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The treatment of enchondromas in the hand by endoscopic curettage without bone grafting
THE TREATMENT OF ENCHONDROMAS ENDOSCOPIC CURETTAGE WITHOUT
IN THE HAND BY BONE GRAFTING
I. SEKIYA, N. M A T S U I , T. O T S U K A , M. K O B A Y A S H I and D. T S U C H I Y A
From the Department of Orthopaedic Surgery, Nagoya City University Medical School, Nagoya, Japan
Nine patients with enchondromas in the hand were treated by endoscopic curettage of the tumour without bone grafting. The procedure was performed on an out-patient basis using axillary block anaesthesia. New bone formation and remodelling of the lesions were observed in all patients. There were no postoperative fractures, infections, recurrences or other complications. Functional recovery was rapid. We conclude that endoscopic curettage without bone grafting is an effective treatment of enchondroma in the hand.
Journal of Hand Surgery (British and European Volume, 1997) 22B." 2:230-234 Enchondroma is the most frequent osseous tumour in the hand, usually presenting as a pathological fracture. In the absence of a fracture, it often presents as a swelling with or without pain, or is discovered accidentally during an unrelated X-ray examination. The standard treatment of enchondroma has been by curettage and filling the resultant bone cavity with cancellous bone. The purpose of this procedure is to allow histological diagnosis, to prevent future pathological fractures and to avoid recurrence of the tumour. Recently there have been several reports advocating curettage without bone grafting. Our results with this procedure were as good as those of curettage with bone grafting. If bone grafting is unnecessary, curettage can be performed endoscopically with minimal surgical trauma. We have performed endoscopic curettage of enchondroma in the hand since 1992. In this paper, we describe this procedure and assess its effectiveness in the treatment of enchondroma in the hand.
patients in this study were examined for at least 6 months after surgery. Eight patients were female and one was male. The mean age at surgery was 30.8 years (range 13-47). In cases of pathological fractures, immobilization with splinting was prescribed for about 3 weeks, and operation was not undertaken until the fracture had healed. The procedure was performed on an out-patient basis using axillary block anaesthesia and a pneumatic tourniquet. A 2 or 3 mm incision was made at the level of the lesion, and the cortex of the bone over the turnout was fenestrated using a Kirschner wire. Generally, the incision was made on the midlateral line of the affected finger, but if the lesion was in the metacarpal or the base of the proximal phalanx, it was made a little more dorsally. A small curette was then inserted into the medullary cavity, and the bulk of the tumour removed without endoscopic assistance. The material obtained was sent for histological examination. The size of the cavity created by the initial excavation was an important factor leading to the ease and efficacy of subsequent endoscopic visualization. Another incision was then made at the opposite side of the lesion, and the cortex of the bone was fenestrated in the same way. The dorsal cortex of the bone over the tumour was also fenestrated, and an 18-gauge needle was inserted for irrigation. Small pieces of enchondroma were flushed out with normal saline solution, and irri-
MATERIALS AND M E T H O D S Ten patients with enchondroma in the hand were seen between November 1992 and July 1995. One patient was treated with conventional open curettage without bone grafting. A retrospective review was performed of the nine patients who were treated with endoscopic curettage without bone grafting (Table 1). All nine Table 1--Patient profiles
Patient 1 2 3 4 5 6 7 8 9
Age/sex 24/F 47/F 34/F 13/F 22/F 42/F 33/M 35/F 27/F
Finger
Site of tumour
Symptoms
Right little Left little Right middle Right little Left ring Right ring Right middle Left little Left thumb
Proximal phalanx Proximal phalanx Distal phalanx Proximal phalanx Metacarpal Metacarpal Distal phalanx Metacarpal Distal phalanx
Swelling with pain Pathological fracture Pathological fracture Pathological fracture Pathological fracture Accidentally found Pathological fracture Pathological fracture Swelling
* Recurrence after curettage with bone grafting at other hospital. 230
Interval betweeno n s e t and surgery (days) 43 55 58 1,152" 52 70 266 72 222
Follow-up (months) 17.6 12.0 25.3 20.6 14.6 13.6 7.3 7.5 7.6
ENDOSCOPIC CURETTAGE OF ENCHONDROMAS
Fig 1
The instruments for endoscopic curettage. On the left is the arthroscopic system for small joints (Shinko Optical, Tokyo, Japan). The diameter of the trocar is 2 ram, and that of the arthroscope is 1.5 mm. In the centre is the cutter of the minishaver system (Stryker endoscopy). The diameter of the cutter is 2.5 mm. On the right are various small curettes.
