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Central column reconstruction following total resection of a third metacarpal giant cell tumour
ARTICLE IN PRESS CENTRAL COLUMN RECONSTRUCTION FOLLOWING TOTAL RESECTION OF A THIRD METACARPAL GIANT CELL TUMOUR J. Y. L. LEE, R. W. H. PHO and D. S. C. YEO From the Department of Hand Surgery, Singapore General Hospital, Singapore, Department of Hand and Microsurgical Reconstruction, National University Hospital, Singapore and Rehabilitation Centre, National University Hospital, Singapore
A wide resection of a giant cell tumour involving the entire middle metacarpal is presented. Reconstruction preserving the central column and metacarpophalangeal joint was achieved using autologous iliac crest bone as a spacer and structural support. The fibro-osseous cartilage portion of the iliac graft was used as a ‘‘hemi-joint’’ replacement. By using a bridging bone graft and screw to fuse the adjacent proximal phalanges of the middle and index fingers, a stable ‘‘internal syndactyly’’ was achieved. Although independent index and middle finger motion was sacrificed, the approach allowed wide resection for local tumour control, re-established structural integrity, preserved metacarpophalangeal joint motion and allowed early motion. The aesthetic result was also good. Journal of Hand Surgery (British and European Volume, 2005) 30B: 6: 650–655 Keywords: hand tumours, giant cell tumours, metacarpal reconstruction, metacarpalphalangeal joint reconstruction, hand reconstruction
The patient refused to have a ray amputation. At operation, exposure was achieved through a dorsal longitudinal curvilinear incision. The tumour was found to involve the distal articular surface of the middle metacarpal and extended to the base of the metacarpal. There was loss of the metacarpal height and rotational deformity. Some palmar and dorsal soft tissue extension was noted but the tendons were uninvolved. En-bloc resection of the middle metacarpal and tumour was performed. Distally, the resection was performed by incising the inter-metacarpal ligaments and proximal insertions of the collateral ligaments of the metacarpophalangeal joint, preserving them for reconstruction. Proximally, a thin remnant of the base of the third metacarpal was preserved with its articular cartilage and subchondral bone. The metacarpal and tumour was elevated from the palmar structures and disarticulated at the metacarpophalangeal joint. The final histopathological report confirmed a Memorial Sloane Kettering Cancer Centre grade 1 giant cell tumour of bone (Huvos, 1991). Following resection, a floating middle finger with a segmental central column deficit required reconstruction. This required (a) a spacer for structural support to provide axial alignment for the middle finger, (b) a proximal metacarpophalangeal joint reconstruction. A non-vascularized, iliac crest, tri-cortical bone graft was harvested from the contralateral hip. Proximal fixation was achieved using a Leibinger square six-hole plate to the capitate. The original shortening of approximately 1 cm was deemed acceptable. The fibro-osseous cartilage of the iliac crest was harvested on the distal edge of the graft and served to resurface the proximal metacarpophalangeal hemi-joint. The collateral ligaments were
CASE REPORT A 52-year-old right-handed Chinese housewife presented with a 6-month history of pain and swelling over the dorsum of the hand and mid-palm. She had first noted the swelling after minor trauma to the back of the hand and had, initially, sought treatment by a traditional Chinese physician. She had no systemic signs or symptoms. On examination, she had visible swelling over the dorsal and palmar aspects of the right hand. Flexor and extensor tendon function was normal. The middle metacarpophalangeal joint range of motion was 101 to 901. There was no sensory deficit. Her full blood count, urea and electrolytes, ESR, CRP and bone biochemistry were all normal. Chest X-ray and CT scans to screen for metastases were normal. X-rays of the right hand revealed an expansile, radiolucent, septated lesion of the middle metacarpal, extending from the proximal shaft to the distal articular surface (Fig 1A and B). The bone was slightly shortened, suggesting a pathological fracture. Further tumour definition was provided by a non-contrast T1 and T2 weighted MRI with axial, sagittal and coronal views (Fig 2A and B). The lesion measured 5.5 3 2.5 cm. It was low on T1, high on T2, with heterogeneity suggestive of necrosis or haemorrhage. There were septations without evidence of fluid levels. The mass involved the distal articular surface but did not involve the metacarpophalangeal joint. The diagnosis of a giant cell tumour of the right middle metacarpal was made. This was graded as Campanacci grade 2 radiographically and as an Enneking stage 2 tumour clinically (Campanacci et al., 1975; Enneking, 1983). 650
ARTICLE IN PRESS CENTRAL COLUMN RECONSTRUCTION
651
Fig 1 (A, B) Pre-operative radiographs demonstrating an expansile, septated radiolucent lesion of the middle metacarpal with cortical penetration and involvement of the articular cartilage of the metacarpophalangeal joint. There is loss of metacarpal height suggesting a pathological fracture had occurred.
