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Wang et al. BMC Musculoskeletal Disorders https://doi.org/10.1186/s12891-020-3084-0 (2020) 21:69 RESEARCH ARTICLE Open Access The functional outcomes and complications of different reconstruction methods for Giant cell tumor of the distal radius: comparison of Osteoarticular allograft and three-dimensional-printed prosthesis Yitian Wang†, Li Min†, Minxun Lu, Yong Zhou, Jie Wang, Yuqi Zhang, Xinzhu Yu, Fan Tang, Yi Luo, Hong Duan and Chongqi Tu* Abstract Background: En bloc excision has been increasingly used for the management of giant cell tumors (GCTs) in the distal radius. An osteoarticular allograft has been used extensively for decades, and custom-made prosthesis reconstruction has been more recently applied. We aimed to compare the clinical outcomes of the two procedures. Methods: We retrospectively analyzed 30 patients with Campanacci III or recurrent GCTs of the distal radius for follow-up at a mean of 33.2 months. In total, 15 underwent osteoarticular allograft reconstruction (allograft group) and 15 received cementless three-dimensional (3D)-printed prosthesis reconstruction (prosthesis group) between March 18, 2013, and May 20, 2018. All patients underwent by clinical and radiological examinations, including pre- and postoperative active range of motion (ROM) of the wrist, VAS score, grip strength, degenerative change of wrist, Mayo wrist score and Musculoskeletal Tumor Society (MSTS) score. Complications were evaluated using the Henderson classification. Results: Both groups showed significantly increased ROM, grip strength, Mayo score and MSTS score postoperatively. Furthermore, the extension, flexion, MSTS, and Mayo score were significantly higher in the prosthesis group. There was no significant difference in grip strength and VAS between the groups. In allograft group, one patient had a late infection one had resorption of allograft without allograft bone fracture. and four had wrist subluxation. All patients had degenerative changes (mean 9 months). In the prosthesis group, three patients developed wrist subluxation, three had separation of the distal radioulnar joint, and none of the patients developed wrist degeneration. Conclusions: Our study compared the objective functional outcomes and complications of two reconstructive methods for Campanacci III or recurrent GCT in the distal radius. 3D-printed prosthesis replacement can partially preserve wrist function better than allograft reconstruction in the short-term. During the design of 3D-printed prosthesis, preoperative morphological assessment of the affected proximal row carpal is helpful to control postoperative dislocation. After allograft reconstruction, wrist degeneration, which has been demonstrated in all patients, severely influence their wrist function. Therefore, compared to allograft reconstruction, 3D-printed prosthesis reconstruction has irreplaceable advantages at early-stage application, especially in wrist function, however, further studied with a larger number of cases and longer follow-up. Keywords: Distal radius, Giant cell tumor, Osteoarticular allograft, 3D-printed prosthesis * Correspondence: tuchongqibone@hotmail.com † Yitian Wang and Li Min contributed equally to this work. Department of Orthopedics, West China Hospital, Sichuan University, No. 37 Guoxuexiang, Chengdu 610041, Sichuan, People’s Republic of China © The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Wang et al. BMC Musculoskeletal Disorders (2020) 21:69 Introduction The distal radius is the third most common location for giant cell tumor (GCT) after the distal femur and proximal tibia, and approximately 10% of GCT involve the distal radius [1, 2]. Although the majority of studies do not support the theory that GCT in the distal radius are more aggressive, controversy exists on the surgical options for patients with GCT in the distal radius, as well as it’s the rate of recurrence. Intralesional curettage and cement packing is the most common treatment for Campanacci I and II lesions [3, 4]. However, for