Eur J Orthop Surg Traumatol
DOI 10.1007/s00590-017-1997-6
ORIGINAL ARTICLE • ELBOW - OSTEOBLASTOMA
Osteoblastoma of the elbow: analysis of 13 patients and literature
review
Andrea Angelini1 • Andrès Felipe Varela-Osorio2 • Giulia Trovarelli1
Antonio Berizzi1 • Gabriele Zanotti3 • Pietro Ruggieri1
Received: 8 April 2017 / Accepted: 16 June 2017
 Springer-Verlag France SAS 2017
Abstract
Purpose To analyze the clinical and radiographic charac-
teristics, treatment, and outcome of patients with elbow
osteoblastoma.
Patients and methods We present 13 patients (7 males and
6 females; mean age, 28 years) diagnosed and treated for
an elbow osteoblastoma from 1975 to 2012. Mean follow-
up was 29 months (range 12–60 months). Clinical pre-
sentation, imaging, surgical treatment, complications,
range of elbow motion, and functional outcome were
evaluated. The MSTS, DASH, and OXFORD scores were
used.
Results Main symptom was pain (all patients) accompa-
nied by stiffness (8 patients) and swelling or tumefaction (7
patients), with a median duration of symptoms of
32 months (range 6–96 months). Distal humerus was
affected in 10 patients, proximal ulna in 2 patients, and
proximal radius in one patient. All patients underwent
surgical therapy that consisted of curettage of the lesion (7
patients), curettage and bone allografting (3 patients), wide
resection (2 patients; total distal humerus and resection of
the radial head), and radiofrequency thermal ablation (1
patient). One patient experienced a recurrence after surgi-
cal treatment. The mean MSTS score after treatment was
& Pietro Ruggieri
pietro.ruggieri@unipd.it
1
Department of Orthopedics and Orthopedic Oncology,
University of Padova, Via Giustiniani 3, 35128 Padua, Italy
2
Istituto Ortopedico Rizzoli, University of Bologna, Bologna,
Italy
3
Department of Orthopedics, Civilian Hospital of Lugo, Lugo,
Ravenna, Italy
•
87% (range 50–100%), which corresponds to excellent
results.
Conclusions Intralesional surgery is successful in tumor
control in most patients with osteoblastoma of the elbow.
Thermal ablation may be successful for smaller lesions.
Most of the patients had a good-to-excellent functional
outcome even if they had tumor-related elbow stiffness at
diagnosis.
Level of evidence Therapeutic study, Level IV-1.
Keywords Osteoblastoma
Elbow
Elbow joint stiffness

Curettage
Local recurrence
Introduction
Tumors around the elbow may prove to be a diagnostic and
therapeutic challenge for the oncologist orthopedic. Elbow
joint (including distal humerus, proximal radius, and
proximal ulna) is an uncommon localization for primary
benign bone tumors. At Rizzoli Institute, only 2% of the
total benign bone tumors are localized in the elbow, most
commonly GCT and osteoid osteoma [1]. Osteoblastoma is
a rare benign bone tumor, initially described by Jaffe in
1932 [2–4] that accounts for approximately 1% of all bone
neoplasms and 3% of all benign primary bone tumors. It
may occur in any area of the skeleton with a predilection
for the spine and sacrum ([40% of the cases) [4, 5]. In the
long bones, osteoblastoma is generally observed in the
meta-diaphysis, and more rarely in adult age it may extend
to the epiphysis. Cases of subperiosteal osteoblastoma have
been reported [4]. In the current literature, there are few
studies about osteoblastoma of the elbow, usually case
reports that describe little information on the radiological
and clinical aspects of this entity [3, 6–12]. Osteoblastoma
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can be an aggressive benign bone tumor, but tragic con-
sequences have been reported when mistaken for
osteosarcoma [6, 13–15].
We performed a search of the literature to identify
patients who had been treated for osteoblastoma of the
elbow. English language and non-English language litera-
ture were searched in PubMed. The search was carried out
using literature of the past 40 years (from 1975 to 2015)
[3, 6–12] (Table 1).
This study aims to report the clinical and imaging
findings, incidence of local recurrence related with the type
of surgery, and clinical and functional outcome of a group
of patients diagnosed and treated for an osteoblastoma of
the elbow.
Patients and methods
We retrospectively studied all patients with histologically
verified osteoblastoma of the elbow, including distal
humerus, proximal radius, and proximal ulna, treated from
November 1975 to December 2015. There were 13 patients
with osteoblastoma of the elbow (7 males and 6 females),
with a mean age of 28 years (range 7–62 years). The data
collected consisted of hospital medical records, operative
notes, and pathologic reports (Table 2). All patients or their
relatives gave written informed consent at the time of
admission for their data to be included in this study.
Patients were studied for clinical and radiologic
findings; imaging studies included radiographs (all
patients), bone scans (7 patients), computed tomography
(CT) scans (9 patients), and/or magnetic resonance
imaging (MRI, 7 patients). All tumors were located in
the metaphysis of the distal humerus and proximal ulna
and radius. No tumor was located in the epiphysis of
these bones. The tumor involved the right elbow in 10
cases (77%) and the left elbow in 3 cases (23%). Distal
humerus was affected in 10 patients, proximal ulna in 2
patients, and proximal radius (Fig. 1) in one patient
(Table 2). Tumor volume was measured on coronal,
transverse, and sagittal MRI or CT scans of the lesion.
Four patients had previous elbow surgery, 3 patients had
intralesional surgery (curettage in 2 patients, and curet-
tage and synovectomy in one patient), and 1 patient had
previous elbow arthroscopy and ulnar nerve exploration
unsuspecting tumor pathology. These patients with pre-
vious intralesional surgery experienced a local recur-
rence and were referred to our institution for further

