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CLINICAL RESEARCH

Does a Modified Technique to Achieve Arthrodesis of the Wrist After Resection of the Distal Radius and Translocating the Ipsilateral Ulna as a Vascularized Graft to Reconstruct the Defect Improve Grip Strength and Outcomes Scores?

Gundavda, Manit K. DNB, Orth; Agarwal, Manish G. MS, Orth; Reddy, Rajeev DNB, Orth; Katariya, Ameya DOrth; Bhadiyadra, Ravi DNB, Orth

Author Information
Clinical Orthopaedics and Related Research: June 2021 - Volume 479 - Issue 6 - p 1285-1293
doi: 10.1097/CORR.0000000000001604

Abstract

Introduction

Reconstruction after tumor resection of the distal radius continues to be a challenge [9]. Wrist arthroplasty using proximal fibular head arthroplasty [21, 23, 32], osteoarticular grafting [7, 22, 25], or prosthetic hemiarthroplasty [14, 30] offers the advantage of wrist movement but carries an associated risk of wrist subluxation, pain, and limited pronosupination [7, 14, 21-23, 30, 34]. Wrist fusion using an autograft [5, 23, 27] or allograft [28] provides long-term wrist stability at the cost of movement. Recent publications have shown that wrist fusion is superior to other reconstruction options in the distal radius [5, 21, 29]. Ipsilateral vascularized ulna transfer with wrist fusion to reconstruct defects of the distal radius after tumor resection was first described 35 years ago [26]. Several surgical technique modifications for ulnar translocation aimed to improve reconstruction outcomes [2], implant fixation, and union rates [4]; one study even attempted to preserve movement of the carpometacarpal joint [15].

Ten years ago, we reported our experience with ipsilateral vascularized ulna transfer and wrist fusion, with excellent oncologic outcomes and good functional results [20]. In that study, we used the ipsilateral ulna as a vascularized graft that translocated into the distal radius defect and performed wrist fusion using the conventional dorsal approach; this often narrowed the wrist because the translocated ulna was usually aligned with the third metacarpal (Fig. 1A-C). We have modified the technique to reduce wrist narrowing by lateralizing the translocated ulna and fusing the wrist and the radius and aligning the translocated ulna with the second metacarpal. To reduce visibility and improve the surgical scar cosmesis, our modification placed the incision over the radial border of the forearm with gentle dorsoradial extension onto the second metacarpal (Fig. 2A-D) as opposed to the conventional dorsal incision, which is centered over the radius and extends to the third metacarpal joint. Our contention was that ulna deviation resulting from this alignment with the second metacarpal would improve grip strength (Fig. 3A-B). Yuvaraj et al. [33] showed improved grip strength with ulnar deviation, but other studies on grip strength after wrist fusion have suggested that positioning the wrist in extension offers better strength; however, these studies did not demonstrate any benefit of ulnar deviation [6, 8]. Therefore, in our study, we maintained wrist dorsiflexion at 10° to 15° as before, which was consistent with the most functional position after fusion in previous reports [10, 18] (Fig. 3C). We aimed to objectively analyze function and wrist narrowing in patients undergoing this modified surgical technique compared with patients in whom this modification was not used.

F1
Fig. 1.:
A-C A 39-year-old man had a diagnosis of giant cell tumor after (A) radiograpy and tissue biopsy were performed. (B) This patient underwent resection of the distal radius tumor through the dorsal approach and (C) the translocated ulna, along with the dorsal tilt, was centralized in line with the third metacarpal and this resulted in wrist narrowing.
F2
Fig. 2.:
A-D A 33-year-old woman presented with left wrist pain and (A) a radiograph showed a lesion of the distal radius. (B) Needle biopsy confirmed the diagnosis of giant cell tumor of bone, and she underwent resection of the distal radius through a modified dorsoradial incision. (C) Radialization of the ulnar graft along with dorsal tilt was confirmed intraoperatively and postoperatively on a radiograph. (D) At the latest follow-up interval (39 months), the patient had comparable wrist circumference to the contralateral side.
F3
Fig. 3.:
A-C A simulation diagram from patient imaging to demonstrate the positioning of the ulna graft and alignment of the radius shaft with the position of the hand in the conventional approach. (A) Centralization of the graft and the radius shaft in line with the third metacarpal, while the modified approach (B) demonstrates the lateralization of the graft and ulnar deviation at the wrist achieved from using the second metacarpal for alignment. (C) Dorsiflexion was constant to both the techniques.

