Journal of Orthopaedic Surgery 2014;22(3):356-9
Reconstruction of the distal radius with nonvascularised fibular graft after resection of giant cell tumour of bone Syed Mujahid Humail, Ghulam Mustaff KK, Itaat Hussain Zaidi
Dow University of Health Sciences/Civil Hospital Karachi, Karachi, Pakistan
ABSTRACT Purpose. To evaluate outcomes of wide resection and reconstruction of the distal radius with nonvascularised autogenous fibular grafts for giant cell tumour (GCT) of bone. Methods. Medical records of 7 men and 5 women aged 22 to 47 (mean, 31) years who underwent wide resection of the distal radius and reconstruction with non-vascularised autogenous fibular grafts for GCT of bone were reviewed. The mean length of the resected radius was 9 (range, 7–11) cm. The ipsilateral proximal fibula with a small portion of attached ligament was harvested. The articular surface of the graft was fixed to the scapholunate articular surface by Kirschner wires, and the ligament of the fibular head was sutured to the carpal ligaments. The graft was fixed to the proximal radius with a small dynamic compression plate. Iliac cancellous bone graft was added. Pain, instability, and functional status were assessed. Wrist joint movements were measured using a goniometer. The grip strength was measured.
The operated and contralateral sides were compared. Results. The mean follow-up was 24 (range, 20–27) months. All patients achieved radiological union after a mean of 16 (range, 14–20) weeks. The mean active range of movement in the operated wrists was 32º dorsiflexion, 38º palmar flexion, 15º radial deviations, 12º ulnar deviations, 50º supination, and 60º pronation. Compared with the contralateral wrists, the operated wrists regained 60% of the function, with satisfactory grip strength, and normal finger and thumb movements and hand sensation. No patient had recurrence after 2 years. Two patients had minor dorsal subluxation, which was resolved with a wrist brace. Three patients had superficial infection, which was resolved with intravenous antibiotics and dressings. Two patients had peroneal nerve palsy, which recovered completely in 12 weeks. Conclusion. Non-vascularised fibular grafts for reconstruction of the distal radius after resection of a GCT of bone achieved good cosmetic and functional outcomes. Key words: autografts; fibula; giant cell tumor of bone; radius
Address correspondence and reprint requests to: Dr Ghulam Mustafa KK, E-10 Sheraton Apartments 13-B Gulshan E Iqbal, Karachi, Pakistan. Email: [email protected]
Vol. 22 No. 3, December 2014
Reconstruction of the distal radius with non-vascularised fibular graft 357
INTRODUCTION Giant cell tumour (GCT) of bone is locally aggressive and tends to recur.1 The distal radius is the third most common site of occurrence following the distal femur and proximal tibia.2,3 Treatment goals for GCT of the distal radius are complete excision of the tumour and preservation of wrist function. Early-stage smaller lesions can be treated with curettage and bone grafting or cementing.4 For large expansile lesions, curettage alone is at risk of high local recurrence rates of 27% to 54%.5–7 Complete excision of the distal radius is therefore recommended,8,9 followed by reconstruction using allografts,10 osteoarticular allografts,11 custommade prostheses,12,13 or vascularised and nonvascularised fibular grafts.14–16 Vascularised fibular grafting enables early healing and can be used for defects >10 cm, but more time and expertise are needed. Non-vascularised fibular grafting is simpler, less expensive, and has good results.14,17 This study evaluated the outcomes of wide resection and reconstruction of the distal radius with non-vascularised autogenous fibular grafts for GCT of bone. MATERIALS AND METHODS Medical records of 7 men and 5 women aged 22 to 47 (mean, 31) years who underwent wide resection of the right (n=8) and left (n=4) distal radius and reconstruction with non-vascularised autogenous fibular grafts for GCT of bone between January 2007 and January 2011 were reviewed. The tumours were classified as Campanacci grade II (n=3) and grade III (n=9). The volar approach was used in all patients, except for one, in whom the dorsal approach was used. A safe margin of 5 cm of normal radius was excised; the mean length of the resected radius was 9 (range, 7–11) cm.
