MRI in the diagnosis of osteoid osteoma

INTRODUCTION: Osteoid osteoma (OO) is a frequently encountered benign bone tumor, seen in young adults with male predominance. MATERIALS AND METHODS: Nine patients complaining of nonspecific extremity pain underwent MRI examination. The sequences obtained were T1 and T2 weighted spin-echo and T2 weighted gradient echo. A CT scan examination followed in all cases, exploring the region of the abnormal signal seen on MRI. The results of both examinations were compared. RESULTS: In six of the nine patients (66.6%) MRI showed evidence suggestive of osteoid osteoma, comparable that seen on CT scan. In three patients (33.3%), MRI showed a nonspecific and ill-defined bone marrow signal abnormality. CT cuts focused on those areas of signal abnormality showed the nidus. DISCUSSION: MRI is more sensitive than CT scan in detecting soft tissue and bone marrow abnormalities adjacent to an osteoid osteoma. This may produce a misleading aggressive appearance on MR images. CT scanning is more specific than MRI, by showing the nidus. In three patients studied, the nidus was only seen by CT, the other six osteoid osteomas were equally seen by CT and by MRI. In our study, MRI revealed abnormalities in all the cases. It was also highly specific for osteoid osteoma in 66.6%. CONCLUSION: MRI is very sensitive in detecting bone marrow and soft tissue abnormalities, and can suggest the diagnosis of OO in a good number of patients. In the remainder cases MRI guides the CT-scan. CT is more accurate and remains the definite examination for the diagnosis of OO, by showing the nidus.     

Osteoid osteoma of the pubic bone. Report of a case

Osteoid osteoma involves the pubic bone in exceptional cases. In this case report, a 23 year-old male patient with osteoid osteoma of the pubic bone, was presented. He was complaining of right groin pain, occurring nocturnally and being relieved by rest and analgesics. Radiographic examination revealed a small lesion in the right pubic bone. The patient was treated surgically, and the nidus was excised. The result of the histopathological examination was "osteoid osteoma". At 1 year postoperatively, recurrence was not seen. It was concluded that, if osteoid osteoma was located in an unusual site, more detailed radiographic examination should be done for exact localization, before the operation.     

Percutaneous therapy of osteoid osteoma

Osteoid osteomas are tumors with intense clinical symptoms and extensive reactive bone changes far exceeding the volume of the lesion itself. Because of their small size they can be approached by minimally invasive surgical procedures. We treated ten symptomatic patients with osteoid osteomas (n 6 hip point, n 1 iliac bone, n 1 femoral diaphysis, n 2 tibial diaphysis) by excision of the nidus with a 3-mm Harlow-Wood needle using a percutaneous CT-guided approach. Seven patients with residual tumor were treated with either thermocautery (n 2) or sclerosis with 1 ml of 96% ethanol (n 5). Six patients had instant and constant relief (3 years' observation) of their pain. In two patients a second transcutaneous intervention was successful. Only two patients needed open resection. Compared with the invasive open resection of the tumors, sometimes even putting the stability of the femoral neck at risk, transcutaneous CT-guided enucleation of the nidus of the osteoid osteoma with additional sclerotherapy is a good alternative method, especially in the region of the femoral neck.     

Discrete synchronous multifocal osteoid osteoma of the humerus

A 24-year-old patient is described who had a 4-year history of pain in the right upper arm, with distinct night pain, that responded to salicylates. From the findings on conventional radiography, bone scintigraphy and MRI a multifocal osteoid osteoma was suspected, with one focus in the cancellous region of the greater tuberosity and a second cortical focus at the proximal humeral diaphysis. The resection "en bloc" of both tumors and histological examination confirmed the diagnosis. The patient was painfree after the curative resection of the two osteoid osteomas. Osteoid osteoma is a frequently found benign bone tumor, accounting for approximately 11% of cases. In rare cases a multicentric occurrence has been described. A possible occurrence of more than one osteoid osteoma in a single bone, not verified histologically, has been reported only three times in the literature. In patients with scintigraphic and radiographic findings of two foci, discrete synchronous multifocal osteoid osteomas should be suspected.     

