The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 80, Issue 3

Articles | March 01, 1998

Reconstruction of the Distal Aspect of the Radius with Use of an Osteoarticular Allograft after Excision of a Skeletal Tumor*

MININDER S. KOCHER, M.D.†; MARK C. GEBHARDT, M.D.‡; HENRY J. MANKIN, M.D.‡, BOSTON, MASSACHUSETTS

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Investigation performed at the Orthopaedic Oncology Service, Massachusetts General Hospital and Harvard Medical School, Boston

J Bone Joint Surg Am, 1998 Mar 01;80(3):407-19

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Abstract

Twenty-four patients had reconstruction of the distal aspect of the radius with use of an osteoarticular allograft, between 1974 and 1992, after excision of a giant-cell tumor (twenty patients), a desmoplastic fibroma (two patients), a chondrosarcoma (one patient), or an angiosarcoma (one patient). Nine giant-cell tumors were recurrent lesions, and eleven were extracompartmental primary lesions that had extended through the cortex or subchondral bone. The average age of the patients was 31.5 years (range, fifteen to sixty-one years); thirteen patients were female and eleven were male. Seventeen lesions involved the right wrist and seven involved the left wrist. The reconstruction was performed through a dorsoradial incision with use of a size-matched, preserved, fresh-frozen, distal radial allograft. All procedures included internal fixation and reconstruction of the radiocarpal ligaments.All patients were followed for a minimum of two years (average, 10.9 years; range, 2.1 to 22.3 years). At the time of follow-up, two patients—one who had a giant-cell tumor and one who had a desmoplastic fibroma—had a local recurrence. Eight patients needed a revision of the osteoarticular allograft, at an average of 8.1 years (range, 0.8 to 17.8 years) after the initial reconstruction. Seven of these patients had an arthrodesis and one had an amputation. The reason for the revision was a fracture of the allograft in four patients, recurrence of the tumor in one, pain in two, and volar dislocation of the carpus in one. There were fourteen other complications, including ulnocarpal impaction necessitating excision of the distal aspect of the ulna (four), painful hardware necessitating removal (four), rupture of the extensor pollicis longus tendon necessitating transfer of the extensor indicis proprius (two), fracture of the allograft necessitating open reduction and internal fixation (two), volar dislocation of the carpus necessitating closed reduction (one), and a ganglion of the dorsal aspect of the wrist necessitating excision (one).Of the sixteen patients in whom the osteoarticular allograft survived, three did not have pain, nine had pain in association with strenuous activities, and four had pain in association with moderate activities. Three patients reported no functional limitation, nine had limitation in the ability to perform strenuous activities, and four had limitation in the ability to perform moderate activities. The average range of motion of the wrist was 36 degrees of dorsiflexion, 21 degrees of volar flexion, 16 degrees of radial deviation, 15 degrees of ulnar deviation, 58 degrees of supination, and 72 degrees of pronation.Reconstruction of the distal aspect of the radius with use of an osteoarticular allograft was associated with a low rate of recurrence of the tumor, a moderately high rate of revision, little pain in association with common activities, good function, and a moderate range of motion. Osteoarticular allografts are an option for reconstruction of the distal aspect of the radius after excision of a malignant tumor or a recurrent or locally invasive benign lesion.

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Introduction

Introduction | Materials and Methods | Results | Discussion | References

The distal aspect of the radius is a relatively common site of skeletal neoplasm and is the third most common location (after the distal aspect of the femur and the proximal aspect of the tibia) of giant-cell tumor^4,7,10,20. Resection of the distal aspect of the radius may be indicated for certain malignant lesions and for recurrent or locally invasive benign lesions. Giant-cell tumors of the distal aspect of the radius can exhibit extraosseous extension at the time of initial presentation, and there may be high rates of local recurrence after intralesional procedures^{4,6-8,10,16,20,26,27,30,38,42,48}. In a recent report from our institution, fifteen (25 per cent) of sixty patients in whom a giant-cell tumor of a long bone had been treated with curettage and packing with methylmethacrylate had a local recurrence; however, five of ten patients who had had a lesion of the distal aspect of the radius had a local recurrence³⁰.

Reconstruction of the wrist after excision of the distal aspect of the radius is a challenge because of the high functional demands on the hand, the young age and relatively long life expectancy of many patients who have a giant-cell tumor, the limited surrounding soft tissue, and the proximity of adjacent nerves and tendons. Various procedures, including resection arthroplasty³, prosthetic replacement^3,14,15, arthrodesis with use of a massive autogenous graft from the tibia or the iliac crest^{3,5,8,19,43,50}, ulnar translocation^2,18,37, centralization of the carpus over the remaining ulna⁵⁰, use of a non-vascularized^{3,17,21,28,29,31,32,35,36,47} or vascularized^{1,33,34,40,49} fibular graft with or without arthrodesis, and allograft replacement^3,39,41, have been used for reconstruction.

