Elsevier

Injury

Volume 52, Issue 12, December 2021, Pages 3624-3634
Injury

The role of VFG in wrist arthrodesis: Long term results in a series of 11 patients and literature review

https://doi.org/10.1016/j.injury.2021.11.004Get rights and content

Highlights

  • Wrist fusion is the standard of care in case of severe traumatic damage or oncological ablation of the distal radius in adults.

  • Optimization of the bony contact, a stable bone fixation and alignment are the key points for a successful total wrist fusion.

  • Long-term radiographical results and the overall functional outcome encourage to use this surgical option over other techniques.

Abstract

Background

Total wrist fusion (TWF) is indicated for longstanding degenerative, posttraumatic and/or post-oncological conditions to provide pain relief and wrist stability at partial expense of wrist motion.

Patients and Methods

A total of 11 consecutive patients who had completed TWF with Vascularized Fibula Graft (VFG) for massive distal radius defects were identified retrospectively from our center using inpatient records. We evaluated bone fusion times and long term functional outcomes following the procedure. Post-operative grip strength (GS) and prono-supination were objectively measured. The new Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to rate disability and symptoms; pre- and post- operative pain with the Visual Analog Scale (VAS) was assessed. A literature review of the present studies about TWF with VFG was performed, with the aim of comparing long-term functional results of the surgical techniques so far reported in the English literature.

Results

Our experience with TWF using VFG appeared slightly better than that found in the literature. The procedure was successful in all the cases, achieving bone union in 4,8 months on average. Complication rate was 27,2%, no flap loss was recorded. There were no wrist instability, deformation or dislocation; mean pronation/supination (P/S) was 57,5°/61,2° Average grip strength resulted 59% of the contralateral side. Mean recorded levels of visual analog scale (VAS) for pain postoperatively were 2,32 ± 0,792, which improved significantly from the pre-operatively value of 7,90 ± 0,79. Mean overall satisfaction was good and all the patients comfortably returned to normal activities.

Conclusions

Wrist arthrodesis by means of VFG resulted to be an effective and reliable option in dealing with massive defects of distal radius with involvement of radio-carpal joint. Although the cohort analyzed is relatively small and definitive conclusions cannot be drawn, the long term radiographs and the overall functional outcomes encourage to use the described surgical option over other techniques, such as prosthetic replacement and non-vascularized bone grafts.

Introduction

Wrist arthrodesis represents to date the standard of care in case of severe traumatic damage or oncological ablation of the distal radius in adults [1]. In case of extended defects affecting the radio-carpal joint, fusion is intended to provide pain relief and preserve as much function as possible in the wrist. As regards bone replacement, the surgical strategies so far reported in the literature include the use of a massive autograft from the tibia [2], ulnar translocation or centralization [3], the use of bone grafts [4], osteoarticular allograft [5] and prosthetic replacement [6]. Since its introduction in the clinical practice by Taylor in 1976 [7], the use of the fibula as vascularized flap has gained popularity over the decades, up to represent the most suitable donor site for extended bony defects reconstructions. The first case of distal radius defect reconstructed by means of a vascularized fibula graft (VFG) dates back to 1977 [8]. Six years later, the same authors reported their experience with the aforementioned after tumor ablation on 10 patients, ascertaining progressive bone graft hyperthrophy, less creeping substitution, fragile fractures and non-unions [9]. Moreover, the studies subsequently carried out, highlighted that fibular length, diameter, geometrical shape and mechanical strength appear ideal for the replacement of the forearm bone losses [10,11]. The use of VFG for total wrist arthrodesis has been rarely reported. On the ground of this, we present our experience with a self-developed wrist fusion technique with VFG practiced in 11 distal radius defects including the radiocarpal joint. The very long-term follow-up allowed us to better assess the functional outcomes of the procedure in terms of functional recovery, complications and re-intervention rate. A literature review was carried out, with the aim of comparing the results we achieved with those of the surgical techniques so far reported in the English literature.

All patients provided written informed consent for the procedure, including that for taking photographs/videos for scientific purposes.