Campanacci III or recurrent GCT of the distal radius, en bloc resection and reconstruction is recommended; this is associated with a lower risk of local recurrence and poorer functional outcomes than intralesional surgery [3, 5–7]. Reconstruction of the wrist joint following en bloc resection of the distal radius is challenging because of the high functional demands of the wrist, limited surrounding soft tissue, limited bone mass and the proximity of important nerves and tendons [8, 9]. Numerous reconstructive procedures have been described including prosthetic replacement [9–11], osteoarticular allograft [12, 13], allograft fusion [14], arthrodesis using bulk autograft [1, 2], ulnar translocation [15], and nonvascularized [16] or vascularized [17] fibular graft with or without arthrodesis [18]. Although these techniques have unique advantages and inevitable complications, a gold standard for distal wrist reconstruction has not yet been established. As a major treatment method, osteoarticular allografts have advantages, including osteoinduction, use as a biologic scaffold, and generally appropriate anatomical match for host proximal row carpel [13, 19]. However, the use of osteoarticular allografts is extremely restricted by the limited quantity and severe complications, including ankylosis, rejection, and allograft fracture [19]. As a result, several prosthetic arthroplasties have been reported in the last decade, and acceptable results of prosthesis reconstruction were demonstrated short- to mid-term [9, 20, 21]. However, potential complications included aseptic loosening caused by cement-fixation and inappropriate anatomical matching [11, 22]. Following technological advances in materialogy and manufacturing, 3-dimensional (3D) printing technology has been introduced in the field of orthopedics. Our institution reported the first study on a custom-made cementless 3D-printed prosthesis for distal radius GCTs [21]. No reports regarding the comparative study of osteoarticular allograft and prosthetic replacement has been published previously. The purpose of this study was to investigate the mid-term clinical outcomes of patients with GCT in the distal radius after these two reconstructive methods. Page 2 of 15 Methods Patients In total, 30 patients, who underwent en bloc resection of Campanacci III or recurrent GCT in the distal radius and allograft or prosthesis reconstruction between March 18,2013, and May 20, 2018, were enrolled in our study. The histopathologic diagnosis for each patient was obtained by needle biopsy. In order to determine the reconstructive option for each subject, the surgical indication was based on patient’s preference. The patients, who selected biological reconstruction and rejected arthrodesis using autograft and/or ulnar translocation, underwent osteoarticular allograft. Whereas, patients, who selected endoprosthetic reconstruction and rejected arthrodesis using autograft and/or ulnar translocation underwent 3D-printed prosthesis replacement. We excluded patients with metastasis and those who had any surgical procedure unrelated for Campanacci III or recurrent GCT in the distal radius. According to the reconstructive methods, we considered a consecutive series in our institution with GCTs of the distal radius treated with osteoarticular allograft (allograft group) and 3D-printed prosthesis (prosthesis group). Preoperative assessments included radiographs of the bilateral forearm and wrist, computed tomography (CT) scan of the chest, bilateral forearm and wrist, magnetic resonance imaging (MRI) of the affected side and an optional total body bone scan. All patients were evaluated for pain according to a 10-cm VAS score, range of motion (ROM) recorded using a goniometer, grip strength of bilateral wrist joint, Mayo wrist score [23] and Musculoskeletal Tumor Rating Scale (MSTS) [24] of the wrist, preoperatively and postoperatively. All patients were assessed every 3 months during the first year of follow-up and every 6 months thereafter with a physical examination, VAS, functional evaluation