Fig 2
Endoscopic image of enchondroma, which is seen as a soft white tissue and is clearly different from normal bone.
gation was continued for several minutes. Then a 1.5 mm diameter endoscope (Fig 1) was introduced into the bone cavity. Enchondroma was observed as a soft white tissue, clearly different from normal bone (Fig2). Thorough curettage of the turnout was performed under endoscopic visualization, using small curettes and a mini-shaver system. The diameter of the mini-shaver was 2.5 mm (Fig 3). Portals were exchanged to ensure complete observation of the interior of the cavity, especially the blind area in the vicinity of the original endoscope portal. If the affected area was too wide and curettage through only two portals was insufficient, three or more portals were necessary. After the lesion had been thoroughly removed, only normal bone was observed in the medullary cavity (Fig 4). Finally, the medullary cavity was washed with irrigation fluid and one stitch applied to each incision. Time required for surgery was approximately 90 minutes. Postoperative immobilization in a bulky compression dressing without splinting was prescribed for about 3 days, then active mobilization and use in daily activity
231
Fig 3
(a) The endoscope has been inserted into the bone cavity and curettage under endoscopic visualization is being done. (b) Endoscopic curettage with a mini-shaver system. (c) Endoscopic image of curettage using a mini-shaver system.
was permitted after explanation of the risk of pathological fracture. Postoperative evaluation was by clinical and X-ray examination. The range of motion of the affected finger was measured and the time until patients were able to use their affected hand about their daily activities without inconvenience was assessed. Two patients lacking
THE JOURNAL OFHAND SURGERY VOL.22BNo. 2 APRIL1997
232
were observed in all patients. On average, new bone formation was observed 2.4 months after surgery, and remodelling of the lesion was observed 4.1 months after surgery. The results of the radiological examination were classified according to the amount of new bone formed in the cavity left after curettage. According to the evaluation of Tordai et al, all the final radiological findings were in G r o u p 1 (Table 3). There were no recurrences. Fig 4
Endoscopic image after thorough curettage of the tumour. Only normal bone is seen in the medullary cavity.
TaMe2--Postoperative radiologicai evaluation proposed by Tordai et al (1990) Group 1 Group 2 Group 3
Bones with normal cortex and spongiosa or bone defects smaller than 3 mm in diameter Bone defects of 4 to 10 mm diameter but with no clear-cut recurrence Bone defects larger than 10 mm and with the characteristics of enchondromata
sufficient records to assess the range of motion were excluded from clinical evaluation. New bone formation and the remodelling of the affected bone were evaluated by plain X-ray films. The final X-ray films were assessed according to the evaluation system proposed by Tordai et al (1990; Table 2). The mean follow-up period was 14.0 months (range 7.3-25.3). RESULTS In all nine cases, the histology confirmed the diagnosis of enchondroma. There were no postoperative fractures, infections or other complications in this series. Functional recovery was very prompt. At 2 weeks after operation, the range of motion of the affected finger showed only minor restriction, with full recovery at 5.6 weeks after surgery on average. No patient complained of inconvenience in daily use by 4 weeks after operation. New bone formation and remodelling of the lesion
Case report Case 2. A 47-year-old woman with enchondroma of the proximal phalanx of the left little finger suffered a pathological fracture. Curettage of the tumour was done under endoscopic visualization 55 days after onset of symptoms. Although she was the oldest case in this series, X-ray films showed good new bone formation 2 months postoperatively. Remodelling of the lesion began at 5 months after surgery, and was complete after 1 year (Fig 5).
DISCUSSION The endoscope is useful for the diagnosis and treatment of m a n y intraarticular disorders. Recently, endoscopic surgery has been widely applied to carpal tunnel release, and there are several reports of the endoscopic treatment of bone tumours (Okutsu et al, 1992; Stricker, 1995). E n c h o n d r o m a is the most frequent osseous tumour in the hand and the standard treatment has been curettage with bone grafting. Although treatment by curettage without bone grafting has been suggested in the past, most authors still recommend grafting of the resultant cavity. Recently, however, it has been reported that the results of curettage without bone grafting were equal to results obtained with bone grafting (Hasselgren et al, 1991; Tordai et al, 1990; Wulle, 1990). I f bone grafting can be omitted from the procedure, then curettage alone can be performed with much less surgical insult by endoscopic means. Whether bone grafting is really unnecessary is a matter of controversy. The mechanical weakness of the exca-
TaMe 3--Results Patient
Time to full range of motion (weeks)
New bone formation (months)
Beginning of remodelling (months)
1 2 3 4 5 6 7 8 9 Mean
8 6 4 3
3 2 1 1 2 4 2 5 2 2.4
5 5 5 3 4 4 3 5 3 4.1
2 8 8 5.6
Evaluation of final X-ray films
Group Group Group Group Group Group Group Group Group
1 1 1 1 1 1 1 1 1
ENDOSCOPIC CURETTAGE OF ENCHONDROMAS
Fig 5
233
Case 2. A 47-year-old woman with enchondroma of the proximal phalanx of the left little finger. (a) Pre-operative view. (b) X-ray film at 5 months showing good new bone formation. (c) X-ray film 1 year after surgery showing good remodelling of the lesion.
