Outcome after reconstruction of the proximal humerus for tumor resection: a systematic review

Complications and functional outcomes after reconstruction of the proximal humerus with allograft-prosthetic composite: a systematic review of the literature

BACKGROUND

Allograft prosthetic composite (APC) reconstruction is performed after resection of proximal humerus tumors or failure of arthroplasty implants. There is limited literature on the postoperative outcomes of this technique. We sought to assess implant survival, failure rates, and postoperative functional outcomes after APC reconstruction of the proximal humerus.

METHODS

A systematic review of the PubMed and Embase databases was conducted. The study was registered on PROSPERO (ID: 448,663). The Strengthening of the Reporting of Observational Studies in Epidemiology checklist was used for quality assessment. Implant failure was determined using the Henderson classification for biological reconstruction. Functional outcome was primarily assessed using the Musculoskeletal Tumor Society score at last follow-up.

RESULTS

Twenty-five studies with a total of 488 patients were included. Mean follow-up in reporting studies ranged from 2.5 to 10 years. Five-year revision-free survival for implants ranged from 41% to 92%. Overall implant failure rate ranged from 9% to 54%, and reoperation rate ranged from 0% to 55%. Graft host nonunion (type 2) was the most common mode of failure, with rates ranging from 0% to 75%. The mean Musculoskeletal Tumor Society scores at last follow-up ranged from 57% to 90% across studies. A trend towards better functional outcomes was seen in patients having an APC with a reverse total shoulder arthroplasty (rTSA) compared with those with hemiarthroplasty.

CONCLUSIONS

APCs show promise in proximal shoulder reconstruction, with heterogeneous functional outcomes that are noninferior to other reconstruction techniques. Graft host nonunion is a common mode of failure and remains a concern in this type of prosthesis. Future studies should compare rTSA-APCs and rTSA endoprostheses while controlling for potential confounders.

Reduced recurrence rate and comparable functionality after wide resection and reverse total shoulder arthroplasty with allograft-prosthetic composite versus curettage for proximal humeral giant cell tumor: a multicenter retrospective study

BACKGROUND

Giant cell tumors of bone (GCTBs) are rare, aggressive tumors, and the proximal humerus is a relatively rare location for GCTBs; limited evidence exists on which surgical approaches and reconstruction techniques are optimal. In the largest case series to date, we evaluated the recurrence rate of proximal humeral GCTBs and the functional outcomes of different resection and reconstruction options in this multicenter study.

METHODS

All 51 patients included in this study received initial surgical treatment for proximal humeral GCTBs from January 2007 to December 2020, with a minimum 2-year follow-up period. Local recurrence and functional outcomes were statistically analyzed in relation to demographic, clinical, and primary surgical variables. Functional outcomes were reported by patients and were assessed by the Musculoskeletal Tumor Society score and QuickDASH instrument (shortened version of the Disabilities of the Arm, Shoulder and Hand instrument).

RESULTS

The mean follow-up period was 81.5 months (range, 30-191 months), and the overall recurrence rate was 17.6% (9 of 51 patients). The majority of recurrences (n = 7) occurred in the first 2 years of follow-up. The intralesional curettage group (n = 23) showed a statistically significant difference in the recurrence rate compared with the en bloc resection group (n = 28) (34.8% vs. 3.6%, P = .007). Among shoulders receiving en bloc resection, 16 were reconstructed with hemiarthroplasty; 8, reverse total shoulder arthroplasty (rTSA) with allograft-prosthetic composite (APC) reconstruction; and 4, arthrodesis. On the basis of intention-to-treat analysis, the mean functional Musculoskeletal Tumor Society scores of the groups undergoing curettage, rTSA with APC, hemiarthroplasty, and arthrodesis were 26.0 ± 3.1, 26.0 ± 1.7, 20.3 ± 2.8, and 22.5 ± 1.3, respectively (P < .001 [with P < .001 for curettage vs. hemiarthroplasty and P = .004 for rTSA with APC vs. hemiarthroplasty]) and the mean QuickDASH scores were 14.0 ± 11.0, 11.6 ± 4.5, 33.1 ± 11.8, and 21.6 ± 4.7, respectively (P < .001 [with P < .001 for curettage vs. hemiarthroplasty and P = .003 for rTSA with APC vs. hemiarthroplasty]).

CONCLUSIONS

On the basis of our data, en bloc resection followed by reverse shoulder arthroplasty showed a lower recurrence rate and no significant difference in functional outcome scores for proximal humeral GCTBs compared with intralesional curettage. Therefore, we believe that rTSA with APC may be reasonable for the initial treatment of proximal humeral GCTBs.

Malawer type I/V proximal humerus reconstruction after tumor resection: a systematic review

BACKGROUND

Several reconstruction methods exist for Malawer type I/V proximal humerus reconstruction after bone tumor resection; however, no consensus has been reached regarding the preferred methods.

METHODS

We conducted a literature search on various types of proximal humerus oncologic reconstruction methods. We collected data on postoperative functional outcomes assessed based on Musculoskeletal Tumor Society (MSTS) scores, 5-year reconstruction survival rates, and complications. We calculated each reconstruction's weighted mean based on the sample size and standard errors. Complications were categorized based on the Henderson classification. Based on these integrated data, our primary objective is to propose an optimal strategy for proximal humerus reconstruction after bone tumor resection.

RESULTS

We examined various reconstruction techniques, including modular prosthesis (752 patients in 21 articles), osteoarticular allograft (142 patients in 6 articles), allograft prosthesis composites (APCs) (236 patients in 12 articles), reverse shoulder total arthroplasty (141 patients in 10 articles), composite reverse shoulder total arthroplasty (33 patients in 4 articles), claviculo-pro-humero (CPH) technique (51 patients in 6 articles), and cement spacer (207 patients in 4 articles). Weighted mean MSTS scores were: modular prosthesis (73.8%), osteoarticular allograft (74.4%), APCs (79.2%), reverse shoulder total arthroplasty (77.0%), composite reverse shoulder total arthroplasty (76.1%), CPH technique (75.1%), and cement spacer (69.1%). Weighted 5-year reconstruction survival rates were modular prosthesis (85.4%), osteoarticular allograft (67.6%), APCs (85.2%), reverse shoulder total arthroplasty (84.1%), and cement spacer (88.0%). Reconstruction survival data was unavailable for composite reverse shoulder total arthroplasty and CPH technique. Major complications included shoulder joint instability: modular prosthesis (26.2%), osteoarticular allograft (41.5%), APCs (33.9%), reverse shoulder total arthroplasty (17%), composite reverse shoulder total arthroplasty (6.1%), CPH technique (2.0%), and cement spacer (8.7%). Aseptic loosening of the prosthesis occurred: modular prosthesis (3.9%) and reverse shoulder total arthroplasty (5.7%). Allograft fracture was observed in 54.9% of patients with osteoarticular allograft.

CONCLUSION

The complication profiles differed among reconstruction methods. Weighted mean MSTS scores exceeded 70% in all methods except cement spacer, and the 5-year reconstruction survival rate surpassed 80% for all methods except osteoarticular allograft. Proximal humerus reconstruction after bone tumor resection should consider potential complications and patients' individual factors.

Reconstruction Strategy for Upper Extremity Defects After Bone Tumor Resection Based on 3D Customized Bone Cement Mold

BACKGROUND

Reconstructing bone defects in the upper extremities and restoring their functions poses a significant challenge. In this study, we describe a novel workflow for designing and manufacturing customized bone cement molds using 3D printing technology to reconstruct upper extremity defects after bone tumor resection.

METHODS

Computer tomography data was acquired from the unaffected upper extremities to create a detachable mold, which can be customized to fit the joint precisely by shaping the bone cement accordingly. Fourteen patients who underwent reconstructive surgery following bone tumor resection in the proximal humerus (13 cases) or distal radius (1 case) between January 2014 and December 2022 were retrospectively evaluated. The medical records of this case series were reviewed for the demographic, radiological, and operative data. Metastasis, local recurrence, and complication were also reviewed. Additionally, Musculoskeletal Tumor Society Score (MSTS) and Visual Analogue Scale (VAS) were used to assess clinical outcomes.

RESULTS

The mean follow-up period was 49.36 ± 15.18 months (range, 27-82 months). At the end of follow-up, there were no cases of metastasis or recurrence, and patients did not experience complications such as infection, dislocation, or implant loosening. Two cases complicated with subluxation (14.3%), and 1 case underwent revision surgery for prosthetic fracture (7.1%). The average MSTS score was 23.2 ± 1.76 (77.4%, range, 66.7%-86.7%), and the postoperative VAS score was 1.86 ± 1.03 (range, 1-4), which was significantly lower than that before surgery (average preoperative VAS score was 5.21 ± 2.00 (range, 2-8)) (P < .001).

CONCLUSION

Customized 3D molds can be utilized to shape bone cement prostheses, which may serve as a potential alternative for reconstructing the proximal humerus and distal radius following en bloc resection of bone tumors. This reconstruction strategy offers apparent advantages, including precise matching of articular surfaces and comparatively reduced costs.

Similar complications, implant survival, and function following modular prosthesis and allograft-prosthesis composite reconstructions of the proximal femur for primary bone tumors: a systematic review and meta-analysis

PURPOSE

There is a lack of consensus regarding the best type of reconstruction of the proximal femur following bone tumor resection. The objective of this study was to analyze the complication risks, implant survival, and functional outcomes following modular prosthesis (MP) and allograft-prosthesis composite (APC) reconstruction of the proximal femur after primary bone tumor resections.

METHODS

We performed a search in the PubMed and Scopus libraries, obtaining 1 843 studies. We included studies reporting functional outcomes, complications, and implant survival of proximal femur reconstruction with MP or APC following primary bone tumor resection with a 2-year minimum follow-up. We excluded studies analyzing metastatic patients or studies with pooled data in which it was impossible to separate the data of patients with primary bone tumors from those with bone metastases.

RESULTS

We analyzed 18 studies (483 patients) reporting on 234 (48%) patients with MP reconstruction and 249 (52%) patients with APC reconstruction. The risk of complications was similar in patients with MP reconstruction (29%; 95% CI [0.11; 0.47]) and APC reconstruction (36%; 95% CI [0.24; 0.47]) (p = 0.48). Implant survival following MP reconstruction ranged from 81 to 86% at 5 years, 75 to 86% at 10 years, and 82% at 15 years. Implant survival following APC reconstruction ranged from 86 to 100% at 5 years and 86% at 10 years, and 86% at 15 years. Functional outcomes following MP reconstruction and APC reconstruction ranged from 24.0 to 28.3 and from 21.9 to 27.8, respectively.

