SLR - May 2023 - Zishan Quader, DPM
Title: Osteoscopic versus open surgery for the treatment of enchondroma in the footReference: Futani H, Kawaguchi T, Sawai T, Tachibana T. Arch Orthop Trauma Surg. 2023 Feb 23. doi: 10.1007/s00402-023-04816-y. Online ahead of print. PMID: 36813947
Level of Evidence: Retrospective cohort study, Level of Evidence II
Reviewed By: Zishan Quader, DPM
Residency Program: New York University Brooklyn Langone, Brooklyn, NY
Podiatric Relevance: Enchondromas are relatively common intramedullary neoplasms among bone tumors. While only a small percent present in the foot, approximately 80% occur in the proximal phalanx. The traditional way to treating symptomatic enchondromas was open surgery to curettage the tumor through a wide cortical window and filling the cavity with bone graft or bone substitutes. Recently, osteoscopic surgery using an endoscopic technique has been developed, but no reports have made the comparison between the methods. This study was designed to evaluate the patient’s functional recovery and rate of complications between the two techniques. The hypothesis is that the osteoscopic surgery would result in early functional recovery and reduce the rate of complications, thus back to normal daily activities quicker.
Methods: This retrospective cohort study was performed on patients who received either open or osteoscopic surgery performed by a single surgeon (H. F.) at a single university hospital in Japan. The inclusion criteria were the presence of histologically proved enchondromas in bone, tumor resection followed by beta-tricalcium phosphate filling, and a 2 year minimum follow up. Patient’s with enchondroma developing from the distal phalanx were excluded. A total of 25 patients who underwent endoscopic (17 patients) or open (8 patients) surgeries were identified. Functional outcomes were assessed using the American Orthopedic Foot and Ankle Society (AOFAS) score and the Musculoskeletal Tumor Society (MSTS) functional rate. Secondary outcome measure was post-operative complications based on joint ROM and occurrence of fracture.
Results: There was significantly higher AOFAS scores within the osteoscopic group compared to the open for the first 2 weeks post-operatively (mean, 89.18 vs 67.25; p=0.001). The MSTS functional rate showed a similar trend as the AOFAS. Complication rates were lower with the osteoscopic group compared to the open (12 vs 50%; p=0.04) with the most frequent complication being limited ROM up to 2 weeks after surgery. There were no significant differences between the 2 groups in age, gender, rate of pathological fracture, the length of tumor, surgical time, the amount of bone substitute (beta-TCP), and the length of follow-up period. The size of the cortical window was significantly smaller in the osteoscopic group (mean, 0.11+/- 0.01 vs 0.61 +/-0.27 cm2 ; p=0.00)
Conclusions: There were a few number of limitations given the nature of the retrospective study design which include, but not limited to, small sample size within each treatment group, no randomization, possible selection bias, and also the uneven distribution of enchondromas between the groups. Osteoscopic surgery seems to feasible method in the management of enchondromas by using a smaller cortical window, which has led to less complications, a quicker recover to activities of daily life, and better ROM. Further prospective randomized controlled studies will be needed to evaluate the efficacy osteoscopic vs open for surgical intervention of enchondromas of the foot.