What Are the Long-term Outcomes of Wrist Arthrodesis Using Structural Iliac Bone Graft After Resection of the Distal Radius for Giant Cell Tumor of Bone? A Minimum 10-year Follow-up.
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BACKGROUND: Most distal radial giant cell tumors are treated with curettage, whereas malignancies and very advanced giant cell tumor of bone (GCTB) may be treated with resection. Wide resection can achieve good local control, but no consensus has been obtained on the optimal reconstruction method. The use of an endoprosthetic wrist arthroplasty offers the advantage of wrist motion. However, it is associated with a high risk of wrist subluxation, pain, and compensation limitations; ultimately, some patients undergo wrist arthrodesis. We previously reported good early outcomes using wrist arthrodesis and structural iliac bone graft for bone defects after wide resection of the distal radius GCTB. This study evaluates the long-term function, complications, and risk factors of this reconstruction technique at > 10 years of follow-up. QUESTIONS/PURPOSES: (1) What were the 5-year and 10-year overall graft survival and revision-free survival rates? (2) What proportion of patients achieved bone union by 6 and 12 months? (3) What were the functional outcomes of patients at final follow-up? (4) What were the overall proportions of patients who experienced complications and complications leading to reoperation and its possible risk factors? METHODS: After approval by our institutional review board, we performed a retrospective study of patients who underwent wrist arthrodesis and structural iliac bone graft reconstruction after wide resection of distal radius primary bone tumors and who had at least 10 years of follow-up, using our institutional database (Jishuitan Sarcoma database) undergoing prospective maintenance by Beijing Jishuitan Hospital. Between January 2005 and January 2025, we treated 231 patients for distal radius GCTB. Of those, we considered patients with Campanacci III GCTB as potentially eligible. Twenty-three percent (53 of 231) of patients underwent curettage. Based on that, 77% (178 of 231) of patients were eligible. Ten percent (18 of 178) were excluded because they received other reconstruction methods, including vascularized fibular graft and massive allografts. Nine percent (16 of 178) of patients who were lost to follow-up were excluded. Forty-five percent (80 of 178) of patients who had < 10 years of follow-up and 36% (64) of patients were included for survivorship and complication analyses here. Of patients who had > 10 years of follow-up, fifty-six percent (36 of 64) were men. The mean ± SD age was 31 ± 11 years. The indication for reconstruction was resection of Campanacci Grade III GCTB. Patient outcomes included overall graft survival, revision-free survival, functional scores (Musculoskeletal Tumor Society Score-93 [MSTS-93], DASH, and Patient-Rated Wrist Evaluation [PRWE] scores), wrist stability (Carpal Translation Index), and grip strength. All complications were classified as major complications and minor complications. A major complication was defined as a complication resulting in an unplanned reoperation. Graft survival rates were calculated by Kaplan-Meier methods. RESULTS: The 5-year and 10-year overall graft survival rates for all 144 patients (including > 10-year and ≤ 10-year follow-up) were 98% (95% confidence interval [CI] 80% to 99%) and 98% (95% CI 80% to 99%), respectively. The 2-year, 5-year, and 10-year revision-free survival rates were 90% (95% CI 83% to 94%), 78% (95% CI 69% to 83%), and 76% (95% CI 60% to 81%), respectively. For patients who had > 10 years of follow-up, sixty-one percent (39 of 64) of grafts achieved union within 6 months, 84% (54 of 64) united within 12 months, and 16% (10 of 64) did not unite. The mean ± SD MSTS-93 score was 95% ± 5% (range 0% to 100%, with higher scores indicating better function), the mean DASH score was 13 ± 5 (range 0 to 100, with lower scores indicating better function), and the mean PRWE score was 18 ± 6 (range 0 to 100, with lower scores indicating better function). Thirty-five percent (51 of 144) of patients had at least one complication. During follow-up, 28% (41 of 144) of patients underwent 51 reoperations because of major complications. After controlling for potentially confounding variables such as gender, age, and previous surgery, we found that the use of reconstruction plates for fixation (cause-specific HR 2.2 [95% CI 1.3 to 12]; p = 0.02) and bone nonunion (cause-specific HR 2.7 [95% CI 2.1 to 7.2]; p = 0.03) were associated with an increased risk of plate fractures. The use of reconstruction plates (cause-specific HR 2.3 [95% CI 1.4 to 2.9]; p = 0.04) and autograft > 8 cm (cause-specific HR 1.7 [95% CI 1.1 to 3.3]; p = 0.03) was associated with an increased risk of bone nonunion. CONCLUSION: Resection followed by wrist arthrodesis and structural iliac bone graft for distal radius GCTB achieved satisfactory oncologic and functional results, albeit with one-third of all patients experiencing some complications at a minimum of 10 years of follow-up. Although wrist arthrodesis sacrificed wrist mobility, making it an option to consider after extensive resection of the distal radius, we cannot compare this with other reconstruction options. Functional outcomes and complications must be investigated further in large prospective studies. LEVEL OF EVIDENCE: Level III, therapeutic study.