The primary aim of this study was to compare the clinical outcomes of osteoid osteoma (OO) between the group of patients with the presence of nidus on biopsy samples from radiofrequency ablation (RFA) with those without nidus. Secondly, we aimed to examine other factors that may affect the outcomes of OO reflecting our experience as a tertiary orthopaedic oncology centre. We retrospectively reviewed 88 consecutive patients diagnosed with OO treated with RFA between November 2005 and March 2015, consisting of 63 males (72%) and 25 females (28%). Sixty-six patients (75%) had nidus present in their biopsy samples. Patients’ mean age was 17.6 years (4-53). Median duration of follow-up was 12.5 months (6-20.8). Lesions were located in the appendicular skeleton in seventy-nine patients (90%) while nine patients (10%) had an OO in the axial skeleton. Outcomes assessed were based on patients’ pain alleviation (partial, complete, or no pain improvement) and the need for further interventions. Pain improvement in the patient group with nidus in histology sample was significantly better than the group without nidus (OR 7.4, CI 1.35-41.4, p=0.021). The patient group with nidus on biopsy demonstrated less likelihood of having a repeat procedure compared to the group without nidus (OR 0.092, CI 0.016-0.542, p=0.008). Our study showed significantly better outcomes in pain improvement in appendicular lesions compared to the axially located lesions (p = 0.005). Patients with spinal lesions tend to have relatively poor pain relief than those with appendicular or pelvic lesions (p=0.007). Patients with nidus on histology had better pain alleviation compared to patients without nidus. The histological presence of nidus significantly reduces the chance of repeat interventions. The pain alleviation of OO following RFA is better in patients with appendicular lesions than spinal or axially located lesions

Aims

The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

Introduction. Ascertaining the etiology of hip pain in young patients can be challenging. Osteoid osteoma about the hip has only been described in case reports and small case series in this sub-population. This study assessed the clinical course, radiologic findings, and treatment approaches in a large series of pediatric osteoid osteoma cases about the hip. Potential diagnostic and treatment pitfalls were identified. Methods. A single-center tertiary care departmental database was queried for all cases of osteoid osteoma seen between Jan 1, 2003 and December 31, 2015. Medical records were reviewed to identify those with lesions identified within or around the hip joint. Clinical, demographic, and radiologic data were analyzed. Results. Fifty children and adolescents (56% female, mean age 12.4 years, range 3–19 years) were identified with osteoid osteoma about the hip. The femoral neck was the most common lesion location (38%), and pain in the hip was the most common presenting chief complaint (60%). Night pain (90%) and symptom relief with NSAIDs (88%) were extremely common, though not universally reported. Sclerosis and/or cortical thickening was visible in 58% of radiographs, though a lucent nidus was visible in only 42%. Thirty patients (60%) underwent MRI, 27 of which were available for review, with focal peri-lesional edema as a universal finding. Amongst intracapsular lesions (n=17, 63%), common findings included medial retinacular thickening (33%), synovitis (45%) and effusion (76%). In the 43 patients (48%) who underwent CT, a diagnostic lucent nidus was a universal finding. Initial alternative diagnoses were recorded in 46% of cases, including, in order of decreasing frequency, femoro-acetabular impingement, minor trauma, hip synovitis, ‘growing pain’, stress fracture, and infection. Abnormal hip range of motion, positive impingement signs, and global synovitis on MRI scan were found to be associated with alternative diagnosis. On multivariate regression analysis, only abnormal hip ROM was independently predictive of alternative diagnosis. Delay in diagnosis of >6 months was seen in 43% of patients. Three patients underwent preceding operative procedures for other hip diagnoses, but had persistent hip pain until the osteoid osteoma was treated. Forty-one patients (82%) ultimately underwent radiofrequency ablation (RFA), and 1 open osteoid osteoma resection was performed. Of those who underwent RFA, 93% achieved complete symptom resolution, with 2 of 3 patients without symptom resolution undergoing revision RFA procedure, 1 of which led to symptom resolution. Complications of treatment included 1 case of deep infection along an RFA track, requiring operative debridement, 1 case of transient weakness and paresthesias in the involved extremity, and 1 case of fracture at the RFA site, requiring ORIF. Conclusions. Alternative andelayed diagnoses are common in osteoid osteoma about the hip, with femoro-acetabular impingement representing the most common alternative initial diagnosis in our series. While varying presenting complaints and nonspecific MRI findings may contribute to diagnostic uncertainty, night pain was present in the vast majority of cases and CT scans provided definitive diagnosis in all patients who received them. As increasing numbers of young, active patients are being evaluated for various causes of hip pain, such as femoro-acetabular impingement, osteoid osteoma should not be overlooked in the differential diagnosis of pain about the hip

