Allograft replacement in giant cell tumour of the hand

Conjoined Free Fibula Transplantation and First Carpometacarpal Joint Prosthesis for Functional Thumb Reconstruction-A Case Report

BACKGROUND

Giant cell tumors grow locally invasive with osseous and soft tissue destruction, requiring wide resection to avoid recurrence. Stable reconstruction of the first carpometacarpal (CMC-1) joint remains a challenge due to its high range of mobility. The latter is of paramount for the functionality of the hand.

PURPOSE

Therefore, the aim of this study was to report our approach for a combined reconstruction of the first metacarpal and the CMC-1 joint.

METHODS

A 58-year-old woman underwent wide resection of a benign giant cell tumor at the base and shaft of the first metacarpal of the left thumb. Because of the loss of the CMC-1 joint and the instability of the thumb, an osseous reconstruction using a vascularized fibular graft combined with a TOUCH Dual Mobility CMC-1 prosthesis was performed to reconstruct the CMC-1 joint.

RESULTS

Osseous healing was observed after 3 months. No tumor recurrence and good joint function were documented at the follow-up investigation after 1 year. The patient reported only minor restrictions during activities of daily living. Thumb opposition was possible with a Kapandji score of 8/10. A slight pain while walking remained as a donor-side morbidity at the right lower leg.

CONCLUSION

Metacarpal reconstruction with vascularized fibula bone grafts allowed a combined joint reconstruction with a commercially available prosthesis, which is an approach to restore the complex range of motion of the thumb.

Massive bone allograft engineered with autologous vessels: A new perspective for the future

Reconstruction is very important to ensure good function and quality of life after bone tumor resection. For metacarpals and phalanges, amputation and toe transfer are the gold-standard indications; nevertheless, allograft reconstruction must also be taken into account. Unfortunately, because of its inert biological behavior, it undergoes progressive resorption, with frequent fracture. Several attempts have been made to induce new vascularization in massive bone allograft, with poor results. However, neo-angiogenesis was reported with vascular loops, and we therefore hypothesized that heterologous graft integration could be enhanced by creating a vascular loop through the graft. A 50-year-old male with chondrosarcoma of the ring finger of the left hand underwent wide resection. An allogenic middle phalanx of comparable size was then prepared to fill the defect. Two small windows were performed proximally and distally on the radial surface of the allogenic phalanx, and a 4 cm-long vein graft was inserted inside the medullary canal. Metacarpophalangeal joint stability was achieved by collateral ligament reconstruction with micro-anchors. The distal part of the allograft was then stabilized to the middle phalanx with a 1.5 mm-thick micro-plate and screws. The radial proper palmar digital artery was proximally and distally sutured end-to-end to the vein graft, under microscopy. At 12-month follow-up, the allograft was fused, and histology performed at plate removal at 18 months revealed viable spindle cells with osteoblastic differentiation, without evidence of atypia, in a dense fibrous stroma. At 22 months' follow-up, the patient was apparently disease-free, and satisfied with his manual function.

New reconstruction for bone integration of non-vascularized autogenous bone graft with better bony union and revascularisation

INTRODUCTION

Phalangeal defects are often seen after tumor resection, infections, and in complex open hand fractures. In many cases, reconstruction is difficult and amputation is performed to avoid prolonged rehabilitation that is often associated with a poor outcome. In these cases, the maintenance of length and function presents a reconstructive challenge.

METHODS

We reviewed 11 patients who underwent extensive phalangeal reconstruction with non-vascularized bone graft from the iliac crest using a key-in-slot-joint technique to provide acceptable function and bony union.

RESULTS

In each case, non-vascularized bone graft with a length of 1.4-6.0 cm was used to reconstruct the phalanx. Follow-up ranged from 6 weeks to 5 months, and in all cases, there was bony union after 6 weeks. We evaluated range of motion, function, and as well pain and grip strength of the fingers.

CONCLUSIONS

This case series suggests that a key-in-slot technique allows non-vascularized bone graft to be used in complex large phalangeal bone defects. Due to better bone contact, a sufficient perfusion and revascularisation of the non-vascularized bone graft can be achieved for a quicker and stable bony union. This method appears to be an alternative to amputation in selected cases with a satisfactory soft-tissue envelope.

A Patient-Matched Entire First Metacarpal Prosthesis in Treatment of Giant Cell Tumor of Bone

Giant cell tumor of the bones occurring in the first metacarpals frequently requires entire metacarpal resection due to the aggressive nature and high rate of recurrence. Bone reconstruction can be performed with autogenous bone grafts. Here we describe a new technique of reconstruction using a patient-matched three-dimensional printed titanium first metacarpal prosthesis. This prosthesis has a special design for ligament reconstruction in the proximal and distal portions. Good hand function and aesthetic appearance were maintained at a 24-month follow-up visit. This reconstructive technique can avoid donor-site complications and spare the autogenous bone grafts for revision options.

Central Column Reconstruction Following Total Resection of a Third Metacarpal Giant Cell Tumour

A wide resection of a giant cell tumour involving the entire middle metacarpal is presented. Reconstruction preserving the central column and metacarpophalangeal joint was achieved using autologous iliac crest bone as a spacer and structural support. The fibro-osseous cartilage portion of the iliac graft was used as a “hemi-joint” replacement. By using a bridging bone graft and screw to fuse the adjacent proximal phalanges of the middle and index fingers, a stable “internal syndactyly” was achieved. Although independent index and middle finger motion was sacrificed, the approach allowed wide resection for local tumour control, re-established structural integrity, preserved metacarpophalangeal joint motion and allowed early motion. The aesthetic result was also good.