Table 1 Summary of the published studies reporting on osteoblastoma of the elbow

Study N. Age, Site Symptoms Stiffness Treatment LR Treatment of Function
pts gender relapse

McLoad et al. [8] 1 14,M D-H Pain - Curettage - - Good

Gil-Albarova et al. 1 21,M D-H Pain, ? Curettage - - Good
[17] stiffness
Lucas et al. [20] 2 n/a D-H n/a n/a n/a n/a n/a n/a
1 n/a P-R n/a n/a n/a n/a n/a n/a
2 n/a P-U n/a n/a n/a n/a n/a n/a
Kawaguchi et al. 1 12,M D-H Pain, ? Wide res. - - Normal
[18] swelling
Van Giffen et al. 1 21,F P-U Wrist pain - Curettage - - Normal
[22]
Louaste et al. [19] 1 40,M P-R Pain, ? Curettage - - Normal
swelling
Berry et al. [2] 2 n/a D-H n/a n/a n/a - n/a n/a
2 n/a P-R n/a n/a n/a 1 n/a n/a
2 n/a P-U n/a n/a n/a 2 n/a n/a
Spence et al. [21] 1 22,M D-H Pain ? Curettage 1 Thermoablation Good
Current study 13 Mean 28 D-H Pain (13) ? (8) Curettage (7) 1 Curettage Mean MSTS
(9) 87%
M7, F6 P-R Stiffness (8) Curettage ? graft
(2) (3)
P-U Swelling (7) Wide resection (2)
(2)
RFA (1)
Systematic review of the literature
Pts patients, LR local recurrence, D-H distal humerus, P-U proximal ulna, P-R proximal radius, RFA radiofrequency ablation, n/a not available

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Table 2 Demographic and clinical features of the 13 patients with elbow osteoblastoma included in this series
Patient no./ Duration of Stiffness Enneking Biopsy Site Tumor Previous Treatment Adjuvants LR MSTS
age/gender symptoms (mos) grade type volume treatment (%)
(cm3)

1/7/M 6 ? 3 Incis D-H 1.5 - Curettage - - 83

2/22/M 12 - 2 Incis D-H 6.6 - Curettage - - 79
3/30/M 24 - 2 Incis D-H 3.0 ? Curettage, bone graft and Phenol - 96
synovectomy
4/33/F 72 ? 2 Frozen P-U 1.9 - Curettage, bone graft - - 75
5/37/M 36 - 2 Trocar D-H 2.0 - RFA - - 95
6/9/F 18 ? 3 Frozen D-H 1.4 - Curettage/Graft Phenol - 100
7/30/F 12 - 3 Frozen D-H 8.5 - Curettage and synovectomy - - 85
8/62/F 12 ? 3 Incis D-H 4.8 - D-H res ? TEA - - 70
9/57/M 96 ? 2 Excis D-H 0.8 - Curettage Phenol - 100
10/9/F 12 - 2 Frozen P-R 2.5 - Curettage - 100
11/14/F 17 ? 2 Excis D-H 8.0 ? Curettage and synovectomy - ?(at 5 mos, repeat 90
curettage)
12/22/M 65 ? 2 Excis P-U 3.0 ? Curettage - - 86
13/40/M 16 ? 3 Excis D-H 7.5 - Curettage and radial - - 73
capitulum resection
Incis incisional, Excis excisional, D-H distal humerus, P-U proximal ulna, P-R proximal radius, RFA radiofrequency ablation, TEA total elbow arthroplasty, LR local recurrence