CONCLUSION

Patients with primary bone tumor of the proximal femur who underwent MP or APC reconstruction seem to have similar complication risks, implant survival, and functional outcomes.

Proximal Humerus Reconstruction for Bone Sarcomas: A Critical Analysis

» The proximal humerus is a common location for primary bone tumors, and the goal of surgical care is to obtain a negative margin resection and subsequent reconstruction of the proximal humerus to allow for shoulder function.» The current evidence supports the use of reverse total shoulder arthroplasty over hemiarthroplasty when reconstructing the proximal humerus after resection of a bone sarcoma if the axillary nerve can be preserved.» There is a lack of high-quality data comparing allograft prosthetic composite (APC) with endoprosthetic reconstruction of the proximal humerus.» Reverse APC should be performed using an allograft with donor rotator cuff to allow for soft-tissue repair of the donor and host rotator cuff, leading to improvements in shoulder motion compared with an endoprosthesis.

What Is the Revision-free Survival of Resurfaced Allograft-prosthesis Composites for Proximal Humerus Reconstruction in Children With Bone Tumors?

BACKGROUND

Reconstruction of the proximal humerus in children who undergo bone tumor resection is challenging because of patients' small bone size and possible limb length discrepancy at the end of skeletal growth due to loss of the physis. There are several options for proximal humerus reconstruction in children, such as clavicula pro humero, free vascularized fibula grafting, massive bone osteoarticular allografting, endoprostheses, and allograft-prosthesis composites, but no consensus exists on the best method for reconstruction. Resurfaced allograft-prosthesis composites could be an alternative surgical option, but little is known about the results of this surgical technique.

QUESTIONS/PURPOSES

(1) What are the complications and what is the survivorship free from reconstruction failure associated with resurfaced allograft-prosthesis composites in a small, single-center case series? (2) What Musculoskeletal Tumor Society scores do patients achieve after reconstructions with resurfaced allograft-prosthesis composites?

METHODS

This study was a retrospective, single-arm case analysis in a single institution. We generally considered resurfaced allograft-prosthesis composites in children with malignant bone tumors involving the metaepiphysis of the proximal humerus in whom there was no evidence of joint contamination and in whom axillary nerve preservation was possible. Between 2003 and 2021, we treated 100 children (younger than 15 years) with bone tumors of the humerus. Thirty children (30%) with diaphyseal tumors (21 children) or distal tumors (9 children) were excluded. Among the potentially eligible children, 52 were not analyzed because they were treated with other procedures such as amputation, modular prostheses, cement spacers, free vascularized fibula grafting, and massive bone osteoarticular allografts. We included 18 children (26% of the potentially eligible children) who were treated with resurfaced allograft-prosthesis composites. There were 9 boys and 9 girls, with a median age of 10 years (range 4 to 15 years) at the time of diagnosis. A long stem (≥ 6 cm) in the resurfaced allograft-prosthesis composite was used in 9 children and a short stem (< 6 cm) was used in the remaining 9. One of the 18 children had a follow-up of less than 2 years. The median follow-up of the remaining 17 children was 4.7 years (range 2 to 19 years). The children' medical records were reviewed for clinical and functional outcomes. We performed a competing risk analysis to calculate the reconstruction failure-free survival of resurfaced allograft-prosthesis composites. Reconstruction failure was defined as removal of the implant or allograft because of implant loosening or breakage and allograft fracture or resorption. We analyzed the children's postoperative complications and functional outcomes at the end of the follow-up period using the Musculoskeletal Tumor Society functional scoring system.

RESULTS

The competing risk analysis revealed that reconstruction failure was 25% (95% confidence interval 7% to 40%) at 3 years, reaching a plateau. Four of 18 children underwent surgical revision with a new reconstruction. The reasons for reconstruction revision were resorption of the allograft at the proximal part (2 children) and fracture of the allograft (2 children). Reconstruction revision was performed in 3 of 9 children who underwent reconstruction with a short stem and in 1 of 9 children who underwent reconstruction with a long stem. Several children had other complications that did not result in removal of the allograft. Allograft resorption was observed in 4 of 18 children, but no additional surgical treatment was performed. Shoulder instability or subluxation was observed in 4 of 18 children, but only 1 child underwent surgery with a reverse shoulder arthroplasty without removal of the resurfaced allograft-prosthesis composite. Limited elbow motion because of plate impingement was observed in 1 child who underwent surgical cutting of the protruding distal part of the plate. Incomplete radial nerve palsy after surgery occurred in 1 child, with spontaneous resolution after 2 months. Screw loosening occurred in 2 children who underwent surgery with removal of loose screws. Two children had a nonunion at the graft-host bone junction; 1 child underwent surgery with bone grafting and refixation of the graft-host bone junction, and the other child with both nonunion and plate breakage was treated with bone grafting and refixation of the graft-host bone junction with a new plate. Among 17 children who had a follow-up longer than 2 years, the median Musculoskeletal Tumor Society functional score at the last follow-up interval was 23 of 30 (range 20 to 26); 1 child was considered to have an excellent result (functional score ≥ 26), 15 children were considered to have a good result (functional score 21 to 25), and 1 child was considered to have a fair result (functional score ≤ 20). The Musculoskeletal Tumor Society functional score did not change after excluding 4 children who underwent replacement of resurfaced allograft-prosthesis composites (24 of 30 [range 20 to 26]). The median angle of flexion of the shoulder was 40° (range 20º to 90°), and the median angle of abduction was 30° (range 20º to 90°).

CONCLUSION

Resurfaced allograft-prosthesis composites showed a high risk of complications, but not all complications resulted in removal of the reconstructed allograft. We used this technique mainly for very young children with small bones and for older children who underwent axillary nerve preservation. Although its success may be limited owing to a high risk of complications, a resurfaced allograft-prosthesis composite could be an alternative surgical option in order to preserve the bone stock and achieve good functional outcomes in very young children. We recommend using a long-stem resurfaced allograft-prosthesis composite, which may reduce the risk of complications.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Outcomes of proximal humeral reconstruction with cemented osteoarticular allograft in pediatric patients: a retrospective cohort study

BACKGROUND

There is no agreement on the best choice of proximal humeral reconstruction following tumor resection in pediatric patients. We reviewed the functional outcomes, oncologic outcomes, and surgical complications in pediatric patients after proximal humeral reconstruction with cemented osteoarticular allograft.

METHODS

Eighteen patients aged 8-13 years who underwent proximal humeral osteoarticular allograft reconstruction following resection of primary bone sarcoma were included. The mean follow-up period was 88 ± 31.7 months. At the last follow-up assessment, limb function was evaluated based on shoulder range of motion, Musculoskeletal Tumor Society score, and Toronto Extremity Salvage Score. Tumor recurrence and postoperative complications were extracted from the patients' medical records.

RESULTS

Mean active forward flexion of the shoulder was 38° ± 18°. Mean active abduction was 48° ± 18°. Mean active external rotation was 23° ± 9°. The mean Musculoskeletal Tumor Society score was 73.4% ± 11.2%. The mean Toronto Extremity Salvage Score was 75.6% ± 12.9%. Local recurrence occurred in 1 patient. Metastasis developed after the operation in 2 additional patients. We recorded 6 postoperative complications in this series, including 1 superficial infection, 1 late-onset deep infection, 1 allograft fracture, 2 cases of nonunion, and 2 cases of shoulder instability. Two complications required allograft removal.

CONCLUSION

In pediatric patients, reconstruction of the proximal humerus with cemented osteoarticular allograft results in acceptable oncologic and functional outcomes while the postoperative complication rate seems to be lower than that of other available techniques.

Oncological and functional outcomes after resection of malignant tumours of the scapula

Aims

The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula.

Methods

We reviewed 61 patients (37 male, 24 female; mean age 42 years (SD 19)) who had undergone resection of the scapula. The most common resection was type 2 (n = 34) according to the Tikhoff-Linberg classification, or type S1A (n = 35) on the Enneking classification.

Results

The ten-year disease-specific survival was 76%. High tumour grade (hazard ratio (HR) 4.27; p = 0.016) and a total resection of the scapula (HR 3.84; p = 0.015) were associated with worse survival. The ten-year metastasis-free and local recurrence-free survivals were 82% and 86%, respectively. Total scapular resection (HR 6.29; p = 0.004) was associated with metastatic disease and positive margins were associated with local recurrence (HR 12.86; p = 0.001). At final follow-up, the mean shoulder forward elevation and external rotation were 79° (SD 62°) and 27° (SD 25°), respectively. The most recent functional outcomes evaluated included the mean Musculoskeletal Tumor Society Score (76% (SD 17%)), the American Shoulder and Elbow Score (73% (SD 20%)), and the Simple Shoulder Test (7 (SD 3)). Preservation of the glenoid (p = 0.001) and scapular spine (p < 0.001) improved clinical outcomes; interestingly, preservation of the scapular spine without the glenoid improved outcomes (p < 0.001) compared to preservation of the glenoid alone (p = 0.05).

Conclusion

Resection of the scapula is a major undertaking with an oncological outcome related to tumour grade, and a functional outcome associated with the status of the scapular spine and glenoid. Positive resection margins are associated with local recurrence.

Are Vascularized Fibula Autografts a Long-lasting Reconstruction After Intercalary Resection of the Humerus for Primary Bone Tumors?

BACKGROUND

A vascularized fibula graft (VFG) is the vascular autograft most frequently used to restore large segmental long bone defects, particularly in the upper limb. Because the use of a vascularized fibula involves an operation in an uninvolved extremity with potential morbidity, it is important to document that this type of reconstruction is successful in restoring function to the humerus. However, the long-term results of VFG after intercalary resection of the humeral diaphysis for bone tumors are still unknown.

QUESTIONS/PURPOSES

(1) What was the complication rate of reconstruction? (2) What was the functional result after surgical treatment, as assessed by the Musculoskeletal Tumor Society (MSTS) score, the American Shoulder and Elbow Society (ASES) score, and Constant score? (3) What was the survivorship of these grafts free from revision and graft removal at 5, 10, and 15 years?