Aims

The number of patients undergoing arthroscopic surgery of the hip has increased significantly during the past decade. It has now become an established technique for the treatment of many intra- and extra-articular conditions affecting the hip. However, it has a steep learning curve and is not without the risk of complications. The purpose of this systematic review was to determine the prevalence of complications during and following this procedure.

The widespread use of MRI has revolutionised the diagnostic process for spinal disorders. A typical protocol for spinal MRI includes T1 and T2 weighted sequences in both axial and sagittal planes. While such an imaging protocol is appropriate to detect pathological processes in the vast majority of patients, a number of additional sequences and advanced techniques are emerging. The purpose of the article is to discuss both established techniques that are gaining popularity in the field of spinal imaging and to introduce some of the more novel ‘advanced’ MRI sequences with examples to highlight their potential uses.

Cite this article: Bone Joint J 2015;97-B:1683–92.

Atypical cartilaginous tumours are usually treated by curettage. The purpose of this study was to show that radiofrequency ablation was an effective alternative treatment.

We enrolled 20 patients (two male, 18 female, mean age 56 years (36 to 72) in a proof-of-principle study. After inclusion, biopsy and radiofrequency ablation were performed, followed three months later by curettage and adjuvant phenolisation. The primary endpoint was the proportional necrosis in the retrieved material. Secondary endpoints were correlation with the findings on gadolinium enhanced MRI, functional outcome and complications.

Our results show that 95% to 100% necrosis was obtained in 14 of the 20 patients. MRI had a 91% sensitivity and 67% specificity for detecting residual tumour after curettage. The mean functional outcome (MSTS) score six weeks after radiofrequency ablation was 27.1 (23 to 30) compared with 18.1 (12 to 25) after curettage (p < 0.001). No complications occurred after ablation, while two patients developed a pathological fracture after curettage.

We have shown that radiofrequency ablation is capable of completely eradicating cartilaginous tumour cells in selective cases. MRI has a 91% sensitivity for detecting any residual tumour. Radiofrequency ablation can be performed on an outpatient basis allowing a rapid return to normal activities. If it can be made more effective, it has the potential to provide better local control, while improving functional outcome.

Cite this article: Bone Joint J 2014;96-B:1540–5.

Introduction. The femoral neck in children is a common site for bone lesions. The majority are benign. However these lesions can cause diagnostic problems. Aim. To present a spectrum of chronic lesions of the femoral neck in children and emphasize the importance of tissue diagnosis. Materials and methods. Thirty two children with isolated chronic bone lesions in the femoral neck treated between 1994 and 2013were retrospectively reviewed. The ages ranged between 1–13 years. Clinical features were pain and limp. Routine blood tests, x-rays and CT scans were done in all and MRI scans in 5 cases. All diagnoses were confirmed histologically. Results. Three radiological patterns were seen: lucent or cystic in 22, infiltrative (permeative)in 2, and localized densities with nidus in 8 cases. Histologically the lesions were subacute osteomyelitis in 4, tuberculosis in 9, simple bone cyst in 7, osteoid osteoma in 7, chondroblastoma in 1, monostotic fibrous dysplasia in 2 and eosinophilic granuloma in 2 cases. Two tuberculous lesions were associated with subluxation of the hip and involvement of the head occurred in 2 others. Treatment and outcome. All lesions were curetted. Bone grafting was done in 10. Immobilisation was by internal fixation in 1, traction in 2 and spica cast in 29 cases. Follow up was 9 months to 11 years. Healing occurred in the majority. Recurrence occurred in 2 cases. Coxa vara developed in 6, and growth disturbance with shortening in 9 patients. Discussion. Femoral neck lesions are mainly benign, present diagnostic difficulty and treatment is challenging. There are problems with immobilization and of purchase with fixation devices due to poor bone stock on the neck of femur. The spica cast is a reliable method of immobilization in children under 10years. Growth disturbance and coxa vara can result after healing. CT scan is useful in assessing the architecture of the bone. NO DISCLOSURES

