Enchondromas and atypical cartilaginous tumors at the proximal humerus treated with intralesional resection and bone cement filling with or without osteosynthesis: retrospective analysis of 42 cases with 6 years mean follow-up

Abstract

BackgroundEnchondromas and atypical cartilaginous tumors (ACT) are often located at the proximal humerus. Most lesions can be followed conservatively, but surgical resection may alleviate pain, avoid pathological fractures, and prevent transformation into higher grade chondrosarcomas. Rigorous intralesional resection and filling with polymethylmethacrylate bone cement has been proposed for enchondromas but also for ACT, as an alternative for extralesional resection. We intended to analyze radiological, clinical, and functional outcome of this strategy and compare bone cement without osteosynthesis to bone cement compound osteosynthesis, which has not been analyzed so far.MethodsWe retrospectively analyzed 42 consecutive patients (mean follow-up 73 months; range 8–224) after curettage and bone cement filling with or without osteosynthesis. Exclusion criteria were Ollier’s disease and cancellous bone filling. Twenty-five patients only received bone cement. Seventeen patients received additional proximal humerus plate for compound osteosynthesis to increase stability after curettage. Demographics and radiological and clinical outcome were analyzed including surgery time, blood loss, hospitalization, recurrences, and complications. An additional telephone interview at the final follow-up assessed postoperative satisfaction, pain, and function in the quick disabilities of the arm, shoulder, and hand (DASH) score and the Musculoskeletal Tumor Society (MSTS) score. Statistics included the Student T tests, Mann-Whitney U tests, and chi-square tests.ResultsNo osteosynthesis compared to compound osteosynthesis showed smaller tumors (4.2 (± 1.5) cm versus 6.6 (± 3.0) cm; p = 0.005) and smaller bone cement fillings after curettage (5.7 (± 2.1) cm versus 9.6 (± 3.2) cm; p = 0.0001). A score evaluating preoperative scalloping and soft-tissue extension did not significantly differ (1.9 (± 0.9) versus 2.0 (± 1.0); rating scale 0–4; p = 0.7). Both groups showed high satisfaction (9.2 (± 1.5) versus 9.2 (± 0.9); p = 0.5) and low pain (1.0(±1.7) versus 1.9(±1.8); p = 0.1) in a rating scale from 0 to 10. Clinical and functional outcome was excellent for both groups in the DASH score (6.0 (± 11.8) versus 11.0 (± 13.2); rating scale 0–100; p = 0.2) and the MSTS score (29.0 (± 1.7) versus 28.7 (± 1.1); rating scale 0–30; p = 0.3). One enchondroma recurrence was found in the group without osteosynthesis. Complications (one fracture and one intra-articular screw) were only detected after osteosynthesis. Osteosynthesis had longer surgery time (70 (± 21) min versus 127 (± 22) min; p < 0.0001), more blood loss (220 (± 130) ml versus 460 (± 210) ml; p < 0.0001), and longer stay in the hospital (6 (± 2) days versus 8 (± 2) days; p = 0.004).ConclusionsIntralesional tumor resection was oncologically safe and clinically successful with or without osteosynthesis. Osteosynthesis did not reduce the risk for fracture but was more invasive.

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

“…The treatment of ACT/enchondroma is usually conservative with observation and follow-up; however, when clinical and radiologic features suggest malignancy, surgery is indicated [7][8][9]. Extralesional resection is the gold-standard treatment for the ACT, as it provides the highest oncological safety [8]. However, as it is usually difficult to distinguish between both entities based on clinical and radiologic grounds, overtreatment of enchondroma and undertreatment of ACT may ensue [10].…”

Arthroscopic Resection of Humeral Enchondroma

“…The majority of enchondromas does not need any treatment other than clinical and imaging surveillance [4]. However, surgical excision is indicated in cases of clinical or radiological aggressiveness such as endosteal scalloping or soft tissue extension, lesion growth or tumors bigger than 6 cm, and untreatable pain [3, 5]. Although extralesional resection has the highest oncological safety, intralesional resection with curettage to treat either enchondromas or ACTs in long bones has good oncological safety and excellent functional outcomes [3, 14].…”

“…However, surgical excision is indicated in cases of clinical or radiological aggressiveness such as endosteal scalloping or soft tissue extension, lesion growth or tumors bigger than 6 cm, and untreatable pain [3, 5]. Although extralesional resection has the highest oncological safety, intralesional resection with curettage to treat either enchondromas or ACTs in long bones has good oncological safety and excellent functional outcomes [3, 14]. The cavity may be filled with autologous bone graft, which is biologically superior, or with bone cement that has the possible advantage to reduce recurrence rates due to heat destruction of the remaining tumor cells, which may be beneficial for large and radiologically aggressive enchondromas [5, 15].…”

“…They may present in any time of life, but are mainly found between the second and fourth decades of life, and are often asymptomatic [1]. However, some cases may present with unspecific pain or some kind of swelling [3].…”

Extended Curettage and Fibular Grafting in Enchondroma of the Acromion

“…Asymptomatic lesions can be managed conservatively with follow-up and serial radiographs. If the lesion grows or if it becomes symptomatic, extended curettage usually is curative [3]. We report the case of a sixyear-old male child with enchondroma of the acromion, which, to the best of our knowledge, has never been published.…”