of the wrist, radiographs of the wrist and chest. The degenerative changes of the wrist were evaluated radiographically according to Knirk and Jupiter scale in both groups [25]. This study was performed according to the principles embodied in the Declaration of Helsinki and the Institutional Review Board of Sichuan University West China Hospital. Written informed consent was obtained from all patients when they began treatment for osteoarticular allograft or 3D-printed prosthesis. Allograft preparation and prosthesis design In the allograft group, to obtain a reconstruction as anatomical as possible, the isometric x-rays of the bilateral side and a 3D-CT scan were taken. Fresh-frozen allografts were supplied by the bone-bank facility (West China Hospital, Chengdu, Sichuan) without soft tissue. In the prosthesis group, all prostheses were custommade for each patient by our team and produced Wang et al. BMC Musculoskeletal Disorders (2020) 21:69 (Chunli, Beijing, People’s Republic of China). Based on our previous study [21] and experience, the design was modified and improved with the help of Mimics V17.0 software (Materialise Corp., Leuven, Belgium). The main components of the 3D-printed prosthesis were an ultrahigh-molecular-weight polyethylene (Orthoplastics Ltd., Lancashire, UK), repairing pores for soft tissue reconstruction, shaft and stem coated with hydroxyapatite (titanium alloy) (Fig. 1). All prostheses were printed by electron beam melting technology (ARCAM Q10, Mölndal, Sweden). It took 2 or 4 weeks to manufacture the prosthesis, during which time the patients were treated with NSAIDs if necessary. Surgical technique and postoperative management Patients were submitted to general anesthesia. The tumor was resected en bloc through a dorsal approach including the previous biopsy and operating incision. Soft tissue dissection, including the wrist ligaments, capsule, triangular fibrocartilage complex (TFCC), biopsy track and hematoma, was dependent on the tumor border. A step-cut osteotomy was performed with a safe margin (1.5 cm from the tumor border) according to Xrays and MRI. In the allograft group, an appropriate locking compression plate (LCP) was fixed to the allograft bone and the remaining radius to obtain initial stability and avoid rotation of the distal radius Allograft bone was fixed with a suitable LCP, Wego, Shandong, People’s Republic of China) to bridge the allograft and the remaining radius [13]. In the prosthesis group, stable fixation between the prosthesis and the reamed radius canal was enhanced by press-fitting the distal stem. The remaining dorsal and/or palmar ligaments, joint capsule and TFCC were sutured to the allograft bone or repairing pores of the prosthesis. Based on the reserved soft tissue, an above-elbow cast was administered to patients with massive resection. Fig. 1 Prosthesis is composed of polyethylene, repairing pores, shaft and stem coated with hydroxyapatite Page 3 of 15 After a 4-week immobilization, active wrist exercises were acceptable. Statistical analysis Survival data were compiled using Kaplan-Meier analysis. Prosthesis survivorship was determined for implants using revision or removal of the components for any reason as an end point, according to Henderson et al. [26]. No complication survivorship was defined for patients without wrist pain, degeneration of the wrist, subluxation, and separation of the distal radioulnar joint at the last follow-up. The normality of the continuous data was verified by the Shapiro-Wilk test. Normally and abnormally distributed parameters were assessed by the independent sample t-test and the Mann-Whitney U test, respectively. A P-value of < 0.05 was determined to be statistically significant. Comparisons were conducted between the allograft and prosthesis group by log-rank test. Data analyses were performed using SPSS 20.0 software (IBM Corporation, Armonk, NY, USA). Results Patient characteristics In total, 30 consecutive patients were enrolled from March 18, 2013 to May 20, 2018. All pathology materials were confirmed at