Purpose of the study. To review the primary bone tumours of the spine treated at our unit. Description of methods. Retrospective review of folders and x-rays of all the patients with primary bone tumours of the spine treated at our unit between 2005 and 2012. All haematological tumours were excluded. Summary of results. We treated 15 cases during this period. The median age at presentation was 36 years (8–65). There was a significant delay from onset of symptoms to diagnosis in most cases (median 7 months). Histological diagnoses included:. -Benign tumours.  Active. Hemangioma. 3. Osteoid osteoma. 1. Eosinophilic granuloma. 1.  Aggressive. Osteoblastoma. 1. Giant cell tumours. 2. Aneurysmal bone cysts. 4. -Malignant tumours.  Osteosarcomas. 2.  Leiomyosarcoma of bone. 1. A variety of definitive surgical methods were utilised. Seven patients had a debulking or intralesional resection of the tumour. Eight patients had an attempted marginal excision. This was achieved through anterior surgery only in 1 case, posterior only surgery in 6 cases and combination anterior and posterior surgery in 8 cases. The anterior and posterior surgery was performed in a single sitting in 5 cases and in a staged fashion in 3 cases. Adjuvant radiotherapy and chemotherapy were used where indicated. Three cases presented with significant neurological impairment. Of these 2 made a significant recovery. There were no cases of neurological deterioration following surgery. All 3 patients with malignant tumours died in the follow up period. We had 1 case of hardware failure due to chronic sepsis. Conclusion. Primary bone tumours of the spine are associated with a significant delay in diagnosis. Surgical treatment options and adjuvant therapy should be tailor made for each case depending on the diagnosis. Acceptable results with minimal complications can be achieved with this approach

Introduction. Hand tumors are usually rare and there is not much literature about series of cases. We have studied a series of 110 cases. Hand tumors do consists of both benign and malignant cases. Methods. We studied series of 110 cases at Karnataka Institute of Medical Sciences, Hubli and Mysore Medical College & Research Institute, Mysore. We retrospectively reviewed the records of 110 patients who underwent double ray amputations at our center over few years: few had amputations of the fourth and fifth rays and others amputation of the second and third rays. Mean age at surgery was 34 years (range, 10–45 years), and minimum follow up was 64 months (mean, 98 months; range, 64–136 months). Some patients had high-grade soft tissue sarcomas of the hand, synovial sarcomas, malignant peripheral nerve sheath tumors, and undifferentiated sarcoma. No patients had detectable metastases at surgery. Results. All patients were completely disease-free at latest follow up. One patient was alive with lung metastases detected 32 months after surgery. No patients developed local tumor recurrence. Functional assessment showed a mean Musculoskeletal Tumor Society score of 24 (range, 19–28) and mean grip strength 24% of the contra lateral side (range, 17%–35%). Conclusions. The majority of osseous tumors of the hand are benign. The surgeon who evaluates and treats osseous tumors of the hand has to be familiar with limb anatomy, tumor biology, various presentations of the tumors and the range of treatment possibilities and their limitations. Lesions in the hand more often present earlier in their course than those at other sites, just because they are more likely to superficial and easily noticed. Ganglion cyst is the most frequently encountered comprising 50–70% of benign tumors of hand. Enchondroma was the next common benign bone tumour followed by osteoid osteoma, osteoblastoma, aneurismal bone cyst, giant cell tumor, epidermoid cyst, and osteochondroma. Although malignant neoplasms in the hand that arise from tissues other than the skin are very rare, the hand may be the site of distant breast, lung, kidney, esophagus, or colon adenocarcinoma metastases, most of which have a predilection for the distal phalanges. Malignant tumours of the hand are rare, although there remain many instances in which marginal excisions are performed for unsuspected malignant hand lesions. Suboptimal biopsy incisions and inadvertent contamination during these excisions may result in larger resections or amputations being necessary to ensure complete removal of the tumour with negative margins

Back pain is a common symptom in children and adolescents. Here we review the important causes, of which defects and stress reactions of the pars interarticularis are the most common identifiable problems. More serious pathology, including malignancy and infection, needs to be excluded when there is associated systemic illness. Clinical evaluation and management may be difficult and always requires a thorough history and physical examination. Diagnostic imaging is obtained when symptoms are persistent or severe. Imaging is used to reassure the patient, relatives and carers, and to guide management.