vated bone has often been pointed out as a disadvantage of curettage without bone grafting, but the contribution of cancellous bone to structural strength is considered very small (Noda et al, 1991). From this point of view, maintaining the integrity of the cortex and avoiding a large cortical defect is important in maintaining the strength of the affected bone; filling the bone cavity with cancellous bone is not. The other problem is whether sufficient new bone formation and remodelling of the lesion can be obtained without grafting of bon~ or other material. In this series, though the resultant cavity was not filled with cancellous bone, good new bone formation and good remodelling of the lesion were observed in all the patients. Previously, we reported that new bone formation and remodelling of the lesion after curettage without bone grafting was the same as that seen after curettage with bone grafting (Sekiya et al, 1995). This has led us to believe that the presence of bone graft has little influence on new bone formation and remodelling of the lesion after curettage of enchondromas in the hand. There are many factors related to bone regeneration such as age, position and size of the lesion, presence or absence of bone grafts,
the condition of surrounding bone and soft tissue, and general health of the patient. Generally, in the case of enchondroma, the lesion is small, the condition of surrounding bone and soft tissue is good, and the patient is otherwise healthy. These could be relevant to the satisfactory new bone formation and remodelling obtained without bone grafting in this series. Endoscopic curettage of enchondroma in the hand offers several benefits: because a magnified image and decreased blind area are obtained with the endoscope, complete curettage is assured even through small portals; because of the minimal surgical insult, postoperative physiotherapy is not needed and early functional recovery is obtained; and because this procedure requires no bone grafting, the operation can be performed on an outpatient basis. Endoscopic curettage without bone grafting can be applied when the lesion is a benign tumour without soft tissue extension, the cavity of the tumour is large enough for endoscopic visualization, two or more adequate portals can be used, and restoration of disrupted joint surfaces is not needed. Therefore, its application is possible in almost all enchondromas in the hands.
234
However, the special instruments and the slightly longer time required for surgery can be considered disadvantages. References Hasselgren G, Forssblad P, Tornvall A (1991). Bone grafting unnecessary in the treatment of enchondromas in the hand. Journal of Hand Surgery, 16A: 139-142. Noda K, Shimizu T, Shinozaki T, Watanabe H, Chigira M (1991). Roentgenographic and computed tomographic observations on benign bone tumor and tumor-like lesions treated by simple curettage without bone grafting (in Japanese). Journal of Japanese Orthopaedic Association, 65: 689-694. Okutsu I, Hamanaka I, Miyoshi K, Kaneoka K, Ninomiya S, Takemura T (1992). Management of benign bone tumors using Universal Subcutaneous Endoscope system (in Japanese). Arthroscopy, 17:11-15.
THE JOURNAL O F H A N D S U R G E R Y VOL. 22B No. 2 APRIL 1997
Sekiya I, Kobayashi M, Otsuka T, Matsui N, Nishi G (1995). Treatment of solitary enchondromas of the hand (in Japanese). Central Japan Journal of Orthopaedic Surgery and Traumatology, 38:939 940. Stricker SJ (1995). Extraarticular endoscopic excision of femoral head chondroblastoma. Journal of Pediatric Orthopaedics, 15: 578-581. Tordai P, Hoglund M, Lngneg~trd H (1990). Is the treatment of enchondroma in the hand by simple curettage a rewarding method? Journal of Hand Surgery, 15B: 331-334. Wulle C (1990). On the treatment of enchondroma. Journal of Hand Surgery, 15B: 320-330.