West China Hospital. The clinical characteristics of the two groups and their comparison are presented in Table 1. Patients of the two treatment groups had no significant difference in gender, age, and follow-up time. Functional outcomes There was no significant difference between the two groups in preoperative functional outcomes. In the allograft group, there was a significant increase in ROM postoperatively, with exception of flexion. The mean postoperative ROM of the wrist, was 38.3 ° active extension (range, 25 ° 65 °, P < 0.01), 26.3 ° flexion (range, 10°-50 °, P = 0.65), 52.0 ° pronation (range, 30°65°, P = 0.04), and 55.0 ° supination (range, 40 °-80 °, P = 0.03). The MSTS wrist score and Mayo wrist score were significantly increased postoperatively, averaging 71.2% (57.1–82.9%, P = 0.03) and 65.0 (55–75, P < 0.01) respectively. Postoperative grip strength was 54.7% (range, 42.5–70.3%) of the normal contralateral hand compared to 29.7% (range, 15.9–38.3%) preoperatively, with a significant increase(P < 0.01). The VAS score was 5.5 (range, 4–7) preoperatively and 1.2 (range, 0–3) postoperatively with significant difference(P = 0.05) (Table 2). In the prosthesis group, with regards to all aspects of the ROM, there were significant differences between the pre- and post-operative measurements. After prosthesis reconstruction there was a 61.7 ° active extension (range, Wang et al. BMC Musculoskeletal Disorders (2020) 21:69 Page 4 of 15 Table 1 Demographic and radiographic characteristics of the two treatment groups Characteristic Osteoarticular allograft group 3D-printed prosthesis group pvalue Mean SD Range Mean SD Range 15 – – 15 – – – Male/female 8/7 – – 6/9 – – 0.50 Age (years) 37.3 12.1 24–63 38.0 10.0 21–56 0.87 Side (right/left) 7/8 – – 8/7 – – 0.67 Primary/Recurrence 11/4 – – 10/5 – – 0.7 Number of patients Length of resection (cm) 8.0 1.0 7–10 5.4 1.7 3.5–9 < 0.001 Follow-up (months) 34.4 16.8 10.7–64.4 31.4 11.8 13.7–48.2 0.52 20 °-85 °, P < 0.01), 45.0 ° flexion (range, 20 °-80 °, P = 0.04), 54.7 ° pronation (range, 30 °-80 °, P < 0.01), and 60.0 ° supination (range, 25 °-85 °, P < 0.01) (Fig. 2). With respect to the MSTS score of the wrist and the Mayo wrist score, there was a significant increase after the operation of 81.7% (60–94.3%, P < 0.01) and 71.0 (40–85, P < 0.01) on average, respectively. There were significant differences between the pre- and post-operatively in grip strength. There were 33.2% (range, 12.8–62.7%, P < 0.01) and 64.4% (range, 31.9–100%, P < 0.01) respectively. Furthermore, there was a significant difference in VAS score, which was 5.5 (range, 4–7) preoperatively and 1.3 (range, 0–4) postoperatively(P < 0.01). (Table 3). With respect to the postoperative functional outcomes, the extension (38.3 vs 61.6, P < 0.01), flexion (26.3 vs 45.0, P = 0.02), grip strength (54.7 vs 64.4, P = 0.03), MSTS score (71.2 vs 81.7, P = 0.01), and Mayo score (65.0 vs 71.0, P = 0.01) were significantly higher in the prosthesis group. There was no significant difference in supination, pronation, and VAS score between the two groups (Table 4). With regards to the variations of functional outcomes before and after surgery, although the prosthesis group showed an improvement in of ROM in the extension, flexion pronation and supination, only the extension (8.7 vs 29.7, P < 0.01) and flexion (1.3 vs 12.0, P = 0.020) were statistically significant. There was a significant difference in the variation of the Mayo wrist score (47.3 vs 51.7, P = 0.03) and the MSTS score (17.1% vs 28.6%, P < 0.01) in two groups. There was no significant difference between the allograft and prosthesis groups in terms of grip strength (25.1% vs 31.2%, P = 0.25) and VAS score (4.3 vs 4.2, P = 0.87) (Table 4). With regards to the variations of satisfaction before and after surgery, there was no significant difference in the variation of satisfaction in the Mayo wrist score (20.9 vs 21.6, P = 0.726) between the two groups. In addition, there was a significant increase in the variation of emotional acceptance in the MSTS score (4.1 