Percutaneous laser photocoagulation of spinal osteoid osteomas under CT guidance

BACKGROUND AND PURPOSE: Spinal osteoid osteomas are rare; when they occur, they are usually treated by surgical or percutaneous excision. The aim of percutaneous interstitial laser photocoagulation (ILP) of osteoid osteomas under CT guidance is thermal destruction of the nidus using low-power laser energy, thus precluding bone resection and open surgery. METHODS: Three cases of spinal osteoid osteomas were treated with percutaneous ILP of the nidus. Under CT guidance, the needle was positioned in the center of the nidus, at least 8 mm from neurologic structures. Using a high-power semiconductor diode laser (805 nm) with a 400-microm optical fiber, we delivered 600 to 800 joules to the nidus, depending on its size. The procedure was performed with the patient under neuroleptanalgesia and required overnight hospitalization. RESULTS: Complete pain relief was obtained in all three patients within 24 hours of the procedure, and no major complications were incurred. Follow-up ranged from 20 months to 60 months. CONCLUSION: Percutaneous ILP of spinal osteoid osteoma is a promising, simple, precise, and minimally invasive technique and may be an alternative to traditional surgical and percutaneous ablations.     

Imaging of huge lingual thyroid gland with goitre

One year after a nonspecific trauma and with a history of pain of four weeks only, an osteoid osteoma of the first phalanx of the left thumb was diagnosed in a 31-year-old man. The radiologic appearance as well as a bone scan were suggestive for an osteoid osteoma. The diagnosis was confirmed histologically after resection of the tumor. As indicated in the literature, osteoid osteoma of the hand is relatively rare. The symptoms and radiologic features (osteolytic nidus and sclerosis) of osteoid osteomas are independent of the tumor location. Surgery with resection of the nidus is the only known curative therapy. The etiological role of trauma is discussed and a review of the literature is done with 15 other cases of posttraumatic osteoid osteoma having been reported.     

Osteoid osteoma in a three-year-old child--a case report

Osteoid osteoma is an uncommon tumour in the very young. We present a case of osteoid osteoma in a three-year-old boy, who was treated as a case of sclerosing osteomyelitis of the femur. Because of persistent pain and lack of response to treatment, further radiological investigation confirmed the diagnosis to be that of an osteoid osteoma.     

Embolization of the nidus of brain arteriovenous malformations with n-butyl cyanoacrylate

OBJECTIVE: To demonstrate that nidus embolization of brain arteriovenous malformations (AVMs) with Histoacryl (B. Braun, Melsungen, Germany) is effective and yields low morbidity and mortality rates. METHODS: We present a retrospective analysis of 54 brain AVMs treated at the University of Illinois at Chicago from April 1994 to December 1995. Treatment modalities included embolization in all cases and then surgical resection or radiosurgery. INSTRUMENTATION: The nidus was reached with the combined use of a Magic microcatheter (Balt, Montmorency, France) and a Terumo 0.010-inch guidewire. TECHNIQUE: Embolization was performed only when the tip of the microcatheter was wedged into the nidus of the AVMs with no reflux of contrast proximally. The embolization was performed using simultaneous biplane roadmapping with the patient under general anesthesia without Amytal testing. RESULTS: Twenty-six of 54 patients are still waiting for more radical treatment. Two deaths and two minor and one severe permanent neurological deficit occurred. Three patients were cured with embolization alone; 11 patients were cured after surgical resection. Three patients underwent radiosurgery, with one cure after 1 year. CONCLUSION: Nidus embolization with Histoacryl is an effective technique that permits complete cure of a large number of brain AVMs, with or without surgical resection and/or radiosurgery.     

Vascularized fibular graft for reconstruction of the wrist after excision of giant cell tumor

Seven patients with a giant-cell tumor involving the distal end of the radius were treated with en bloc resection and reconstruction with a free vascularized fibular graft. Two patients with stage 2 disease of Enneking's surgical staging and grade 2 of Campanacci's radiographic grading system were reconstructed with an articular fibular head graft. Five patients with stage 3 and grade 3 disease underwent wrist arthrodesis using fibular shaft transfer. There was radiographic evidence of bone union at the host-graft junctions in all cases. No local recurrence was seen in any of the patients at the most recent follow-up examinations. There were six good and one excellent functional results. Wrist arthroplasty using a vascularized fibula head graft is the best procedure for a stage 2 or grade 2 giant-cell tumor of the distal end of the radius. In cases of stage 3 or grade 3 disease, wrist arthrodesis using a vascularized fibular shaft graft is indicated.     