Cite this article: Bone Joint J 2014;96-B:717–23.

Osteoid osteoma is treated primarily by radiofrequency (RF) ablation. However, there is little information about the distribution of heat in bone during the procedure and its safety. We constructed a model of osteoid osteoma to assess the distribution of heat in bone and to define the margins of safety for ablation. Cavities were drilled in cadaver bovine bones and filled with a liver homogenate to simulate the tumour matrix. Temperature-sensing probes were placed in the bone in a radial fashion away from the cavities. RF ablation was performed 107 times in tumours < 10 mm in diameter (72 of which were in cortical bone, 35 in cancellous bone), and 41 times in cortical bone with models > 10 mm in diameter. Significantly higher temperatures were found in cancellous bone than in cortical bone (p <  0.05). For lesions up to 10 mm in diameter, in both bone types, the temperature varied directly with the size of the tumour (p < 0.05), and inversely with the distance from it. Tumours of > 10 mm in diameter showed a trend similar to those of smaller lesions. No temperature rise was seen beyond 12 mm from the edge of a cortical tumour of any size. Formulae were developed to predict the expected temperature in the bone during ablation. Cite this article: Bone Joint J 2014; 96-B:677–83

Osteoid osteoma is a benign bone-forming lesion, characterized by its small size, its clearly demarcated outline and by the usual presence of a surrounding zone of reactive bone formation. It often poses a diagnostic challenge due to its ambiguous presentation. The aetiology of osteoid osteoma is poorly understood. The previous suggestion that osteoid osteoma was not associated with trauma or infection has been challenged by more recent literature raising the possibility that it could be a reactive or healing response or a phenomenon associated with the revascularisation process. This case report describes an unusual presentation of a post-traumatic osteoid osteoma. Two years following a diaphyseal, spiral tibial fracture treated nonoperatively, the patient developed new pain at the previous fracture site. The pain was constant, relieved by non-steroidal analgesia and not associated with systemic upset. It was initially attributed to other more likely diagnoses such as osteomyelitis and neuropathic pain. Multiple investigations and interventions were undertaken prior to the definitive diagnosis being obtained by surgical excision of the lesion and histological studies five years after the injury and three years following the initiation of the discomfort. In both English and foreign language literature there are only seven case reports that document osteoid osteoma following fracture, these are predominantly in the lower limb with no predominance to operative or nonoperative management. This case report should raise the index of clinical suspicion of osteoid osteoma occurring post fracture

Purpose. The hip region is the second most common site for tuberculosis following the spine in children. The aim is to describe the variable radiological patterns of presentation and their resemblance to pyogenic infection, tumours and other benign conditions of bone in children. Methods. The clinical and radiological records of 29 children aged 10 months–13 years with confirmed tuberculosis of the hip region seen between 1990 and 2011 were reviewed retrospectively. Clinical features were pain, limp and flexion, adduction contractures. Abscesses and sinuses were seen in 4 children. The ESR ranged between 7–110 mm/hr. Mantoux was positive in 20 children. All cases were histologically confirmed. Treatment involved biopsy, currettage of bone defects, limited synovectomy and adductor tenotomy. Patients were immobilised for 4 weeks on a spica cast or traction. Antituberculous treatment was administered for 9–12 months. Results. Radiologically 9 lesions were extra-articular and 20 involved the joint synovium and articular surface. Extra-articular lesions were seen in the pubis, greater and lesser trochanter, ilium, proximal femur and peri-acetabular regions. Intra-articular lesions were seen in the femoral head, neck and acetabulum. Dislocations and subluxations occurred in 8 patients; various lesions mimicked pyogenic arthritis, idiopathic chondrolysis, chondrobastoma, Perthes disease, eosinophilic granuloma and osteoid osteoma. Follow up ranged between 8 months and 5 years. Good range of movement was seen in 20 children. Nine children had flexion adduction contractures, four of these had ankylosed hips and five required abduction extension osteotomies. Other changes seen were coxa vara (2) coxa magna (1) and avascular necrosis (3). Conclusion. The variable radiological picture of tuberculosis of the hip region can mimic various osteoarticular conditions in children. Biopsy is essential and should be taken from the bony lesion and not the synovium alone. NO DISCLOSURES