reconstructed by suturing the distal collateral ligament remnants to the graft using 4/0 interosseous Ethibond. Antero-posterior and rotational stability of the construct was achieved using a 3.5 mm AO cancellous screw between the distal 1/3 of the index and middle metacarpals, augmented with two 1.1 mm K-wires. The adjacent proximal phalangeal bases of the middle and index fingers were rawed and ‘‘internally-syndactylized’’ using a bridging strut bone graft secured by the passage of a 1.1 mm K-wire through the bone strut. A 3.5 mm cortical screw passed palmar to the bone strut provided further stability to the construct (Fig 3). The wound was closed over a drain with bulky dressings and a POP backslab for support. Ward nursing included elevation and circulation monitoring. The patient’s progress was uncomplicated and she was discharged on the fourth postoperative day. Postoperatively, the hand was maintained in a thermoplastic resting splint and a programme of active and passive interval mobilization initiated 7 days after surgery. Additional buddy splinting of the index to middle fingers allowed early
mobilization at the metacarpophalangeal joints. The transfixion K-wires were removed at 8 months, the screw and bone bridge providing continued stability. At 1 year and 9 months after surgery, preservation of graft alignment was demonstrated on X-ray with minimal graft resorption and no further loss of metacarpal height (Fig 4A and B). Her hand function at this time is indicated in Table 1. She was unable to make a full fist and her grip strength was diminished. She was however, able to oppose all her fingertips and exhibited excellent key pinch and tripod pinch (Figs 5 and 6). She was able to perform all her activities of daily living, including the use of kitchen implements and chopsticks, independently, with her affected hand.
DISCUSSION Giant cell tumours of the hand account for approximately 2% to 5% of all giant cell tumours (Athanasian et al., 1997a). The metaphyseal region of the metacarpals
ARTICLE IN PRESS 652
THE JOURNAL OF HAND SURGERY VOL. 30B No. 6 DECEMBER
2005
Fig 2 (A, B) MRI scans demonstrated a 5.5 3 2.5 cm expansile lesion with septations.
and phalanges is the site of origin for most of these tumours. Compared with giant cell tumours arising at more proximal locations, these tumours arising in the hand more commonly present at advanced stages with significant bony destruction and diaphyseal extension. Joint involvement is not uncommon and complicates treatment. The primary goal of treatment of these benign but locally aggressive tumours of the hand must be eradication of disease. Concerns of reconstruction and function must be given secondary consideration and compromise of these principles in tumour treatment may result in increased rates of recurrence (Athanasian et al., 1997). Given the high local recurrence rates for giant cell tumours in the hand with simple curettage and bone grafting (Athanasian et al., 1997; Patel et al., 1987; Sanjay et al., 1996), we carried out a local resection despite the reconstructive problems following nearcomplete resection of a metacarpal. Precise relationships between length, mobility and position of each ray are necessary for optimal convergence during digito-palmar grip. The central column of the hand is a longitudinal kinetic chain extending from the lunate and capitate to the central metacarpals to the phalanges, the keystone of which is the metacarpophalangeal joint. The central metacarpal also forms the keystone of the transverse metacarpal arch, being the fixed element against which the peripheral metacarpals
approximate in order to deepen the concavity of the palmar gutter. Preservation of the curvatures of both the transverse and longitudinal axes is essential for prehension. Preservation of the length of the central metacarpal maintains the obliquity of the transverse palmar axis, which again contributes to convergence during digito-palmar grip (Tubiana, 1981). Wide excision permits digital salvage but creates a segmental defect. Several reconstructive techniques have been described to provide strut support and stabilization of the metacarpal, allowing preservation of motion and opposability. Replacement of metacarpal loss may be achieved by autogenous structural bone grafts, allogeneic bone grafts (Patradul et al., 2001; Smith and Brushart, 1985; Trumble and Friedlaender, 1987; Upton and Glowacki, 1992) or silastic spacers (Chatterjee et al., 2004). Vascularized osteocutaneous flaps have also been used (Akin et al., 2002; Lee et al., 2000), but these vascularized transfers are perhaps most useful for composite tissue defects involving bone and soft tissue. The concurrent loss of the metacarpophalangeal joint further complicates reconstruction. Arthodesis of the metacarpophalangeal joint is an option but results in a significant functional impediment and disability, especially in the central rays. It does, however, provide a functional and durable result appropriate for young patients with heavy, weight-bearing, occupational demands (Athanasian et al., 1997). In other patients, the
ARTICLE IN PRESS CENTRAL COLUMN RECONSTRUCTION
653
Fig 3 (A, B) Postoperative radiographs demonstrating the use of a tricortical iliac crest bone graft and the method of internal syndactyly.
