Current management of hand enchondroma: a review

Impact of Patient and Tumor Characteristics on Range of Motion and Recurrence Following Treatment of Enchondromas of the Hand

PURPOSE

The approach to the treatment of enchondromas of the hand is varied, and there is no clear consensus on graft source, fixation, or need for intraoperative adjuvant therapy. We reviewed a cohort of patients who underwent curettage and bone grafting with cancellous allograft chips without internal fixation or adjuvant therapy and reported on postoperative range of motion (ROM) and recurrence rates.

METHODS

We performed a retrospective review of patients who underwent surgical treatment for hand enchondroma over a 23-year period. We collected information on demographics and presenting enchondroma characteristics, including Takigawa classification and presence of pathologic fracture or associated syndromes. Patients were treated with open biopsy with curettage and grafting with cancellous allograft chips. Postoperative ROM, complications, and recurrences were recorded.

RESULTS

Our series included 111 enchondromas in 104 patients. Seventeen of 104 patients (16%) had a diagnosis of Ollier disease. Average length of follow-up was 3.1 years. Eighty-one percent of patients achieved full ROM. Treatment of patients who presented with preoperative pathologic fracture resulted in a greater frequency of reduced postoperative ROM at 28% (9/32) compared to 15% (11/72) of those patients who did not present with preoperative pathologic fracture. Local recurrence developed in 5 of 50 (10%) patients with a minimum of 2 years of follow-up. Local recurrence occurred at higher-than-average rates in patients with giant form Takigawa classification (43%, 3/7) and Ollier disease (23%, 3/13).

CONCLUSIONS

Treatment of enchondromas with biopsy, curettage, and allograft results in full ROM in 81% of patients. Patients with preoperative pathologic fracture should be advised of a greater risk of postoperative extension deficit. Recurrence remains rare and is associated with syndromic presentation and giant form lesions.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

Clinical and Radiological Outcome of Osteoscopic-Assisted Treatment of Enchondroma in Hand with Artificial Bone Substitute or Bone Graft: A 7-Year Case Series and Literature Review

Background: This study aims to look at the intermediate-term clinical, functional and radiological outcomes of patients with enchondroma in hand treated with osteoscopic-assisted curettage and artificial bone substitute or bone graft. The addition of osteoscopy allows direct visualisation of the bone cavity during and after curettage of tumour tissue without the need of creating a large opening in the bone cortex. This could lead to better clearance of tumour tissue and lower risk of iatrogenic fracture. Methods: A total of 11 patients who received surgery from December 2013 to November 2020 were retrospectively reviewed. All cases had histological diagnosis of enchondroma. Patients with a follow-up period of less than 3 months were excluded. The mean duration of follow-up was 20.9 months. For the clinical outcome, we measured the total active motion (TAM) and graded with Belsky score grip strength. For the functional outcome, the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH) score was used. For the radiological outcome, we evaluated the X-ray for bone cavity filling defect, new bone formation according to the system proposed by Tordai. Results: The mean TAM of patients was 257º. A total of 60% patients had Belsky score grading excellent, 40% patients had Belsky score grading good. The mean percentage of grip strength compared with the contralateral side was 86.2%. The mean QuickDASH score was 7.7. For the wound aesthetic rating by patients, 81.8% patients reported as excellent. For the radiological outcome, the postoperative X-ray of all patients showed bone filling defect less than 3 mm. The mean time to complete bone consolidation was 3.8 months. None of the patients showed any radiological signs of recurrence. Conclusions: Our study showed that patients with enchondromas in hand treated with this minimally invasive method demonstrated good functional and radiological outcome. Its application may also be extended into treating other benign bone lesions in hand. Level of Evidence: Level IV (Therapeutic).

Outcome of surgical interventions for solitary enchondromas of the hand : Controversial issues

BACKGROUND

Enchondromas are the most common primary bone tumors of the hand and are benign cartilaginous tumors. This study evaluated the clinical and radiologic results of patients who underwent surgical interventions for isolated hand enchondromas with a minimum follow-up of 1 year and focused on controversial issues.