The February 2013 Oncology Roundup. 360 . looks at: proximal fibular tumours; radiotherapy-induced chondrosarcoma; mega-prosthesis; CRP predictions of sarcoma survival; predicting survival in metastatic disease; MRI for recurrence in osteoid osteoma; and a sarcoma refresher

Pathological fractures in children can occur as a result of a variety of conditions, ranging from metabolic diseases and infection to tumours. Fractures through benign and malignant bone tumours should be recognised and managed appropriately by the treating orthopaedic surgeon. The most common benign bone tumours that cause pathological fractures in children are unicameral bone cysts, aneurysmal bone cysts, non-ossifying fibromas and fibrous dysplasia. Although pathological fractures through a primary bone malignancy are rare, these should be recognised quickly in order to achieve better outcomes. A thorough history, physical examination and review of plain radiographs are crucial to determine the cause and guide treatment. In most benign cases the fracture will heal and the lesion can be addressed at the time of the fracture, or after the fracture is healed. A step-wise and multidisciplinary approach is necessary in caring for paediatric patients with malignancies. Pathological fractures do not have to be treated by amputation; these fractures can heal and limb salvage can be performed when indicated.

Introduction. Bony tumours of the foot account for approximately 3% of all osseous tumours. However, literature regarding os calcis and talar tumours comprises individual case reports, short case series or literature reviews with no recent large series. Methods. We retrospectively reviewed the medical notes and imaging for all patients with calcaneal or talar tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed. Results. 34 calcaneal tumours and 23 talar tumours were identified. Calcaneal tumours. 2:1 male prevalence, mean age at presentation 30, average length of symptoms 9 months. 4 cases presented with pathological fracture. 21 benign tumours including 6 unicameral bone cysts, 3 chondroblastoma, and a wide variety of individual lesions. 13 malignant tumours comprising 6 osteosarcoma, 5 chondrosarcoma and 2 Ewings sarcoma. Talar Tumours. male to female ratio 3:1, mean age at presentation 28, average length of symptoms 5 months. 20 benign cases including 7 osteoid osteoma, 4 chondroblastoma, and several individual lesions. 3 malignant lesions comprising 2 chondrosarcoma, 1 osteosarcoma. Discussion. Tumours of the hindfoot frequently are delayed in diagnosis due to their rarity and lack of clinician familiarity. They are more common in men, especially talar tumours, which are most commonly benign osteoid osteoma or chondroblastoma. Calcaneal tumours have 1 in 3 risk of malignancy and cover a wider variety of lesions. Osteosarcoma of the foot tends to present later than other anatomical regions. Outcome is dependant on early diagnosis, timely surgery and most importantly neo-adjuvant chemotherapy. Diagnosis is often made on plain radiograph but MRI is the gold standard. Despite their rarity clinicians should maintain a high index of suspicion as accurate and timely diagnosis is important to management and outcome

Introduction. CT guided percutaneous radiofrequency thermo coagulation is the treatment of choice for osteoid osteomas. Good results with a low complication rate have been shown for spinal lesions. When lesions are within close proximity to neurological structures or if patients have radicular symptoms surgery rather than radiofrequency ablation has been advocated. We present our experience of radiofrequency ablation of spinal osteoid osteomas which are less than 5mm from neurological structures, including those causing radicular symptoms. Methods. Data was collected prospectively on all patients with a spinal osteoid osteoma within 5mm of nerve roots or the spinal cord as measured on CT scanning. There were nine patients, five female and four males. Four were located in the thoracic spine, three in the lumbar spine and two in the cervical spine. The mean distance to the nearest neurological structure was 3mm. Radicular symptoms were present in two patients. The mean number of probe positions used was two. Lesions were heated to 90 degrees for 5 minutes for each probe position. There were two cases of recurrence, both treated successfully with one further procedure each. There were no cases of neurological injury. The two patients with radicular symptoms had full resolution of their symptoms. At a mean follow up of 2 years following treatment all patients are asymptomatic. Conclusion. Radiofrequency ablation can be safely performed to treat osteoid osteomas located within 5mm of neurological structures and has a low rate of recurrence