We therefore asked: (1) Is there an objective improvement in grip strength and functional scores (Musculoskeletal Tumor Society [MSTS] and Mayo wrist) when the translocated ulna is lateralized and the wrist is fused with the translocated ulna and aligned with the second metacarpal versus when the translocated ulna is aligned with the third metacarpal? (2) Did lateralization caused by the wrist fusion aligned with the second metacarpal minimize wrist narrowing as measured by the circumference compared with the fusion aligned with the third metacarpal?

Patients and Methods

Study Design and Setting

From 2010 and 2018, we treated 40 patients with tumors of the distal radius (Fig. 4). Thirty patients underwent an en bloc resection for bone tumors of the distal radius at our institution. Two were skeletally immature and did not undergo a wrist fusion and were therefore excluded from this study. Twenty-eight patients underwent an ipsilateral ulna translocation and wrist arthrodesis by aligning the radius and translocated ulna with either the second (n = 15) or the third (n = 13) metacarpals. Two patients in the second metacarpal group and three patients in the third metacarpal group were lost to follow-up before 24 months after surgery and were not included in the study. Patients treated before 2010 who were reported on in our study published in 2010 [20] were not included in this study because they were not available for analysis to the senior author (MGA), who changed institutions in 2010.

F4
Fig. 4.:
A study flow chart for patients with distal radius tumors treated at our insititution during the study period.

Participants

All patients were evaluated preoperatively with local imaging (radiographs and MRI) for surgical planning. Chest radiographs were used to stage giant cell tumors, and positron emission tomography-CT was used to stage malignant bone tumors. When indicated by a multidisciplinary tumor board consultation, patients with malignant tumors underwent neoadjuvant therapy.

The two groups were created on the basis of the metacarpal with which the translocated ulna and radius were aligned and on which the plate was fixed. Twenty-three patients (12 men and 11 women) were available at latest follow-up (minimum 24 months; mean [range] follow-up duration 52 months [24 to 87] in the second metacarpal group and 90 months [28 to 123] in the third metacarpal group) and their data recorded for analysis (Table 1). Thirteen patients were in the second metacarpal group (eight with their nondominant wrist and five with their dominant wrist) and 10 were in the third metacarpal group (six with their nondominant wrist and four with their dominant wrist). The distal radius resections in our series were performed for 20 giant cell tumors and three malignant bone tumors; three patients who underwent resection of giant cell tumors had soft tissue recurrences (two recurrences in the second metacarpal group and one recurrence in the third metacarpal group) at 9, 15, and 20 months postoperatively. All three patients underwent excision of their soft tissue recurrences and were disease-free at the latest follow-up examination. There were too few soft tissue recurrences to assess differences between the two groups. There was no bony recurrence in this series.

Table 1. - Patient demographics and study results
Demographics Second metacarpal (n = 13) Third metacarpal (n = 10) p value
Dominant side 5 4
Nondominant side 8 6
Follow-up in months, mean (range) 52 (24-87) 90 (28-123)
MSTS score 30 (24-30) 26.5 (22-30) 0.21
Mayo wrist score 83 (65-100) 72 (50-90) 0.10
Difference in wrist circumference in mm 10 (3-35) 30 (15-35) 0.04
Percentage difference in grip strength between the operated and unoperated wrista 12% (-30% to 35%) 28% (15%-42%) 0.006
Data provided as median (range) unless otherwise noted; MSTS = Musculoskeletal Tumor Society.
aCorrected for dominance.

Initially, we had not paid attention to whether the second or third metacarpal was used for plate fixation. In most patients, it was the third metacarpal by convention. In some patients, the second was used because it aligned better during surgery. Over time, as we critically asessed our results, we realized that the wrist narrowing measured by circumference was reduced when the translocated ulna was radialized in line with the second metacarpal, and this became our favored approach. As the technique evolved after 2015, there were more patients in the second metacarpal group (11 patients between 2015 and 2018). Again, the only reason to revert to the third metacarpal after 2015 was that in two patients, it was easier to fit the plate on the third metacarpal during surgery.

Description of Experiment, Treatment, or Surgery

The incision was dorsal and extended onto the third metacarpal joint in the third metacarpal group (Fig. 1B) or dorsoradial and extended to the second metacarpal joint as a modification in our more recently treated patients (Fig. 2B). After resection of the distal radius, we osteotomized the ulna at the same level as the radius and then translocated it into the radial defect as a vascularized bone graft, keeping the soft tissues intact, particularly on the interosseous side. Alignment with the metacarpal resulted in the radiocarpal fusion being performed to the lunate in the third metacarpal group or to the scaphoid/scapholunate in the second metacarpal group. The construct was held by using a standard compression plate that bridged the radius and ulna or a locking plate that extended from the third or second metacarpal to the radial shaft. None of the patients with a dorsal skin incision had any wound-related complications, while one patient with the modified incision developed superficial skin necrosis at the angle formed by the longitudinal incision and the extension of the incision to the second metacarpal joint. This patient had undergone intralesional surgery with a volar incision 18 months prior. The skin necrosis healed with nonoperative management. Of the 46 junctions, only one proximal radioulnar junction did not heal at 15 months postoperatively and was treated with needle bone grafting. There was no difference in oncologic and reconstruction-, implant-, or ulnar graft-related outcomes between the two groups.

