Operative technique of distal radius resection and wrist fusion with iliac crest bone graft

Abstract

Malignant lesions of distal radius and appropriately selected cases of benign aggressive lesions (giant cell tumor) of distal radius require resection for limb salvage. Post resection, reconstruction of that defect can be accomplished by either arthrodesis or arthroplasty both having their own pros and cons. In cases undergoing arthrodesis as modality of reconstruction, small defects (≤6 cm) can be reconstructed using autologous iliac crest bone graft which results in good cosmetic appearance and functional outcome. We have described in detail, the preoperative planning, surgical steps and rehabilitation of wrist fusion with iliac crest bone grafting post distal radius resection.

1. Introduction

Malignant lesions and appropriately selected cases of benign aggressive lesions [giant cell tumor (GCT)] of distal radius require resection for limb salvage.¹ Post resection, reconstruction options available are arthroplasty (vascularized or non-vascularized auto fibula, allograft fibula, megaprosthesis) or arthrodesis (vascularized or non-vacularized autog fibula, ulna translocation, ulna centralization, iliac crest bone grafting). Each of these have their pros and cons.^{2, 3, 4, 5, 6, 7} The ideal reconstruction modality depends both on patient's need and surgeon's experience and preference. Arthrodesis after a resection <6 cm can be accomplished using autologous tricortical iliac crest bone graft. We describe in detail the steps involved in preoperative planning, surgical resection and reconstruction to enable surgeons to optimise their results if they choose this procedure. (see Fig. 1, Fig. 2)

Fig. 1.

Pictorial depection of reconstruction using iliac crest bone graft.

Fig. 2.

a) and b) Pre-operative radiograph (AP and lateral plane) of distal radius giant cell tumor of bone, c) intra-operative images of skin incision islanding out biopsy scar; d) dissected Extensor Pollicis Longus (single arrow), Extensor Pollicis Brevis (double arrow) and Abductor Pollicis Longus (double arrow) tendons; e) wound after resection of distal radius and denuded carpal cartilage; f) harvested iliac crest graft; g) preparation of graft; h) osteosynthesis with 3.5 mm dynamic compression plate; h) and i) post operative radiograph in both AP and lateral plane.

2. Preoperative planning

A detailed preoperative evaluation is necessary utilising plain radiographs in two planes and magnetic resonance imaging (MRI) of the forearm. Surgical planning includes determining the surgical approach, measuring the extent of bony resection, evaluating the soft tissue extent of the lesion and its proximity to tendons, nerves and vessels and identification of potential danger zones for tumor contamination during surgery. Arthrodesis after a resection,< 6 cm can be accomplished using autologous tricortical iliac crest bone graft. Adequate counselling of patient regarding outcome of procedure i.e. loss of wrist movement, retention of prono-supination, need for splint and restricted weight lifting in early rehabilitation phase is necessary. Specific inquiry regarding any history of bone harvesting surgery or any other procedure in pelvic area should be documented more so in cases with recurrence. Patient is always counselled about conversion to alternative procedure i.e ulna translocation or centralization if iliac crest bone grafting is not feasible intra-operatively. If there is a history of bone harvesting surgery, it is mandatory to clinically examine that area and do a screening plain radiograph to rule out disease due to “implantation seeding”.⁸

3. Resection

After necessary preoperative investigations and fitness from the anaesthesiologists, the patient is scheduled for surgery.

The patient is positioned supine, with the affected limb placed on an arm board and a sandbag under the ipsilateral hip. Tourniquet is applied to the limb. Limb and the iliac crest are scrubbed, painted and draped. Incision is taken on dorsal surface from distal third of 3rd metacarpal to mid forearm on dorsal surface of radius going just medial to lister's tubercle, islanding out the biopsy scar. Radial and ulnar flaps are raised, maintaining an intact tumor capsule. Extensor Pollicis Brevis (EPB), Abductor Pollicis Longus (ABPL), Extensor pollicis Longus (EPL) and Extensor digitorum are identified and dissected off radius. If soft tissue is encasing these tendons, the tendons are cut proximal to soft tissue component. Tendon distal to soft tissue is pulled to retrieve the cut end distally, after resection and reconstruction cut ends are sutured (cutting tendon proximally at musculotendinous junction is preferred for better healing). This is followed by identification of Extensor Carpi Radialis Longus (ECRL), Extensor Carpi Radialis Brevis (ECRB) and Brachioradialis which are cut (function is not compromised as the wrist is being fused). The Distal Radio Ulnar Joint (DRUJ) is exposed. Dissection is carried out on the volar aspect. The radial vessels and superficial radial nerve are identified proximally beneath brachioradialis and dissected away from tumor carefully along whole length of resection until radial vessels enter anatomical snuff box. The osteotomy site is marked on radius at the proposed resection level from joint line. Using an oscillating saw, osteotomy is completed after protecting the surrounding soft tissue using bone spikes. Using a bone holding forceps, the specimen is held and manipulated to facilitate subsequent dissection. The interosseous membrane is cut on the ulnar side and Distal Radio Ulnar Joint (DRUJ) exposed followed by the wrist joint between 1st carpus row and radius. Opening DRUJ first decreases the chances of inadvertent opening of wrist joint in between carpal rows. Volar dissection is continued exposing the volar capsule. All the flexor tendons and median nerve are safeguarded and retracted anteriorly. Pronator quadratus is kept as margin on tumor and cut at its insertion on ulna. The wrist joint capsule is now cut on the volar aspect and the specimen is delivered after severing out the remainder of soft tissue attachments. A thorough lavage is given, tourniquet deflated and hemostasis is achieved. The resected specimen length is reconfirmed as this will determine the length of graft to be harvested.