By searching the appropriate billing codes and text-based surgical database, we identified 11 patients with distal radius defects treated between 2003 and 2018. Indications for wrist fusion with VFG included 3 post-traumatic bone losses and 8 post-oncological defects after Giant Cell Tumor (GCT) Campanacci grade III resection of the distal radius (n = 8 patients). Three cases were secondary procedures after prosthetic replacement (n = 1) and osteoarticular allograft (n = 2). In one case, a single bone forearm was created by distal ulna translation onto the radius due to oncological issues. In all the cases bone fixation was obtained with a single bridging plate. All the reconstructive procedures were performed by the senior author, in a double-team setting. Mean age at surgery was 37 years (range 23–56 yr.). Female:Male (F:M) ratio was 0,22 (3F:8 M). The dominant limb was involved in 8 cases. Mean bone gap was 9,7 cm (range 8–15 cm). Fibula donor site was contralateral in 10 cases (Tables 1 and 2).

Objective evaluations: strength was measured with a hydraulic hand dynamometer (Sh 5001, Saehan Corporation, South Korea); prono-supination was assessed by means of a goniometer; bone fusion times assessed via post-operative radiographs collected every two months for a year.

Subjective evalauations: patients’ daily activities and general postoperative quality of life were estimated with the new DASH-questionnaire; pain with the visual analog SCALE (VAS) scale; to rate patients’ satisfaction a 4-points grading scale (1 = unsatisfied, 2 = slightly satisfied, 3 = satisfied, 4 = very satisfied) was used.

DASH score was calculated with the following formula:Dashdisabilty/symptonscore=[(sumofnresponse)1]×25nwhere n is equal to the number of n completed responses.

The patiens were followed up at 1–2 weeks, 1–3–6 and 12 months and/or until complete bone healing. The follow-up was on average 93,5 months (range 66–181 months). The self-developed operative techniques used for 9 total and 2 partial wrist fusions in this case series are described below.

The management of the recipient site is as important as the reconstructive procedure itself and it should take into account some general principles which may be resumed as follows: eradication of infection, debridement of scarred soft tissue and resection of necrotic bone. In case of severely contaminated bone it may be advisable to implant an antibiotic spacer after aggressive resection of distal radius including the epiphysis and delay the reconstruction by at least 2 months. In every case the proximal resection of the radius must be radical and reach healthy and well vascularized bone: this is a prerequisite of paramount importance in order to obtain early bone fusion after the implant of the graft. The anterior (Henry) approach to the radius shaft was always used. It is suggested to perform a step cut osteotomy of the proximal bony stump in order to increase the contact with the transferred fibula and improve stability. Before releasing the tourniquet, the recipient vessels are selected for microvascular anastomosis. The cephalic vein is usually preferred due to similarities in size with the peroneal veins. When possible, the common interosseous artery is used for arterial anastomosis to preserve the major vessels.

The patient is placed in supine position with hip and knee flexed at 45° The fibula is exposed according to the classical lateral approach in the plane between peroneus brevis and gastrocnemius muscles. After section of the interosseous membrane, proximal and distal osteotomies are performed at desired location according to the length of the defect. We extend the harvest of periosteum beyond the osteotomy site in order to obtain a periosteal flap which should overlap the bone junction at the recipient site (Fig. 1). When needed, an osteocutaneous flap may be harvested including a skin paddle supplied by cutaneous perforators available in the distal half of the leg (Fig. 2). The skin flap may be measuring up to 10 × 20 cm9 which is very useful and reliable in case of soft tissue defect. Small islands may be used with the aim to monitor the vascularity of the buried bone.

With the double purpose to maximize the stability of the assemblage and to minimize the dorsal bulging of the plate, the following refinements have been routinely adopted in the present cases series:

  • (1)

    A longitudinal groove (Fig. 3) is dug with high speed bur in the carpal bones along the axis of 3rd metacarpal bone in order to host the fibula which should reach the basis of the 3rd metacarpal bone to optimize the contact. The direction of the groove may be adapted to the desired angle of ulnar deviation. The furrow must be large and deep enough to contain the fibula which must be placed at the same level of the metacarpal bones (Fig. 4a,b), minimizing the bulking and optimizing the bone contact.