loss of side to side metacarpophalangeal joint mobility and the inability to place the hand flat may be unacceptable (Athanasian et al., 1997). When total reconstruction includes the metacarpophalangeal joint, motion preserving options include vascularized joint transfers, osteoarticular autografts (Pardo-Montaner et al., 1998), interpositional arthroplasties and implant arthroplasties. The literature includes descriptions of free vascularized metatarsal and metatarsophalangeal joint transfers from the foot (Rose, 1984). Vascularized joint transfers from the foot provide the potential for useful, although limited, range of motion in the metacarpophalangeal joint. The technical complexity and donor-site morbidity of this procedure, however, may make it inappropriate for oncologic reconstructions, in which recurrence risk is high. In the elderly patient, the potential risk of ambulatory disability would make this option less acceptable. Two cases of autogenous fibular graft and silicone implant arthroplasty (Athanasian et al., 1997) and one case using iliac crest bone graft and silicone implant arthroplasty (Carlow and Khuri, 1985) have been
described with good functional results. This technique sacrifices the uninvolved articular cartilage of the proximal phalanx. These authors acknowledged that the risks of bone resorption, implant loosening and implant failure are considerable and that this technique should only be considered as a temporary solution, with a long-term durability that has not yet been established. Our approach utilizes the concept of (a) transferring iliac crest structural bone graft with overlying fibroosseous cartilage and periosteum as a hemi-joint transfer and (b) an ‘‘internal syndactyly’’ which stabilizes the floating proximal phalanx by means of an internal ‘‘buddy splint’’ and allows early mobilization of the metacarpophalangeal joint. This is achieved by the use of a bridging bone graft between the bases of the proximal phalanges of adjacent digits. This technique relieves the axial stress loading along the cortical graft to minimize stress fracture and collapse. This stability is sufficient to permit early mobilization. The bone syndactyly is hidden well within the existing webspace and the aesthetic result is pleasing (Fig 5). This technique of ‘‘internal syndactyly’’ was probably first used by Dr BB Joshi, in India, on a rheumatoid patient
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2005
Fig 4 (A, B) Radiographs demonstrating the postoperative appearance at 1 year. Minimal graft resorption has occurred and there is no loss of metacarpal height. Table 1—The results of assessment at 1 year from surgery (A) Ranges of motion of the joints of the fingers of the right hand Digit MCPj (deg) PIPj (deg) DIPj (deg) Index Middle Ring Little
18 to 64 10 to 64 18 to 68 25 to 75
5 to 64 10 to 34 18 to105 18–102
(B) Strength of the hand Strength Right (kg)
Left (kg)
Grip Key pinch Tripod pinch
9.0 3.5 3.5
8 to 62 35 to 75 18 to 50 5 to 62
24.0 4.7 3.5
to correct ulnar drift (unpublished) and was subsequently used in trauma cases and first published in the French literature (Foucher, 1995). While the plain radiographs at 1 year and 9 months demonstrate persistence of the graft without evidence of
Fig 5 Postoperative appearance of the hand at 8 months. A good aesthetic result is achieved.
resorption or collapse, these findings can occasionally be deceptive and there are concerns as to the long-term survival of larger non-vascularized bone grafts. Bone
ARTICLE IN PRESS CENTRAL COLUMN RECONSTRUCTION
Fig. 6 A strong stable tripod pinch is preserved.
