SCIENTIFIC ARTICLE

An Alternative Technique for the Management of

Phalangeal Enchondromas With Pathologic Fractures
Sung-Yen Lin, MD, Peng-Ju Huang, MD, Hsuan-Ti Huang, MD, Chung-Hwan Chen, MD,
Yuh-Min Cheng, MD, and Yin-Chih Fu, MD

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 post-
pones 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 assess-
ments, 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 interpha-
langeal 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 postopera-
tively. 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 sup-
plemental internal fixation, allowed early mobilization, and resulted in minimal joint
stiffness. (J Hand Surg 2013;38A:104–109. Copyright © 2013 by the American Society
for Surgery of the Hand. All rights reserved.)
Type of study/level of evidence Therapeutic IV.
Key words Enchondroma, pathologic fracture, calcium sulfate.

common benign formity, and swelling. Asymptomatic solitary enchon-

E
NCHONDROMAS ARE THE MOST
bone tumor in the hand.1–3 Because of asymp- dromas may be treated by observation only, whereas
tomatic growth, enchondroma commonly pres- surgery is usually needed for symptomatic manifesta-
ents as a pathologic fracture associated with pain, de- tions. The goals of treatment of enchondroma with

From the Department of Orthopedics, Kaohsiung Municipal Ta-Tung Hospital; and the Department of Corresponding author: Yin-Chih Fu, MD, Department of Orthopedics, Faculty of Medicine, Kaohsi-
Orthopedics, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan. ung Medical University, Kaohsiung Municipal Hsiao-Kang Hospital, No. 482, San-Ming Rd., Hsiao-
Received for publication December 12, 2011; accepted in revised form August 30, 2012. Kang Dist., Kaohsiung, Taiwan; e-mail: microfu@ms.kmuh.org.tw.

No benefits in any form have been received or will be received related directly or indirectly to the 0363-5023/13/38A01-0018$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2012.08.045
subject of this article.

104 䉬 ©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved.

 TREATMENT OF ENCHONDROMAS WITH FRACTURES 105

FIGURE 1: Surgical procedure. A We approached the finger through a lateral incision. The extensor and flexor tendons were
retracted in the dorsal and volar directions, respectively, to expose the lesion. B We created an extended lateral cortical window
(approximately 3 mm in width) on the diaphysis along the long axis of the finger with a high-speed burr drill. Then, we removed
the tumor with a small curet under direct visualization. C We filled the cavity remaining after tumor evacuation with MIIG X3.

pathologic fracture are fracture stabilization and tumor surgery, we created an extended lateral cortical window
removal. Because it is technically difficult to stabilize a through a lateral approach, instead of creating a dorsal
fracture and remove a tumor in the finger in 1 proce- bone window in a dorsal approach.
dure, the fracture is usually permitted to heal before In this study, we report the results of treating acute
tumor curettage and bone grafting. Although effective, pathologic fractures caused by phalangeal enchondro-
this results in a prolonged period of pain and disability. mas using a modified surgical technique and an inject-
Similar to other orthopedic surgeons,4 – 6 we favor treat- able high-strength calcium sulfate for reconstruction.
ment with early curettage and fracture stabilization for
enchondroma in the presence of a pathologic fracture, MATERIALS AND METHODS
because it provides early histological diagnosis and pain From November 2006 to February 2010, we screened
relief. all patients presenting with a pathologic fracture of the
The traditional surgical procedure for enchondromas finger resulting from an enchondroma as potential can-
with healed fractures involves a dorsal approach, tumor didates for this study. The inclusion criteria included
excision, and bone grafting. For reconstruction of the solitary enchondroma of a digit with a nondisplaced or
defects after tumor evacuation, autogenous bone or minimally displaced pathologic fracture diagnosed on
allograft is still the reference standard grafting material. radiographic examination, no joint involvement, and
However, the donor site morbidity of cancellous au- the patient’s willingness to participate and attend regu-
tograft is a major concern,7 and allografts may carry lar postoperative visits for at least 1 year. We excluded
immunogenicity as well as a potential risk of disease patients with other conditions such as Ollier disease,
transmission.8 To solve these problems, many types of vascular or neurologic diseases, or uncontrolled diabe-
bone graft substitute have been used to fill the void after tes. After enrollment, all patients meeting the inclusion
tumor removal. Unfortunately, none provides sufficient criteria received surgery performed by the same sur-
stability for early mobilization, and supplemental inter- geon within 1 week after diagnosis.
nal fixation is needed.9 Therefore, for better stability, During surgery, we used a lateral approach to expose
we have used commercially available injectable cal- the lesion. Through a longitudinal incision made over
cium sulfate,10 which is characterized by high initial the lateral aspect of the fractured phalanx, we bluntly
strength and is commonly used for the reconstruction of dissected the soft tissue and retracted the extensor and
compression fractures and bone defects resulting from flexor tendons in dorsal and volar directions, respec-
trauma. To minimize irritation to the extensor mecha- tively, to expose the diaphysis (Fig. 1A). We created an
nism and permit technically easy injection of the ce- extended lateral cortical window (approximately 3 mm
ment into the full length of the tumor cavity during in width) longitudinally passing through the entire di-

