Osteoid osteoma is a relatively common bone tumor, accounting for approximately one eighth to one tenth of all symptomatic benign bone tumors and 5% of all primary bone tumors. Osteoid osteoma is generally a condition of the young, but it can affect a wide range of individuals aged 8 months to 70 years. Patients with osteoid osteoma can present with an atypical history and lesions in unusual locations. Histologically, osteoid osteoma is almost identical to osteoblastoma, osteosarcoma, and enostosis. Osteoid osteoma can appear as spondylolysis on bone scans; both can appear as abnormal activity in the spine. Atar et al (1992) described two stages of the disease. The first is an acutely painful stage that lasts 18-36 months, during which patients require steady use of analgesics. Symptoms of osteoid osteoma can last from weeks to years before diagnosis and eventual surgery. Osteoid osteoma should be considered in any young patient with pain in the back or neck, painful scoliosis, or radicular or referred-type pain into the lower limb or shoulder. Osteoid osteoma has been linked to prostaglandins, which may explain the inflammatory features of the lesion. Several authors have noted extremely high levels of prostaglandin metabolites, especially prostaglandins E2, I2, and F1 I±, which have been seen at levels 100-1000 times normal levels, especially in the nidus. Two pathways have been postulated for pain generation in osteoid osteoma secondary to the effects of prostaglandin. Delays of 11.8-36 months have been reported in the diagnosis and treatment of osteoid osteoma.
Osteoid osteoma elicits a profound osteoblastic response in surrounding medullary and cortical bone and shows the characteristic picture of sclerosis around a lucent nidus. Intracapsular lesions usually manifest as proliferative synovitis with joint effusion and soft-tissue swelling and no sclerosis.
Epiphyseal and metaphyseal lesions may show only minimal sclerotic changes around the nidus. Regarding the diagnostic value of radiography, some authors have reported that the combination of clinical and radiographic features confirms the diagnosis. Osteoid osteoma is associated with a nonspecific but intense, well-defined uptake of activity on bone scans. Radionuclide scanning also has the advantage of aiding the surgeon and the pathologist in confirming resection of the tumor and locating the lesion for histologic examination. To date, no negative bone-scan findings have been reported in patients with osteoid osteoma. Osteoid osteoma can sometimes be confused with spondylolysis, especially in the lower lumbar spine, as both result in a hot spot on bone scans.
Images obtained immediately after injection showed minimal or no abnormal activity in spondylolysis. By comparison, images of osteoid osteoma demonstrated easily detectable uptake of the tracer in all cases.
On CT scans, osteoid osteoma appears as a circumscribed annular lesion with a double-attenuating sign. A noncalcified nidus has homogeneous enhancement on contrast-enhanced, fat-suppressed T1-weighted MRI. On T1-weighted MRI, the lesion is an area of decreased signal intensity, sometimes with a bell of highly decreased signal intensity at its center.
Assoun et al noted that MRI interpretation resulted in notable errors in diagnosis, most often confusion with malignancies. Guzey et al confirmed this finding. Regardless of the method of treatment, its success highly depends on preprocedural localization of the nidus. Various methods have been used for intraoperative localization and identification of osteoid osteomas to minimize bone resection and to help ensure complete excision of the tumor. Klonecke et al reported that intraoperative scanning has evolved because of the excessively wide excision necessary in the past that had to be planned to help guarantee complete removal of the lesion. However, even with the use of frozen sections, adequate excision is not ensured. Intraoperative radiography can be helpful in localizing the lesion in reference to a guide pin inserted into the bone. Rinsky et al first described intraoperative radioisotope scanning for osteoid osteoma. Advantages include intraoperative localization by radionuclide scintillation probe that is easy and reliable, minimizes bone resection, and does not prolong surgery. Whether the pathophysiology of osteoid osteoma is neoplastic or inflammatory has been a controversial subject.
Pain in osteoid osteoma has been typically attributed to the nidus, with its associated hyperostosis and neural elements in the reactive fibrous tissue. Golding described radially oriented trabeculae of surrounding reactive bone, which implied an increased pressure in the vascular nidus. This arrangement of the bony trabeculae was attributed to the stresses placed on them. Schulman et al supported this observation, finding increased amounts of unmyelinated nerve fibers, with greatest abundance next to arterioles. These prostaglandins and other mediators of bone formation and inflammation are believed to provide the final common pathway for pain generation. Healey and Ghelman described two pathways of pain generation due to prostaglandins. The first involves permeability and vasodilatory effects, which increase the size and flow of vessels in the bony lesion, increasing pressure and pain. Osteoid osteoma typically consists of a discrete central nidus, usually smaller than 1 cm with diffuse peripheral sclerosis.