scans are unreliable evidence of viability as the region is likely to be ‘‘hot’’ long after surgery. Similarly, MRIs would not be appropriate, due to the presence of metallic implants. There is however, a very vascular bed supporting the iliac bone graft in this situation. The graft is shielded from excessive stress loading by the distal bony phalangeal syndactyly and the structural support provided by adjacent metacarpals, reducing the potential for micro-fracture and collapse. This technique, however, sacrifices independent motion of the adjacent finger. Any resultant stiffness in the reconstructed joint will also jeopardize the motion of adjacent joints. While independent index pointing is lost, a strong dynamic tripod or tridactyl, is preserved (Fig 6). A tripod pinch strength equal to the contralateral side was achieved. References Akin S, Ozgenel Y, Ozcan M (2002). Osteocutaneous posterior interosseous flap for reconstruction of the metacarpal bone and soft-tissue defects in the hand. Plastic and Reconstructive Surgery, 109: 982–987. Athanasian EA, Bishop AT, Amadio PC (1997). Autogenous fibular graft and silicone implant arthroplasty following resection of giant cell tumor of the metacarpal: a report of two cases. Journal of Hand Surgery, 22A: 504–507. Athanasian EA, Wold LE, Amadio PC (1997a). Giant cell tumors of the bones of the hand. Journal of Hand Surgery, 22A: 91–98.
655
Campanacci M, Giunti A, Olmi R (1975). Metaphyseal and diaphyseal localization of giant cell tumors. La Chirurgia degli Organi di Movimento, 62: 29–34. Carlow SB, Khuri SM (1985). Metacarpal resection with a contoured iliac bone graft and silicone rubber implant for metacarpal giant cell tumour: a case report. Journal of Hand Surgery, 10A: 275–278. Chatterjee A, Dholakia DB, Vaidya SV (2004). Silastic replacement of metacarpal after resection of giant cell tumor: a case report. Journal of Hand Surgery, 29B: 402–405. Enneking WF. Musculoskeletal tumor surgery, New York, Churchill, Livingstone, 1983. Foucher G (1995). Une technique de sauvetage: l’ope´ration ‘‘Perroquet’’. Annales de Chirurgie de la Main et du Membre Superieur, 14: 96–99. Huvos AG. Chapter 17: giant cell tumor of bone. In: Bone tumors: diagnosis, treatment and prognosis, 2nd edn. Philadelphia, WB Saunders, 1991: 429–468. Lee HB, Tark KC, Kang SY, Kim SW, Chung YK (2000). Reconstruction of composite metacarpal defects using a fibula free flap. Plastic and Reconstructive Surgery, 105: 1448–1452. Pardo-Montaner J, Pina-Medina A, Barcelo-Alcan˜iz M (1998). Recurrent metacarpal giant cell tumour treated by en bloc resection and metatarsal transfer. Journal of Hand Surgery, 23B: 275–278. Patel MR, Desai SS, Gordon SL, Nemberg GA, Sclafani SJ, Vigorita VJ, Mirra JH, Song HW (1987). Management of skeletal giant cell tumours of the phalanges of the hand. Journal of Hand Surgery, 12A: 70–77. Patradul A, Kitidumrongsook P, Parkpian V, Ngarmukos C (2001). Allograft replacement in giant cell tumour of the hand. Hand Surgery, 6: 59–65. Rose EH (1984). Reconstruction of central metacarpal ray defects of the hand with a free vascularised double metatarsal and metatarsophalangeal joint transfer. Journal of Hand Surgery, 9A: 28–31. Sanjay BKS, Raj GA, Younge DA (1996). Giant cell tumours of the hand. Journal of Hand Surgery, 21B: 683–687. Smith RJ, Brushart TM (1985). Allograft bone for metacarpal reconstruction. Journal of Hand Surgery, 10A: 325–334. Trumble TE, Friedlaender GE (1987). Allogeneic bone in the treatment of tumors, trauma and congenital anomalies of the hand. Orthopedic Clinics of North America, 18: 301–310. Tubiana R. Chapter 4: Architecture and function of the hand. In: Tubiana R (Ed). The hand, Philadelphia, WB Saunders, 1981, vol. 1: 19–53. Upton J, Glowacki J (1992). Hand reconstruction with allograft demineralised bone: twenty-six implants in twelve patients. Journal of Hand Surgery, 17A: 704–713. Received: 21 December 2004 Accepted after revision: 6 July 2005 Dr Jonathan Y.L. Lee, Department of Hand Surgery, Singapore General Hospital, Outram Road, 169608, Singapore. Tel.: +65 6321 4588; fax: +65 6321 3573. E-mail: leeyiliang@pacific.net.sg
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2005.07.007 available online at http://www.sciencedirect.com