Multicentric giant cell tumor of the fourth and fifth metacarpals with lung metastases

Giant cell tumors of bone (GCTB) are generally benign neoplasms, but recently, some authors consider them to be low-grade malignant neoplasms because they have a relatively high rate of recurrence and at least some potential for metastases. The majority of GCTB are unifocal, and less than 1 % are multicentric. We report a rare case of a multicentric GCTB arising simultaneously in the non-dominant fourth and fifth metacarpals of a 25-year-old female. The patient underwent ray amputation of the two involved digits, and the surgical margins were histologically negative for tumor. The tumor had the classic histologic appearance of a benign GCTB. A year after the amputation, the patient developed pulmonary metastasis which was treated with pulmonary lobe resection. She is currently over 2.5 years postsurgical treatment of the primary lesion with no evidence of local recurrence or distant metastasis.

Giant cell tumours of the small bones of the hands and feet

Giant cell tumours (GCTs) of the small bones of the hands and feet are rare. Small case series have been published but there is no consensus about ideal treatment. We performed a systematic review, initially screening 775 titles, and included 12 papers comprising 91 patients with GCT of the small bones of the hands and feet. The rate of recurrence across these publications was found to be 72% (18 of 25) in those treated with isolated curettage, 13% (2 of 15) in those treated with curettage plus adjuvants, 15% (6 of 41) in those treated by resection and 10% (1 of 10) in those treated by amputation.

We then retrospectively analysed 30 patients treated for GCT of the small bones of the hands and feet between 1987 and 2010 in five specialised centres. The primary treatment was curettage in six, curettage with adjuvants (phenol or liquid nitrogen with or without polymethylmethacrylate (PMMA)) in 18 and resection in six. We evaluated the rate of complications and recurrence as well as the factors that influenced their functional outcome.

At a mean follow-up of 7.9 years (2 to 26) the rate of recurrence was 50% (n = 3) in those patients treated with isolated curettage, 22% (n = 4) in those treated with curettage plus adjuvants and 17% (n = 1) in those treated with resection (p = 0.404). The only complication was pain in one patient, which resolved after surgical removal of remnants of PMMA. We could not identify any individual factors associated with a higher rate of complications or recurrence. The mean post-operative Musculoskeletal Tumor Society scores were slightly higher after intra-lesional treatment including isolated curettage and curettage plus adjuvants (29 (20 to 30)) compared with resection (25 (15 to 30)) (p = 0.091). Repeated curettage with adjuvants eventually resulted in the cure for all patients and is therefore a reasonable treatment for both primary and recurrent GCT of the small bones of the hands and feet.

Cite this article: Bone Joint J 2013;95-B:838–45.

[Giant cell tumor of the thumb proximal phalanx: resection-iliac graft and double arthrodesis]

Giant cell tumours (GCT) of bone are frequent, with variable behaviour, high risk of recurrence and an often benign histological appearance. Their location in the hand is uncommon, and there are few publications on the subject. Surgical treatment as described in the literature is very variable. We report a case of recurrent grade II GCT, arising in the proximal phalanx of the thumb, aggressive and causing a pathological fracture. After a surgical biopsy, we performed an "en bloc" resection of the first phalanx, with an iliac crest graft reconstruction and a double arthrodesis of the metacarpophalangeal and interphalangeal joint. No recurrence or lung metastasis was seen at 18 months follow-up.

Nonvascularized osteoarticular allograft replacement of the proximal interphalangeal joint after extensive loss of bone, joint, and extensor tendon

Nonvascularized small-joint allografts are a potentially attractive alternative to prosthetic implantation in cases of posttraumatic destruction of the proximal interphalangeal joint combined with metaphyseal and diaphyseal metacarpal or phalangeal bone loss, as well as soft tissue tendon defects of the digital extensor mechanism. Benefits include the absence of donor site defect, the ability to simultaneously reconstruct deficiency of the extensor mechanism, restore digital length and phalangeal (and metacarpal) bone stock in the face of bone loss, and the provision of an osteoinductive platform onto which creeping substitution can occur. Difficulties include an increased potential for infection and the potential for narrowing of the joint space because of articular cartilage loss. Early results suggest that the benefit of this technique lies in its ability to restore bone stock and soft tissue integrity that would make later prosthetic joint replacement feasible.

Giant-cell tumors of the carpus

Giant cell tumor (GCT) of bone is a rare, benign tumor with some aggressive characteristics such as a high recurrence rate. The tumor usually occurs in the distal radius although it has been reported in the carpus. We reviewed 63 manuscripts published from 1935 to 2005 and report on the treatment of GCT of carpal bone in 29 cases. Intralesional procedures, such as curettage, were associated with a high incidence of recurrence (24%), whereas cases treated with an excisional procedure did not recur.

Silastic replacement of metacarpal after resection of giant cell tumour. A case report

Giant cell tumours are aggressive lesions, albeit benign. Lesions in the hand, especially those arising from metacarpals require resection with adequate margins and definitive structural reconstructions to ensure preservation of hand architecture, function and cosmesis. Almost all the described reconstructive procedures require a stump of tumour free metacarpal base after resection, for reconstruction of the metacarpal. This report describes replacement of the entire metacarpal with a silastic prosthesis, in a case of giant cell tumour involving the entire metacarpal head and shaft to within 7 mm of the base.