Journal of Medicine and Life Vol. 7, Issue 2, April-June 2014, pp.223-225 [613859]

Journal of Medicine and Life Vol. 7, Issue 2, April-June 2014, pp.223-225

Finger enchondroma treated with bone substituents
– a case presentation

Raducu L*, Anghel A**, Vermesan S***, Sinescu RD**
*Department of Plastic Surgery, “Agrippa Ionescu ” Military Emergency Hospital, Bucharest, Romania
**Department of Plastic Surgery and Reconstructive Microsurgery, “E lias” Emergency University Hospital, “Carol Davila“ Universi ty of
Medicine and Pharmacy, Bucharest, Romania
***Department of Orthopedic Surgery, “Agrippa Ionescu” Military Emergency Hospital, Bucharest, Romania

Correspondence to: Ruxandra Diana Sinescu, MD, PhD
Department of Plastic Surgery and Reconstructive Microsurgery, “Elias” Emergency University Hospital, Bucharest, Romania
17 Marasti Boulevard, District 1, postal code 011461, Bucharest, Romania,
Mobile phone: +40 722 545 83, E-mail: [anonimizat]

Received: January 18th, 2014 – Accepted: March 25th, 2014

Abstract
About 90% of the hand bone tumors are enchondromas. Treatment of choice is complete curettage and bone grafting, usually with
bone autografts. We present a case of finger enchondroma in a 27- year-old female patient who was treated with curettage and
synthetic bone grafting. Clinical, surgical and pathological findi ngs in this case are presented along with a brief discussion of
literature.
Keywords: enchondroma, bone tumor surgery, bone grafting, bone substituents
Introduction
Enchondromas are benign cartilaginous lesions
predominantly seen in the skeleton of the hand (approximately 35% of all enchondromas develop in the hand) and are the most frequent (as many as 90%) osseous tumors of the hand [ 1,2].
Enchondromas may present as solitary,
monostotic lesions with a peak incidence in the fourth decade and with a predilection for the short tubular bones (proximal phalanx, metacarpal / metatarsal, middle phalanx) of the hands and feet, distal femur, and proximal humerus, or as multiple / polyostotic lesions in Ollier's disease (enchondromatosis), a non-heritable condition, and in Maffucci's syndrome, a combination of multiple enchondromas and hemangiomas. Malignant degeneration of monostotic enchondroma to chondrosarcoma, although rare, has been well described [1].
Given the fact that individuals with
enchondromas usually have few symptoms and signs (typically a localized painle ss swelling), or sometimes
none at all, an enchondroma may be diagnosed during a routine physical examination, as an incidental finding on plain radiographs, or in the event of a pathologic fracture commonly caused by minor trauma and favored by the presence of the tumor.
Radiographs typically demonstrate a well-
defined lytic lesion, central or eccentric, expansive or not, habitually containing calcified chondroid matrix and non-invading into the surrounding tissue. Additional diagnostic imaging for enchondroma may include radionuclide bone
scan, magnetic resonance imaging (MRI) and computed tomography scan (CT), but in the overwhelming majority of cases, plain radiographs are sufficient for the diagnosis [1].
While the attitude in small asymptomatic lesions
may be conservative, consisting of a simple observation, curettage has recently become the mainstay of surgical treatment for the large or symptomatic enchondromas. If the enchondroma is diagnosed as a pathologic fracture, the lesion may be treated immediately or after the fracture has healed. Although several authors recently reported excellent results with simple bone curettage, the bone defects resulting from curettage of enchondroma are usually filled with autologous bone grafts (e.g., iliac crest, distal radius), fresh frozen or freeze-dried irradiated allografts, or bone substitutes (calcium phosphate, calcium sulphate, tricalcium phosphate, hydroxyapatite). These newer materials eliminate the morbidity of the bone graft harvest site and lower the disease’s transmission risk of the allograft [ 3].

Patient, methods and result
We present a case of a young patient with a
finger enchondroma investigated, diagnosed and treated with bone substituents. A 27-year-old woman was admitted in our Department with one-week history of pain and moderate swelling on the fifth right finger’s proximal phalanx. The pain had a sudden onset after the patient

Journal of Medicine and Life Vo l. 7, Issue 2, April-June 2014
224 opened her car's door. There was no significant history of
smoking or alcohol consumption or trauma. Clinical examination revealed a painful palpable mass on the phalanx, crepitation and limited passive/active PIP flexion. Frontal radiography of little finger revealed a lytic expansive lesion on the proximal phalanx associated with thinning of the bone cortex and a pathological fracture at the same level ( Fig. 1 ).

Because of the small incidence of malignant
transformation associated with pathologic fractures [ 4], we
decided to curettage the tumor and wait for the pathology
result. We used a dorsal approach and an appropriate-
sized cortical window to expose the tumor and we removed it by curettage. The pathology exam showed
mature lobules of hyaline cartilage, foci of calcification
and enchondreal ossification, which confirmed the
diagnosis of enchondroma ( Fig. 2 ).