4. Harvesting of graft

The operating team changes its gloves and utilises a completely fresh instrument set including a new suction canula. An incision is taken on the iliac crest (length depends on the length of graft to be harvested). Osteotomy sites are marked on iliac crest as per the required graft length (approx. 0.5 cm longer than resection length to allow for adequate shaping of the edges).

Using an oscillating saw, the iliac crest is cut. Care is taken to keep both the cuts parallel and the depth not exceeding 2 cm in depth. Now the graft is harvested by cutting at the base of graft using a combination of an oscillating saw and curved osteotomes.

The wound is packed with a saline soaked mop and covered. It is subsequently closed in layers at the end of surgery (accounting for the extremely rare occasion that additional graft is required).

5. Fixation of graft (choosing the right implant)

The carpal bones are exposed and the carpal surface bared down for osteosynthesis. The 2nd or 3rd MC surface is exposed for fixation.

An adequate size plate is chosen to make sure there are at least 3 screws in MC and one in carpus and 3 screws in the radius. 3.5 mm Dynamic Compression Plate (DCP) is preferred as it is comparatively a stronger implant. The plate is now contoured at 4th – 5th hole from distal in order to keep the wrist in 15° of extension. The distal tip of the plate is bent on the palmar side to prevent plate prominence post fixation. The edges of the graft are freshened and shaped to ensure an appropriate end to end fit at the radial and carpal ends.

While maintaining the position of the temporary construct using a combination of bone holding forceps and digital pressure, adequacy of prono supination is checked and correct position of the hand with respect to the forearm is confirmed.

The plate is secured to radius with bone holding forceps and the distal end is centred over the metacarpal. Complete range of supination and protonation should be confirmed at this stage. Any repositioning if necessary to correct the prono-supination is easier on the radius as compared to the metacarpals A single screw through the graft ensures that is graft is held in correct position. The initial radius screws are then positioned eccentrically to ensure compression at the radial end of the graft. An angled cancellous screw is passed through the plate into the carpus to pull carpus towards graft enabling compression between the graft and carpus. Any remaining screws in radius and metacarpal are then positioned appropriately. Adequacy of prono-supination is rechecked and the construct positioning confirmed with C-arm. Wound is closed in layers under negative suction drain.

6. Rehabilitation

Volar below elbow slab with arm pouch is given for 3 weeks. Finger and elbow mobilization is started in immediate post-operative period. Supination and protonation can be started after removal of slab i.e. after 3 weeks. Weight lifting is allowed gradually once osteotomy sites start uniting.

7. Discussion

Defect after distal radius resection can be reconstructed by many methods. While a fibula arthroplasty and mega prosthesis may retain wrist movement, the grip strength is reduced. Donor site morbidity post fibula arthroplasty and implant failure post prosthesis arthroplasty combined with the possibility of subsequent arthritis are additional disadvantages. Among the wrist fusion techniques, ulna centralization sacrifices forearm rotations. Ulna translocation while retaining forearm rotations has the disadvantage of decreased wrist girth with sub optimal cosmesis. The advantages of utilising the iliac crest as a graft; the functional outcome is comparable to other modalities of arthrodesis, it avoids donor site morbidity (associated with harvesting fibula) and provides better cosmesis (compared to ulna translocation or centralization).^5,6,7,9 Though it is associated with donor site morbidity i.e. fracture of anterior superior iliac spine, seroma formation, sensory disturbances and pain, the chances of these complication are very rare.¹⁰ Another limitation is that it is not advisable for resection defects exceeding 6 cms as it is anatomically not possible to harvest straight graft more than 6 cms from iliac crest.

8. Conclusion

As per our own experience,⁶ tricortical iliac crest bone grafting for wrist arthrodesis results in good oncological and functional outcome for distal radius lesions requiring resection, provided there is meticulous preoperative planning and proper execution as per the surgical step mentioned.

Funding

No funds, grants, or other support was received.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author contributions

All author equally participated in study design, data collection, data interpretation, and writing/review of the manuscript. All authors substantially contributed to interpretation of data, critical revision of manuscript, and consented to the final version of the case report. All authors meet ICMJE criteria and all those who fulfilled those criteria are listed as authors. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Ethics statement

Patient related data is not included in this publication, so ethics committe approval was not required.

Consent to participate

No patients were involved in this study.

Consent for publication

Not applicable.

Declaration of competing interest

The authors have no relevant financial or non-financial interests to disclose.