During surgery, an increased number of fine, punctuate vessels and adherent periosteum overlying the lesion may be observed. On microscopic evaluation, the nidus is typically composed of a mass of irregular osteoid tissues that lie in a highly vascular stroma of connective tissue containing osteoblastic cells.
The microscopic appearance of osteoid osteoma may vary with the degree of lesional maturity. Pathologic confirmation of the diagnosis of osteoid osteoma by means of percutaneous needle biopsy yields reliable results in only 50% of cases. Initial treatment of osteoid osteoma remains nonoperative, with medications consisting of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs).
The response to salicylates is not universal, however; it can vary and is therefore not as reliable a sign as it was previously thought to be. Several authors have suggested that because the general mechanism of action of aspirin and NSAIDs is inhibition of prostaglandin synthesis leading to pain relief, any intervention that decreases the concentration of prostaglandins in the osteoma will also decrease the related pain. If medical management is selected, blood counts and serum chemistries should be periodically monitored in all patients. Kneisl et al mentioned several contraindications for NSAID use, including sensitivity to the medications, progressive deformity of the limb, and uncertainty about the diagnosis. Surgical intervention is generally indicated for patients whose pain is unresponsive to medical therapy, patients who cannot tolerate prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), and those who are not amenable to activity restrictions. Lesions in anatomically inaccessible areas, such as the femoral head and neck, result in considerable surgical morbidity, and their removal may cause complications or disability more severe than that associated with the original condition.
Other disadvantages include difficulties in identifying and localizing the nidus at the time of surgery, postoperative restriction of activity that may be required after bone is removed, and an awkward anatomic location of the tumor that may require an extensive surgical approach. Timing of surgery has not been an issue for osteoid osteoma anywhere in the body except for the spine.
Mehta and Murray reported that patients with scoliosis reach a critical point after which the continuing discharge of painful stimuli results in a structural change of the spine that precludes resolution of the deformity after the tumor is removed. In their study, painful symptoms that were present during the patient's growth spurt were most likely to cause progression of the scoliosis. Pettine et al observed that 15 months was the critical duration of symptoms for antalgic scoliosis to spontaneously correct after excision. In patients with symptoms lasting less than 15 months, scoliosis is decreased or completely corrected within a short time after excision alone.
Complete surgical excision of the nidus, even if it is intralesional, is the treatment of choice for patients with osteoid osteoma in whom conservative management fails. En-bloc resection of the lesion with surrounding bone is recommended in the treatment of osteoid osteoma, but this is not always possible.
Disadvantages of this procedure include excessive resection of normal bone in the effort to completely excise the lesion. The procedure of unroofing and curettage entails unroofing of the nidus by gradually removing the overlying reactive bone, followed by excision with curettes and burrs.
Subperiosteal lesions may be visible as a superficial deformation of a few millimeters in size. Intracortical lesions are difficult to localize by just scrutinizing the bone surface if it is covered by thick periosteum. Intra-articular or medullary types cause little or no periosteal reaction; therefore, they are difficult to identify visually. About 9-28% of osteoid osteomas recur after surgical extirpation, where the rate of local recurrence is inversely proportional to the aggressiveness of the surgery. Proper preoperative and intraoperative localization of the tumor is critical to ensure adequate resection of the tumor and minimize the likelihood of recurrence. Failure to relieve pain is associated with a bad prognosis, and it most probably indicates incomplete removal of the tumor.
Direct visualization and intralesional excision of the nidus is associated with a primary cure rate of 100%.
The use of radionuclides in surgery started in 1949, when attempts were made to facilitate surgery by taking advantage of the property of certain lesions to concentrate radiopharmaceuticals.