Received: 30 Ap61 1996 Accepted after revision: 16 June 1996 Dr I. Sekiya, Department of Orthopaedic Surgery, Nagoya City University Medical School, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467 Japan. © 1997 The British Society for Surgery of the Hand
IN THE HAND BY BONE GRAFTING
I. SEKIYA, N. M A T S U I , T. O T S U K A , M. K O B A Y A S H I and D. T S U C H I Y A
From the Department of Orthopaedic Surgery, Nagoya City University Medical School, Nagoya, Japan
Nine patients with enchondromas in the hand were treated by endoscopic curettage of the tumour without bone grafting. The procedure was performed on an out-patient basis using axillary block anaesthesia. New bone formation and remodelling of the lesions were observed in all patients. There were no postoperative fractures, infections, recurrences or other complications. Functional recovery was rapid. We conclude that endoscopic curettage without bone grafting is an effective treatment of enchondroma in the hand.
Journal of Hand Surgery (British and European Volume, 1997) 22B." 2:230-234 Enchondroma is the most frequent osseous tumour in the hand, usually presenting as a pathological fracture. In the absence of a fracture, it often presents as a swelling with or without pain, or is discovered accidentally during an unrelated X-ray examination. The standard treatment of enchondroma has been by curettage and filling the resultant bone cavity with cancellous bone. The purpose of this procedure is to allow histological diagnosis, to prevent future pathological fractures and to avoid recurrence of the tumour. Recently there have been several reports advocating curettage without bone grafting. Our results with this procedure were as good as those of curettage with bone grafting. If bone grafting is unnecessary, curettage can be performed endoscopically with minimal surgical trauma. We have performed endoscopic curettage of enchondroma in the hand since 1992. In this paper, we describe this procedure and assess its effectiveness in the treatment of enchondroma in the hand.
patients in this study were examined for at least 6 months after surgery. Eight patients were female and one was male. The mean age at surgery was 30.8 years (range 13-47). In cases of pathological fractures, immobilization with splinting was prescribed for about 3 weeks, and operation was not undertaken until the fracture had healed. The procedure was performed on an out-patient basis using axillary block anaesthesia and a pneumatic tourniquet. A 2 or 3 mm incision was made at the level of the lesion, and the cortex of the bone over the turnout was fenestrated using a Kirschner wire. Generally, the incision was made on the midlateral line of the affected finger, but if the lesion was in the metacarpal or the base of the proximal phalanx, it was made a little more dorsally. A small curette was then inserted into the medullary cavity, and the bulk of the tumour removed without endoscopic assistance. The material obtained was sent for histological examination. The size of the cavity created by the initial excavation was an important factor leading to the ease and efficacy of subsequent endoscopic visualization. Another incision was then made at the opposite side of the lesion, and the cortex of the bone was fenestrated in the same way. The dorsal cortex of the bone over the tumour was also fenestrated, and an 18-gauge needle was inserted for irrigation. Small pieces of enchondroma were flushed out with normal saline solution, and irri-
MATERIALS AND M E T H O D S Ten patients with enchondroma in the hand were seen between November 1992 and July 1995. One patient was treated with conventional open curettage without bone grafting. A retrospective review was performed of the nine patients who were treated with endoscopic curettage without bone grafting (Table 1). All nine Table 1--Patient profiles
Patient 1 2 3 4 5 6 7 8 9
Age/sex 24/F 47/F 34/F 13/F 22/F 42/F 33/M 35/F 27/F
Finger
Site of tumour
Symptoms
Right little Left little Right middle Right little Left ring Right ring Right middle Left little Left thumb
Proximal phalanx Proximal phalanx Distal phalanx Proximal phalanx Metacarpal Metacarpal Distal phalanx Metacarpal Distal phalanx
Swelling with pain Pathological fracture Pathological fracture Pathological fracture Pathological fracture Accidentally found Pathological fracture Pathological fracture Swelling
* Recurrence after curettage with bone grafting at other hospital. 230
Interval betweeno n s e t and surgery (days) 43 55 58 1,152" 52 70 266 72 222
Follow-up (months) 17.6 12.0 25.3 20.6 14.6 13.6 7.3 7.5 7.6
ENDOSCOPIC CURETTAGE OF ENCHONDROMAS
Fig 1
The instruments for endoscopic curettage. On the left is the arthroscopic system for small joints (Shinko Optical, Tokyo, Japan). The diameter of the trocar is 2 ram, and that of the arthroscope is 1.5 mm. In the centre is the cutter of the minishaver system (Stryker endoscopy). The diameter of the cutter is 2.5 mm. On the right are various small curettes.
