Megaprosthetic replacement of the distal humerus: still a challenge in limb salvage

Reconstruction of the elbow with distal humerus endoprosthetic replacement after tumor resection: a systematic review of the literature and institutional case series

BACKGROUND

Distal humerus replacement (DHR) is a modular endoprosthesis mainly used for bone reconstruction after resection of primary or metastatic bone lesions. Studies on DHR failure rates and postoperative functional outcomes are scarce. We sought to assess implant survival, modes of failure, and functional outcomes in patients undergoing DHR for oncologic indications.

METHODS

A systematic review of the PubMed and Embase databases was performed. PRISMA guidelines were followed for this manuscript. Our study was registered on PROSPERO (457,260). Quality appraisal of included studies was conducted using the STROBE checklist. Prosthetic failure was assessed using the Henderson classification for megaprosthetic failures. We additionally performed a retrospective review of patients treated with a DHR for oncologic indications at a large tertiary care academic center. Weighted means were calculated to pool data.

RESULTS

Eleven studies with a total of 162 patients met the inclusion criteria. Mean follow-up was 3.7 years (range, 1.66-8 years). Henderson type 2 failures (aseptic loosening) were the most common mode of failure, occurring in 12% of cases (range, 0%-33%). Five-year implant survival was 72% (range, 49%-93.7%). Mean postoperative Musculoskeletal Tumor Society (MSTS) score was 81.1 (range, 74-84.3). In our institutional case series, 2 out of 5 patients had DHR revision for periprosthetic fracture and aseptic loosening at 16 and 27 months after surgery, respectively.

CONCLUSIONS

Distal humerus replacement is a successful reconstruction strategy for tumors of the distal humerus, with high implant survival and good to excellent functional outcomes.

Biological Prosthesis (Hollow 3D-Printed Titanium Custom-Made Prosthesis and Bone Graft) for Humeral Reconstruction in Pediatric Oncologic Patients: Surgical Indications and Results

This study presents the mid-term outcomes of a novel "biological prosthesis" for pediatric humerus reconstruction after major bone tumor removal. This approach involves a hollow 3D-printed titanium custom-made prosthesis combined with bone grafting. The primary aim was to preserve and revitalize the unaffected autologous proximal or distal humeral stump. Between 2017 and 2021, we treated five pediatric patients (mean age 11.2 years; range 7-17) with humeral bone sarcomas. A one-stage surgical procedure involved tumor resection and implanting a hollow 3D-printed custom-made prosthesis. In two cases, we preserved the proximal humerus; in two, the distal part; and in one, both. Graft materials included homologous bone chips in three cases and free vascularized fibular grafts in two cases. All patients were clinically and radiographically assessed after a mean follow-up of 32.2 months (range of 14-68). No significant complications were observed, and no implant revisions were needed. Osseointegration was evident in all cases within eight months post-surgery; vascular support for the remaining autologous stump was demonstrated in all cases. Our hollow 3D-printed custom-made prosthesis and bone grafting offer the potential for partial or complete articular surface preservation. This approach encourages revascularization of the epiphysis, leading to satisfactory outcomes in humerus reconstruction within the pediatric population.

Outcomes of management of primary benign aggressive or malignant bone tumors around the elbow by limb-salvage surgery

PURPOSE

Bone tumors around the elbow are rare, with frequently delayed diagnosis. The current study aimed to assess the functional and oncological outcomes of limb salvage surgery for primary benign aggressive or malignant bone tumors around the elbow.

METHODS

We conducted a retrospective review of patients with primary aggressive benign and malignant bone tumors around the elbow treated with limb salvage surgery between 1995 and 2020 at a single musculoskeletal oncology center. The minimum follow-up period was 24 months. Functional results were assessed using the Musculoskeletal Tumor Society (MSTS) scoring system at the last follow-up visit. Local recurrence, chest metastasis, and complications were recorded.