Since 1971, we have had extensive experience with use of massive fresh-frozen cadaveric allografts for the treatment of defects created by excision of skeletal tumors^22-25. Reconstruction of the distal aspect of the radius with use of an osteoarticular allograft after excision of a skeletal tumor has several theoretical advantages, including preservation of the function of the wrist, restoration of the anatomy, the ability to repair large defects due to the plentiful supply of allografts, and avoidance of the donor-site morbidity associated with use of autogenous grafts. However, this procedure also can be associated with complications, including non-union, fracture, and infection of the allograft. The purpose of the current study was to review the oncological and functional results after reconstruction of the distal aspect of the radius with use of an osteoarticular allograft.

*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. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115.

‡Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts 02114.

*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. No funds were received in support of this study.

†Department of Orthopaedic Surgery, Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115.

‡Orthopaedic Oncology Service, Massachusetts General Hospital, Boston, Massachusetts 02114.

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TABLE I DATA ON THE TWENTY-FOUR PATIENTS

*ORIF = open reduction and internal fixation.

Range of Motion (Degrees)

Grip Strength

Case

Gender, Age (Yrs.)

Side

Diagnosis

Presenting Symptom

Date of Index Op.

Duration of Follow-up (Yrs.)

Complications (Treatment)*

Result

Dorsiflex./ Volar Flex.

Radial/ Ulnar

Supinat./ Pronat.

Involved Side (Lbs. [kg])

Uninvolved Side (Lbs. [kg])

Involved Side/ Uninvolved Side (Per cent)

Pain

Function

Work

M, 22

Recur. giant-cell tumor

Pathological fract.

4/74

22.3

Ulnocarpal impact. (excis.); carpal disloc. (arthrod.)

With mod. activ.

Restrict. of mod. activ.

Restrict.

Fusion

M, 23

Primary giant-cell tumor

Pain

10/74

21.4

Painful hardware (removal); fract. (ORIF & iliac-crest bone-grafting); non-union (arthrod.)

With mod. activ.

Restrict. of strenuous activ.

No restrict.

Fusion

F, 15

Recur. giant-cell tumor

Pain

7/74

21.7

Painful hardware (removal); ulnocarpal impact. (excis.)

With mod. activ.

Restrict. of mod. activ.

Restrict.

45/25

20/15

85/55

50 (22.7)

54 (24.5)

F, 23

Recur. desmoplastic fibroma

Pain

1/77

7.8

With mod. activ.

Restrict. of mod. activ.

No restrict.

40/22

20/15

70/80

F, 25

Recur. desmoplastic fibroma

Mass

4/77

17.8

Painful hardware (removal); rupture, extensor pollicis longus (transfer, extensor indicis proprius); recur. tumor (amp.)

Amp.

F, 21

Recur. multifocal giant-cell tumor

Pain

1/78

18.2

Carpal disloc. (closed reduct.)

None

Restrict. of strenuous activ.

No restrict.

20/30

30/12

45/90

43 (19.5)

92 (41.7)

F, 34

Recur. giant-cell tumor

Pain

2/78

18.1

Carpal disloc. (reloc.); fract. (ORIF & iliac-crest bone-grafting); non-union (arthrod.)

With mod. activ.

Restrict. of light activ.

Disabled

Fusion

F, 34

Primary giant-cell tumor

Pathological fract.

6/78

12.9

Fract. (arthrod. & iliac-crest bone-grafting); recur. tumor (resect. & arthrod.)

With strenuous activ.

Restrict. of strenuous activ.

Restrict.

Fusion

F, 28

Primary giant-cell tumor

Pain

1/81

2.1

With mod. activ.

Restrict. of mod. activ.

No restrict.

10/10

15/90

M, 24

Primary giant-cell tumor

Pain

3/81

5.6

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

30/15

25/10

60/60

68 (30.8)

118 (53.5)

M, 32

Primary giant-cell tumor

Pain

6/81

12.4

Fract. (arthrod. & iliac-crest bone-grafting)

None

Restrict. of strenuous activ.

No restrict.

Fusion

M, 53

Primary chondrosarcoma

Pathological fract.

6/81

14.3

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

30/10

5/10

80/60

M, 35

Primary giant-cell tumor

Pathological fract.

5/83

3.6

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

30/20

10/20

20/45

F, 57

Recur. giant-cell tumor

Incidental radiographic finding

6/84

11.8

Fract. (ORIF & iliac-crest bone-grafting); painful hardware (removal)

With mod. activ.

Restrict. of mod. activ.

Restrict.

30/15

20/20

50/60

M, 46

Primary angiosarcoma

Pathological fract.

