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Application of LARS Ligament Combined with 3D Printed
Prosthesis in Reconstruction of Radial Half Wrist Joint
after Tumor Resection _ Radius _ Function _ Clinical
Original Title Application of LARS Ligament Combined with
3D Printed Prosthesis in Reconstruction of Radial Half
Wrist Joint after Tumor Resection Chinese Journal of
Reparative and Reconstructive Surgery Ding Hao Shao
Xianhao Yang Qiang Li Ka Li Jianmin Li Zhenfeng
Department of Bone Oncology Qilu Hospital Shandong
University (Jinan 250000) Corresponding author Li Jianmin
Email gkljm@163com; Li
titanium tubing
price Zhenfeng Email zhenfengli163@163com Key
words Distal radius; Bone tumor; LARS ligament; 3D-
printed prosthesis; Hemi-wrist reconstruction Citation
Ding Hao Shao Xianhao Yang Qiang et al Application of
LARS Ligament Combined with 3D Printed Prosthesis in
Reconstruction of Radial Half Wrist Joint after Tumor
Resection Chinese journal of reparative and
reconstructive surgery 2022 36(7) 822-827 doi
107507/1002-1892202202086 Summary Purpose To investigate
the effect of LARS ligament and 3D printing prosthesis on
the reconstruction of the radial half wrist joint after
distal radius tumor resection Method From September 2017
to March 2021 the clinical data of 12 patients with
distal radius tumor resection combined with LARS ligament
and 3D printing prosthesis for radial half wrist
reconstruction were retrospectively analyzed There were 7
males and 5 females with an average age of 418 years
(range 19-63 years) There were 8 cases on the left side
and 4 cases on the right side There were 10 cases of
giant cell tumor of bone and 2 cases of osteosarcoma The
course of disease
Titanium welding
pipe ranged from 1 to 20 months with an average of
81 months The length of osteotomy operation time and
intraoperative blood loss were recorded and the wrist
function was evaluated by Mayo score and American
Musculoskeletal Oncology Society (MSTS) score before and
after operation; The range of motion (ROM) of the wrist
joint was measured including dorsiflexion flexion radial
deviation and ulnar deviationBone ingrowth and
osseointegration at the bone-prosthesis interface of the
wrist joint were observed
ti6al4v eli by
imaging follow-up and the occurrence of wrist
complications was recorded Result The operation was
successfully completed in all 12 patients with an average
osteotomy length of 6 8 cm (5 0 to 10 5 cm) an average
operation time of 213 8 min (180 to 250 min) and an
average intraoperative blood loss of 61 7 mL (30 to 150
mL) All patients were followed up for 11 to 52 months
with an average of 308 months Imaging follow-up showed
that bone ingrowth and osseointegration at the bone-
prosthesis interface were observed in all patients and
biological fixation was gradually achieved During the
follow-up period the stability motor function and range
of motion of the wrist joint were good and there
titanium round
bar were no complications such as arthritis
subluxation prosthesis loosening infection tumor
recurrence and metastasis Mayo score and MSTS score at
the last follow-up were (821 ± 54) and (275 ± 15)
respectively which were significantly improved compared
with (488 ± 135) and (164 ± 14) before operation (t =
− 10761 P < 0001; t = − 26600 P < 0001) The grip
strength of the affected side was 59% ~ 88% of that of
the healthy side with an average of 705% Wrist ROM was 55
° to 80 ° in dorsiflexion (mean 6542 °) 35 ° to 60 °
in flexion (mean 4458 °) 10 ° to 25 ° in radial
deviation (mean 1792 °) and 10 ° to 25 ° in ulnar
deviation (mean 1833 °) Conclusion Expand the full text
The combined application of LARS ligament and 3D printing
prosthesis is an effective way to reconstruct bone and
joint defects after distal radius tumor resection which
can improve wrist function reduce complications and
improve wrist stability Text Clinically giant cell tumor
of bone is more common in distal radius and other bone
tumors can also invade the site and the tumor often
invades the wrist joint affecting its function In order
to reduce the possibility of recurrence and improve the
prognosis most of the invasive benign and malignant
tumors of the distal radius need en bloc resection and
reconstruction
The traditional reconstruction of radial half wrist joint
mostly uses autogenous fibula which has some
disadvantages including progressive degeneration wrist
