Retrospective review of outcome after surgical treatment of enchondromas in the hand

Surgical Management of Enchondromas of the Hand: A 12-Year Experience

Objective  Enchondromas are benign tumours of hyaline cartilage most frequently arising in the bones of the hand and the optimum surgical management strategy for these is debated. We present an audit of the surgical management of 57 enchondromas referred to our tertiary hand surgery department over a period of 12 years (2008-2020) and describe our surgical technique for this procedure as well as a comparison with other studies in the literature. Materials and Methods  Retrospective audit of our practice. Data were extracted from our institutional operative database to identify all patients undergoing surgical management of enchondromas during the time period. The individual electronic patient records were then evaluated to extract demographics and outcome data. Results  Our results demonstrate excellent clearance of enchondroma (74% Tordai group 1 radiological resolution) with very low complication rates and no recurrence. Our results also emphasize the importance of surgical management of enchondromas to allow diagnosis of rare chondrosarcoma (3.5% in this study). Conclusion  A larger randomized controlled trial is still required to adequately determine the differences between the surgical options available and determine the best possible surgical approach to these cases. Level of evidence is III.

Radiofrequency ablation for the treatment of a presumed enchondroma in the flat bones of the pelvis

Herein, a 30-year-old Caucasian female who presented with a persistent pain in the right pelvic region due to an enchondroma and treated with RF ablation is described. An initial MRI of the pelvis revealed a well-circumscribed lesion in the right inferior ischiopubic ramus with a maximum diameter of 9.5 mm. The final diagnosis was established by a percutaneous CT-guided bone biopsy, which excluded malignancy and revealed an enchondroma. About a month after the biopsy, a percutaneous radiofrequency ablation (RFA) of the lesion was performed. The symptoms resolved completely gradually 2 months after the treatment and a follow-up imaging with MRI showed complete resolution of the pathological enhancement indicating necrosis of the lesion. RFA has not been previously reported as a treatment option of enchondromas found in flat bones of the pelvis and could be a safe alternative minimally invasive treatment option in such cases, avoiding major operations.

Early Surgical Treatment of Both Tumor and Fracture in Patients With Enchondroma of the Hand Combined With Pathologic Fracture

PURPOSE

The aims of this study were to evaluate the degree of cortical thinning and the tumor area in simple radiographs in patients with enchondroma of the hand combined with pathologic fracture and to determine the surgical outcome of simultaneous tumor curettage and internal fixation of fracture.

METHODS

We enrolled 23 bone lesions of 21 patients diagnosed with enchondroma of the hand. Of them, 9 bone lesions of 8 patients had pathologic fracture. We evaluated the degree of cortical thinning and tumor area in simple radiographs and compared them between patients with and without pathologic fracture. For patients with pathologic fracture, we performed curettage of the tumor through the fracture site and fixed the fracture using K-wires. We then evaluated the clinical outcome of these patients using the visual analog scale to measure pain intensity and Takigawa's criteria 1 year after surgery.

RESULTS

There was a significant difference in the degree of cortical thinning between the 2 groups (P < 0.001); however, there was no significant difference in the percentage of tumor area (P = 0.259). The average time from surgery to bony union was 8.5 weeks in patients with pathologic fracture. The patients reported that they could return to their previous activities of daily living within 12 weeks of surgery. The average visual analog scale score was 0.6 at 1 year after surgery, and 6 patients were graded as excellent and 2 as good according to Takigawa's criteria.

CONCLUSIONS

Cortical thinning seems to be related to pathologic fracture. Our scoring system for cortical thinning may be helpful in evaluating the risk for pathologic fracture. Early 1-stage surgical treatment for pathologic hand fracture with enchondroma is a very useful method with satisfactory outcomes that could shorten the treatment period.

Surgical management of an enchondroma of the proximal phalanx of the foot: An illustrative case report

Enchondromas are benign tumours that may become symptomatic due to expansive pressure on the surrounding bone. In this case, a 27-year-old male developed a symptomatic enchondroma within the proximal phalanx of his left fourth toe. Resection and insertion of a bone graft were considered optimal management. Histopathology testing confirmed the diagnosis of an isolated enchondroma. The patient was monitored closely for 3 months postoperatively and reported full satisfaction at his 12-month review. Enchondroma resection and insertion of a tibial bone graft may provide an effective long-term solution for a symptomatic enchondroma of the toe.

