Allograft reconstruction for the treatment of musculoskeletal tumors of the upper extremity

Postoperative Outcomes of Total Humerus Replacement for Oncologic Reconstruction of the Upper Limb: A Systematic Review of the Literature

BACKGROUND

Total humerus replacement (THR) is a reconstruction procedure performed after resection of massive humeral tumors. However, there is limited literature on the rates of failure and functional outcomes of this implant. Our study aimed to determine the main failure modes, implant survival, and postoperative functional outcomes of THR.

METHODS

A comprehensive search of the PubMed and Embase databases was conducted. We registered our study on PROSPERO (448684) and used the Strengthening the Reporting of Observational Studies in Epidemiology checklist for quality assessment. The Henderson classification was used to assess endoprosthesis failure and the Musculoskeletal Tumor Society (MSTS) score for functional outcomes. Weighted means and standard deviations were calculated.

RESULTS

Ten studies comprising 171 patients undergoing THR were finally included. The overall failure rate was 32.2%. Tumor progression (12.6%) and prosthetic infections (9.4%) were the most common failure modes, followed by soft-tissue failures (5.9%), aseptic loosening (3.5%), and structural failure (1.8%). Two-year, 5-year, and 10-year implant survival rates for the entire cohort were 86%, 81%, and 69.3%. Ten-year implant survival for primary THRs was 78.3%, compared with 38.6% for revision THRs (p = 0.049). The mean MSTS score at the last follow-up was 77%. Patients whose implants did not fail had a higher MSTS score (79.3%) than those with failed implants (71.4%) (p = 0.02).

CONCLUSION

One-third of THR will fail, mostly due to tumor progression and prosthetic infection. Overall functional scores were acceptable, with MSTS scores displaying great hand and elbow function but limited shoulder function.

LEVEL OF EVIDENCE

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

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.

Long-Term Follow-Up of Biological Reconstruction with Free Fibular Graft after Resection of Extremity Diaphyseal Bone Tumors

This study aimed to evaluate the clinical outcomes and complications of reconstruction with a composite free fibula inside other biological grafts. We retrospectively reviewed 26 patients who underwent reconstruction after bone tumor resection of the diaphysis of the long bone. Surgical data, time to bony union, functional outcomes, and complications were evaluated in all cases. The median follow-up was 72.5 months. The limb salvage rate was 100%. Primary osseous union was achieved in 90.4% of the junctions. The union rates at the metaphyseal and diaphyseal junctions were 100% and 85.7%, respectively (p = 0.255). The mean time of bony union in the upper (87.5%) and lower (91.7%) extremity was 4.6 ± 1.6 months and 6.9 ± 2 months, respectively. The mean MSTS score was 27.2 ± 3.2, with a mean MSTS rating of 90.7%. Complications occurred in 15.4% of the cases. The administration of vascularized or non-vascularized grafts did not significantly influence the union time (p = 0.875), functional outcome (p = 0.501), or blood loss (p = 0.189), but showed differences in operation time (p = 0.012) in lower extremity reconstruction. A composite free fibula inside other biological grafts provides a reasonable and durable option for osseous oncologic reconstruction of the long bone diaphysis of the extremities with an acceptable rate of complications. A higher union rate was achieved after secondary bone grafting. In lower-extremity reconstruction, two plates may be considered a better option for internal fixation. Vascularizing the fibula did not significantly affect the union time.

Patient-Specific Instruments for Forearm Sarcoma Resection and Allograft Reconstruction in Children: Results in 4 Cases

For pediatric malignant bone tumors located in the limbs, limb salvage surgery is the gold standard, but it requires adequate resection margins to avoid local recurrence. Primitive bone sarcomas of the forearm (radius or ulna) are very rare and the reconstruction remains challenging. We describe a method to ensure minimal but adequate resection bone margins with precision in four consecutive patients with primitive bone sarcomas of the forearm. During the preoperative planning, magnetic resonance imaging (MRI) was used to delineate the tumor and the tumor volume was transferred to computerized tomography (CT) by image fusion. A patient-specific instrument (PSI) was manufactured by 3D printing to allow the surgeon to perform the surgical cuts precisely according to the preoperative planning. The first PSI was used for the resection of the tumor, which adopted a unique position at the bony surface. A second PSI was intended for the cutting of the bone allograft so that it fitted perfectly with the bone defect. In all four cases, the safe margin obtained into the bone was free of tumor (R0: microscopically margin-negative resection). The functional result was very good in all four patients. This limb salvage surgical technique can be applied in forearm bone sarcoma and improves surgical precision while maintaining satisfactory local tumor control. It can also reduce the surgical time and allow a stable osteosynthesis.

