Radiofrequency ablation of osteoid osteoma using a three-dimensional navigation system

The surgical management of osteoid osteoma: A systematic review

Background

Osteoid osteoma (OO) comprises approximately 11%-14% of benign bone tumors. The main symptom of OO is localized pain accompanied by nighttime aggravation. Surgical treatment is frequently used in clinic, including open surgery and percutaneous ablation, the latter including radiofrequency ablation, cryoablation, and microwave ablation, but there is no consensus on when and how to choose the best treatment for OO.

Purpose

We did a systematic review of the literature on existing surgical treatments of OO to assess the safety and efficacy of surgical treatments of OO and to evaluate the surgical options for different locations of OO.

Methods

The inclusion criteria in the literature are 1. Patients diagnosed with osteoid osteoma and treated surgically; 2. Include at least five patients; 3. Perioperative visual analogue scale (VAS), postoperative complications, and recurrence were recorded; 4. Literature available in PubMed from January 2014 to December 2021.

Results

In the cohort, 1565 patients (mainly adolescents) with OO received 1615 treatments. And there are 70 patients with postoperative recurrence and 93 patients with postoperative complications (minor: major=84:9). The results of Kruskal-Wallis examination of each experimental index in this experiment were clinical success rate H=14.818, p=0.002, postoperative short-term VAS score H=212.858, p<0.001, postoperative long-term VAS score H=122.290, p<0.001, complication rate H=102.799, p<0.001, recurrence rate H=17.655, p<0.001, the technical success rate was H=45.708, p<0.001, according to the test criteria of α=0.05, H₀ was rejected. The overall means of the outcome index in each group were not completely equal.

Conclusion

Percutaneous ablation and open surgery are safe and reliable for OOs, and the technical success rate of percutaneous ablation is higher than that of open surgery. Open surgery and cryoablation can be selected for OOs close to the nerve and atypical sites, while radiofrequency ablation and microwave ablation can be selected for OOs in most other sites.

CT-guided radiofrequency ablation for osteoid osteomas: a systematic review

OBJECTIVES

CT-guided radiofrequency ablation (CT-RFA) is considered to be the gold standard for treatment of osteoid osteoma (OO) yet treatment failures (TFs) continue to be reported. This systematic review was conducted to evaluate factors associated with TF, such as ablation time, lesion location, and patient age as well as evaluating how TF has trended over time.

METHODS

Original studies reporting on patients undergoing CT-RFA of OO published between 2002 and 2019 were identified. TF was defined as patients with (1) recurrent or persistent pain +/- (2) imaging evidence of persistent OO. TFs were subdivided into those occurring after the index procedure (primary TF) or those occurring after repeat RFA (secondary TF). Subgroup analysis was performed for TF based on the study date (2002-2010 or 2010-2019), time duration of ablation at 90 °C (6 min or > 6 min), patient age, and tumor location (spinal vs. appendicular).

RESULTS

Sixty-nine studies were included for a total of 3023 patients. The global primary TF rate was 8.3% whereas the secondary TF rate was 3.1%. The TF rate reported in studies published after 2011(7%) was about half that during the earlier time period 2002-2010 (14%). There was no statistical difference in TF corrected for age, OO location, or duration of ablation (respectively p = 0.39, 0.13, and 0.23). The global complication rate was 3%, the most frequent being skin burns (n = 24; 0.7%).

CONCLUSIONS

A decrease in TF observed between 2011-2019 compared to 2002-2010 may reflect improvements in operator technique or advancements in equipment. Duration of ablation, patient age, or location of OO failed to significantly correlate with TF.

KEY POINTS

• CT-guided radiofrequency ablation of osteoid osteomas is a safe technique with a low rate of treatment failure (8.3% failure rate after the primary radiofrequency reducing to 3.1% following a secondary treatment). • The treatment failure rate has decreased over time, possibly due to an improved understanding of the disease process, better technique, and advances in equipment. • Duration of ablation, patient age, or lesion location did not significantly correlate with treatment failure.

Intraoperative 2D C-arm and 3D O-arm in children: a comparative phantom study

PURPOSE

Exposure to ionizing radiation is a concern for children during intraoperative imaging. We aimed to assess the radiation exposure to the paediatric patient with 2D and 3D imaging.

METHODS

To evaluate the radiation exposure, patient absorbed doses to the organs were measured in an anthropomorphic phantom representing a five-year-old child, using thermoluminescent dosimeters. For comparative purposes, organ doses were measured using a C-arm for one minute of fluoroscopy and one acquisition with an O-arm. The cone-beam was centred on the pelvis. Direct and scattered irradiations were measured and compared (Student's t-test). Skin entrance dose rates were also evaluated.

RESULTS

All radiation doses were expressed in µGy. Direct radiation doses of pelvic organs were between 631.22 and 1691.87 for the O-arm and between 214.08 and 737.51 for the C-arm, and were not significant (p = 0.07). Close scattered radiation on abdominal organs were between 25.11 and 114.85 for the O-arm and between 8.03 and 55.34 for the C-arm, and were not significant (p = 0.07). Far scattered radiation doses on thorax, neck and head varied from 0.86 to 6.42 for the O-arm and from 0.04 to 3.08 for the C-arm, and were significant (p = 0.02). The dose rate at the skin entrance was 328.58 µGy.s^-1 for the O-arm and 1.90 with the C-arm.

