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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 17  |  Issue : 4  |  Page : 150-153

The role of olecranon autograft as a void filler in the surgical management of enchondroma of the phalanx- A case report


Department of Orthopaedics, JSS Hospital, Mysore, Karnataka, India

Date of Submission08-Jul-2019
Date of Acceptance17-Jun-2020
Date of Web Publication19-Oct-2020

Correspondence Address:
Dr. Supreeth Nekkanti
No 160, 11th Cross, 5th Main, 1st Stage, Ngef Layout, Nrupatunganagar, Nagarbhavi, Bengaluru - 560 072, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_59_19

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  Abstract 


Enchondromas of the phalanx are common benign tumours. They exhibit a monostotic or polyostotic pattern of presentation.These lesions are symptomatic and are usually diagnosed coincidentally. We report a 56-year-old female patient who presented to us with complaints of pain and swelling of the left-hand fourth finger when it was jammed in a gate. Plain radiograph of the hand confirmed the diagnosis of an enchondroma. A surgical curettage and olecranon bone graft was performed in this patient. In this article, the authors attempt to highlight the advantages of olecranon bone harvesting and the good functional results associated with this graft. Our patient had a good functional outcome with no evidence of recurrence at the end of one year.

Keywords: Bone graft, curettage, enchondroma, olecranon


How to cite this article:
Mruthyunjaya M, Nekkanti S, Sheshagiri V, Siddartha A, Pramod T, Likhit C S, Ameen M. The role of olecranon autograft as a void filler in the surgical management of enchondroma of the phalanx- A case report. J Clin Sci 2020;17:150-3

How to cite this URL:
Mruthyunjaya M, Nekkanti S, Sheshagiri V, Siddartha A, Pramod T, Likhit C S, Ameen M. The role of olecranon autograft as a void filler in the surgical management of enchondroma of the phalanx- A case report. J Clin Sci [serial online] 2020 [cited 2020 Nov 29];17:150-3. Available from: https://www.jcsjournal.org/text.asp?2020/17/4/150/298458




  Introduction Top


Enchondromas are common benign tumors of the tubular bones of the hand such as the phalanges and the metacarpals.[1] The most common bone involved is the proximal phalanx of the hand. They form 2.5% of all benign and malignant tumors.[1],[2] They usually present in the fourth decade of life.[3] These lesions are slow growing and are diagnosed incidentally. Some patients present with pain following trivial trauma. We report a case of enchondroma of the proximal phalanx of the ring finger in a 56-year-old female patient, who was diagnosed coincidentally after minor trauma to her ring finger. She was successfully managed by surgical curettage and olecranon bone grafting. In this article, the authors attempt to establish the advantages of using olecranon autologous bone graft as a void filler after the surgical curettage of the enchondroma.


  Case Report Top


This report discusses a 56-year-old female patient who trapped the fourth finger of her left hand in her house gate. The patient sustained a small wound over the left fourth finger. The patient presented to us 2 days after the incident. The patient was already suffering from leukocytoclastic vasculitis with inflammatory arthritis for 9 years and was on regular medications.

The patient was also suffering from hypothyroidism for 3 years and was on regular medications. On inspection, there was a healing wound over the proximal aspect of the left ring finger around 1 cm × 0.25 cm. There was no bone or tendon exposed. The movements of the fourth finger were restricted due to pain. There was a bony tenderness present. A plain radiograph of the hand was taken, which revealed an expansile lytic lesion at the base of the proximal phalanx with calcification which was suggestive of an enchondroma [Figure 1]. There was no evidence of fracture. Under axillary block anesthesia, a 6- to 10-mm oval window was created in the dorsal cortex using a small osteotome and curettes, and cancellous bone graft was obtained with straight and curved curettes. After obtaining around 1–2 cc of cancellous graft for the planned procedure, the periosteal flaps and bursa were reapproximated with absorbable sutures. The tumor lesion was thoroughly curetted, and the resulting cavity was packed with olecranon bone graft [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. The postoperative period was uneventful. A check radiograph was done to confirm the successful curettage of the lesion [Figure 3]. Histopathological studies of the excised mass showed multiple grayish-white cartilaginous fragments measuring 1 cm × 1 cm in size. Microscopic studies revealed multiple lobules of cartilage encased by bone with foci of calcifications and hemorrhage. These results confirmed our diagnosis of enchondroma. The patient was followed up for 1 year with no clinical or radiological evidence of recurrence [Figure 4] and [Figure 5].
Figure 1: Preoperative radiograph showing osteolytic lesion base of the proximal phalanx ring finger