METHODS

Between 1987 and 2021, 127 patients were treated at our institution with en bloc resection for a primary malignant or an aggressive benign bone tumor of the humerus; we excluded patients treated with extra-articular resection or amputation. Of those, 14% (18 of 127) were treated with intercalary resection of the humeral diaphysis for primary bone tumors and reconstruction with VFG, with or without a bulk allograft, and were analyzed in this retrospective study. Generally, our indications for reconstruction with VFG are intercalary resection of the humerus for primary malignant or aggressive benign bone tumors in patients with long life expectancy and high functional demands, in whom adequate bone stock of the proximal and distal epiphysis can be preserved. In 13 patients, VFG was used alone, whereas in five patients, a massive allograft was used. Our policy was to use VFG combined with a massive allograft in patients undergoing juxta-articular joint-sparing resections in which proximal osteotomy was performed close to the anatomic neck of the humerus to obtain more stable fixation and better tendinous reattachment of the rotator cuff and deltoid. All 18 patients who were treated with a VFG were available for follow-up at a minimum of 2 years (median follow-up 176 months, range 26 to 275 months), and although three have not been seen in the past 5 years and are not known to have died, they had 172, 163, and 236 months of follow-up, and were included. The median age at surgery was 25 years (range 2 to 63 years), the median humeral resection length was 15 cm (range 8 to 21 cm), and the median fibular length was 16 cm (range 12 to 23 cm). Complications and functional scores were ascertained by chart review that was performed by an individual not involved in patient care. Functional results were assessed with the MSTS score (range 0 to 30), the ASES score (range 0 to 100), and the Constant score (range 0% to 100%). Survivorship was estimated using a Kaplan-Meier survivorship estimator, which was suitable because there were few deaths in this series.

RESULTS

Seven patients underwent a revision procedure (one radial nerve transient palsy because of screw impingement, four nonunions in three patients with one humeral head avascular necrosis, treatment for screw-related pain in one patient, and two VFG fractures), and one patient underwent VFG removal. Donor site complications were observed in four patients (one ankle valgus deformity and three claw toes-the first toe in two patients and the other toes in the third). At the final clinical control, at a median follow-up of 176 months (range 26 to 275 months), the median MSTS score was 30 of 30 (range 28 to 30), the median ASES score was 98.3 (range 93 to 100), and the median Constant score was 93.5% (range 79% to 100%). Revision-free survival was 71% (95% CI 53% to 96%) at 5 years and 57% (95% CI 37% to 88%) at 10 and 15 years; VFG removal-free survival was 94% (95% CI 83% to 100%) at 5, 10, and 15 years.

CONCLUSION

VFG appears to be an effective reconstructive option after humeral intercalary resection for primary bone tumors. These are complex procedures and should be performed by an experienced team of surgeons who recognize that complications may occur frequently in the first years after the procedure. The frequency of mechanical complications observed in the first 5 years postoperatively may be lessened by using long spanning-plate fixation, and if successful, this reconstruction provides a long-term, durable reconstruction with excellent functional results.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Outcomes of Sling Procedure Using a Free Vascularized Fibular Graft After Resection of the Proximal Humerus

Background

The proximal humerus is a common site for both primary and metastatic bone tumors. Although various methods have been developed for reconstruction following resection of the proximal humerus, a consensus on which technique is best has not been established. We focused on the sling procedure using a free vascularized fibular graft (FVFG) and conducted what we believe to be the largest retrospective study of patients to undergo this surgery to date.

Methods

We retrospectively reviewed the data of 19 patients who underwent the sling procedure with use of an FVFG at our hospital between 1998 and 2022. The median age was 20 years, and the median follow-up duration was 63.1 months. Surgical data, oncological outcomes, the postoperative course, complications, and functional outcomes as measured with use of the Musculoskeletal Tumor Society (MSTS) score were thoroughly reviewed.

Results

The median operative duration was 555 minutes, and the median blood loss was 374 mL. The median length of the bone defect was 17.0 cm, and the median length of the graft was 20.0 cm. With respect to oncological outcomes, 9 patients were continuously disease-free, 9 patients had no evidence of disease, and 1 patient was alive with disease. Bone union was present in 13 of the 17 patients for whom it was evaluable. The median time to bone union was 4 months. Graft growth was observed in 2 pediatric patients. Postoperative fracture was a major complication at the recipient site. The incidence of pseudarthrosis significantly increased when the FVFG could not be inserted into the remaining humeral bone or was split in half (p = 0.002). Although a few patients demonstrated peroneal nerve palsy at the donor site, the symptom was temporary. The overall functional outcome was favorable, with an average MSTS score of 66.9%.

Conclusions

The sling procedure demonstrated a low complication rate and a favorable functional outcome overall. Therefore, we believe that this procedure is a useful reconstruction method for patients in a broad age range who have a wide defect of the proximal humerus.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Epiphyseal Metastasis to the Proximal Humerus Secondary to Breast Carcinoma: A Case Report

Metastasis to the bone is a known risk of breast cancer, with the humerus being the most common upper extremity site of metastases, with most lesions located at the humeral diaphysis. We present a unique case of proximal humeral metastasis involving the epiphysis secondary to primary invasive ductal carcinoma in a middle-aged Caucasian female. It is important to have a high degree of suspicion for metastasis when musculoskeletal pain occurs in breast cancer patients, as it may be masked by common, degenerative conditions about the shoulder girdle. When humeral metastases involve the epiphysis, treatment options are complicated by its location, which jeopardizes the integrity of articular cartilage and the function of the shoulder girdle. External beam irradiation provides pain control in a non-invasive manner, sans surgical risks. Surgical intervention will vary depending on the characteristics of the bony lesion, but the use of endoprosthetics has emerged as the most effective option for restoring range of motion and pain control with acceptable rates of implant survival.

Functional outcome and quality of life following resection of the proximal humerus performed for musculoskeletal tumors and reconstruction done by four different methods

INTRODUCTION

The proximal humerus is a frequent site for both primary and secondary bone tumors. Several options are currently available to reconstruct the resected humerus, but there is no consensus regarding optimal reconstruction. The aim of this retrospective study was to compare the functional outcome, complications and patient compliance following four different types of reconstructive techniques.

MATERIAL AND METHODS

The authors performed 90 proximal humerus resections due to primary and secondary bone tumors over the past 21 years. Four different procedures were performed for reconstruction following the resection: fibula autograft transplantation, osteoarticular allograft implantation, modular tumor endoprosthesis (hemiarthroplasty) and reconstruction of the defect with a reverse shoulder prosthesis-allograft composite. A retrospective analysis of the complications and patient's physical status was performed. Functional outcome and life quality was evaluated by using the MSTS and SF-36 scores.

RESULTS

The best range of motion was observed following arthroplasty with a reverse shoulder prosthesis-homograft composite followed by a fibula autograft reconstruction. Revision surgery was required due to major complications most frequently in the osteoarticular allograft group, followed by the reverse shoulder prosthesis-allograft composite group, the autologous fibula transplantation group; the tumor endoprosthesis hemiarthroplasty group had superior results regarding revision surgery (40, 25, 24 and 14% respectively). MSTS was 84% on average for the reverse shoulder prosthesis-allograft composite group, 70% for the autologous fibula group, 67% for the anatomical hemiarthroplasty group and 64% for the osteoartricular allograft group. Using the SF-36 questionnaire for assessment no significant differences were found between the four groups regarding quality of life.

DISCUSSION

Based on the results of our study the best functional performance (range of motion and patient compliance) was achieved in the a reverse prosthesis-allograft combination group-in cases where the axillary nerve could be spared. The use of an osteoarticular allograft resulted in unsatisfying functional results and high complication rates, therefore we do not recommend it as a reconstructive method following resection of the proximal humerus due to either primary or metastatic bone tumors. Young patients who have good life expectancy but a small humerus or intramedullar cavity reconstruction by implantation of a fibula autograft is a good option. For patients with a poor prognosis (i.g. bone metastases) or in cases where the axillary nerve must be sacrificed, hemiarthroplasty using a tumor endoprosthesis was found to have acceptable results with a low complication rate. According to the MSTS and SF-36 functional scoring systems patients compliance was nearly identical following all four types of reconstruction techniques; the underlying cause may be the complexity of the shoulder girdle. However, we recommend the implantation of a reverse shoulder prosthesis-allograft whenever indication is appropriate, as it has been demonstrated to provide excellent functional outcomes, especially in young adults.

Allograft Prosthesis Composite (APC) for Proximal Humeral Bone Loss: Outcomes and Perspectives

(1) Background: Allograft prosthetic composite (APC) represents one of the techniques used for reconstruction in large proximal humeral bone deficits. The present systematic review aimed at summarizing the state of the art of the technique and analyzing its outcomes. (2) Methods: The PRISMA guidelines were followed to perform this systematic review. A systematic electronic search was performed using PubMed (MEDLINE), EMBASE, and the Cochrane Library databases. All the studies analyzing the rates of allograft prosthesis composite were pooled, and the data were extracted and analyzed. (3) Results: A total of 10 studies were eligible for inclusion in this systematic review for a total of 239 patients. The rate of patient satisfaction with surgery was reported in 7 studies with a mean of 86.4% ± 13.64. The mean constant score was 45.7 ± 3.51, the mean ASES score was 63.58 ± 8.37, and the mean SST was 4.6 ± 1.04. The mean revision rate observed was 10.32% ± 3.63 and the mean implant survival was 83.66% ± 14.98. (4) Conclusions: Based on the currently available data, allograft prosthesis composite represents a valuable option for the reconstruction of proximal humeral deficits. All studies analyzed showed the favorable impact of this surgical technique on clinical outcomes and patient satisfaction.

Salvage of a Fractured Proximal Ulnar Osteoarticular Allograft Using a Medial Femoral Condyle Free Flap: A Case Report

CASE

We present the case of a 47-year-old paraplegic woman who underwent resection of an intermediate-grade chondrosarcoma in the proximal ulna, which was initially reconstructed with an osteoarticular allograft. However, after more than 25 years without complications, she sustained an intra-articular fracture of the allograft, which was then successfully treated using a vascularized medial femoral condyle (MFC) flap and anterolateral thigh flap. The patient has subsequently recovered her baseline elbow function, has no pain, and can use her wheelchair without restrictions.

CONCLUSION

Free MFC flaps are viable options to salvage osteoarticular allografts that are affected by intra-articular fractures.