For radionuclide-guided excision, patients undergo bone scintigraphy at diagnosis by using technetium-99m-labeled hydroxymethylene diphosphonate (HMDP) and dichloromethylene diphosphonate (DMDP). This method can be used to locate the projection of the nidus with a precision of 2 mm, facilitating excision of lesions with minimal damage to normal bone. Disadvantages of this method include the narrowness and depth of the operative field, which causes difficulty in positioning the probe perpendicular to the bone surface. Preoperative insertion of a needle under the guidance of computed tomography (CT) is important for localizing the nidus of an osteoid osteoma during surgery.
Complications associated with this procedure include postoperative fracture, limitation of activity and impaired weight bearing for as long as 3 months after surgery, skin burns due to high rotation speed of the instrument, muscle hematoma, irritation of adjacent nerves with transient paresis, and osteomyelitis.
Bown et al first described percutaneous laser photocoagulation in 1983. The technique entails CT-guided localization of the nidus. Percutaneous radiofrequency coagulation is performed by using an electrode placed in the lesion, coupled with a radiofrequency generator that produces local tissue destruction by converting radiofrequency into heat. The technique involves CT-guided insertion of a trocar, followed by application of an electrode. Over the next 6 weeks, marrow fat necrosis and reactive fibrosis replaced this hemorrhage. After 6 weeks, a thin, circular rim of intramedullary reactive bone surrounded this area of fat necrosis.
Vanderschueren et al reported factors that decrease or increase risk of treatment failures.
Rehnitz et al used a questionnaire to follow-up with 72 patients who underwent CT-guided radiofrequency ablation (RFA). Percutaneous radiofrequency coagulation is currently the preferred treatment for osteoid osteoma because it does not require hospitalization, is not associated with complications, and is associated with rapid convalescence.
The main disadvantages of this procedure are recurrence or persistence of the osteoid osteoma and the lack of histologic verification.
Computer-assisted surgery is a collection of techniques in which imaging and use of three-dimensional (3D) tracking devices are combined to improve surgical performance.
The technique entails intraoperatively registering the patient to the preoperative image by determining a rigid-body transformation.
The advantage of this technique is that it can provide precise and accurate localization of lesions in bone. Magnetic resonancea€“guided focused ultrasound (MRgFUS) is a novel imaging-guided surgical technique that allows the performance of noninvasive and radiation-free ablation. Rosenthal et al noted that in 23% of patients, symptoms persisted following percutaneous RFA. Toddlers are active adventurers who are always one step ahead of us, fearless explores who are mesmerized by the world around them. Our job is to support, inspire and encourage their natural curiosity, assuring their safety and providing them with the tools they need to have meaningful experiences they can learn from.
Parents and teachers are given the opportunity to exchange information and help one another to make learning in the toddler room an extension of what it is at home and vice-versa. Daily reports about children’s normal routine is provided with detailed notes about each child’s day.
An emergent curriculum is one that comes from the children’s interests, the teachers are the greatest supporters that make room for what is naturally being explored and the experiences the children are eager to learn from. Observing is key in this process, teachers are in tune with their children so they can capture their thoughts and what can sparkle new learning experiences. The teaching is intentional and all the material that is incorporated to their daily activities is meant to give opportunities for learning about a topic in many different ways, so the new information acquired may be captured in a meaningful way.
Children are exposed to letters, numbers, shapes and colors daily, not in a fragmented way but the way we see around us, everywhere and with a purpose. The femur, particularly the intertrochanteric or intracapsular regions of the hip, is affected in two thirds of cases.[7, 8] The diaphyseal part of the tibia and the humerus are other common sites. Involvement here most commonly manifests as painful scoliosis, but painless conditions can also occur.
Wells et al observed this predilection in 75% of cases, with 33% involving the lamina, 20% involving the articular facets, and 15% involving the pedicles. About 59% of osteoid osteomas affect the lumbar spine. Because of this presentation, osteoid osteomas can be confused with osteomyelitis, especially Brodie abscesses, eosinophilic granulomas, and other benign cysts. However, benign osteoblastoma has a uniform pattern of thick, closely packed trabeculae with increased cellularity and vascularity. Wells et al noted that in cases of spondylolysis, immediate postinjection images showed minimal or no abnormal activity but that abnormal activity was observed when imaging was delayed after the injection. Early uptake of tracer is detectable in all cases of osteoid osteoma. The literature suggests a history of resolving pain and healing of the lesions, but no histologic confirmation of the diagnosis has been reported.