vs 1.4, P < 0.01) in the prosthesis group. There was a significantly lower pain reported in the prosthesis group with both the Mayo (25.00 vs 21.88, P < 0.01) and MSTS (5.00 vs 4.38, P = 0.02) scores. Complications In the allograft group, all patients were alive, of the 15 patients, only one had a late infection (50 months after surgery), which was caused by plate exposure (type 1B), resulting in debridement and removal of the plate. Four patients had wrist subluxation (type 1A) that occurred 2, 3, 6 and 36 months after surgery. At the lastest followup, all patients had degenerative changes (three had grade 2, fourteen had grade 3, mean, 9 months; range 3– 12 months), according to the Knirk and Jupiter scale [25]. One patient had resorption of the allograft (type 2B) without allograft bone fracture. None of the included patients had structural failures, soft-tissue failures, nonunion, metastasis, or pain. In the prosthesis group, none of the patients died; of 15 patients, three patients developed wrist subluxation (type 1A) that occurred within 1 month after surgery. Three patients had separation of the distal radioulnar joint; two of the three patients which occurred in 1 month after surgery, while the other developed within 7 months of the surgery. None of the included patients had structural failures, soft-tissue failures, aseptic loosening, infection, pain, or degenerative changes because of the surgery. There was no significant difference between the allograft and prosthesis group with regards to complications according to the Henderson classification. There was no significant difference between the allograft and prosthesis group in terms of implant survival (P = 0.98) (Fig. 3), and the median survival time was not reached in either of the groups. Finally, no patients had died by the time of the last follow-up. Discussion Campanacci III and/or recurrent GCT in the distal radius are characterized by strong invasion and a high recurrence rate. The primary goal of treatment is an oncologic cure. and further functional satisfaction is intensely demanded. The present study is the first to Age (years)/ gender 40/M 38/M 33/M 25/M 29/M 25/M 62/F 37/F 35/M 27/F 63/F 24/F 35/F 45/M 42/F Patient number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 III III Recurrent III III III III III III III Recurrent III Recurrent Recurrent III Campanacci grade 32 42 43 18 20.9 22.5 24.5 27.9 10.7 13.1 50 38.2 47 61.8 64.4 Follow-up (months) 35/45 30/50 25/40 25/30 20/25 30/30 20/25 45/25 35/30 20/25 35/65 35/65 20/25 40/65 30/30 Extension (°) 20/25 25/25 5/25 25/25 20/10 25/20 15/35 45/25 40/35 10/20 40/25 30/50 30/20 25/30 20/25 Flexion (°) Range of motion 45/65 50/65 20/50 35/55 30/45 40/45 35/50 45/45 35/60 20/40 20/65 30/80 25/50 35/55 30/55 Supination (°) Table 2 preoperative/postoperative details in allograft group 30/60 35/50 35/55 40/35 30/45 40/45 25/55 45/65 40/60 15/55 25/55 35/65 35/40 40/55 40/40 Pronation (°) 38.3/55.6 21.3/46.5 28.1/47.2 28.1/44.2 28.1/46.4 38.0/62.3 37.9/51.1 34.5/61.3 28.2/45.8 37.9/61.7 24.6/70.3 15.9/63.3 32.6/42.5 18.7/60.2 33.2/63.0 Grip strength(% of normal side)(%) 6/1 4/1 7/2 6/2 5/3 5/1 4/1 6/1 5/1 6/0 6/1 5/1 7/1 5/2 6/0 VAS score II/12 II/9 III/12 III/8 III/6 III/12 III/9 III/6 III/12 III/3 III/12 III/12 III/6 III/12 III/9 Degenerative grade/ Occurrence time after operation (month) 20/70 15/65 15/60 20/60 15/55 20/65 15/60 20/70 20/65 20/70 15/75 10/75 15/55 25/65 20/65 Mayo score 48.6/65.7 54.3/77.1 45.7/71.4 65.7/71.4 42.9/71.4 60.0/71.4 60.0/65.7 54.3/77.1 54.3/77.1 60.0/65.7 48.6/71.4 60.0/82.9 48.6/57.1 60.0/65.7 48.6/77.1 total MSTS 5/5 5/5 3/5 5/5 3/5 5/5 3/5 5/5 5/5 3/5 5/5 5/5 3/5 5/5 5/5 motion 1/5 3/5 0/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5 1/5 Extension (°) 5/5 5/5 5/5 5/5 5/3 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 Flexion (°) 5/5 5/5 5/5 5/5 5/3 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/3 3/5 5/5 Supination (°) 1/3 1/3 3/3 3/3 1/3 1/3 3/3 1/3 1/3 3/3 1/3 1/3 1/3 1/3 1/3 Pronation (°) 1/3 1/3 1/3 1/3 3/3 3/3 3/3 3/3 1/3 3/1 3/3 