Anterior luxtasphincteric stapled rectumresection

BACKGROUND/AIMS: Sphincter saving deep anterior rectumresection improved the live quality of the rectal cancer patients. With the technical progress the resection level could be moved significant distally. The initial experiences are referred with the use of the stapler with flexible shaft in six patients operated due to very deep rectal cancer. METHODOLOGY: After the usual rectum mobilization the Proximate access AX55 mm (Ethicon) is positioned onto the stretched rectum. The flexible shaft has to be curved to the front and the jaw has to be angled parallel to the handle. The partially closed jaw of the stapler is then pushed towards the anus and then fired. The rectum is the resected. The operation is completed with EEA stapled anastomosis. RESULTS: Excellent results in all six patients could be noticed 3-18 months after the procedure. No cancer recurrence occurred. Functional sphincter investigation was performed in two patients with result of physiologic sphincter function. Stolen frequency has been stabilised between 2-8 a day. CONCLUSION: Improved transabdominal stapled method of rectum resection guarantees comfortable and oncologically safe resection of the distal rectum with maintenance of the sphincter function.     

Radiotherapy in the adjuvant therapy of rectal cancer: comparison of two treatment schedules

From 1988 to 1991 54 patient with carcinoma of the distal part of the rectum were cured in our Department. These patients were divided into two groups (similar with regard to sex, age and advance of disease). In group I (28 patients) abdomino-perineal resection was performed, accompanied (according to histo-pathological indications) by adjuvant radiotherapy to maximal dose 6000 cGy. In group II such procedure was preceded by "short" radiotherapy (4 x 500 cGy). Local recurrence rate was 17.8% in group I and 11.5% in group II. CONCLUSIONS: Preoperative radiotherapy (for example "short" schedule 4 x 500 cGy) may decrease number of local recurrences after abdomino-perineal resections in rectal cancer cases. This procedure effects no technical problems and complications during and after operations.     

Use of Medicare claims data to measure county-level variations in the incidence of colorectal carcinoma

We report retrospective and prospective studies to identify the causes of fracture of the femoral neck associated with femoral shaft nailing on the same side. Of a total of 14 neck fractures in a series of 152 shaft nailings, eight were not visible on the initial pelvic radiographs. We used CT scans before and after operation, and fluoroscopy during the procedure in our prospective series, and reviewed abdominal CT scans retrospectively with the window set to bone level. Six of the eight undisplaced fractures were shown to have been present before operation, but two were iatrogenic. We recommend the preoperative use of CT scans of the femoral neck in high-risk patients such as those with associated fractures of the acetabulum, the distal femur or the patella. Early diagnosis will allow better general management and early fixation of the neck fracture.     

Pain in osteoid osteoma: histological facts

Six cases of osteoid osteoma were studied histologically using the Gross technique. When the nidus is located centrally, it is reached by amyelinic fibers accompanying the vessel branches or as independent fibers. The pain is generally considered to reflect changes in vessel pressure and it could also be due to direct irritation of the nerve fibers included in or near the calcification focus.     

Angiosarcomas associated with bone infarcts

OBJECTIVE: A bone infarct may occasionally dedifferentiate to osteogenic sarcoma, fibrosarcoma or malignant fibrous histiocytoma. However, the association of an angiosarcoma with a bone infarct is extremely rare. Such an association is presented in three patients. Their clinical course is compared with that of patients with bone infarcts associated with other sarcomas. DESIGN AND PATIENTS: The three patients were men with a mean age of 43 years. Cases 1 and 3 presented with a pathological fracture at the site of the angiosarcoma. Plain radiography was done in the three patients, computed tomography (CT) was performed in cases 1 and 3 and magnetic resonance imaging (MRI) in case 3. The femur was the site of the three tumors: midshaft in cases 1 and 3 and distal shaft in case 2. On the basis of the radiographic findings, and clinical examination, an open biopsy was performed for the three men, which confirmed the diagnosis of a high-grade angiosarcoma associated with a bone infarct. RESULTS: Case 1 was treated with high-above knee amputation and is still alive after 18 months from the time of operation. Segmental resection of the distal femur with adjuvant chemotherapy and local irradiation was the treatment for case 2, who is still alive with no tumor recurrence on metastatic disease 3 years from the operation. Intramedullary rodding was done for case 3 who died 6 months later. CONCLUSION: The association of an angiosarcoma with a bone infarct has been established in only five cases. Although the number of such associations is small, it seems that such an association may be prognostically more or less the same as in those cases in which a bone infarct is associated with either osteosarcoma, fibrosarcoma or malignant fibrous histiocytoma, where the survival rate is unfavorable. A cause-and-effect relationship may exist between a bone infarct and subsequent development of a bone sarcoma.     