instability and long operation time [1-4] In addition the
ti6al4v
artificial semi-wrist prosthesis is initially used in
clinic but there are also common complications such as
wrist subluxation and aseptic loosening and the
instability of surrounding soft tissue support can also
lead to the failure of prosthesis implantation [1] On
this basis further improvement of bone and joint
reconstruction conditions around the prosthesis can
achieve more reliable biological fixation improve the
survival rate of implants and improve the long-term
function of wrist joint Compared with hip arthroplasty
with mature technology and satisfactory results [25]
hemi-wrist arthroplasty needs to consider individual
differences complex anatomical structure residual joint
capsule reconstruction solid bone and soft tissue
reconstruction to achieve more satisfactory wrist
function so the reconstruction method is more complex [1]
The LARS ligament is an artificial fabric made of
polyethylene terephthalate with excellent
biocompatibility for cellular and connective tissue
ingrowth [36] In previous studies LARS ligaments have
been used for soft tissue reconstruction in limb salvage
surgery for humeral femoral and tibial tumors which can
effectively improve postoperative function [6-9] In
addition 3D printing prosthesis as an effective method
for repair and reconstruction has been preliminarily
confirmed as a suitable choice for semi-wrist
reconstruction after distal radius resection [10-11]
However there have been no studies on the combined use of
LARS ligaments and 3D-printed prostheses for the
reconstruction of the distal radial hemi-carpal joint nor
in other appendicular skeletons Based on this clinical
demand we designed a combined implant of LARS ligament
and 3D printing prosthesis and carried out preliminary
clinical application The clinical data of 12 patients
with distal radius tumor resection combined with LARS
ligament and 3D printing prosthesis for radial half wrist
reconstruction from September 2017 to March 2021 were
retrospectively analyzed The report is as follows 1
Clinical data 11 General information There were 7 males
and 5 females with an average age of 418 years (range 19-
63 years) There were 8 cases on the left side and 4 cases
on the right side There were 10 cases of giant cell tumor
of bone and 2 cases of osteosarcoma The course of disease
ranged from 1 to 20 months with an average of 81 months
The general information of the patients is detailed in
Table 1 12 3D Printed Prosthesis and LARS Ligament Design
The 3D-printed prosthesis (Beijing Lidakang Technology Co
Ltd) consists of three parts including a custom polymer
polyethylene liner a 3D-printed titanium shaft and a
proximal intramedullary stem Taking the distal radius of
the healthy side of each patient as the design template
combined with the three-dimensional reconstruction data
of the affected radius the distal ulnar and radial edges
of the polyethylene liner were individually designed to
achieve the precise matching of the residual radiocarpal
joint distal radioulnar joint and brachioradialis tendon
At the same time there are prefabricated holes on the
edge of the polyethylene liner for the suture and
fixation of the surrounding soft tissue and joint capsule
and also provide anchor points for the fixation of LARS
ligament before prosthesis implantation Based on the
individual anatomical characteristics of the patient and
the area and length of the bone defect the titanium shaft
and the proximal intramedullary stem were customized as a
whole and the titanium particle coating was prepared on
the surface of the intramedullary stem which could better
promote bone ingrowth and osseointegration See Figure 1A
The LARS ligament (LARS France) is a 40 cm × 6 cm piece
of industrial-strength high-toughness polyester fiber
(polyethylene terephthalate) which is tightly sutured to
the 3D-printed prosthesis through a prefabricated hole in
an appropriate area so that the LARS ligament tightly
wraps the prosthesis (Fig 1b) to prevent loosening Fig 1
Intraoperative application of 3D printing prosthesis and
LARS ligament a 3D printed prosthesis 1 Polyethylene
liner 2 3D printed titanium shaft 3 Proximal
intramedullary stem; B During the operation The LARS
ligament was tightly sutured to the prosthesis through a
preformed hole 13 Operation method The patient was placed
in the supine position under general anesthesia The
distal radial approach was used to dissect the
