Journal of Advanced Plastic Surgery Research, 2019, 5, 27-31 27 E-ISSN: 2414-2093/19 © 2019 Green Publishers Wrist Arthrodesis with Vascularized Fibular Graft after Failed Allograft Replacement for Giant-Cell Tumor Resection Stefano Bastoni 1 , Elena Lucattelli 2,* , Luca Delcroix 2 , Fabio Sciancalepore 1 , Primo Andrea Daolio 1 , Marco Innocenti 2 1 C.O.O., Azienda Socio Sanitaria Territoriale Gaetano Pini, Milan, Italy 2 Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy Abstract: Giant-cell tumor (GCT) is locally aggressive bone neoplasm, with an unpredictable pattern of biological aggressiveness. The optimal treatment had to achieve a negligible local recurrence rate while maximizing musculoskeletal function. Numerous options for reconstruction are available, but in the literature there is a lack of salvage surgery data. We present a case of a 67-year-old woman who underwent complete wrist arthrodesis with vascularized fibular graft as salvage procedure for allograft necrosis, after excision of a distal radius GCT. The patient did not complain of any impairment in daily use, and the functional score was 22 points (73%) at latest follow-up of 14 months. Despite joint salvage remains the most favorable treatment with regard to functional outcome for aggressive tumors of the distal radius, vascularized fibular grafts is a valuable alternative especially in salvage procedures, where the use of another allograft could lead to higher complications rate. Keywords: Vascularized fibular graft, Wrist arthrodesis, Giant-Cell Tumor, Fibula free flap. INTRODUCTION Giant-cell tumor (GCT) is locally aggressive bone neoplasm, with an unpredictable pattern of biological aggressiveness, pulmonary metastasis in about 2% and pathological fractures in 5-10% of patients [1]. They typically occur in patients aged 20 to 45 years, and the distal end of the radius is the third most common site affected after the distal femur and the proximal tibia. The optimal treatment had to achieve a negligible local recurrence rate while maximizing musculoskeletal function, but wide excision often leads to considerable functional loss. Once the tumor has been resected, numerous options for reconstruction are available. By definition, arthroplasty is performed to obtain wrist mobility. After radio-carpal arthrodesis, midcarpal motion is preserved, and after total wrist arthrodesis, no mobility is left [2]. The bone used to bridge the gap may be allograft [3], non-vascularized [4] or vascularized autograft [5]. None of these types of graft have been shown to be superior to others. However, after failure of a first reconstructive attempt with allograft, the best solution is to use vascularized autologous tissues. In literature, not much importance has been given to rescue procedures after allograft failure, and there is a lack of salvage surgery data. We present a case of complete wrist arthrodesis with vascularized fibular graft as salvage procedure after allograft necrosis in a patient who had already undergone removal of a GCT of the distal radius. *Address correspondence to this author at the AOU Careggi Largo Piero Palagi 1, 50139 Firenze (FI), Italy; E-mail: elena.lucattelli@gmail.com REPORT OF THE CASE A 67-year-old woman noticed pain and swelling in her right wrist. Radiographs of the wrist revealed an extensive lytic lesion in the distal radius (Figure 1a), and histological examination confirmed the diagnosis of a typical GCT. She underwent initial treatment with en bloc resection of the tumor and allograft replacement. Temporary K-wires were removed after one month. Eighteen months postoperatively, the patient presented painful swelling of the wrist. Physical examination revealed volar carpal subluxation and X-Rays showed clear signs of allograft necrosis and articular surface resorption (Figure 1b). After 4 months the patient underwent surgical debridement of the necrotic allograft and plate removal (Figure 2a). The defect was reconstructed with a wrist arthrodesis performed with a 12-cm-long free vascularized fibula graft (Figure 2b). Under fluoroscopic control, the wrist joint was totally stabilized by a reconstruction plate (Figure 2c). The radial stump was fixed to the proximal carpal row and the third metacarpal bone in order to obtain a complete wrist arthrodesis. The peroneal artery and vein were anastomosed in end-to-end fashion to the radial artery and the cephalic vein. The donor site was closed primarily. Enoxaparin was administered pre and post- operatively to prevent microvascular thrombosis. Fair postoperative soft-tissue swelling was resolved maintaining sloping position of the arm. Surgical sites healed uneventfully. The long arm cast was removed after 4 weeks and a splint wrist brace was used for an additional 30 days. Radiographs taken 3 months postoperatively revealed union at both junctions (Figure 3a, 3b), and there were no signs of tumor recurrence