Adenoviral gene transfer in arteries of hypercholesterolemic nonhuman primates

Osteoid osteoma, a benign bone tumor, has traditionally been treated with operative excision. A recently developed method for percutaneous ablation of the tumor has been proposed as an alternative to operative treatment. The relative outcomes of the two approaches to treatment have not previously been compared, to our knowledge. The rates of recurrence and of persistent symptoms were compared in a consecutive series of eighty-seven patients who were managed with operative excision and thirty-eight patients who were managed with percutaneous ablation with radiofrequency. Patients who had a spinal lesion were excluded. The minimum duration of follow-up was two years. There was a recurrence, defined as the need for subsequent intervention, after operative treatment in six (9 per cent) of sixty-eight patients who had been managed for a primary lesion and in two of nineteen who had been managed for a recurrent lesion. The average length of the hospital stay was 4.7 days for the patients who had a primary lesion and 5.1 days for those who had a recurrent lesion. There was a recurrence after percutaneous treatment in four (12 per cent) of thirty-three patients who had been managed for a primary lesion and in none of five who had been managed for a recurrent lesion. The average length of the hospital stay was 0.2 day for these thirty-eight patients. With the numbers available, we could detect no significant difference between the two treatments with regard to the rate of recurrence. The rate of persistent symptoms (that is, symptoms that did not necessitate additional treatment) was greater than the rate of recurrence. According to responses to a questionnaire, eight (30 per cent) of twenty-seven patients had persistent symptoms after operative treatment and six (23 per cent) of twenty-six patients had persistent symptoms after percutaneous treatment with radiofrequency. Two patients had complications after operative excision, necessitating a total of five additional operations. There were no complications associated with the percutaneous method. The results of the present study suggest that percutaneous ablation with radiofrequency is essentially equivalent to operative excision for the treatment of an osteoid osteoma in an extremity. The percutaneous method is preferred for the treatment of extraspinal osteoid osteoma because it generally does not necessitate hospitalization, it has not been associated with complications, and it is associated with a rapid convalescence.     

Painless osteoid osteoma of the rib in an adult. A case report and a review of the literature

BACKGROUND: An asymptomatic rib lesion was discovered by means of a bone scan obtained during the clinical evaluation of an adult man with biopsy proven prostate adenocarcinoma. Clinically and radiologically considered to be a metastatic focus, on resection it proved to be an osteoid osteoma (OO). METHODS: A review of the English medical literature on OO was conducted with emphasis on the occurrence in older patients, costal location, and the absence of pain. RESULTS: OO in patients older than age 50 years is rare (1% - 2% of cases). Only 18 cases of painless OO were found. Of these, 8 (44%) occurred in the phalanges, and 3 (17%) in the cranial-facial bones, both uncommon sites for OO; only 7 (39%) arose in the long bones, the most common site for conventional OO. A disproportionate number of these patients (44%) were younger than age five years, a rarity for OO. Fourteen reported examples of costal OO were found, all of which were associated with pain. The possible mechanisms involved in the production of pain, including analysis of the effect of its site of origin and the presence of nerve fibers, is reviewed. CONCLUSIONS: Costal OO is distinguished from osteoblastoma and from what has been described as painless fibro-osseous lesion of the rib. The infrequency of metastases as a cause of solitary rib lesion is emphasized.     

Retrograde nailing of humerus shaft fractures with the unreamed humerus nail. An international multicenter study

Combined with the new unreamed humeral nail (UHN) (Synthes), the retrograde approach to the endomedullary canal of the humeral shaft promises careful reduction and fixation of humeral shaft fractures. This prospective multicenter study reports and analyses 102 retrograde nailings with the UHN and their operative procedures. Seven patients with pathological fractures have died meanwhile, but 75 patients could be followed up until bone healing. Seventy-three fresh humeral shaft fractures, 12 pseudarthrosis, 3 refractures and 14 pathological fractures have been treated with the UHN. In 98 cases (96.1%) the surgeon estimated fracture stability well enough to initiate immediate postoperative elbow and shoulder mobilization. The difficulties involved with free-hand interlocking proximally at the nail tip in 5.9%, fissure or avulsion at the insertion point in 3.9% and radial nerve palsy also in 3.9% of the cases were the most important intraoperative complications. In all 75 patients followed up, bone healing occurred, but five fractures (6.7%) needed more than 8 months connected with a second operative procedure. In one case spongious bone transplantation and new locking bolts had been performed. In three cases a special compression device has been used, whereas in one case also a new nail and in the second spongious bone transplantation had been added. In the fifth case plate osteosynthesis had been performed. At the end of treatment 89.4% of the patients had excellent shoulder function and 88.0% excellent elbow function. Once the indication for surgery is established, the UHN can be considered a reliable and safe implant for stabilizing humeral shaft fractures.     