Surgical Treatment of Solitary Enchondromas of the Hand

Objective: The present retrospective study evaluated the clinical and radiologic results of patients who underwent complete curettage and autologous bone grafting for hand-located isolated enchondromas with a minimum follow-up period of one year.

Patients and Methods: Thirty-two patients with a follow-up period of at least 12 months who underwent operation between August 2010 and October 2018 due to the presence of solitary enchondroma of the hand were included in the study. All patients underwent complete curettage and filling of the defect via autologous bone grafting. Autologous bone graft was harvested from the iliac crest and distal radius in 24 and eight patients, respectively. The patients underwent radiography on the first postoperative visit and at six weeks, 12 weeks, and annually. The range of movement of the finger joint was evaluated by comparing it with the healthy contralateral side. Functional outcomes and radiologic outcomes were evaluated. The frequency of complications and recurrences were established.

Results: Twelve patients were male and 20 were female. The average age was 34 (range: 16-56) years. The most common digit involved was the little finger (nine cases, 28.125%); the proximal phalanx was the most common location (17 cases, 53.125%). Control radiography in the sixth week revealed graft consolidation in all patients. No case of nonunion or recurrence was detected clinically or radiologically, with a mean follow-up period of 54 (range: 12-96) months. Functional outcomes were classified as excellent in 28 patients and as good in four patients. The final radiographic appearances included Tordai’s group 1 in 28 bones and group 2 in four bones. 

Conclusion: Curettage and autologous bone grafting are safe, costless, and effective treatment options for hand enchondroma, with satisfactory functional and radiographic outcomes. Harvesting bone graft from the distal radius provides a shorter length of hospital stay and lower complication rates compared to obtaining the graft from the iliac crest.

Enchondromas of the Hand: A 20-year Experience

Objective  Enchondromas are the commonest tumors of the bones of the hand. Treatment approaches vary. The present article presents the characteristics of the tumors, diagnostic methods, and treatments.

Methods  We discuss the approach used in our institution, where we have treated 48 patients with enchondromas of the hand between 1996 and 2016. Our technique of treatment, which has remained the same over 2 decades, comprises the use of curettage, high-speed burr, and autologous bone graft (harvested with a minimally invasive technique, using a Craig biopsy needle).

Results  Pain and fractures were the most common symptoms leading the patients to consultation, at frequencies of 33.3% and 31.3%, respectively. A total of 27.1% of the cases were asymptomatic, and their lesions were discovered incidentally. The mean age was 34.4 years (SD = 12.9 years). Tumors were more frequently presented in the ulnar side of the hand, in the fifth ray (41.5%) and in the proximal bones (in the proximal phalanges [43.8%], and in the metacarpal [33.3%]). The size of the tumors ranged from 0.2 cm ² to 5.7 cm ² , with a mean of 1.7 cm ² (standard deviation [SD] = 1.0 cm ² ) and were not associated with fracture ( p  = 0.291). Fracture was also not associated with any of the symptoms, neither with the age of the patients ( p  = 0.964). After the treatment, most patients achieved full range of motion (91.7%), with good integration of the bone graft. Three patients presented deficit in range of motion (6.3%) and the incidence of complications was also 6.3% (3 patients). At the end, after the needed surgical revisions, these three patients also recovered full function. They achieved full bone graft integration, regained full range of motion and returned to work. There was no tumor recurrence case during the follow-up period evaluated. For all cases, no donor site complications occurred.

Conclusion  Our method of treatment has consistently provided good outcomes, with only a few minor complications. Therapeutic level of evidence: IV.

Nonsurgical Treatment as Alternative to Surgical Treatment in Enchondromas of the Distal Phalanx. Analysis of a Series of 11 Cases

PURPOSE

To describe the results of nonsurgical and surgical treatment of enchondromas of the distal phalanx of the hand.