RESULTS

This study included 30 patients, 19 males and 11 females, with a mean age of 25.4 ± 14.2 years. The tumor location was the distal humerus (n = 21), proximal radius (n = 5), and proximal ulna (n = 4). Reconstruction was done by elbow fusion using fibular graft (n = 10), mobile endoprosthesis (n = 9), excision arthroplasty (n = 7), and extracorporeal freezing and reimplantation (n = 4). The mean follow-up period was 36.2 ± 21.3 months. The median follow-up MSTS score was 27 [Interquartile range (IQR): 26-30]. Skeletally immature patients had a significantly higher MSTS score. The rate of postoperative complications was 26.7%.

CONCLUSION

Limb salvage surgery with different reconstructive options for benign aggressive and malignant bone tumors around the elbow can achieve good functional and oncological outcomes.

LEVEL OF EVIDENCE

Level IV.

Outcomes of Humeral Allograft-Prosthetic Composites with Plate Fixation in Revision Total Elbow Arthroplasty

Background

Traditionally, the reconstruction of severe distal humeral bone loss at the time of revision total elbow arthroplasty (TEA) has used allograft-prosthetic composites (APCs) stabilized with cerclage wires or cables. We have migrated to plate fixation when revision TEA using a humeral APC is performed. This study shows the outcomes of patients treated with a humeral APC with plate fixation during revision TEA.

Methods

Between 2009 and 2019, 41 humeral APCs with plate fixation of distal humeral allograft to the native humerus were performed in the setting of revision TEA. There were 12 male patients (29%) and 29 female patients (71%), with a mean age of 63 years (range, 41 to 87 years). The mean allograft length was 12 cm. All elbows had a minimum follow-up of 2 years (mean follow-up, 3.3 years). Patients were evaluated for visual analog scale pain scores, range of motion, the ability to perform select activities of daily living, and the Mayo Elbow Performance Score (MEPS). Outcomes including reoperations, complications, and revisions were noted. The most recent radiographs were evaluated for union at the allograft-host interface, failure of the plate-and-screw construct, or component loosening.

Results

The mean postoperative flexion was 124° (range, 60° to 150°) and the mean postoperative extension was 26° (range, 0° to 90°); the mean arc of motion was 99° (range, 30° to 150°). The mean MEPS was 58 points (range, 10 to 100 points). Two surgical procedures were complicated by neurologic deficits. The overall reoperation rate was 14 (34%) of 41. Of the 33 patients with complete radiographic follow-up, 12 (36%) had evidence of nonunion at the allograft-host interface with humeral component loosening, 1 (3%) had evidence of partial union, and 1 (3%) had ulnar stem loosening.

Conclusions

Revision TEA with a humeral APC using compression plating was successful in approximately two-thirds of the elbows. Further refinement of surgical techniques is needed to improve union rates in these complex cases.

Level of Evidence

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

Distal Humeral Replacement in Patients with Primary Bone Sarcoma: The Functional Outcome and Return to Sports

Distal humeral replacement (DHR) is a limb-salvage option for the endoprosthetic reconstruction of bone defects following the resection of a primary bone sarcoma. As primary bone sarcomas are only occasionally located around the distal humerus, there is a paucity of information regarding postoperative function, and patients' resumption of sporting activities. With advances in diagnostics and in surgical and oncological treatment leading to an increased patient life expectancy and higher quality of life, patients' functional outcome and return to sports activities are of increasing interest. Between 1997 and 2021, a total of 24 patients underwent DHR with a single-design modular implant at a tertiary sarcoma center. A total of 14 patients who died of their disease were excluded, leaving a study cohort of 10 patients, with a median age of 30 years on the day of surgery (IQR 20-37). At the last follow-up, after a median of 230 months (IQR 165-262), the median MSTS was 19 (IQR 13-24), the median TESS was 79 (IQR 66-87), the median SEV was 38% (IQR 24-53), the median TS was 6 (IQR 4-7), and the median WAS was 3 (IQR 1-8). Among the variables of gender, surgery on the dominant extremity, intraoperative nerve resection, extra-articular tumor resection, chemotherapy, radiotherapy, and revision surgeries, none were associated with a better/lower functional outcome score or return to sports activities. However, a higher level of sports performance prior to diagnosis (WAS > 10) was associated with a higher level of sports performance postoperatively (p = 0.044).