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Fig. 1 a Antero-posterior and b lateral radiograph of the right elbow
of a 9-year-old boy with nocturnal pain of several months’ duration
showed an osteoblastoma of the proximal radius. c Axial CT scan
shows a prevalent osteolytic lesion with internal matrix mineraliza-
tion, cortical thinning in absence of cortical breakthrough
treatment. Two patients were administered previous
intra-articular injections for epicondylitis.
Histologic diagnosis was obtained by open biopsy in 12
patients (incisional biopsy, frozen section biopsy and
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Eur J Orthop Surg Traumatol
excisional biopsy in 4 patients, each), or trocar biopsy (1
patient). Three patients had chronic synovitis and 2 of them
experienced elbow stiffness. One patient had histologic
suspicion of malignancy with epithelioid proliferation. The
final diagnosis by immunohistochemistry was osteoblas-
toma (patient no. 8). One patient was diagnosed as
osteoblastoma of the bone surface. Three patients were
initially diagnosed as osteoid osteoma (Table 2, patient no.
2, 4, and 5); re-review of the histological slides in these
patients confirmed the diagnosis of osteoblastoma (Fig. 2).
According to Enneking’s system for the Staging of Benign
Bone Tumors [16] and the clinical and radiographic fea-
tures, eight patients were stage 2 and five patients were
stage 3.
Routine follow-up examination was performed every
6 months for the first 2 years and then annually. Progres-
sion-free survival (PFS) was defined as the time elapsed
between date of treatment and tumor progression/local
recurrence or date of last follow-up for the patients who did
not have any such events. The time to local recurrence was
evaluated using the univariate Kaplan–Meier analysis [17].
Function was evaluated with the Musculoskeletal Tumor
Society (MSTS) score for the upper limb [18, 19], the
shortened disabilities of the arm, shoulder and hand ques-
tionnaire (QuickDASH) [20, 21], and the Elbow Oxford
score [22].
Results
Most common symptom at presentation was pain (all
patients) accompanied by elbow stiffness (8 patients) and
swelling or tumefaction (7 patients). Seven patients had
limited flexion–extension of their involved elbow joint, two
patients had limited pronation–supination, and 4 patients
had a full range of motion [23]. Of the eight patients with
elbow stiffness, five experienced swelling or palpable
tumefaction. Three patients had neurological symptoms,
specifically hand paresthesia at the distribution of the ulnar
nerve. The mean time from onset of symptoms to diagnosis
and treatment was 30 months (range 6–96 months).
Two patients had no evidence of tumor features at X-ray
(patients 7 and 9) (Fig. 3). Imaging findings included an
osteolytic round area with a central area of calcification
associated to the area of surrounding bone sclerosis (7
patients), marked osteolysis and/or bone destruction with-
out a significant periosteal reaction (4 patients), periosteal
reaction mimicking a Codmańs triangle (one patient), and a
nidus with surrounding sclerosis mimicking an osteoid
osteoma (one patient).
All patients underwent surgical treatment that consisted
of curettage (7 patients), curettage and bone allografting (3
patients), wide resection (2 patients; a distal humerus and a
Eur J Orthop Surg Traumatol
Fig. 2 a Lateral radiograph of the right elbow of a 33-year-old
female with a painful osteolytic lesion of the distal humerus
corresponding to the olecranon fossa. b Antero-posterior radiograph
humeral head resection), and radiofrequency thermal
ablation (1 patient). Phenol was used as local adjuvant to
curettage in 3 patients. Distal humeral resection and total
elbow arthroplasty were performed due to a clinical and
histological suspicion of malignancy, which, however,
after histological and immunohistochemical examination
of the complete tumor specimen, proved to be an
osteoblastoma (Fig. 4). The patient with osteoblastoma of
the bone surface underwent radiofrequency thermal abla-
tion. Postoperative management included analgesics
administration and cast immobilization or progressive
mobilization with a functional brace according to type of
surgery.
At a mean follow-up of 29 months (range
12–60 months), overall local recurrence rate was 8% (case
1/13). Twelve patients remained continuously local recur-
rence-free after treatment, and 1 patient experienced local
recurrence after surgical treatment in our institution
shows a well-defined ostelytic lesion. c Axial CT scan showed the
exact extension of the lesion diagnosed as osteoblastoma at frozen
biopsy before curettage
(Table 2; Patient no. 12). This patient was initially treated
at another hospital and was referred to our institution for
further treatment due to inadequate tumor excision and
local recurrences. He underwent repeat curettage at our
institution and presented local recurrence 10 months later
that treated with another curettage without any evidence of
local recurrence at the last follow-up, 4 years after initial
diagnosis and treatment.
Seven patients (Table 2; patient no. 1, 4, 6, 8, 9, 11, and
13) with elbow stiffness at diagnosis had a tumor at the
distal humerus. The mean MSTS score after treatment was
87% (range 50–100%), which corresponds to excellent
results. The patient with distal humerus resection and total
elbow arthroplasty had the worst results (MSTS score 70%)
with limitation of elbow motion and lifting ability impaired
that, however, did not interfere with daily activities. The
mean Oxford Elbow Score improved from 28 points (range
23–35 points) to 42 points (range 36–50 points), whereas
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Fig. 3 a Lateral radiograph of the elbow in a 57 year-old male rugby suppression of the elbow revealed a nonspecific osteolytic lesion in
player with a persistent pain despite arthroscopic debridement and the medial condyle accompanied by severe articular inflammatory
ulnar nerve neurolysis shows marked degenerative features and volar changes. d, e, f CT scan confirmed an ostelytic lesion between the
calcification. b Coronal and c axial T2-weighted MRI with fat medial condyle and olecranon fossa with cortical breakthrough