CONCLUSION

During imaging of the pelvis, absorbed doses for a 3D O-arm acquisition were higher than with one minute fluoroscopy with the C-arm. Further clinical studies comparing effective doses are needed to assess ionizing risks of the intraoperative imaging systems in children.

Osteoid osteoma: Contemporary management

Osteoid osteoma is a benign bone-forming tumor with hallmark of tumor cells directly forming mature bone. Osteoid osteoma accounts for around 5% of all bone tumors and 11% of benign bone tumors with a male predilection. It occurs predominantly in long bones of the appendicular skeleton. According to Musculoskeletal Tumor Society staging system for benign tumors, osteoid osteoma is a stage-2 lesion. It is classified based on location as cortical, cancellous, or subperiosteal. Nocturnal pain is the most common symptom that usually responds to salicyclates and non-steroidal anti-inflammatory medications. CT is the modality of choice not only for diagnosis but also for specifying location of the lesion, i.e. cortical vs sub periosteal or medullary. Non-operative treatment can be considered as an option since the natural history of osteoid osteoma is that of spontaneous healing. Surgical treatment is an option for patients with severe pain and those not responding to NSAIDs. Available surgical procedures include radiofrequency (RF) ablation, CT-guided percutaneous excision and en bloc resection.

Percutaneous excision of difficult osteoid osteomas using intraoperative AIRO CT navigation: a preliminary report

Osteoid osteomas are well known for intraoperative technical difficulties for localization and adequate excision, especially when they are not clearly visualized on plain radiographs or when they occur in difficult and inaccessible situations. Localization in the radiology suite and shifting the patient to the operating room can be cumbersome, and can result in errors because of lack of real-time imaging. In these scenarios, intraoperative navigation will be useful. We report a technique of intraoperative computed tomography (CT) navigation for localization and excision of osteoid osteomas of the long bones. Six patients (four femoral and two tibial lesions) with a radiological diagnosis of osteoid osteoma, in whom the nidus could not be visualized clearly on plain radiographs, were treated with this technique. Intraoperative CT navigation with AIRO was performed and the images were registered to the computer. The lesion was then localized and excised using a high-speed burr. All patients underwent postexcision on-table CT scans, which showed complete excision of the nidus. All patients became symptom free and are doing well at a minimum follow-up of 6 months. Intraoperative CT navigation helps to exactly localize the nidus and also helps to confirm complete excision of the nidus. This is a safe, effective and minimally invasive method to treat osteoid osteomas, particularly those that are not amenable to excision under C arm guidance.

A review of literature: Mosaicoplasty as an alternative treatment for resection of patellar osteoid osteoma and cartilage reconstruction

Osteoid osteoma is an uncommon benign tumor and causes severe pain, being worse at night, that responds dramatically to nonsteroidal anti-inflammatory medications. An osteoid osteoma of the patella is very rare and if it arise close to chondral surface differential diagnosis may be challenging. In three patients the osteoid osteoma was completely excised by nidus removal by mosaicoplasty set with open surgical technique. The patients were followed up in average for 31 (16-48 months) months with annual clinical and radiographic evaluations. There were no relapse of the pain and no residual recurrent tumor. The aim of the treatment for osteoid osteoma is to remove entire nidus by open surgical excision or by percutaneous procedures such as percutaneous radiofrequency and laser ablation. Mosaicoplasty is a good alternative for treatment of osteoid osteoma of the patella in the subchondral bone.

Present role and future perspectives of interventional radiology in the treatment of painful bone lesions

Interventional radiology has experienced an exponential growth in the last years. Nowadays it is possible to treat painful benign lesions or metastases with optimal results in terms of pain management and disease control. Among the benign lesions, osteoid osteoma is the most frequently treated with minimal invasive techniques and the results are excellent. Another lesion, traditionally treated with surgery (osteoblastoma) represent today another field of application. In the oncological field, metastases are, numerically, the most diffuse indications for treatment. Research carried out during the last decades has provided the interventional radiologist with a great variety of techniques of ablation and devices for monitoring the sensitive structures close to the target lesion. New ablation techniques and monitoring devices contribute to the achievement of significantly increasing rates of effectiveness and safety of interventional radiology procedures.

Arthroscopic Excision of an Osteoid Osteoma of the Lesser Trochanter of the Femoral Neck

Osteoid osteoma frequently requires surgical treatment, especially among young, active patients. However, surgeons are reluctant to perform open surgery for an osteoid osteoma of the femoral neck area because the conventional surgical approach requires a large incision in muscular patients, and percutaneous resection with a trephine has the attendant risk of subsequent fracture. Recently, arthroscopic excision of an osteoid osteoma has been reported as a less invasive, safer procedure than traditional open curettage. Hip arthroscopy using the burr-down technique under C-arm guidance to locate and remove the lesion of the femur neck has also shown promise. The presented technique minimizes muscle damage around the femur and enables surgeons to confirm complete resection of the lesion through direct, detailed visualization. Furthermore, early return to previous activity can be achieved after excising the lesion located at the calcar femorale, which is an area with a heavy weight-bearing load. The objective of this Technical Note was to describe our preferred technique for the surgical excision of osteoid osteoma located at the base of the femoral neck through the use of arthroscopy.