A wide resection of a giant cell tumour involving the entire middle metacarpal is presented. Reconstruction preserving the central column and metacarpophalangeal joint was achieved using autologous iliac crest bone as a spacer and structural support. The fibro-osseous cartilage portion of the iliac graft was used as a ‘‘hemi-joint’’ replacement. By using a bridging bone graft and screw to fuse the adjacent proximal phalanges of the middle and index fingers, a stable ‘‘internal syndactyly’’ was achieved. Although independent index and middle finger motion was sacrificed, the approach allowed wide resection for local tumour control, re-established structural integrity, preserved metacarpophalangeal joint motion and allowed early motion. The aesthetic result was also good. Journal of Hand Surgery (British and European Volume, 2005) 30B: 6: 650–655 Keywords: hand tumours, giant cell tumours, metacarpal reconstruction, metacarpalphalangeal joint reconstruction, hand reconstruction
The patient refused to have a ray amputation. At operation, exposure was achieved through a dorsal longitudinal curvilinear incision. The tumour was found to involve the distal articular surface of the middle metacarpal and extended to the base of the metacarpal. There was loss of the metacarpal height and rotational deformity. Some palmar and dorsal soft tissue extension was noted but the tendons were uninvolved. En-bloc resection of the middle metacarpal and tumour was performed. Distally, the resection was performed by incising the inter-metacarpal ligaments and proximal insertions of the collateral ligaments of the metacarpophalangeal joint, preserving them for reconstruction. Proximally, a thin remnant of the base of the third metacarpal was preserved with its articular cartilage and subchondral bone. The metacarpal and tumour was elevated from the palmar structures and disarticulated at the metacarpophalangeal joint. The final histopathological report confirmed a Memorial Sloane Kettering Cancer Centre grade 1 giant cell tumour of bone (Huvos, 1991). Following resection, a floating middle finger with a segmental central column deficit required reconstruction. This required (a) a spacer for structural support to provide axial alignment for the middle finger, (b) a proximal metacarpophalangeal joint reconstruction. A non-vascularized, iliac crest, tri-cortical bone graft was harvested from the contralateral hip. Proximal fixation was achieved using a Leibinger square six-hole plate to the capitate. The original shortening of approximately 1 cm was deemed acceptable. The fibro-osseous cartilage of the iliac crest was harvested on the distal edge of the graft and served to resurface the proximal metacarpophalangeal hemi-joint. The collateral ligaments were
CASE REPORT A 52-year-old right-handed Chinese housewife presented with a 6-month history of pain and swelling over the dorsum of the hand and mid-palm. She had first noted the swelling after minor trauma to the back of the hand and had, initially, sought treatment by a traditional Chinese physician. She had no systemic signs or symptoms. On examination, she had visible swelling over the dorsal and palmar aspects of the right hand. Flexor and extensor tendon function was normal. The middle metacarpophalangeal joint range of motion was 101 to 901. There was no sensory deficit. Her full blood count, urea and electrolytes, ESR, CRP and bone biochemistry were all normal. Chest X-ray and CT scans to screen for metastases were normal. X-rays of the right hand revealed an expansile, radiolucent, septated lesion of the middle metacarpal, extending from the proximal shaft to the distal articular surface (Fig 1A and B). The bone was slightly shortened, suggesting a pathological fracture. Further tumour definition was provided by a non-contrast T1 and T2 weighted MRI with axial, sagittal and coronal views (Fig 2A and B). The lesion measured 5.5 3 2.5 cm. It was low on T1, high on T2, with heterogeneity suggestive of necrosis or haemorrhage. There were septations without evidence of fluid levels. The mass involved the distal articular surface but did not involve the metacarpophalangeal joint. The diagnosis of a giant cell tumour of the right middle metacarpal was made. This was graded as Campanacci grade 2 radiographically and as an Enneking stage 2 tumour clinically (Campanacci et al., 1975; Enneking, 1983). 650
ARTICLE IN PRESS CENTRAL COLUMN RECONSTRUCTION
651
Fig 1 (A, B) Pre-operative radiographs demonstrating an expansile, septated radiolucent lesion of the middle metacarpal with cortical penetration and involvement of the articular cartilage of the metacarpophalangeal joint. There is loss of metacarpal height suggesting a pathological fracture had occurred.