Elbow hemiarthroplasty with a 3D-printed prosthesis for distal humeral bone defects after tumor excision: a case report

INTRODUCTION

The distal humerus is a rare site for primary and metastatic bone tumors. Due to the scarcity of cases and lack of standardized surgical strategies, it is often difficult for surgeons to choose the right choice. The application of a 3D-printed prosthesis with hemiarthroplasty for the treatment of the distal humerus after tumor resection can be a very effective option.

CASE PRESENTATION

We present a clinical case of a 3D-printed distal humeral prosthesis for the treatment of bone defects caused by metastatic bone tumors. The preoperative evaluation was aggressively performed, and the decision was made to distal humeral hemiarthroplasty (DHH) after wide resection of the tumor segment bone. Processing of the Digital Imaging and Communications in Medicine (DICOM) data from CT scans performed after mirror conversion using CT data of the contralateral humerus, we designed a 3D-printed distal humeral prosthesis with hemiarthroplasty. After reconstruction of bone and surrounding soft tissue by the 3D-printed prosthesis combined with the LARS ligament and regular follow-up for 12 months, the patient had an MSTS-93 score of 29 and an MEP of 100, which reached a good level, and the patient was fully competent in normal daily activities.

CONCLUSIONS

Our results show that the 3D-printed modular prosthesis with hemiarthroplasty is a very effective option for cases of large elbow bone defects due to primary bone tumors or metastatic disease. However, careful preoperative preparation is required for the best outcome. Careful preoperative preparation and long-term follow-up are essential for the best outcome.

Extended deltopectoral approach for revision total elbow arthroplasty requiring humeral allograft-prosthetic composites in patients with severely compromised proximal humerus bone stock

Background

Severe humeral bone loss in the setting of failed total elbow arthroplasty (TEA) poses a particularly challenging reconstructive problem. The objective of this study was to review the rationale, indications, contraindications, and detailed surgical technique for using an extended anterior deltopectoral approach to perform a revision TEA when substantially long allografts are required in the presence of severely compromised proximal humerus bone stock.

Methods

The authors developed this exposure and reconstructive strategy for failed elbow arthroplasties where the remaining segment of proximal humerus is extremely short, which makes adequate plate fixation of an allograft-prosthetic composite (APC) to the native bone extremely challenging. From an anterior deltopectoral approach, it is possible to use dedicated long, precontoured proximal humerus locking plates to maximize fixation in any remaining proximal humerus. This exposure still makes it possible to provide adequate access to the coupling mechanism of the humeral and ulnar components for implantation of a linked elbow arthroplasty. This exposure also allows for adequate judgment of humeral length and rotation.

Pitfalls and Challenges

Crucial steps in the surgery include extending the dissection past the elbow flexion crease such that one can obtain circumferential exposure of the distal humerus. It is also important to couple the humeral and ulnar components prior to committing to the length of the APC. Special attention must be paid to gauge appropriate APC rotation and length for proper soft tissue tension. When performing fixation of the proximal humeral plate, screw purchase must be maximized in both the remaining native proximal humerus and the APC. Compression across the allograft-host interface is paramount for healing to occur.

Conclusion

An extended anterior deltopectoral approach to perform a revision TEA when very long APCs are required is a viable option to restore humeral bone stock and regain humeral stem fixation in the setting of failed TEA with extensive humeral bone loss.

Elbow hemiarthroplasty with a 3D-printed megaprosthesis for defects of the distal humerus or proximal ulna after tumour resection : a preliminary report

AIMS

The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection.

METHODS

From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients.

