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Wrist Reconstruction Using Free Vascularized Fibular Head Graft Following Intralesional Excision for Campanacci Grade 3 Giant Cell Tumors Involving the Articular Surface of the Distal Radius
Reconstruction with a free vascularized fibular head graft after en bloc excision of a Campanacci grade 3 giant cell tumor of bone in the distal radius can effectively control local recurrence. However, it leads to the loss of wrist movement, subsequent radiocarpal subluxation, and an osteoarthritic change. Another treatment option for grade 3 lesions is intralesional excision and cementation, which preserves wrist movement but does not restore the articular surface. We report a case of wrist reconstruction using a free vascularized fibular head graft after the intralesional excision of a Campanacci grade 3 giant cell tumor of bone with invasion of the articular surface of the distal radius. In patients with this type of a lesion, wrist reconstruction using a free vascularized fibular head graft after intralesional excision can help prevent local tumor recurrence, restore the articular surface, and maintain movements of the wrist joint.
The standard treatment ranges from intralesional excision to en bloc excision and reconstruction. Because intralesional excision preserves the wrist joint, the functional outcomes of intralesional excision are generally considered better than those of en bloc excision.
Reconstruction with a free vascularized fibular head graft (FVFG) after the en bloc excision of a grade 3 GCTB can help achieve effective control of local recurrence.
Some authors have reported that grade 3 GCTBs with limited cortical perforation have been successfully treated, with an acceptable rate of local recurrence and range of motion after intralesional treatment.
However, in the case of limited cortical perforation, the articular surface cannot be restored by cementation after intralesional treatment if the articular surface has been invaded.
Here, we present a case of a patient treated with a reconstructive technique using an FVFG after the intralesional excision of a grade 3 GCTB of the distal radius with articular surface invasion and limited cortical perforation. This study was approved by the institutional review board of our hospital, and patient consent was obtained.
Case Report
A 25-year-old man visited our hospital because of pain and swelling in the left wrist, which had been progressively worsening over a period of 3 months. A physical examination revealed mild tenderness of the left wrist. The range of motion of the left wrist was 60° of flexion, 70° of extension, 30° of ulnar deviation, 10° of radial deviation, 90° of pronation, and 80° of supination. There were flexion and extension losses of 20° and 15° in the affected wrist, respectively, compared with that on the contralateral side. The grip strength of the left hand was 31 kg, which was 87% of that of the contralateral side. The overlying skin was intact and showed no signs of an infection.
Plain radiography of the wrist revealed a lytic lesion measuring 3 × 2.5 cm without a sclerotic peripheral rim, located in the epiphyseal-metaphyseal region of the distal radius. The margin was relatively well defined, and no deformation was observed (Fig. 1). Computed tomography scans showed cortical destruction of the dorsal, volar, and ulnar aspects of the articular surface. Magnetic resonance imaging revealed a well-defined lesion measuring 2.7 × 2.4 × 2.3 cm, which was heterogeneous and had a low signal intensity on T2-weighted imaging (Fig. 2). The imaging findings were consistent with those of GCTB. A core needle biopsy was performed before surgery and revealed spindle-shaped mononuclear cells with osteoclastic giant cells, compatible with GCTB. Based on the combination of clinical, radiological, and histopathological features, the patient was diagnosed with grade 3 GCTB with tumor perforation involving the soft tissues.
Figure 1A Anteroposterior and B oblique radiographs reveal a 3 × 2 cm lytic lesion without a sclerotic rim and cortical thinning of medial and articular side cortices at the distal epiphyseal-metaphyseal region of the distal radius.
Figure 2A Coronal and sagittal images of a computed tomography scan revealed cortical destruction of the anterior, posterior, and ulnar aspects of the articular surface. B Sagittal and axial images taken using magnetic resonance imaging revealed a well-defined, 2.7 × 2.4 × 2.3 cm lesion with soft tissue invasion to the pronator quadratus involving the distal radius, which was heterogeneous and had a low signal intensity on T2-weighted imaging.
In patients with grade 3 lesions with invasion of the articular surface, it is necessary to reconstruct the articular surface. Because this patient had a grade 3 lesion with a relatively adequate bone stock, we elected to treat him with intralesional excision and an FVFG.
A volar incision was made in the space between the flexor carpi radialis and radial artery. Volar cortical perforations were observed during the surgery. The area of cortical perforation was resected with the overlying pronator quadratus, thereby creating a window in the radius. The metaphyseal cavity containing the articular surface and dorsal cortex invaded by the giant cell tumor was subjected to curettage. Subsequently, 3 cycles of high-speed burring, electrocauterization, and irrigation were performed (Fig. 3A ). The contralateral proximal fibular head was harvested and positioned inside the cavity of the radius through the window (Fig. 3B, C). Next, graft fixation was performed using a screw and a plate (Fig. 3D). End-to-end anastomosis of the anterior tibial artery to the radial artery was performed at the recipient site.
Figure 3A The lesion with cortical perforation was excised, including resection of the tumor with the overlying pronator quadratus, and the metaphyseal cavity containing the articular surface and posterior cortex invaded by the tumor through this window was subjected to curettage. B Intraoperative C-arm imaging reveals the curetted lesion including the articular surface. C The contralateral proximal fibular head was harvested, and the harvested proximal fibula was positioned inside the cavity of the radius through the window. D Intraoperative C-arm imaging reveals graft fixation to the host bone using a screw and a plate.
Role of intravenous zoledronic acid in management of giant cell tumor of bone—a prospective, randomized, clinical, radiological and electron microscopic analysis.