1/85

11.3

None

No restrict.

45/45

10/5

40/70

80 (36.3)

100 (45.4)

80%

F, 19

Primary giant-cell tumor

Pain

9/85

8.6

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

35/20

15/15

70/80

F, 26

Primary giant-cell tumor

Pain

5/86

10.0

With strenuous activ.

No restrict.

45/25

20/15

75/85

M, 47

Primary giant-cell tumor

Pain

1/88

7.8

None

No restrict.

70/30

20/30

90/90

F, 61

Recur. giant-cell tumor

Pain

2/88

8.1

Ulnocarpal impact. (excis.); pain (arthrod.); pseudoarth. (arthrod.)

With mod. activ.

Restrict. of light activ.

Restrict.

Fusion

F, 21

Recur. giant-cell tumor

Pain

3/88

8.2

Ganglion, dorsal aspect of wrist (excis.)

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

47/50

15/35

55/75

77 (34.9)

162 (73.5)

M, 41

Primary giant-cell tumor

Pain

9/89

5.8

Rupture, extensor pollicis longus (transfer, extensor indicis proprius); fract. (ORIF & iliac-crest bone-grafting)

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

15/5

10/10

45/45

M, 21

Recur. giant-cell tumor

Pain

1/91

5.2

Pain (arthrod. & iliac-crest bone-grafting)

With strenuous activ.

No restrict.

Fusion

M, 17

Primary giant-cell tumor

Pain

3/93

3.2

With strenuous activ.

Restrict. of strenuous activ.

Restrict.

40/20

15/15

75/80

F, 30

Recur. giant-cell tumor

Pain

10/92

3.3

Ulnocarpal impact. (excis.)

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

45/-5

10/10

50/90

29 (13.2)

46 (20.9)

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TABLE I DATA ON THE TWENTY-FOUR PATIENTS

*ORIF = open reduction and internal fixation.

Range of Motion (Degrees)

Grip Strength

Case

Gender, Age (Yrs.)

Side

Diagnosis

Presenting Symptom

Date of Index Op.

Duration of Follow-up (Yrs.)

Complications (Treatment)*

Result

Dorsiflex./ Volar Flex.

Radial/ Ulnar

Supinat./ Pronat.

Involved Side (Lbs. [kg])

Uninvolved Side (Lbs. [kg])

Involved Side/ Uninvolved Side (Per cent)

Pain

Function

Work

M, 22

Recur. giant-cell tumor

Pathological fract.

4/74

22.3

Ulnocarpal impact. (excis.); carpal disloc. (arthrod.)

With mod. activ.

Restrict. of mod. activ.

Restrict.

Fusion

M, 23

Primary giant-cell tumor

Pain

10/74

21.4

Painful hardware (removal); fract. (ORIF & iliac-crest bone-grafting); non-union (arthrod.)

With mod. activ.

Restrict. of strenuous activ.

No restrict.

Fusion

F, 15

Recur. giant-cell tumor

Pain

7/74

21.7

Painful hardware (removal); ulnocarpal impact. (excis.)

With mod. activ.

Restrict. of mod. activ.

Restrict.

45/25

20/15

85/55

50 (22.7)

54 (24.5)

F, 23

Recur. desmoplastic fibroma

Pain

1/77

7.8

With mod. activ.

Restrict. of mod. activ.

No restrict.

40/22

20/15

70/80

F, 25

Recur. desmoplastic fibroma

Mass

4/77

17.8

Painful hardware (removal); rupture, extensor pollicis longus (transfer, extensor indicis proprius); recur. tumor (amp.)

Amp.

F, 21

Recur. multifocal giant-cell tumor

Pain

1/78

18.2

Carpal disloc. (closed reduct.)

None

Restrict. of strenuous activ.

No restrict.

20/30

30/12

45/90

43 (19.5)

92 (41.7)

F, 34

Recur. giant-cell tumor

Pain

2/78

18.1

Carpal disloc. (reloc.); fract. (ORIF & iliac-crest bone-grafting); non-union (arthrod.)

With mod. activ.

Restrict. of light activ.

Disabled

Fusion

F, 34

Primary giant-cell tumor

Pathological fract.

6/78

12.9

Fract. (arthrod. & iliac-crest bone-grafting); recur. tumor (resect. & arthrod.)

With strenuous activ.

Restrict. of strenuous activ.

Restrict.

Fusion

F, 28

Primary giant-cell tumor

Pain

1/81

2.1

With mod. activ.

Restrict. of mod. activ.

No restrict.

10/10

15/90

M, 24

Primary giant-cell tumor

Pain

3/81

5.6

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

30/15

25/10

60/60

68 (30.8)

118 (53.5)

M, 32

Primary giant-cell tumor

Pain

6/81

12.4

Fract. (arthrod. & iliac-crest bone-grafting)

None

Restrict. of strenuous activ.

