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CASE REPORT Table of Contents   
Year : 2004  |  Volume : 38  |  Issue : 3  |  Page : 183-184
Osteoid osteoma- puzzling presentation & effective management a case report


Department of Orthopaedics, PD Hinduja National Hospital & Research Centre, Mumbai, India

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How to cite this article:
Agarwala S, Rajput B S. Osteoid osteoma- puzzling presentation & effective management a case report. Indian J Orthop 2004;38:183-4

How to cite this URL:
Agarwala S, Rajput B S. Osteoid osteoma- puzzling presentation & effective management a case report. Indian J Orthop [serial online] 2004 [cited 2019 Dec 7];38:183-4. Available from: http://www.ijoonline.com/text.asp?2004/38/3/183/37289

   Introduction Top


Osteoid Osteoma is a benign osteoblastic tumour of enchondral bones. This is usually found in the patients between the ages of 7 and 25 with a male to female ratio of approximately 3:1. The tumour is characterised histologically by a central core of vascular osteoid tissue (nidus) surrounded by a zone of sclerotic bone[1]. The commonest site of involvement is the femur followed by the tibia, humerus and spine. Hands and feet may also be involved. The hallmark of osteoid osteoma is the insidious onset of symptoms which start as a dull ache and progress to intense and persistent pain. Here we report a case of osteoid osteoma where a double pathology confused the presentation due to overlapping symptoms.


   Case Report Top


A young boy of 17 years presented with complaints of low back ache with pain radiating to left thigh and calf for 6 months. On examination SLR was 600 with ankle and knee jerks normal and grade IV power in the extensor hallucis longus with no paraesthesia on the affected side. The hip movements were full and free with no localized tenderness. X-ray lumbosacral spine was unremarkable while MRI showed L4/5 posterolateral disc prolapse with indentation over left sided L5 nerve root.

Due to persistence of pain in the left lower limb and inability to attend college in spite of conservative treatment, a lumbar microdiscectomy was performed with disc excision at L4/5 and left sided L5 root clearance. Post operatively the patient's LBA and calf pain disappeared for the first two days however from 3rd post operative day he complained of pain in left lower limb localizing it now to the front of left thigh with radiation upto the left knee.

A repeat MRI was done and cord and nerve root clearance were confirmed. The severity of pain warranted a relook surgical exposure. This confirmed a total clearance around the nerve root. The patient recovered for two days, however he had recurrence of pain on 3rd day. Since the pain was episodic and persistent a bone scan was ordered and this revealed a high activity zone around lesser trochanter. A CT and MRI of the affected region were done which confirmed an osteolytic lesion surrounded by a zone of sclerosis in the anteromedial part of the femoral neck proximal to lesser trochanter [Figure - 1]a,b.

It was elected to excise the nidus as the pain was persistent. The patient was taken on fracture table and through a lateral incision the nidus was localized under Carm image intensifier. It was in the anteromedial quadrant and only seen in the 15 external rotation. Recognizing that a surgical defect left behind could result in a stress fracture subsequently, it was planned to protect this by a spanning DHS plate. The nidus was precisely excised using a high speed Midas rex cutting K 1 burr [Figure - 2].This is a high revolution pointed bone cutter and helps cutting a precise piece of bone. Next a DHS plate fixation was done to avoid chances of a stress fracture neck femur. The excised piece was immediately screened under C arm to confirm the complete removal of the nidus.The surgically created gap was filled by an exactly sized muscle pedicle corticocancellous bone graft from the greater trochanter. The patient was completely relieved of his symptoms and discharged on elbow crutches.


   Discussion Top


Though posterolateral disc is frequent, the symptoms of osteoid osteoma can be missed, particularly in the presence of co-morbid pathology. The spine surgery in this case was justified for the persistent pain, distress and the EHL weakness, which recovered after surgery. The annoying pain in the thigh led us to suspect a painful hip rather than the spine as a cause for the pathology. MRI helped in localising the lesion[2].

The removal of the localized nidus, though simple enough due to C-Arm localization, would have left a major defect in the weight bearing bone of this active young man. This was a surgical challenge, as it would entail 3 months of bedrest but surgical expertise had something else to offer.

Here we elected to buttress and protect the stress raiser( left behind by the defect in the calcar) with a dynamic hip screw, a device used for fractures in that region of hip , which often permits immediate partial weight bearing.

The second important step was the mobilization of a precisely cut muscle pedicle corticocancellous bone graft through the same incision from anterior greater trochanter area and impacting it in the defect left behind from the excised nidus. This helped bring bone and blood into the defect and permitted early mobilization. Both of them we feel have helped in the excellent net outcome.

 
   References Top

1.Resnick D, Niwayama G. Tumour & tumour like lesions of bone. Philadelphia, W B Saunders.1995:3620-35.  Back to cited text no. 1    
2.Davies M, Cassar-Pullicino VN et al. The diagnostic accuracy of MRimaging in osteoid osteoma. Skeletal radiology. 2002;31:559-569.  Back to cited text no. 2    

Top
Correspondence Address:
B S Rajput
Department of Orthopaedics, PD Hinduja National Hospital & Research Centre, Mahim, Mumbai,
India
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Source of Support: None, Conflict of Interest: None


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    Figures

  [Figure - 1], [Figure - 2]



 

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    Introduction
    Case Report
    Discussion
    References
    Article Figures
 

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