reconstructed by suturing the distal collateral ligament remnants to the graft using 4/0 interosseous Ethibond. Antero-posterior and rotational stability of the construct was achieved using a 3.5 mm AO cancellous screw between the distal 1/3 of the index and middle metacarpals, augmented with two 1.1 mm K-wires. The adjacent proximal phalangeal bases of the middle and index fingers were rawed and ‘‘internally-syndactylized’’ using a bridging strut bone graft secured by the passage of a 1.1 mm K-wire through the bone strut. A 3.5 mm cortical screw passed palmar to the bone strut provided further stability to the construct (Fig 3). The wound was closed over a drain with bulky dressings and a POP backslab for support. Ward nursing included elevation and circulation monitoring. The patient’s progress was uncomplicated and she was discharged on the fourth postoperative day. Postoperatively, the hand was maintained in a thermoplastic resting splint and a programme of active and passive interval mobilization initiated 7 days after surgery. Additional buddy splinting of the index to middle fingers allowed early
mobilization at the metacarpophalangeal joints. The transfixion K-wires were removed at 8 months, the screw and bone bridge providing continued stability. At 1 year and 9 months after surgery, preservation of graft alignment was demonstrated on X-ray with minimal graft resorption and no further loss of metacarpal height (Fig 4A and B). Her hand function at this time is indicated in Table 1. She was unable to make a full fist and her grip strength was diminished. She was however, able to oppose all her fingertips and exhibited excellent key pinch and tripod pinch (Figs 5 and 6). She was able to perform all her activities of daily living, including the use of kitchen implements and chopsticks, independently, with her affected hand.
DISCUSSION Giant cell tumours of the hand account for approximately 2% to 5% of all giant cell tumours (Athanasian et al., 1997a). The metaphyseal region of the metacarpals
ARTICLE IN PRESS 652
THE JOURNAL OF HAND SURGERY VOL. 30B No. 6 DECEMBER
2005
Fig 2 (A, B) MRI scans demonstrated a 5.5 3 2.5 cm expansile lesion with septations.
and phalanges is the site of origin for most of these tumours. Compared with giant cell tumours arising at more proximal locations, these tumours arising in the hand more commonly present at advanced stages with significant bony destruction and diaphyseal extension. Joint involvement is not uncommon and complicates treatment. The primary goal of treatment of these benign but locally aggressive tumours of the hand must be eradication of disease. Concerns of reconstruction and function must be given secondary consideration and compromise of these principles in tumour treatment may result in increased rates of recurrence (Athanasian et al., 1997). Given the high local recurrence rates for giant cell tumours in the hand with simple curettage and bone grafting (Athanasian et al., 1997; Patel et al., 1987; Sanjay et al., 1996), we carried out a local resection despite the reconstructive problems following nearcomplete resection of a metacarpal. Precise relationships between length, mobility and position of each ray are necessary for optimal convergence during digito-palmar grip. The central column of the hand is a longitudinal kinetic chain extending from the lunate and capitate to the central metacarpals to the phalanges, the keystone of which is the metacarpophalangeal joint. The central metacarpal also forms the keystone of the transverse metacarpal arch, being the fixed element against which the peripheral metacarpals
approximate in order to deepen the concavity of the palmar gutter. Preservation of the curvatures of both the transverse and longitudinal axes is essential for prehension. Preservation of the length of the central metacarpal maintains the obliquity of the transverse palmar axis, which again contributes to convergence during digito-palmar grip (Tubiana, 1981). Wide excision permits digital salvage but creates a segmental defect. Several reconstructive techniques have been described to provide strut support and stabilization of the metacarpal, allowing preservation of motion and opposability. Replacement of metacarpal loss may be achieved by autogenous structural bone grafts, allogeneic bone grafts (Patradul et al., 2001; Smith and Brushart, 1985; Trumble and Friedlaender, 1987; Upton and Glowacki, 1992) or silastic spacers (Chatterjee et al., 2004). Vascularized osteocutaneous flaps have also been used (Akin et al., 2002; Lee et al., 2000), but these vascularized transfers are perhaps most useful for composite tissue defects involving bone and soft tissue. The concurrent loss of the metacarpophalangeal joint further complicates reconstruction. Arthodesis of the metacarpophalangeal joint is an option but results in a significant functional impediment and disability, especially in the central rays. It does, however, provide a functional and durable result appropriate for young patients with heavy, weight-bearing, occupational demands (Athanasian et al., 1997). In other patients, the
ARTICLE IN PRESS CENTRAL COLUMN RECONSTRUCTION
653
Fig 3 (A, B) Postoperative radiographs demonstrating the use of a tricortical iliac crest bone graft and the method of internal syndactyly.
