M. K. Gundavda, M. G. Agarwal, R. Reddy, A. Katariya, R. Bhadiyadra , P.D. Hinduja Hospital and Medical Research Centre, Mumbia, India.
The first two authors contributed equally to this manuscript.
Clin Orthop Relat Res. 2021 Jun 1;479(6):1285-1293. doi: 10.1097/CORR.0000000000001604.
Ten years ago, we reported the results of a procedure in which we translocated the ipsilateral ulna as a vascularized autograft to reconstruct defects of the distal radius after tumor resection, with excellent functional results. At that time, wrist arthrodesis was achieved by aligning the translocated ulna with the scapholunate area of the carpus and usually the third metacarpal. This resulted in wrist narrowing. We then wondered if aligning the translocated ulna with the scaphoid and the second metacarpal would result in ulnar deviation and thereby improve grip strength. We believed lateralization would reduce the wrist narrowing that occurs with fusion to the third metacarpal and would make the cosmesis more acceptable. We also modified the incision to dororadial to make the scar less visible and thus improve the cosmesis.
QUESTIONS/PURPOSES: (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?
From 2010 and 2018, we treated 40 patients with distal radius tumors at our institution, 30 of whom had a distal radius enbloc resection. Twenty-eight patients had an ipsilateral ulna translocation and wrist arthrodesis in which the radius and translocated ulna were aligned 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 excluded. A retrospective analysis of 23 patients (20 with giant cell tumors and three with malignant bone tumors) included a review of radiographs and institutional tumor database for surgical and follow-up records to study oncologic (local disease recurrence), reconstruction (union of osteotomy junctions, implant breakage or graft fracture, and wrist circumference), and functional outcomes (MSTS and Mayo wrist scores and objective grip strength assessment compared with the contralateral side). The results were compared for each study group (second metacarpal versus third metacarpal). There was no difference in the incidence of local recurrence or the time to union between the two groups. There were no implant breakages or graft fractures noted in either group.
Patients in the second metacarpal group lost less grip strength compared with the unoperated side in the third metacarpal group (median 12% [range -30% to 35%] versus median 28% [15% to 42%], difference of medians 16%; p = 0.006). 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). The second metacarpal group also had less wrist narrowing as seen from the median difference in circumference between the operated and unoperated wrists (median narrowing 10 mm [3 to 35 mm] in the second metacarpal group versus median 30 mm [15 to 35 mm] in the third metacarpal group, difference of medians 20 mm; p = 0.04).
Wrist arthrodesis after ulna translocation with alignment of the translocated ulna and the second metacarpal provides a functional position with ulnar deviation that offers some improvement in grip strength but no improvement in the MSTS or Mayo scores. Radialization/lateralization of the translocated ulna achieved from the alignment with the second metacarpal decreases the reduction in the wrist circumference and therefore reduces wrist narrowing.
Level III, therapeutic study.
十年前，我们报告了一项手术的结果，在这项手术中，我们将同侧尺骨作为带血管的自体移植物进行横向移植，以重建肿瘤切除后远端桡骨的缺损，取得了良好的功能结果。当时，腕关节融合通过将移植的尺骨与腕骨的舟月区和通常的第三掌骨对齐来实现，这导致了腕部变窄。然后我们想知道，如果将移植的尺骨与舟骨和第二掌骨对齐，是否会导致尺侧偏斜，从而改善握力。我们认为，侧方化会减少与第三掌骨融合时发生的腕部变窄，并使美容效果更可接受。我们还修改了切口，使其从桡侧到背侧，使疤痕不那么明显，从而改善美容效果。
问题/目的：（1）当将移植的尺骨横向化并与桡骨融合，与第二掌骨对齐，与将移植的尺骨与第三掌骨对齐相比，握力和功能评分（肌肉骨骼肿瘤学会[MSTS]和 Mayo 腕）是否有客观改善？（2）与与第三掌骨对齐的融合相比，与第二掌骨对齐的腕关节融合是否会导致尺侧偏斜，从而最小化腕部周长的缩小，从而测量腕部变窄？
2010 年至 2018 年，我们在我院治疗了 40 例远端桡骨肿瘤患者，其中 30 例接受了远端桡骨整块切除术。28 例患者进行了同侧尺骨移植和腕关节融合，其中桡骨和移植的尺骨与第二（n=15）或第三（n=13）掌骨对齐。第二掌骨组中有 2 例患者和第三掌骨组中有 3 例患者在手术后 24 个月前失访并被排除在外。回顾性分析了 23 例患者（20 例为巨细胞瘤，3 例为恶性骨肿瘤），包括对手术和随访记录的影像学和机构肿瘤数据库进行了回顾，以研究肿瘤学（局部疾病复发）、重建（骨切开术交界处的愈合、植入物断裂或移植物骨折、腕部周长）和功能结果（MSTS 和 Mayo 腕评分以及与对侧相比的客观握力评估）。比较了每个研究组（第二掌骨与第三掌骨）的结果。两组之间局部复发的发生率或愈合时间没有差异。两组均未发现植入物断裂或移植物骨折。
与第三掌骨组相比，第二掌骨组患者的握力损失较少，与未手术侧相比（中位数 12%[范围-30%至 35%]与中位数 28%[15%至 42%]，中位数差异 16%；p=0.006）。在 MSTS（中位数 30[24 至 30]与中位数 26.5[22 至 30]，中位数差异 3.5；p=0.21）或 Mayo 腕评分（中位数 83[65 至 100]与中位数 72[50 至 90]，中位数差异 11；p=0.10）方面，两组之间没有差异。第二掌骨组的腕部变窄也较小，从手术侧和未手术侧腕部周长的中位数差异来看（中位数变窄 10 毫米[3 至 35 毫米]与第三掌骨组的中位数 30 毫米[15 至 35 毫米]，中位数差异 20 毫米；p=0.04）。
尺骨横向移植后进行腕关节融合，将移植的尺骨与第二掌骨对齐，可提供尺侧偏斜的功能位置，从而改善握力，但 MSTS 或 Mayo 评分没有改善。通过与第二掌骨对齐，使移植的尺骨桡侧化/侧方化可减少腕部周长的减少，从而减少腕部变窄。
III 级，治疗性研究。