METHODS

A retrospective study included 66 patients with solitary hand enchondromas with follow-up >12 months who underwent surgical interventions between January 2014 and July 2020. Patients with multiple enchondromas, low-grade chondrosarcoma, or who missed follow-up were excluded. All patients underwent thorough curettage with or without filling. Follow-up visits were done at 6 weeks, 3 months, 6 months, and annually. Demographic characteristics, clinical presentation, surgical details, final histologic examination, rehabilitation program, complications, and recurrences were recorded. The range of movement of the affected hand was compared to the contralateral one. Radiological evaluation of defect filling using the modified Neer classification was done.

RESULTS

Of the patients 25 were male and 41 were female (38 right hand affection, 28 left hand affection), the mean age was 30.4 ± 11.9 years. Indications for surgery were local pain, swelling, and pathological fractures. The mean follow-up period was 28.8 ± 12.9 months (range 12-67 months). The mean MSTS score was 28.73 ± 1.6 (range 24-30). The middle finger was most frequently affected (18 cases, 27.3%) and the proximal phalanx was the most common location (37 cases, 56.1%). The mean length of lesions was 18.9 ± 6.67 mm and the mean width was 12.3 ± 4.1 mm. According to the modified Neer classification, 50 cases were classified as grade 1 (healed), 16 cases as grade 2 (healed with defects), and no case presented as persistent or recurrent lesions.

CONCLUSION

Solitary hand enchondroma can be effectively treated with adequate curettage, with or without autologous bone grafting, with positive functional and radiological outcomes. When compared to grafting from the iliac crest, harvesting bone from the distal radius provides a shorter hospital stay and reduced complication rates.

Is three-dimension-printed mesh scaffold an alternative to reconstruct cavity bone defects near joints?

PURPOSE

Reconstruction of cavity bone defects after curettage of benign bone tumours around the joint remains challenging. We designed a novel 3D-printed mesh scaffold as a substitute for bone cement, aiming to support the articular surface, protect the subchondral bone, and reduce complication rates.

METHODS

We retrospectively analyzed seven patients who received curettage and reconstruction using a 3D-printed mesh scaffold between January 2020 and June 2021. Pain and function were evaluated using the 10-cm Visual Analogue Scale (VAS) score and the 1993 version of the Musculoskeletal Tumor Society (MSTS-93) score. Radiographs were used to evaluate articular surface supporting, subchondral bone protection, and complications.

RESULTS

The median functional MSTS-93 and VAS scores were both improved after surgery, and the median 3D-printed mesh scaffold volume was smaller than the median defect volume. Articular surface supporting, subchondral bone preservation, and osteogenesis were observed post-operatively. No related complications were observed during the last follow-up.

CONCLUSIONS

The 3D-printed mesh scaffold provided sufficient mechanical support for the articular surface and protected the subchondral bone. We recommended the 3D-printed mesh structure as an alternative to repair cavity bone defects around joints.

Simple curettage and allogeneic cancellous bone chip impaction grafting in solitary enchondroma of the short tubular bones of the hand

Enchondroma is the most common bone tumor in the hand. While standard surgical procedure is intra-lesional excision and bone grafting, there is a dispute between allogeneic bone, autogenous bone, and synthetic bone substitute grafting. Diverse adjuvant treatments have been introduced to reduce recurrence, but results are mixed with controversies. Meanwhile, whether existing descriptive classification could predict treatment outcome remains unclear. Thus, we reviewed patients with solitary enchondroma of the hand who underwent simple curettage followed by allogeneic cancellous bone chip impaction grafting. Eighty-eight patients with more than 5 years of follow-up were enrolled. Demographic data, local recurrence, and complications were reviewed. Duration of consolidation and the difference according to Takigawa classification were assessed. Range of motion (ROM), and functional scores were also evaluated. There were 51 women and 37 men, with a mean age of 37.9 years. Mean follow-up was 10.2 years. Recurrence occurred only in one patient. There was no complication. Mean postoperative total active motions of fingers and thumb were 239° and 132.9°. Mean modified Disabilities of the Arm, Shoulder, Hand score, and Musculoskeletal Tumor Society Score were 1.63, and 99.2 at the last follow-up. Consolidation, ROM, and functional scores according to Takigawa classification showed no significant differences. This study suggests that simple curettage with impaction grafting of allogeneic cancellous bone chip is a feasible method for treating solitary enchondromas involving short tubular bone of the hand with good long-term outcomes. Postoperative recurrence and complication rates were very low. Radiographic and clinical results were good regardless of the previous radiological classification.

