Oarmbilm

tp

CAmi

FsS

M

aa

tS

7

Radiofrequency Ablation inOsteoid Osteoma of the Finger

Luis Ramos, PhD, José Ángel Santos, PhD,Genoveva Santos, MD, Salamanca, Spain,

Jesús Guiral, PhD, Segovia, Spain

The occurrence of osteoid osteomas of the hand is rare and their treatment usually is surgical. A26-year-old man with an osteoid osteoma in the proximal phalanx of the right middle finger wastreated with percutaneous radiofrequency ablation. Two years later he remains free of pain andfinger function is normal. (J Hand Surg 2005;30A:798–802. Copyright © 2005 by the AmericanSociety for Surgery of the Hand.)

Key words: Osteoid osteoma, phalanx, finger, percutaneous, radiofrequency.

itai

psAspoiacar

oscbcteTef3

steoid osteoma is a benign osteoblastic lesion char-cterized by a nidus of usually less than 1 cm sur-ounded by a zone of reactive sclerosis. It is esti-ated that it accounts for approximately 11% of all

enign bone tumors.1 Although it generally is locatedn the femur and the tibia, 13% to 31% of theseesions are found in the upper extremity,2,3 and it

ay be present in the hand in up to 5% of cases.2,4

Percutaneous radiofrequency ablation of an os-eoid osteoma in the phalanx of the hand has beenerformed exceptionally.5

ase Report26-year-old right-handed man described a 30-

onth history of pain, swelling, and limited motionn his right middle finger. He described the pain as an

rom the Departments of Orthopaedic Surgery and Radiology, Univer-ity Hospital, Salamanca, Spain; and the Department of Orthopaedicurgery, General Hospital, Segovia, Spain.Received for publication November 11, 2004; accepted in revised formarch 15, 2005.No benefits in any form have been received or will be received fromcommercial party related directly or indirectly to the subject of this

rticle.Corresponding author: Luis Ramos, PhD, Department of Trauma-

ología y Cirugı́a Ortopédica, Paseo de San Vicente, 108-182, 37007-alamanca, Spain; e-mail: luisramospascua@usuarios.retecal.es.Copyright © 2005 by the American Society for Surgery of the Hand0363-5023/05/30A04-0023$30.00/0

wdoi:10.1016/j.jhsa.2005.03.009

98 The Journal of Hand Surgery

ntense, continuous, and nocturnal ache that was con-rolled partially by analgesics. He never took aspirin,nd there was no significant history of trauma ornfection.

Physical examination showed tenderness over theroximal interphalangeal joint and proximal phalanx,welling, and decreased range of motion (Fig. 1).nteroposterior and lateral radiographs showed a

mall lytic lesion in the distal metaphysis of theroximal phalanx with mild reactive-appearing peri-steal bone formation (Fig. 2). A bone scan showedncreased uptake (Fig. 3), and computed tomographynd magnetic resonance imaging confirmed the lu-ent nidus in the volar aspect of the proximal phalanxnd soft-tissue inflammation (Figs. 4, 5). Laboratoryesults were normal.

By using computed tomography the nidus of thesteoid osteoma was localized. Under local anesthe-ia, a 1.5 mm K-wire was placed into the lesion’senter through a palmar approach between the ulnarorder of the flexor tendon and the ulnar neurovas-ular bundle. A cannula was placed over the wire andhe wire was replaced through the cannula by a straightlectrode (TEW-STC; Radionics, Burlington, MA).he electrode was insulated throughout the lengthxcept for the terminal 5 mm and was heated to 75°Cor 4 minutes with a radiofrequency generator (RFG-CF; Radionics) (Fig. 6). The neurovascular bundle

as 6 mm from the electrode tip. The electrode and

twaf

tePmmch7l

DAapTswletCmF

t

Ramos et al / Radiofrequency Ablation in Osteoid Osteoma 799

he cannula were removed and the small skin woundas closed with sterile tape. A light dressing was

pplied to the finger. A specimen was not obtainedor histologic testing.

Figure 1. Initial appearance of right middle finger.

igure 2. Posteroanterior x-ray of the proximal phalanx of

lhe middle finger. The arrow indicates the nidus.

