commonly affected bone in the foot [5]. The incidences in phalanges of the hand and foot are reported to be 7% and 1%, respectively. Unique features in the phalanx of the toe are soft tissue swelling and a nidus frequently located in the cancellous or subperiosteal region [6,7]. We are aware of only two other cases in the literature of an osteoid osteoma of the great toe [8,9].
We report a case of a 20-year-old female student who presented with a 3-year history of a painful, swollen left great toe. There was no history of trauma. The pain was a dull deep aching pain occasionally occurring at night which was slightly relieved with non-steroidal anti-inflammatories and aspirin. She was otherwise fit and well with no other joint pain elsewhere and no relevant family history. On examination she had a swollen left hallux (Fig. 1), which was tender on palpation. Her hallux interphalangeal joint was stiffer on the left and had 308 of motion compared to 608 on the right. The neurovascular status was normal and the overlying skin was of normal colour with a slight increase in temperature. Inflammatory markers were within the normal range. Radiographs showed a lesion at plantar aspect of the proximal phalanx of the great toe (Fig. 2). This was confirmed on computerised tomography, which also revealed a sclerotic matrix with a lucent area (Fig. 3). The lesion on the CT scan showed it to start almost flush with the head of the proximal phalanx and extend towards the central part of the phalanx proximally. The appearances were suggestive of an osteoid osteoma at the plantar aspect of the head of the proximal phalanx of the great toe. The patient underwent surgical excision of the head of the proximal phalanx and interphalangeal joint fusion due to the close proximity of the lesion to the joint in order not to leave an unstable joint (Fig. 4).
* Corresponding author. Tel.: +44 07970 645055; fax: +44 01202 740696. E-mail addresses: [email protected] (Charlie R.J. Jowett), [email protected] (D. Singh). 1 Tel.: +44 07980 802706.
1268-7731/$ – see front matter ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2009.04.005
C.R.J. Jowett, D. Singh / Foot and Ankle Surgery 16 (2010) e12–e15
e13
Fig. 3. MRI scan confirming lesion on plantar aspect of proximal phalanx with a sclerotic matrix and lucent area extending from the head of the proximal phalanx almost to the middle of the phalanx. Fig. 1. Photo of swollen left hallux.
Histopathology of the specimen showed an osteoid osteoma with typical morphological features with a central nidus surrounded by irregular reactive new bone (Fig. 5). The articular cartilage showed minor degenerative changes and the synovium showed a conspicuous number of mast cells but was otherwise unremarkable. Postoperatively the patient was put into a wedge shoe and was non-weight bearing for two weeks. The wedge shoe was worn for a total of four weeks and the patient had an uneventful postoperative recovery. It took six weeks to achieve union postoperatively. 3. Discussion This case represents an unusual location of an osteoid osteoma that was correctly diagnosed on MRI scan. However the preoperative diagnosis is only presumptive and definitive diagnosis was only confirmed with complete resection and histologic examination.
The previous cases described in the great toe reported similar histories of ongoing pain in a young person with spontaneous onset. Jaffe and Lichenstein [9] described a case which revealed a lesion in the proximal medial corner of the distal phalanx of the great toe, as in our case this was treated with excision but not fusion and the symptoms were completely alleviated. Microscopy revealed numerous trabeculae and irregular patches of osteoid set in a substratum of highly vascular osteogenic connective tissue. Kahn et al. [8] presented a case of a young female with a 10 month history of a dull ache in the right great toe, this was associated with mild erythematous changes and thought to be onychocryptosis, for which she had a partial nail avulsion. This did not alleviate the symptoms and new X-rays revealed a suspicious area of radiolucency on the distal lateral tuft of the distal phalanx of the right hallux. The lesion was partially calcified with a sclerotic border, this was excised and microscopy revealed signs consistent with an osteoid osteoma. Although an uncommon finding in the foot it should always be considered a differential diagnosis in young patients presenting
Fig. 2. There is sclerosis and expansion of the proximal phalanx of the great toe. Cortical thickening appears most marked distally and there is a small focus of lucency in the plantar aspect of the proximal phalanx.