No restrict.

Fusion

M, 53

Primary chondrosarcoma

Pathological fract.

6/81

14.3

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

30/10

5/10

80/60

M, 35

Primary giant-cell tumor

Pathological fract.

5/83

3.6

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

30/20

10/20

20/45

F, 57

Recur. giant-cell tumor

Incidental radiographic finding

6/84

11.8

Fract. (ORIF & iliac-crest bone-grafting); painful hardware (removal)

With mod. activ.

Restrict. of mod. activ.

Restrict.

30/15

20/20

50/60

M, 46

Primary angiosarcoma

Pathological fract.

1/85

11.3

None

No restrict.

45/45

10/5

40/70

80 (36.3)

100 (45.4)

80%

F, 19

Primary giant-cell tumor

Pain

9/85

8.6

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

35/20

15/15

70/80

F, 26

Primary giant-cell tumor

Pain

5/86

10.0

With strenuous activ.

No restrict.

45/25

20/15

75/85

M, 47

Primary giant-cell tumor

Pain

1/88

7.8

None

No restrict.

70/30

20/30

90/90

F, 61

Recur. giant-cell tumor

Pain

2/88

8.1

Ulnocarpal impact. (excis.); pain (arthrod.); pseudoarth. (arthrod.)

With mod. activ.

Restrict. of light activ.

Restrict.

Fusion

F, 21

Recur. giant-cell tumor

Pain

3/88

8.2

Ganglion, dorsal aspect of wrist (excis.)

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

47/50

15/35

55/75

77 (34.9)

162 (73.5)

M, 41

Primary giant-cell tumor

Pain

9/89

5.8

Rupture, extensor pollicis longus (transfer, extensor indicis proprius); fract. (ORIF & iliac-crest bone-grafting)

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

15/5

10/10

45/45

M, 21

Recur. giant-cell tumor

Pain

1/91

5.2

Pain (arthrod. & iliac-crest bone-grafting)

With strenuous activ.

No restrict.

Fusion

M, 17

Primary giant-cell tumor

Pain

3/93

3.2

With strenuous activ.

Restrict. of strenuous activ.

Restrict.

40/20

15/15

75/80

F, 30

Recur. giant-cell tumor

Pain

10/92

3.3

Ulnocarpal impact. (excis.)

With strenuous activ.

Restrict. of strenuous activ.

No restrict.

45/-5

10/10

50/90

29 (13.2)

46 (20.9)

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Figs. 1-A through 1-D: Case 11. Fig. 1-A: Radiograph showing a primary giant-cell tumor.

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Fig. 1-B: Radiograph made after reconstruction with use of an osteoarticular allograft.

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Fig. 1-C: Radiograph showing a fracture of the osteoarticular allograft ten months after the reconstruction.

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Fig. 1-D: Radiograph made five years after a radiocarpal arthrodesis.

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Figs. 2-A through 2-E: Case 22. Fig. 2-A: Radiograph showing a recurrent giant-cell tumor after curettage of the primary lesion and packing with polymethylmethacrylate.

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Fig. 2-B: Gross pathological specimen with the tumor.

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Fig. 2-C: Radiograph showing ulnocarpal subluxation after reconstruction with use of an osteoarticular allograft.

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Fig. 2-D: Radiograph made 1.6 years after the reconstruction, at which time the patient had pain and subluxation.

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Fig. 2-E: Radiograph made 2.4 years after an arthrodesis and excision of the distal aspect of the ulna.

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Figs. 3-A through 3-D: Case 6. Fig. 3-A: Radiograph showing a recurrent multifocal giant-cell tumor in a non-vascularized autogenous graft from the fibula.

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Fig. 3-B: Gross pathological specimen with the tumor.

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Fig. 3-C: Radiograph made after reconstruction with use of an osteoarticular allograft. There is ulnocarpal subluxation and impingement as well as widening of the distal radioulnar joint.

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Fig. 3-D: Radiograph made 18.2 years after the reconstruction, showing additional degenerative changes of the radiocarpal joint.

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Figs. 4-A through 4-D: Case 24. Figs. 4-A: Radiograph showing a recurrent giant-cell tumor after curettage of the primary lesion and packing with polymethylmethacrylate.

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Fig. 4-B: Gross pathological specimen with the tumor.

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Fig. 4-C: Radiograph made after reconstruction with use of an osteoarticular allograft.