METHODS

Eleven enchondromas of the distal phalanx were retrospectively reviewed. Five patients underwent surgery (curettage and autogenous cancellous bone graft from the iliac crest) and 6 patients were treated nonsurgically. Clinical records and radiographs were reviewed for each patient. We recorded complications and cosmetic and functional results. Radiographic healing in surgical patients was scored according to the classification of Tordai and to the criteria of Wilhelm and Feldmeier. The average follow-up of the nonsurgical and surgical cases was 45 and 62 months, respectively.

RESULTS

Eight patients were women. Average age at diagnosis was 40 years. Nine patients presented with a pathological fracture. The demographic characteristics of the surgical group and nonsurgical group were similar. Among the cases treated nonsurgically (6), 1 had 2 pathological fractures after diagnosis. At final follow-up, the average pain on a visual analog scale was 2.8. With the exception of 1 patient, the range of motion of the fingers was normal or minimally reduced. Among the surgical cases (5), there were no complications in the bone graft donor site, 2 patients developed infections in the operated finger, and no postoperative pathological fractures were found. At final follow-up, the average pain was 3.2. Joint mobility was normal in 3 patients. Postoperative radiological examination revealed complete bone healing in all patients (grade I in the Tordai classification). No local recurrence was seen. According to the criteria of Wilhelm and Feldmeier, there were 3 excellent, 1 good, and 1 satisfactory results in the surgical group, and 2 excellent, 3 good, and 1 satisfactory results in the nonsurgical group.

CONCLUSIONS

Surgical and nonsurgical treatment in distal phalanx enchondromas appear to be associated with satisfactory results, although each has their own advantages and disadvantages.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Parosteal extra-axial chordoma of the second metacarpal bone: a case report with literature review

Extra-axial chordoma is a chordoma that occurs in non-axial locations. It is a very rare tumor, with 20 cases reported to date; 14 in bone and six in soft tissue. Of the 14 skeletal extra-axial chordomas, ten were intramedullary and four were intracortical. We report the first case of parosteal extra-axial chordoma arising in the second metacarpal bone, expressing brachyury on immunohistochemical analysis, and describe the pathologic and radiologic findings. We suggest that extra-axial chordoma can occur in parosteal bone lesions or the hand, without features of bone distribution or bone-specific sites.

Exploring the key genes and pathways in enchondromas using a gene expression microarray

Enchondromas are the most common primary benign osseous neoplasms that occur in the medullary bone; they can undergo malignant transformation into chondrosarcoma. However, enchondromas are always undetected in patients, and the molecular mechanism is unclear. To identify key genes and pathways associated with the occurrence and development of enchondromas, we downloaded the gene expression dataset GSE22855 and obtained the differentially expressed genes (DEGs) by analyzing high-throughput gene expression in enchondromas. In total, 635 genes were identified as DEGs. Of these, 225 genes (35.43%) were up-regulated, and the remaining 410 genes (64.57%) were down-regulated. We identified the predominant gene ontology (GO) categories and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways that were significantly over-represented in the enchondromas samples compared with the control samples. Subsequently the top 10 core genes were identified from the protein-protein interaction (PPI) network. The enrichment analyses of the genes mainly involved in two significant modules showed that the DEGs were principally related to ribosomes, protein digestion and absorption, ECM-receptor interaction, focal adhesion, amoebiasis and the PI3K-Akt signaling pathway.Together, these data elucidate the molecular mechanisms underlying the occurrence and development of enchondromas and provide promising candidates for therapeutic intervention and prognostic evaluation. However, further experimental studies are needed to confirm these results.

Enchondroma of the Hand: Result of Surgery Curettage and Grafting and Possible Factors Affecting the Outcome

A retrospective review for enchondroma in the hand which had undergone operative treatment is presented. Twenty patients were treated operatively over a 10-year period. A total of 70% of the patients presented with pathological fracture. Enchondromas were most commonly located in the little finger (65%) and proximal phalange (60%). Enchondromas presented with pathological fractures and were treated definitively after the fracture had healed, except for one patient with open reduction, internal fixation of fracture, and bone grafting. All 20 patients underwent curettage of the enchondroma. In the same operative occasion, 16 patients received bone grafting, three patients received bone substitutes, and one had received bone cement. Fourteen (70%) of the patients suffered no major postoperative complications. Postoperative stiffness was encountered in seven patients. A secondary operation for relief of postoperative stiffness was performed in three patients. Factors were assessed for their risk of resulting in postoperative stiffness and occurrence of secondary operation. Factors included sex, age, pathological fracture, location of lesion, and preoperative stiffness. Only preoperative stiffness was a statistically significant risk factor contributing to postoperative stiffness and occurrence of a secondary operation.