Aftercare

After surgery, the patients were splinted in a removable cockup splint and encouraged to perform active finger movements. A splint was a precaution to help the patient avoid lifting weight and to protect from external injury; we felt that active support was not needed owing to stable fixation afforded by the plate. A soft ball was provided to practice grip strength. Elbow and shoulder movements were encouraged. Elevation was strictly maintained. The patients were encouraged to remove the splint intermittently and perform pronation and supination both passively and actively. Carrying weight more than 2 to 3 kg was not permitted until union was seen on radiographs.

Description of Follow-up Routine

In accordance with our institutional follow-up protocol after bone tumor surgery, all patients underwent local clinical and radiologic evaluation with radiographs every 3 months for 3 years after surgery; after that, follow-up was done every 6 months for another 2 years. All patients followed up annually after 5 years postoperatively. Oncologic outcomes were recorded as the status of local and systemic disease (chest imaging every 3 months included a radiograph and CT scan at every other follow-up for malignant tumors and a chest radiograph every year for giant cell tumors) at each follow-up visit. Radiographs at follow-up were reviewed to evaluate the outcomes of reconstruction, including assessments of union across osteotomy junctions by assessing bridging callus in three of the four cortices on orthogonal radiographic views or disapperance of osteosynthesis line, implant breakage, or graft fracture.

Variables, Outcome Measures, Data Sources, and Bias

At every evaluation at a minimum 12 months postoperatively, we analyzed functional and patient-reported outcomes. We evaluated MSTS and Mayo wrist scores. Wrist circumference was measured on the unaffected side using a tape measure over the Lister tubercle of the radius passed around the ulna, and a corresponding level of measurement was used for the operated side. We assessed the objective grip strength of the operated-on wrist compared with that of the contralateral side using a hand dynamometer. Isometric grip force in kilograms was evaluated and assessed as the percentage difference between the operated-on and unaffected limbs, and we compared results between each group after correction for dominance using the 10% rule for dominant-hand grip strength [19]. This report suggested that the dominant hand possesses 10% greater grip strength; however, this increased grip strength was identified only in people with right-hand dominance; in those with left-hand dominance, the grip strength is considered equal for both hands [1, 19]. Variances in the 10% rule have been demonstrated [1, 17]; however, because of the lack of prospectively (preoperative or ideally before disease onset) collected patient grip stengths for both hands, in patients with right-hand dominance, we made a 10% correction of their measured grip strength to eliminate the inherent difference.

Study Population

Twenty-three patients with a minimum of 24 months of follow-up were considered for the study and classified based on the metacarpal joint used for alignment of the wrist and use of plate fixation for arthrodesis after ulna translocation: second metacarpal (modification) group (n = 13) (mean [range] follow-up 52 months [24 to 87]) and third metacarpal (conventional) group (n = 10) (mean follow-up 90 months [28 to 123]). Five other patients who had the procedure done but were lost to follow-up before 24 months were excluded from this study.

Accounting for All Patients

Twenty-three patients who were included in the study were available at latest follow-up (annual follow-up after 5 years since surgery or more frequently if before 5 years). Five patients were lost to follow-up before 24 months postoperatively. Two of these patients were not residents of our country and have not followed up in person since surgery, and the other three patients were lost at 3, 4, and 7 months, respectively.

Ethical Approval

Our institution waived approval of the human protocol for this retrospective study, and all investigations were conducted in conformity with ethical principles of research.

Statistical Analysis

Parameters were analyzed and compared between the two groups. We developed a spreadsheet for data entry, including demographic data, surgical treatment, patient outcomes, complications, and other patient-specific information. Descriptive statistics are presented as frequencies and percentages (categorical variables) or as means/medians and SDs (continuous variables), and a comparative analysis of independent datasets was performed using the Mann-Whitney U test, with two-tailed p values significant at p < 0.05. This analysis was performed using SPSS Version 25 (IBM Corp, Armonk, NY, USA).