3/3 1/0 1/3 1/3 Functional Activity 1/1 1/3 1/3 3/3 1/3 1/3 1/3 3/3 1/3 1/1 1/3 1/5 1/1 5/3 1/5 Emotional Acceptance Wang et al. BMC Musculoskeletal Disorders (2020) 21:69 Page 5 of 15 Wang et al. BMC Musculoskeletal Disorders (2020) 21:69 Page 6 of 15 Fig. 2 a: The Campanacci III GCT of left distal radius was diagnosed; b: 10 months after surgery comparing allograft and prosthesis reconstruction for the treatment of GCTs in the distal radius. To highlight differences between the 3D-printed prosthesis and allograft reconstruction, the comparison was performed with regards to functional outcomes and complications. With respect to functional outcome, the MSTS and Mayo score were evaluated; in general, the prosthetic group had a significantly higher scores when compared to the variation of before and after surgery (17.1% vs 28.6%, P < 0.01 and 47.3 vs 51.7, P = 0.03). In addition, the prosthetic group had a significantly higher score in both MSTS and Mayo, compared to the postoperative evaluation (Table 4). Comparison of range of motion (ROM) For the variation of ROM in the Mayo score, there was a significantly higher score in the prosthesis group compared to the allograft group (4.0 vs 6.4, P = 0.04). There was no significant difference between groups with regards to the variation of ROM in the MSTS score (0.67 vs 0.60, P = 0.84). This discrepancy in ROM between the Mayo and MSTS scores may be partially explained by the fact that ROM is given a weighting of 25% in the Mayo score compared to 14% in the MSTS system. In addition, most patients received full marks in the MSTS system because the ROM was more than 120 °, and included extension, flexion, supination, pronation, and radial and ulnar deviation. However, the ROM score is valued by a percentage of the contralateral side in the Mayo system, which rarely receives gets full marks. In previous studies, custom-made cemented prosthesis reconstruction obtained reasonable ROM, with different types, including distal radial prosthesis [9, 11, 20], and total wrist joint prosthesis prothesis [22, 27, 28]. For our 3D-printed uncemented prosthesis, not only the individual and precise design, but also the “press-fit” fixation make surgery easy and result in considerable functional outcomes [21]. Our 3D-printed prosthesis has three main advantages. First, a thick and suitable polyethylene liner is made according to the contralateral side; second, the reserved bone crest of the distal radius on the shaft ensure appropriate implantation without any rotation; and third, seven or eight pores, on the distal prosthetic edge, provide a sufficient area for soft tissue reconstruction. For the allograft group, all patients developed grade 2 or 3 degeneration of the wrist joint (Fig. 4), and the median degeneration-time was 9 months (95% CI: 8.03– 9.97) (Fig. 5). There might be an explanation in that creeping substitution, the process through which the allograft is gradually replaced by living bone [29], goes to tide mark under dead articular cartilage, therefore there is a risk of subchondral collapse [30]. With respect to forearm rotation, the distal radioulnar joint (DRUJ) plays a critical role. We reveal that four patients developed separation of the DRUJ (Fig. 6) in prosthetic reconstruction. Based on the tumor border, most structures of the triangular fibrocartilage complex (TFCC) were not preserved in the four patients; therefore, there was a tendency for separation of the DRUJ. With respect to the stabilizing structures of the DRUJ, which includes the TFCC, surrounding ligament, tendon, muscle, interosseous membrane, the bone itself, and the capsule [31]. The TFCC, containing superficial and deep fibers, is the main stabilizer of the DRUJ [32]. Many studies concluded that the dorsal superficial fibers tighten in pronation, as do the deep palmar fibers and vice versa [31]. Therefore, we speculate that the relative decrease in pronation and supination is associated with insufficient reconstruction of Age (years)/ gender 42/F 45/M 34/F 37/M 45/F 46/M 37/F 27/F 24/F 21/F 45/M 45/F 56/M 