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Fig. 4-D: Radiograph made 3.3 years after the reconstruction and after excision of the distal aspect of the ulna.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Between 1971 and 1996, the Orthopaedic Oncology Service at the Massachusetts General Hospital implanted more than 1000 massive fresh-frozen cadaveric allografts, including more than 600 osteoarticular allografts, for the reconstruction of defects created by the resection of skeletal tumors. Twenty-four of these osteoarticular allografts were used in twenty-four patients for reconstruction of the distal aspect of the radius, between 1974 and 1992.

All twenty-four patients were evaluated preoperatively with appropriate studies, including radiography, computerized tomography, bone-scanning, and magnetic resonance imaging. All patients who had a primary lesion had a needle or incisional biopsy for diagnosis before the reconstruction. Patients were considered candidates for the reconstruction if they had a primary benign lesion that had extended through the cortex or articular surface of the distal aspect of the radius, a recurrent benign lesion that was invasive, or a non-metastatic malignant lesion that was amenable to wide resection.

The osteoarticular distal radial allografts were obtained from our institutional bone bank. The organization, screening measures, technology of procurement, cryopreservation, handling, and storage methods of this tissue bank have been described previously^9,13,44-46 and are in accordance with the guidelines of the American Association of Tissue Banks¹². The specimens are obtained under sterile operating-room conditions. Soft-tissue tendinous insertions and ligaments are retained on the allograft. The donors are screened for infectious disease (including hepatitis and acquired immunodeficiency syndrome), and ABO blood-typing and leukocyte antigen-typing are performed. Cultures of specimens of the allograft are performed at the time of procurement. The viability of the articular cartilage is partially preserved with use of glycerin or 8 per cent dimethyl sulfoxide in Ringer lactate solution^25,44. The graft is stored at -70 to -80 degrees Celsius. An appropriate allograft is chosen for reconstruction with use of radiographic size-matching. At the time of the reconstruction, cultures of specimens of the allograft again are performed and the graft is thawed in warm Ringer lactate and antibiotic solution.

The reconstruction was performed through a dorsal approach to the wrist, with wide or marginal resection of the tumor. All patients received antibiotics perioperatively. Histological examination of the excised specimen was performed intraoperatively to ensure adequate margins of resection and to confirm the diagnosis. The osteoarticular allograft was adjusted to fit the defect. Care was taken not to lengthen or shorten the radius excessively as this could lead to tightness or looseness of the extrinsic tendons. The allograft was stabilized with internal fixation, usually a dorsoradial 3.5-millimeter dynamic-compression plate. The palmar ligaments of the wrist and the triangular fibrocartilage complex were sutured to the corresponding ligaments of the allograft. The wrist joint was fixed with a longitudinal Kirschner wire, which was removed after three to four weeks. The limb was immobilized in an above-the-elbow cast for six to eight weeks. A volar splint was then used for one to two months, until there was healing at the site of the osteosynthesis.

Postoperatively, twenty-one patients were followed at our institution and three were followed elsewhere by the referring orthopaedist. All patients were followed for at least two years (average, 10.9 years; range, 2.1 to 22.3 years). The patients were assessed clinically and radiographically for recurrence of the tumor, fracture, non-union, infection, and other complications¹¹. They also were assessed for pain, the ability to perform specific activities, work restrictions, and range of motion. The patients were asked if they had constant pain that necessitated the chronic use of analgesics; constant pain that did not necessitate the use of analgesics; pain in association with light activities, such as grooming and eating; pain in association with moderate activities, such as yard work and sports; pain in association with strenuous activities, such as manual labor and heavy lifting; or no pain in association with any activities. The patients also were asked if they could use the hand as a helper only; if they could perform only light activities, such as grooming or eating; if they could perform moderate activities, such as yard work or sports; if they could perform strenuous activities, such as manual labor or heavy lifting; or if they were without limitation. In addition, the patients were asked if they were disabled because of the wrist, employed but restricted because of the wrist, or employed with no restriction.

Results

Introduction | Materials and Methods | Results | Discussion | References

The average age of the twenty-four patients was 31.5 years (range, fifteen to sixty-one years). Thirteen patients were female and eleven were male. Seventeen lesions involved the right wrist and seven involved the left wrist. The diagnoses included giant-cell tumor (twenty patients), desmoplastic fibroma (two patients), chondrosarcoma (one patient), and angiosarcoma (one patient) (Table I). Seventeen patients were initially seen because of pain in the wrist or the distal aspect of the radius; five, because of a pathological fracture; one, because of a mass in the wrist; and one, because of an incidental radiographic finding.

Eleven giant-cell tumors were primary lesions and nine were recurrent. None of the patients who had a giant-cell tumor had metastatic disease, as seen on bone scans and radiographs of the chest. One patient had a multifocal giant-cell tumor with other lesions in the small bones of the hand. All of the primary lesions were locally invasive and had extended through the distal radial cortex or subchondral bone. Of the patients who had a recurrent lesion, five had had previous intralesional curettage with use of methylmethacrylate; two, bone-grafting; one, use of liquid nitrogen and bone-grafting; and one, use of phenol and bone-grafting. Three patients had had more than two intralesional procedures.