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C.R.J. Jowett, D. Singh / Foot and Ankle Surgery 16 (2010) e12–e15
Fig. 4. Postoperative radiographs taken 3 weeks following excision of the head of the proximal phalanx and interphalangeal joint fusion.
with a history of pain and a local increase in temperature at the affected site and no history of trauma [10]. The treatment of choice in our unit for removal is CT guided radiofrequency ablation. Rosenthal et al. were the first to describe the application of radiofrequency ablation in the treatment of osteoid osteoma [11]. This method allows the precise delivery of heat under image guidance to the targeted tissue. High frequency alternating current at 500,000 Hz transmitted through a delivery probe induces local ionic agitation and frictional heat in the tissue about the probe leading to coagulation necrosis. Difficulty in lesion localisation at surgery has made this method increasingly favourable [12]. Complications associated with radiofrequency ablation have been recurrence of the lesion and damage to neighbouring neurovascular structures particularly if ablating cancellous bone. Convalescence after hand radiofrequency ablation is
shorter than that for lower extremity lesions, therefore it is more popular for these lesions. Surgical excision also has its advantages. It allows histological confirmation and examination to ensure complete or partial excision and is more appropriate for appendicular lesions where the nidus is within 1.5 cm of the neurovascular bundle [13]. Most patients have dramatic relief of symptoms following surgery, and the recurrence rate is rare [14]. In this case surgical excision and fusion was the most appropriate choice due to the close proximity of the lesion to the joint and neurovascular structures, as excision or radiofrequency alone would have left an unstable joint. Although radiofrequency ablation of osteoid osteoma is a highly effective, efficient, minimally invasive and safe method of treating osteoid osteoma surgery still has an important role in certain cases.
C.R.J. Jowett, D. Singh / Foot and Ankle Surgery 16 (2010) e12–e15
Fig. 5. Histology showing typical osteoid osteoma appearances of a central nidus surrounded by irregular reactive new bone.
References [1] Jaffe HL. Osteoid osteoma. A benign osteoblastic tumour composed of osteoid and atypical bone. Arch Surg 1935;31:709–28.
e15
[2] Anderson WA, Kissane JM. Pathology. St. Louis: C.V. Mosby; 1977. pp. 1970– 2011. [3] Campanacci M, Ruggiere P, Gasbarrini A, Ferraro A, Campanacci L. Osteoid osteoma. Direct visual identification and intralesional excision of nidus with minimal removal of bone. J Bone Joint Surg 1999;81B: 814–20. [4] de Souza, Diaz L, Frost H. Osteoid osteoma-osteoblastoma. Cancer 1974;33: 1075–81. [5] Sherman MS. Osteoid osteoma. Review of the literature and report of thirty cases. J Bone Joint Surg 1947;29:918–30. [6] LaCroix ML, Thomas JR, Nicholas RW. Subperiosteal osteoid osteoma of the distal phalanx of the fourth toe. Orthopedics 2001;24:695–6. [7] Onoue K, Kudawara I. Osteoid osteoma with cartilage formation of the distal phalanx in the toe. Orthopedics 2007;30:670. [8] Kahn MD, Tiano FJ, Lillie RC. Osteoid osteoma of the great toe. J Foot Surg 1983;22(4):325–8. [9] Jaffe HL, Lichenstein L. Osteoid osteoma: further experience with this benign tumor of bone. J Bone Joint Surg 1940;22:645–82. [10] Freschi S, Dodson NB. Osteoid Osteoma: an uncommon cause of foot pain. J Am Podiatr Med Assoc 2007;97:405–9. [11] Rosenthal DI, Alexander A, Rosenberg AE, Sprongfield D. Ablation of osteoid osteomas with percutaneously placed electrode: a new procedure. Radiology 1992;183:29–33. [12] Cantwell CP, Obyrne J, Eustace S. Current trends in treatment of osteoid osteoma with an emphasis on radiofrequency ablation. Eur Radiol 2004;14: 607–17. [13] Yildiz Y, Baykracki K, Altay, Saglik Y. Osteoid osteoma: the results of surgical treatment. Int Orthop 2001;25:119–22. [14] Shereff MJ, Cullivan WT, Johnson KA. Osteoid osteoma of the foot. J Bone Joint Surg Am 1983;65:638–41.