The Donauspital-Stolzalpe concept (Danube Hospital, Vienna, Austria). Corrective osteotomy with selective labrum surgery following preoperative MRI arthrography

Concomitant pathologies (labral lesions, intra-/extra-osseous ganglia and stress bone marrow edema) in adult residual hip dysplasia (RHD) might influence the outcome of conservative hip surgery. The aim of our prospective clinical study was to assess the value of preoperative MR arthrography in diagnosing concomitant lesions and in making surgical decisions in RHD. The first 37 consecutive patients with a minimum follow-up of 18 months have been analysed. All 37 patients presented RHD with the clinical symptomatology of labral lesions and underwent routine preoperative MRA. According to clinical, radiological and MR arthrographical criteria, these 37 patients were subdivided into four therapeutic subgroups: (1) reorientation of the acetabulum using the T?nnis triple pelvic osteotomy (TPO); (2) intertrochanteric varisation osteotomy (IVO); (3) palliative decompression with only symptomatic partial resection of the torn labrum (PALL); (4) primary total hip replacement (TEP). Based on the preliminary clinical and radiological outcomes of these four subgroups, the following conclusions can be drawn: labral lesions are considered to be a sign of chronic joint instability. Therefore, acetabular malorientation should be corrected by redirectional osteotomy of the acetabulum (TPO-subgroup) even in low grades of RHD if labral lesions are present. "Palliative" labral resections without corrective osteotomy (PALL subgroup) in secondary osteoarthritis due to RHD are definitively obsolete, because they rapidly progress to severe osteoarthritis due to surgically accelerated joint instability. In RHD with highly osteoarthritic hip joints and concomitant lesions, one should not hesitate to perform primary THR even in young patients.     

Hair dysplasia in oculo-dento-digital syndrome. Apropos of a mother-daughter case

Oculo-dento-digital syndrome (SODD) as defined by Meyer-Schwickerath in 1957 is a rare entity (84 cases) which belongs to ectodermal dysplasias. It consists of: the characteristic features (long face, pinched nose); syndactyly; ocular, dental and bone abnormalities. This entity is usually transmitted on the autosomal dominant mode. We report two cases (a mother and daughter) with polymalformations which we classed as SODD. Furthermore, agenesis of lacrimal duct and genitourinary abnormalities were noted. The mother had a very particular complex hair shaft dysplasia (incomplete pili torti, "tiger tail" aspect, fractures) with alopecia since she was fifteen years old. The daughter's hair was normal at birth. In SODD, fine and sparse hair is often observed (44 p. 100). Only one patient had hair shaft investigation under polarized light: pili annulati and monilethrix were described but not found in our cases. These two reports incite to the systematic hair shaft study in SODD as other ectodermal dysplasia syndromes.     

Acetabular growth potential in congenital dislocation of the hip and some factors upon which it may depend

The factors which determine the rate and amount of acetabular growth in congenital dislocation of the hip are ill-understood. A prospective radiological study has been devised in order to assess the influence of the age of congruity, femoral anteversion and neck/shaft angles on acetabular growth. To be included, the children must have reached at least 8 years of age. Those with associated congenital abnormalities and subluxation were excluded, as were those who had operations for acetabular reconstruction. Seventy-four hips were suitable for analysis, and the age range at follow-up was from 8 to 17 years. The acetabular angle was used as an index of acetabular growth. Measurement of this angle, and the anteversion and neck/shaft angles were made before, and each year after reduction of the hip. Congruity was assessed from a radiograph with the legs in the functional position. A satisfactory acetabulum was obtained in 44 hips and the mean age of congruity was 33 months; the acetabulum was unsatisfactory in 30 hips, with a mean age of congruity of 48 months. Four years is the critical age, for if congruity is obtained later, the risk of producing a moderate or severely dysplastic acetabulum is more than doubled. If congruity is obtained under four years of age, growth of the acetabulum with continue in most patients up to 8 and in some to 11 YEARS OF age; the resulting acetabulum was normal or mildly dysplastic. Fifty-nine per cent of the satisfactory hips at follow-up had a normal anteversion angle, and 6 per cent a normal neck/shaft angle. Correction of these angles by themselves, seems not to be a major importance for promoting acetabular growth.