Arthroscopic Excision of the Intra-articular Osteochondroma: A Technical Note

Abstract

Osteochondromas are relatively common benign bone tumors that, when located intra-articularly, can cause severe joint pain, mechanical symptoms, and functional limitation. Classically removed with an open approach, the development of a less-invasive surgical technique for the removal of this lesion can aid in decreasing future morbidity for these patients. This Technical Note describes a surgical technique for arthroscopic excision of intra-articular osteochondromas, combining precision, adequate visualization, and a minimally invasive approach.

Osteochondromas are relatively common benign bone tumors characterized by a bony outgrowth covered by cartilaginous tissue.^1,2 These tumors are the most common benign bone tumors and account for roughly 20% to 35% of all benign pediatric tumors.³ The pathogenetic theory suggests that a portion of the bone’s physis herniates through the periosteum, continuing to grow outward from the metaphysis.⁴ The distal femur and proximal tibia are the most commonly affected sites, with lesions arising within the joint (intra-articular) or in close proximity to the knee capsule (para-articular).^5,6 While these lesions are often asymptomatic and discovered as incidental imaging findings, osteochondromas may cause pain, mechanical symptoms, functional limitation, and joint damage when located within a joint.^7,8

Historically, both intra-articular and extra-articular osteochondromas have been excised using an open approach, providing adequate visualization but at the expense of invasiveness. In the pediatric patient, excellent visualization is critical to ensure complete removal of the lesion, including the cartilage cap, to prevent recurrence. Open excision of solitary osteochondromas around the knee in pediatric and adolescent patients generally yields excellent outcomes with a low incidence of recurrence; however, a small subset of patients experiences wound-healing issues and cosmesis concerns, such as scarring or keloid formation.⁵ Arthroscopic management offers potential benefits, including reduced pain, fewer complications, lower risk of arthrofibrosis, decreased overall morbidity, and shorter recovery times. However, careful attention to adequate visualization remains essential to ensure complete excision and prevent recurrence.

The literature supports the arthroscopic technique as an appropriate modality for managing periarticular osteochondromas but with only a few isolated case reports documenting the removal of intra-articular osteochondromas.7, 8, 9, 10, 11 Over time, this technique has evolved, incorporating several technological advancements and enhanced visualization and access to ensure safe and complete excision. This Technical Note presents a simple, precise, and minimally invasive method for excising solitary intra-articular or para-articular osteochondromas of the knee, which may be generalized for use in other joints.

Surgical Technique

The patient is positioned supine on the operating table, and a nonsterile tourniquet is applied to the operative thigh, based on the surgeon’s preference. The lower extremity is then prepped and draped in a standard sterile fashion. Once ready, the tourniquet is inflated to minimize local bleeding and ensure proper visualization of the osteochondroma throughout the procedure. Standard anterolateral and anteromedial portals are used for the excision of the osteochondroma. A complete diagnostic arthroscopy is performed, visualizing all compartments of the knee. Using a standard 30° arthroscope, along with a shaver and ArthroCare wand, the osteochondromal site is identified. In most cases, scar tissue and inflammatory synovium are present in the area, necessitating removal. Once the scar tissue and adhesions between the osteochondroma and the capsule are cleared, the size, location, and characteristics of the osteochondroma are assessed with fluoroscopy (Fig 1A).

Fig 1.

(A) Radiographic examination of the osteochondroma. AP and oblique view of the X-rays of the left knee. (B) Confirmation of complete excision and smooth surface of the femur.

A 70° arthroscope or a Panoscope (Arthrex) is then employed to provide optimal visualization of the osteochondroma’s base. Using a combination of a radiofrequency wand and an arthroscopic shaver, the base of the osteochondroma and the underlying cortical surface of the femur are clearly identified and marked (Fig 2A). This step is crucial for ensuring complete resection of the exostosis at its base, thereby reducing the risk of recurrence. The osteochondroma is then carefully dissected using a radiofrequency wand, osteotome, and 4.5-mm or 5.5-mm burrs to thin and detach its base from the femur. Multiple viewing angles provided by the Panoscope or a standard 70° arthroscope are essential to meticulously resect the base, leaving only a thin rim (Fig 2B). The lesion’s base is then smoothed with a 4.0-mm burr and treated with radiofrequency ablation to minimize the risk of recurrence and to manage subsequent bleeding (Fig 2C). The arthroscopic portal is then widened to allow removal of the lesion en bloc. An arthroscopic grasper is used to remove the osteochondroma with extreme care to remove the lesion as a whole, with its cartilaginous cap intact (Fig 3). Fluoroscopy is used to ensure complete removal and smooth femoral surfaces (Fig 1B).