Functional Outcomes and Shoulder Instability in Reconstruction of Proximal Humerus Metastases

(1) Background: Some of the goals of orthopedic surgical oncology are saving limbs and function. The humerus is the third most frequent site in primary tumors and one of the most involved sites for metastases. Prosthetic replacement with modular megaprosthesis is one of the treatment choices, but there are several types of complications, such as problems with function and pain. The aim of our study is to assess functional outcomes and shoulder instability in the reconstruction of proximal humerus metastases. (2) Methods: This is a retrospective observational study. Twenty-eight patients, with proximal humerus metastases, admitted to the department of Orthopaedics and Traumatology of our University Hospital between 2014 and 2022 were recruited. Each patient underwent resection and prosthetic replacement surgery with modular megaprosthesis. Clinical evaluation was assessed through MSTS score, WOSI index, and DASH score. (3) Results: Twenty patients were included in the study. Fairly good results, especially regarding pain, function, and emotional acceptance, were obtained in all three tests: DASH, MSTS, and WOSI. Patients who reported shoulder instability actually have worse outcomes than those who report having stable shoulders. In addition, patients with a resection >10 cm have worse outcomes than those who had a resection of 10 cm. No significant differences were found between the deltopectoral approach group and the lateral approach group. (4) Conclusions: Reconstructive surgery with megaprosthesis of the proximal humerus in patients with metastases can be considered a treatment option, especially in patients with pathological fractures or injuries with a high risk of fracture and good life expectancy. This study shows how this type of surgery affects instability, but in terms of functionality, pain, and patient satisfaction, it gives satisfactory results.

Management of Proximal Humeral Oncologic Lesions

The proximal humerus is a common location for primary tumors, benign lesions, and metastatic disease. Advances in neoadjuvant and adjuvant therapy have allowed for limb-salvage surgery in most of the cases. There are numerous of options for surgical management of proximal humerus lesions and the decision to pursue one over another depends on factors such as age, comorbidities, pathology, location within the proximal humerus, planned resection margins/size of defect, and bone quality. Long-term outcomes for these techniques tend to be retrospective comparative studies, with recent studies highlighting the improved outcomes of reverse total shoulders.

Does reverse total shoulder arthroplasty with allograft-prosthesis composite (APC) have surgical benefits over hemiarthroplasty with APC in patients with tumors of the proximal humerus?

Background

The research on surgical outcomes of hemiarthroplasty and reverse total shoulder arthroplasty using allograft-prosthesis composites for the proximal humeral oncologic condition is still scarce. Therefore, this study aimed to compare surgical outcomes of shoulder joint reconstruction with hemiarthroplasty and reverse total shoulder arthroplasty using allograft-prosthesis composites for tumors of the proximal humerus.

Methods

Eleven patients underwent hemiarthroplasty or reverse total shoulder arthroplasty using allograft-prosthesis composites for tumors of the proximal humerus between July 2011 and April 2018 were reviewed. Radiographic analysis for bone union of allograft-host bone junction, implant loosening, stress shielding and shoulder dislocation or subluxation was performed. Functional outcomes were evaluated using visual analog scales for pain, range of motion, Simple Shoulder Test score and Musculoskeletal Tumor Society score. Furthermore, oncologic outcome and complications were also assessed, respectively.

Results

There were five patients with hemiarthroplasty (mean age, 23.2 years) and six patients with reverse total shoulder arthroplasty (mean age, 46.8 years, P = 0.05). Radiographically, there were no events associated with implant loosening, stress shielding and shoulder dislocation or subluxation in the two groups. There were no differences in functional outcomes between the two groups. There was no local recurrence in entire cohort. In the hemiarthroplasty group, one patient was required revision surgery to reverse total shoulder arthroplasty at postoperative 6 years due to rotator cuff dysfunction. In the reverse total shoulder arthroplasty group, one patient showed the fracture occurred at allograft-host bone junction at postoperative 6 months.

Conclusions

Surgical outcomes of hemiarthroplasty with allograft-prosthesis composites were not inferior to reverse total shoulder arthroplasty when applied in properly selected patients. The authors recommended that hemiarthroplasty with allograft-prosthesis composites could be used for young age patients without glenoid metastasis involvement, and reverse total shoulder arthroplasty with allograft-prosthesis composites could be used for patients with old age or metastatic bone tumors.

Prosthetic Reconstruction of the Shoulder After Resection of Proximal Humerus Bone Tumor

Prosthetic reconstruction after wide resection of tumors of the proximal humerus presents a unique challenge. The shoulder is a complex articulation, and patients have high expectations for postoperative function. The goal of this study is to compare functional outcomes, oncologic outcomes, and complication rates for 2 reconstructive methods. Forty patients with proximal humeral tumors were reviewed retrospectively. Proximal humeral endoprosthesis (PHE) was used for 21 patients, and reverse shoulder arthroplasty (RSA) was used for 19 patients. Clinical results, oncologic outcomes, and complication rates were assessed. The functional outcomes of the patients were assessed with the Musculoskeletal Tumor Society scoring system (MSTS), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and shoulder range of motion. The mean follow-up was 62±15 months. Shoulder dislocations occurred among 8 patients with PHE and 1 patient with RSA (P=.021). The other complication rates were similar for the 2 groups (P<.05). At the latest follow-up, the mean MSTS score was 68±10.3 for those with PHE and 76±7.7 for the patients with RSA (P=.72). However, the QuickDASH score was significantly better (P=.031) for those with RSA (mean, 19±6.3) compared with patients with PHE (mean, 30±4.8). Additionally, shoulder active abduction and forward flexion were significantly greater for the RSA group (P=.04 and P=.03, respectively). Five patients had local recurrence. Prosthetic reconstruction after oncologic re-section of the proximal humerus is associated with significant limitation of shoulder range of motion and a high rate of revision surgery. However, in this study, RSA was associated with fewer dislocations, improved Quick-DASH score, and greater abduction and forward flexion compared with PHE. [Orthopedics. 2022;45(6):e335-e341.].

Anatomical and reverse megaprosthesis in proximal humerus reconstructions after oncologic resections: a systematic review and meta-analysis

AIM

Anatomic (AN) Endoprosthesis (EPR) reconstructions of the shoulder after intra-articular proximal humerus (Malawer type 1) resections are characterized by early recovery and low complications rate. However, shoulder instability and limited mobility can occur. Reverse shoulder (RS) EPR has been introduced to improve functional outcome. The aim of this systematic review is to evaluate shoulder reconstructions with AN or RS EPR after Malawer type 1 resection, comparing complications and functional results.

METHODS

Through an electronic systematic search of PubMed, articles concerning EPR after shoulder Malawer type 1 resections were reviewed. Complications rate, range of motion (ROM) and functional outcome (Musculoskeletal Society Tumor Society-MSTS score) of AN and RS EPR were evaluated.

RESULTS

Sixteen studies were included. A similar complication rate was observed between AN and RS EPR rate (26.4% and 22.4%, respectively, p = 0.37). Soft tissue failure was the most frequent complication and cause of revision in both groups. Mean post-operative flexion and abduction ROM and MSTS scores were significantly higher in RS EPR, particularly among patients with preserved deltoid function (p = 0.013, p = 0.025 and p = 0.005, respectively).

CONCLUSIONS

Anatomic and reverse shoulder EPR represent safe and effective implants for shoulder reconstruction, with similar implant stability and complication rates. RS EPR significantly improves post-operative ROM and functional outcomes, especially when at least a partial function of the abductor apparatus is preserved.

Early functional and therapeutic effect of reversed tumour shoulder prosthesis reconstruction after proximal humerus tumour resection

Introduction

Reconstruction of proximal humeral tumours after resection is still controversial. And there are few articles describing oncology patients' postoperative function after reversed tumour shoulder prosthesis reconstruction. We investigated the functional results of patients who underwent reversed tumour shoulder prosthesis, including those who did not preserve the deltoid ending point.

Patients and methods

We retrospectively evaluated 16 patients with proximal humerus tumours who had undergone reversed tumour shoulder prosthesis. All patients underwent type Malawer I proximal humeral resection surgery and standard reverse tumour shoulder arthroplasty with a modular reverse shoulder prosthesis. We sutured the severed end of the deltoid to the brachialis muscle using the artificial patch for patients who had their deltoid ending point resected. Patients are rehabilitated and followed up according to our instructions.

Result

All patients were followed up for a mean of 27.4 months (13–59), and their mean age was 45.9 years (15–74). The mean length of the humeral resection was 11.6 cm (5–15). The mean shoulder mobility was 122° (82°–180°) in forward flexion; 39° (31°–45°) in posterior extension; 102° (65°–172°) in abduction; 43° (30°–60°) in external rotation; 83° (61°–90°) in internal rotation, and a mean MSTS score of 77.9% (63.3%–93.3%). The mean DASH score was 20.8 (2.5–35.8). The mean VAS score was 0.9. For patients who had their deltoid ending point resected, the mean length of the humeral resection was 14.0 cm; the mean shoulder mobility was 109° in forward flexion; 37.8° in posterior extension; 102.0° in abduction; 38.3° in external rotation; 86.3° in internal rotation, and the mean MSTS score was 78.8%; the mean DASH score was 21.6; the mean VAS score was 1.0.

Conclusion

Patients who underwent reverse tumour shoulder arthroplasty can achieve good early postoperative function, survival rate and low complication rate. In addition, patients who had their deltoid ending point removed also obtained good function after particular reconstruction.

Efficacy and safety of a 3D-printed arthrodesis prosthesis for reconstruction after resection of the proximal humerus: preliminary outcomes with a minimum 2-year follow-up

Background

The purpose of this study was to investigate the feasibility of using a three-dimensional (3D)-printed arthrodesis prosthesis for reconstruction of the proximal humeral defect after tumor resection.

Methods

A novel proximal humeral prosthesis was designed to restore bone continuity and shoulder arthrodesis and was fabricated via 3D printing technology. Ten patients with primary malignancies in the proximal humerus underwent intra-articular resection and replacement with this prosthesis from 2017 to 2019. Baseline and operative data, oncological and prosthetic survival, and functional status were summarized.