loss of side to side metacarpophalangeal joint mobility and the inability to place the hand flat may be unacceptable (Athanasian et al., 1997). When total reconstruction includes the metacarpophalangeal joint, motion preserving options include vascularized joint transfers, osteoarticular autografts (Pardo-Montaner et al., 1998), interpositional arthroplasties and implant arthroplasties. The literature includes descriptions of free vascularized metatarsal and metatarsophalangeal joint transfers from the foot (Rose, 1984). Vascularized joint transfers from the foot provide the potential for useful, although limited, range of motion in the metacarpophalangeal joint. The technical complexity and donor-site morbidity of this procedure, however, may make it inappropriate for oncologic reconstructions, in which recurrence risk is high. In the elderly patient, the potential risk of ambulatory disability would make this option less acceptable. Two cases of autogenous fibular graft and silicone implant arthroplasty (Athanasian et al., 1997) and one case using iliac crest bone graft and silicone implant arthroplasty (Carlow and Khuri, 1985) have been
described with good functional results. This technique sacrifices the uninvolved articular cartilage of the proximal phalanx. These authors acknowledged that the risks of bone resorption, implant loosening and implant failure are considerable and that this technique should only be considered as a temporary solution, with a long-term durability that has not yet been established. Our approach utilizes the concept of (a) transferring iliac crest structural bone graft with overlying fibroosseous cartilage and periosteum as a hemi-joint transfer and (b) an ‘‘internal syndactyly’’ which stabilizes the floating proximal phalanx by means of an internal ‘‘buddy splint’’ and allows early mobilization of the metacarpophalangeal joint. This is achieved by the use of a bridging bone graft between the bases of the proximal phalanges of adjacent digits. This technique relieves the axial stress loading along the cortical graft to minimize stress fracture and collapse. This stability is sufficient to permit early mobilization. The bone syndactyly is hidden well within the existing webspace and the aesthetic result is pleasing (Fig 5). This technique of ‘‘internal syndactyly’’ was probably first used by Dr BB Joshi, in India, on a rheumatoid patient
ARTICLE IN PRESS 654
THE JOURNAL OF HAND SURGERY VOL. 30B No. 6 DECEMBER
2005
Fig 4 (A, B) Radiographs demonstrating the postoperative appearance at 1 year. Minimal graft resorption has occurred and there is no loss of metacarpal height. Table 1—The results of assessment at 1 year from surgery (A) Ranges of motion of the joints of the fingers of the right hand Digit MCPj (deg) PIPj (deg) DIPj (deg) Index Middle Ring Little
18 to 64 10 to 64 18 to 68 25 to 75
5 to 64 10 to 34 18 to105 18–102
(B) Strength of the hand Strength Right (kg)
Left (kg)
Grip Key pinch Tripod pinch
9.0 3.5 3.5
8 to 62 35 to 75 18 to 50 5 to 62
24.0 4.7 3.5
to correct ulnar drift (unpublished) and was subsequently used in trauma cases and first published in the French literature (Foucher, 1995). While the plain radiographs at 1 year and 9 months demonstrate persistence of the graft without evidence of
Fig 5 Postoperative appearance of the hand at 8 months. A good aesthetic result is achieved.
resorption or collapse, these findings can occasionally be deceptive and there are concerns as to the long-term survival of larger non-vascularized bone grafts. Bone
ARTICLE IN PRESS CENTRAL COLUMN RECONSTRUCTION
Fig. 6 A strong stable tripod pinch is preserved.