RESULTS

Preparation of the prosthesis was a mean of 8.0 days (SD 1.5), during which time no patients experienced tumour progression. The mean operating time and intraoperative blood loss were 158.1 minutes (SD 67.6) and 176.9 ml (SD 187.8), respectively. All of the prostheses were implanted successfully. During a mean follow-up of 25.7 months (SD 7.8), no patients died, but four had complications (two superficial wound problems, one temporary palsy of radial nerve, and one dislocation). No aseptic loosening, structural failure, infection, heterotopic ossification, or degenerative arthritis was seen in this study. The mean flexion of the elbow was 119.6° (SD 15.9°) and the mean extension lag was 11.9° (SD 13.8°). The mean Musculoskeletal Tumor Society 93 score and Mayo Elbow Performance Score were 28.4 (SD 0.9) and 97.7 (SD 4.4), respectively.

CONCLUSION

The custom-made, 3D-printed megaprosthesis with hemiarthroplasty is a feasible option for functional reconstruction after resection of a tumour in the distal humerus or proximal ulna. Cite this article: Bone Joint J 2022;104-B(6):747-757.

Wide resection and reconstruction of giant cell tumor of the distal humerus with favorable outcomes in 3 months: A case report

Introduction and importance

A giant cell tumor is a locally aggressive tumor with low-risk progression into malignant and rarely metastasize, but a high risk of recurrence and notable disturbance of bony architecture in peri-articular locations. Wide resection provides a more advantageous therapy option, but the functional outcome is often hampered.

Case presentation

A 36-years old woman came with a lump on the left elbow as chief of complaint since a year ago that kept growing bigger with pain, local tenderness, and limited motion. She underwent several examinations and was diagnosed with a giant cell tumor in the distal humerus. Wide excision and reconstruction surgery using megaprosthesis, rotational flap, nerve graft, and skin graft were done. After 3 months follow-up, the patient had favorable functional outcomes.

Clinical discussion

The primary aim of treating giant cell tumors is wide resection with good functional than cosmesis outcomes. This manner was common and expected to reduce the potential risk of infection.

Conclusion

Reconstruction with megaprosthesis, nerve and skin graft, is a reasonable option after wide resection of the giant cell tumor in the left humerus with favorable functional outcomes within 3 months compared with other treatment modalities.

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A giant cell tumor is a locally aggressive tumor with high recurrence rate.

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Wide resection removes the entire mass, but may hamper functional outcome.

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Reconstruction using megaprosthesis, nerve and skin graft may be used.

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Reconstruction results in satisfactory outcome with lower recurrence rate.

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.

Joint replacement surgery for elbow tumours: a systematic review of outcomes

BACKGROUND

Tumour resection followed by joint reconstruction is a surgical option in the appropriate patient. The evidence for such reconstructive surgery of the elbow joint is limited. The aim of this study is to review the literature to evaluate the outcomes of joint replacement surgery in tumours of the elbow.

METHODS

A systematic review of PUBMED and EMBASE databases was conducted. Case series and comparative studies reporting results after total elbow arthroplasty, modular endo-prosthetic replacement and custom prosthesis were eligible for inclusion.

RESULTS

Eleven eligible studies were identified (n = 134). At mean follow-up of 44 months, the overall revision rate was 14% and complication rate was 28%. The mean Mayo Elbow Performance Score was 75, with 56% of patients reporting good or excellent outcomes. The mean post-operative range of motion was 97°.

DISCUSSION

Elbow prosthesis reconstruction after tumour resection can provide good functional outcomes at mid-term follow-up. The complication and revision rates are comparable to other indications for elbow replacement surgery. Further prospective studies are required to compare outcomes between different elbow arthroplasty options after tumour resection.

Total elbow arthroplasty as a reconstruction option for distal humerus osteosarcoma: A case report

Introduction

Osteosarcoma is the second most common malignant bone tumor. The humerus is the third most common anatomical location for osteosarcoma, however, osteosarcoma around the elbow joint is uncommon. The intricacy of the elbow joint, limited soft tissue coverage, and proximity to nerves and arteries make the surgical resection and reconstruction complicated.