superficial soft tissue According to the extent and
nature of the lesion part of the radioulnar joint
radiocarpal joint capsule and brachioradialis tendon were
carefully preserved and the pronator quadratus muscle and
dorsal extensor tendon were preserved as far as possible
According to the preoperative imaging examination the
lesion was resected within a safe range and the proximal
radius was osteotomized The radius was reamed the
prosthesis was installed the 3D printed prosthesis
wrapped with LARS ligament was used to repair bone and
soft tissue defects and the wrist joint capsule ulnar-
radial joint capsule and brachioradialis tendon were
tightly sutured with the prefabricated holes around the
prosthesis properly firmly and accurately to ensure its
multi-directional stability Prevent displacement of the
surrounding soft tissue relative to the LRAS ligament and
prosthesis and the LARS ligament relative to the
prosthesis while reducing potential dead space The
proximal intramedullary stem was fixed with bone cement
or biological fixation according to the specific
situation After all steps were completed radiographs were
performed to ensure satisfactory implant placement 14
Postoperative treatment and follow-up index The wrist was
fixed in the hyperextension position for 14 to 21 days
after the operation After the brace was removed the
patient was advised to perform multidirectional exercises
including dorsiflexion palmar flexion radial deviation
ulnar deviation and rotation The length of osteotomy
operation time and intraoperative blood loss were
recorded Radiological follow-up was performed every month
in the first 3 months and every 3 months thereafter to
observe the bone ingrowth and osseointegration at the
bone-prosthesis interface of the wrist Before and after
the operation Mayo wrist function score and American
Musculoskeletal Oncology Society (MSTS) score were used
to evaluate the wrist function after reconstruction from
pain
3d titanium wire
activity and other aspects [12-13] The grip strength of
the affected limb was expressed as a percentage of the
grip strength of the healthy upper limb and the range of
motion (ROM) of the wrist joint was measured including
dorsiflexion flexion radial deviation and ulnar
deviation; the occurrence of wrist complications was
recorded [314] 15 Statistical methods All data were
analyzed by SPSS230 statistical software The measurement
data were subjected to normality test and were in line
with normal distribution The data were expressed as mean
± standard deviation and paired t test was used for
comparison before and after operation; the test level was
α = 005 2 Result The osteotomy length was 5 0 to 10 5 cm
with an average of 6 8 cm; the operation time was 180 to
250 min with an average of 213 8 min; and the
intraoperative blood loss was 30 to 150 mL with a mean of
61 7 mL All patients were followed up for 11 to 52 months
with an average of 308 months Imaging follow-up showed
that bone ingrowth and osseointegration at the bone-
prosthesis interface were observed in all patients and
biological fixation was gradually achieved During the
follow-up period the stability motor function and range
of motion of the wrist joint were good and there were no
complications such as arthritis subluxation prosthesis
loosening infection tumor recurrence and metastasis At
the last follow-up the Mayo score and MSTS score were
(821 ± 54) and (275 ± 15) respectively which were
significantly improved compared with (488 ± 135) and
(164 ± 14) before operation and the difference was
statistically significant (t = − 10761 P < 0001;
t=−26600，P<0001）。 The grip strength of the affected
side was 59% ~ 88% of that of the healthy side with an
average of 705% Wrist ROM was 55 ° to 80 ° in
dorsiflexion (mean 6542 °) 35 ° to 60 ° in flexion
(mean 4458 °) 10 ° to 25 ° in radial deviation (mean
1792 °) and 10 ° to 25 ° in ulnar deviation (mean 1833
°) See Table 1 and Figure 2 Fig 2 Patient female 33
years old giant cell tumor of left distal radius a
Preoperative X-ray film; B Intraoperative tumor resection
and prosthesis installation ；c、d Postoperative
immediate AP and lateral position X-ray film showed that
the prosthesis implantation was satisfactory; e f
Postoperative At 7 months anteroposterior and lateral X-
ray films showed bone ingrowth and osseointegration; G ~
J Postoperative Wrist function at 11 months 3 Discussion