Results

Grip Strength and Outcomes Scores

Patients in the second metacarpal group lost less grip strength adjusted for dominance compared with the unoperated side (median [range] 12% [-30% to 35%] versus the third metacarpal group (median 28% [15% to 42%], difference of medians 16%; p = 0.006). However, there were no between-group differences in terms of MSTS (median 30 [24 to 30] versus median 26.5 [22 to 30], difference of medians 3.5; p = 0.21) or Mayo wrist scores (median 83 [65 to 100] versus median 72 [50 to 90], difference of medians 11; p = 0.10).

Wrist Circumference

The median difference in circumference between the operated and unoperated wrists was less in the second metacarpal group than the third metacarpal group (median 10 mm [3 to 35] versus median 30 mm [15 to 35], difference of medians 20 mm; p = 0.04).

Discussion

For benign tumors like giant cell tumors, although curettage and bone grafting or cementing are probably the best methods of retaining wrist anatomy and function, they have been accompanied by a high risk of local recurrence in larger tumors and tumors with soft tissue extension [34]. Our experience suggests a lower incidence of local recurrence after en-bloc resections, and this is consistent with published evidence [24, 29]. Many of our patients have preferred an en bloc resection rather than risking recurrence that often leads to multiple procedures with the associated hospitalizations and costs, as seen from the large percentage of resections in all distal radius tumors. Restoring hand function is the ultimate goal after tumor resection of the distal radius [5]. There has been a continuing debate on the functional outcomes of wrist restoration versus those of wrist fusion after reconstruction of distal radius defects. Instability and degenerative arthritis have been reported in some patients after joint restoration with proximal fibula arthroplasty [23], distal radius allograft [22, 25] or recycled autograft reconstruction [7], and custom prosthetic reconstruction [14, 30]. Despite obvious radiological changes, many patients do not experience pain or dysfunction that lead to additional surgical procedures [21]. Ulna translocation with wrist fusion provides a strong and stable wrist [5, 21, 29]. Donor site morbidity may occur when using an autograft of the iliac crest [31], fibular grafts [5, 21, 23, 32], or a hemicortical strut tibia [27]. Allograft-related concerns like nonunions and infection when using allografts for wrist fusion may be reduced when the wrist is reconstructed with ulna translocation [28]. In 2010, the senior author (MGA) reported good functional results, with a median (range) MSTS scores of 26 (20 to 28) in 87% of patients at a mean follow-up duration of 26 months [20]. These patients are not a part of this study as the senior author (MGA) changed hospitals in 2010 and no longer has access to their records. Encouraged by these results, we have continued to perform the ulna translocation and report our 10-year experience in this study. These results have been replicated [16, 24, 29], without improvement in objective or patient-reported outcomes. Modifications to ulna translocation have been suggested, and these variations have aimed to limit the failure of reconstruction [4] or preserve the mobility of the carpometacarpal joint [15]; however, these studies did not assess the functional and cosmetic outcome of the procedure. With our alteration of the surgical technique, we found better hand grip strength without a difference in MSTS or Mayo scores and improved cosmesis with respect to reduced wrist narrowing, as objectively measured by the wrist circumference.

Limitations

The biggest study limitation is that this is a retrospective analysis of a patient cohort. We acknowledge our lack of foresight in studying the modification prospectively. When we started performing the modification, we were not certain whether it would be very different, other than reducing the narrowing. We then realized that radialization also gave us ulnar deviation and better grip strength. The small numbers in each group is another drawback of this study. This is owing to the smaller numbers of such surgeries done overall. However, there are still differences between the two groups we have compared. Additionally, these groups were not well defined in the earlier period, when the second or third metacarpals were used without much thought except when plate fixation fit better. This may have expectedly introduced a selection bias. It seemed to make sense that the third metacarpal be aligned to the radius as it was in the center of the hand. In a few patients, the second metacarpal was used only because the plate we used for osteosynthesis fit better on the second metacarpal. As we analyzed the function and cosmesis, we realized that aligning the reconstructed radius with the second metacarpal would give better grip strength and cosmesis. This explains why in our study, there was an increased number of patients in the second metacarpal group from 2015 onward (8 of 10 patients in the third metacarpal group between 2010 and 2015 and 11 of 13 patients in the second metacarpal group between 2015 and 2018). Again, the only reason for using the third metacarpal in the more recent period was that the plate fit better when the third metacarpal was used.