Case report

A 17-year-old boy came with a chief complaint of lump and pain on his left elbow. One month later, the patient felt there was a lump with a size of a marble on the left elbow, which getting bigger to a size of a tenis ball. Physical examination showed mass on the posterior aspect of the elbow with the size 14x12cm. Plain radiographs revealed osteolytic lesion and periosteal reaction of the distal humerus and the magnetic resonance imaging (MRI) showed a low intensity on T2-weighted imaging. Histopathological examination suggested osteosarcoma. The patient underwent neoadjuvant chemotherapy for 3 cycles. The patient was treated with limb salvage surgery by wide excision, cryosurgery followed by total elbow arthroplasty and ORIF with plate and screw. Postoperative plain radiographs showed the plate and screws are well-fixated. The patient can slowly regain his elbow motion without limitation one month postoperatively.

Conclusions

Distal humerus in an unusual site for osteosarcoma. Total elbow arthroplasty and ORIF with plate and screw is a favorable reconstruction option for distal humerus osteosarcoma with excellent postoperative functional outcomes.

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Osteosarcoma around elbow joint is very rare

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Limb salvage surgery is the standard procedure for the osteosarcoma, but the involvement of elbow joint made the decision for preservation difficult

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Total elbow arthroplasty and ORIF with plate and screw for distal humerus osteosarcoma provides good functional outcome

Non-oncologic indication for elbow megaprothesis replacement: 2 cases report

Introduction

Treatment of elbow bone defects is still a huge challenge in orthopaedic in order to restore the shape and function of the elbow joint. Bone defect reconstruction is very difficult due to biomechanical complexity of the elbow joint and the poor coverage tissue of this area, so mega-prothesis can be considered the most optimal solution in these cases.

Case report

We present two clinical cases of megaprosthesis elbow replacement for treatment of bone defects caused by sequelae of trauma. There is one case of 3 cm bone defect at proximal ulna and one case of 3 cm bone defect at distal humerus. In the 1st case, the elbow joint is fusioned and the second case, the elbow joint is degenerated totally after 3 previous surgery. We performed total elbow replacement with a customized megaprosthesis for them. The Mayo elbow function assessment scale [1] pre-surgery was poor at 50 points. The average age is 35 years old. The mean post-operative follow-up time was 14 months. Range of elbow flexed motion was 135 degrees, both patients were maximally extension, the forearm pronation and supination were 90 and 75 degrees, respectively. The Mayo score is very good with 97,5 points. Both patients were completely satisfied with the postoperative results.

Conclusion

Our results show that megaprosthesis elbow replacement is a very effective option for cases large elbow bone defects due to trauma sequelae. However, careful preoperative preparation is required for the best outcome.

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Megaprosthesis replacement is more popular for bone tumor around elbow

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Massive bone defect sequelae around elbow after trauma is really challenged to treat successfully. It will be more difficult if there is a problem with elbow joint: stiffness, degeneration, or fusion. In the past, functional arthrodesis of elbow was the main indication to resolve this problem.

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With the development of 3D technology and biomaterial science, megaprosthesis is the best solution for limb preservation after bone tumor wide resection.

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Application of megaprosthesis was not only limited for bone tumor, but we can also use it in some rare non-oncologic case, especially around elbow.

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We introduced 2 cases with posttraumatic massive bone loss of distal humerus and proximal ulnar which are treated by. megaprosthesis successfully.