Results

This cohort consisted of 9 males and 1 female with a mean age of 32.1 ± 16.1 years. Diagnoses included 5 cases of osteosarcoma, 3 cases of chondrosarcoma and 1 each case of undifferentiated pleomorphic sarcoma and malignant myoepithelioma. The mean operative duration, intraoperative hemorrhage and postoperative length of hospitalization were 151.5 ± 61.0 min, 410.0 ± 353.4 ml and 5.3 ± 1.9 d, respectively. The mean follow-up duration was 29.3 ± 6.4 months, with a minimum of 24 months for the surviving patients. Two patients experienced local recurrence, and four patients developed distant metastases. Detachment of the taper occurred in two patients. One was managed conservatively, and the other received amputation due to concurrent tumor recurrence. The mean MSTS-93 and ASES scores and ranges of forwards flexion and abduction were 24.9 ± 3.1, 79.4 ± 8.3, 71.3 ± 19.4°, and 61.3 ± 16.4°, respectively. The functional outcomes were independent of the preservation of the axillary nerve. Histological study of the glenoid component showed evidence of bone ingrowth at the bone-prosthesis porous interface.

Conclusion

Application of the 3D-printed arthrodesis prosthesis might be a safe and efficacious method for functional reconstruction in patients who underwent resection of the proximal humerus, especially for those without preservation of the axillary nerve.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05581-6.

Reconstruction by allograft-prosthetic composite reverse shoulder arthroplasty after proximal humerus tumor resection: Clinical and radiographic assessment at a minimum 2years' follow-up

INTRODUCTION

Reverse shoulder arthroplasty (RSA) is an option to conserve limb function after resection of proximal humerus malignancy. An allograft-composite RSA is an alternative to a tumor prosthesis, and can restore proximal humeral bone stock. The aim of the present study was to assess medium-term radiographic and clinical results for such composite implants.

METHODS

Patients with malignant proximal humerus tumor treated by resection and reconstruction by composite RSA were retrospectively analyzed at a minimum 24months' follow-up. Clinical assessment used Constant score, Subjective Shoulder Value (SSV) and ADLER score. Standard radiographic work-up assessed allograft absorption and screened for implant loosening.

RESULTS

Eleven patients were included, with a mean age of 51years (range: 19-87years) and mean 30months' follow-up (range: 24-84months). Mean tumor resection was 10cm (range: 6-17cm). Etiologies comprised chondrosarcoma (n=6), osteosarcoma (n=2), B-cell lymphoma (n=1) and single metastasis (n=2). Bony increased-offset allograft was associated to humerus reconstruction in 8 cases, and latissimus dorsi tendon transfer in 5 cases. Mean Constant score was 49 points, SSV 52%, and ADLER score 20 points. Increased glenoid implant offset associated to tendon transfer significantly improved anterior elevation and external rotation. Radiographic allograft consolidation to the native humerus was acquired in 73% of cases, while osteolysis in the epiphyseal-metaphyseal zone was found in 64%. There were no cases of humeral implant loosening. Glenoid allograft absorption was systematic (8/8 cases), without inducing loosening of the implant baseplate.

CONCLUSION

Composite reverse shoulder arthroplasty is functionally effective after massive resection. However, allograft absorption is a drawback, casting doubt on continued use on the glenoid side.

LEVEL OF EVIDENCE

IV.

New special approach for shoulder stability after Malawer type IVB shoulder girdle resection: A case report

Introduction and importance

Scapular prostheses are useful in shoulder stability after shoulder girdle resection for malignant bone tumors; however, they are difficult to obtain in Japan. Therefore, other methods must be considered, depending on the extent of resection. We report a case in which a clavicle-locking plate, Nesplon tape, and a proximal humeral prosthesis were used to ensure shoulder stability and preserve stable upper limb function.

Case presentation

A 56-year-old man presented with a large mass and edema over the entire right scapula, which caused severe pain, limited the shoulder's range of motion, and impaired function of the entire upper extremity. Clinical imaging and pathological findings indicated a diagnosis of conventional chondrosarcoma. Using the Malawer technique type IVB, we resected the shoulder girdle and secured shoulder stability with a clavicle-locking plate, Nesplon tape, and a proximal humeral prosthesis. To evaluate the patient, we obtained his Musculoskeletal Tumor Society (MSTS) and Disabilities of Arm, Shoulder, and Hand (DASH) scores 3 months postoperatively.

Clinical discussion

To preserve the function of the patient's elbow and hand, the stability of his shoulder was important. We could achieve this stability by using a prosthesis available in Japan. The patient's MSTT and DASH scores improved remarkably.

Conclusion

A clavicle-locking plate, Nesplon tape, and a proximal humeral prosthesis can be used to ensure shoulder stability after scapular girdle resection and can preserve or improve upper limb function.

Outcomes of modular endoprosthesis reconstruction versus cement spacer reconstruction following resection of proximal humeral tumors

BACKGROUND

There is no agreement about the best reconstructive option following resection of proximal humerus tumors. The purpose of this study was to compare the functional outcomes of endoprosthesis reconstruction versus nail cement spacer reconstruction after wide resection of proximal humeral tumors.

METHODS

This retrospective comparative study included 58 patients with proximal humerus tumors who had undergone tumor resection and reconstruction with modular endoprosthesis (humeral hemiarthroplasties) or cement spacer. Medical records were reviewed for the epidemiological, clinical, radiological, and operative data. Lung metastasis, local recurrence, and complication were also reviewed. The functional outcome was evaluated using the Musculoskeletal Tumor Society scoring (MSTS) system.

RESULTS

Nineteen patients with a mean age of 33.4 ± 17.5 years underwent reconstruction by modular endoprosthesis, and 39 patients with a mean age of 24.6 ± 14.3 years underwent reconstruction by cement spacer. The mean MSTS score was 24.8 ± 1.1 in the endoprosthesis group and 23.9 ± 1.4 in the spacer group, P = 0.018. Complications were reported in 5 (26.3%) patients in the endoprosthesis group and 11 (28.2%) patients in the spacer group, P = 0.879. There were no statistically significant differences in the functional outcomes in both patient groups with or without axillary or deltoid resection.

CONCLUSIONS

Both endoprostheses and cement spacers are durable reconstructions with almost equal functional outcomes with no added advantage of the expensive endoprosthesis.

Survivorship of Reverse Shoulder Arthroplasty According to Indication, Age and Gender

Background. The indications for reverse shoulder arthroplasty (RSA) have been widely expanded, but only a few studies report the long-term survival of these implants. Our objective was to report the long-term survivorship of a large series of RSAs implanted for different etiologies. Methods. A retrospective multicenter study including all the RSAs was performed in six shoulder-specialized centers with at least 2 years of follow up. We reviewed 1611 RSAs, operated between 1993 and 2010, including 497 cuff-tear arthropathies (CTA), 239 revision RSAs, 188 massive cuff tears (MCT), 185 fracture sequelae (FS), 183 failed previous cuff repairs (FCR), and 142 primary osteoarthritis (POA). The mean follow-up was 5.6 ± 3.9 years (range 2−20). Results. Overall, 266 RSAs (16.5%) had at least one complication leading to 64 reoperations (4.0%) and 110 revision surgeries (6.8%). The most frequent complications were infection (3.8%), instability (2.8%), and humerus-related complications (2.8%). At 10 years, the survival without revision surgery was 91.0% in primary RSAs and 80.9% in revision RSAs for failed arthroplasty (p < 0.001). In the primary RSA group, MCT and FCR led to 10-year survivals for over 95% but fracture sequelae and tumors had the lowest 10-year survivals (83.9% and 53.1%). Younger patients had a lower 10-year survival. In revision RSAs, male patients had a significantly lower survival than females (72.3% vs. 84.5% at 10 years, p = 0.020). Discussion. Primary RSA for cuff-deficient shoulders or POA leads to a high 10-year survival, but revision RSA or primary RSA for FS and tumors are at high-risk for revision. Surgeons should be aware of high rates of complications and lower survival rates of RSA in younger patients, in males, and in RSAs for revision surgery.

Implant Survival, Clinical Outcome and Complications of Megaprosthetic Reconstructions Following Sarcoma Resection

Simple Summary

Malignant bone and soft tissue tumors are usually surgically removed with an envelope of healthy tissue as a barrier. If located in the long bones of the upper and lower extremity, this approach leads to a large bone defect commonly affecting a joint. One way to rebuild the bone defect and the neighboring joint is the use of a megaprosthesis that is anchored in the remaining bone comparable to a conventional joint replacement. In general this approach is popular as it provides early stability and allows the affected patient to begin rehabilitation early on. However, complications leading to long-term unplanned reoperation are common. This article provides an overview of current implant survival, types of complication and long-term outcomes of megaprostheses used following tumor resection.

Abstract

Megaprosthetic reconstruction of segmental bone defects following sarcoma resection is a frequently chosen surgical approach in orthopedic oncology. While the use of megaprostheses has gained popularity over the last decades and such implants are increasingly used for metastatic reconstructions and in non-tumor cases, there still is a high risk of long-term complications leading to revision surgery. This article investigates current implant survivorship, frequency and types of complications as well as functional outcomes of upper and lower limb megaprosthetic reconstructions.

Allograft prosthetic composite reconstruction using a reverse total shoulder arthroplasty for failed oncologic proximal humerus reconstruction

INTRODUCTION

Endoprosthetic or allograft reconstruction are the preferred reconstruction techniques for proximal humeral bone tumors. Failure of these reconstructions may occur, but historically revision is performed rarely due to the lack of reliable options. Reverse shoulder arthroplasty with an allograft prosthetic composite (rAPC) may provide a revision option. The purpose of the current study was to evaluate our institutional outcome of these procedures.

METHODS

Eleven (6 male, 5 female) patients (mean age 51 ± 17 years) underwent revision of a failed oncologic reconstruction of the proximal humerus utilizing a rAPC. The most common indication for revision was subluxation (n = 6) and the most common previous implant was an endoprosthesis (n = 5).

RESULTS

Revision resulted in improvements in shoulder elevation (39° vs. 62°, p = 0.02), external rotation (13° vs. 25°, p = 0.04), American Shoulder and Elbow Surgeons score (39 vs. 58, p = 0.004) and Musculoskeletal Tumor Society Scores (51% vs 69%, p = 0.002). There were 2 re-revision procedures performed. One for an allograft fracture and one for allograft resorption and loosening.

CONCLUSIONS

Revision with a rAPC can effectively restore patient function. Due to the complexity of the cases, we advocate for these procedures to be performed by subspecialty upper extremity surgeons trained in complex revision shoulder arthroplasty.

Reverse total shoulder arthroplasty for oncologic reconstruction of the proximal humerus: a systematic review

BACKGROUND

In recent years, there has been growing interest in the use of reverse total shoulder arthroplasty (rTSA) for reconstruction of the proximal humerus after oncologic resection. However, the indications and outcomes of oncologic rTSA remain unclear.