The second is the recovery stage, which includes healing of the nidus and which usually takes 3-7 years. It is described as a continuous, deep, aching, and intense pain with varying quality and severity. The pain is responsive to oral salicylates, often with dramatic beneficial results, but the response is not universal.
Its symptoms can simulate those of a herniated disk, or the lesion may produce radicularlike symptoms in the shoulders and arms.
Tenderness is present in 62% of patients and usually occurs with subperiosteal lesions; it is relatively uncommon with medullary lesions. Janin et al and MacLellan et al noted a 25% incidence of neurologic abnormalities.[26, 27] Reports in the literature describe fewer neurologic abnormalities, such as monoparesis and paraparesis, with osteoid osteoma than with osteoblastoma because osteoid osteomas are smaller than osteoblastomas.
Some authors have postulated that prostaglandins may have a fundamental role in the development of osteoid osteoma.
One pathway involves vasodilatory and permeability effects related to an increase in both the size of blood vessels and flow in blood vessels in the bony lesion that increases pain and pressure.
It appears as cortical thickening and diffuse medullary sclerosis on radiographs (see the image below).
Courtesy of Cincinnati Children's Hospital Medical Center, Department of Pediatric Orthopaedics. Lesions can appear as only a radiolucent zone, only a radiopaque area, or as a central sclerosis with surrounding radiopacity.
Wells et al urged that bone scans be performed when radiographic findings are normal or inconclusive, especially in pediatric patients with back pain. Rinsky et al reported that technetium-99m scintigraphy is sensitive for osteoid osteoma in its early stages. In fact, the diagnostic delay is reduced from 35 months to 12 months with the use of bone scans. However, abnormal activity was noted with spondylolysis when a delay occurred between injection and imaging. It is recommended when the nidus is not visible on conventional radiography, when residual or recurrent tumor is present, or when the tumor is located in a critical area (eg, spine or femoral neck).
When CT is performed with intravenous contrast material, scans of osteoid osteoma typically show a rapid, early arterial phase of enhancement and then a slow exit of the contrast material from the nidus, consistent with delayed flow in the venous phase. By comparison, a calcified nidus has ring enhancement, the intensity of which is proportional to the extent of the remaining part of the vascularized nidus.
It is reserved for equivocal cases because it can suggest the diagnosis of osteoid osteoma. In fact, most authors agree that exact localization of the lesion is the most important determinant of successful operative removal.
The difficulty of intraoperative identification of the nidus often leads to nonexcision of the lesion. Multiplanar fluoroscopy can help in localizing the nidus if it is in cancellous bone, where sclerotic reactions are minimal. It can aid the surgeon and pathologist in confirming resection of the tumor and in localizing the lesion for histologic examination. It is also helpful in precisely defining the location of the tumor and the extent of osseous involvement. The presence of atypical cellular and trabecular components support the view that osteoid osteoma is a neoplasia; however, the relatively small size of the lesion, its self-limited nature, and the presence of intracellular viral particles (as observed on electron microscopy) may suggest an inflammatory process.
This increased pressure due to vasodilatation and edema is thought to directly stimulate intraosseous nerve endings, generating pain. Several authors have even suggested that they may have a fundamental role in the development of osteoid osteoma.
Furthermore, the dramatic response to salicylates or nonsteroidal anti-inflammatory drugs (NSAIDs), which affect prostaglandin synthesis, supports the suggested role of prostaglandins in the pathophysiology of pain. The second involves its effect in the bradykinin system, which potentiates pain akin to injured soft tissues. The nidus is usually a distinct, well-circumscribed cavity, surrounded by dense reactive bone of varying thickness. Osteoid osteoma is usually cortical and may extend into the periosteal or endosteal surface of the bone. It consists of irregular lacelike osteoid and calcified matrix lined by plump osteoblasts and osteoclasts with a well-vascularized but bland stroma.