The ipsilateral proximal fibula with a small portion of attached ligament was harvested. The articular surface of the graft was fixed with the scapholunate articular surface by one or 2 Kirschner wires, and the ligament of the fibular head was sutured to the carpal ligaments. The graft was fixed to the proximal radius with a small dynamic compression plate (Fig.). To stabilise the newly created fibulo-ulnar joint, a Kirschner wire or screw was inserted transversely, and iliac cancellous bone graft was added. Postoperatively, a plaster backslab was applied for 6 to 8 weeks. After removing the Kirschner wires, a forearm brace was applied until radiological union (Fig.). Patients were followed up 2 weekly initially and then 4 weekly until union, and 6 monthly thereafter. Pain, instability, and functional status were assessed. Wrist joint movements were measured using a goniometer. Grip strength was measured based on the maximum weight the patient could hold with a nylon rope. The operated and contralateral sides were compared. RESULTS The mean follow-up period was 24 (range, 20–27) months. All patients achieved radiological union after a mean of 16 (range, 14–20) weeks. The mean active range of movement in the operated wrists was 32º dorsiflexion, 38º palmar flexion, 15º radial deviations, 12º ulnar deviations, 50º supination, and 60º pronation. Compared with the contralateral wrists, the operated wrists regained 60% of the function, with satisfactory grip strength, and normal finger and thumb movements and hand sensation. No patient had recurrence after 2 years. Two patients had minor dorsal subluxation, which was resolved with a wrist brace. Three patients had
Figure Radiographs showing reconstruction of the distal radius using a non-vascularised fibular graft, a dynamic compression plate, Kirschner wires, and screws.
Journal of Orthopaedic Surgery
358 SM Humail et al.
superficial infection: 2 at the recipient site and one at the donor site; these were resolved with intravenous antibiotics and dressings. Two patients had peroneal nerve palsy, which recovered completely in 12 weeks. DISCUSSION GCT of the distal radius is difficult to treat owing to the surrounding complex structures.18 In the advanced stage (grade III), the tumour breaks through the cortex and invades the wrist joint; en bloc resection is recommended to minimise recurrence.19–21 The large defects pose problems for restoration of wrist function. The ipsilateral proximal fibula is a good substitute for the distal radius as its proximal shape and curve matches the convexity of the proximal carpal row. The recurrence rates have been reported to be 0%21 or 5% to 25%.17,22 In a series of 16 patients, 10 developed wrist subluxation.23 In 15 patients
treated with plate fixation, 2 developed severe wrist subluxation resulting in severe pain, deformity, and loss of function.24 In one study using non-vascularised free fibular graft for recurrent GCT of the distal radius, no wrist subluxation was reported.25 In a series of 18 patients, 5 developed nonunion, owing to inadequate fixation of the fibular graft.22 In 10 patients using free non-vascularised fibular graft for post-traumatic lower limb bone loss, the union rate was 100%.26 CONCLUSION Non-vascularised fibular grafts for reconstruction of the distal radius after resection of a GCT of bone achieved good cosmetic and functional outcomes. DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Eckardt JJ, Grogan TJ. Giant cell tumour of bone. Clin Orthop Relat Res 1986;204:45–58. 2. Dahlin DC, Cupps RE, Johnson EW Jr. Giant cell tumour: a study of 195 cases. Cancer 1970;25:1061–70. 3. Goldenberg RR, Campbell CJ, Bonfiglio M. Giant-cell tumor of bone. An analysis two hundred and eighty cases. J Bone Joint Surg Am 1970;52:619–64. 