Benign Hand Tumors (Part I): Cartilaginous and Bone Tumors

Background: Benign tumors of the hand present in a wide array of histological subtypes and compose most of the bony tissue tumors in the hand. This study evaluates the characteristics and treatment of benign bone tumors in light of one institution's experience. Methods: Histologically confirmed benign tumors of the hand were retrospectively identified using International Classification of Diseases codes from 1992 to 2015. A medical chart review was conducted to collect patient characteristics and tumor epidemiology and treatment. Results: A total of 155 benign bone tumors were identified. The median age of patients at the time of surgery was 39.9 ± 12.8 years. All bone tumors were located in the digits, and most were treated by intralesional curettage (n = 118, 76%). Pathologic fractures occurred in 79 bone tumors (51%). Conclusion: Enchondromas (n = 118, 76%) were the most common bone tumor in this series, whereas giant cell tumors were the most destructive and also had the highest recurrence rate (40%). Awareness of tumor features may help physicians with diagnosis, and awareness of recurrence rates is important when counseling patients.

The surgical management of the cavity and bone defects in enchondroma cases: A prospective randomized trial

BACKGROUND

We compared the curettage/bone grafting and the curettage/bone graft substitutes surgical techniques in their relation to functional outcomes, oncologic outcome (recurrence, malignant transformation), the rate of postsurgical complications, durations of surgery and of postsurgical immobilization for hand-localized cases of solitary and multiple enchondromas.

METHODS

The current prospective randomized trial analyzed 200 adult patients (2012-2017) with enchondroma who underwent surgical intervention. The cases were randomly divided into Group 1 (n = 100; F 56, M 44) for surgeries with curettage and autogenous bone grafting, and Group 2 (n = 100; F 55, M 45) for surgeries with curettage and bone graft substitutes. The placebo control Group 3 consisted of cases operated by curettage only (n = 56; F 31, M 25). The follow-up period was set at 30 months.

RESULTS

The duration of surgery was 51 ± 4 min in Group 1 and 27 ± 1 min in Group 2 (p = 0.008). In Group 1, the rate of recurrence was 6% against 1% in Group 2 (p = 0.005). No other statistically significant differences in postsurgical outcomes between three involved groups were noted.

CONCLUSION

In cases of enchondroma of the hand, postsurgical functional outcomes, the rate of postsurgical complications, the duration of immobilization, and the time to complete recovery are not influenced by the type of chosen grafting material. The implementation of HAp-collagen bone substitutes in granules instead of autogenous bone grafting reduces the duration of surgery. The implementation of autogenous bone grafting may increase the rate of tumor recurrence.

Total Knee Arthroplasty and Atypical Cartilaginous Tumor/Enchondroma of the Distal Femur

Enchondroma is a common benign chondrogenic tumor, which typically occurs in the short bones of hands and feet. However, when affecting the long bones, it is difficult to rule out the low-grade chondrosarcoma, called atypical cartilaginous tumor (ACT), because of the highly similar clinical and radiologic features. This study reports 2 patients with advanced knee osteoarthritis, scheduled for total knee arthroplasty, who had a distal femoral lesion on imaging suggestive of ACT/enchondroma. We believe that the treatment of these patients could be a challenge for arthroplasty surgeons. This is because it might be difficult to decide whether a periarticular chondral tumor of an osteoarthritic knee is malignant and changes the plan. In this report, we described our approach to address both knee osteoarthritis and ACT/enchondroma of the distal femur. To the best of our knowledge, this issue has not yet been discussed in the literature.