Contents lists available at ScienceDirect
Foot and Ankle Surgery journal homepage: www.elsevier.com/locate/fas
Case report
Osteoid osteoma of the great toe: A case report Charlie R.J. Jowett MBBS, BSc(Hons.), MRCS*, Dishan Singh FRCS(Orth.)1 Royal National Orthopaedic Hospital, Stanmore, Flat 84 Garand Court, Hornsey Street, London, N7 8EB, UK
A R T I C L E I N F O
A B S T R A C T
Article history: Received 3 December 2007 Received in revised form 6 April 2009 Accepted 14 April 2009
Osteoid osteoma of the great toe is an uncommon finding and usually treated with radiofrequency ablation. We present a case that is more appropriately treated with surgical excision. ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Osteoid osteoma Great toe Radiofrequency ablation Surgical excision
1. Introduction
2. Case report
Osteoid osteoma is a tumour of bone first described in 1935 by Jaffe [1]. It is a benign osteoblastic lesion characterised by a well demarcated core of usually less than 1 cm, and by a distinctive surrounding zone of reactive bone formation [2]. The characteristic features are of pain and an increase in local temperature. The pain is usually relieved with non-steroidal anti-inflammatory drugs. The pain caused by these tumours results from production of large amounts of prostaglandins, thus NSAIDS are typically effective for analgesia in these patients [3] It most commonly affects adolescents and young adults, occurring more commonly in males [4]. Osteoid osteomatas are most often found in the long bones of the legs and arms, particularly the femur. Several studies have indicated that the talus is the most commonly affected bone in the foot [5]. The incidences in phalanges of the hand and foot are reported to be 7% and 1%, respectively. Unique features in the phalanx of the toe are soft tissue swelling and a nidus frequently located in the cancellous or subperiosteal region [6,7]. We are aware of only two other cases in the literature of an osteoid osteoma of the great toe [8,9].
We report a case of a 20-year-old female student who presented with a 3-year history of a painful, swollen left great toe. There was no history of trauma. The pain was a dull deep aching pain occasionally occurring at night which was slightly relieved with non-steroidal anti-inflammatories and aspirin. She was otherwise fit and well with no other joint pain elsewhere and no relevant family history. On examination she had a swollen left hallux (Fig. 1), which was tender on palpation. Her hallux interphalangeal joint was stiffer on the left and had 308 of motion compared to 608 on the right. The neurovascular status was normal and the overlying skin was of normal colour with a slight increase in temperature. Inflammatory markers were within the normal range. Radiographs showed a lesion at plantar aspect of the proximal phalanx of the great toe (Fig. 2). This was confirmed on computerised tomography, which also revealed a sclerotic matrix with a lucent area (Fig. 3). The lesion on the CT scan showed it to start almost flush with the head of the proximal phalanx and extend towards the central part of the phalanx proximally. The appearances were suggestive of an osteoid osteoma at the plantar aspect of the head of the proximal phalanx of the great toe. The patient underwent surgical excision of the head of the proximal phalanx and interphalangeal joint fusion due to the close proximity of the lesion to the joint in order not to leave an unstable joint (Fig. 4).
* Corresponding author. Tel.: +44 07970 645055; fax: +44 01202 740696. E-mail addresses: [email protected] (Charlie R.J. Jowett), [email protected] (D. Singh). 1 Tel.: +44 07980 802706.
1268-7731/$ – see front matter ß 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.fas.2009.04.005
C.R.J. Jowett, D. Singh / Foot and Ankle Surgery 16 (2010) e12–e15
e13
Fig. 3. MRI scan confirming lesion on plantar aspect of proximal phalanx with a sclerotic matrix and lucent area extending from the head of the proximal phalanx almost to the middle of the phalanx. Fig. 1. Photo of swollen left hallux.
Histopathology of the specimen showed an osteoid osteoma with typical morphological features with a central nidus surrounded by irregular reactive new bone (Fig. 5). The articular cartilage showed minor degenerative changes and the synovium showed a conspicuous number of mast cells but was otherwise unremarkable. Postoperatively the patient was put into a wedge shoe and was non-weight bearing for two weeks. The wedge shoe was worn for a total of four weeks and the patient had an uneventful postoperative recovery. It took six weeks to achieve union postoperatively. 3. Discussion This case represents an unusual location of an osteoid osteoma that was correctly diagnosed on MRI scan. However the preoperative diagnosis is only presumptive and definitive diagnosis was only confirmed with complete resection and histologic examination.
The previous cases described in the great toe reported similar histories of ongoing pain in a young person with spontaneous onset. Jaffe and Lichenstein [9] described a case which revealed a lesion in the proximal medial corner of the distal phalanx of the great toe, as in our case this was treated with excision but not fusion and the symptoms were completely alleviated. Microscopy revealed numerous trabeculae and irregular patches of osteoid set in a substratum of highly vascular osteogenic connective tissue. Kahn et al. [8] presented a case of a young female with a 10 month history of a dull ache in the right great toe, this was associated with mild erythematous changes and thought to be onychocryptosis, for which she had a partial nail avulsion. This did not alleviate the symptoms and new X-rays revealed a suspicious area of radiolucency on the distal lateral tuft of the distal phalanx of the right hallux. The lesion was partially calcified with a sclerotic border, this was excised and microscopy revealed signs consistent with an osteoid osteoma. Although an uncommon finding in the foot it should always be considered a differential diagnosis in young patients presenting
Fig. 2. There is sclerosis and expansion of the proximal phalanx of the great toe. Cortical thickening appears most marked distally and there is a small focus of lucency in the plantar aspect of the proximal phalanx.