The management and surgical intervention timing of enchondromas: A 10-year experience

Enchondroma, reportedly the most common primary tumor of the long bones of the hand, usually develops during the first till fourth decades of life. However, there has no consensus been reached regarding the surgical intervention timing for these patients. We aim to evaluate the optimal surgical intervention timing for the patients with fractures due to enchondromas, investigate the impact of pathological fractures on the treatment and outcomes in these patients.Medical records and X-rays of patients treated for enchondroma of the hand from 2005 to 2015 were retrospectively reviewed. We collected 148 cases in total and 92 of them had complete information including X-rays, medical records, and files of follow up.There were no significant differences in terms of consolidation time after surgery, recurrence rate, and DASH scores between the groups with and without fractures; the treatment costs were higher in the group with fractures than those without fractures; however, patients without fractures were able to resume work earlier than those with fractures.The pathological fractures associated with enchondromas have no significant impact on the treatment outcomes compared to those with simple nonfractured enchondromas. Although the cost was more expensive for patients treated primarily with pathological fractures due to enchondromas, these patients could resume their work normally much earlier than those treated by delayed surgery. Early surgical intervention is recommended for better results and no increased risks for patients with pathological fractures caused by enchondromas.

Diagnostic imaging of benign and malignant osseous tumors of the fingers

Primary lesions of the tubular bones of the digits are not uncommon, and the vast majority of these lesions are benign. Benign intramedullary lesions such as enchondromas are frequently discovered incidentally, unless they are associated with a pathologic fracture. Expansile lesions or lesions that are pedunculated and protrude from the cortex may manifest with pain and functional deficits from local inflammatory reactions. Systemic disorders such as sarcoidosis and local soft-tissue lesions with involvement of adjacent bone may mimic primary phalangeal bone tumors. Primary or secondary malignant lesions of the phalanges, most commonly chondrosarcomas, are extremely rare, and their characterization may require the use of multiple modalities, including radiography, computed tomography, and magnetic resonance imaging. Although ultrasonography is extremely useful in the evaluation of soft-tissue lesions of the hand, its role in the evaluation of osseous lesions is limited. The authors describe the imaging features of the most common benign osseous and chondral lesions of the fingers, including enchondromas, cystic lesions, and osteochondromas. In addition, they discuss malignant entities that may occur in the fingers (eg, chondrosarcomas and metastatic lesions) and commonly encountered mimics of primary osseous lesions (eg, glomus tumors, intraosseous epidermal inclusion cysts, infectious entities, and manifestations of systemic diseases). They also discuss the advantages and disadvantages of the most commonly used imaging modalities in differentiating benign from malignant lesions.

Current management of hand enchondroma: a review

Enchondromas are benign bone tumours originating from cartilages. It is mainly discovered incidentally in radiographs or due to symptoms like pathological fracture or pain. Conservative treatment through regular check-up and surgical excision using curettage are the two major treatment methods for enchondromas. This review concludes that small localized asymptomatic lesions can be treated conservatively while most expanding or symptomatic lesions should be treated with simple curettage. Adjuvant treatments like high-speed burring or alcohol instillation are not recommended.

The surgical management of hand enchondroma without postcurettage void augmentation: authors' experience and a systematic review

BACKGROUND

Postcurettage void augmentation in the management of hand enchondroma is a debated practice. The objectives of this study are to present the outcomes of hand enchondroma treatment by curettage without void augmentation at the authors' institution and to systematically review the literature pertinent to this aspect of management.