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106 TREATMENT OF ENCHONDROMAS WITH FRACTURES

TABLE 1. Demographic Data of Patients

Patient Number Age Sex Location Tumor Size (cm) Deformity (°)

1 26 F PP/right index finger 3.1 ⫻ 1.1 ⫻ 1 0

2 35 M PP/left little finger 1.4 ⫻ 1.2 ⫻ 0.8 9
3 26 F PP/right middle finger 2.6 ⫻ 0.7 ⫻ 1.2 5
4 23 F PP/left little finger 1 ⫻ 1.7 ⫻ 1.7 0
5 21 F PP/left little finger 1.7 ⫻ 0.8 ⫻ 1.8 10
6 13 M PP/left index finger 1.8 ⫻ 0.7 ⫻ 0.7 0
7 25 F PP/left index finger 1.6 ⫻ 0.8 ⫻ 1 0
8 26 M PP/right middle finger 1.7 ⫻ 1.1 ⫻ 1.2 0
Mean 24 3

PP, proximal phalanx.

aphysis with a high-speed bur drill while protecting the RESULTS

insertion of the collateral ligament. The entire lesion We enrolled 8 patients (5 females and 3 males)
was exposed and then completely removed with a small with an average age of 24 years (range, 13–35 y)
curette (Fig. 1B). After tumor excision, we used Mini- with phalangeal enchondromas meeting the inclu-
mally Invasive Injectable Graft X3 (MIIG X3; Wright sion criteria. Fractures involved the proximal pha-
Medical Technology, Inc., Arlington, TN), a type of langes of 3 index fingers, 2 middle fingers, and 3
calcium sulfate cement, to fill the cavity. After 30 little fingers. Table 1 lists the demographic data.
seconds of mixing, we put the material into a syringe, Among the 8 patients in our study, 5 had nondis-
injected it into the intraosseous void through the cortical placed fractures and 3 had minimally displaced
window, and then sculpted it to fill the entire cavity fractures with an average angulation of 8° (5°, 9°,
(Fig. 1C). Alignment was maintained 10 minutes until and 10°). The mean preoperatively VAS pain score
the cement had hardened, and no supplemental internal was 9.5. The average time of follow-up was 19
fixation was used. months. Table 2 displays the results of preopera-
After surgery, the operated finger was immobilized tive and postoperative clinical assessments. In all
with a volar aluminum strip and taped to the adjacent cases, the diagnosis of enchondroma was con-
finger for 2 weeks, followed by buddy taping for a firmed by histological examination, and no pa-
protected return to normal activities within 4 weeks. We tients required the surgical placement of hardware
scheduled patients for postoperative evaluations, in- for additional stability (Fig. 2B, 2E).
cluding radiographs and clinical assessments every 2 The fractures of all patients healed after a mean of 8
weeks during the first 2 months, and then at 3, 6, and 12 weeks postoperatively (Table 2). Radiographically, the
months after surgery. An independent examiner who calcium sulfate cement appeared to be completely ab-
was not a member of the surgical team performed sorbed and replaced by newly formed bone at 12 weeks
clinical assessments including evaluation of pain expe- postoperatively in all patients (Fig. 2F). We noted full
rienced during daily activities and joint range of motion. range of motion of the involved digit in all patients at
W evaluated pain status with a pain visual analog scale 3-month follow-up. All patients returned to ordinary
(VAS), in which 10 points represented the maximal daily activities by 3 months postoperatively, and the
imaginable pain. We measured range of motion of the range of VAS pain scores was 0 to 1 at that time. We
metacarpophalangeal and proximal interphalangeal found no major complications, such as remarkable mal-
joints with a goniometer. We determined the time re- alignment (⬎ 5° of angulation), nonunion, infection, or
quired for bone union and graft resorption, as well as tumor recurrence, during follow-up.
any tumor recurrence, by examining anteroposterior
and lateral radiographs. Bone union was defined as a DISCUSSION
combination of clinical evidence of the disappearance It is challenging to determine the optimal method for
of pain in the fracture area and radiographic evidence, treating enchondromas with pathological fractures in a
both on anteroposterior and lateral views, of bone tra- single stage. The use of autogenous bone grafts,11 allo-
beculae crossing the fracture site. grafts,12 or artificial bone substitutes13 for reconstruc-