scans are unreliable evidence of viability as the region is likely to be ‘‘hot’’ long after surgery. Similarly, MRIs would not be appropriate, due to the presence of metallic implants. There is however, a very vascular bed supporting the iliac bone graft in this situation. The graft is shielded from excessive stress loading by the distal bony phalangeal syndactyly and the structural support provided by adjacent metacarpals, reducing the potential for micro-fracture and collapse. This technique, however, sacrifices independent motion of the adjacent finger. Any resultant stiffness in the reconstructed joint will also jeopardize the motion of adjacent joints. While independent index pointing is lost, a strong dynamic tripod or tridactyl, is preserved (Fig 6). A tripod pinch strength equal to the contralateral side was achieved. References Akin S, Ozgenel Y, Ozcan M (2002). Osteocutaneous posterior interosseous flap for reconstruction of the metacarpal bone and soft-tissue defects in the hand. Plastic and Reconstructive Surgery, 109: 982–987. Athanasian EA, Bishop AT, Amadio PC (1997). Autogenous fibular graft and silicone implant arthroplasty following resection of giant cell tumor of the metacarpal: a report of two cases. Journal of Hand Surgery, 22A: 504–507. Athanasian EA, Wold LE, Amadio PC (1997a). Giant cell tumors of the bones of the hand. Journal of Hand Surgery, 22A: 91–98.
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Campanacci M, Giunti A, Olmi R (1975). Metaphyseal and diaphyseal localization of giant cell tumors. La Chirurgia degli Organi di Movimento, 62: 29–34. Carlow SB, Khuri SM (1985). Metacarpal resection with a contoured iliac bone graft and silicone rubber implant for metacarpal giant cell tumour: a case report. Journal of Hand Surgery, 10A: 275–278. Chatterjee A, Dholakia DB, Vaidya SV (2004). Silastic replacement of metacarpal after resection of giant cell tumor: a case report. Journal of Hand Surgery, 29B: 402–405. Enneking WF. Musculoskeletal tumor surgery, New York, Churchill, Livingstone, 1983. Foucher G (1995). Une technique de sauvetage: l’ope´ration ‘‘Perroquet’’. Annales de Chirurgie de la Main et du Membre Superieur, 14: 96–99. Huvos AG. Chapter 17: giant cell tumor of bone. In: Bone tumors: diagnosis, treatment and prognosis, 2nd edn. Philadelphia, WB Saunders, 1991: 429–468. Lee HB, Tark KC, Kang SY, Kim SW, Chung YK (2000). Reconstruction of composite metacarpal defects using a fibula free flap. Plastic and Reconstructive Surgery, 105: 1448–1452. Pardo-Montaner J, Pina-Medina A, Barcelo-Alcan˜iz M (1998). Recurrent metacarpal giant cell tumour treated by en bloc resection and metatarsal transfer. Journal of Hand Surgery, 23B: 275–278. Patel MR, Desai SS, Gordon SL, Nemberg GA, Sclafani SJ, Vigorita VJ, Mirra JH, Song HW (1987). Management of skeletal giant cell tumours of the phalanges of the hand. Journal of Hand Surgery, 12A: 70–77. Patradul A, Kitidumrongsook P, Parkpian V, Ngarmukos C (2001). Allograft replacement in giant cell tumour of the hand. Hand Surgery, 6: 59–65. Rose EH (1984). Reconstruction of central metacarpal ray defects of the hand with a free vascularised double metatarsal and metatarsophalangeal joint transfer. Journal of Hand Surgery, 9A: 28–31. Sanjay BKS, Raj GA, Younge DA (1996). Giant cell tumours of the hand. Journal of Hand Surgery, 21B: 683–687. Smith RJ, Brushart TM (1985). Allograft bone for metacarpal reconstruction. Journal of Hand Surgery, 10A: 325–334. Trumble TE, Friedlaender GE (1987). Allogeneic bone in the treatment of tumors, trauma and congenital anomalies of the hand. Orthopedic Clinics of North America, 18: 301–310. Tubiana R. Chapter 4: Architecture and function of the hand. In: Tubiana R (Ed). The hand, Philadelphia, WB Saunders, 1981, vol. 1: 19–53. Upton J, Glowacki J (1992). Hand reconstruction with allograft demineralised bone: twenty-six implants in twelve patients. Journal of Hand Surgery, 17A: 704–713. Received: 21 December 2004 Accepted after revision: 6 July 2005 Dr Jonathan Y.L. Lee, Department of Hand Surgery, Singapore General Hospital, Outram Road, 169608, Singapore. Tel.: +65 6321 4588; fax: +65 6321 3573. E-mail: leeyiliang@pacific.net.sg
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2005.07.007 available online at http://www.sciencedirect.com