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Current management of hand enchondroma: a

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Hand Surgery, Vol. 20, No. 1 (2015) 191–195

© World Scientific Publishing Company
DOI: 10.1142/S0218810415300028

CURRENT MANAGEMENT OF HAND

ENCHONDROMA: A REVIEW

Chris Tang, Marcus Chan, Margaret Fok and Boris Fung

Department of Orthopaedics and Traumatology
Queen Mary Hospital, Hong Kong

Received 1 August 2014; Revised 24 August 2014; Accepted 25 August 2014; Published 20 January 2015
by THE UNIVERSITY OF HONG KONG on 01/22/15. For personal use only.
Hand Surg. 2015.20:191-195. Downloaded from www.worldscientific.com

ABSTRACT
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.

Keywords: Enchondroma; Treatment; Hand Surgery.

INTRODUCTION \outcome", \treatment" and \recurrence". The inclusion

Enchondroma is the most common hand tumour (47.1% of
all hand tumours).1 It involves a persistent cartilaginous island
that arised from physis.2 Common symptoms of presentation
include pain, swelling, deformity and pathological fracture at
the site of tumour. The proximal phalanges (48.9%) and the
little fingers (34.3%) were the most common sites involved.3
Malignant transformation of enchondromas to chondrosarcoma
is rare.2 Treatment methods include conservative regular follow-
up or surgical excision by means of curettage. Currently, no
standard protocol for treating enchondromas of hand has been
established. This review aims at giving readers a holistic view on
the treatment strategies of hand enchondroma and suggesting a
treatment approach under the support of current literatures.
MATERIALS AND METHODS
Electronic databases of PubMed and Google Scholar was sear-
ched with the keywords \hand enchondroma", \curettage",
Correspondence to: Dr. Chris Tang, 5/F, Professorial Block, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong. E-mail: medic.chris.tang@gmail.com
criteria were (1) publication in English and (2) papers con-
cerning the treatment of hand enchondroma. Recurrence rate,
complications were reviewed. References in review papers were
screened for potentially relevant studies not yet identified.
RESULTS
Contemporary treatment of hand enchondroma involve ob-
servation, curettage alone and curettage with augmentation
(bone graft or cement injection).
Observation
A number of cases of enchondroma discovered incidentally are
actually asymptomatic while other patients may observe de-
formity without experiencing any pain. Meanwhile, invasive
surgical treatment of curettage and bone graft may result in
prolonged immobilization period. The formation of adhesions
together with immobilization may also result in certain degree