  • (2)

    We used of a Limited Bone Contact Dynamic compression plate (LC-DCP) with variable thickness and screws dimension. Namely, a plate thicker in the forearm with screws 3.5 and thinner at the capometacarpal level with screws 2.7 (Fig. 5).

  • (3)

    With a single bridging plate, the fibula is:

    • (i)

      fixed to the residual radius with a step cut osteotomy (Fig. 6).

    • (ii)

      secured to the volar cortex of lunate and capitate previously dug.

    • (iii)

      fixed to the 3rd metacarpal bone, ensuring making sure of correct alignment.

In case of preservation of the carpal bones, a limited arthrodesis is preferred in order to maintain some motion at the midcarpal joint. Since the scaphoid bridges the two carpal rows, an osteotomy of the scaphoid is mandatory to maintain motion when a Radio-Schapo-Lunate (RSL) arthrodesis is performed. A single fibula is difficult to fix properly to the residual proximal pole of the scaphoid and the lunate because of the limited bone contact. In order to implement the bone stock and maximize stability, we perform a Sauve Kapandji (SK) procedure between the caput ulnae and the distal tip of the fibula (Fig. 7). This provides a larger bone contact with lunate and scaphoid and simultaneously prevents possible mismatching in length of the ulna and guarantees a good pronation and supination. Once removed the articular cartilage of lunate and scaphoid, a four bones arthrodesis (fibula, caput ulnae, scaphoid and lunate) can be safely performed using a distal radius plate.

A search strategy was developed to look for published studies involving Total Wrist Fusion (TWF) with Vascularized Fibula Graft (VFG) after trauma or tumor ablation in the distal radius in two electronic databases: PubMed and Google Scholar. These electronic databases were considered from the earliest date available to the 30th of July 2021. A first advanced search was carried out using the following couple of ‘quest phrases’ ‘’total wrist fusion’’ AND “vascularized fibula”. A second search was made utilizing “distal radius reconstruction” AND “fibula”. The third advanced search involved the use of “wrist arthodesis” OR “fusion” AND “fibula” AND “radius”.

Inclusion criteria: studies describing total wrist fusion by means of vascularized fibula, with the full text available and written in English. If two or more articles from the same author or group of authors presented overlapping data, the article with the greatest amount of data was included in the literature review. Only the articles with available data regarding the functional outcomes (pronation/supination/grip strenght) analyzed in this paper were included.

Exclusion criteria: experimental studies, reviews, commentaries, letters to the editor, non-indexed articles and duplicates. We excluded all the articles discussing other surgical strategies (i.e. wrist arthroplasty, prostethic replacement, usage of non-vascularized grafts, usage of vascularized non-fibular grafts and others).

Manual searching of the reference lists of included studies and citation tracking were conducted to ensure that all relevant studies were found. The initial search resulted in 222 publications, of which 166 ones were screened and excluded by titles and abstracts. Two independent authors analyzed the full text of the articles obtained with the initial search to discriminate the studies that met the inclusion criteria.

Subsequent exclusion criteria were as follows: papers with incomplete data, full-text not written in English and/or not available, papers discussing total wrist fusion with VFG utilized for multiple donor areas in which it was not possible to extrapolate the specific data related to wrist outcomes.

The selected 9 articles were examined and collected data were recorded in a spreadsheet for statistical analysis (Table 3). In order to compare the outcomes of our applied technique with those reported in the literature we applied the Mann-Whitney-U- test. Difference between the two groups were considered statistically significant with p value. P ≤ .0.05. It is noteworthy to mention that in some works individual values for each patients were not available; in such cases reported values were used for comparison.

