Allograft replacement with distal radioulnar joint fusion and ulnar osteotomy for treatment of giant cell tumors of the distal radius Three patients with advanced giant cell tumors of the distal radius received a frozen allograft replacement
of the distal radius, accompanied
by a distal radioulnar
arthrodesis
with ulnar
osteotomy proximal to the wrist. Follow-up ranged from 2 to 4 years. During this time this combined procedure provided the following advantages: morbidity, retention of pronation-supination, radial ulnar joint. (J HAND
complete tumor resection, no donor site
and avoidance of pain or subluxation at the distal
S~JRG 1990;15A:929-33.)
Robert M. Szabo, MD, Eric P. Thorson, MD, and John R. Raskind, MD, Sacramento,
Calif.
T
he distal radius is the third most common location of giant cell tumor.’ Curettage and bone grafting is the accepted method of primary treatment; adjuvant procedures such as radiation therapy and cryotherapy have proven ineffective in the hand and forearm and have a high rate of complications.24 The rate of recurrence of high-grade giant cell tumors in the hand after curettage and bone grafting is significant, reaching 55% in one series.5 Treatment of the wrist in these recurrent cases is a challenging problem that has inspired trials of numerous procedures. Previous authors have described treatment of giant cell tumor of the distal radius with amputation,‘j wrist prosthesis,6, ’ massive allograft from ilium’ or tibia,‘, lo distal ulnar translocation on the radius,” nonvascularized fibular autograft, “-” vascularized fibular transplant,‘8. I9 and allograft replacement.*’ None of these procedures is clearly superior, and they have been troubled by instability, poor range of motion, and/or donor site morbidity. From the University mento, Calif.
of California,
Received for publication 25, 1989.
Davis,
Medical
Center, Sacra-
Aug. 9, 1989; accepted in revised form Oct.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Robert M. Szabo, MD, Associate Professor, Chief, Hand and Upper Extremity Service, Department of Orthopaedic Surgery, 2230 Stockton Blvd., Sacramento, CA 95817. 3/1/18517
We have devised a procedure in which a distal radius allograft is combined with distal radioulnar joint arthrodesis and a distal ulnar osteotomy (Suave-Kapandji procedure). With this procedure, forearm rotation is preserved, some wrist flexion-extension is maintained, and distal radioulnar joint incongruity is avoided. Technique
The tumor is excised en bloc including the pronator quadratus by stepcut osteotomy of the radius 3 cm proximal to the radiographic tumor margin. Palmar wrist capsule is tagged with a nonabsorbable suture. A freshfrozen allograft is obtained to match the defect. Marrow is removed with curets and high speed bur. The radial fossa is denuded of cartilage. After checking rotation, a reciprocal stepcut osteotomy is made in the proximal radial allograft. Care is taken not to lengthen the radius that could lead to extrinsic tendon tightness and stiff fingers. The distal ulnar surface is denuded. The allograft is then fixed with a compression screw across the stepcut osteotomy site. The palmar wrist ligaments and the triangular fibrocartilage complex (TFCC) are sutured to the allograft wrist ligaments with nonabsorbable sutures. A 3.5 DC plate is then contoured and fixed to the dorsoradial surface of the radius. One or two 3.5 mm cortical screws are used to secure the distal ulna under compression to the radial fossa. An ulna osteotomy is made 2 to 3 cm proximal to the ulnocarpal joint and a 10 to 15 mm segment of ulna is removed. The carpus is transfixed to the radius in neutral position with a Steinman pin, which is removed after 6 weeks.
THE IOURNALOFHANDSURGERY
929
930
The Journal of HAND SURGERY
Szabo, Thorson, and Raskind
Fig. 1. A-B, Preoperative loss of palmar cortex.
A
PA and lateral x-ray films show a lytic lesion on the distal radius with
B
Fig. 2. A-C, Technetium 99 bone scans at three intervals (left to right): A, The preoperative scan showing intensely increased uptake in the lesion. B, Bone scan at 17 months after operation showing moderately increased uptake at the proximal radial and distal ulnar osteosynthesis sites, with little activity in the allograft segment. C, Bone scan at 26 months after operation shows continued increased activity at both the proximal and distal osteosynthesis sites, with more activity present in the allograft segment.