e14
C.R.J. Jowett, D. Singh / Foot and Ankle Surgery 16 (2010) e12–e15
Fig. 4. Postoperative radiographs taken 3 weeks following excision of the head of the proximal phalanx and interphalangeal joint fusion.
with a history of pain and a local increase in temperature at the affected site and no history of trauma [10]. The treatment of choice in our unit for removal is CT guided radiofrequency ablation. Rosenthal et al. were the first to describe the application of radiofrequency ablation in the treatment of osteoid osteoma [11]. This method allows the precise delivery of heat under image guidance to the targeted tissue. High frequency alternating current at 500,000 Hz transmitted through a delivery probe induces local ionic agitation and frictional heat in the tissue about the probe leading to coagulation necrosis. Difficulty in lesion localisation at surgery has made this method increasingly favourable [12]. Complications associated with radiofrequency ablation have been recurrence of the lesion and damage to neighbouring neurovascular structures particularly if ablating cancellous bone. Convalescence after hand radiofrequency ablation is
shorter than that for lower extremity lesions, therefore it is more popular for these lesions. Surgical excision also has its advantages. It allows histological confirmation and examination to ensure complete or partial excision and is more appropriate for appendicular lesions where the nidus is within 1.5 cm of the neurovascular bundle [13]. Most patients have dramatic relief of symptoms following surgery, and the recurrence rate is rare [14]. In this case surgical excision and fusion was the most appropriate choice due to the close proximity of the lesion to the joint and neurovascular structures, as excision or radiofrequency alone would have left an unstable joint. Although radiofrequency ablation of osteoid osteoma is a highly effective, efficient, minimally invasive and safe method of treating osteoid osteoma surgery still has an important role in certain cases.
C.R.J. Jowett, D. Singh / Foot and Ankle Surgery 16 (2010) e12–e15
Fig. 5. Histology showing typical osteoid osteoma appearances of a central nidus surrounded by irregular reactive new bone.
References [1] Jaffe HL. Osteoid osteoma. A benign osteoblastic tumour composed of osteoid and atypical bone. Arch Surg 1935;31:709–28.
e15
[2] Anderson WA, Kissane JM. Pathology. St. Louis: C.V. Mosby; 1977. pp. 1970– 2011. [3] Campanacci M, Ruggiere P, Gasbarrini A, Ferraro A, Campanacci L. Osteoid osteoma. Direct visual identification and intralesional excision of nidus with minimal removal of bone. J Bone Joint Surg 1999;81B: 814–20. [4] de Souza, Diaz L, Frost H. Osteoid osteoma-osteoblastoma. Cancer 1974;33: 1075–81. [5] Sherman MS. Osteoid osteoma. Review of the literature and report of thirty cases. J Bone Joint Surg 1947;29:918–30. [6] LaCroix ML, Thomas JR, Nicholas RW. Subperiosteal osteoid osteoma of the distal phalanx of the fourth toe. Orthopedics 2001;24:695–6. [7] Onoue K, Kudawara I. Osteoid osteoma with cartilage formation of the distal phalanx in the toe. Orthopedics 2007;30:670. [8] Kahn MD, Tiano FJ, Lillie RC. Osteoid osteoma of the great toe. J Foot Surg 1983;22(4):325–8. [9] Jaffe HL, Lichenstein L. Osteoid osteoma: further experience with this benign tumor of bone. J Bone Joint Surg 1940;22:645–82. [10] Freschi S, Dodson NB. Osteoid Osteoma: an uncommon cause of foot pain. J Am Podiatr Med Assoc 2007;97:405–9. [11] Rosenthal DI, Alexander A, Rosenberg AE, Sprongfield D. Ablation of osteoid osteomas with percutaneously placed electrode: a new procedure. Radiology 1992;183:29–33. [12] Cantwell CP, Obyrne J, Eustace S. Current trends in treatment of osteoid osteoma with an emphasis on radiofrequency ablation. Eur Radiol 2004;14: 607–17. [13] Yildiz Y, Baykracki K, Altay, Saglik Y. Osteoid osteoma: the results of surgical treatment. Int Orthop 2001;25:119–22. [14] Shereff MJ, Cullivan WT, Johnson KA. Osteoid osteoma of the foot. J Bone Joint Surg Am 1983;65:638–41.