191
 January 14, 2015 1:19:29pm WSPC/135-HS 1530002
192 C. Tang et al.
of loss in motion. In a retrospective review of 73 enchondroma
patients, Müller et al.4 also suggested that regular radiological
follow-up of asymptomatic enchondromas is a better option
due to their low malignant potential (solitary enchondromas,
2–3%) and the high complications rate of surgical treatment
(23%, include upper limb, lower limb and pelvis). For such
reasons, conservative treatment with regular check-up should
be considered in small localized asymptomatic lesions. The
relatively more invasive surgical procedures also mean that
conservative treatment may be a better option for elderly
patients and patients with poor immune function.
Surgical Treatment: Curettage
by THE UNIVERSITY OF HONG KONG on 01/22/15. For personal use only.
Hand Surg. 2015.20:191-195. Downloaded from www.worldscientific.com
The excision of enchondromas is done by simple curettage. A
cortical window was first made to allow clearance of all tu-
mour materials using a hand curette. Some surgeons will also
do extra adjuvant treatment like high-speed burring or alcohol
instillation to reduce the recurrence rate. After excision, the
traditional approach of reconstructing the tumour cavity
involves insertion of an autograft of cancellous bone harvested
from the iliac crest or an allograft. Other augmentation
methods include cement injection using Plaster of Paris,
calcium phosphate cement (CPC) or polymethylmethacrylate
(PMMA). Other surgeons adopt simple curettage without
augmentation. The cortical window is also replaced in most
cases.
Simple Curettage without Augmentation
Due to the fact that bone regeneration occur spontaneously
even without augmentation, there has been doubt whether
bone grafting or cement injection is necessary after curettage.
Schaller and Baer reported that no significant difference in
bone density and functional results was found between 16
patients without bone graft and eight patients with additional
bone graft.5 Morii et al. compared bone formation period
of patients treated with simple curettage with those treated
with hydroxyapatite injection. No significant difference was
found.6
Curettage with Augmentation
by Bone Graft
Bone graft is traditionally placed in the tumour cavity to
promote regeneration of bone tissues and restore mechanical
FA1
strength of the bone. The most common method is to harvest
autogenous bone graft from the iliac crest or other sources. An
alternative method is to use allografts from suitable donors.
Bauer et al. compared the surgical outcomes of 12 enchon-
droma patients treated using allografts with 16 patients treated
using autografts. The bone grafts incorporated and remodeled
in all patients and no recurrence and complications are
found in patients treated with allografts.7 Jewusiak et al. also
obtained satisfactory outcome in 23 patients treated with
freeze-dried allografts. Bone healing was achieved without any
recurrence.8
Curettage with Augmentation
by Cement Injection
As an alternative to bone graft, different types of cement are
also injected into the tumour cavity for augmentation. The in
situ curing property of the cement allows immediate me-
chanical stability. Early mobilization can therefore be achieved
to reduce joint stiffness. Common types of cement include
Plaster of Paris, CPC, hydroxyapatite and PMMA. Cement
injection has a low complications rate and recurrence rate
overall. Gaasbeek et al. also achieved excellent function
according to the Musckuloskeletal Tumour Society Score and
no recurrence using plaster filling.9 Satisfactory results have
also been yielded for construction using CPC. Kim and Kim
reported no complications and 93–99% mean arc of motion for
joints in 10 patients treated with CPC injection.10 Yasuda et al.
obtained similar result in 10 patients but one case of malunion
was reported for a patient undergoing early curettage before
fracture healing.11 Similar good results are also reported for
hydroxyapatite12 and PMMA.13 However, it was noted that 54%
of patients treated using PMMA had decreased flexion range
without functional limitations.13
Adjuvant Treatment
Aiming at reducing the recurrence rate of enchondromas, some
surgeons adopt adjuvant treatments like extensive curettage
using high-speed burring, alcohol instillation of tumour cavity
or even laser sterilization. Cha et al. compared the surgical
outcome of alcohol instillation and high-speed burring and
found no significant difference.14 Giles et al. treated eight
patients with curettage followed by CO2 laser sterilization of
tumour margins. No complications or recurrence was found.15
January 14, 2015 1:19:29pm WSPC/135-HS 1530002
Treatment Timing
Large enchondroma may accompany with pathological frac-
tures. The usual practice is to allow the fracture to heal first
before curettage is performed. This ensures mechanical stability
for curettage and augmentation. However, the drawback is that
the immobilization period of patients will be long and definitive
diagnoses will be delayed. Some surgeon, therefore, prefer early
curettage before the fracture is healed, which allows early
mobilization and reduce joint stiffness. A 0% complications rate
was obtained in a study on eight patients treated with early
curettage and stabilization using injectable calcium sulfate
cement.16 Another review comparing early and late treatment of
enchondromas noted a significantly higher complications rate
by THE UNIVERSITY OF HONG KONG on 01/22/15. For personal use only.
for early treatment (67%) compared to delayed treatment
Hand Surg. 2015.20:191-195. Downloaded from www.worldscientific.com
(10%).17 Yasuda et al. also reported a case of patient having
malunion after early curettage and fixation using injectable
calcium phosphate bone cement.11
Recurrence
Various recurrence rates were reported in different publications
with different treatments. In the retrospective review on 102
patients by Sassoon et al., a 6% recurrence rate was noted.2
Gaulke and Supplena reported a 14% recurrence rate in a long-
term follow-up (mean, nine years) of 21 patients and all three
recurrences were discovered over 10 years after operation.18
DISCUSSION
Some cases of enchondroma are presented as incidental find-
ings in radiographs with no obvious symptoms or pain. Some
research has suggested that the majority of these tumours are
latent (Latent lesions are defined as having well-demarcated
borders according to the Enneking staging system19) and the
risk of pathological fracture is low.20 Conservative treatment
should be considered as the major treatment approach for these
patients due to the low malignant potential (solitary enchon-
dromas, 1.5–3%) and slow growth of enchondromas.4,20 Small
localized asymptomatic enchondromas which are classified as
latent in the Enneking staging system are especially suitable for
conservative treatment. Surgical treatment may cause pro-
longed out-of-work period and certain degree of joint stiffness
due to postoperative adhesion. Biopsies should be taken in
suspected cases or uncertain diagnosis. A regular six-month
radiographic follow-up should be adopted to monitor the
FA1
Current Management of Hand Enchondroma 193
growth and expansion of the tumour. The six-month period is
an arbitrary interval suggested by the author. Clinical data on
the spontaneous resolution rate and the natural history of
enchondromas, however, are still largely absent. This is leading
to the lack of evidence to support conservative treatment in
clinical practices. More long-term follow-up studies are nec-
essary in this field.
Despite having satisfactory outcomes in some studies, early
curettage of enchondroma before fracture healing is still not
recommended in most cases.16 Other reviews showed that early
curettage can lead to much higher complications rate (67%)
compared to delayed treatment (10%) and cases of malunion
were reported.11,17 Such high-risk surgery lacks adequate ev-
idence to back up its necessity. It is also more technically
demanding for surgeons due to the instability of the fracture
location if it is located in the juxta-articular region. Corrective
osteotomy to treat malunion is also difficult after cement
injection.
Studies showed that simple curettage without augmentation
can achieve similar bone strength at similar recovery time
compared to augmentation methods like bone grafting and
cement injection. Augmentation using autograft inevitably
create an extra surgical wound and increases the risk of in-
fection. Augmentation using cement also does not improve the
surgical outcome. It is therefore recommended that simple
curettage should be prioritized in treatment of enchondromas.
Cement augmentation should only be reserved for large tumour
cavities to ensure mechanical stability of bones.
Additional adjuvant treatments like high-speed burring,
alcohol instillation and laser sterilization are not recommended
for treating enchondroma. Although some satisfying results are
yielded, similar outcomes are also achieved without such ad-
ditional measures.9,13–15,21,22 Added with the damage to sur-
rounding bone tissues, such prevention methods may be more
suitable for low grade chondrosarcomas.
The current literatures were summarized in Table 1. Based
on the current evidence, the authors proposed a treatment
algorithm (Fig. 1). Despite years of research on treatment
methods of enchondroma, current literatures still have quite a
number of obvious short-comings which may reduce the ac-
curacy of research data. Firstly, the follow-up period is too
short. Most studies have follow-up period of less than five years.
However, a long-term study has found three out of 21 patients
have recurrence over 10 years after curettage.18 The actual
recurrence rate may therefore be higher than reported.
 January 14, 2015 1:19:31pm WSPC/135-HS 1530002
FA1

