Osteoma Osteóide e Corpo Estranho

Osteoid osteoma and foreign body.

Osteoid osteoma and foreign body. Male patient, 37 years old, with a history of pain in the posterior region of the distal third of the left leg, which began in 2016, without a history of trauma, with worsening at night and improvement related to the use of salicylates. The radiography and tomography, figures 1 to 8, showed a sclerotic image with increased thickness of the cortical bone of the distal tibia E, with an apparent central niche. Osteoid osteoma?
Figura 1: Radiografia,frente, com esclerose na cortical óssea do 1/3 distal da tíibia esquerda
Figure 1: Radiograph, front, with sclerosis in the cortical bone of the distal 1/3 of the left tibia
Figura 2: Radiografia,perfil, com esclerose na cortical póstero medial.
Figure 2: Radiograph, profile, with sclerosis in the posteromedial cortex.
Figura 3: Tomografia axial com esclerose cortical na face póstero medial da tibia.
Figure 3: Axial tomography with cortical sclerosis on the posteromedial aspect of the tibia.
Figura 4: Tomografia axial com evidente nicho central na cortical da face póstero medial da tibia.
Figure 4: Axial tomography with an evident central niche in the cortex of the posteromedial aspect of the tibia.
Figura 5: Tomografia axial, densidade para tecidos moles, com esclerose cortical.
Figure 5: Axial tomography, density for soft tissues, with cortical sclerosis.
figura 6: TC sagital, densidade para tecidos moles, com esclerose na cortical posterior da tíbia.
figure 6: Sagittal CT, soft tissue density, with sclerosis in the posterior cortex of the tibia.
Figura 7: Tc coronal com a já referida área de condensação.
Figure 7: Coronal Tc with the aforementioned condensation area.
Figura 8: TC sagital evidenciando a lesão na cortical posterior.
Figure 8: Sagittal CT showing the lesion in the posterior cortex.
To plan the resection of the lesion, using radioguided surgery, with the aid of the gammaprobe. We first performed a bone scan the day before surgery. This bone mapping should preferably be carried out between 3 and 12 hours before the procedure, to obtain the best concentration of the radiopharmaceutical in the tumor, figures 9 to 12.
Figura 9: Paciente posicionado na gama camara.
Figure 9: Patient positioned in the camera range.
Figura 10: Mapeamento ósseo evidenciando a captação do tecnécio no 1/3 distal da tíbia esquerda.
Figure 10: Bone mapping showing technetium uptake in the distal 1/3 of the left tibia.
Figura 11: Captação no terço distal da tíbia.
Figure 11: Capture in the distal third of the tibia.
Figura 12: Nesta etapa, o operador posiciona o Gamma probe sobre a perna do paciente onde há maior captação, e marca sobre a tela este ponto.
Figure 12: In this step, the operator positions the Gamma probe on the patient's leg where there is greater uptake, and marks this point on the screen.
Video 1 : Identification of the point of greatest uptake on the patient’s tibia
Video 2 : Demonstration of this point.
The surgery was scheduled for the morning after planning with Tecnésio. Unfortunately, the surgical procedure was suspended due to the hypertensive crisis. After 15 days, during outpatient rescheduling, the patient complained of severe pain in the soft tissues of the posterolateral side of the leg, with great sensitivity to a simple touch. This pain was continuous with worsening flexion-extension of the ankle, not compatible with osteoid osteoma. Inflammatory process? In order to clarify this clinical picture, we requested an MRI study, figures 13 to 18.
Figura 13: RM coronal T1 com ponto homogêneo de baixo sinal no terço distal da perna.
Figure 13: Coronal T1 MRI with a homogeneous spot of low signal in the distal third of the leg.
Figura 14: RM sagital T1 evidencia área cilíndrica homogênea de baixo sinal e logo acima há uma imagem linear com alto sinal !!!
Figure 14: T1 sagittal MRI shows a homogeneous cylindrical area with low signal and just above there is a linear image with high signal!!!
Figura 15 : Rm coronal com captação linear do contraste.
Figure 15: Coronal MRI with linear contrast capture.
Figura 16 : Rm sagital com captação linear do contraste.
Figure 16: Sagittal MRI with linear contrast capture.
Figura 17: Rm axial T1 com imagem de baixo sinal circuferencial homogênea. Artefato?
Figure 17: Axial T1 MRI with homogeneous circumferential low signal image. Artifact?
Figura 18: Rm axial evidenciando imagem circuferencial homogênea com captação de contraste na periferia.
Figure 18: Axial MRI showing homogeneous circumferential image with contrast uptake in the periphery.
These changes found are located in the soft tissues, having nothing to do with the osteoid osteoma existing in the cortical bone of the tibia highlighted in the previous figures. What injury would these images correspond to? Seeking to clarify, we studied the tomography with thinner sections, which presented a cylindrical image, figures 19 to 22.
Figura 19: Tomografia axial com seta em vermelho destacando imagem densa no septo intermuscular do flexor longo do hálux. A quê corresponde esta imagem???
Figure 19: Axial tomography with red arrow highlighting dense image in the intermuscular septum of the flexor hallucis longus. What does this image correspond to???
Figura 20: Tomografia com densidade para tecidos moles no mesmo nível, persistindo a imagem radio-opaca.
Figure 20: Density tomography for soft tissues at the same level, with the radio-opaque image persisting.
Figura 21: Tomografia com densidade óssea num segmento mais distal.
Figure 21: Tomography with bone density in a more distal segment.
Figura 22: Tomografia com densidade para tecidos moles num segmento mais distal.
Figure 22: Density tomography for soft tissues in a more distal segment.