Case reports Case 1. A 24-year-old, right-handed woman, a convenience store cashier, was seen with left wrist pain and swelling. The wrist pain began after minor trauma, which occurred while riding over a pothole on her bicycle. X-ray films demonstrated a 3 X 5 cm lytic lesion in the distal radius (Fig. 1). Active wrist range of motion measured: flexion 10
degrees, extension 10 degrees, no radial or ulnar deviation with the wrist fixed in 45 degrees of pronation. Bone scan demonstrated increased uptake isolated to the left radius. Results of other staging studies were negative. Incisional biopsy done through the third dorsal compartment provided the diagnosis of giant cell tumor. Eight days later, the left distal radius was removed en bloc, and replaced
Vol. 15A, No. 6 November 1990
Treatment of giant cell tumors of distal radius
931
Fig. 4. A-B, Preoperative
PA and oblique x-ray films show a lytic lesion throughout the distal radius penetrating the ulnar cortex proximal to the distal radioulnar joint.
Fig. 3. A-B, Postoperative
PA and lateral x-ray films 44 months after allograft replacement of distal radius and distal radioulnar joint fusion and ulnar osteotomy.
with a fresh-frozen allograft. This replacement included a distal ulnar osteotomy with arthrodesis of the distal radioulnar joint (Suave-Kapandji procedure). The proximal and distal osteosynthesis sites were bone grafted with autogenous iliac crest bone. Postoperative serial technetium bone scans were done 17 and 26 months later. The initial postoperative scan demonstrated increased uptake at both the proximal, osteosynthesis site, and the distal radioulnar arthrodesis site, as well as relative absence of tracer in the distal third of the radius (Fig. 2). The other region of increased uptake occurred at the proximal end of the ulnar osteotomy. The scan done more than 2 years after operation demonstrated a similar pattern of isotope uptake with some activity in the distal diaphyseal portion of the radial allograft . At follow-up, 44 months after operation, the allograft is united and nontender (Fig. 3). The patient has occasional mild pain at the distal fusion site, which does not interfere with function, and mild bilateral carpal tunnel syndrome with normal electrodiagnostic studies. Range of wrist motion measured: flexion 30 degrees, extension 5 degrees, pronation 80 degrees, supination 60 degrees, ulnar deviation - 10 degrees, and radial deviation 20 degrees. Case 2. A 30-year-old, right-handed farmer was referred with a 3-year history of wrist pain and recurrent giant cell tumor of the distal radius. He initially sought treatment in Mexico where he had curettage and bone grafting for treatment of a giant cell tumor in December 1986. Review of his pathologic specimen from the initial resection demonstrated a well-differentiated giant cell temor. Pain and swelling re-
Fig. 5. A-B, PA and lateral x-ray films at 26 months after operation after distal radius replacement with allograft combined with distal radioulnar joint fusion and proximal ulnar osteotomy.
turned within 4 months of the initial operation, and he was seen in June 1987 for treatment of a recurrent tumor. A preoperative evaluation to rule out metastatic disease was negative, and Aug. 31, 1987 he had an en bloc excision of the left distal radius. Replacement of the resected radius
932
Szabo, Thorson, and Raskind
was done with frozen allografi and accompanied by a distal radioulnar joint fusion and proximal ulnar osteotomy with iliac crest bone grafting to the proximal osteosynthesis and distal radioulnar fusion sites. At seventeen months after operation, the allograft was united with minimal tenderness. The patient returned to farming with only occasional symptoms of wrist pain. Range of motion on the last follow-up visit measured: flexion 25 degrees, extension 15 degrees, pronation 85 degrees, supination 75 degrees, radial deviation 10 degrees, ulnar deviation 5 degrees. Case 3. A 65-year-old, right-handed retired industrial consultant and avid fly fisherman was seen with a 2-month history of pain and swelling without antecedent trauma in the right wrist. X-ray films showed an expansile lytic lesion in the right distal radius with cortical destruction (Fig. 4). A preoperative evaluation ruled out metastatic disease. Results of incisional biopsy provided a diagnosis of giant cell tumor. After the biopsy, the patient had an en bloc resection of the right distal radius combined with fresh-frozen allograft replacement. As in the previous two cases, a distal radioulnar joint fusion and proximal ulnar osteotomy and iliac crest bone grafting of both osteosynthesis sites was performed. Symptoms of tendonitis developed over the proximal osteosynthesis site, which were referable to a bony prominence. These symptoms resolved after a minor operation to remove the bone spur (pathologic examination was negative for giant cell tumor). Follow-up 26 months after operation demonstrated that the allograft was united and nontender (Fig. 5). The patient was able to actively use the involved wrist for fly fishing without any pain. Wrist range of motion at that time measured: flexion 30 degrees, extension 30 degrees, pronation 80 degrees, supination 90 degrees, radial deviation 10 degrees, ulnar deviation 10 degrees.