Two patients—a fifty-three-year-old man who had a low-grade chondrosarcoma and a forty-six-year-old man who had an angiosarcoma—had a malignant lesion. Both patients were initially seen because of a pathological fracture, and neither had evidence of metastatic disease. Two patients had a recurrent desmoplastic fibroma: one, who was first seen because of pain, had had four previous intralesional procedures, and the other, who was initially seen because of a mass in the wrist, had had one previous intralesional procedure.

Two patients had a local recurrence of the tumor after the reconstruction. In one of these patients, who had had a primary giant-cell tumor, the lesion recurred 4.5 years after the index procedure and 1.2 years after the allograft was revised to an arthrodesis because of a fracture. She had repeat excision of the lesion, and the wrist fused without additional evidence of recurrence during 8.5 years of subsequent follow-up. In the other patient, who had had a desmoplastic fibroma, the lesion recurred within nine months after the index procedure, with destruction of the bone and soft tissue proximally. She had an above-the-elbow amputation and had no additional evidence of recurrence during seventeen years of subsequent follow-up.

Eight patients needed a revision of the osteoarticular allograft: seven had an arthrodesis and one had an amputation, at an average of 8.1 years (range, 0.8 to 17.8 years). The reason for the revision included fracture in four patients (Figs. 1-A, 1-B, 1-C through 1-D), recurrence of the tumor in one, pain in the wrist in two (Figs. 2-A, 2-B, 2-C, 2-D through 2-E), and volar dislocation of the carpus in one. The arthrodeses were performed with use of autogenous bone graft from the iliac crest. One patient needed a second bone-grafting procedure to attain fusion. Of the seven patients who had an arthrodesis, four had pain in association with moderate activities, two had pain in association with strenuous activities, and one had no pain with activities. Two patients were limited in their ability to perform light activities, one was limited in his ability to perform moderate activities, three were limited in their ability to perform strenuous activities, and one had no limitation. One patient was unable to work because of the wrist, three were employed but restricted, and three were employed without restriction.

Of the sixteen patients who had a surviving osteoarticular allograft, four had pain in association with moderate activities, nine had pain in association with strenuous activities, and three had no pain with activities (Figs. 3-A, 3-B, 3-C, 3-D, 4-A, 4-B, 4-C through 4-D). Four patients were limited in their ability to perform moderate activities, nine were limited in their ability to perform strenuous activities, and three had no limitation. Three patients were employed but restricted, and thirteen were employed and had no restriction.

The average range of motion of the wrist (and standard deviation) was 36 ± 14.5 degrees (range, 10 to 70 degrees) of dorsiflexion, 21 ± 13.8 degrees (range, -5 to 50 degrees) of volar flexion, 16 ± 16.6 degrees (range, 5 to 30 degrees) of radial deviation, 15 ± 7.8 degrees (range, 5 to 35 degrees) of ulnar deviation, 58 ± 21.9 degrees (range, 15 to 90 degrees) of supination, and 72 ± 16.0 degrees (range, 45 to 90 degrees) of pronation.

Grip strength, measured in six patients, averaged 65 ± 18.4 per cent (range, 47 to 93 per cent) that of the uninvolved side. Radiographs showed narrowing of the joint space in fifteen patients, ulnocarpal impaction in thirteen, carpal subluxation in ten, formation of osteophytes and subchondral sclerosis in eight, and widening of the distal radioulnar joint in eight.

In addition to the eight complications that necessitated revision to an arthrodesis or amputation, there were fourteen other complications, including ulnocarpal impaction necessitating resection of the distal aspect of the ulna (four), painful hardware that had to be removed (four), rupture of the extensor pollicis longus tendon necessitating transfer of the extensor indicis proprius (two), fracture of the allograft necessitating open reduction and internal fixation (two), volar dislocation of the carpus necessitating closed reduction (one), and a ganglion of the dorsal aspect of the wrist necessitating excision (one). Of the six fractures of the allograft, four were treated with open reduction and internal fixation with use of bone graft from the iliac crest; two of the fractures healed, and two went on to non-union, necessitating an arthrodesis. The two remaining fractures were treated with an arthrodesis with use of bone graft from the iliac crest. There were no non-unions of the allograft-host junction and no infections of the allograft.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The treatment of neoplastic lesions of the distal aspect of the radius and reconstruction of the defect that remains after wide or marginal resection is challenging. The oncological goal is the prevention of local recurrence with adequate resection and adjuvant therapy as indicated. However, the eventual functional outcome of any reconstructive procedure must be considered as well. Thus, when the architecture of the distal aspect of the radius has been preserved, intralesional curettage is the procedure of choice for primary benign lesions, and many believe that recurrent benign lesions should be treated with repeat curettage. However, when a lesion is malignant or an extracompartmental benign lesion extends through the radial cortex or subchondral bone and the residual bone stock is poor, reconstruction of the distal aspect of the radius with use of an osteoarticular allograft permits wide or marginal resection and a lower rate of local recurrence.