The coronal and sagittal sections, with density for bone and soft tissues continued to show this radio-opaque image which, in these sections revealed to be linear, figures 23 to 26. Metallic artifact???

Figura 23: Tomografia coronal com seta em vermelho destacando imagem linear densa no terço distal da perna.
Figure 23: Coronal tomography with red arrow highlighting dense linear image in the distal third of the leg.
Figura 24: Tomografia coronal com janela para tecidos moles evidenciando a mesma imagem.
Figure 24: Coronal tomography with soft tissue window showing the same image.
Figura 25: Tomografia sagital com densidade óssea com imagem densa nos tecidos moles da região posterior da perna.
Figure 25: Sagittal bone density tomography with dense image in the soft tissues of the posterior region of the leg.
Figura 26: Tomografia coronal com densidade de tecidos moles com persistência do artefato.
Figure 26: Coronal tomography with soft tissue density with persistence of the artifact.
Figura 27: Radiografia frente da perna, a seta em amarelo destaca uma imagem metálica que já existia na radiografia inicial (figura 1).
Figure 27: Front X-ray of the leg, the yellow arrow highlights a metallic image that already existed on the initial X-ray (figure 1).
Figura 28: Radiografia perfil da perna, seta azul mostra a imagem nos tecidos moles. Corpo estranho ???
Figure 28: Lateral x-ray of the leg, blue arrow shows the image in the soft tissues. Strange body ???
Figura 29: Cicatriz na face lateral da perna esquerda causada por ferimento com a tampa de uma lata, ocorrido aos doze anos de idade. Esta cicatriz havia passado desapercebida até este momento e provavelmente foi a porta de entrada para este corpo estranho.
Figure 29: Scar on the side of the left leg caused by an injury with a can lid, which occurred at the age of twelve. This scar had gone unnoticed until this moment and was probably the gateway to this foreign body.
This image is of a possible foreign body, which was asymptomatic until the bone scintigraphy was performed. This clinical manifestation occurred after manipulation with the Gamma probe, whose foreign body began to irritate the soft tissue structures in this region (muscle/nerve), causing a local irritative process, with significant symptoms. After the MRI, the pain increased, causing limping. This worsening may have been caused by movement due to the magnetic attraction of the resonance. We opted for excision of this probable foreign body first, figures 30 to 37.
Figura 30: Paciente em decúbito ventral, com apoio sob o tornozelo.
Figure 30: Patient in prone position, with support under the ankle.
Figura 31: Radioescopia para localização do corpo estranho. A pinça sinaliza a posição, para marcamos na pele.
Figure 31: Radioscopy to locate the foreign body. The tweezers signal the position, so we mark it on the skin.
Figura 32: Radioescopia para localização do corpo estranho.
Figure 32: Radioscopy to locate the foreign body.
Figura 33: Imagem da via de acesso realizada.
Figure 33: Image of the access route created.
Figura 34: Imagem intraoperatória, mostrando a exploração cirúrgica.
Figure 34: Intraoperative image, showing surgical exploration.
Figura 35: Imagem de radioescopia que sinaliza a manipulação do objeto com a pinça.
Figure 35: Radioscopic image that signals the manipulation of the object with the tweezers.
Figura 36: Fotografia demonstrando o processo de remoção do objeto.
Figure 36: Photograph demonstrating the process of removing the object.
Figura 37: Imagem em detalhe do corpo estranho e do tecido inflamatório adjacente.
Figure 37: Detail image of the foreign body and adjacent inflammatory tissue.
Figura 38: Cicatriz após uma semana da cirurgia, desaparecimento do processo inflamatóriao e da dor incapacitante.
Figure 38: Scar one week after surgery, disappearance of the inflammatory process and disabling pain.
Figura 39: Retirados os pontos apos duas semanas.
Figure 39: Stitches removed after two weeks.
Figura 40: Boa cicatrização após seis semanas da cirurgia de retirada do corpo estranho, provável fragmento de lata que ocasionou o ferimento corto contuso aos doze anos de idade.
Figure 40: Good healing after six weeks of surgery to remove the foreign body, probably a fragment of tin that caused the blunt cut wound at twelve years of age.

Upon outpatient return six weeks after removal of the foreign body, the patient reported the disappearance of the acute and disabling pain but reported the persistence of nighttime pain caused by the osteoid osteoma.

Surgery was scheduled to excise the tumor, following the initial planning with the aid of gammagraphy, to be performed shortly.

Author: Prof. Dr. Pedro Péricles Ribeiro Baptista

 Orthopedic Oncosurgery at the Dr. Arnaldo Vieira de Carvalho Cancer Institute

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