4. Persson BM, Wouters HW. Curettage and acrylic cementation in surgery of giant cell tumors of bone. Clin Orthop Relat Res 1976;120:125–33. 5. Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone joint Surg Am 1987;69:106–14. 6. Gitelis S, Mallin BA, Piasecki P, Turner F. Intralesional excision compared with en bloc resection for giant-cell tumor of bone. J Bone Joint Surg Am 1993;75:1648–55. 7. McDonald DJ, Sim FH, McLeod RA, Dahlin DC. Giant-cell tumor of bone. J Bone Joint Surg Am 1986;68:235–42. 8. Vander Griend RA, Funderburk CH. The treatment of giant-cell tumors of distal part of the radius. J Bone Joint Surg Am 1993;75:899–908. 9. Carenesale PG. Tumors. In: Crenshaw AH, editor. Campbell’s operative orthopaedics. 7th ed. St Louis: Mosby; 1987:738–9. 10. Makin HJ. Allograft replacement for the management of skeletal defects incurred in tumor surgery or trauma. In: Chao EY, Ivins JC, editors. Tumor prostheses for bone and joint reconstruction. New York: Thieme Stratton; 1983:23–4. 11. Bianchi G, Donati D, Staals EL, Mercuri M. Osteoarticular allograft reconstruction of the distal radius after bone tumour resection. J Hand Surg Br 2005;30:369–73. 12. Scales JT, Wright KW. Major bone and joint replacement using custom implants. In: Chao EY, Ivins JC, editors. Tumor prostheses for bone and joint reconstruction, New York: Thieme Stratton; 1983:279–89. 13. Hatano H, Morita T, Kobayashi H, Otsuka H. A ceramic prosthesis for the treatment of tumours of the distal radius. J Bone Joint Surg Br 2006;88:1656–8. 14. Van Demark RE Jr, Van Demark RE Sr. Nonvascularized fibular autograft to treat recurrent giant cell tumor of the distal radius. J Hand Surg Am 1988;13:671–5. 15. Pho RW. Malignant giant-cell tumor of distal end of the radius treated by a free vascularized fibular transplant. J Bone Joint Surg Am 1981;63:877–84. 16. Ihara K, Doi K, Sakai K, Yamamoto M, Kanchiku T, Kawai S. Vascularized fibular graft after excision of giant cell tumor of the distal radius. A case report. Clin Orthop Relat Res 1999;359:189–96. 17. Saikia KC, Borgohain M, Bhuyan SK, Goswami S, Bora A, Ahmed F. Resection-reconstruction arthroplasty for giant cell tumor of distal radius. Indian J Orthop 2010;44:327–32. 18. Briggs TW, Cobb J, McAuliffe T, Pringle J, Kemp H. Giant cell tumour of bone. J Bone Joint Surg Br 1990;72:937–41. 19. Maruthainar N, Zambakidis C, Harper G, Calder D, Cannon SR, Briggs TW. Functional outcome following excision of the tumours of the distal radius and reconstruction by autologous non-vascularized osteoarticular fibula grafting. J Hand Surg Br 2002;27:171–4.
Vol. 22 No. 3, December 2014
Reconstruction of the distal radius with non-vascularised fibular graft 359
20. Harness NG, Mankin HJ. Giant-cell tumor of the distal forearm. J Hand Surg Am 2004;29:188–93. 21. Cheng CY, Shih HN, Hsu KY, Hsu RW. Treatment of giant cell tumor of the distal radius. Clin Orthop Relat Res 2001;383:221– 8. 22. Murray JA, Schlafly B. Giant-cell tumors in the distal end of the radius. Treatment by resection and fibular autograft interpositional arthrodesis. J Bone Joint Surg Am 1986;68:687–94. 23. Dhamni IK, Jain AK, Maheswari AV, Singh MP. Giant cell tumours of the lower end of radius: problems and solutions. Indian J Orthop 2005;39:201–5. 24. Saraf SK, Goel SC. Complications of resection and reconstruction in giant cell tumour of distal end of radius. An analysis. Indian J Orthop 2005;39:206–11. 25. Lawal YZ, Garba ES, Ogirima MO, Dahiru IL, Maitama MI, Abubakar K, et al. Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss. Ann Afr Med 2011;10:25–8. 26. Lin KC, Tarng YW, Hsu CJ, Renn JH. Free non-vascularized fibular strut bone graft for treatment of post-traumatic lower extremity large bone loss. Eur J Orthop Surg Traumatol 2014;24:599–605.