Discussion A giant cell tumor in the distal radius is challenging for the treating surgeon. While the surgeon must remove all pathologic tissue, the resulting defect frequently compromises hand function. The relatively thin soft tissue envelope, the requirement for gliding in the soft tissues, and the desirability of maintaining some wrist motion combine to limit reconstructive options. In addition, most patients are relatively young and active with a normal life expectancy. Amputation for treatment of giant cell tumor is rare today except in the small bones of the hand, where complete excision may leave little remaining function of the affected digit. Also, the sacrifice of only one digit leaves a hand that has satisfactory function. There is only one report of prosthetic wrist replacement after resection of a giant cell tumor, and this was a failure.7 The technique used most commonly after giant cell tumor resection is bridging the bone defect with autog-
The Journal of HAND SURGERY
enous bone. Early reconstruction using autogenous iliac graft with radioulnar synostosis’ or autogenous tibia1 graft with tibial-scapho-lunate fusionslo left the wrist with limited motion, and the tibial grafts had a 50% rate of fracture through the graft. Results with fibular autografts have been better,13’ l4 in part because of the similarity of the ends of the fibula and radius. In three patients treated with a fibular autograft, spontaneous fusion of the fibular head to the lunate and scaphoid occurred; therefore, in 1.5 additional patients Murray’4 added arthrodeses of these joints at the time of grafting. Grip strength and range of motion were reduced but satisfactory. Five of 18 patients had a nonunion at the proximal osteosynthesis site, and 7 of 8 had persistent knee pain. Vascularized autografts have included distal ulnar translocation in two patients”; these patients retained good pronation and supination, but wrist flexion and extension were very limited, and a proximal nonunion developed in one of the two patients. Vascularized fibular autografts supplied by the radial artery achieved good success after giant cell tumor resection in five patients. I8 Two of these received fibularcarpal fusions. Of the other three who received ligamentous stabilization, one required a fusion after the development of painful subluxation of the carpus on the fibula. The patients with fusions had full pronation/ supination; those with ligamentous stabilization obtained half of the normal range of supinationpronation. Complications included one recurrence, one infection, one median nerve palsy, and one delayed union. Donor site complications included one peroneal nerve palsy. The author noted that this technique is demanding, requires a long operative time, and it also requires preoperative angiographic studies to map the nutrient vessels of the fibula and to determine that the arm is adequately supplied by the ulnar artery. Finally, distal radial allografts in three patients was reviewed by Smith2’ after giant cell tumor requiring distal radius resection. All allografts were frozen to -70 degrees to decrease bone antigenicity. The patient’s distal radius was removed 3 cm proximal to the radiographic margin of tumor. Because of the incongruity of the distal radioulnar joint, the distal ulna was also removed. Follow-up in this series averaged slightly less than 2 years. Average wrist motions were: pronation 70 degrees, supination 72 degrees, flexion 31 degrees, extension 37 degrees with full radial and ulnar deviation. Complications included palmar subluxation 1 to 2 years after operation. All allografts healed well and the patients had relatively pain-free motion. Distal radial allografts offer several advantages in the
Vol. 15A, No. 6 November 1990
of giant cell tumors of the distal radius. There is relatively good restoration of the anatomy while avoiding the significant donor site morbidity of fibular autografts. This procedure provides good functional wrist motion with little pain, and the allograft tissue heals to the proximal radius in a time period similar to autogenous tissue grafts. The possibility of transmission of disease by allograft is low in a carefully screened donor population. In the world literature on allograft replacement, one recipient became human immunodeficiency virus (HIV) positive; however, the donor in that case was not screened for risk factors. The chance of obtaining donor tissue infected with HIV that fails to be excluded by the rigorous donor selection criteria, HIV screening, and histopathologic studies has been estimated at about one in four million. ” This series represents a preliminary report on a small group of patients and long-term follow-up is warranted.
