Ressecção ampla e transposição fibular no tratamento do TCG da extremidade distal do rádio

Wrist arthroplasty for treatment of infected distal radius nonunion using free vascularised proximal fibular bone graft

OBJECTIVE

Management of infected distal radius nonunion with a bone defect and radiocarpal and distal radio-ulnar joint arthritis is considered an orthopaedic challenge. Although several methods have been described but none provide a satisfactory solution. Free vascularised fibula bone graft constitutes a good option to eradicate the infection, correct the deformity, compensate for the shortening and maintain motion.

MATERIAL AND METHODS

This study included 15 cases with infected distal radius nonunion associated with bone defects. Nine cases were males and six were females. The average age of the patient was 20 years (range 8 - 60 years). The right wrist was involved in 10 patients and left was affected in 5 patients. Nine cases resulted from a motor vehicle accident, four cases after a firearm injury and two cases due to falling from a height. The average number of previous surgical procedures was three (range 2 -6). The principle of treatment was debridement, excision of distal radius and trimming of the proximal part of radius back to healthy bleeding bone, inserting the free vascularised proximal fibular bone graft to compensate the defect and fixation of the graft.

RESULTS

The procedure was successful in 13 of 15 cases. Bone union was achieved at an average of 4 months. No clinical evidence of osteomyelitis or or infection at final follow-up. Pain was completely relieved in all cases. Wrist joint range of motion averaged flexion 50˚, extension 45˚ and handgrip was the same as the normal site. Twelve cases out of 15 returned to their daily activities.

CONCLUSION

Free vascularised proximal fibula bone graft is a new indication for the treatment of an infected distal radius nonunion with a bone defect.

Functional outcome in giant cell tumor of distal radius treated with excision and fibular arthroplasty: a case series

INTRODUCTION

Giant cell tumor (GCT) of bone is a locally aggressive benign neoplasm that is associated with a wide spectrum of biological activity ranging from latent benign to highly recurrent and has occasional metastatic potential. It affects the meta-epiphyseal region of long bones of young adults with most common site involved is the distal femur, followed by the distal radius. Plain radiographs and contrast-enhanced magnetic resonance imaging are the imaging modalities widely used followed by definite histopathology for diagnosis. Surgical treatment with curettage is considered optimal for local tumor control. Tumor excision with tumor-free margins is associated with lesser recurrence rates; however, for periarticular lesions this is usually accompanied with a suboptimal functional outcome.

METHODS

Eleven eligible patients (all females, mean age 39.2 years) with Campanacci grade III GCT of the distal radius who were treated by en bloc resection and reconstruction with non-vascularized proximal fibular autografts at a single centre between July 2016 and December 2017 were included in the study. The patients had a clinical and radiographic review every month for the first 6 months, then biannually for minimum of 2 years. The functional, oncologic and radiological outcomes of the patients were analyzed and recorded.

RESULTS

The mean duration of follow-up was 31.9 months. Bony union was achieved in all cases. The mean VAS score at 6 months was 1.1 (range 0-2). The mean Mayo Wrist score was 66.36 (range 55-80) with mean MSTS score was 21.09 (range 18-24). The average range of motion of the wrist was: 37.3° ± 6.9° of flexion, 47.1° ± 7.5° of extension, 57.3° ± 7.8° of supination and 63.6° ± 6.4° of pronation. The average graft length used was 15.6 cm. The complications noted were lung metastases which developed preoperatively, local site recurrence, wrist joint subluxation, foot drop and wound complication.

DISCUSSION AND CONCLUSIONS

The primary aim of treating GCT distal radius is oncologically sound resection with good functional outcome and cosmesis being secondary. Reconstruction with a non-vascularized proximal fibular autograft is a reasonable option after en bloc resection of the distal radius for giant cell tumor of bone having comparable results with other treatment modalities.