Fig. 4 a Antero-posterior and b lateral radiograph of the elbow of a 62-year-old female with a large osteoblastoma of the distal humerus.
c Antero-posterior and d lateral radiograph show the result after distal humerus resection and reconstruction with total elbow arthroplasty

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the QuickDash score showed good-to-excellent results
(mean, 13.5 points; range 0–52 points).
Discussion
Elbow is an uncommon location for osteoblastoma
[2, 4, 12]. The present series aimed to address the clini-
copathological findings and outcome of a group of patients
with this entity and discuss the relationship with elbow
joint stiffness. The main limitations of this study are the
retrospective type of the analysis and the distribution of the
treated patients over a 40-year period. However, consid-
ering the relatively rare tumor location, the findings of our
study would be useful for the related literature.
In a previous study [4], the mean age at presentation of
patients with osteoblastoma of the elbow was 20.4 years,
with a wide range of 6 months–75 years. The typical age at
presentation is between 10 and 20 years of age with
approximately 90% being diagnosed before the age of
30 years; males are slightly more commonly affected
[2–5, 8, 10, 11]. The most common presenting symptoms
are pain and stiffness [2–4], while it is not uncommon the
presence of swelling and soft tissue mass [4, 6–8, 11]. In all
reported cases with articular involvement [3, 8–10],
mobility is impaired, especially elbow extension. The
present study confirmed these reports regarding age and
gender, and clinical symptoms at presentation of the
patients. Radiographs should be the initial imaging inves-
tigation at the staging process of a tumor patient; however,
the diagnosis of small osteoblastoma may be impaired on
radiographs [11], as in 8 patients in the present study.
Moreover, radiographic features may not be distinctive,
creating problems in the differential diagnosis from
osteosarcoma, osteoid osteoma, aneurysmal bone cyst,
chondroblastoma, and chondrosarcoma. The dominant
finding is a single and round area of osteolysis, character-
ized by boundaries that are not always well defined,
sometimes marked by moderate reactive osteoesclerosis
(usually not as intense and extensive as in osteoid
osteoma). Osteoblastoma may reach a considerable size, up
10 cm in maximum diameter, and whether it is central or
eccentric, it may attenuate the cortex and expand the bone,
at times with aspects that are similar to those of aneurysmal
bone cyst. Approximately, one-fourth of these tumors have
a radiographic appearance consistent with malignancy,
even if there is hardly any or only a fair amount of peri-
osteal reaction [4, 6]. In the present study, 4 patients
showed marked osteolysis or bone destruction on radio-
graphs, but only one had intense periosteal reaction mim-
icking a Codmańs triangle. Although bone scintigraphy
will typically show marked tracer uptake, images are
nonspecific. CT scan is probably the imaging method of
choice because it will detect the lesion and reveal marginal
sclerosis, expansion, and internal matrix mineralization
[11]. On MRI, findings are relatively nonspecific with a
fairly well-defined expansive lesion [5, 11]. There is often
surrounding bone marrow edema and reactive synovitis in
intra-articular tumors [5, 11]. Main problems with MRI are
that the edema is a nonspecific inflammatory response to
tumor and visualization of the margins between the osseous
and soft tissue component of the tumor is less defined
resulting in inaccurate diagnosis of an aggressive or
malignant tumor [5].
Aggressive osteoblastoma can mimic osteosarcoma
[4, 6, 15, 24]. There are several reports about aggressive
osteoblastoma in the mandible, proximal humerus, mas-
toid process of temporal bone, and hand with marked
bone destruction and periosteal reaction simulating the
behavior of a malignant tumor [6, 25–27]. McLeod and
Dahlin [6] reported 3 cases of osteoblastoma with an
initial and erroneous diagnosis of osteogenic sarcoma due
to their size, shape, and histologic features with bizarre
nuclei. Although the exact histopathologic differential
diagnosis between osteosarcoma and osteoblastoma may
be difficult in some cases, current molecular genetic
examination may help solve this problem [4–6, 10]. In the
present study, three patients were initially diagnosed as
bone sarcoma due to the clinical and radiographic fea-