After surgery the patient noted immediate relief ofhe previous finger pain, although he had transient par-sthesia on the ulnar side of the finger for 2 months.roximal interphalangeal joint motion was started im-ediately and the patient returned to work after 1onth. At the 2-month follow-up evaluation he was

ompletely free of pain and had full range of motion ofis finger. Two years later he remains without pain (Fig.). Radiographic examination showed a persistent smallytic lesion in the phalanx (Fig. 8).

iscussionpproximately 6% of osteoid osteomas in the hand

nd half to three quarters of these are located in thehalanges, especially in the proximal phalanx.3,6–8

he appearance of osteoid osteoma in the handhows certain similarities to osteoid osteoma else-here in the skeleton, but it can be unusual. Painless

esions and synovitis with effusion in the finger canxist.4,9–11 Radiologically the typical aspects of os-eoid osteoma are found in only 65% of cases.12

onsequently the diagnosis and treatment may beissed and delayed,6,13 especially in the distal pha-

Figure 3. Bone scan showing increased uptake.

anx.14 The clinical and radiographic presentation of

occ

ibdno

bema

iscc

hows

F

800 The Journal of Hand Surgery / Vol. 30A No. 4 July 2005

steoid osteoma in our patient was typical. Mostases are diagnosed by history and then confirmed bylinical examination and specific imaging methods.8,15

The classic treatment of an osteoid osteoma, includ-ng those of the hand, is to remove all of the nidus by enloc resection or curettage.3,7–9,12,14,16–18 It can beifficult to know how much bone to remove and mayecessitate using grafts, internal fixation, and post-perative immobilization. In the hand curettage may

Figure 4. Computed tomography scan in the axial plane s

igure 5. Magnetic resonance image in the axial plane on T1 show

e incomplete, leaving residual tumor cells that mayxplain the recurrence of the lesion.17 Other times itay be necessary to perform an arthrodesis8 or evenfingertip amputation.6,14

Percutaneous radiofrequency ablation, introducedn 1992 by Rosenthal et al,19 has primary clinicaluccess rates between 73% and 95% with minimalomplications.19,20 The procedure causes thermal ne-rosis of a spheric area approximately 1 cm in diam-

a typical nidus in the volar aspect of the phalanx (arrow).

s a typical nidus on the volar surface of the phalanx (arrow).

estm

ttafatttWt

cocdfltmccRptnn

s the

Fa

Ramos et al / Radiofrequency Ablation in Osteoid Osteoma 801

ter. Because the effect of the treatment is not tissuepecific, no vital structures should be within 1 cm ofhe tip of the electrode.1,15 Because of this require-

ent, Torriani and Rosenthal,6 with over 250 pa-

Figure 6. Computed tomography scan show

igure 7. Appearance of the finger 2 years after thermoco-

igulation.

ients treated, declined to treat osteoid osteomas ofhe hand and posterior elements of the spine. Barei etl1 also suggested that this technique should be usedor patients with extraspinal osteoid osteomas thatre not immediately adjacent to neurovascular struc-ures. In contrast, Vanderschueren et al5 said thathermocoagulation is safe and effective at any loca-ion, and cases in the spine have been published.21–25

ith the same precautions it could be performed inhe phalanges of the hand.

In the finger, thermal damage to digital neurovas-ular structures or tendons could take place becausef the close proximity to the treated area.26 In ourase the neurovascular bundle was more than 5 mmistant from the active portion of the electrode. Theexor tendons were less than 5 mm away, however,

hey remained intact. Because of the effects of theonopolar radiofrequency energy to produce joint

apsular shrinkage,27 stiffness of the finger alsoould take place.27 Neither happened in our case.adiofrequency ablation of osteoid osteomas in thehalanges of the hand has been published in 2 pa-ients, including our case, and complications of tech-ical difficulties associated with the procedure haveot been reported.5

Percutaneous radiofrequency ablation of the nidus

radiofrequency electrode within the nidus.

n osteoid osteomas recently has been introduced and

ordaaeti

R

1

1

1

1

1

1

1

1

1

1

2

2

2

2

2

2

2

2

Ft

802 The Journal of Hand Surgery / Vol. 30A No. 4 July 2005

ffers advantages as compared with traditional openesection. In the phalanges of the hands the proce-ure could be performed on outpatients with localnesthesia and the patients could resume all dailyctivities immediately without casts, splints, or otherxternal supports. A larger series of phalangeal os-eoid osteomas treated with radiofrequency ablations necessary to determine the safety and efficacy.

eferences1. Barei DP, Moreau G, Scarborough MR, Neel MD. Percuta-

neous radiofrequency ablation of osteoid osteoma. Clin Or-thop 2000;373:115–124.

2. Yildiz Y, Bayrakci K, Altay M, Saglik Y. Osteoid osteoma:the results of surgical treatment. Int Orthop 2001;25:119–122.

3. Bednar MS, McCormack RR Jr, Glasser D, Weiland AJ.Osteoid osteoma of the upper extremity. J Hand Surg 1993;18A:1019–1028.