treatment
REFERENCES 1. Eckardt JJ, Grogan TJ. Giant cell tumor of bone. Clin Orthop 1986;204:45-58. 2. Johnson EW, Dahlin DC. Treatment of giant cell tumor of bone. J Bone Joint Surg 1959;41A:895-904. 3. Marcove RC, Weis LD, Vaghaiwalla MR, Pearson R. Cryosurgery in the treatment of giant cell tumors of bone. Clin Orthop 1978;134:275-89. 4. Riley LH, Hartmann WI-I, Robinson RA. Soft tissue recurrence of giant cell tumor of bone after irradiation and excision. J Bone Joint Surg 1967;491\:365-8. 5. Averill RM, Smith RJ, Campbell CJ. Giant cell tumors of the bones of the hand. J HAND SURG 1980;5:39-49. 6. Gold AM. Follow-up notes on articles previously published in the journal-use of a prosthesis for the distal portion of the radius following resection of a recurrent giant cell tumor. J Bone Joint Surg 1965;47A:216-18. 7. Gold AM. Use of prosthesis for the distal portion of the radius following resection of a recurrent giant cell tumor. J Bone Joint Surg 1957;39A:1374-80.
Treatment of giant cell tumors of distal radius
933
8. Wilson PD, Lance EM. Surgical reconstruction of the
skeleton following segmental resection for bone tumors. J Bone Joint Surg 1965;47A:1629-56. 9. Higginbotham NL, Coley BL. The treatment of bone tumors by resection and replacement with massive grafts. Instructional course lectures, American Academy of Orthopaedic Surgeons 1950;7:26-33. 10. Campbell CJ, Akbamia BA. Giant cell tumor of the distal radius treated by massive resection and tibia1 bone graft. J Bone Joint Surg 1975;57A:982-6. 11. Seradge H. Distal ulnar translocation in the treatment of giant cell tumors of the distal end of the radius. J Bone Joint Surg 1982;64A:67-72. 12. Lawson TL. Fibular transplant for osteoclastoma of the radius. J Bone Joint Surg 1952;34B:74-5. 13. Mack GR, Lictman DM, MacDonald RI. Fibular autografts for distal defects of the radius. J HAND SURG 1979;4:576-83. 14. Murray JA, Schiafly B. Giant cell tumors in the distal end of the radius. J Bone Joint Surg 1986;68A:687-93. 15. Noellert RC, Louis DS. Long-term follow-up of nonvascularized fibular autografts for distal radial reconstruction. J HAND SURG 1985;1OA:335-40. 16. Parrish FF. Treatment of bone tumors by total excision and replacement with massive autologous and homologous grafts. J Bone Joint Surg 1966;48A:968-89. 17. Sakellarides HT. Extensive giant cell tumor of the lower end of the radius. Clin Orthop 1965;42:151-6. 18. Pho RWH. Malignant giant cell tumor of the distal end of the radius treated by a free vascularized fibular transplant. J Bone Joint Surg 1981;63A:877-84. 19. Pho RWH. Free vascularized fibular transplant for replacement of the lower radius. J Bone Joint Surg 1979;61B:362-5. 20. Smith RJ, Mankin HJ. Allograft replacement of distal radius for giant cell tumor. J HAND SURG 1977;2:299309. 21. Buck BE, Malinin TI, Brown MD. Bone transplantation and human immunodeficiency virus: an estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop 1989;240:129-36.
of the distal radius, accompanied
by a distal radioulnar
arthrodesis
with ulnar
osteotomy proximal to the wrist. Follow-up ranged from 2 to 4 years. During this time this combined procedure provided the following advantages: morbidity, retention of pronation-supination, radial ulnar joint. (J HAND
complete tumor resection, no donor site
and avoidance of pain or subluxation at the distal
S~JRG 1990;15A:929-33.)