tures; one of these patients was treated as a bone sarcoma;
however, histological and immunohistochemical analysis
of the final tumor specimen confirmed the diagnosis of
osteoblastoma.
Treatment of osteoblastoma depends on the stage and
site of the tumor [4, 5]. In stage 1 (latent) or stage 2 (ac-
tive), curettage is indicated, with or without local adjuvants
such as phenol. In stage 3 (aggressive) a marginal or wide
resection is indicated depending on extension of bone
involvement. Wide resection, when indicated, should
minimize the chance of local recurrence but at the cost of
increase risk of surgical morbidity and articular function
impairment [5, 28]. More recently, imaging-guided
radiofrequency thermal ablation is being increasingly used
for small osteoblastomas, less than 2 cm in maximum
diameter [2–4, 7, 17, 28–31]. Rehnitz et al. [30] reported a
series of 77 patients with osteoblastoma and osteoid
osteoma concluding that even large tumors and in those
tumors located in critical areas can safely be treated with
radiofrequency thermal ablation, improving pain and
quality of life and avoiding surgical complications.
Osteoblastoma tend to be locally aggressive with
recurrence rates ranging from 21 to 24% [3, 4, 6, 10]. The
local recurrence rates for osteoblastoma of the elbow after
curettage are not clear; some studies report a higher like-
lihood of recurrence and a correlation between the inci-
dence of recurrence and a previous inadequate treatment in
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non-referral centers [5, 32]. As in one patient in this series,
Spense et al. [11] reported a case of distal humerus
osteoblastoma treated with curettage and then after recur-
rence with thermal ablation. Overall, in the present series, 4
patients experienced a local recurrence; one patient after
initial treatment at our institution and 3 patients that were
referred to us for local recurrences.
Elbow joint range of motion is usually affected in
patients with juxta-articular tumors; stiffness is a common
complaint in these patients, however, it usually improves
after surgical excision of the tumor [6–9, 11]. In the
elbow, a flexion arc of 30 Æ to 130 is required to perform
most activities of daily living, with a minimum of 120 of
flexion required to enable the hand to reach the mouth
[11, 23]. In line with the literature [6–9, 11], in the pre-
sent series, the functional results were good or excellent
after surgical treatment. Gil-Albarova et al. [7] reported a
patient with osteoblastoma of the elbow with associated
stiffness and a good final function after surgical man-
agement. Similarly, Louaste et al. [9] reported a patient
with an osteoblastoma in the proximal radioulnar joint
with significant functional limitation and complete
recovery after surgery. Spense et al. [11] reported a
flexion arc of 5 to 120 and full rotation after radiofre-
quency thermal ablation. Kawaguchi et al. [8] reported a
12-year-old patient with periosteal osteoblastoma in the
distal humerus; range of motion was reduced and became
normal 20 months after surgical management. Elbow
arthroplasty is a good option in elderly patients with acute
traumatic and posttraumatic conditions and to manage
inflammatory arthritis. In bone defects, there is little
experience, and conversely, many associated complica-
tions [33–35]; however, the patient with elbow
osteoblastoma treated with an elbow arthroplasty in this
series had a good function, without any complications
until the period of this study.
Conclusion
Elbow is an uncommon location for osteoblastoma. The
treating physicians should be aware of the similar imaging
findings of this entity with osteoid osteoma and possibly
osteosarcoma, and opt for preoperative biopsy and histo-
logical diagnosis. Curettage with or without adjuvant
therapy is usually appropriate for osteoblastoma of the
elbow, and pain and stiffness improve after surgical
treatment.
Compliance with ethical standards
The IRB approval has not been requested due to the retrospective
nature of the study, according to the policy of Ethic Committee of our
Institute.
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Conflict of interest None of the authors have any financial and
personal relationships with other people or organizations that could
inappropriately influence (bias) their work. Each author certifies that
the manuscript has been read and approved and that the manuscript
represents honest work.
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