Revision total elbow replacement

The range of general and specific adverse event in total elbow arthroplasty is similar in principle and practice to all other revision prosthetic arthroplasty but with three particular challenges: loss of humeral and ulnar bone stock; insufficiency of the extensor 'mechanism'; and the management of the ulnar nerve. Total elbow replacement is presently performed for the management of complex non-reconstructable distal humeral fractures in osteoporotic bone, for post-traumatic arthropathy, and for medically managed inflammatory arthritides in which metaphyseal bone architecture is often preserved while the articular surface is degenerate. In all these conditions the patient often presents for revision total elbow arthroplasty with relevant co-morbidities and relevant musculoskeletal dysfunction (for example: ipsilateral shoulder, wrist, thumb or hand dysfunction). Infection is a universal concern for revision arthroplasty but where the soft tissue 'envelope' is compromised and already limited, as in the proximal forearm, it is difficult to eradicate, particularly in immunocompromised patients. Bone loss compromises subsequent implantation of a revision prosthesis, while failure to restore the working lengths of the humerus and ulna reduces the strength of the flexor and extensor compartment muscles for elbow motion. Failure to restore the continuity of the triceps aponeurosis - antebrachial fascia and triceps medial head-olecranon components of the extensor 'mechanism' also compromises extensor power. Prior triceps-dividing surgical approaches will determine the elasticity, and therefore pliability, of the extensor 'mechanism': this will have a role in determining how much gain in length of the humeral side can be safely achieved. The ulnar nerve, and its management during elbow arthroplasty, is a source of frequent concern, particularly for revision of an elbow arthroplasty undertaken for distal non-reconstructable humeral articular fractures or post-traumatic arthropathy, in which the position of the ulnar nerve is never anatomic. For these reasons revision total elbow replacement (RTER) is challenging: it requires experience with surgical exposures of the elbow including the major nerve trunks, familiarity with the restoration of bone stock, a range of prostheses and techniques for prosthetic implantation, the ability to achieve adequate soft tissue cover and primary closure, and a logical approach to individualised rehabilitation.

Total elbow arthroplasty for tumors of the distal humerus and elbow

INTRODUCTION

The elbow is a rare location for primary and metastatic tumors in the upper extremity. The goal of reconstruction is to provide painless motion and stability for hand function. Total elbow arthroplasty (TEA) is commonly utilized, with either off-the-self components, modular segmental endoprosthesis, or allograft-prosthesis composites (APC). The purpose of this study was to analyze and compare commonly utilized elbow reconstructions and report outcomes of (1) patient function and (2) implant survival and complications.

METHODS

We reviewed 33 patients (18 females and 15 males) undergoing elbow arthroplasty for reconstruction of an underlying oncologic process including linked TEA (n = 22, 67%), APC (n = 9, 27%), and endoprosthesis (n = 2, 6%). The most common indication was metastatic disease (n = 17, 52%), with 24 patients (73%) presenting with a pathologic fracture.

RESULTS

Five-year implant survival was following elbow reconstruction was 88%. The mean most recent Mayo Elbow Performance Score and Musculoskeletal Tumor Society Score were 84 ± 18 and 78 ± 15%. Postoperative complications occurred in 15 elbows (45%), most commonly periprosthetic fracture (n = 5, 15%), leading to reoperation in six elbows (18%).

CONCLUSION

Although elbow arthroplasty is associated with a high incidence of complications, it provides a stable platform for upper extremity function in patients with oncologic processes of the elbow.

Augmented Total Elbow Arthroplasty with Femoral Strut Allograft for Revision of Prosthetic Joint Infection with Distal Humerus Bone Loss and Incomplete Union of Periprosthetic Humeral Shaft Fracture

Total elbow arthroplasty (TEA) prosthetic joint infection (PJI) in the setting of distal humerus bone loss poses a challenge for restoration of function. This can be complicated by a periprosthetic humeral fracture. Revision surgery in the setting of these pathologies possesses a significant challenge, especially when two or, in this case, all three problems are treated simultaneously. We present the clinical course, operative findings, and definitive treatment with the use of an augmented total elbow arthroplasty and femoral strut allograft reinforcement in detail. A review of the literature regarding the identification and management of infected TEA with augmented prosthesis and bone allograft augmentation of humerus fractures will be outlined in this case report.

Reconstruction of the elbow using pedicle joint freezing after wide excision for soft tissue sarcoma: A case report

A 35-year-old man presented with a four-year history of a growing mass on the anterior aspect of his left elbow. Magnetic resonance imaging revealed a soft tissue tumor in the brachialis muscle extending to the cubital fossa. Following an open biopsy, the tumor was diagnosed as a monophasic fibrous synovial sarcoma. After neoadjuvant chemotherapy, the patient underwent wide excision and reconstruction of the elbow joint with a pedicle frozen autograft. At the final follow-up four years after surgery, the elbow range of motion was 0-120˚. Although there were signs of osteoarthritis, there was no narrowing of the joint -, and the patient experienced only mild pain. To the best of our knowledge, the present case report is the first to describe wide tumor excision and reconstruction using a pedicle frozen autograft of the elbow. This method should be considered after excision of malignant bone and soft tissue tumors, especially in non-weight-bearing joints. Further cases have to be evaluated to understand the complications and long-term prognosis of this procedure.