Robert M. Szabo, MD, Eric P. Thorson, MD, and John R. Raskind, MD, Sacramento,
Calif.
T
he distal radius is the third most common location of giant cell tumor.’ Curettage and bone grafting is the accepted method of primary treatment; adjuvant procedures such as radiation therapy and cryotherapy have proven ineffective in the hand and forearm and have a high rate of complications.24 The rate of recurrence of high-grade giant cell tumors in the hand after curettage and bone grafting is significant, reaching 55% in one series.5 Treatment of the wrist in these recurrent cases is a challenging problem that has inspired trials of numerous procedures. Previous authors have described treatment of giant cell tumor of the distal radius with amputation,‘j wrist prosthesis,6, ’ massive allograft from ilium’ or tibia,‘, lo distal ulnar translocation on the radius,” nonvascularized fibular autograft, “-” vascularized fibular transplant,‘8. I9 and allograft replacement.*’ None of these procedures is clearly superior, and they have been troubled by instability, poor range of motion, and/or donor site morbidity. From the University mento, Calif.
of California,
Received for publication 25, 1989.
Davis,
Medical
Center, Sacra-
Aug. 9, 1989; accepted in revised form Oct.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Robert M. Szabo, MD, Associate Professor, Chief, Hand and Upper Extremity Service, Department of Orthopaedic Surgery, 2230 Stockton Blvd., Sacramento, CA 95817. 3/1/18517
We have devised a procedure in which a distal radius allograft is combined with distal radioulnar joint arthrodesis and a distal ulnar osteotomy (Suave-Kapandji procedure). With this procedure, forearm rotation is preserved, some wrist flexion-extension is maintained, and distal radioulnar joint incongruity is avoided. Technique
The tumor is excised en bloc including the pronator quadratus by stepcut osteotomy of the radius 3 cm proximal to the radiographic tumor margin. Palmar wrist capsule is tagged with a nonabsorbable suture. A freshfrozen allograft is obtained to match the defect. Marrow is removed with curets and high speed bur. The radial fossa is denuded of cartilage. After checking rotation, a reciprocal stepcut osteotomy is made in the proximal radial allograft. Care is taken not to lengthen the radius that could lead to extrinsic tendon tightness and stiff fingers. The distal ulnar surface is denuded. The allograft is then fixed with a compression screw across the stepcut osteotomy site. The palmar wrist ligaments and the triangular fibrocartilage complex (TFCC) are sutured to the allograft wrist ligaments with nonabsorbable sutures. A 3.5 DC plate is then contoured and fixed to the dorsoradial surface of the radius. One or two 3.5 mm cortical screws are used to secure the distal ulna under compression to the radial fossa. An ulna osteotomy is made 2 to 3 cm proximal to the ulnocarpal joint and a 10 to 15 mm segment of ulna is removed. The carpus is transfixed to the radius in neutral position with a Steinman pin, which is removed after 6 weeks.
THE IOURNALOFHANDSURGERY
929
930
The Journal of HAND SURGERY
Szabo, Thorson, and Raskind
Fig. 1. A-B, Preoperative loss of palmar cortex.
A
PA and lateral x-ray films show a lytic lesion on the distal radius with
B
Fig. 2. A-C, Technetium 99 bone scans at three intervals (left to right): A, The preoperative scan showing intensely increased uptake in the lesion. B, Bone scan at 17 months after operation showing moderately increased uptake at the proximal radial and distal ulnar osteosynthesis sites, with little activity in the allograft segment. C, Bone scan at 26 months after operation shows continued increased activity at both the proximal and distal osteosynthesis sites, with more activity present in the allograft segment.