Reconstruction of the distal radius with nonvascularised fibular graft after resection of giant cell tumour of bone Syed Mujahid Humail, Ghulam Mustaff KK, Itaat Hussain Zaidi
Dow University of Health Sciences/Civil Hospital Karachi, Karachi, Pakistan
ABSTRACT Purpose. To evaluate outcomes of wide resection and reconstruction of the distal radius with nonvascularised autogenous fibular grafts for giant cell tumour (GCT) of bone. Methods. Medical records of 7 men and 5 women aged 22 to 47 (mean, 31) years who underwent wide resection of the distal radius and reconstruction with non-vascularised autogenous fibular grafts for GCT of bone were reviewed. The mean length of the resected radius was 9 (range, 7–11) cm. The ipsilateral proximal fibula with a small portion of attached ligament was harvested. The articular surface of the graft was fixed to the scapholunate articular surface by Kirschner wires, and the ligament of the fibular head was sutured to the carpal ligaments. The graft was fixed to the proximal radius with a small dynamic compression plate. Iliac cancellous bone graft was added. Pain, instability, and functional status were assessed. Wrist joint movements were measured using a goniometer. The grip strength was measured.
The operated and contralateral sides were compared. Results. The mean follow-up was 24 (range, 20–27) months. All patients achieved radiological union after a mean of 16 (range, 14–20) weeks. The mean active range of movement in the operated wrists was 32º dorsiflexion, 38º palmar flexion, 15º radial deviations, 12º ulnar deviations, 50º supination, and 60º pronation. Compared with the contralateral wrists, the operated wrists regained 60% of the function, with satisfactory grip strength, and normal finger and thumb movements and hand sensation. No patient had recurrence after 2 years. Two patients had minor dorsal subluxation, which was resolved with a wrist brace. Three patients had superficial infection, which was resolved with intravenous antibiotics and dressings. Two patients had peroneal nerve palsy, which recovered completely in 12 weeks. Conclusion. Non-vascularised fibular grafts for reconstruction of the distal radius after resection of a GCT of bone achieved good cosmetic and functional outcomes. Key words: autografts; fibula; giant cell tumor of bone; radius
Address correspondence and reprint requests to: Dr Ghulam Mustafa KK, E-10 Sheraton Apartments 13-B Gulshan E Iqbal, Karachi, Pakistan. Email: [email protected]
Vol. 22 No. 3, December 2014
Reconstruction of the distal radius with non-vascularised fibular graft 357
INTRODUCTION Giant cell tumour (GCT) of bone is locally aggressive and tends to recur.1 The distal radius is the third most common site of occurrence following the distal femur and proximal tibia.2,3 Treatment goals for GCT of the distal radius are complete excision of the tumour and preservation of wrist function. Early-stage smaller lesions can be treated with curettage and bone grafting or cementing.4 For large expansile lesions, curettage alone is at risk of high local recurrence rates of 27% to 54%.5–7 Complete excision of the distal radius is therefore recommended,8,9 followed by reconstruction using allografts,10 osteoarticular allografts,11 custommade prostheses,12,13 or vascularised and nonvascularised fibular grafts.14–16 Vascularised fibular grafting enables early healing and can be used for defects >10 cm, but more time and expertise are needed. Non-vascularised fibular grafting is simpler, less expensive, and has good results.14,17 This study evaluated the outcomes of wide resection and reconstruction of the distal radius with non-vascularised autogenous fibular grafts for GCT of bone. MATERIALS AND METHODS Medical records of 7 men and 5 women aged 22 to 47 (mean, 31) years who underwent wide resection of the right (n=8) and left (n=4) distal radius and reconstruction with non-vascularised autogenous fibular grafts for GCT of bone between January 2007 and January 2011 were reviewed. The tumours were classified as Campanacci grade II (n=3) and grade III (n=9). The volar approach was used in all patients, except for one, in whom the dorsal approach was used. A safe margin of 5 cm of normal radius was excised; the mean length of the resected radius was 9 (range, 7–11) cm.