31 Limitations of previous methods for reconstruction of
the radial half of the wrist With the development of
comprehensive treatment and surgical techniques the
prognosis of patients with bone tumors has been
significantly improved On this basis how to shorten the
operation time reduce the incidence of postoperative
complications and obtain better limb function has become
an urgent problem to be solved
Complications such as articular cartilage degeneration
separation of the distal radioulnar joint and nonunion
often occur when using traditional fibular autograft to
reconstruct the hemi-wrist joint after resection of a
bone tumor in the distal radius [3-4 15-16] As a new type
of implant 3D printing prosthesis has been initially
applied to the repair and reconstruction of bone and
joint defects after tumor resection in extremities [17-
18] Wang et al [10] pointed out that the application of
3D printing prosthesis for semi-wrist reconstruction
after resection of giant cell tumor of distal radius has
irreplaceable advantages in improving wrist function
Firstly the matching polyethylene liner was made
according to the contralateral radius and the shape was
anastomosed; secondly the medullary cavity of the radial
shaft was matched with the customized prosthesis stem
which could avoid the rotation of the prosthesis during
implantation; thirdly there were 7 to 8 small holes on
the distal edge of the prosthesis which provided enough
space and anchor points for joint and soft tissue
reconstruction However if there is no reliable soft
tissue ingrowth to provide sufficient fixation strength
for 3D printing prosthesis reconstruction complications
such as subluxation and aseptic loosening may also occur
[68] Wang et al [10] observed 3 cases (20%) of wrist
subluxation and 3 cases (20%) of distal radioulnar joint
separation Covering the prosthesis with biocompatible
materials to improve the stability of soft tissue is one
of the feasible improvement methods Synthetic mesh
including synthetic tube LARS ligament and other types is
mainly used to wrap and cover the prosthesis in a tubular
manner which has been applied in the resection of
proximal humeral tumors and prosthesis reconstruction and
the improvement of shoulder function after surgery has
also been preliminarily confirmed [8] LARS ligament can
reconstruct the joint capsule improve joint stability
enhance soft tissue strength reduce dislocation rate and
enable patients to obtain better limb function and
greater range of motion [7-9] The above views provide
justification and feasibility for the use of LARS
ligaments in this study In the functional reconstruction
of wrist joint although one case of autogenous fibular
graft wrapped with synthetic mesh has been reported in
the literature and the results show that positive
progress has been made in preventing postoperative wrist
dislocation [19] the research on the use of synthetic
mesh in distal radius tumor resection and semi-wrist
joint reconstruction is still very limited 32 Advantages
of combined reconstruction of LARS ligaments and 3D-
printed prostheses Compared with other reconstruction
methods the application of LARS ligament in this study
significantly enhanced the stability of prosthesis joint
capsule and surrounding soft tissue greatly promoted the
improvement of wrist function after operation and
effectively reduced the occurrence of complications
Specifically through the suture of the residual
radiocarpal joint capsule the residual radioulnar joint
capsule and the brachioradialis tendon the structural
stability of the distal anterior posterior medial and
lateral soft tissues was enhanced respectively while the
soft tissues around the lesion were tightly sutured with
the LARS ligament and the prosthesis from the distal to
the proximal end to form a tightly integrated soft tissue
package Potential differences in soft tissue stability in
different orientations are reduced and the likelihood of
soft tissue loosening relative to the prosthesis is
reduced In addition the customized polyethylene liner
perfectly matches the residual articular surface of each
patient avoiding the complications of wrist dislocation
and subluxation after traditional reconstruction methods
The polyethylene liner and the preformed hole in the
distal titanium shaft can not only be used to precisely
suture the residual soft tissue on the prosthesis during
the operation but also help to firmly integrate the LARS