Case reports Case 1. A 24-year-old, right-handed woman, a convenience store cashier, was seen with left wrist pain and swelling. The wrist pain began after minor trauma, which occurred while riding over a pothole on her bicycle. X-ray films demonstrated a 3 X 5 cm lytic lesion in the distal radius (Fig. 1). Active wrist range of motion measured: flexion 10
degrees, extension 10 degrees, no radial or ulnar deviation with the wrist fixed in 45 degrees of pronation. Bone scan demonstrated increased uptake isolated to the left radius. Results of other staging studies were negative. Incisional biopsy done through the third dorsal compartment provided the diagnosis of giant cell tumor. Eight days later, the left distal radius was removed en bloc, and replaced
Vol. 15A, No. 6 November 1990
Treatment of giant cell tumors of distal radius
931
Fig. 4. A-B, Preoperative
PA and oblique x-ray films show a lytic lesion throughout the distal radius penetrating the ulnar cortex proximal to the distal radioulnar joint.
Fig. 3. A-B, Postoperative
PA and lateral x-ray films 44 months after allograft replacement of distal radius and distal radioulnar joint fusion and ulnar osteotomy.
with a fresh-frozen allograft. This replacement included a distal ulnar osteotomy with arthrodesis of the distal radioulnar joint (Suave-Kapandji procedure). The proximal and distal osteosynthesis sites were bone grafted with autogenous iliac crest bone. Postoperative serial technetium bone scans were done 17 and 26 months later. The initial postoperative scan demonstrated increased uptake at both the proximal, osteosynthesis site, and the distal radioulnar arthrodesis site, as well as relative absence of tracer in the distal third of the radius (Fig. 2). The other region of increased uptake occurred at the proximal end of the ulnar osteotomy. The scan done more than 2 years after operation demonstrated a similar pattern of isotope uptake with some activity in the distal diaphyseal portion of the radial allograft . At follow-up, 44 months after operation, the allograft is united and nontender (Fig. 3). The patient has occasional mild pain at the distal fusion site, which does not interfere with function, and mild bilateral carpal tunnel syndrome with normal electrodiagnostic studies. Range of wrist motion measured: flexion 30 degrees, extension 5 degrees, pronation 80 degrees, supination 60 degrees, ulnar deviation - 10 degrees, and radial deviation 20 degrees. Case 2. A 30-year-old, right-handed farmer was referred with a 3-year history of wrist pain and recurrent giant cell tumor of the distal radius. He initially sought treatment in Mexico where he had curettage and bone grafting for treatment of a giant cell tumor in December 1986. Review of his pathologic specimen from the initial resection demonstrated a well-differentiated giant cell temor. Pain and swelling re-
Fig. 5. A-B, PA and lateral x-ray films at 26 months after operation after distal radius replacement with allograft combined with distal radioulnar joint fusion and proximal ulnar osteotomy.
turned within 4 months of the initial operation, and he was seen in June 1987 for treatment of a recurrent tumor. A preoperative evaluation to rule out metastatic disease was negative, and Aug. 31, 1987 he had an en bloc excision of the left distal radius. Replacement of the resected radius
932
Szabo, Thorson, and Raskind
was done with frozen allografi and accompanied by a distal radioulnar joint fusion and proximal ulnar osteotomy with iliac crest bone grafting to the proximal osteosynthesis and distal radioulnar fusion sites. At seventeen months after operation, the allograft was united with minimal tenderness. The patient returned to farming with only occasional symptoms of wrist pain. Range of motion on the last follow-up visit measured: flexion 25 degrees, extension 15 degrees, pronation 85 degrees, supination 75 degrees, radial deviation 10 degrees, ulnar deviation 5 degrees. Case 3. A 65-year-old, right-handed retired industrial consultant and avid fly fisherman was seen with a 2-month history of pain and swelling without antecedent trauma in the right wrist. X-ray films showed an expansile lytic lesion in the right distal radius with cortical destruction (Fig. 4). A preoperative evaluation ruled out metastatic disease. Results of incisional biopsy provided a diagnosis of giant cell tumor. After the biopsy, the patient had an en bloc resection of the right distal radius combined with fresh-frozen allograft replacement. As in the previous two cases, a distal radioulnar joint fusion and proximal ulnar osteotomy and iliac crest bone grafting of both osteosynthesis sites was performed. Symptoms of tendonitis developed over the proximal osteosynthesis site, which were referable to a bony prominence. These symptoms resolved after a minor operation to remove the bone spur (pathologic examination was negative for giant cell tumor). Follow-up 26 months after operation demonstrated that the allograft was united and nontender (Fig. 5). The patient was able to actively use the involved wrist for fly fishing without any pain. Wrist range of motion at that time measured: flexion 30 degrees, extension 30 degrees, pronation 80 degrees, supination 90 degrees, radial deviation 10 degrees, ulnar deviation 10 degrees.