During the initial stage of the disease, proliferation occurs in osteoblasts and vascularized spindle cell stroma with minimal new bone formation. Use of autoimaging and scintigraphy has increased in the pathologic examination of osteoid osteoma specimens. Saville et al noted good responses to therapeutic doses of naproxen after trials with aspirin, indomethacin, ibuprofen, and fenoprofen were tried. They noted resolution of pain after 22 months of treatment, with complete resolution of pain after 33 months. Sequential radiographs should also be obtained at 3- to 6-month intervals during treatment. Furthermore, the patient's age at the onset of symptoms and the duration of symptoms were the most important determinants at this critical point. Age was a less important factor than symptom duration, but patients who were relatively old at onset of symptoms and those who were young at time of surgery were most likely to have spontaneous correction of the curve. The procedure is contraindicated in patients with lesions in areas difficult to access, such as the acetabulum or femoral head and neck, where it leads to substantial morbidity. Changes on the bone surface in the form of a focal increase in the diameter of the superficial bone vessels, a pink area of millimetric dimensions, or both may reveal the presence of such lesions.
However, these lesions cause extensive bone reaction that typically surrounds the nidus of the tumor. Healey et al noted that intralesional resection or curettage had the highest recurrence rate and that en bloc resection had the lowest rate. Several authors linked this finding to incomplete removal of the nidus. Successful excision substantially eliminates tumor-related pain within hours to days after surgery.
Three hours before surgery, the radionuclide is given to the patient, followed by control scanning encompassing the hot spot 1 hour after the injection.
In addition, narrow probes can cause false-negative readings and, hence, imprecise localization of the lesion. Campanacci et al noted a primary cure rate of 83% after a percutaneous procedure, with an additional 9% cured after a second procedure. A bare optical fiber or fibers are inserted directly into the target tissue, followed by treatment with low levels of power or laser energy (2-4 W) for several minutes.
Maximal effect was reached with delivery of 1000-1200 J; application of more energy yielded no alteration in the area of coagulation.
Electrode placement is then confirmed with CT, and after confirmation, the lesion is heated to 90A°C for 4 minutes. Neither varying the duration of heating from 30 seconds to 4 minutes nor increasing the size of the tip altered the area of necrosis. Patients are sent home on the day of surgery, and they have no limitations in weightbearing, though aggressive athletics are restricted for 2-3 months. Advanced age (mean, 24 years) and increased number of needle positions during thermocoagulation decrease the risk of treatment failure. Recurrent lesions can be managed with repeat percutaneous RFA, but lesions should be confirmed histologically by means of needle biopsy before ablation.[84, 85] Lesions that are resistant to percutaneous RFA can easily be treated with open surgery.
Optical trackers mounted on modified surgical instruments are attached to the patient to allow for intraoperative tracking with an optical system. It is useful for small lesions located deep in the cortical bone, where there may be subtle or no surface changes to guide the surgeon.
Roger et al observed incomplete resection in 35.7% of patients, as assessed by immediate follow-up scintigraphy following CT-guided percutaneous excision. Rosenthal et al[60, 61] and Barei et al noted a 12% recurrence rate in patients who underwent percutaneous RFA.
Uber eine eigenartige, warscheinlich bisher nicht beschriebene osteoblastische Krankheit in den langen Knochen in der Hand und des Fusses.
Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents.
The peroperative use of the mobile gamma camera for the localization of spinal osteoid osteoma. Use of radionuclide method in preoperative and intraoperative diagnosis of osteoid osteoma of the spine. Intraoperative use of the mobile gamma camera in localizing and excising osteoid osteomas of the spine. Gamma probe guided surgery for osteoid osteoma: Is there any additive value of quantitative bone scintigraphy?. Intraarticular osteoid osteoma: clinical features, imaging results, and comparison with extraarticular localization. A computer-assisted guidance technique for the localization and excision of osteoid osteoma. Osteoid osteoma and osteoblastoma: MRI appearances and the significance of ring enhancement. Vertebral osteoid osteoma associated with paravertebral soft-tissue changes on magnetic resonance imaging. Osteoid osteoma is reported to occur in the cortex of the shafts of long bones in 80-90% of cases. Rates in other areas are 27% in the cervical spine, 12% in the thoracic spine, and 2% in the sacrum. Intra-articular osteoid osteoma occurs in 10% of cases and can involve the hip, elbow, and ankle.