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 TREATMENT OF ENCHONDROMAS WITH FRACTURES 107

TABLE 2. Results of Radiographic and Clinical Assessments

Postoperative Motion Arc (°) VAS

6 wk 3 mo
Length of Time to 3-Month
Patient Number Follow-Up (mo) Healing (wk) MCP PIP MCP PIP Preoperative Follow-Up

1 36 8 60 40 90 95 9 0
2 12 8 45 30 90 90 9 0
3 36 8 50 30 90 95 10 0
4 14 8 60 35 90 95 10 1
5 12 8 50 30 90 90 9 1
6 12 6 60 30 90 100 10 0
7 13 8 60 30 90 95 10 0
8 14 8 50 30 90 95 9 0
Mean 19 8 54 32 90 94 10 0.3

MCP, metacarpophalangeal joint; PIP, proximal interphalangeal joint.

tion of the tumor cavity necessitates supplemental hard- malunion who required additional surgeries to correct
ware fixation for fracture stabilization while bone the digital overlap, but the presence of CPC made early
healing occurs. This may prevent early mobilization corrective osteotomy difficult in that patient. In this
and result in postoperative tendon adhesions and joint study, we used injectable high-strength calcium sulfate
stiffness. To solve this problem, several types of inject- cement to fill the tumor cavity and provide initial me-
able bone cement have been used to fill the cavity chanical strength for fracture stabilization in patients
resulting from tumor removal, to provide immediate with phalangeal enchondromas. Our clinical results
stability. Bickels et al5 used nonresorbable polymethyl- were satisfactory. All of the fractures and defects united
methacrylate (PMMA) and intramedullary hardware to without complications, and the calcium sulfate cement
reconstruct the cavity after tumor excision. Despite the appeared to be completely absorbed and replaced by
advantages of early mobilization, the authors reported new bone within 12 weeks in all patients.
that 50% of the patients lost some degree of joint Calcium sulfate has been used as an osteoconductive
motion. At present, apart from PMMA, most of the bone graft substitute since the 19th century,15 and dif-
available injectable bone graft substitutes are based on ferent forms of calcium sulfate have been made avail-
either calcium phosphate or calcium sulfate. Joosten et able in the form of powder or pellets. This material has
al14 used injectable calcium phosphate cement (CPC) the advantage of having a uniform crystalline structure
(BoneSource; Leibinger Corp., Kalamazoo, MI) to treat such that its resorption is relatively fast compared with
enchondromas of the hands without internal fixation, calcium phosphate, which will remain several years
and reported good clinical outcomes. However, they after implantation.16 Turner et al17 used calcium sulfate
reported that there was little evidence of new bone pellets in an animal model of bone defects and reported
formation in the cavities over the 1-year assessment that its resorption rate corresponded to that of new bone
period. A subsequent study by Yasuda et al13 treated 10 growth with little or no foreign-body giant cell reaction.
patients with digital enchondromas with curettage and Another study showed that the amount of new bone
CPC (Biopex; Mitsubishi Materials Corp., Tokyo, Ja- formation in bone defects packed with calcium sulfate
pan) grafting with a minimum of 2 years of follow-up was approximately equivalent to that observed in de-
evaluation. They presented good results in 5 patients fects treated with autogenous bone.18 However, the
without pathologic fractures and 4 patients with patho- initial mechanical strength of conventional calcium sul-
logic fractures treated by delayed surgery after fracture fate bone graft substitutes is not great enough to allow
healing. Only 1 patient treated with multiple pins to load-bearing without support from additional fixation.
stabilize a displaced fracture experienced a malunion. MIIG X3 is a recently developed surgical-grade cal-
However, in 2 patients in their series, the CPC did not cium sulfate cement in which the powder constituent is
completely resorb. One of them was a patient with alpha calcium sulfate hemihydrate. Similar to other