Discussion A giant cell tumor in the distal radius is challenging for the treating surgeon. While the surgeon must remove all pathologic tissue, the resulting defect frequently compromises hand function. The relatively thin soft tissue envelope, the requirement for gliding in the soft tissues, and the desirability of maintaining some wrist motion combine to limit reconstructive options. In addition, most patients are relatively young and active with a normal life expectancy. Amputation for treatment of giant cell tumor is rare today except in the small bones of the hand, where complete excision may leave little remaining function of the affected digit. Also, the sacrifice of only one digit leaves a hand that has satisfactory function. There is only one report of prosthetic wrist replacement after resection of a giant cell tumor, and this was a failure.7 The technique used most commonly after giant cell tumor resection is bridging the bone defect with autog-
The Journal of HAND SURGERY
enous bone. Early reconstruction using autogenous iliac graft with radioulnar synostosis’ or autogenous tibia1 graft with tibial-scapho-lunate fusionslo left the wrist with limited motion, and the tibial grafts had a 50% rate of fracture through the graft. Results with fibular autografts have been better,13’ l4 in part because of the similarity of the ends of the fibula and radius. In three patients treated with a fibular autograft, spontaneous fusion of the fibular head to the lunate and scaphoid occurred; therefore, in 1.5 additional patients Murray’4 added arthrodeses of these joints at the time of grafting. Grip strength and range of motion were reduced but satisfactory. Five of 18 patients had a nonunion at the proximal osteosynthesis site, and 7 of 8 had persistent knee pain. Vascularized autografts have included distal ulnar translocation in two patients”; these patients retained good pronation and supination, but wrist flexion and extension were very limited, and a proximal nonunion developed in one of the two patients. Vascularized fibular autografts supplied by the radial artery achieved good success after giant cell tumor resection in five patients. I8 Two of these received fibularcarpal fusions. Of the other three who received ligamentous stabilization, one required a fusion after the development of painful subluxation of the carpus on the fibula. The patients with fusions had full pronation/ supination; those with ligamentous stabilization obtained half of the normal range of supinationpronation. Complications included one recurrence, one infection, one median nerve palsy, and one delayed union. Donor site complications included one peroneal nerve palsy. The author noted that this technique is demanding, requires a long operative time, and it also requires preoperative angiographic studies to map the nutrient vessels of the fibula and to determine that the arm is adequately supplied by the ulnar artery. Finally, distal radial allografts in three patients was reviewed by Smith2’ after giant cell tumor requiring distal radius resection. All allografts were frozen to -70 degrees to decrease bone antigenicity. The patient’s distal radius was removed 3 cm proximal to the radiographic margin of tumor. Because of the incongruity of the distal radioulnar joint, the distal ulna was also removed. Follow-up in this series averaged slightly less than 2 years. Average wrist motions were: pronation 70 degrees, supination 72 degrees, flexion 31 degrees, extension 37 degrees with full radial and ulnar deviation. Complications included palmar subluxation 1 to 2 years after operation. All allografts healed well and the patients had relatively pain-free motion. Distal radial allografts offer several advantages in the
Vol. 15A, No. 6 November 1990
of giant cell tumors of the distal radius. There is relatively good restoration of the anatomy while avoiding the significant donor site morbidity of fibular autografts. This procedure provides good functional wrist motion with little pain, and the allograft tissue heals to the proximal radius in a time period similar to autogenous tissue grafts. The possibility of transmission of disease by allograft is low in a carefully screened donor population. In the world literature on allograft replacement, one recipient became human immunodeficiency virus (HIV) positive; however, the donor in that case was not screened for risk factors. The chance of obtaining donor tissue infected with HIV that fails to be excluded by the rigorous donor selection criteria, HIV screening, and histopathologic studies has been estimated at about one in four million. ” This series represents a preliminary report on a small group of patients and long-term follow-up is warranted.
