HIP

Arthroscopic treatment of recurrent acetabulum osteoid osteoma

Anastasios Tokis • Georgios Tsakotos •

Theano Demesticha

Received: 29 July 2013 / Accepted: 30 November 2013

� Springer-Verlag Berlin Heidelberg 2013

Abstract In this case report, arthroscopic treatment of a

recurrent osteoid osteoma in the posterior column of the

pelvis extending to the acetabular fovea in a young ado-

lescent is being presented.

Level of evidence IV.

Keywords Hip arthroscopy � Osteoid osteoma �Acetabulum

Introduction

Osteoid osteoma is a relative common benign bone tumour

accounting for approximately 12 % of all benign skeletal

neoplasms, most commonly located in the long bones of

the lower extremities in the second and third decade of life

[8]. The presenting symptom is increasing pain, usually at

night with pain relief by use of aspirin and nonsteroidal

anti-inflammatory drugs.

Only 1–3 % of all cases involve the pelvis area and

0.5 % the acetabulum [3]. In intraarticular osteoid osteoma,

the classic symptoms may not always be present, and the

diagnosis might mislead for a long period. There are cases

where hip osteoid osteoma is misinterpreted as transient

osteoporosis of the hip joint, osteonecrosis, septic arthritis,

inflammatory arthritis, osteoarthritis, labrum tear, stress

fracture or synovitis.

Treatment options include radiofrequency ablation [7],

percutaneous computed tomography-guided resection [14],

fluoroscopic-guided percutaneous technique [11], magnetic

resonance-guided focused ultrasound ablation [12], open

surgical procedure with femoral head dislocation, arthro-

scopic excision [1, 6, 9] and arthroscopy-assisted radio-

frequency ablation technique [15].

Case report

A 19-year-old man presented in May 2012, 14 months after

his initial treatment with percutaneous computed tomog-

raphy-guided radiofrequency ablation for a left intraartic-

ular acetabular osteoid osteoma, suffering from recurrent

symptoms. He reported that pain was never subsided

completely after his treatment. Moreover, 3 months after

his initial treatment pain was the same or even worse than

the initial clinical presentation.

Clinically, the patient mentioned pain at the left hip

joint, increased at night, and restriction of the hip joint

range of motion. The diagnostic work-up revealed recur-

rent osteoid osteoma as the most possible diagnosis.

Computed tomography (Fig. 1) and MRI (Fig. 2) showed

the lesion located at the left posterior column of the pelvis

extending to the acetabular fovea.

Arthroscopic excision of the lesion was the preferable

choice of treatment. A second radiofrequency ablation

could damage the articular cartilage. Moreover, the loca-

tion of the lesion was difficult to access, and the excessive

synovitis could not be addressed with radiofrequency

ablation. In addition, the traditional open surgical proce-

dure with hip dislocation has higher rates of complications

compared with arthroscopy.

Hip arthroscopy was performed under general anaesthesia

using a traction table. The patient was in the supine position,

and the affected hip joint was distracted. The standard

anterior, anterolateral and anteroinferior portals were used.

A. Tokis (&) � G. Tsakotos � T. Demesticha

Department of Orthopaedic Surgery and Sports Medicine,

Metropolitan Hospital Athens, Athens, Greece

e-mail: tatokis@yahoo.gr

123

Knee Surg Sports Traumatol Arthrosc

DOI 10.1007/s00167-013-2805-4

Arthroscopy revealed a hyperaemic synovium, which

was removed with a motorized shaver. The nidus and the

reactive bone of the lesion were removed by the use of

curettes and aggressive burrs. Loose bone fragments were

also removed. The remaining cavity was cleaned. Speci-

mens from the lesion (Fig. 3) were sent for histological

examination and culture.

Total operation time was 90 min. There were no post-

operative neurological or vascular complications. Cultures

were negative, and the histological examination confirmed

the diagnosis of recurrent osteoid osteoma.

Partial weight-bearing for 10 days was recommended.

The pain and the patient’s symptoms disappeared imme-

diately after the operation, and full range of motion of the

left hip joint was gradually gained. The patient returned to

his daily activity after 1 month, and at 12-month follow-up,

he remains symptoms free with full strength and range of

motion. Computed tomography 6 months postoperatively

depicts progressive ossification of the remaining acetabular

cavity after the excision of the lesion (Fig. 4).

Discussion

Osteoid osteoma is a benign bone tumour. Pain, especially

at night, is the leading symptom, and the usual radiological

sign is a nidus surrounded by reactive sclerotic bone.

Therefore, when the osteoid osteoma is intraarticular, as in

the acetabulum, the symptoms and radiological features

may be nonspecific, and patients complain for articular

pain, joint tenderness and effusion.

Radiofrequency ablation is a common method of treat-

ment. Recurrence of osteoid osteoma is likely in case of

incomplete excision of the lesion. For adequate pain relief,

the entire nidus has to be removed. Recurrence after

radiofrequency ablation has been reported in up to 24 % of

cases treated [5], mainly in the first 7 months after treat-

ment. In this case report, the patient reported recurrence of

his symptoms 3 months after his initial treatment with

radiofrequency ablation.

Secondary intervention with radiofrequency ablation of

the recurrent lesion is a treatment option, but there is

serious concern about possible thermal damage and

destruction of the acetabular and femoral head cartilage

[4].

In such cases of recurrence, conventional surgical

approach is the treatment of choice. Surgery requires large

incision, wide resection and possible femoral head dislo-

cation, in order to access the lesion, with higher rates of

postoperative complications and recovery time.

Arthroscopic excision of osteoid osteoma [2, 13], in

general, is effective and causes minimal damage to normal

Fig. 3 Specimens from the lesion

Fig. 4 Postoperative CT scan

Fig. 1 Preoperative CT scan

Fig. 2 Preoperative MRI

Knee Surg Sports Traumatol Arthrosc

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bone and cartilage or the adjacent growth plate in children

[10], and synovectomy for concomitant synovitis can also

be addressed. Also, an adequate biopsy specimen can be

taken for histopathological examination.

To the best of our knowledge, this is the first case in the

literature, where a recurrent acetabular osteoid osteoma

was treated successfully arthroscopically.

Conclusions

Recurrence of osteoid osteoma usually requires wide sur-

gical excision as a definite method of treatment. Intraar-

ticular recurrent osteoid osteoma, as at the acetabulum,

presents difficulties regarding lesion access. In such cases,

especially when weight-bearing joints are involved, less

invasive techniques—as hip arthroscopy—could be a reli-

able and effective method of treatment. In summary, hip

arthroscopy can address not only the primary acetabular

osteoid osteoma but also its recurrence. Arthroscopical

process enables direct visualization and approach of the

tumour, which achieves less morbidity in contrast with

other methods, immediate relief of symptoms and faster

return to previous functional level.

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