25/F 41/M Patient number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Recurrent III Recurrent III III III III III III Recurrent III Recurrent III Recurrent III Campanacci grade 13.7 14.4 14.4 36.7 42.4 17.9 26.3 30.7 31.7 33.8 34.7 35.4 45.3 45.7 48.2 Followup (months) 30/35 50/65 10/55 20/70 15/20 30/85 15/50 60/75 50/75 30/80 50/65 10/60 40/60 45/85 25/45 Extension (°) 25/30 40/50 5/40 30/50 20/20 30/30 10/45 60/60 40/50 40/60 70/80 30/45 30/40 25/35 40/40 Flexion (°) Range of motion 50/50 50/70 20/60 45/60 20/25 45/85 30/60 50/65 50/60 20/50 20/50 20/50 45/60 50/80 25/75 Supination (°) Table 3 preoperative/postoperative details in prosthesis group 40/50 40/60 30/60 30/35 20/30 45/55 20/60 50/70 45/55 30/50 30/50 30/50 30/45 30/50 40/80 Pronation (°) 62.7/83.6 30.4/56.7 37.8/56.7 39.0/64.6 41.8/53.2 18.4/100.0 38.3/76.7 22.9/56.7 32.2/81.5 35.9/85.0 42.6/73.9 34.0/54.3 21.3/46.8 28.3/45.2 12.8/31.9 Grip strength(% of normal side)(%) 6/1 4/1 7/2 6/2 5/4 5/1 4/1 6/1 5/1 6/1 5/1 7/1 6/1 5/2 6/0 VAS score None None None None None None None None None None None None None None None Degenerative grade/ Occurrence time after operation (month) 25/60 20/75 10/70 15/75 15/40 30/85 15/75 25/75 20/80 15/75 20/75 15/75 15/75 20/70 30/60 Mayo score 57.1/60.0 57.1/82.9 54.3/88.6 57.1/82.9 62.9/60.0 51.4/94.3 51.4/82.9 54.3/88.6 57.1/82.9 57.1/82.9 57.1/82.9 51.4/82.9 45.7/88.6 51.4/77.1 31.4/88.6 Total MSTS 5/5 5/5 3/5 5/5 3/3 5/5 3/5 5/5 5/5 5/5 5/5 3/5 5/5 5/5 3/5 motion 1/5 3/5 0/5 1/3 3/3 1/5 3/5 1/5 1/5 1/3 1/5 1/5 1/5 1/3 1/5 Pain 5/3 3/5 5/5 5/5 5/3 5/5 5/3 5/5 5/3 5/3 5/3 5/3 3/3 3/3 3/5 Stability 5/3 5/5 5/5 5/5 5/1 5/5 5/5 5/5 5/3 5/5 5/5 5/5 5/5 5/5 3/5 Deformity 3/3 3/3 3/3 3/3 3/3 1/5 1/3 1/3 3/3 3/3 3/3 3/3 3/3 3/3 0/3 Strength 1/1 1/3 3/3 1/3 3/3 1/5 1/3 1/3 1/5 1/5 1/3 1/5 1/5 1/3 0/3 Functional Activity 0/1 0/3 0/5 0/5 0/5 0/3 0/5 1/5 0/5 0/5 0/5 0/3 0/5 0/5 1/5 Emotional Acceptance Wang et al. BMC Musculoskeletal Disorders (2020) 21:69 Page 7 of 15 Wang et al. BMC Musculoskeletal Disorders (2020) 21:69 Page 8 of 15 Table 4 Statistical comparison of clinical results between the two treatment groups Measure Osteoarticular allograft group (N = 15) 3D-printed prosthesis group (N = 15) p-value allograft vs prosthesis Extension (°) 38.3 (range 25~65) 61.7(range 20~85) < 0.01 Flexion (°) 26.3 (range 10~50) 45.0 (range 20~80) 0.02 Postoperative Supination (°) 55.0 (range 40~80) 60.0(range 25~85) 0.187 Pronation (°) 52.0 (range 30~65) 54.7 (range 30~80) 0.683 Mayo score 65.0 (range 55~75) 71.0 (40~85) 0.013 MSTS score 71.2 (range 57.1~82.9) 81.7 (range 60~94.3) 0.01 VAS score 1.2 (range 0~3) 1.3 (range 0~4) 0.806 Grip strength (% of normal side) (%) 54.7 (range 42.5~70.3) 64.4 (range 31.9~100) 0.03 Extension (°) 8.7 (range − 20~30) 29.7 (range 5~55) < 0.01 Flexion (°) 1.3 (rang −20~20) 12.0 (range 0~35) 0.02 Supination (°) 22.0 (range 0~50) 24.0 (range 0~50) 0.624 Pronation (°) 18.0 (range − 5~40) 20.7 (range 10~40) 0.635 Mayo score 47.3 (rang 40~65) 51.7 (range 25~60) 0.03 The variations before and after surgery MSTS score 17.1 (range 5.7~28.6) 28.6 (range − 2.9~57.1) < 0.01 VAS score 4.3 (range 2~6) 4.2 (range 1~6) 0.870 Grip strength (% of normal side) (%) 25.1 (range 10.0~47.4) 31.2 (range 11.4~81.6) 0.250 Fig. 3 The Kaplan-Meier curve shows the overall implant survival for allograft and prosthesis group, respectively Wang et al. BMC Musculoskeletal Disorders (2020) 21:69 Page 9 of 15 Fig. 4 The serial X-rays show the nature of radiological degeneration with allograft reconstruction. A: before surgery; B: 2 days after surgery; C: 2 months after surgery; D: 10 months after surgery; E: 24 months after surgery; F: 54 months after surgery the TFCC. When soft tissue reconstruction is achieved, we suggest that the retained fibers of the TFCC should be precisely reconstructed by suturing. No separation of the DRUJ was detected in allograft patients, because of selection bias and longer immobilization postoperatively. Comparison of pain Compared to the postoperative pain, there was a significantly lower level of pain