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Figure 2: (a) Intraoperative photograph showing curetted bone defect after excision of the mass. (b) Intraoperative photograph showing curetted material. (c) Intraoperative photograph showing harvesting of olecranon bone graft. (d) Intraoperative photograph showing insertion of harvested bone graft into the phalanx of the ring finger

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Figure 3: Postoperative radiograph showing well-seated bone graft inside the cavity

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Figure 4: One-year follow-up radiograph showing no recurrence of tumour

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Figure 5: Clinical photograph of operated site at 1-year follow-up showing no recurrence of the tumor

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  Discussion Top


Enchondromas are common benign tumors of the tubular bone such as the phalanges.[4] This tumor arises from the medullary cavity and grows into the bony cortex forming an endogenous mass in the bone.[4],[5] A lack of consistent symptoms makes it challenging to diagnose enchondromas clinically.[6]

Most of the cases are diagnosed only after a radiograph is taken usually following a history of trauma. These tumors present in as well-defined lytic lesions with central lucency with or without specs of calcification in the diaphysis or metaphysis of the phalanges. Endosteal scalloping, cortical thinning, and remodeling of the bone become obvious over time as these lesions grow.[2] Magnetic resonance imaging and computed tomography allow treating physicians to delineate the boundary of the tumor. They have a limited role in the diagnosis of enchondromas.[2]

The treatment of these tumors is dependent on the patient's symptoms. Asymptomatic cases with nonexpanding lesions rarely require any treatment. However, periodic follow-up radiographs to assess the progress of the lesions are recommended.[2] Surgery is the mainstay of the treatment of symptomatic tumors.[7] Surgical options include curettage, curettage with bone grafting, or void fillers or amputation.[8] Malignant transformation is seen in less than 1% of the cases.[6],[9] Our patient underwent a curettage with bone grafting. We used the olecranon process as a source of bone graft in our patient. No significant difference was observed in the complication rates between early and late treatments by curettage, bone grafting, or internal fixation of the affected bone.[10]

The iliac crest as a source of autologous bone graft has always been the choice of the graft. However, the need for general anesthesia, prolonged hospitalization time, and possible complications such as meralgia paresthetica, hematoma, infection, chronic postoperative pain at the donor site, urethral injury, and hernia limit its use in hand surgery.[11] Kim et al. demonstrated a higher complication rate with iliac bone graft than previously reported. They also reported a 16.5% rate of persistent pain and difficulty in walking after 1 year.[12]

The olecranon donor site is free of any major neurovascular structures. The ulnar nerve is the closest structure present to the olecranon donor site, but it is sufficiently far off not to interfere in the surgical field while harvesting the graft. The graft is harvested 1.5 cm distal to the tip of the olecranon, thereby the final scar is below the pressure contact points of the elbow and the forearm. Mersa et al. reported zero cases having donor-site morbidity in terms of pain in their study of 48 patients with 19-month follow-up.[11] Periosteal flaps sutured over the cortical window reduce the risk of hematoma. The quality and quantity of the olecranon bone graft are proportional to the bone mineral density. Elderly and osteoporotic patients are poor candidates for harvesting olecranon bone graft due to the risk of pathological fracture of the olecranon. Two cases aged 63 and 66 years, who suffered pathological fractures of the olecranon during bone harvest, were reported by Walker et al.[13]

Other possible donor sites include the distal radius and the lateral condyle of the humerus.[11],[14] Although these sites have the advantage of not requiring additional general anesthesia, neighboring neurovascular damage during harvest is a significant risk. Distal radius grafts have low complication rates of up to 1.7%; however, donor-site sensitivity, de Quervain's tenosynovitis, and superficial radial nerve injury have been reported.[15]

The authors would recommend olecranon bone graft as a source of autograft during hand surgery. There is no requirement for general anesthesia. The axillary block used for hand surgery is sufficient to harvest the olecranon graft as well. There is very minimal to none donor-site morbidity. There are no major neurovascular structures in the area of harvest. The cortical bone segment may be replaced back to its place without the need for internal fixation. Periosteal repair allows rapid healing with no contour deformities.[11] The literature is very limited regarding the use of bone substitutes for bone filling in hands as some authors advocate that a simple curettage without filling is a sufficient and a less-expensive option. β-tricalcium phosphate ceramics appear to be well suited as they provide good functional and radiological results compared to autologous bone.[16]

Recurrence of enchondromas is diagnosed very late. The rate of recurrence is difficult to estimate and has been reported to vary from 5% to 14.3%.[2],[5],[10] The complications after surgical management of enchondromas include recurrence, pathological fractures, stiffness, and rarely malignant transformation if the lesion is recurrent. Our patient encountered stiffness after surgery which was managed by passive mobilization and staged physiotherapy and had a good range of movement of her fingers.[17] There was no recurrence of the tumor at the end of a 1-year follow-up.