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108 TREATMENT OF ENCHONDROMAS WITH FRACTURES

FIGURE 2: Plain radiographs of two 26-year-old patients with enchondromas over the right index finger A–C and the right middle finger
D–F, respectively. A, D Preoperative radiographs show an osteolytic lesion on the proximal phalanx with a pathologic fracture. B, E
Postoperative radiographs show satisfactory reduction of the fracture and filling of the tumor cavity with calcium sulfate cement. C, F
Follow-up radiographs demonstrate union of the fracture in 8 weeks C and complete resorption of the cement in 3 months F.

types of calcium sulfate-based bone substitutes, MIIG Compared with CPCs, MIIG X3 also has greater
X3 has good biocompatibility and biodegradability. It mechanical strength. One in vitro study21 reported that
has been reported to be completely resorbed within 12 the compression strength of MIIG X3 22 MPa on av-
weeks.10 During resorption, it creates a slightly acidic erage, which is higher than that of some commonly
environment that may result in demineralization of ad- used CPC products. Carroll et al22 studied the mechan-
jacent bone19 with release of matrix-bound morphoge- ical properties of MIIG X3 in treating vertebral com-
netic proteins that have a stimulatory effect on bone pression fractures and reported that the compressive
formation.20 Because the cement is pastelike and inject- strength of MIIG X3 was comparable to that of PMMA
able, it has the additional advantage of better void filling but much higher than that of CPCs. Because of the high
in irregularly shaped defects than calcium sulfate pel- mechanical strength of MIIG X3, it can provide instant
lets. Most important, its modified crystalline structure skeletal stability such that no internal fixation is re-
results in a nearly 3-fold increase in initial strength quired during surgery. Although the property often used
against compressive loading compared with that of con- to characterize the mechanical behavior of injectable
ventional surgical-grade calcium sulfate.10 This in- bone substitutes is their compressive strength, rotational
crease potentially allows for its use in a broader range and bending moments are more considerable in phalan-
of clinical applications. geal fracture fixation rather than the compression