Fig 2
Endoscopic image of enchondroma, which is seen as a soft white tissue and is clearly different from normal bone.
gation was continued for several minutes. Then a 1.5 mm diameter endoscope (Fig 1) was introduced into the bone cavity. Enchondroma was observed as a soft white tissue, clearly different from normal bone (Fig2). Thorough curettage of the turnout was performed under endoscopic visualization, using small curettes and a mini-shaver system. The diameter of the mini-shaver was 2.5 mm (Fig 3). Portals were exchanged to ensure complete observation of the interior of the cavity, especially the blind area in the vicinity of the original endoscope portal. If the affected area was too wide and curettage through only two portals was insufficient, three or more portals were necessary. After the lesion had been thoroughly removed, only normal bone was observed in the medullary cavity (Fig 4). Finally, the medullary cavity was washed with irrigation fluid and one stitch applied to each incision. Time required for surgery was approximately 90 minutes. Postoperative immobilization in a bulky compression dressing without splinting was prescribed for about 3 days, then active mobilization and use in daily activity
231
Fig 3
(a) The endoscope has been inserted into the bone cavity and curettage under endoscopic visualization is being done. (b) Endoscopic curettage with a mini-shaver system. (c) Endoscopic image of curettage using a mini-shaver system.
was permitted after explanation of the risk of pathological fracture. Postoperative evaluation was by clinical and X-ray examination. The range of motion of the affected finger was measured and the time until patients were able to use their affected hand about their daily activities without inconvenience was assessed. Two patients lacking
THE JOURNAL OFHAND SURGERY VOL.22BNo. 2 APRIL1997
232
were observed in all patients. On average, new bone formation was observed 2.4 months after surgery, and remodelling of the lesion was observed 4.1 months after surgery. The results of the radiological examination were classified according to the amount of new bone formed in the cavity left after curettage. According to the evaluation of Tordai et al, all the final radiological findings were in G r o u p 1 (Table 3). There were no recurrences. Fig 4
Endoscopic image after thorough curettage of the tumour. Only normal bone is seen in the medullary cavity.
TaMe2--Postoperative radiologicai evaluation proposed by Tordai et al (1990) Group 1 Group 2 Group 3
Bones with normal cortex and spongiosa or bone defects smaller than 3 mm in diameter Bone defects of 4 to 10 mm diameter but with no clear-cut recurrence Bone defects larger than 10 mm and with the characteristics of enchondromata
sufficient records to assess the range of motion were excluded from clinical evaluation. New bone formation and the remodelling of the affected bone were evaluated by plain X-ray films. The final X-ray films were assessed according to the evaluation system proposed by Tordai et al (1990; Table 2). The mean follow-up period was 14.0 months (range 7.3-25.3). RESULTS In all nine cases, the histology confirmed the diagnosis of enchondroma. There were no postoperative fractures, infections or other complications in this series. Functional recovery was very prompt. At 2 weeks after operation, the range of motion of the affected finger showed only minor restriction, with full recovery at 5.6 weeks after surgery on average. No patient complained of inconvenience in daily use by 4 weeks after operation. New bone formation and remodelling of the lesion
Case report Case 2. A 47-year-old woman with enchondroma of the proximal phalanx of the left little finger suffered a pathological fracture. Curettage of the tumour was done under endoscopic visualization 55 days after onset of symptoms. Although she was the oldest case in this series, X-ray films showed good new bone formation 2 months postoperatively. Remodelling of the lesion began at 5 months after surgery, and was complete after 1 year (Fig 5).
DISCUSSION The endoscope is useful for the diagnosis and treatment of m a n y intraarticular disorders. Recently, endoscopic surgery has been widely applied to carpal tunnel release, and there are several reports of the endoscopic treatment of bone tumours (Okutsu et al, 1992; Stricker, 1995). E n c h o n d r o m a is the most frequent osseous tumour in the hand and the standard treatment has been curettage with bone grafting. Although treatment by curettage without bone grafting has been suggested in the past, most authors still recommend grafting of the resultant cavity. Recently, however, it has been reported that the results of curettage without bone grafting were equal to results obtained with bone grafting (Hasselgren et al, 1991; Tordai et al, 1990; Wulle, 1990). I f bone grafting can be omitted from the procedure, then curettage alone can be performed with much less surgical insult by endoscopic means. Whether bone grafting is really unnecessary is a matter of controversy. The mechanical weakness of the exca-
TaMe 3--Results Patient
Time to full range of motion (weeks)
New bone formation (months)
Beginning of remodelling (months)
1 2 3 4 5 6 7 8 9 Mean
8 6 4 3
3 2 1 1 2 4 2 5 2 2.4
5 5 5 3 4 4 3 5 3 4.1
2 8 8 5.6
Evaluation of final X-ray films
Group Group Group Group Group Group Group Group Group
1 1 1 1 1 1 1 1 1
ENDOSCOPIC CURETTAGE OF ENCHONDROMAS
Fig 5
233
Case 2. A 47-year-old woman with enchondroma of the proximal phalanx of the left little finger. (a) Pre-operative view. (b) X-ray film at 5 months showing good new bone formation. (c) X-ray film 1 year after surgery showing good remodelling of the lesion.