  Conclusion Top


Enchondromas are common benign tumors of the hand. We report the successful management of a solitary enchondroma of the proximal phalanx of the ring finger in a 56-year-old woman by surgical curettage and olecranon bone graft. Olecranon bone harvesting is easy and safe to harvest with almost no donor-site morbidity. There was no recurrence at the end of 1-year follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Raducu L, Anghel A, Vermesan S, Sinescu RD. Finger enchondroma treated with bone substituents – A case presentation. J Med Life 2014;7:223-5.  Back to cited text no. 1
    
2.
Mysore M, Murthy S, Nekkanti S, Nanjesh P. A rare case of recurrent enchondroma of the thumb involving the first metacarpophalangeal joint – An unusual disease pattern. Hand Microsurg 2018;7:1.  Back to cited text no. 2
    
3.
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;18:405-8.  Back to cited text no. 3
    
4.
Lu H, Chen Q, Yang H, Shen H. Enchondroma in the distal phalanx of the finger: An observational study of 34 cases in a single institution. Medicine (Baltimore) 2016;95:e4966.  Back to cited text no. 4
    
5.
Gaulke R, Suppelna G. Solitary enchondroma at the hand. Long-term follow-up study after operative treatment. J Hand Surg Br 2004;29:64-6.  Back to cited text no. 5
    
6.
Noble J, Lamb DW. Enchondromata of bones of the hand. A review of 40 cases. Hand 1974;6:275-84.  Back to cited text no. 6
    
7.
Tang C, Chan M, Fok M, Fung B. Current management of hand enchondroma: A review. Hand Surg 2015;20:191-5.  Back to cited text no. 7
    
8.
Montero LM, Ikuta Y, Ishida O, Fujimoto Y, Nakamasu M. Enchondroma in the hand retrospective study-recurrence cases. Hand Surg 2002;7:7-10.  Back to cited text no. 8
    
9.
Müller PE, Dürr HR, Nerlich A, Pellengahr C, Maier M, Jansson V. Malignant transformation of a benign enchondroma of the hand to secondary chondrosarcoma with isolated pulmonary metastasis. Acta Chir Belg 2004;104:341-4.  Back to cited text no. 9
    
10.
Sassoon AA, Fitz-Gibbon PD, Harmsen WS, Moran SL. Enchondromas of the hand: Factors affecting recurrence, healing, motion, and malignant transformation. J Hand Surg Am 2012;37:1229-34.  Back to cited text no. 10
    
11.
Mersa B, Ozcelik IB, Kabakas F, Sacak B, Aydin A. Olecranon bone graft: Revisited. Tech Hand Up Extrem Surg 2010;14:196-9.  Back to cited text no. 11
    
12.
Kim DH, Rhim R, Li L, Martha J, Swaim BH, Banco RJ, et al. Prospective study of iliac crest bone graft harvest site pain and morbidity. Spine J 2009;9:886-92.  Back to cited text no. 12
    
13.
Walker LG, Meals RA. Pathologic fracture of the proximal ulna through a bone graft donor site. J Hand Surg Am 1990;15:781-4.  Back to cited text no. 13
    
14.
Charles LM, Louis DS. The lateral epicondyle as a bone graft donor site in procedures about the elbow. J Hand Surg Am 1997;22:547-9.  Back to cited text no. 14
    
15.
Patel JC, Watson K, Joseph E, Garcia J, Wollstein R. Long-term complications of distal radius bone grafts. J Hand Surg Am 2003;28:784-8.  Back to cited text no. 15
    
16.
Milgram JW. The Origins of Osteochondromas and Enchondromas A Histopathologic Study. Clinical Orthopaedics and Related Research®. 1983;174:264-84.  Back to cited text no. 16
    
17.
Hung YW, Ko WS, Liu WH, Chow CS, Kwok YY, Wong CW, et al. Local review of treatment of hand enchondroma (artificial bone substitute versus autologous bone graft) in a tertiary referral centre: 13 years' experience. Hong Kong Med J 2015;21:217-23.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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