The proximal fibular graft survived, which was demonstrated by increased uptake in a bone scan performed 6 weeks after the surgery. Plain radiographs confirmed graft union at the recipient site 16 weeks after the surgery. The patient was able to bear weight and permitted to engage in heavy activities 6 months after the surgery. In magnetic resonance imaging scans taken 3 years after the surgery, the articular cartilage of the fibular head was found to have replaced the cartilage of the host bone, which had been previously destroyed by the tumor (Fig. 4). The range of motion of the left wrist was 70° of flexion, 85° of extension, 30° of ulnar deviation, 10° of radial deviation, 90° of pronation, and 80° of supination. The affected wrist had a range of motion similar to that of the contralateral side, except for a flexion loss of 10° (Fig. 5). The grip strength was measured to be 38 kg. There was no difference in the grip strength between the affected side and contralateral sides, and there was no pain during movement. Although superficial peroneal nerve palsy occurred after the surgery, it spontaneously recovered 12 weeks after the surgery, without sequelae. Plain radiographs demonstrated the graft to be fully incorporated into the recipient site, without any sign of subluxation and an arthritic change in the wrist joint and with tumor recurrence 4 years after the surgery. There was no evidence of lung metastasis, as determined using chest radiography at the final follow-up visit.
Figure 4A Anteroposterior and lateral radiographs taken 4 years after the surgery reveal graft union to the host bone and nearly normal alignment, without joint subluxation and recurrence. B Magnetic resonance imaging scans taken 3 years after the surgery show that the articular cartilage of the fibular head had replaced the cartilage of the host bone, which was previously destroyed by the tumor.
Intralesional excision and cementation with or without adjuvants are generally considered for the treatment of Campanacci grade 1 or 2 GCTB of the distal radius.
However, the effectiveness of these treatments for grade 3 lesions in terms of the preservation of wrist function versus local recurrence control is controversial.
performed en bloc excision and reconstruction using an osteochondral allograft in 7 patients and preformed curettage and cementation in 3 patients with grade 3 GCTB of the distal radius. After a mean follow-up duration of 14 years, of the 7 patients who underwent en bloc excision, recurrence was observed in 1, whereas all 3 patients who underwent curettage showed recurrence. Lans et at
reported that intralesional excision was the only independent risk factor for recurrence. Although en bloc excision and reconstruction are appropriate treatment methods for the control of local recurrence, the wrist joint is sacrificed with these methods. Depending on the reconstruction method, complications, including a limited range of movements, joint subluxation, and arthritis, can develop.
performed intralesional excision in 6 patients and en bloc excision in 6 patients with grade 3 GCTB of the distal radius and reported no local recurrence in either group, with better functional results in the group treated with intralesional excision. They suggested that intralesional excision should be considered as a possible treatment option for grade 3 lesions when the tumor has not invaded the wrist joint and has not destroyed more than 50% of the cortex. Kang et al
compared 9 patients treated with intralesional excision and 6 patients treated with en bloc excision of grade 3 GCTB of the distal radius. After a mean follow-up duration of 60 months, recurrences occurred only in 2 patients treated with intralesional excision. Although 2 patients treated with intralesional excision experienced recurrence, no recurrence occurred after repeated intralesional excision, and the intralesional excision group had better functional outcomes than the en bloc excision group. They suggested that a grading system for subclassification should be used, designated as (p), to denote a single site of nonarticular cortical perforation. They also claimed that grade 3 (p) lesions can be surgically downstaged to grade 2 by creating a single cortical window.
suggested that intralesional excision could be a possible treatment option for patients with grade 3 lesions with limited cortical perforation and nonarticular surface invasion. We agree with their opinions, except with those on nonarticular surface invasion. According to these opinions, our patient should have been recommended arthrodesis or reconstruction using an FVFG after en bloc excision because of articular surface invasion. However, our patient had a relatively adequate bone stock, and intralesional excision could have been attempted if the reconstruction of the articular surface were possible. Hence, we reconstructed the articular surface using an FVFG after intralesional excision.
Preventing local recurrence is a challenge in the treatment of GCTB. The apoptotic effect of bisphosphonate on the osteoclastic-like multinucleated giant cells and stromal cells of GCTB has been demonstrated in in vitro studies.
compared 24 patients treated with perioperative bisphosphonate (2 doses before surgery and 3 doses after surgery) and 20 patients treated without bisphosphonate. The local recurrence rate was 4.2% in the bisphosphonate group and 30% in the control group. Gouin et al
performed intralesional excision, followed by 5 courses of zoledronate (4 mg intravenously every 3 weeks), in 20 patients with GCTB. Seven of the 20 patients had grade 3 lesions. Among the 7 patients, only 1 patient with GCTB of the sacrum experienced recurrence. The patient subsequently underwent recurettage, and local control of the tumor was achieved. To reduce the risk of local recurrence after intralesional excision, we used zoledronate as an adjuvant treatment according to the regimen recommended by Gouin et al.
Although we could not confirm the effect of bisphosphonate on local recurrence, it was not observed 4 years after the surgery in our patient.
The advantage of this technique is that it can preserve the articular surface not yet invaded by the tumor and help reconstruct the articular surface by replacing it with the cartilage of the fibular head, thereby preserving joint congruency and wrist function. This technique is technically more demanding than cementation because it requires a microsurgery and makes it difficult to check for local recurrence.
Although en bloc excision and reconstruction are excellent treatment methods for local tumor control in patients with grade 3 GCTB of the distal radius, the reconstruction of the articular surface using an FVFG after intralesional excision might be a useful treatment option in the case of lesions with limited cortical perforations and articular surface invasion, but with an adequate bone stock.
References
Lalla R.N.
Bhupathi S.C.
Treatment of giant cell tumor of the distal radius by ulnar translocation: a case report and review of the literature.
Role of intravenous zoledronic acid in management of giant cell tumor of bone—a prospective, randomized, clinical, radiological and electron microscopic analysis.
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