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.

'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.

Proximal Humerus Reconstruction after Tumor Resection: An Overview of Surgical Management

Proximal humerus is one of the anatomical sites that are most frequently involved by bone and soft tissue malignant tumors. Alone or in association with adjuvant treatments, surgery represents the main therapeutic option to treat and eradicate these diseases. Once the first-line option, in the last decades, amputation lost its role as treatment of choice for the large majority of cases in favor of the modern limb sparing surgery that promises to preserve anatomy and-as much as possible-upper limb functionality. Currently, the main approaches used to replace proximal humerus after a wide resection in oncologic surgery can be summarized in biological reconstructions (allografts and autografts), prosthetic reconstructions (anatomic endoprostheses, total reverse shoulder prostheses), and graft-prosthetic composite reconstructions. The purpose of this overview is to present nowadays surgical options for proximal humerus reconstruction in oncological patients, with their respective advantages and disadvantages.

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.

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.

A retrospective review of revision proximal humeral allograft-prosthetic composite procedures: an analysis of proximal humeral bone stock restoration

BACKGROUND

Allograft-prosthetic composite (APC) reconstruction of the proximal humerus is a technique for reconstruction of large bone deficits, provides improvement in pain and function, and is thought to restore bone if revision surgery is needed. The purpose of this study was to evaluate the ability of proximal humeral APCs to restore usable bone at the time of revision surgery.

METHODS

Two institutional electronic medical records were reviewed to evaluate proximal humeral APC procedures performed between 1970 and 2018. We identified 115 cases, of which 14 underwent revision for aseptic causes. The indications for revision included nonunion (n = 7), glenohumeral instability (n = 5), and allograft fracture (n = 2). Three categories were used to classify the amount of usable allograft retained at revision surgery: type A, complete allograft retention; type B, partial retention; and type C, no retention.

RESULTS

A total of 14 patients (6 male and 8 female patients) underwent revision of the APC reconstruction at a mean of 22.8 months. At revision, allograft retention was classified as type A in 6 shoulders, type B in 3, and type C in 5. Type A cases were associated with nonunion with a well-fixed stem, type B cases were associated with instability and were converted from a hemiarthroplasty to a reverse total shoulder arthroplasty, and type C cases were associated with an allograft fracture or nonunion with a loose humeral component.

CONCLUSION

A substantial number of revisions of proximal humeral APC reconstructions maintain a portion of the allograft bone (64.3%). This study supports the ongoing use of the APC reconstruction technique for large bone deficits.

There is a role for allografts in reconstructive surgery of the elbow and forearm

PURPOSE

Allografts play an important role in tendon, ligament, and bone reconstruction surgery, particularly when suitable available autologous tissue is limited. Enthusiasm for the use of allografts in reconstructive orthopedic surgery has increased over the past decade, with an increase in allograft use in a variety of procedures. The purpose of this review is to provide an overview of the various applications and indications for the use of allografts in reconstructive surgical procedures of the elbow and forearm.

METHODS

MEDLINE/PubMed was searched from 1990 through October 2018 for studies on tendon and bony allografts in elbow and forearm reconstructive surgery.

RESULTS

The Achilles tendon allograft is the most frequently used tendinous allograft, predominantly used in distal biceps and triceps reconstruction. Although reconstruction of the ulnar collateral ligament of the elbow is generally performed using autografts, it has been shown that semitendinosus and gracilis allografts may be equally effective. Extensor hallucis longus allografts are recommended for reconstruction of the lateral collateral ligaments in patients with posterolateral rotatory instability, and there may be a role for osteochondral allograft transplantation in capitellar osteochondral defects. In addition, the use of allografts in reconstruction of the interosseous membrane and various bone pathologies (fractures, bone tumors, forearm nonunions) has been described in current literature.

CONCLUSION

There is a large variety of pathology and procedures involving the use of various types of allografts in orthopedic reconstructive surgery of the elbow and forearm.