The ipsilateral proximal fibula with a small portion of attached ligament was harvested. The articular surface of the graft was fixed with the scapholunate articular surface by one or 2 Kirschner wires, and the ligament of the fibular head was sutured to the carpal ligaments. The graft was fixed to the proximal radius with a small dynamic compression plate (Fig.). To stabilise the newly created fibulo-ulnar joint, a Kirschner wire or screw was inserted transversely, and iliac cancellous bone graft was added. Postoperatively, a plaster backslab was applied for 6 to 8 weeks. After removing the Kirschner wires, a forearm brace was applied until radiological union (Fig.). Patients were followed up 2 weekly initially and then 4 weekly until union, and 6 monthly thereafter. Pain, instability, and functional status were assessed. Wrist joint movements were measured using a goniometer. Grip strength was measured based on the maximum weight the patient could hold with a nylon rope. The operated and contralateral sides were compared. RESULTS The mean follow-up period was 24 (range, 20–27) months. All patients achieved radiological union after a mean of 16 (range, 14–20) weeks. The mean active range of movement in the operated wrists was 32º dorsiflexion, 38º palmar flexion, 15º radial deviations, 12º ulnar deviations, 50º supination, and 60º pronation. Compared with the contralateral wrists, the operated wrists regained 60% of the function, with satisfactory grip strength, and normal finger and thumb movements and hand sensation. No patient had recurrence after 2 years. Two patients had minor dorsal subluxation, which was resolved with a wrist brace. Three patients had
Figure Radiographs showing reconstruction of the distal radius using a non-vascularised fibular graft, a dynamic compression plate, Kirschner wires, and screws.
Journal of Orthopaedic Surgery
358 SM Humail et al.
superficial infection: 2 at the recipient site and one at the donor site; these were resolved with intravenous antibiotics and dressings. Two patients had peroneal nerve palsy, which recovered completely in 12 weeks. DISCUSSION GCT of the distal radius is difficult to treat owing to the surrounding complex structures.18 In the advanced stage (grade III), the tumour breaks through the cortex and invades the wrist joint; en bloc resection is recommended to minimise recurrence.19–21 The large defects pose problems for restoration of wrist function. The ipsilateral proximal fibula is a good substitute for the distal radius as its proximal shape and curve matches the convexity of the proximal carpal row. The recurrence rates have been reported to be 0%21 or 5% to 25%.17,22 In a series of 16 patients, 10 developed wrist subluxation.23 In 15 patients
treated with plate fixation, 2 developed severe wrist subluxation resulting in severe pain, deformity, and loss of function.24 In one study using non-vascularised free fibular graft for recurrent GCT of the distal radius, no wrist subluxation was reported.25 In a series of 18 patients, 5 developed nonunion, owing to inadequate fixation of the fibular graft.22 In 10 patients using free non-vascularised fibular graft for post-traumatic lower limb bone loss, the union rate was 100%.26 CONCLUSION Non-vascularised fibular grafts for reconstruction of the distal radius after resection of a GCT of bone achieved good cosmetic and functional outcomes. DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Eckardt JJ, Grogan TJ. Giant cell tumour of bone. Clin Orthop Relat Res 1986;204:45–58. 2. Dahlin DC, Cupps RE, Johnson EW Jr. Giant cell tumour: a study of 195 cases. Cancer 1970;25:1061–70. 3. Goldenberg RR, Campbell CJ, Bonfiglio M. Giant-cell tumor of bone. An analysis two hundred and eighty cases. J Bone Joint Surg Am 1970;52:619–64. 