Osteosarcoma and parosteal osteosarcoma are more cellular than osteoid osteoma, and they are anaplastic with elaborate malignant osteoid. The course of this disease is unpredictable and protracted, with intervals of resolution of pain that sometimes last 6-15 years. Unexplained, rigid, or painful scoliosis, especially if the pain is referred to the concavity of the curve, has been associated with osteoid osteoma. These lesions may be associated with proliferative synovitis due to prostaglandin secretion that decreases range of motion. In the second pathway, the effects of the bradykinin system potentiate pain akin to that due to injured soft tissue because of increased capillary permeability. Radiography usually reveals a radiolucent area of about 1 cm in diameter, called the nidus, with a center that is sometimes calcified, resulting in a radiopaque point called the bell. Therefore, repeat radiographs should be obtained from time to time to document osseous manifestations. Swee et al reported that 25% of patients with osteoid osteoma presented with negative radiographic findings but positive bone scans. They recommended that bone scanning be done in suspected cases when radiographic findings are normal. On delayed images, both spondylolysis and osteoid osteoma showed hot spots, but spondylolysis resulted in unilateral or bilateral abnormalities, whereas osteoid osteoma led to intense tracer accumulation. It is sensitive in detecting bone marrow, peritumoral edema, and soft-tissue abnormalities. Radionuclide scanning assists in the localization and diagnosis of osteoid osteoma in its early stages. By comparison, cortical lesions contain reactive sclerosis that may obscure the nidus, leading to incomplete removal of the lesion and resulting in recurrence.
It is the only technique that aids in verifying complete surgical excision of the lesion (success rate, 94%). Support is derived from reports of a 100- to 1000-fold increase in levels of prostaglandins, particularly prostaglandins E2 and I2 (prostacyclin), in the nidus that was reversible on extirpation of the tumor.
It is typically cherry-red in color and can be shelled out of the surrounding reactive bone. In the intermediate stage, patches of calcified osteoid between the neoplastic stromal cells appear. Autoimaging helps direct attention to the hottest fragment, which corresponds to the nidus.
Observed radiographic changes that suggest healing of the lesion are ossification of the nidus and increased bone formation around the nidus. Complete surgical excision is the most predictable way to cure osteoid osteoma and should be the goal of surgical intervention.
Unroofing and curettage is especially helpful in treating lesions in a structurally vital location, such as the femoral neck, wherein the tumor is eradicated without disrupting the underlying central sclerotic bone.
Recurrence is typically observed within 1 year after excision; hence, the patient should be monitored for a minimum of 1 year.
Also, at the end of the operation, confirmation of complete removal of the lesion is difficult because of the altered anatomy of the site. Then, with CT guidance, a Kirschner wire (K-wire) is inserted and drilled through the cortex into the nidus. Patients may then return to normal activities immediately or within 24-48 hours after surgery. Given the transformation between patient and image, the computer displays the 3D location and orientation of an instrument by superimposing a graphical representation of the instrument on the preoperative computer-generated image.
The procedure is conducted without fluoroscopy; fluoroscopy is used only at completion of the operation to document bone-tunnel placement.
This rate was not significantly different from that associated with surgical excision of the nidus. Direct visual identification and intralesional excision of the nidus with minimal removal of bone.
It is also reported in the epiphyseal and metaphyseal regions of both small and large bones of the axial and appendicular skeletons, especially the femur, tibia, and humerus. In fact, Barei et al noted that 70% of osteoid osteomas occurred in patients younger than 20 years. The tumor is less common in patients older than 30 years, accounting for 13% of cases.
The nidus is surrounded by a rim or halo of radiodense cortical hypertrophy or hyperostosis.
Localization of the nidus is often difficult because of an abundance of reactive bone and edema surrounding the lesion that is occasionally misleading. If the nidus is not in the specimen, further resection of the bone is required, resulting in unnecessary and excessive removal of bone. The nidus varies in consistency from vascular, soft, friable, gritty, and granular to densely sclerotic. The mature stage manifests with densely packed atypical bony trabeculae with decreased vascularity and stroma. Thus, it decreases false-negative reports, which most commonly occur because of sampling error. A small incision is created, a biopsy punch is inserted over the K-wire, and the specimen is completely removed.
On the other hand, CT can assist in preoperative localization, and it is useful in precise localization of the nidus in the hip or the spine.
Furthermore, this procedure requires only a small osseous access to allow insertion of the electrode; therefore, no substantial structural weakening of the bone occurs. Some patients may have an exertional component, especially those with intracapsular lesions with synovitis and restricted range of motion. Radiographs may reveal the lack of an intense perifocal sclerotic margin and perinidal bone marrow edema.
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