Introduction. Chondroblastomas are rare bone tumours accounting for approximately 1% of all benign bone lesions. They occur in children and adolescents and are more frequent in males. The conventional treatment for chondroblastomas is surgery, however, this can be difficult and disabling due to the apo- or epiphyseal location. Surgery is curative in most cases, but recurrence rates of 10%–35% have been reported in the literature. Radiofrequency ablation is well established in the treatment of osteoid osteomas and painful bone metastases. We report our experience with the use of radiofrequency ablation in the treatment of chondroblastomas. Methods. Seven patients were identified from our Tumour database with biopsy proven chondroblastomas who were treated with Percutaneous CT Guided Radiofrequency Thermo coagulation. Results. The tumour was successfully treated in all patients with no recurrences. In two cases, complications occurred; infraction of a sub-articular chondroblastoma in one case and cartilage and bone damage in the unaffected compartment of a knee joint in the other. Discussion. Radiofrequency thermocoagulation of chondroblastomas offers a minimally invasive alternative to open surgery. The risk of complications would appear lower than with open surgery. Multi-tined expandable electrode systems allow the treatment of large chondroblastomas

Introduction. Bony tumours of foot account for approximately 3% of osseous tumours. However, literature regarding calcaneal tumours comprises individual case reports, short case series or literature reviews, with last large case series in 1973. Literature on bony tumours of the talus is limited to case reports only. Methods. We retrospectively reviewed medical notes and imaging for all patients with calcaneal or talar tumours recorded in the Scottish Bone Tumour Registry since the 1940's. Demographics, presentation, investigation, histology, management and outcome were reviewed. Results. 38 calcaneal tumours and 24 talar tumours were identified. Calcaneal tumours. Mean age at presentation 30 with heel pain and swelling, average length of symptoms 9 months. 4 cases present with pathological fracture. 24 tumours benign including 6 unicameral bone cysts, 3 chondroblastoma, 3 PVNS with calcaneal erosion, and wide variety of individual lesions. 13 malignant tumours comprising 6 osteosarcoma, 5 chondrosarcoma and 2 Ewing's sarcoma. 1 metastatic carcinoma. Talar Tumours. Mean age at presentation 28 with ankle pain and occasionally swelling, average length of symptoms 5 months. 20 benign cases including 7 osteoid osteoma, 4 chondroblastoma, and variety of individual lesions. 3 malignant lesions comprising 2 chondrosarcoma, one osteosarcoma. Discussion. Tumours of hindfoot frequently are delayed in diagnosis due to rarity and lack of clinician familiarity. They are more common in men especially talar tumours which are most commonly benign osteoid osteoma or chondroblastoma. Calcaneal tumours have 1 in 3 risk of malignancy. Diagnosis is often made on plain radiograph but MRI is the gold standard. Conclusion. We present largest case series of calcaneal tumours and first case series of talar tumours from the Scottish Bone Tumour Registry. Despite their rarity clinicians should maintain a high index of suspicion as accurate and timely diagnosis is important to management and outcome

Objective. To evaluate the rise in impedance during percutaneous radiofrequency thermo coagulation (PRFTC) of osteoid osteomas as a predictor of local recurrence. Design and Patients. A prospective study of 23 patients (24 PRFTC procedures) with minimum of 2.25-year follow-up (average 3.3 years). Average age 19.6 years (range 4–44), sex ratio 15□:□8 (male□:□female), 16 non-diaphyseal, 7 diaphyseal. Results. In 19 procedures, an increase in impedance was measured—no recurrences have occurred in this group to date. In 5 procedures, no increase in impedance was seen (3 non-diaphyseal, 2 diaphyseal), and 1 recurrence has been seen in this group to date. This difference is statistically significant with a P value of .05