METHODS

We conducted a systematic review to identify studies that reported outcomes of patients who underwent rTSA for oncologic reconstruction of the proximal humerus. Extracted data included demographic characteristics, indications, operative techniques, outcomes, and complications. Weighted means were calculated according to sample size.

RESULTS

Twelve studies were included, containing 194 patients who underwent rTSA for oncologic reconstruction of the proximal humerus. The mean patient age was 48 years, and 52% of patients were male. Primary malignancies were present in 55% of patients; metastatic disease, 30%; and benign tumors, 9%. The mean humeral resection length was 12 cm. The mean postoperative Musculoskeletal Tumor Society score was 78%; Constant score, 60; and Toronto Extremity Salvage Score, 77%. The mean complication rate was 28%, with shoulder instability accounting for 63% of complications. Revisions were performed in 16% of patients, and the mean implant survival rate was 89% at a mean follow-up across studies of 53 months.

CONCLUSIONS

Although the existing literature is of poor study quality, with a high level of heterogeneity and risk of bias, rTSA appears to be a suitable option in appropriately selected patients undergoing oncologic resection and reconstruction of the proximal humerus. The most common complication is instability. Higher-quality evidence is needed to help guide decision making on appropriate implant utilization for patients undergoing oncologic resection of the proximal humerus.

Application and improvement of ipsilateral clavicle turnover during proximal humeral tumorous bone defect repair

PURPOSE

To investigate the clinical effects and complications that may arise as a result of ipsilateral clavicle turnover during tumorous bone defect repair of the proximal humerus, and to explore the feasibility of performing combined free fibula transplantation and internal fixation in reducing complications METHODS: We treated 13 patients with clavicle turnover or free fibular transplantation from September 1998 to February 2020. There were 7 males and 6 females with the average age of 26.2 years (7-50 years). The histological diagnoses were osteosarcoma in 6 patients (Enneking IIB), giant cell tumors in 3 patients (Campanacci III) and one patient each with Ewing's sarcoma (Enneking IIB), chondrosarcoma (Canceration of multiple osteochondromatosis), fibrosarcoma and metastatic cancer of bone (Bone metastasis of lung cancer). Pathological fractures were found in 7 of the 13 patients.

RESULTS

The operation was successfully performed for all 13 patients. We followed 12 patients for 18 to 274 months (average 92.7 months). For 6 patients treated with simple clavicle turnover using a short plate, the average healing time was 7 months (4-12 months). Among them, there were 3 cases of clavicle fracture and 3 cases of overturned bone healed well. For the 7 patients treated with clavicle turnover and free fibula using a long plate, the healing time was 6.7 months. However, one patient died of tumor metastasis 19 months after operation, without reversal of clavicle fracture and other complications.

CONCLUSION

Clavicle turnover is a feasible method for the treatment of tumorous bone defect of the proximal humerus. Flipping clavicle fracture is the most common complication. The application of total clavicle fixation and free fibular transplantation strengthens the flipping clavicle and reduces the risk of clavicle fracture.

Implant cement spacer-a cost-effective solution for reconstruction of proximal humerus defects after tumor resection

The proximal humerus is a common location for both primary benign and malignant bone tumors and may require sacrificing deltoid muscles, axillary nerve and/or rotator cuff along with proximal humerus resection. Thus, post operatively shoulder movements are restricted. The main goals of reconstruction are to maintain a stable shoulder so that the function of elbow and hand can be optimized. Various reconstruction options are available after proximal humerus resection. We present our experience in using implant-cement spacers as a primary reconstruction option for limb salvage in the primary tumors of proximal humerus. All cases were retrieved from our prospectively maintained surgical database. 142 patients (96 males and 46 females) with a median age of 17.5 years (3-70 years) were operated with implant cement spacer between January 2006 and April 2019. Median follow up was 34 months (1-174 months). Functional outcome of the surgery was assessed in survivors by Musculoskeletal Tumor Society score (MSTS). Implant survival was assessed by Kaplan Meier analysis and competing risk analysis. On last follow up, out of 142 cases, 81 patients had died, 54 are alive and seven were lost to follow up. 18(13%) patients underwent revision surgery for symptomatic proximal migration, implant failure or infection. Four (2.8%) patients underwent forequarter amputation for local recurrence. The five years implant survival (IS) by Kaplan Meier analysis was 79.6% and as per competing risk analysis, the chances of implant revision are 12% and 18% at five and ten years respectively. Mean MSTS score in survivors was 71% (60-80%). Implant cement spacer is a cost-effective alternative for reconstruction of proximal humerus with revision rates and function comparable to other reconstructions in cases where deltoid, axillary nerve and/or rotator cuff are excised.

Do reverse total shoulder replacements have better clinical and functional outcomes than hemiarthroplasty for patients undergoing proximal humeral tumor resection using devitalized autograft composite reconstruction: a case-control study

Objective

To compare the efficacy and prognosis of reverse total shoulder arthroplasty (rTSA) with shoulder hemiarthroplasty (SHA) using devitalized autograft or allograft composite reconstruction after proximal humeral tumor resection.

Methods

We retrospectively reviewed patients who underwent SHA (32) and rTSA (20) for tumor resections of the proximal humerus from January 2014 to July 2020. The clinical results included duration of the operation, intraoperative blood loss, bone union, visual analog scale (VAS) score, shoulder range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) shoulder score, recurrence, and overall survival.

Results

Fifty-two patients were followed up for a mean of 30 months. Thirty-two patients were SHA with allograft-prosthetic composite (APC) reconstructions, while other 20 were rTSA with devitalized autograft-prosthetic composite reconstructions. At the end of the follow-up, 2 recurrence, 3 postoperative infections, and 4 subluxations occurred among the SHA patients. Two patients in the rTSA group had postoperative anterior dislocation and underwent revision surgery with surgical mesh, and 2 (2/20) had grade II scapular notching. The mean VAS score of the shoulder was 1.5 ± 0.8 in the rTSA group and 2.3 ± 1.2 in the SHA group (p < 0.05). The mean active forward flexion of the shoulder joint was 50.6 ± 6.0 in the SHA group and 100 ± 7.6 in the rTSA group (p < 0.05). The ASES shoulder score was 78 ± 3.0 in the rTSA group and 52 ± 5.6 in the SHA group (p < 0.05). The overall 3-year survival rate of all patients was 60.0%, and patients in the rTSA group showed better survival in terms of the mean 3-year OS than patients in the SHA group (p = 0.04).

Conclusion

rTSA with devitalized autograft-prosthetic composite can offer a reasonable reconstruction of the shoulder joint after Malawer type I tumor resection. Compared with patients who underwent SHA, patients who underwent rTSA present good outcomes, a better range of motion, better bone union, and no increase in instability rate in the mid-term.

Additively manufactured patient-specific prosthesis for tumor reconstruction: Design, process, and properties

Design and processing capabilities of additive manufacturing (AM) to fabricate complex geometries continues to drive the adoption of AM for biomedical applications. In this study, a validated design methodology is presented to evaluate AM as an effective fabrication technique for reconstruction of large bone defects after tumor resection in pediatric oncology patients. Implanting off-the-shelf components in pediatric patients is especially challenging because most standard components are sized and shaped for more common adult cases. While currently reported efforts on AM implants are focused on maxillofacial, hip and knee reconstructions, there have been no reported studies on reconstruction of proximal humerus tumors. A case study of a 9-year-old diagnosed with proximal humerus osteosarcoma was used to develop a patient-specific AM prosthesis for the humerus following tumor resection. Commonly used body-centered cubic (BCC) structures were incorporated at the surgical neck and distal interface in order to increase the effective surface area, promote osseointegration, and reduce the implant weight. A patient-specific prosthesis was fabricated using electron beam melting method from biocompatible Ti-6Al-4V. Both computational and biomechanical tests were performed on the prosthesis to evaluate its biomechanical behavior under varying loading conditions. Morphological analysis of the construct using micro-computed tomography was used to compare the as-designed and as-built prosthesis. It was found that the patient-specific prosthesis could withstand physiologically-relevant loading conditions with minimal permanent deformation (82 μm after 105 cycles) at the medial aspect of the porous surgical neck. These outcomes support potential translation of the patient-specific AM prostheses to reconstruct large bone defects following tumor resection.

Megaprosthesis Versus Allograft Prosthesis Composite for the Management of Massive Skeletal Defects: A Meta-Analysis of Comparative Studies

PURPOSE OF REVIEW

Megaprosthesis and Allograft Prosthesis Composite (APC) are the established treatment modalities for massive skeletal defects. There are a handful of studies comparing the use of megaprosthesis and APC in the management of substantial bone loss and it has always been a topic of debate regarding the superiority of one modality over the other. Therefore, we aim to compare the functional outcome and implant survivorship of each modality including complications, revision rates, amputation rate and mortality.

RECENT FINDINGS

The Allograft Prosthesis Composite (APC) constitutes a skeletal allograft implanted with a revision type prosthesis in it. The biological environment provided by the allograft allows attachment of the muscles and tendons imparting better stability and function. However, the literature is not kind enough with APC due to associated risk of infection, disease transmission and nonunion at the graft-host junction. The megaprosthesis (MP) on the other hand is a nonbiologic modality with better survivorship but subservient functional outcome. Infection has been a major issue in both the modalities. Advancement in metallurgy using silver coated megaprosthesis also failed to provide strong evidence in preventing infection. The functional outcome is better with APC in both the upper and lower limbs. However, the survivorship is better with megaprosthesis, especially in the upper limb when revision rates were compared between the two modalities. Deep infection and mechanical complications were significantly higher in the APC group. There was no significant difference between the two groups in terms of amputation rate, mortality, and local recurrence.

LEVEL OF EVIDENCE (CEBM)

2a.

Pedicle screw system reconstruction in shoulder resection type IV-total scapulectomy: A case report and short term follow up

Introduction

Shoulder resection remains a challenging procedure after scapulectomy for tumour resection. The results have various functional outcome, wound coverage, and cosmetic aspect. In this case report, we reported the outcome of pedicle screw application after scapulectomy procedure within 1 month follow up after surgical tumour excision.

