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Vascularized Metatarsophalangeal Joint Transfer for Giant Cell Tumor of the Proximal Phalanx of the Hand

Kanaya, Kohei M.D.; Wada, Takuro M.D.; Kitajima, Kumiko M.D.; Yamashita, Toshihiko M.D.

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Plastic and Reconstructive Surgery: January 2008 - Volume 121 - Issue 1 - p 354-355
doi: 10.1097/01.prs.0000300298.56732.ce
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Sir:

When en bloc excision of a giant cell tumor of the phalanx in the hand involving the articular surface is performed, joint reconstruction poses an additional problem.1–4 We describe a case that was treated using a vascularized metatarsophalangeal joint transfer to reconstruct the metacarpophalangeal joint, after en bloc excision that included the metacarpal head for a giant cell tumor in the base of the proximal phalanx.

A 33-year-old electrical engineer was referred to our hospital due to a 5-month history of progressive swelling and pain in the proximal portion of the right middle finger. Radiographs demonstrated cortical thinning with a pathological fracture and a lytic expansile lesion in the proximal end of the proximal phalanx (Fig. 1). A pathological diagnosis of giant cell tumor was made. En bloc excision of the tumor including the metacarpophalangeal joint was performed. The proximal two-thirds of the proximal phalanx and the metacarpal head including the metacarpophalangeal joint were excised. The extensor mechanism and flexor tendons were preserved. The metatarsophalangeal joint of the right second toe was raised and reversed by 180 degrees rotation axially and was fixed in place in the hand using Kirschner wires, as previously described.5

Fig. 1.
Fig. 1.:
Initial radiograph of the patient’s hand showing a lytic epiphyseal tumor in the proximal phalanx of the middle finger.

At 2 years after surgery, the metacarpophalangeal joint was stable and had 85 degrees of flexion and no lack of extension (Fig. 2). Good lateral mobility was seen. Radiographs revealed no arthritic change and maintenance of joint space. Grip strength was 55 kg in the right hand and 58 kg in the left hand. The patient was pleased with the functional results and appearance and had returned to work as an electrical engineer.

Fig. 2.
Fig. 2.:
Metacarpophalangeal joint of the right middle finger flexed in 85 degrees.

Treatment of aggressive benign phalangeal bone tumors such as giant cell tumors and aneurysmal bone cysts is controversial.1–4 Some authors have recommended primary en bloc excision or amputation because of the high rate of recurrence after curettage and bone grafting.1 When en bloc excision of a tumor involving the articular surface is performed, joint reconstruction poses an additional problem.

Results of reconstruction with a nonvascularized osteoarticular autograft from the foot or an osteroarticular allograft have been reported by several authors.2–4 They reported that there was no recurrence after 2 or 3 years and that the operated fingers had retained satisfactory function, but long-term preservation of the joints was not described.

To our knowledge, this is the first report of application of a vascularized toe joint transfer after en bloc excision of a giant cell tumor including the metacarpophalangeal joint. We previously reported that the metatarsophalangeal joint transfer provided a large range of motion and good lateral stability and mobility, and preserved its joint space for 14 years.5 Therefore, the transferred joint function is expected to be preserved for more than 10 years after surgery. While the disadvantages are a long procedure for microsurgery and risk of failure, the use of an metatarsophalangeal joint transfer for reconstruction after en bloc excision of a giant cell tumor of the phalangeal bone involving the metacarpophalangeal joint is a valuable alternative to an osteoarticular autograft or allograft.

Kohei Kanaya, M.D.

Takuro Wada, M.D.

Kumiko Kitajima, M.D.

Toshihiko Yamashita, M.D.

Department of Orthopedic Surgery

Sapporo Medical University

Sapporo, Japan

REFERENCES

1. Averill, R. M., Smith, R. J., and Campbell, C. J. Giant-cell tumors of the bones of the hand. J. Hand Surg. (Am.) 5: 39, 1980.
2. Athanasian, E. A., Wold, L. E., and Amadio, P. C. Giant cell tumors of the bones of the hand. J. Hand Surg. (Am.) 22: 91, 1997.
3. Smith, J. A., and Millender, J. H. Treatment of recurrent giant-cell tumor the digit by phalangeal excision and toe phalanx transplant: A case report. J. Hand Surg. (Am.) 4: 164, 1979.
4. Pardo-Montaner, J., Pina-Medina, A., and Barcelo-Alcaniz, M. Recurrent metacarpal giant cell tumour treated by en bloc resection and metatarsal transfer. J. Hand Surg. (Br.) 23: 275, 1998.
5. Kanaya, K., Wada, T., Usui, M., et al. Fourteen-year results of reversed vascularized second metatarsophalangeal joint transfer: A case report. J. Hand Surg. (Am.) 30: 120, 2005.

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