Management of Metastatic Disease of the Upper Extremity

Metastatic disease is the most common pathologic cause of bone destruction, and the upper extremity is frequently involved. This location presents many surgical challenges, but there have been several recent implant and technique-related advances that have improved outcomes. Patients can be treated nonsurgically, with radiation or with surgery, depending on patient characteristics, signs/symptoms, primary diagnosis, location, and extent of bone destruction. Most locations in the upper extremity besides the humerus can be treated nonsurgically or with radiation. This is also true of the humerus, but when surgery is indicated, plate fixation is acceptable when adequate proximal and distal cortical bone is present for screw purchase. Intramedullary nailing is used frequently in metastatic humeral disease as well, especially in the diaphysis. When extensive destruction or disease progression precludes internal fixation, a resection with endoprosthetic reconstruction can be considered. Oncologic hemiarthroplasty endoprosthetics still have a role, but reverse shoulder designs are beginning to show improved function. Humeral prosthesis designs are continuing to improve, and are becoming more modular, with custom implants still playing a role in certain challenging scenarios.

[Complication management following resection and reconstruction of the upper limbs and shoulder girdle]

BACKGROUND

Sarcomas of the upper limbs commonly affect the proximal humerus or scapula. Complications after tumor resection and reconstruction are rare but cannot be neglected, particularly after tumor endoprosthetic reconstructions.

MATERIALS AND METHODS

The most common complications after resection of sarcomas of the upper limbs and shoulder girdle are described, and current knowledge regarding complication management is presented. Additionally, a selective literature search was performed, incorporating personal experiences.

RESULTS

Wound healing disorders and infections after tumor resection without specific reconstruction (clavicle resection, scapulectomy) usually respond well to conservative or surgical treatment. However, periprosthetic infections after reconstruction using a megaendoprosthesis constitute a severe and frequent complication, with an incidence of 5-10%. Two-stage implant replacement still represents the gold standard, although in selected cases, one-stage revision with retention of the prosthetic stem appears warranted. Secondary amputation as a result of periprosthetic infection is rare compared to the situation with infections of the lower limb. Mechanical complications necessitating surgical revision are mostly limited to joint dislocation after inverse total shoulder replacement (TSR). (Sub)luxation in anatomic TSR can be tolerated provided there is no tendency toward perforation of the skin in a asymptomatic patient. Biological reconstructions are most often indicated for reconstruction of intercalary defects of the humerus, and revision is necessitated most frequently by mechanical complications. Despite multiple surgical revisions, stable reconstructions and limb salvage can usually be achieved in the upper limb.

Limb Salvage and Reconstruction Options in Osteosarcoma

Advances in chemotherapy, sophisticated imaging, and surgical techniques over the last few decades have allowed limb-salvage surgery (LSS) to become the preferred surgical treatment for bone sarcomas of the extremities. The goal of LLS is to maximize limb functionality to allow for the maintenance of quality of life without compromising overall survival and tumor local recurrence rates. Today, limb-salvage procedures are performed on 80-95% of patients with extremity osteosarcoma, and the 5-year survival rate in extremity osteosarcoma patients is now 60-75%.This chapter will focus on LSS for extremity osteosarcoma. Common types of surgical reconstruction techniques including endoprostheses, intercalary or osteoarticular allografts, vascularized fibular autografts, and allograft prosthetic composites (APC), and their complications such as infection, local recurrence, graft fracture, implant failure, and nonunion will be discussed in detail. Anatomic locations of lesions discussed include the proximal femur, distal femur, proximal tibia, distal tibia, proximal humerus, distal humerus, and forearm bones.