vated bone has often been pointed out as a disadvantage of curettage without bone grafting, but the contribution of cancellous bone to structural strength is considered very small (Noda et al, 1991). From this point of view, maintaining the integrity of the cortex and avoiding a large cortical defect is important in maintaining the strength of the affected bone; filling the bone cavity with cancellous bone is not. The other problem is whether sufficient new bone formation and remodelling of the lesion can be obtained without grafting of bon~ or other material. In this series, though the resultant cavity was not filled with cancellous bone, good new bone formation and good remodelling of the lesion were observed in all the patients. Previously, we reported that new bone formation and remodelling of the lesion after curettage without bone grafting was the same as that seen after curettage with bone grafting (Sekiya et al, 1995). This has led us to believe that the presence of bone graft has little influence on new bone formation and remodelling of the lesion after curettage of enchondromas in the hand. There are many factors related to bone regeneration such as age, position and size of the lesion, presence or absence of bone grafts,
the condition of surrounding bone and soft tissue, and general health of the patient. Generally, in the case of enchondroma, the lesion is small, the condition of surrounding bone and soft tissue is good, and the patient is otherwise healthy. These could be relevant to the satisfactory new bone formation and remodelling obtained without bone grafting in this series. Endoscopic curettage of enchondroma in the hand offers several benefits: because a magnified image and decreased blind area are obtained with the endoscope, complete curettage is assured even through small portals; because of the minimal surgical insult, postoperative physiotherapy is not needed and early functional recovery is obtained; and because this procedure requires no bone grafting, the operation can be performed on an outpatient basis. Endoscopic curettage without bone grafting can be applied when the lesion is a benign tumour without soft tissue extension, the cavity of the tumour is large enough for endoscopic visualization, two or more adequate portals can be used, and restoration of disrupted joint surfaces is not needed. Therefore, its application is possible in almost all enchondromas in the hands.
234
However, the special instruments and the slightly longer time required for surgery can be considered disadvantages. References Hasselgren G, Forssblad P, Tornvall A (1991). Bone grafting unnecessary in the treatment of enchondromas in the hand. Journal of Hand Surgery, 16A: 139-142. Noda K, Shimizu T, Shinozaki T, Watanabe H, Chigira M (1991). Roentgenographic and computed tomographic observations on benign bone tumor and tumor-like lesions treated by simple curettage without bone grafting (in Japanese). Journal of Japanese Orthopaedic Association, 65: 689-694. Okutsu I, Hamanaka I, Miyoshi K, Kaneoka K, Ninomiya S, Takemura T (1992). Management of benign bone tumors using Universal Subcutaneous Endoscope system (in Japanese). Arthroscopy, 17:11-15.
THE JOURNAL O F H A N D S U R G E R Y VOL. 22B No. 2 APRIL 1997
Sekiya I, Kobayashi M, Otsuka T, Matsui N, Nishi G (1995). Treatment of solitary enchondromas of the hand (in Japanese). Central Japan Journal of Orthopaedic Surgery and Traumatology, 38:939 940. Stricker SJ (1995). Extraarticular endoscopic excision of femoral head chondroblastoma. Journal of Pediatric Orthopaedics, 15: 578-581. Tordai P, Hoglund M, Lngneg~trd H (1990). Is the treatment of enchondroma in the hand by simple curettage a rewarding method? Journal of Hand Surgery, 15B: 331-334. Wulle C (1990). On the treatment of enchondroma. Journal of Hand Surgery, 15B: 320-330.
Received: 30 Ap61 1996 Accepted after revision: 16 June 1996 Dr I. Sekiya, Department of Orthopaedic Surgery, Nagoya City University Medical School, 1 Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, 467 Japan. © 1997 The British Society for Surgery of the Hand