Comparative Effectiveness and Safety of Radiofrequency Ablation, Surgery, and Emerging Image-guided Therapies for Osteoid Osteoma: A Systematic Review and Meta-analysis

Osteoid osteoma (OO) is a benign osteoblastic tumor that can cause significant morbidity. While radiofrequency ablation (RFA) has emerged as the preferred minimally invasive therapy, uncertainty remains regarding its comparative performance against surgery and newer image-guided techniques. We conducted a systematic review and meta-analysis to evaluate the effectiveness and safety of RFA relative to surgical excision, cryoablation, microwave ablation (MWA), and MR-guided focused ultrasound (MRgFUS). PubMed, Scopus, and Web of Science were searched from January 1990 to March 2025 in accordance with PRISMA 2020. Eligible studies included patients with radiologically or histologically confirmed OO treated with RFA and at least one comparator. Outcomes assessed were clinical success, recurrence, and complications. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. Risk of bias was assessed with the Newcastle–Ottawa Scale. A total of 16 studies including approximately 1,350 patients were analyzed, of which 10 provided comparative data. RFA demonstrated similar success to surgery (pooled OR 0.66, 95% CI 0.28–1.55) with lower, though not statistically significant, recurrence rates. Complication rates were comparable (OR 1.02, 95% CI 0.26–4.04). Two propensity score–matched cohorts showed MRgFUS achieved equivalent efficacy (OR 3.38, 95% CI 0.52–22.11) and safety (OR 1.84, 95% CI 0.15–22.57). Evidence for MWA and cryoablation was limited to small non-comparative series. RFA remains the gold standard treatment for OO, combining high efficacy with low morbidity. MRgFUS is an effective noninvasive alternative where feasible, while cryoablation and MWA show promise but require further comparative evaluation.