4. Unni KK. Osteoid osteoma. In: Unni KK, ed. Dhalin’s bonetumors. General aspects and data on 11,087 cases. 5th ed.Philadelphia: Lippincott-Raven Publishers, 1996:121–130.

5. Vanderschueren GM, Taminiau AHM, Obermann WR,Bloem JL. Osteoid osteoma: clinical results with thermoco-agulation. Radiology 2002;224:82–86.

6. Torriani M, Rosenthal DI. Percutaneous radiofrequencytreatment of osteoid osteoma. Pediatr Radiol 2002;32:615–

igure 8. Posteroanterior x-ray 2 years after thermocoagula-ion.

618.

7. De Smet L, Fabry G. Osteoid osteoma of the hand andcarpus: peculiar presentations and imaging. Acta OrthopBelg 1995;61:113–116.

8. Allieu Y, Lussiez B. L’Ostéome ostéoïde au niveau de lamain. A propos de quarante-six cas. Ann Chir Main 1988;7:298–304.

9. Chen SC, Caplan H. An unusual site of osteoid osteoma inthe proximal phalanx of a finger. J Hand Surg 1989;14B:341–344.

0. Walker LG, Meals RA. Painless osteoid osteoma of thephalanx. Orthopedics 1989;12:774–776.

1. Wiss DA, Reid BS. Painless osteoid osteoma of the fingers.Report of three cases. J Hand Surg 1983;8:914–917.

2. Allieu Y, Lussiez B, Benichou M, Cenac P. A double nidusosteoid osteoma in a finger. J Hand Surg 1989;14A:538–541.

3. O’Hara JP III, Tegtmeyer C, Sweet DE, McCue FC. An-giography in the diagnosis of osteoid-osteoma of the hand.J Bone Joint Surg 1975;57A:163–166.

4. Brown RE, Russell JB, Zook EG. Osteoid osteoma of thedistal phalanx of the finger: a diagnostic challenge. PlastReconstr Surg 1991;90:1016–1021.

5. Rosenthal DI, Springfield DS, Gebhardt MC, Rosenberg AE,Mankin HJ. Osteoid osteoma: percutaneous radio-frequencyablation. Radiology 1995;197:451–454.

6. Rex C, Jacobs L, Nur Z. Painless osteoid osteoma of themiddle phalanx. J Hand Surg 1997;22B:798–800.

7. Soler JM, Pizà G, Aliaga F. Special characteristics of osteoidosteoma in the proximal phalanx. J Hand Surg 1997;22B:793–797.

8. Inagaki H, Inoue G. Osteoid osteoma of the distal phalanx.Orthopedics 1999;22:1093–1094.

9. Rosenthal DI, Alexander A, Rosenberg AE, Springfield DS.Ablation of osteoid osteomas with a percutaneously placedelectrode: a new procedure. Radiology 1992;183:29–33.

0. Ambrosia JM, Wold LE, Amadio PC. Osteoid osteoma ofthe hand and wrist. J Hand Surg 1987;12A:794–800.

1. Cové JA, Taminiau AH, Obermann WR, VanderschuerenGM. Osteoid osteoma of the spine treated with percutaneouscomputed tomography-guided thermocoagulation. Spine2000;25:1283–1286.

2. Dupuy DE, Hong R, Oliver B, Goldberg SN. Radiofrequencyablation of spinal tumors: temperature distribution in the spinalcanal. AJR Am J Roentgenol 2000;175:1263–1266.

3. Lindner NJ, Ozaki T, Roedl R, Gosheger G, Winkelmann W,Wörtler K. Percutaneous radiofrequency ablation in osteoidosteoma. J Bone Joint Surg 2001;83B:391–396.

4. Osti OL, Sebben R. High-frequency radio-wave ablation ofosteoid osteoma in the lumbar spine. Eur Spine J 1998;7:422–425.

5. De Berg JC, Pattynama PMT, Obermann WR, Bode PJ,Vielvoye GJ, Taminiau AHM. Percutaneous computed-to-mography-guided thermocoagulation for osteoid osteomas.Lancet 1995;346:350–351.

6. Letcher FS, Goldring S. The effect of radiofrequency currentand heat on peripheral nerve action potential in the cat.J Neurosurg 1968;29:42–47.

7. Lopez MJ, Hayashi K, Vanderby R Jr, Thabit G III, FantonGS, Markel MD. Effects of monopolar radiofrequency en-ergy on ovine joint capsular mechanical properties. Clin

Orthop 2000;374:286–297.