Assessment of vascularized fibular graft one year after reconstruction of the wrist after excision of a giant-cell tumour

Functional Outcome after Treatment of Aggressive Tumours in the Distal Radius: Comparison between Reconstruction using Proximal Fibular Graft and Wrist Fusion

Introduction: Restoration of a functional hand is the ultimate goal following a distal radius tumour resection. The early outcomes of mobile wrist reconstruction are satisfactory; however, long-term results are unpredictable due to late wrist instability and degenerative arthritis. Our aim is to compare mobile wrist reconstruction with wrist fusion (pan-carpal fusion) in our cohort of patients.

Materials and Methods: A retrospective cohort study was performed for functional outcomes of all patients who underwent resection for distal radius tumour and treated with either fusion or reconstruction of the wrist in a single institution from years 2000-2013 with a minimum of three years follow-up.

Results: Eleven patients were included in the study, six of whom had wrist reconstruction with proximal fibula graft and the remaining five wrist fusion, with a mean follow-up of 6.3 years. The mean Musculoskeletal Tumour Society (MSTS) score was 82.78%, ranging from 70% to 93.3%. Average grip strength compared to the normal contralateral hand was 60.0% for total wrist fusion, which was better than wrist reconstruction with 58.07%. There was no difference in the functional outcome between fusion and mobile reconstruction in our study. Osteoarthritis changes and subluxation of the wrist joint were the most common findings in the long-term follow-up for this group.

Conclusion: There was no difference in the functional outcome of the long-term follow-up between the two groups.

Vascularized graft from the metatarsal base for reconstructing major osteochondral distal radius defects

PURPOSE

To present our experience of reconstructing distal radius articular defects with a vascularized osteochondral graft from the metatarsal base and to present the mid-term outcomes.

METHODS

Seven patients (average age, 36 y; range, 26-55 y) who had reconstruction of major defects of the articular surface of the radius are presented. In 5, the lunate facet and sigmoid notch were reconstructed; in 1, an isolated defect on the surface of the lunate facet was reconstructed; and in 1, the scaphoid facet was reconstructed. In 6, the base of the third metatarsal was transferred, and in 1, the base of the second was transferred.

RESULTS

All flaps survived without complications. At the latest follow-up (range, 20 mo to 8 y), the flexion-extension arc improved an average of 50°, and the pain on a visual analog scale decreased from 8 to 1 on average. Disabilities of the Arm, Shoulder, and Hand score improved from 54 to 11 on average. One patient did not improve. No major complaints related to the donor site were mentioned (average American Orthopedic Foot and Ankle Society score of 96/100).

CONCLUSIONS

Our mid-term results are promising; however, the decision-making process and the operation are complex. The operation is not indicated when the carpals are devoid of cartilage or when the defect involves the whole radius surface.

Limited arthrodesis of the wrist for treatment of giant cell tumor of the distal radius

PURPOSE

To present the functional results of a technique of radiocarpal arthrodesis and reconstruction with a structural nonvascularized autologous bone graft after en bloc resection of giant cell tumors of the distal radius.

METHODS

A total of 13 patients with a mean age of 37 years with aggressive giant cell tumor (Campanacci grade III) of distal radius were managed with en bloc resection and reconstruction with a structural nonvascularized bone graft. The primary outcome measure was the disability evaluated by the Musculoskeletal Tumor Society rating score of limb salvage. Secondary outcomes included survival of the reconstruction measured from the date of the operation to revision procedure for any reason (mechanical, infectious, or oncologic). Other outcomes included active wrist motion and ability to resume work.

RESULTS

Mean follow-up period was 6 years (range, 2-14 y). The median arc of motion at the midcarpal joint was 40°, median wrist flexion was 20°, and median extension was 10°. The median Musculoskeletal Tumor Society score based on the analysis of factors pertinent to the patient as a whole (pain, functional activities, and emotional acceptance) and specific to the upper limb (positioning of the hand, manual dexterity, and lifting ability) was 86%. Five patients underwent a second surgical procedure. The cumulative probability of reoperation for mechanical reason was 31% at similar follow-up times at 2, 5, and 10 years.

CONCLUSIONS

This technique provided a stable wrist and partially restored wrist motion with limited pain. However, further surgical procedures may be necessary to reach this goal.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Functional outcome of en bloc resection and osteoarticular allograft reconstruction with locking compression plate for giant cell tumor of the distal radius

BACKGROUND

Giant cell tumors of the distal radius at Campanacci grade III are particularly challenging to treat. We have treated 15 cases of giant cell tumor of the distal radius by en bloc excision and osteoarticular allograft reconstruction with locking compression plate (LCP). The purpose of this study was to assess the intermediate outcomes of all patients treated with this surgery.