treatment
REFERENCES 1. Eckardt JJ, Grogan TJ. Giant cell tumor of bone. Clin Orthop 1986;204:45-58. 2. Johnson EW, Dahlin DC. Treatment of giant cell tumor of bone. J Bone Joint Surg 1959;41A:895-904. 3. Marcove RC, Weis LD, Vaghaiwalla MR, Pearson R. Cryosurgery in the treatment of giant cell tumors of bone. Clin Orthop 1978;134:275-89. 4. Riley LH, Hartmann WI-I, Robinson RA. Soft tissue recurrence of giant cell tumor of bone after irradiation and excision. J Bone Joint Surg 1967;491\:365-8. 5. Averill RM, Smith RJ, Campbell CJ. Giant cell tumors of the bones of the hand. J HAND SURG 1980;5:39-49. 6. Gold AM. Follow-up notes on articles previously published in the journal-use of a prosthesis for the distal portion of the radius following resection of a recurrent giant cell tumor. J Bone Joint Surg 1965;47A:216-18. 7. Gold AM. Use of prosthesis for the distal portion of the radius following resection of a recurrent giant cell tumor. J Bone Joint Surg 1957;39A:1374-80.
Treatment of giant cell tumors of distal radius
933
8. Wilson PD, Lance EM. Surgical reconstruction of the
skeleton following segmental resection for bone tumors. J Bone Joint Surg 1965;47A:1629-56. 9. Higginbotham NL, Coley BL. The treatment of bone tumors by resection and replacement with massive grafts. Instructional course lectures, American Academy of Orthopaedic Surgeons 1950;7:26-33. 10. Campbell CJ, Akbamia BA. Giant cell tumor of the distal radius treated by massive resection and tibia1 bone graft. J Bone Joint Surg 1975;57A:982-6. 11. Seradge H. Distal ulnar translocation in the treatment of giant cell tumors of the distal end of the radius. J Bone Joint Surg 1982;64A:67-72. 12. Lawson TL. Fibular transplant for osteoclastoma of the radius. J Bone Joint Surg 1952;34B:74-5. 13. Mack GR, Lictman DM, MacDonald RI. Fibular autografts for distal defects of the radius. J HAND SURG 1979;4:576-83. 14. Murray JA, Schiafly B. Giant cell tumors in the distal end of the radius. J Bone Joint Surg 1986;68A:687-93. 15. Noellert RC, Louis DS. Long-term follow-up of nonvascularized fibular autografts for distal radial reconstruction. J HAND SURG 1985;1OA:335-40. 16. Parrish FF. Treatment of bone tumors by total excision and replacement with massive autologous and homologous grafts. J Bone Joint Surg 1966;48A:968-89. 17. Sakellarides HT. Extensive giant cell tumor of the lower end of the radius. Clin Orthop 1965;42:151-6. 18. Pho RWH. Malignant giant cell tumor of the distal end of the radius treated by a free vascularized fibular transplant. J Bone Joint Surg 1981;63A:877-84. 19. Pho RWH. Free vascularized fibular transplant for replacement of the lower radius. J Bone Joint Surg 1979;61B:362-5. 20. Smith RJ, Mankin HJ. Allograft replacement of distal radius for giant cell tumor. J HAND SURG 1977;2:299309. 21. Buck BE, Malinin TI, Brown MD. Bone transplantation and human immunodeficiency virus: an estimate of risk of acquired immunodeficiency syndrome (AIDS). Clin Orthop 1989;240:129-36.
