The Promise of the Ultrasonic Bone Scalpel in Osteoid Osteoma

Ultrasonic surgical instruments, first introduced in dentistry in 1952 for cavity preparation, have now been used therapeutically for decades1. Since the 1980s, the ultrasonic bone scalpel (UBS), which is based on the piezoelectric effect, has been developed as an alternative to traditional drills and saws2. This technology enables selective bone-cutting while minimizing injury to adjacent soft tissues3. With these advantages, the UBS has gained increasing use in spine surgery, offering a wider safety margin, reduced blood loss, and lower risks of dural and neural injury compared with traditional techniques4. However, its application in the surgical management of osteoid osteoma has not yet been reported. Osteoid osteoma, a benign bone lesion first described in 19305, accounts for roughly 10% of benign bone tumors and typically affects young adults6. These patients present with nocturnal, dull pain that is responsive to nonsteroidal anti-inflammatory drugs and that is sometimes accompanied by limping when the lesion involves the lower extremity. Although radiographs can show small cortical lytic lesions, computed tomography (CT) is best for visualizing the central nidus. Surgical resection and curettage are both highly effective, but minimally invasive approaches—particularly CT-guided radiofrequency ablation (RFA)—have gained popularity due to comparable efficacy and lower complication rates7,8. Nonetheless, RFA has limitations in sclerotic or anatomically challenging lesions. In this context, UBS use, alone or combined with RFA, represents a novel and promising strategy. This pilot study is commendable for being the first to assess UBS use in osteoid osteoma treatment. In this single-center retrospective series of 77 patients, the authors evaluated 3 minimally invasive strategies: UBS alone, RFA alone, and UBS and RFA combined. Pain scores improved dramatically across all groups, with visual analogue scale (VAS) scores decreasing from a mean and standard deviation of 4.55 ± 1.12 preoperatively to 0.25 ± 0.52 at 1 month. Importantly, the UBS-only group and the combined treatment group demonstrated faster gait recovery than the RFA-only group. No major complications were reported. These results suggest that the UBS, which has traditionally been applied in spinal and joint surgery, may be a safe and effective alternative to, or adjunct to, RFA in treating osteoid osteoma. Introducing the UBS into osteoid osteoma management is notable for multiple reasons. First, its selective bone-cutting capability minimizes damage to surrounding soft tissues, which is advantageous when managing lesions that are adjacent to critical neurovascular or articular structures. Second, the UBS allows precise nidus removal under navigation, which may reduce the risk of recurrence in densely sclerotic cortical lesions in which RFA has limited effectiveness. Combining the UBS with RFA offers a synergistic approach that may be particularly valuable for large, intra-articular, or recurrent lesions. The reported superiority of UBS use with respect to gait recovery raises important questions regarding the underlying mechanisms of its functional benefits. Both the UBS and RFA enable precise mechanical removal of the nidus, which may lead to more complete decompression and thereby expedite functional restoration. However, RFA can induce a transient inflammatory response in the surrounding tissues, potentially delaying recovery and resulting in slightly inferior functional outcomes compared with UBS. These differences warrant further investigation through prospective, comparative studies. Nevertheless, several limitations temper the interpretation of these findings. The retrospective design introduces inherent selection bias. Although the sample size of 77 patients is respectable for a single-center study, it is still not large enough, which limits the statistical power of the study. Another concern is generalizability: UBS use requires specialized equipment such as O-arm navigation and dedicated ultrasonic devices, but these resources are not universally available, particularly in community hospital or resource-limited settings. This study identifies a few directions for future research. Prospective randomized trials comparing RFA and UBS use across lesion subtypes are needed to clarify the relative efficacy of these treatment modalities, and studies with longer-term follow-up are needed to assess recurrence. Cost-effectiveness analyses will also be important, given the higher expense associated with the UBS. Finally, treatment algorithms that integrate lesion size and anatomical location should be validated in multicenter cohorts to refine patient selection and guide clinical decision-making. The UBS, alone or combined with RFA, appears to be safe and effective for select patients. Although preliminary, these findings suggest that ongoing technological advances may further enhance the role of the UBS and broaden the therapeutic options for both surgeons and patients.