METHODS

From July 2002 to January 2009, we followed up 15 patients with giant cell tumors of the distal radius who were treated with en bloc excision and osteoarticular allograft reconstruction with LCPs that were long enough to approach the distal end of the allograft. All of the cases were evaluated based on clinical and radiologic examinations, the passive range of motion of the wrist joint, complications, Mayo wrist score, and short form (SF)-36.

RESULTS

The clinical follow-up time after reconstruction averaged 5.2 years. The mean resected length of the radius was 8.1 cm. One patient had tumor recurrence in the soft tissues after 3 years (recurrence rate 6.67 %). No patient had allograft bone fracture, nonunion, or metastases. Subchondral bone alterations and joint narrowing were present in all cases, with 1 patient suffering from the pain, but the pain could be endured without the need for analgesics. The average range of motion of the wrist was 46.7° of dorsiflexion, 33.3° of volar flexion, 61.3° of supination, and 72.3° of pronation. The mean Mayo wrist score was 70 and the mean modified SF-36 score was 71.

CONCLUSIONS

En bloc excision and osteoarticular allograft reconstruction with an appropriate LCP for a Campanacci grade III giant cell tumor of the distal radius result in a reasonable functional outcome at intermediate follow-up evaluation. This method can excise the tumor integrally with a low rate of recurrence, good function, and a satisfactory range of motion.

The use of osteo-articular allografts for reconstruction after resection of the distal radius for tumour

Several techniques have been described to reconstruct a mobile wrist joint after resection of the distal radius for tumour. We reviewed our experience of using an osteo-articular allograft to do this in 17 patients with a mean follow-up of 58.9 months (28 to 119).

The mean range of movement at the wrist was 56° flexion, 58° extension, 84° supination and 80° pronation. The mean ISOLS-MSTS score was 86% (63% to 97%) and the mean patient-rated wrist evaluation score was 16.5 (3 to 34). There was no local recurrence or distant metastases. The procedure failed in one patient with a fracture of the graft and an arthrodesis was finally required. Union was achieved at the host-graft interface in all except two cases. No patient reported more than modest non-disabling pain and six reported no pain at all. Radiographs showed early degenerative changes at the radiocarpal joint in every patient.

A functional pain-free wrist can be restored with an osteo-articular allograft after resection of the distal radius for bone tumour, thereby avoiding the donor site morbidity associated with an autograft. These results may deteriorate with time.

Vascular basis of free transfer of proximal epiphysis and diaphysis of fibula: an anatomical study

INTRODUCTION

Transfer of proximal epiphysis and diaphysis of fibula is a treatment of bony defects in children. Although there are few reports of this procedure, different arteries or combination of arteries have been used as supplying pedicle and the reported success rates are different. This is an anatomical study to clarify the vascular anatomy of this region.

MATERIALS AND METHODS

A total of 16 fresh cadavers were enrolled. An incision was made in the popliteal fossa to find the popliteal artery, which was dissected distally and the lateral inferior genicular artery, anterior tibial artery, tibioperoneal trunk and its bifurcation were located. In eight subjects popliteal artery was cannulated above the level of femoral condyles and injected by latex. In the next eight cases the same material was injected in the anterior tibial artery. The next steps of dissection were done by 4.3-loupe magnification. Lateral inferior genicular artery was dissected from its origin to the fibular head and branches of anterior tibial artery were also dissected. In three specimens, the fibula and its supplying arteries were removed after dissection and put in diluted hydrochloric acid to be opened for studying the medullary vasculature.

RESULTS

This study confirms the existence of not only periosteal but also intramedullary anastomosis between artery of the neck and peroneal artery. Artery of the neck was usually a branch of anterior tibial artery and in 24% of the subjects a branch of popliteal artery. In the latter condition the pedicle would be too short to permit the surgeon to do this surgery. Therefore preoperative angiography is mandatory to identify the origin of the artery of the neck.

CONCLUSION

According to these dissections, a classification system of arterial supply of proximal fibular epiphysis is introduced in this article.

Functional outcome following excision of a tumour and reconstruction of the distal radius

We retrospectively studied the functional and oncological results of 15 patients after reconstruction of the distal radius with osteoarticular allograft or non-vascularised fibular graft following wide excision of an aggressive benign or malignant tumour. Eight patients underwent osteoarticular allograft and seven patients had a non-vascularised autogenous fibular graft reconstruction. The average time for incorporation of the graft was 6 and 5 months in each reconstruction respectively. There was no tumour recurrence after follow up over 41.5-95.5 (average 60.5) months. All patients had good and excellent functional results. Three patients in the group reconstructed with osteoarticular allograft had plate loosening and graft fractures which were successfully treated subsequently.

[Ilizarov reconstruction of the distal radius after resection of a giant-cell tumor: a case report]

We present a case of Ilizarov reconstruction after en bloc resection of the distal radius. An 8-cm resection was required to remove a giant-cell tumor. Reconstruction was based on the ascension technique using an Ilizarov external fixator after corticotomy of the proximal fragment of the radius. Satisfactory reconstruction with formation of a neoarticulation between the radius and the carpus was achieved. Satisfactory wrist function was achieved and the patient was recurrence free at five years. The arguments leading to this therapeutic option are discussed.