in the prosthesis group in terms of both Mayo (22.3 vs 15.3, P < 0.01) and MSTS (5.30 vs 3.13, P = 0.04) score. However, the postoperative pain score was not significantly different with VAS evaluation (1.2 vs 1.3, P = 0.985). Although the pain was fairly decreased postoperatively in both reconstruction methods, the patients in the prosthesis group complained less of pain compared to those in the allograft group. We speculate that the anatomical and precise design increases the matching of joint compatibility and improved comfort for patients. For prosthesis reconstruction, Zhang et al. reported that only 1 patient complained of moderate pain in a total of 11 patients [9], Wang et al. reported that no patients suffered pain with activity in a total of 10 patients [20]. Secondly, allograft reconstruction has shown a high rate of joint degeneration, which increased the level of pain and decreased the ROM. Rabitsch et al. reported 100% joint degeneration in 4 patients [33], while Duan et al. reported 100% joint degeneration in 15 patients [13]. Comparison of satisfaction With respect to postoperative satisfaction in terms of MSTS score, there was a significantly higher satisfaction in the prosthesis group compared to allograft group (2.88 vs 4.25, P < 0.01). Nevertheless, there was no significant difference between groups 22.19 vs 23.44, P = 0.30) with regards to the Mayo score. This discrepancy may be partially explained by the difference in the weighting of satisfaction in the Mayo and MSTS scores. Although the discrepancy was found in the Mayo and MSTS scores evaluating functional outcomes, a comprehensive comparison was performed between groups using the Mayo and MSTS score. Overall, the prosthetic reconstruction had a better functional outcome, compared to the allograft reconstruction. Comparison of complications with Henderson classification With respect to complications, the main potential problems for the allograft, including nonunion, allograft fracture, wrist osteoarthritis, slow incorporation of the allograft, and rejection, have been reported after en bloc resection (Table 5). Indeed, Bus et al’s compared the Wang et al. BMC Musculoskeletal Disorders (2020) 21:69 Page 10 of 15 Fig. 5 The Kaplan-Meier curves show that the median degeneration-time of wrist was 9 months (95% CI: 8.03–9.97), in all patients with allograft reconstruction after en bloc excision Fig. 6 The serial X-rays show the separation of left DRUJ after prosthetic reconstruction. A: 2 days after surgery; B: 1 month after surgery; C: 12 months after surgery; D: 42 months after surgery complication rates of allograft reconstruction between different sites, and demonstrated that the distal radius showed a significantly lower risk in structural failure and infection compared to the proximal tibia, distal femur, and proximal humerus [38]. Furthermore, the LCP makes reconstructions easy and may be expected to result in fewer complications [13]. As a result, previous authors have suggested that if an intercalary allograft survives the critical 3 to 4 years, it is likely to last for many years [39]. In our study, four patients had palmer subluxation, three of which developed palmer subluxation within the 6 months after surgery. There are three potential reasons for this finding: firstly, the strength of the flexor is greater than that of the extensor [31], developing the tendency of palmer dislocation; secondly, all the patients underwent a dorsal approach, protecting most of the stabilizing structures in the palmar; and thirdly, without the pores in the prosthesis, the retained soft tissue suturing is tedious and unreliable. One patient progressively acquired palmer subluxation in the third year after operation (Fig. 7). According to the radiograph, we speculate that the subluxation was subordinate to the carpal degeneration. The main potential complications associated with prosthesis are subluxation, aseptic loosening, infection, soft-tissue failure and fracture of the prosthesis [9, 11, 20, 22, 40] (Table 6). In the present study, three patients