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 TREATMENT OF ENCHONDROMAS WITH FRACTURES 109

strength. However, to the best of our knowledge, the 4. Ablove RH, Moy OJ, Peimer CA, Wheeler DR. Early versus delayed
treatment of enchondroma. Am J Orthop (Belle Mead NJ). 2000;
literature is lacking in studies of the mechanical 29(10):771–772.
strength of injectable calcium sulfate cement in bending 5. Bickels J, Wittig JC, Kollender Y, et al. Enchondromas of the hand:
or rotation, and further study is needed. treatment with curettage and cemented internal fixation. J Hand Surg
Am. 2002;27(5):870 – 875.
In this study, we performed a modified surgical tech- 6. Figl M, Leixnering M. Retrospective review of outcome after sur-
nique using a lateral approach and created an extended gical treatment of enchondromas in the hand. Arch Orthop Trauma
lateral cortical window on the diaphysis for tumor ex- Surg. 2009;129(6):729 –734.
7. Younger EM, Chapman MW. Morbidity at bone graft donor sites.
cision. The lateral cortical window extended beyond the J Orthop Trauma. 1989;3(3):192–195.
tumor area, which differs from the limited one created 8. Graham SM, Leonidou A, Aslam-Pervez N, et al. Biological therapy of
on the dorsal cortex of the digital bone through a dorsal bone defects: the immunology of bone allo-transplantation. Expert Opin
Biol Ther. 2010;10(6):885–901.
approach also commonly used in hand surgeries. The 9. Yu B, Han K, Ma H, et al. Treatment of tibial plateau fractures with
lateral approach to tumor curettage presents 2 advan- high strength injectable calcium sulphate. Int Orthop. 2009;33(4):
tages over the dorsal approach. Primarily, the lateral 1127–1133.
10. Urban RM, Turner TM, Hall DJ, et al. Effects of altered crystalline
approach does not require the dorsal apparatus of the structure and increased initial compressive strength of calcium sul-
extensor mechanism to be split, and therefore poten- fate bone graft substitute pellets on new bone formation. Orthope-
tially avoids scarring and adhesion formation between dics. 2004;27(1 suppl):S113–S118.
11. Shimizu K, Kotoura Y, Nishijima N, Nakamura T. Enchondroma of
the osteotomy site and the tendon. In addition, direct the distal phalanx of the hand. J Bone Joint Surg Am. 1997;79(6):
injection of the bone cement through the extended lat- 898 –900.
eral cortical window facilitates controlling the amount 12. Bauer RD, Lewis MM, Posner MA. Treatment of enchondromas of
the hand with allograft bone. J Hand Surg Am. 1988;13(6):908 –916.
of cement and the delivery rate during injection, thus 13. Yasuda M, Masada K, Takeuchi E. Treatment of enchondroma of the
minimizing the risk of cement extravasation. As a re- hand with injectable calcium phosphate bone cement. J Hand Surg
sult, the overall rate of postoperative stiffness is low Am. 2006;31(1):98 –102.
14. Joosten U, Joist A, Frebel T, Walter M, Langer M. The use of an in
with the lateral approach. We suggest that this is why situ curing hydroxyapatite cement as an alternative to bone graft
all patients in our study achieved full motion of the following removal of enchondroma of the hand. J Hand Surg Br.
operated fingers, whereas in the report by Bickel et al,13 2000;25(3):288 –291.
15. Peltier LF. The use of plaster of Paris to fill large defects in bone: a
half of the patients lost some degree of joint motion preliminary report. 1959. Clin Orthop Relat Res. 2001;(382):3–5.
after a surgical procedure involving the dorsal approach 16. Frankenburg EP, Goldstein SA, Bauer TW, Harris SA, Poser RD.
as a result of the proximity of the PMMA to the exten- Biomechanical and histological evaluation of a calcium phosphate
cement. J Bone Joint Surg Am. 1998;80(8):1112–1124.
sor mechanism. 17. Turner TM, Urban RM, Gitelis S, Haggard WO, Richelsoph K.
This was a pilot study regarding the use of injectable Resorption evaluation of a large bolus of calcium sulfate in a canine
calcium sulfate in treating acute pathologic fracture medullary defect. Orthopedics. 2003;26(5 suppl):S577–S579.
18. Turner TM, Urban RM, Gitelis S, Kuo KN, Andersson GB. Radio-
without supplemental internal fixation. Therefore, graphic and histologic assessment of calcium sulfate in experimental
knowledge about its potential use on displaced or un- animal models and clinical use as a resorbable bone-graft substitute,
stable fractures with angular or rotational deformity a bone-graft expander, and a method for local antibiotic delivery.
One institution’s experience. J Bone Joint Surg Am. 2001;83(suppl 2
remains unknown. We have no experience regarding pt 1):8 –18.
whether this technique is applicable to comminuted or 19. Walsh WR, Morberg P, Yu Y, et al. Response of a calcium sulfate
highly unstable fractures, and further studies are re- bone graft substitute in a confined cancellous defect. Clin Orthop
Relat Res. 2003;(406):228 –236.
quired to identify its broad applications. 20. Sidqui M, Collin P, Vitte C, Forest N. Osteoblast adherence and
resorption activity of isolated osteoclasts on calcium sulphate hemi-
REFERENCES hydrate. Biomaterials. 1995;16(17):1327–1333.
21. Van Lieshout EM, Van Kralingen GH, El-Massoudi Y, Weinans H,
1. Payne WT, Merrell G. Benign bony and soft tissue tumors of the Patka P. Microstructure and biomechanical characteristics of bone
hand. J Hand Surg Am. 2010;35(11):1901–1910. substitutes for trauma and orthopaedic surgery. BMC Musculoskelet
2. Morii T, Mochizuki K, Tajima T, Satomi K. Treatment outcome of Disord. Feb 2011;12:34.
enchondroma by simple curettage without augmentation. J Orthop 22. Carroll M, Lewis G, Xu J, Moseley J, Cole J, Haggard W. Evaluation
Sci. 2010;15(1):112–117. of a synthetic bone defect test model to aid in the selection of
3. Jacobson ME, Ruff ME. Solitary enchondroma of the phalanx. materials for use in vertebral body compression fracture repair.
J Hand Surg Am. 2011;36(11):1845–1847. Orthopedics. 2004;27(1 suppl):S119 –S122.

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