METHODS

Initially, a retrospective case series of patients treated for hand enchondroma at the authors' institution was conducted to assess postoperative complications and radiographic consolidation. All patients were treated by curettage without void augmentation. Next, a systematic review was conducted. Postcurettage void management was categorized into four groups: (1) curettage alone, (2) curettage followed by augmentation with cancellous autograft, (3) curettage followed by augmentation with bioactive and osteoconductive materials other than autograft, and (4) curettage followed by augmentation with bone cements. Complication and recurrence rates were compared.

RESULTS

The authors' series was composed of 24 patients with 26 lesions. The mean age was 38.9 years (range 14-61), and the mean follow-up was 26 months (range 3-120). There was one recurrence but no postoperative fractures or nonunions. As for the systematic review, a total of 22 studies involving 591 patients and 609 lesions were assessed. Complications occurred at an incidence of 0.7 % following curettage alone, 3.5 % following autograft, 0 % following augmentation with bioactive/osteoconductive materials, and 2.0 % following cement augmentation. No statistical differences were noted for complication or recurrence rates.

CONCLUSIONS

Simple curettage is an effective and inexpensive technique that does not lead to increased complication rates in the treatment of most hand enchondromas.

Phenolization and coralline hydroxyapatite grafting following meticulous curettage for the treatment of enchondroma of the hand. A case series of 82 patients with 5-year follow-up

BACKGROUND

Enchondromas are benign cartilaginous tumours. The most common location is in the long bones of the hand. Treatment methods fall into a broad spectrum ranging from conservative, medical therapies, to a variety of surgical procedures, which may or may not employ the use of local adjuvant treatment or bone grafting. The purpose of this study was to report our experience and evaluate the long-term results of patients with enchondroma of the hand, treated in our department with meticulous curettage, phenolization and coralline hydroxyapatite grafting.

METHODS

We present 82 patients with hand enchondromas treated surgically in our department during the last 10 years. The patients were treated operatively with meticulous curettage of the bone lesion, with use of phenol 5 % as local adjuvant and coralline hydroxyapatite bone graft to fill in the remaining cavity.

RESULTS

At a minimum of 5-year follow-up, radiographs and clinical examination showed adequate bone formation at the site of enchondroma excavation and no evidence of recurrence, fracture, infection or other complication related to the procedure.

CONCLUSION

We concluded that the combination of meticulous curettage of the lesion, with the use of phenol as local adjuvant and coralline hydroxyapatite graft is a safe technique that prevents recurrence and allows adequate and uncomplicated local new bone formation.

Modified technique for one-stage treatment of proximal phalangeal enchondromas with pathologic fractures

PURPOSE

To evaluate the treatment outcome for enchondromas of the proximal phalanx with pathological fracture.

METHODS

Between June 2008 and October 2012, we treated 9 patients with solitary proximal phalanx enchondromas and pathologic fractures by curetting the tumor, filling the void with a block of autogenous bone chip, and applying a low-profile miniplate. Postoperative follow-up included clinical assessment, pain evaluation, and radiographs.

RESULTS

Follow-up time ranged from 13 to 42 months (mean, 30 mo). No major complications such as notable malalignment, nonunion, infection, or tumor recurrence were observed. All fractures healed after a mean of 8 weeks postoperatively. Full motion was achieved in 5 patients and extension lag (5° to 10°) of the proximal interphalangeal joint persisted in 4. Function was excellent in all patients according to the Takigawa criteria. All patients reported they were pain free and had resumed presurgical function within 12 weeks after surgery.

CONCLUSIONS

Tumor curettage, reconstruction of the bone defect with a block of autogenous bone chip, and low-profile miniplate fixation provided one-stage treatment with immediate rigid stabilization and good functional outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

A biomechanical analysis of treatment options for enchondromas of the hand

PURPOSE

Enchondromas are the most common benign bone tumor affecting the hand. Standard treatment has consisted of curettage with bone grafting. It has become increasingly common for surgeons to use biologic cement in these cases. The purpose of this study was to evaluate different treatment options used to fill voids after curettage of hand enchondromas to determine if any provide more rigid fixation.