The procedures were performed by a single surgeon (MGA), with a comparative analysis. It could be argued that the better results in the later group are because the surgeon gained experience and expertise over time. However, the senior surgeon (MGA) has performed ulna translocation since 2005, which is sufficient time to have passed the learning curve. Therefore, we believe that the outcome improvement is from the better alignment rather than better surgical skills. For this study, we included only patients operated on after 2010 because the senior surgeon changed hospitals in 2010. This is also the reason why we could not include our previous patients with a longer follow-up in this study; these patients were not accessible to us. We lost five patients to follow-up before 24 months; with only 28 patients overall, this is a serious limitation.

It is also a limitation that the functional evaluation was done by the treating team, adding bias. However, although those measuring grip strength were not blinded to the procedure, they had no idea of the study design regarding grip strength, which would prevent bias toward any group. In addition, grip strength and wrist circumference were measured objectively to eliminate the bias. In the absence of prospectively recorded grip strength (presurgical or ideally pretumor), corrections for hand dominance were based on the reports of the 10% rule for dominant-hand grip strength, its variance in the population, and limitation to right-handedness [2, 17, 19]; however, the use of the patient’s prospectively reported grip strength would better normalize the data in future studies.

Grip Strength and Outcomes Scores

Using a dynamometer to objectively measure grip strength, we were able to show that loss of grip strength was less in the second metacarpal group compared with the third metacarpal group after we corrected for dominance. This slightly better grip strength was not enough to cause a change in the functional sores like the MSTS or Mayo because the MSTS does not objectively mesure grip strength and the Mayo score would detect a change only if there is at least a 25% difference, which was not the case in our series. Some loss of grip strength is expected with a wrist fusion when compared with the normal side. In addition to reports supporting wrist dorsiflexion [3, 6, 8, 11-13], we reasoned that grip strength could be slightly improved by further radializing the translocated ulna and aligning it with the second metacarpal joint to achieve ulnar deviation, as demonstrated by Yuvaraj et al. [33]. The loss of grip strength from using the second metacarpal was less than the outcomes reported by Vyas et al. [29] and Qu et al. [21] (loss of 29% grip strength in operated limb). Although we cannot provide a direct comparison for a clinically important difference, we note that the median MSTS scores were higher in the second metacarpal group when compared with our previous series (median MSTS 27) [20] and when compared with Qu et al. [21] (mean MSTS 28) when wrist arthrodesis was performed without our modification.

Wrist Circumference

The wrist’s circumference was objectively improved through our modification of translocating the ulna segment to the radial-most carpus (scaphoid or scapholunate) and in axis with the second metacarpal versus the conventional lunate-scaphoid carpal fusion and third metacarpal axis, resulting in centralization over a single bone of the forearm and wrist narrowing. Leaving only one bone in the forearm in the distal part should reduce the wrist circumference and be visually obvious as a narrower wrist. We found no other reports that discussed wrist circumference. Although ulna translocation was first reported in 1982 [26], it did not become widely used. We reported our results in 2010 [20], and we still find that it has not become a popular method for reconstructing distal radius defects. Perhaps the main obstacle has been the obvious wrist narrowing associated with a single bone remaining in the distal forearm and the necessity of wrist fusion with accompanying loss of motion and grip strength. For surgeons who reconstruct distal radious defects, this procedure is not technically complicated.

Other Relevant Findings

The three soft tissue recurrences in this study were probably the result of narrow margins in two patients with very large tumors and contamination from a previous intralesional procedure in one patient. We do not believe that modifying the surgical technique has any effect on disease recurrence, but determining this was not the aim of the study. There were no complications related to reconstruction, infection, lysis, or fracture of the translocated ulna graft in our series, nor were there any implant-related complications. We attributed this to the presence of a live vascularized ulna segment with an attached periosteal and soft tissue cover that provided an environment for healing and inherent protection from infection compared with a free nonvascularized autograft or allograft. However, this is speculation based on the results of this study and an assessment of complications described in reports of other reconstruction methods [9]. A larger multicenter series and longer follow-up duration would be necessary to substantiate the outcomes of our modification of the ulna translocation procedure.

With our described modifications, we believe that the grip strength and cosmesis in terms of wrist circimference narrowing have been improved. We therefore hope that the procedure gains more widespread acceptance.

Conclusion

Our modification of an established procedure, wrist arthrodesis, after ulna translocation using the second metacarpal joint provides a functional position with ulnar deviation and is associated with a slightly improved grip strength but no difference in MSTS or Mayo wrist scores. Radialization of the ulna by using the second metacarpal and a modified dorsolateral surgical incision reduces the narrowing of wrist circumference for patients undergoing reconstruction with a single-bone wrist arthrodesis, which has been one of the drawbacks of this procedure. We hope that this improvement in wrist appearance and grip strength encourages more surgeons to consider this modification when offering wrist arthrodesis to their patients.

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