For the filling of the re sulted bone defect, we
decided to use a bone graft substitute because of the lack of complications and donor-site morbidity, ease of use
and rapid local improvement. We used CaSO
4 minimally
invasive injectable graft (MII GX3), with faster resorption
and bone repopulation. The substance consolidated in
situ several minu tes after the injection with high
compressive strength ( Fig. 3 ).

The patient maintained finger spica split for 4
weeks; afterwards the range of motion therapy was initiated. Radiography at 4 weeks postoperatively revealed a well-mineralized bone ( Fig. 4 ).

At 8 weeks from surgery, the patient showed
normal flexion-extension movements in the PIP joint.
Discussion
Bone grafting is an essential procedure in
musculoskeletal tumor surgery, more than 2.2 million
Fig. 1 Frontal radiography of little finger
Fig. 2 The pathology exam confirmed the diagnosis of
enchondroma Fig. 3 Injection with high compressive strength
Fig. 4 Radiography at 4 weeks postoperatively

Journal of Medicine and Life Vo l. 7, Issue 2, April-June 2014
225 bone grafts being performed annually for the repair of
bone defects and approximately 10% of all skeletal
reconstructive surgery requiring bone grafting [ 5]. The
large defects created after bone tumor curettage may
require bone grafts (autogeneic, allogeneic or synthetic)
as part of the treatment.
Autologous bone graft from the iliac crest,
cortical or cancellous, is the most current choice, but it is
associated with a 8-39% complication rate (infection,
hematoma, urethral injury, pelvic instability, cosmetic
disadvantages, chronic pain) [ 3] and with a risk of donor-
field contamination with tumor cells.
The use of bone allografts, available in various
shapes and sizes, decreases the operating time and does not associate any donor-site morbidity or complications.
Nevertheless, since the allografts are harvested from
deceased donors, a small risk of transmission of infectious agents still exists, despite the strict measures of
tissue processing and sterilization applied.
All the above-mentioned limitations of bone auto-
and allografts stimulated the development of alternatives
(synthetic) bone substitutes, currently numerous products such as hydroxyapatite, bicalcium or tricalcium
phosphate, calcium sulphate, BMP2, BMP7 being
available). Each of these substances has its characteristics, indications and specific uses, as
demonstrated by recent clinical studies.
Dreesmann made the first reported use of
CaSO4 in 1892, filling cavities in tuberculosis patients [ 6].
Nowadays, CaSO
4 is available in the form of paste,
granules or blocks. It functions as a resorbable osteoconductive scaffold, fully dissolving in 6-12 weeks,
that provides the structural framework necessary for
angiogenesis and osteogenesis. It is mainly used to fill gaps resulted from tumor resection and periarticular
fractures, but it does not offer sufficient structural support
to be utilized in minimal weight baring bones [ 3].
Conclusions
We report a case of a finger bone tumor believed
to be an enchondroma at presentation. In our case, the
presence of a pathological bone fracture and the width of
the tumor warranted the need of bioptic curettage, since the tumor could have been either an enchondroma or a
low-grade central chondrosarcoma. The histopathological
exam confirmed the enchondroma diagnosis.
Our patient was a young woman who did not
accept the donor site comorb idities of a bone autograft, so
we offered her the possibility of using a bone substitute
instead.
Curettage and CaSO
4 injected graft (MIIGX3)
proved to be a safe, promising treatment modality for
hand enchondroma. It led to an excellent functional and
radiological result, as it reduced the operating and recovery time and had no donor site morbidity. Further
studies are necessary to demonstrate its worth as a
standard choice of treatment for hand bone defects.
Disclosures: none

References

1. Athanasian EA. Bone and Soft Tissue
Tumors. In: Green DP, editor. Green's
Operative Hand Surgery, 5th ed., 2005, Philadelphia: Elsevier Churchill Livingstone, 2228-51.
2. Naito K, Obayashi O, Mogami A, Itoi A,
Kaneko K. Fracture of the calcium
phosphate bone cement which used to enchondroma of the hand: a case report.
Eur J Orthop Surg Traumatol. 2008;
18:405–408. doi 10.1007/s00590-008-0321-x. 3. Van der Stok J, Van Lieshout EMM, El-
Massoudi Y, Van Kralingen GH, Patka
P. Bone substitutes in the Netherlands –
a systematic literature review. Acta Biomater. 2011 Feb; 7(2): 739-50. doi: 10.1016/j.actbio.2010.07.035.
4. Kocher MS, Jupiter JB. Enchondroma
versus chondrosarcoma of the phalanx. Orthopedics. 2000 May; 23(5):493-4.
5. Van Lieshout EM, Van Kralingen GH,
El-Massoudi Y, Winans H, Patka P.
Microstructure and biomechanical characteristics of bone substituents for
trauma and orthopaedic surgery. BMC
Musculoskelet Disord. 2011 Feb 2; 12:34. Epub 2011 Feb 2.
6. Hyuk Kim J, Han Oh J, Han I, Kim HS,
Won Chung S. Grafting Using Injectable
Calcium Sulphate in Bone Tumor Surgery: Comparison with Demineralized Bone Matrix-based Grafting. Clinics in
Orthopedic Surgery. 2011; 3:191-201.