ligament with the 3D-printed prosthesis before the
operation and also provide a simple and effective anchor
point for soft tissue ingrowth The application of 3D
titanium coating on the intramedullary stem provides the
interface conditions of biostimulation and microporous
structure which can effectively promote bone ingrowth and
osseointegration thus effectively reducing the occurrence
of nonunion and delayed union of the implant In this
study bone ingrowth was observed at the proximal bone-
prosthesis interface to facilitate biofixation
Based on the advantages of fully wrapped structure tight
suture and combination of bone and soft tissue this study
has achieved satisfactory clinical results in wrist
function and complication rate after operation Mayo score
and MSTS score after operation are (821 ± 54) and (275
± 15) respectively It is similar to or even better than
the prognosis results reported in the literature (Mayo
score and MSTS score are 710 and 245 respectively [10-
11]) which also verifies the advantages of 3D printing
prosthesis in bone tumor defect reconstruction Compared
with traditional reconstruction methods the combination
of LARS ligament and 3D printing prosthesis can achieve
better joint stability and motor function through the
close combination of joint capsule and surrounding soft
tissue and personalized reconstruction of wrist joint The
combination of temporary fixation and functional exercise
in the early stage after operation is beneficial to the
regeneration of soft tissue Patients are usually
immobilized in hyperextension because volar flexion
forces are generally stronger and volar subluxations are
more common [13] Postoperative functional exercise should
be combined with multi-directional exercise including
dorsiflexion flexion radial deviation ulnar deviation and
rotation in order to promote the multi-directional
synchronous improvement of wrist range of motion
According to the different methods of prosthesis fixation
there are differences in the range of postoperative
exercise between patients with bone cement fixation and
patients with biological fixation The range of exercise
in patients with biological fixation is usually more
limited which leads to the relatively poor long-term
wrist function Due to the small number of patients no
statistical analysis was performed in this study 33
Limitations This study has the following limitations
First due to the small number of patients with distal
radius tumors and the short duration of combined
application of LARS ligament and 3D-printed prosthesis
the number of patients participating in this study is
limited and a multi-center large-scale and long-term
study is needed as a new reconstruction method Secondly
this study lacks comparative studies with other semi-
wrist reconstruction methods such as autogenous fibular
graft reconstruction and simple 3D printing prosthesis
reconstruction Third because of the complexity of the
reconstruction method surgeons with skilled operation
skills are required to perform intraoperative suture
reconstruction Fourthly the patients were clearly
informed of the characteristics of the combined
reconstruction method of LARS ligament and 3D printing
prosthesis before operation which led to the selection
bias To sum up compared with the traditional semi-wrist
reconstruction method the combination of LARS ligament
and 3D printing prosthesis has achieved better
postoperative function and reduced the incidence of
complications This satisfactory preliminary result may be
attributed to the advantages of LARS ligaments and 3D-
printed prostheses in reconstructing bone and joint
defects and the application of special surgical
techniques This novel and effective modality of
reconstruction for patients with bone and joint defects
caused by aggressive tumors of the distal radius may
broadly improve the overall outcome and deserves further
exploration References omitted This article cover picture
originates from the network the invasion deletes CJRRS
Chinese journal of reparative and reconstructive surgery
This article is reprinted from other websites and does
not represent the views and positions of the health
community
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pictures please contact us in time (email
guikequan@hmkxcn) and return to Sohu to see more
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Topic: Application of LARS Ligament Combined wit