Case presentation

A 74-year-old female presented with a painful lump on the left shoulder since nine months before admission. We performed physical examination, radiological evaluation using x-ray and MRI. We performed limb salvage surgery with shoulder girdle resection of tumour procedure using Malawer technique type IVB and applied pedicle and screw in proximal end clavicula and proximal end of humerus. We performed histopathological examination to ensure the tumour. We evaluated the patient one month after surgery using DASH score.

Discussion

MRI examination revealed that there was a solid mass with malignant characteristic destructing left scapular bone with the acromioclavicular and glenohumeral joint involvement. We used pedicle and screw to reconstruct the patient with efficient cost spending consideration. Clinical valuation showed there was no pain left and hand-free movement except the limitation of shoulder abduction. DASH score evaluation pre operative and post operative showed improvement from 70.8 to 45.0.

Conclusion

Limb salvage procedure using pedicle screw system may be one of treatment of choice for treating tumour of the shoulder affecting glenohumeral joint with excellent result of evaluation both clinical and functional outcome.

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Limb salvage surgery with shoulder girdle resection of tumour procedure using Malawer technique type IVB

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Pedicle screw application after scapulectomy procedure

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Excellent DASH score evaluation

'Umbrella construct' - an innovative technique for reconstruction of the proximal humerus after curettage in locally aggressive benign bone tumours

AIM

Reconstructing locally aggressive benign bone tumours of the proximal humerus after intralesional curettage is a challenge. We present a novel reconstruction technique 'Umbrella construct' where a femoral head and a strut allograft are combined to reconstruct the cavity. Complications, graft incorporation time, functional (Musculoskeletal Tumor Society score [MSTS]) and oncological outcomes were evaluated.

METHODS

Between January 2006 and June 2017, 11 cases (10 giant cell tumours, 1 chondroblastoma) underwent curettage followed by reconstruction with Umbrella construct. There were six females and five males with a mean age of 23 years (range 14-36 years). The maximum longitudinal extent of disease was 9 cm (range 5-9 cm).

RESULTS

The median follow-up was 54 months (range 34-122 months). The mean allograft incorporation time was 7 months (5-8 months). One patient had a graft fracture which was managed conservatively. Two cases developed local recurrence and the construct was revised to a prosthesis in both. The mean MSTS score for the nine cases with retained graft was 27 (23-29).

CONCLUSIONS

Umbrella construct is an effective reconstruction modality which helps to maintain joint congruity and limb length. It has acceptable oncological outcomes with good function.

Reconstruction Using Free Vascularized Fibular Grafts after Wide Resection of Humerus Chondrosarcoma in a Patient with Cleidocranial Dysplasia

Cleidocranial dysplasia is characterized by hypoplasia of the clavicles, unerupted teeth, narrow pelvis, short stature, and craniofacial malformations. A cause of this skeletal dysplasia is heterozygous mutations of the runt-related transcription factor 2 gene (Runx2), a master regulator for bone and cartilage development. Chondrosarcoma is a primary malignant bone tumor that is usually treated by wide resection surgery. This report shows a case of a 25-year-old female patient with cleidocranial dysplasia who was affected with chondrosarcoma of the left humerus. We performed wide resection of the tumor and reconstruction of the large bone defect of the humerus using free vascularized fibular grafts. The patient preserved the hand function and activity of daily life as the same level as preoperative condition more than five years after the surgery.

Reverse Allograft-Prosthesis Composite with Pectoralis Major Transfer After Shoulder Osteosarcoma: A Case Report

CASE REPORT

We present a case of a 30-year-old man with proximal humerus osteosarcoma and periarticular soft-tissue involvement. Severe humeral and glenoid bone loss was observed, with nonfunctional deltoid after limb-sparing resection and a failed attempt of stabilization. The shoulder was reconstructed using a reverse allograft-prosthesis composite, with deltoid reconstruction by pectoralis major transfer.

CONCLUSIONS

To the best of our knowledge, this is the first time that this reconstruction technique has been reported in an oncological patient. Favorable clinical and radiological results were achieved at the 24-month follow-up.

Complications and Survivorship of Distal Humeral Allograft Reconstruction After Tumor Resection: Literature Review and Case Series

Primary bone sarcomas of the proximal humerus represent most bone sarcomas in the upper extremity. However, limited literature exists on the survival and complications of distal humeral allograft reconstruction because of the relative rarity of disease at the distal end.

Mesh patch and anchors can improve clinical results of prosthetic replacement after resection of primary proximal humerus malignant tumor

The purpose of this study was to evaluate the functional results, complications and related factors of prosthesis reconstruction after malignant tumor resection of primary proximal humeral, and also evaluate whether soft tissue reconstruction with mesh patch and anchors can improve clinical results. From 2002 to 2016, forty-one patients were enrolled in this study. The pathological diagnosis contained 27 cases of osteosarcoma, 7 cases of chondrosarcoma and other primary malignant bone tumors. Both mesh patch and anchors were used in the reconstruction of joint capsule and the surrounding soft tissues in 27 cases. The mean postoperative follow-up was 60.6 months. The average active abduction angle and passive abduction angle was 33.5 (5–71) degrees and 72.4 (52–104) degrees. The prosthetic humeral head displacement was over 2 cm in 5 cases (12.2%). The average MSTS score was 23.1. The overall 5-year survival rate of prosthesis was 88.2%. The length of osteotomy, whether preserving deltoid muscle, whether applying mesh patch and anchors had significant effects on the abduction angle of shoulder joint; the length of osteotomy, whether applying mesh patch and anchors had significant effects on the degree of upward displacement of prosthesis. The application of both mesh patch and anchors in prosthesis reconstruction achieved more stable result and better function of shoulder joint. To ensure the stability of shoulder joint and the firm wrapping of surrounding soft tissue are key factors affecting the postoperative function.

Clinical observation of mineralized collagen bone grafting after curettage of benign bone tumors

Curettage of benign bone tumor is a common cause for bone defect. For such bone defect repair, autogenous bone, allogeneic bone and traditional artificial bone graft substitutes have many disadvantages. In recent years, a biomimetic mineralized collagen (MC) with similar composition and microstructures to the natural bone matrix was developed and used for treating various bone defects. In this work, a retrospective study analyzed clinical outcomes of patients treated with curettage of benign bone tumors and bone grafting with MC, in comparison to another group treated with the same surgical method and autogenous bone. Lane–Sandhu X-ray score of the autogenous bone group was superior to the MC group at 1 month after the operation, but the two groups had no statistical difference at 6 and 12 months. The MC group was better in Musculoskeletal Tumor Society scoring at 1 and 6 months after the operation, and the two groups had no statistical difference at 12 month. Therefore, the MC performed not as good as autogenous bone in early stage of bone healing but achieved comparable outcomes in long-term follow-ups. Moreover, the MC has advantages in function recovery and avoided potential complications induced by harvesting autogenous bone.

What sports activity levels are achieved in long-term survivors with modular endoprosthetic humerus reconstruction following primary bone sarcoma resection?

Background

The aim of the study was to assess (1) sports activity, (2) sports involving the upper extremities, (3) functional outcome and (4) sports-related complications of long-term survivors of primary malignant bone tumors of the proximal humerus.

Methods

A total of 18 patients with an endoprosthetic reconstruction for primary malignant bone sarcoma of the proximal humerus (8 male, 10 female, mean age 19.9 ± 8.4 years, range 7.8–37.4 years) with an average follow-up of 18.1 ± 7.4 years (range 6.7–29.8 years) were included. The type of sport, frequency, duration of each sport session and the University of California, Los Angeles (UCLA) activity score were assessed before surgery, at 1 year, 3 years and at the latest follow-up. Functional outcome was assessed by the Toronto extremity salvage score (TESS).

Results

The mean UCLA activity score decreased from 8.0 (±1.3, range 5–9) preoperative to 4.2 (±1.7, range 3–8) at 1‑year follow-up (p < 0.05). After 3 years it increased to 5.1 (±1.75, range 3–8) and further to 7 (±1.8, range 4–9) at the last follow-up. The mean postoperative TESS was 80.8 (±6.4, range 75.7–91.4) at the latest follow-up. Patients who were initially more active without reconstruction including a synthetic mesh were more likely to develop soft tissue complications accompanied by proximal endoprothesis migration.

Conclusion

Patients with a modular endoprosthetic reconstruction of the humerus following primary bone sarcoma resume participation in sports. Regarding the low incidence of periprosthetic infections, utilization of a synthetic mesh for reconstruction to prevent soft tissue complications in active patients should be considered.

Humeral stress shielding following cemented endoprosthetic reconstruction: An under-reported complication?

INTRODUCTION

The proximal humerus is a common location for primary and non-primary tumors. Reconstruction of the proximal humerus is commonly performed with an endoprosthesis with low rates of structural failure. The incidence and risk factors for stress shielding are under reported.

METHODS

Thirty-nine (19 male, 20 female) patients underwent resection of the proximal humerus and reconstruction with a cemented modular endoprosthesis between 2000 and 2018. The mean resection length was 12 ± 4 cm and was most commonly performed for metastatic disease (n = 26, 67%).

RESULTS

Stress shielding was observed in 9 (23%) patients at a mean of 29 (6-132) months postoperatively. Patients with stress shielding were noted to have shorter intramedullary stem length (87 vs. 107 mm, p < .001), longer extramedullary implant length (16 vs. 14 cm, p = .01) and a higher extramedullary implant to stem length ratio (2.1 vs. 1.1, p < .001). The incidence of stress shielding was higher (p = .003) in patients reconstructed with 75 mm stem (n = 6, 67%) lengths.

CONCLUSION

Stress shielding of the humerus was associated with the use of shorter stems and long extramedullary implants. The long-term ramifications of stress shielding on implant stability, complications at the time of revision surgery, and overall patient outcomes remain unknown.

Reverse shoulder-allograft prosthesis composite, with or without tendon transfer, for the treatment of severe proximal humeral bone loss

BACKGROUND

The treatment of severe proximal humeral bone loss (PHBL) secondary to tumor resection or failed arthroplasty is challenging. We evaluated the outcomes and complications of reconstruction with reverse shoulder-allograft prosthesis composite (RS-APC), performed with or without tendon transfer.

METHODS

An RS-APC procedure was performed in 25 consecutive patients with severe PHBL (>4 cm): 12 after failed reverse shoulder arthroplasty, 5 after failed hemiarthroplasty for fracture, 6 after failed mega-tumor prosthesis placement, and 2 after tumor resection. The median length of humeral bone loss or resection was 8 cm (range, 5-23 cm). Humeral bone graft fixation was obtained with a long monobloc reverse stem and a "mirror step-cut osteotomy," without plate fixation. Nine infected shoulders underwent a 2-stage operation with a temporary cement spacer. In addition, 9 patients (36%) underwent an associated L'Episcopo procedure. The median follow-up duration was 4 years (range, 2-11 years).

