Arthroscopic Excision of an Intra-articular Osteoid Osteoma
Now open: Certificate Course in Management of Covid-19 by Govt. Of Gujarat and PlexusMDKnow more...Now open: Certificate Course in Management of Covid-19 by Govt. Of Gujarat and PlexusMDKnow more...
A 30-year-old man presented with persistent pain, swelling, and stiffness of the right elbow for 18 months with partial relief of symptoms on non-steroidal anti-inflammatory drugs (NSAIDs) and disease-modifying anti rheumatoid drugs. No fever, night pain, or any other joint involvement was noted and there was no history of any trauma. On physical examination, there was moderate effusion, 20–110° of flexion-extension, normal pronosupination, and a stable elbow joint. X-ray was normal and inflammatory markers were all negative. Synovial fluid analysis suggested non-specific inflammation and the culture was sterile. Computed tomography (CT) evaluation revealed a well-defined lucent nidus with a central sclerotic focus (5 mm) breaching the articular margins of the trochlear notch with limited sclerosis in the periphery. There was also reactive fluffy periosteal reaction and edema involving the adjacent intermuscular plane of the proximal forearm. Magnetic resonance imaging (MRI) showed a hypointense central nidus in the trochlear notch on T1 and T2 sequences with minimal T2 hyperintensity in the periphery suggesting unmineralized stroma. Surrounding hypointense sclerosis was visualized in the T1 sequence. There was also bone edema involving the proximal ulna with minimal joint effusion and synovial proliferation of the elbow joint.

Under general anesthesia, the patient was positioned in lateral decubitus, arm suspended in elbow support, and a proximal tourniquet placed. Insufflation with 20 ml saline through the soft spot portal helped in distension of capsule and pushing away of the major neurovascular structures from the field. Diagnostic arthroscopy was done using a 2.8 mm 30° arthroscope through a direct lateral (soft spot) portal. There was a florid synovial reaction in the ulnohumeral joint overlying a purplish red area in the trochlear notch. An inside-out proximal anteromedial working portal was made 1 cm proximal and in front of the medial epicondyle. Blunt probe palpation revealed a soft and easily yielding lesion with surrounding dense unyielding trabecular bone. Synovial tissue was sampled for evaluation using a cupped biter. An accessory posterolateral portal was made through which the joint was debrided using a 4 mm shaver blade. This improved the vision drastically and the lesion was seen as a small bump into the joint. Using a straight chisel, the lesion was excised en bloc. An arthroscopic biter and a ring curette were used to remove the surrounding sclerotic bone and were completed with a 4 mm arthroscopic burr. Radiofrequency ablation of the base of the lesion was done using a 90° radio frequency probe in short pulses. No capsular release was done.

Postoperatively, he was put on a sling and gentle range of motion (ROM) exercises were started immediately. The patient had significant pain relief and improvement in ROM. He was out of sling on the 8th day. Histopathological evaluation was suggestive of OO with a characteristic nidus with varying degrees of maturity and an interlacing network of osteoid and bony trabeculae. Synovial biopsy was suggestive of nonspecific synovitis. At the 6th month follow-up, the patient was asymptomatic with full elbow ROM.