METHODS

A cadaveric model of hand enchondromas was designed by making a standardized size corticotomy (0.6 × 1.0 cm) in 60 cadaver metacarpals. Resultant voids were then filled with either no material, bovine demineralized bone matrix (Synthes Paoli, PA, USA), or one of two different calcium phosphate bone cements: a carbonated apatite (Synthes Norian SRS Skeletal Repair System) and a hydroxyapatite (Stryker HydroSet) calcium phosphate. An apex dorsal three-point bend was applied to the metacarpals through an MTS machine, and load to failure and stiffness were recorded.

RESULTS

Biomechanically, load to failure for intact metacarpals was significantly superior to those in which a corticotomy was created (p = 0.04). There was a significant increase in load to failure between the metacarpals treated with the calcium phosphate bone cement and the negative controls (p = 0).

CONCLUSIONS

In a biomechanical analysis of a cadaveric model of hand enchondromas, calcium phosphate bone cement provided significantly increased strength as compared to curettage alone and approximated the strength of intact metacarpals. It is unknown whether the use of biologic cements in this clinical setting leads to less postoperative immobilization, earlier digital motion, a quicker return to work, or increased patient satisfaction.

An alternative technique for the management of phalangeal enchondromas with pathologic fractures

PURPOSE

Enchondroma of the hand with a pathologic fracture is generally treated by tumor curettage and bone grafting after the fracture has healed. However, delayed surgery postpones definitive diagnosis and prolongs the period of disability. We have treated pathologic fractures in a single stage through a modified lateral surgical approach with curettage of the tumor and stabilization using injectable calcium sulfate cement. The aim of this study was to report the outcomes of treatment with this material and the modified approach.

METHODS

Between 2006 and 2010, we enrolled 8 patients with solitary hand enchondromas and pathologic fractures. The surgical procedure involved a lateral approach, an extended lateral cortical window, thorough tumor evacuation, and reconstruction of the bone defects using commercially available injectable calcium sulfate cement. We performed evaluations before surgery and in the postoperative follow-up series by radiographs and clinical assessments, including measurement of joint motion by goniometry and a visual analog pain scale.

RESULTS

The average time of follow-up was 19 months (range, 12-36 mo). The pathologic fractures of all patients healed clinically and radiographically within 8 weeks after surgery, and the mean active motion arcs of the metacarpophalangeal joints and proximal interphalangeal joints of the involved digit were 90° and 94°, respectively at 3-month follow-up. All patients returned to ordinary daily activities without obvious pain by 3 months postoperatively. We found no major complications, such as unacceptable alignment, nonunion, infection, or tumor recurrence, during follow-up.

CONCLUSIONS

This study demonstrated the outcomes of early management of phalangeal enchondromas with pathologic fractures using a lateral approach and injectable calcium sulfate cement for reconstruction. This combined approach avoided the need for supplemental internal fixation, allowed early mobilization, and resulted in minimal joint stiffness.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

CURETTAGE AND CALCIUM PHOSPHATE BONE CEMENT INJECTION FOR THE TREATMENT OF ENCHONDROMA OF THE FINGER

Ten consecutive patients with digital enchondroma were treated by curettage and calcium phosphate bone cement (CPC) injection under digital nerve block. Mean patient age at surgery was 39 years old (range, 26–54), and the mean follow-up period was 19 months (range, 12–31). Two patients had a pathologic fracture at the first visit. Active finger motion was allowed at three days postoperatively and all patients returned to work within four weeks of surgery. The surgical procedures were uneventful in all patients, and no complications were encountered during follow-up. The mean total arc of motion of the PIP joints and MP joints of the affected fingers was 93% of and 99%, respectively, of the arcs of the corresponding joints of the contralateral unaffected fingers at final follow-up. CPC injection is a good option for the treatment of enchondroma of the finger.

Malignant Natural-Killer cell neoplasm presenting as a mucous cyst on the distal interphalangeal joint of the finger

This case report describes a very rare and highly malignant type of lymphoma, which presents as a mucous cyst on the finger. The cyst was excised and the specimen pathohistologically analyzed. The analysis revealed the presence of a Natural-Killer cell neoplasm. This case illustrates and stresses the importance of a pathohistological examination when doubts arise about the initial diagnosis of a benign tumorous lesion.