4. Persson BM, Wouters HW. Curettage and acrylic cementation in surgery of giant cell tumors of bone. Clin Orthop Relat Res 1976;120:125–33. 5. Campanacci M, Baldini N, Boriani S, Sudanese A. Giant-cell tumor of bone. J Bone joint Surg Am 1987;69:106–14. 6. Gitelis S, Mallin BA, Piasecki P, Turner F. Intralesional excision compared with en bloc resection for giant-cell tumor of bone. J Bone Joint Surg Am 1993;75:1648–55. 7. McDonald DJ, Sim FH, McLeod RA, Dahlin DC. Giant-cell tumor of bone. J Bone Joint Surg Am 1986;68:235–42. 8. Vander Griend RA, Funderburk CH. The treatment of giant-cell tumors of distal part of the radius. J Bone Joint Surg Am 1993;75:899–908. 9. Carenesale PG. Tumors. In: Crenshaw AH, editor. Campbell’s operative orthopaedics. 7th ed. St Louis: Mosby; 1987:738–9. 10. Makin HJ. Allograft replacement for the management of skeletal defects incurred in tumor surgery or trauma. In: Chao EY, Ivins JC, editors. Tumor prostheses for bone and joint reconstruction. New York: Thieme Stratton; 1983:23–4. 11. Bianchi G, Donati D, Staals EL, Mercuri M. Osteoarticular allograft reconstruction of the distal radius after bone tumour resection. J Hand Surg Br 2005;30:369–73. 12. Scales JT, Wright KW. Major bone and joint replacement using custom implants. In: Chao EY, Ivins JC, editors. Tumor prostheses for bone and joint reconstruction, New York: Thieme Stratton; 1983:279–89. 13. Hatano H, Morita T, Kobayashi H, Otsuka H. A ceramic prosthesis for the treatment of tumours of the distal radius. J Bone Joint Surg Br 2006;88:1656–8. 14. Van Demark RE Jr, Van Demark RE Sr. Nonvascularized fibular autograft to treat recurrent giant cell tumor of the distal radius. J Hand Surg Am 1988;13:671–5. 15. Pho RW. Malignant giant-cell tumor of distal end of the radius treated by a free vascularized fibular transplant. J Bone Joint Surg Am 1981;63:877–84. 16. Ihara K, Doi K, Sakai K, Yamamoto M, Kanchiku T, Kawai S. Vascularized fibular graft after excision of giant cell tumor of the distal radius. A case report. Clin Orthop Relat Res 1999;359:189–96. 17. Saikia KC, Borgohain M, Bhuyan SK, Goswami S, Bora A, Ahmed F. Resection-reconstruction arthroplasty for giant cell tumor of distal radius. Indian J Orthop 2010;44:327–32. 18. Briggs TW, Cobb J, McAuliffe T, Pringle J, Kemp H. Giant cell tumour of bone. J Bone Joint Surg Br 1990;72:937–41. 19. Maruthainar N, Zambakidis C, Harper G, Calder D, Cannon SR, Briggs TW. Functional outcome following excision of the tumours of the distal radius and reconstruction by autologous non-vascularized osteoarticular fibula grafting. J Hand Surg Br 2002;27:171–4.
Vol. 22 No. 3, December 2014
Reconstruction of the distal radius with non-vascularised fibular graft 359
20. Harness NG, Mankin HJ. Giant-cell tumor of the distal forearm. J Hand Surg Am 2004;29:188–93. 21. Cheng CY, Shih HN, Hsu KY, Hsu RW. Treatment of giant cell tumor of the distal radius. Clin Orthop Relat Res 2001;383:221– 8. 22. Murray JA, Schlafly B. Giant-cell tumors in the distal end of the radius. Treatment by resection and fibular autograft interpositional arthrodesis. J Bone Joint Surg Am 1986;68:687–94. 23. Dhamni IK, Jain AK, Maheswari AV, Singh MP. Giant cell tumours of the lower end of radius: problems and solutions. Indian J Orthop 2005;39:201–5. 24. Saraf SK, Goel SC. Complications of resection and reconstruction in giant cell tumour of distal end of radius. An analysis. Indian J Orthop 2005;39:206–11. 25. Lawal YZ, Garba ES, Ogirima MO, Dahiru IL, Maitama MI, Abubakar K, et al. Use of non-vascularized autologous fibula strut graft in the treatment of segmental bone loss. Ann Afr Med 2011;10:25–8. 26. Lin KC, Tarng YW, Hsu CJ, Renn JH. Free non-vascularized fibular strut bone graft for treatment of post-traumatic lower extremity large bone loss. Eur J Orthop Surg Traumatol 2014;24:599–605.