The rate of local recurrence in the current series was low (only two of twenty-four patients). One of these patients had an aggressive desmoplastic fibroma that recurred and destroyed the bone and soft tissue proximally shortly after excision, eventually necessitating an above-the-elbow amputation for local control. The other patient had a late recurrence, 4.5 years after excision of a locally invasive primary giant-cell tumor. Thus, the overall rate of recurrence of the giant-cell tumors was 5 per cent (one of twenty). This rate is considerably lower than those reported after intralesional procedures involving the distal aspect of the radius (as high as 80 per cent in series ranging from twelve to fifty-two patients^4,6,16,20 and five of ten patients in a recent series from our institution³⁰). Neither of our patients who had a malignant lesion (a chondrosarcoma and an angiosarcoma) had local recurrence or metastasis after wide excision at the time of follow-up (at 14.3 and 11.3 years, respectively). Similarly, Sheth et al. found no local recurrence in ten patients in whom a giant-cell tumor of the distal aspect of the radius had been excised en bloc compared with five recurrences in eighteen patients in whom a similar lesion had been treated with intralesional curettage and cryosurgery³⁸.

Procedures that have been used for reconstruction after excision of the distal aspect of the radius have included resection arthroplasty³, prosthetic replacement^3,14,15, arthrodesis with use of a massive autogenous graft from the tibia or the iliac crest^{3,5,8,19,43,50}, ulnar translocation^2,18,37, centralization of the carpus over the remaining ulna⁵⁰, use of a non-vascularized^{3,17,21,28,29,31,32,35,36,47} or vascularized^{1,33,34,40,49} fibular graft with or without arthrodesis, and allograft replacement^3,39,41.

Campanacci et al. performed resection arthroplasty in a patient who had a giant-cell tumor of the distal aspect of the radius; the hand became aligned in marked ulnar deviation with serious loss of function³. Those authors concluded that some sort of stable reconstruction was necessary after resection of the distal aspect of the radius. Gold implanted an acrylic prosthesis after excision of the distal aspect of the radius because of a recurrent giant-cell tumor; the prosthesis failed two years later, and the patient eventually had a below-the-elbow amputation^14,15. Campanacci et al. also used a metal endoprosthesis for reconstruction of the wrist; the joint became rigid and painful, necessitating an arthrodesis with use of autogenous graft from the tibia³.

Other authors have performed arthrodesis with use of large autogenous grafts from the iliac crest or the tibia to bridge the defect in the distal aspect of the radius and to provide a stable wrist^{3,5,8,19,43,50}. In general, these procedures have resulted in a wrist with very limited motion and have been associated with fairly high rates of fracture of the graft and donor-site morbidity.

After excision of the distal aspect of the radius, Wilson performed translocation of the carpus over the ulna with carpoulnar arthrodesis; this resulted in deviation of the hand with little motion⁵⁰. Translocation of the ulna to the distal radial defect with carpoulnar arthrodesis was performed in two patients reported on by Seradge³⁷ and in six patients reported on by Bhan and Biyani². The advantages of this procedure include avoidance of the donor-site morbidity that can be associated with use of an autogenous graft and preservation of the vascularity of the graft. These patients retained an excellent functional pronation-supination arc of 120 to 160 degrees; however, flexion and extension through the preserved midcarpal joint were very limited. In addition, four of the eight patients had delayed union or non-union of the proximal radioulnar site of osteosynthesis, necessitating revision internal fixation with autogenous cancellous bone-grafting.

Both non-vascularized and free vascularized fibular grafts, with and without arthrodesis, have been used to reconstruct the wrist after excision of the distal aspect of the radius. Twenty-nine patients from several series had non-vascularized fibular transfer without arthrodesis^{3,17,21,29,35,36,47}. In general, these patients had a limited but functional range of motion of the wrist. There was arthrosis of the carpofibular joint and narrowing of the joint space over time, but pain was minimum. Complications included non-union and delayed union, fracture of the graft, subluxation of the wrist, and donor-site morbidity. Murray and Schlafly reported on eighteen patients who were managed with an interpositional arthrodesis with use of a non-vascularized fibular autogenous graft²⁸. These patients had limited motion secondary to the arthrodesis but were largely pain-free. Complications included a non-union of the radiofibular graft in five patients and a fracture of the graft in three. The use of a vascularized fibular autogenous graft without arthrodesis was described in thirteen patients, in several series^1,33,34,40, and the use of a vascularized fibular autogenous graft with arthrodesis was described in two patients³⁴. The advantages of free vascularized fibular autogenous grafts without arthrodesis include preservation of motion with earlier incorporation of the graft and hypertrophy. Complications included delayed union in four patients; the need for an arthrodesis because of painful carpal subluxation in one patient; frequent narrowing of the carpofibular joint space in association with pain in the wrist; and donor-site morbidity, including a peroneal nerve palsy in two patients^1,33,34,40.