Reconstruction of the distal radius facet by a free vascularized osteochondral autograft: anatomic study and report of a patient

PURPOSE

Large chondral defects of the distal radius after fractures present a reconstructive challenge. The purpose of this study was to present the anatomic findings from a cadaver of a vascularized osteochondral autograft taken from the third metatarsal appropriate for reconstructing the distal radius articular facet. A patient is presented in whom 70% of the scaphoid fossa was reconstructed with this technique.

METHODS

The base of the third metatarsal was studied in the feet of 20 cadavers. The size and shape of the cartilage were measured. Additionally vessel distribution was recorded and the diameters of vascular foramina were measured with Juch's method.

RESULTS

The base of the third metatarsal is pear shaped and is wider dorsally than plantarly. It averages 19.2 mm long on its main axis. Its cartilaginous surface is minimally concave or flat and it is slanted slightly proximal-dorsal to distal-plantar and proximal-peroneal to distal-tibial. Nutrient foramina were found in every case in the dorsum and on both sides of the proximal shaft. At least 1 nutrient vessel could be tracked back to the dorsalis pedis in every dissected specimen.

CONCLUSIONS

The anatomic features of the base of the third metatarsal make it a potential vascularized autograft to consider for osteochondral defects of the distal radius.

Free vascularized fibula grafting for reconstruction of the wrist following wide tumor excision

Free vascularized fibula transfer is an established method for reconstruction of the wrist following tumor resection. In cases of resection of the radial articular surface, three reconstructive options are possible: fibular head transfer along with the shaft to replace the radial joint surface, fixation of the fibula to the scaphoid and lunate, or a complete wrist fusion. Three patients with a tumor involving the distal end of the radius were treated with wide resection, and subsequent wrist reconstruction was performed, using the above-mentioned procedures. Although our experience included only a small number of patients, both radio-carpal hemiarthroplasty and fibulo-scapho-lunate fusion similarly provided successful wrist stability and functional range of motion in these cases. Even when the wrist was totally fused with the fibula, its function was still acceptable.

Fibulo-scapho-lunate arthrodesis as a motion-preserving procedure after tumour resection of the distal radius

Free microvascular fibula transfer is an established method for reconstruction of the distal radius following tumour resection. If the radial articular surface is resected, fixation of the fibula to the carpus is either performed as a complete wrist fusion, or the fibular head is transferred together with the shaft to replace the radial joint surface, thus allowing some wrist mobility but providing only limited wrist stability. Fibulo-scapho-lunate fusion represents an alternative. This reconstruction in two patients provided excellent wrist stability and a functional range of midcarpal motion.

Vascularized fibular graft after excision of giant-cell tumor of the distal radius: wrist arthroplasty versus partial wrist arthrodesis

Several reconstructive procedures have been described for the complete defect of the distal radius that is created after a wide excision of a giant-cell tumor of bone, including hemiarthroplasty using the vascularized fibular head and partial wrist arthrodesis between a vascularized fibula and the scapholunate portion of the proximal carpal row. The objectives of this study are to compare clinical and radiographic results between the partial wrist arthrodesis and the wrist arthroplasty, and to discuss which procedure is superior. Four patients with giant-cell tumors involving the distal end of the radius were treated with en bloc resection and reconstruction with a free vascularized fibular graft. The wrists in two patients were reconstructed with an articular fibular head graft and the remaining two patients underwent partial wrist arthrodesis using a fibular shaft transfer. There was radiographic evidence of bone union at the host-graft junctions in all cases. In the newly reconstructed wrist joint, there was palmar subluxation of the carpal bones and degenerative changes in both patients. Local recurrence was seen in one patient. According to the functional results described by Enneking et al., the mean functional score was 67 percent. The functional scores including wrist/forearm range of motion in the cases with partial wrist arthrodesis were superior to those with wrist arthroplasty. A partial wrist arthrodesis using a vascularized fibular shaft graft appears a more useful and reliable procedure for reconstruction of the wrist after excision of the giant-cell tumor of the distal end of the radius than a wrist arthroplasty using the vascularized fibular head, although our study includes only a small number of patients.

Reverse segmental pedicled ulna transfer as a salvage procedure in wrist fusion

A new technique for wrist fusion using vascularized bone graft is described. A distally based, pedicled segment of the distal ulna, nourished by the ulnar artery or the distally based palmar-ulnar branch of the anterior interosseus artery was used in three patients to restore carpal height after infection (n=2) or tumour resection (n=1). The forearm is converted to a situation similar to a wide ulnar resection. All three wrist fusions healed uneventfully. This new technique is suitable in cases where a vascularized bone graft is required, but microsurgical techniques are not appropriate or are rejected by the patient.