The results of our case series are shown in Table 6. Fibula fusion was seen in all the patients, after a mean time of 4,7 months (range 3–7 months). Excluding the single patient with one bone forearm, mean pronation was 57,5° (range 90°−10°), supination 61° (range 90°−0°). Average grip strength (GS) resulted 59% (range 20–100%) of the contralateral side. In particular, for oncological patients (8) mean prono-supination (P/S) was 84°−62° (range 90°/70°−90°/0°) and GS was 67% (range 20–100%). For post-traumatic patients (3) mean prono-supination was 60°−65° (range 35°/85°–70°/80°) and GS 12% (range 7–17%). Complications rate was 27,2% and specifically corresponding to: (i) 1 case of ulnar impingement with painful prono-supination, then treated with caput ulnae resection (Darrach procedure); (ii) 2 wounds dehiscence, with one of them resulting in exposure and partial necrosis of the previous fibula flap (thus requiring a second osteo-cutaneous fibula free flap); (iii) 1 stress fracture at the fibula-radius interface after plate removal for extensors tenosynovitis with the need of a new bone fixation. The donor sites had no major complications. DASH score was 12,8% (range 6–33%) for oncological cases (8) and 32,3% (range 7–77%) for non-oncological ones (3). None of the interviewed patients reported instability of the donor leg from which the fibula was harvested, nor pain or paresthesia. No one complained of pain in the reconstructed upper limb, neither at rest nor during activity. Mean recorded levels of VAS for pain postoperatively were 2.32 ± 0.792, which improved significantly from the pre-operation value of 7.90 ± 0.79. The overall satisfaction was good (mean 3,27 points) and everyone returned to their usual employment (Table 4) (Fig. 8a,b) .

This study was designed to evaluate bone union times after TWF with VFG and achieved long-term functional outcomes in terms of forearm arc of rotation and GS. The presented literature search identified 9 papers [10], [11], [12], [13], [14], [15], [16], [17], [18] which met the inclusion criteria. According to this review, after ablative procedures at the distal radius, mean bone gap was 11,5 cm (range 7,2–18 cm). In most of the cases fibula graft fixation was examined utilizing compression plates and screws. Additional cancellous bone grafting at the junction sites is reported as well [11]. The reported bone union time was 5,2 months (range 3–8,6 months). It required a mean immobilization time of 8,7 weeks (a period of 6 weeks is the most reported [13], [14], [15], [16], [17]), over a follow up of 36,7 months (range 11,6–75,6 months) in average. Overall complication rate was 13, 5%, with a 18, 9% of cases for which an additional surgery was needed. More specifically, proximal non-union is the most reported complication following this procedure, with an incidence of 8,1%. It was treated either with a secondary iliac crest bone graft [10] or by means of a new bone fixation [18]. Only one case of skin flap loss is reported [11], managed with removal of the cutaneous paddle. Functional outcomes resulted as follows: pronation (P) was 51.2° (range 10–80°), supination (S) was 36,2° (range 10–65°) and GS was 50.8% (range 42–60%) of the contra-lateral side (Tables 5 and 6).

Section snippets

Discussion

Different pathological disorders may need Total Wrist Fusion (TWF) by means of Vascularized Fibula Graft (VFG) [19], [20]. The most frequent oncological condition which leads to distal radius resection is the Giant Cell Tumour (GCT) but also ablation of sarcomas and severe traumas may require this major surgery [21,22]. There is a plethora of techniques which have the potential for success including prosthesis, allografts and autografts, both non-vascularized and vascularized [23].

Conclusion

In our experience wrist fusion with vascularized fibula resulted to be reliable and effective for wrist stability and pain relief. It appeared to be saddled with minimal, if any, recipient site morbidity and low complication rate, evaluated over a very long-term follow-up. The suggested technical refinements allowed to overcome some weak points of the standard procedure, such as dorsal bulging and stability of the osteosynthesis, providing encouraging results from both functional and esthetic

Declaration of Competing Interest

None.

Acknowledgments

We thank Federica Calabrese (Ph.D. student at Helmholtz center for Environmental research—UFZ—Leipzig) for assistance with statistical analysis and graphics and for giving comments that greatly improved the manuscript.

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