RESULTS

Overall, 76% of patients (19 of 25) were satisfied. In 8 patients (32%), a reoperation was needed. At last follow-up, we observed incorporation at the allograft-host junction in 96% of the cases (24/25); partial graft resorption occurred in 3 cases and severe in 1. The median adjusted Constant score was 53% (range 18-105); Subjective Shoulder Value, 50% (range 10%-95%). Additional tendon transfers significantly improved active external rotation (20° vs. 0°, P < .001) and forward elevation (140° vs. 90°, P = .045).

CONCLUSIONS

(1) Shoulder reconstruction with RS-APC provides acceptable shoulder function and high rates of graft survival and healing. (2) Additional L'Episcopo tendon transfer (when technically possible) improves active shoulder motion. (3) The use of a long monobloc (cemented or uncemented) humeral reverse stem with mirror step-cut osteotomy provides a high rate of graft-host healing, as well as a limited rate of graft resorption, and precludes the need for additional plate fixation. (4) Although rewarding, this reconstructive surgery is complex with a high risk of complications and reoperations. The main advantages of using an allograft with a reverse shoulder arthroplasty (compared with other reconstruction options) are that this type of reconstruction (1) allows restoration of the bone stock, thus improving prosthesis fixation and stability, and (2) gives the possibility to perform a tendon transfer by fixing the tendons on the bone graft to improve shoulder motion.

Comparison of reconstructive techniques following oncologic intraarticular resection of proximal humerus

INTRODUCTION

The proximal humerus is a common site of primary and metastatic disease in the upper extremity. Historically, the goal of a hemiarthroplasty reconstruction was to provide a stable platform for hand and elbow function, with limited shoulder function. Techniques utilizing a reverse endoprosthesis (endoprosthetic replacement [EPR]) and allograft-prosthetic composite (APC) have been developed; however, there is a paucity of comparative studies.

METHODS

A total of 83 (42 females, 41 males) patients undergoing an intraarticular resection of the humerus were reviewed. Reconstructions included 30 reverse and 53 hemiarthroplasty; including hemiarthroplasty EPR (n = 36) and APC (n = 17), and reverse EPR (n = 20) and APC (n = 10).

RESULTS

Reverse reconstructions had improved forward elevation (85° vs. 44°, p < .001) and external rotation (30° vs. 21°; p < .001) versus a hemiarthroplasty. Reverse reconstructions had improved American Shoulder and Elbow Surgeons scores (65 vs. 57; p = .01) and Musculoskeletal Tumor Society 93 scores (72 vs. 63; p < .001) versus hemiarthroplasty. Subluxation of the reconstruction was a common (n = 23, 27%), only occurring in hemiarthroplasty patients (EPR [n = 13, 36%] and APC [n = 10, 59%]).

CONCLUSION

The current series highlights the improved functional outcome in patients undergoing reconstruction with a reverse arthroplasty compared to the traditional hemiarthroplasty. Currently reverse shoulder arthroplasty (APC or EPR) is our preferred methods of reconstruction in this patient population.

Implementation of the three-dimensional printing technology in treatment of bone tumours: a case series

PURPOSE

With the ability to overcome specific anatomical and pathological challenges, 3D printing technology is setting itself as an important tool in patient-specific orthopaedics, delivering anatomical models, patient-specific instruments, and custom-made implants. One of the most demanding procedures in limb salvage surgery is the reconstruction of bony defects after tumour resection. Even though still limited in clinical practice, early results of the use of 3D technology are gradually revealing its potentially huge impact in bone tumour surgery. Here, we present a case series illustrating our experience with the use of 3D printing technology in the reconstruction of bone defects after tumour resection, and its impact on cosmesis and quality of life.

METHODS

We performed a retrospective analysis of 11 patients in whom a custom-made 3D-printed prosthesis was used to reconstruct a bone defect after resection for a bone tumour. Ten out of 11 patients were children (aged between 5 and 16 years) with osteosarcoma or Ewing sarcoma of the pelvis (2 children) or the arm (8 children), and one patient was a 67-year-old lady with a chondrosarcoma of the pelvis. All underwent wide resections resulting in considerable bone defects necessitating further reconstruction.

RESULTS

Custom-made implants were extremely useful both in reconstruction of bone defects and in terms of cosmesis, recovery facilitation, and quality of life. In this respect, pelvic and humeral reconstructions with 3D-printed custom implants particularly showed a great potential. The mean follow-up was 33 months. Four patients died of disease (36%) and overall the major and minor complication rate was 54% (6 out of 11 patients). Three patients had implant dislocation (27% [3/11 cases]), one had leg-compartment syndrome, and one patient reported limited range of motion. Only two out of 11 patients developed local recurrence.

CONCLUSION

Use of 3D customized implant helped us achieve two major goals in orthopaedic oncology-clear surgical resection and functional recovery with a good quality of life. Large studies with long-term follow-up are needed to reveal the value and future of 3D printing in orthopaedic oncology.

Biologic osteosynthesis in the treatment of benign and malignant bone tumors

BACKGROUND AND OBJECTIVES

Mechanical augmentation with metal implants in the treatment of bone tumors limits magnetic resonance imaging and computerized tomography scan imaging due to the scattering effect. In addition, modulus of elasticity differences may cause chronic pain. We present a surgical technique in which cortical allografts are used as plates. This is a two-center experience focusing on functional and radiographic outcomes and complications.

METHODS

Under IRB approval, we performed a retrospective patient review. Demographics, treatment indications, tumor characteristics, and complications were collected. Radiographic studies were reviewed to determine the time to osseous incorporation. The last follow-up functional evaluation included the Musculoskeletal Tumor Society (MSTS) score, the Karnofsky scale, and Eastern Cooperative Oncology Group (ECOG).

RESULTS

Thirty patients, seventeen female and thirteen male, 16-year-old in average were included. The most common diagnoses were the humeral aneurysmal bone cyst and unicameral bone cyst. The Median follow-up was 6 years. Cortical allograft incorporation median time was 8.8 months whereas allograft void bone incorporation was 3 months. The average time to full weight-bearing without impact activity was 3.1 months. The most common complication was symptomatic hardware. Other complications included a superficial infection successfully treated with antibiotics, a temporary radial nerve neuropraxia, and an allograft fracture requiring revision surgery. Most patients had an MSTS score higher than 90 (excellent). Patients with malignant tumors had ECOG of 0 and a Karnofsky score of 100.

CONCLUSION

Biological osteosynthesis is a bone preserving and effective modality for mechanical augmentation with excellent functional results and low complication rates.

Successful treatment of a dedifferentiated chondrosarcoma of the proximal humerus with a hemicortical articular surface sparing allograft: A case report

INTRODUCTION

Dedifferentiated chondrosarcomas are rare and highly malignant tumors that require wide surgical resection. Survival is extremely poor without adequate surgical margins. We present a case of articular sparing surgery of the shoulder for dedifferentiated chondrosarcoma with excellent functional outcomes and no evidence of disease after fifty-six months.

PRESENTATION OF CASE

A 29-year-old male was found to have a non-metastatic right proximal humerus dedifferentiated chondrosarcoma. He underwent resection with clear one centimeter margins sparing the medial cortex and the articular surface. Reconstruction of the bone was accomplished using a hemicortical allograft. A dermal allograft was used to help reconstruct the rotator cuff to the allograft bone. At fifty-six months after surgery he has excellent functional range of motion. His current MSTS, Quick Dash, and Constant Shoulder scores are 29, 2.3, and 80, respectively. He has remained free of disease, is back to work without restrictions and is active in outdoor activities.

DISCUSSION

Dedifferentiated chondrosarcoma has high recurrence and poor survival rates. Adequate surgical resection is vital for its treatment. Previously described reconstructive techniques have consisted of articular replacement with a prosthesis, allograft, or allograft-prosthetic composites. To our knowledge, this is the first report of an articular sparing reconstruction for dedifferentiated chondrosarcoma with fifty-six month survival and functional outcomes. When possible, sparing the articular surface can provide good functional outcomes that improve over time.

CONCLUSION

If adequate surgical margins can be obtained, an articular surface sparing reconstruction of the shoulder can provide effective functional outcomes and an alternative to joint replacement.

Long-Term Clinical Outcomes of Intercalary Allograft Reconstruction for Lower-Extremity Bone Tumors

BACKGROUND

Improved survival rates for patients with primary bone tumors of the extremities have increased the demand for reliable and durable reconstruction techniques. Some authors have stated that, after successful ingrowth, allografts are a durable long-term solution. This hypothesis is largely based on small studies with short-to-midterm follow-up. In order to determine the durability of intercalary allograft reconstructions in the lower extremities, we evaluated the long-term clinical outcomes at a minimum of 10 years.

METHODS

All patients who received an intercalary allograft reconstruction in a lower extremity between 1980 and 2006 were included in this retrospective multicenter cohort study. One hundred and thirty-one patients with a median age of 19 years were included. Eighty-nine (68%) had a femoral reconstruction, and 42 (32%) had a tibial reconstruction. The most prevalent diagnoses were osteosarcoma (55%), Ewing sarcoma (17%), and chondrosarcoma (12%). The median follow-up was 14 years. A competing risk model was employed to estimate the cumulative incidences of mechanical failure and infection. Patient mortality or progression of the disease was used as a competing event.

RESULTS

Nonunion occurred in 21 reconstructions (16%), after a median of 16 months, and was associated with intramedullary nail-only fixation (p < 0.01) and fixation with nonbridging plate(s) (p = 0.03). Allograft fracture occurred in 25 reconstructions (19%) after a median of 42 months (range, 4 days to 21.9 years). Thirteen (52%) of the allograft fractures occurred within 5 years; 8 (32%), between 5 and 10 years; and 4 (16%), at >10 years. With failure for mechanical reasons as the end point, the cumulative incidences of reconstruction failure at 5, 10, and 15 years were 9%, 14%, and 21%, respectively.

CONCLUSIONS

Intercalary allograft reconstruction is an acceptable reconstructive option, mainly because of the absence of superior alternatives with a known track record. However, a considerable and continuing risk of mechanical complications should be taken into account.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.