Fig 2.

(A) Arthroscopic visualization of the osteochondroma’s base with the underlying cortical surface of the femur are clearly identified and marked with an open sheath bur. Left knee with the patient supine. Viewing from the anteromedial portal. (B) An osteotome is used initially to detach its base from the femur. (C) The lesion’s base is then smoothed with a 4.0-mm burr.

Fig 3.

Complete removal of the osteochondroma as a whole with its cartilaginous cap intact.

After surgery, standard wound care as for arthroscopic procedures is recommended. Weightbearing as tolerated is allowed immediately after surgery with a recommendation of the usage of crutches for few days to allow a pain-free environment. No brace is used postoperatively, and full range of motion as tolerated is encouraged. Icing is recommended to prevent severe joint effusion postoperatively. The full technique can be seen in Video 1.

Discussion

Historically, symptomatic osteochondromas have been excised via open surgery, particularly around the knee in pediatric and adolescent patients, with generally excellent outcomes and low recurrence rates. However, a small subset of patients may experience wound-healing complications and cosmetic concerns, such as scarring or keloid formation.⁵ While open excision remains effective, the advantages of arthroscopic techniques offer a minimally invasive alternative. Few reports exist documenting arthroscopic excision of intra-articular knee osteochondromas.7, 8, 9, 10, 11 The technique we describe builds on these approaches by using the technology that offers improved visualization and access, combined with a radiofrequency wand to dissect soft tissue and allow safe access and surgical approach of the lesion. These tools enhance visibility and precision, ensuring thorough removal of the lesion base, a crucial factor in preventing recurrence in pediatric patients.

The key benefit of arthroscopy is avoiding the invasive nature of an open procedure. Postoperatively, patients experience reduced pain, fewer complications, a lower risk of arthrofibrosis, and shorter recovery times. The precision offered by arthroscopic instruments further enhances outcomes. However, the approach may limit visibility of certain structures, such as vascular and neural tissues, as well as the lesion itself. This could theoretically increase the risk of incomplete excision and recurrence. The use of a panoramic view, along with thorough soft tissue dissection and postremoval fluoroscopic assessment, helps mitigate these risks. Clinicians should be aware that not all lesions are ideal candidates for arthroscopic management. Lesions located in areas that are not well evaluated with intra-articular arthroscopy would require an open approach. Thus, preoperative evaluation of the lesion’s candidacy to be arthroscopically managed should always be performed. A detailed comparison of advantages and disadvantages is outlined in Table 1.

Table 1.

Advantages and Disadvantages

Advantages	Disadvantages
Minimally invasive approach	Decreased visualization of neurovascular structures
Increased precision	Limitation of lesion location
Decreased postoperative pain	Limitation of lesion size
Decreased risk of complications
Decreased length of recovery

When performing this procedure, surgeons should prioritize the use of a 70° or a panoramic view arthroscope for optimal visualization, perform meticulous soft tissue dissection to expose the osteochondroma’s base, and apply radiofrequency at the excision site to reduce recurrence risk. Common challenges include inadequate soft tissue dissection, which can hinder lesion removal, and attempting excision through a portal that is too small. A full list of surgical tips and potential pitfalls is provided in Table 2. By adhering to these principles, this technique offers a safe, straightforward, and reproducible method for arthroscopic excision of intra-articular osteochondromas in the knee, which may also be adapted for other joint spaces.

Table 2.

Pearls and Pitfalls

Pearls	Pitfalls
Careful soft tissue dissection to visualize osteochondroma base, allowing full resection and preventing recurrence	Forgetting to extend the port, preventing en bloc lesion removal Ensuring proper study of advanced imaging to ensure the appropriateness of arthroscopic excision
Use of 70° or panoramic view arthroscope to improve visualization
Use of a radiofrequency device at the site of the removed lesion to prevent recurrence

Disclosures

All authors (K.N.R., C.W., R.N.P., S.F.Z., N.K.P.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

Arthroscopic excision of the intra-articular osteochondroma. Left knee with the patient in supine position. Viewing from the anteromedial portal the lesion present at the distal lateral femur.