Reconstruction of the distal aspect of the radius with use of an osteoarticular allograft after excision of a tumor has several theoretical advantages, including preservation of function of the wrist, restoration of the anatomy, the ability to repair large defects, and avoidance of the donor-site morbidity that can be associated with use of an autogenous graft. Such a reconstructive procedure was first performed at our institution in 1974, and Smith and one of us (H. J. M.) reported on three patients in 1977³⁹. At an average of 13.7 months, the preliminary results included no local recurrences; little pain; an average grip strength that was 35 per cent that on the uninvolved side; and an average of 35 degrees of dorsiflexion, 27 degrees of volar flexion, 17 degrees of radial deviation, 12 degrees of ulnar deviation, 72 degrees of supination, and 70 degrees of pronation. Complications included volar subluxation of the carpus in one patient. In 1979, Campanacci et al. reported the results of reconstruction of the distal aspect of the radius with use of an osteoarticular allograft after resection of a chondrosarcoma in a twenty-eight-year-old man³. Two years postoperatively, the patient had not had a local recurrence and was pain-free. He had loss of the joint space radiographically, with motion limited to 10 degrees of palmar flexion, 20 degrees of dorsiflexion, and 50 degrees of pronation-supination. Szabo et al. reported on three patients who had had replacement with an osteoarticular allograft as well as an arthrodesis of the distal radioulnar joint and an ulnar osteotomy after resection of a giant-cell tumor of the distal aspect of the radius⁴¹. At an average of twenty-nine months, there were no local recurrences; pain was minimum; and the average motion was 17 degrees of dorsiflexion, 28 degrees of volar flexion, 12 degrees of radial deviation, 3 degrees of ulnar deviation, 75 degrees of supination, and 82 degrees of pronation. One patient had extensor tendinitis necessitating excision of a bone spur.

In summary, the results of the current study provide long-term oncological and functional follow-up data on a large series of patients who had reconstruction of the distal aspect of the radius with use of an osteoarticular allograft after excision of a skeletal tumor. As expected, there was a low rate of local recurrence; higher rates have been reported after intralesional procedures^16,20,38. One-third of the allografts had to be revised, most commonly secondary to fracture; however, revision to an arthrodesis with use of autogenous graft from the iliac crest was successful, and repeat bone-grafting was necessary in only one patient. There were no non-unions at the allograft-host bone junction or infections at the site of the allograft, whereas in a series of 718 patients who had allograft replacements in the extremities eighty-two (11 per cent) had an infection and 122 (17 per cent), a non-union²². The sixteen patients in whom the osteoarticular allograft survived generally had mild pain, a limited range of motion, and limited grip strength. There was a moderate rate of reoperation for complications, including ulnocarpal impaction and dysfunction of the distal radioulnar joint. Radiographs commonly showed degenerative changes and subluxation of the radiocarpal joint. However, these patients generally had good function and little limitation in the ability to perform activities of daily living. Thus, when a patient has a primary or recurrent benign lesion of the distal aspect of the radius with extensive local disease and poor residual bone stock, or a malignant lesion of the distal aspect of the radius, reconstruction with use of an osteoarticular allograft provides good local control of the tumor; allows avoidance of the donor-site morbidity that can be associated with use of an autogenous graft; and results in little pain, moderate motion, and good function.

NOTE: The authors thank Diane Heislein, P.T., for her assistance in the follow-up assessments, and Waldo E. Floyd, III, M.D., Dudley S. Burwell, Jr., M.D., and Charles E. Spingola, M.D., for the follow-up of patients at institutions other than Massachusetts General Hospital. The authors dedicate this paper to the late Dr. Richard J. Smith, whose surgical expertise and academic interest were intimately manifest in this group of patients.

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Topics

fracture ; giant cell tumors ; pain ; radius ; reconstructive surgical procedures ; wrist ; neoplasms ; allografting ; arthrodesis

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MININDER S. KOCHER, MARK C. GEBHARDT, HENRY J. MANKIN; Reconstruction of the Distal Aspect of the Radius with Use of an Osteoarticular Allograft after Excision of a Skeletal Tumor*. The Journal of Bone & Joint Surgery. 1998 Mar;80(3):407-19.

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