194 C. Tang et al.

Table 1 Summary of Treatment of Enchondroma.

Patient Complications Recurrence

Study Follow-Up Number Rate (%) Rate (%) Remarks
Simple curettage without augmentation
Goto et al.21 At least six months 23 0 0
Hasselgren et al.22 Six years 28 0 0
Curettage and augmentation using bone graft
Bauer et al.7 NA 12 0 0 Cortico-cancellous allograft
Jewusiak et al.8 NA 23 0 0 Freeze-dried cancellous-bone allograft
Figl and Leixnering23 47 months 27 7 0 Autogenous spongy bone graft
Curettage and augmentation using cement injection
Gaasbeek et al.9 53 months 19 0 0 Plaster filling
Kim and Kim10 19 months 10 0 NA Calcium phosphate bone cement
Yasuda et al.11 41 months 10 10 NA Calcium phosphate bone cement, early curettage is performed in the
by THE UNIVERSITY OF HONG KONG on 01/22/15. For personal use only.
Hand Surg. 2015.20:191-195. Downloaded from www.worldscientific.com

only case of complications

Joosten et al.12 NA 8 0 NA Hydroxyapatite cement
Bickels et al.13 More than two years 13 0 0 Cemented internal fixation using PMMA, high speed drill burring after
curettage
Adjuvant treatment
Cha et al.14 40.8 months 29 0 0 High-speed burring
33 0 0 Alcohol instillation
Giles et al.15 35.4 months 8 0 0 CO2 laser sterilization
Early curettage
Lin et al.16 19 months 8 0 0 Lateral approach, reconstruction using calcium sulfate cement
Ablove et al.17 NA 6 67 NA

Enchondroma suspected by X-ray features

(well-defined, centrally placed osteolyc lesion at the juncon of metaphysis &
diaphysis; somemes the bone is slightly expanded)

presenta
on

incidental finding pathological fracture

wait
ll fracture healed

X-ray features of inadequate bone support:

- polycentric (diffuse & lobulated)
- central lesion with significant corcal thinning
- giant lesions (significant corcal expansion)

Yes No

cure
age +/- augmentaon Need for
ssue diagnosis

with bone gra or cement Yes No

injecon

biopsy regular follow

up with
radiograph
every 6 months

Fig. 1 Treatment algorithm of enchondroma in hand.

January 14, 2015 1:19:32pm WSPC/135-HS 1530002
Secondly, the sample size was too small. Most studies enrolled
less than 30 patients and it was less than 10 in some studies.
This leads to the lack of representation and reliability of the
research data.
In summary, small localized asymptomatic enchondromas
that show no sign of impending growth can be treated with
regular six month radiographical check-up. Expanding or
symptomatic enchondromas should be treated with simple
curettage without augmentation. Cement augmentation can be
considered for particularly large tumour cavities for mechan-
ical stability. Adjuvant treatments are not recommended due to
the lack of sufficient clinical evidence that support its necessity.
by THE UNIVERSITY OF HONG KONG on 01/22/15. For personal use only.
Hand Surg. 2015.20:191-195. Downloaded from www.worldscientific.com
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