The distal radius is the third most common site for giant cell tumors of bone.This tumor is known to be very locally aggressive and recursin situquite frequently after excision.,En bloc resection, removing a wide margin through normal tissue planes, ensures the lowest rate of recurrence.Wrist arthroplasty using the fibular head as anon-vascularizedgraft has been established as one of the procedures of choice because of its similarity in shape to the distal radius.Several articles have reported satisfactory functional results after reconstruction.However, the longest follow-ups available so far were all less than 20 years, and few articles focused on theradiographic changes of the carpus.
Non-vascularized fibular graft for distal radial reconstruction: 42 years follow-up
第一作者：Yang Yong
2014-01-26 我要说
Yang Yong, Tian Wen, Sunil Thirkannad and Tian Guanglei
Our case provides a unique opportunity to evaluate the 42-year outcome of non-vascularized fibular grafting.Radiographic evaluation of the carpus revealed the gradual but relentlessly progressive deformities of the wrist. These affected the ulno-fibular, the fibulo-carpal and the midcarpal joints. We tried to describe the changes noted in each of these locations and discuss the probable causes that led to the deformities.
A 66-year-old lady presented to our clinic in June 2009 with recent complaints of numbness and tingling in her right hand. While it was established that her current problem was carpal tunnel syndrome because of tenosynovitis, we realized that she had undergone reconstruction of her right wrist 42 years ago. A review of her case records from 1966 revealed the following.
The lady, who was at the time 24 years old, presented with complaints of pain and swelling in her right wrist that had started 6 months before. Radiographs revealed a lytic lesion of the distal right radius. On November 11, 1966, en bloc resection of the distal radius was performed. The tumor was well encapsulated and it was possible to resect the entire tumor en-block along with 8 cm of the distal radius.A nonvascularized proximal fibular graft of suitable length was harvested from her left leg. The graft was then fixed with a cortical screw to the remaining proximal part of the radius via a step-cut osteotomy. The remnants of the carpal ligaments on the radial side of the carpus were then sutured to the remnant of lateral collateral ligament on the fibular head. The right upper extremity was immobilized in a long-arm cast. The excised tumor was sent for histopathology, which confirmed the diagnosis of giant cell tumor in grade II. Bone union was deemed to be satisfactory 4 months after surgery. The patient was then returned to her regular activities and discharged from follow-up.
Since that time, the patient continued to work as an accountant till she again returned to our clinic with her recent problem of carpal tunnel syndrome. Sensing the uniqueness of the situation, we took the opportunity of re-evaluating her wrist and found that she had a good functional range of motion. Her extension was 40°, flexion was 25°, pronation was 70°, supination was 35°, radial deviation was 5° and ulnar deviation was 25°. Her grip strength was excellent at 97% of the unoperated contralateral side.
We also performed a detailed radiographic evaluation of the patients wrist. Plain x-ray revealed a significant diastasis of the ulno-fibular joint. The lunate was deformed and was “V” shaped. It was found to have migrated proximally into the diastatic interval between the ulna and fibula (Figure 1A). The scaphoid and lunate were both noted to be in a flexed position with a scapho-lunate angle of 50° and a capito-lunate angle of 35°(Figure 1B). This suggested a mid carpal collapse pattern with a “Z” deformity of the wrist. A CT scan revealed degenerative changes that were severe at the ulno-carpal joint and mild at the fibulo-carpal and capito-lunate joint (Figure 1C).
There was no correlation between the severity of radiographic degeneration and the patients clinical status. As mentioned above, the patient retained a very functional range of movement and grip. Her Disabilities of arm, shoulder and hand (DASH) score was 12.1 and Mayo wrist score was 70. The patient had no limitation and no pain in her wrist and donor site in activities of daily life or recreational activities, such as badminton and mountain-climbing. On a subjective level, the patient graded her result to be “excellent”.
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