Vascularized Fibular Graft after Excision of Giant-Cell Tumor of the Distal Radius: Wrist Arthroplasty versus Partial Wrist Arthodesis

Author(s): Minami A, Kato H, Iwasaki N

Source: Plastic and Reconstr Surg 110: 112-117, 2002

Summary:

The treatment of benign giant-cell tumors of bone involving the distal metaphysis of the radius presents a difficult reconstructive challenge following radical resection.  Treatment of these tumors typically involves exteriorization of the lesion with extensive curettage and grafting or methacrylate placement.  Occasionally, cure requires resection of the entire articular surface of the distal radius creating a free-floating carpus with a defect.  The authors present four cases, comprising a 13-year experience, of reconstruction of the distal radius and radiocarpal joint for Enneking Stage 2 and 3 giant-cell tumors.  All reconstructions utilized free fibular grafts as bony replacements.  The grafts were placed to bridge the longitudinal defect and distally constructed as either radiocarpal fusions (n=2) or radiocarpal arthroplasties (n=2).  The arthroplasties were constructed by using the fibular head as a distal radial analog, articulating with the scaphoid and lunate.  The fusions were constructed to form a fusion mass between the distal fibular graft and the scaphoid and lunate, simulating a radioscapholunate fusion.  Graft lengths averaged 11.3 cm, and the grafts were always based on the peroneal vascular pedicle.  Ligament stabilization of the arthroplasties was attempted with the fibular collateral ligament to the radial collateral, and the ECRB tendon to the dorsal carpal ligamentous remnants in an effort to prevent carpal subluxation.  Follow-up averaged 9 years 8 months (range 3 years 2 months to 15 years 6 months).  All bony junctures united by 13 weeks, both distally and proximally.  The authors evaluated results based on radiographic stability and degeneration over time as well as functionally by the Enneking Evaluation System.  These included ratings of pain, function, emotional acceptance, hand positioning, manual dexterity, lifting ability, and an overall score and a percent recovery.  The results of partial fusion were superior to arthroplasty in both radiographic and functional criteria.  Both arthroplasties experienced gradual palmar subluxation of the carpus and osteoarthritic degeneration at the fibular head/carpal articulation.  Motion was limited and pain was more severe than in the fusions.  The fusions both maintained a functional arc of motion in flexion and extension, as well as superior lifting strength when compared with the arthroplasties. 

This paper documents a limited experience with two approaches for reconstruction of total distal radial resection.  There is much support in the literature for both fibular head arthroplasty and partial or total wrist arthrodesis.  These authors suggest that the functional results and long-term stability of partial arthrodesis are superior.  Indeed, although the differences between their populations were not statistically evaluated due to small sample size, they appear quite remarkable.  The arthroplasty patients had a very limited total arc of motion (15 degrees average flexion/extension) in long-term follow-up.  This raises questions about post-operative immobilization, therapy, and intra-operative placement of the graft, all of which would be expected to have significant impact on the results of a motion-sparing procedure.  Radiographic changes of degeneration are certainly easily understood in the context of an inexact replication of the radiocarpal contours with fibular head arthroplasty.  The lack of proprioception (Charcot joint) may also play a role, as well as the  long-term follow-up provided in this report.  Despite the limitations related to the small number of cases, this paper serves to illustrate two viable methods of successful reconstruction of a very challenging problem.  It suggests that partial or total wrist arthrodesis with vascularized bone grafting may be the more favorable option.

 


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