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.

Mallet Finger Fracture through Enchondroma of the Distal Phalanx

A 46-year-old man injured his ring finger and developed a mallet deformity. Radiographs showed a mallet finger fracture through an osteolytic lesion of the distal phalanx. Magnetic resonance imaging showed low intensity on T1-weighted imaging and high intensity on T2-weighted imaging, which suggested the clinical diagnosis of enchondroma. The bone tumor was excised, and osteosynthesis was performed using Ishiguro's extension block pinning, and a flexion block pin was added to prevent flexor tendon avulsion fracture through the enchondroma, followed by an autologous iliac cancellous bone graft. One year after surgery, the patient had no pain or extension lag of the affected ring finger, and his quickDASH score was 0 points. Radiographs showed no recurrence and minimal arthritic change of the distal interphalangeal joint. One-stage treatment of a mallet finger fracture through an enchondroma using Ishiguro's method was effective.

Fibroma of tendon sheath embedded in carpal bones mimicking carpal enchondroma: A case report

RATIONALE

Fibroma of tendon sheath is a rare entity that is typically attached to the tendon sheath.

PATIENT CONCERNS

A 43-year-old man presented with a painful mass in his right wrist, which was initially misdiagnosed as an enchondroma.

DIAGNOSIS

Fibroma embedded into carpal bones, which exhibited lytic radiographic features similar to those of enchondroma. Excisional biopsy demonstrated spindle-shaped cells and collagen-like stroma.

INTERVENTIONS

The patient underwent lesion resection surgery.

OUTCOMES

The patient recovered well and showed no signs of recurrence at 6-month follow-up.

LESSONS

This case provides valuable insights for hand surgeons. While radiograph is helpful in multiple diseases, histological examination is indispensable for establishment of final diagnosis.

Giant cell tumour of the middle phalanx of the middle finger

Giant cell tumour (GCT) of bones in the hand is very rare, only 2% of all hand tumours, but unacceptably high recurrence rates (up to 90%) have been reported by several authors. Diagnosis can be challenging due to its rarity and enchondroma-mimicking characteristics. We report on a case of GCT of the middle phalanx of the left middle finger in a 49-year-old woman who underwent middle phalanx resection and reconstruction with bone grafting. At the 1-year follow-up, no evidence of recurrence was detected and the patient was pain-free.

Enchondroma in the distal phalanx of the finger: An observational study of 34 cases in a single institution

The goal of our study was to report the clinical presentation, treatment, and complications of enchondroma in the distal phalanx of the finger. This was a retrospective study of 34 patients (19 women and 15 men) who underwent surgery between May 2004 and September 2012 for enchondroma in the distal phalanx of the finger. The average age of the patients was 39.38 ± 10.97 years old (range 14-59). The presenting symptoms and imaging features were recorded. The surgical procedure was performed under regional or general anesthesia. The surgical technique involved removal of tumors by opening a cortical window and curetting the cavity. The defects were filled with an injectable calcium phosphate cement. All patients received follow-up in our outpatient clinic every 6 months. Expansion of bone or thinning of the cortex present in the radiological imaging, including anteroposterior and lateral plain radiographs of the fingers, was used to assess for tumor recurrence. The observational end-point was reoperation.All tumors were confirmed as enchondromas by the pathological results. None of the patients had a tumor recurrence. Three patients (9% of cases) developed an infection. After antibiotic treatment, 2 patients were cured, and 1 patient required an amputation. Enchondroma in the distal phalanx of the finger presents with a variety of clinical symptoms. Injectable calcium phosphate cement is adequate for bone grafting. Postoperative infection is more common than tumor recurrence. If patients have an infection or bilateral bone cortex defects, bone grafting is challenging.

LEVEL OF EVIDENCE

Therapeutic study, Level IV.