A giant cell rich osteosarcoma of the proximal ulnar bone treated by elbow arthroplasty: A case report

•

Osteosarcoma of the proximal ulnar bone is a malignant progressive bone tumors.

•

Diagnosis of these cases needs a comprehensive history taking physical examination and additional diagnostic test.

•

Limb salvage surgery using wide excision and reconstruction with elbow arthroplasty by our institution was a challenging procedure.

•

Latissimus dorsi flap is important to close the defect left by wide excision.

Introduction

Osteosarcoma is a malignant tumor of the bone. The treatment and prognosis have changed dramatically these days. Limb salvage surgery is a widely accepted alternative to amputation in patients with sarcoma. In most cases, the diagnosis of osteosarcoma is not difficult. We reported a rare location and a rare type of osteosarcoma case treated by elbow arthroplasty along with the challenging diagnostic and treatment.

Case presentation

We reported 46 years old female complained of pain on her left elbow for 5 months. An x-ray showed lytic lesion on the medial side of the elbow while the MRI examination suggested a malignant bone tumor in the epi-meta-diaphyseal of left ulnar bone. Core biopsy showed a Giant Cell containing lesion. The histology of resected tumor and Ki67 staining confirmed the diagnosis of giant cell-rich type osteosarcoma.

Discussion

Giant cell rich osteosarcoma is an uncommon variant of osteosarcoma which characterized by an abundance of osteoclastic giant cells and lack of tumor osteoid. Involvement of forearm in conventional osteosarcoma is extremely rare. This was the epidemiologic reason why the osteosarcoma was not the first diagnosis of our case. Being a very rare location of the osteosarcoma, the management poses a special challenge. They are the surgical technique, which is not well described, and the implant that need to be custom made.

Conclusion

Giant cell rich osteosarcoma is difficult to diagnose because its histology and radiologic feature mimic a benign giant cell tumor.

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

BACKGROUND

The distal humerus is a rare location of bone tumors. Because of the complexity of the elbow joint, poor soft-tissue coverage, and proximity of nerves and vessels, resection and endoprosthetic reconstruction are demanding.

METHODS

This retrospective study evaluated the clinical results after distal humeral resection and megaprosthetic reconstruction in 12 patients with an average age of 46 years. All patient files were reviewed for clinical information, and postoperative function and patients' contentment were assessed using the Musculoskeletal Tumor Society score.

RESULTS

The predominant diagnoses were bone and soft-tissue sarcoma (n = 6), giant cell tumor (n = 2), and renal cell carcinoma metastasis (n = 2). Local recurrence was the reason for secondary amputation in all cases (n = 3). The prosthetic survival rate after surgery was 82% at 2 years and 64% at 5 years. Reconstruction failure was mainly caused by aseptic loosening of the humeral stem, occurring in 27% (n = 3), followed by aseptic loosening of the ulnar stem in 9% (n = 1) and periprosthetic infection in 9% (n = 1). The mean Musculoskeletal Tumor Society score was 24 points (range, 20-30 points). An extension lag of more than 10° was noted in 6 patients (55%).

CONCLUSION

Our results suggest that limb salvage with a distal humeral replacement can achieve good functional results in most patients, although the complication rate with special emphasis on the loosening rate of the humeral stem is high. However, limb salvage was not achieved in 27% of patients because of local recurrence.

Allograft reconstruction of the humerus: Complications and revision surgery

BACKGROUND AND OBJECTIVES

Allograft reconstruction of the humerus after resection is preferred by many because of bone stock restoration and biologic attachment of ligaments and muscles to the allograft, theoretically obtaining superior stability and functionality. Our aim was to assess the prevalence of complications and the incidence and etiology for revision surgery in humeral allograft reconstructions.

METHODS

We included patients 18 years and older who underwent wide resection and allograft reconstruction of the humerus for primary and metastatic lesions at our institution between 1990 and 2013. Our primary outcome measures were complications and revision surgery. We used competing risk regression to assess allograft survival.

RESULTS

Of the 84 patients we included, 47 patients (51%) underwent allograft reconstructions of the proximal humerus, 30 (36%) intercalary, and seven (8%) of the distal humerus. Fifty-one patients (61%) had at least one complication after surgery. Eighteen patients (21%) underwent revision surgery. The 5-year allograft survival was 71%.

CONCLUSION

Although allograft reconstructions of the humerus are a valuable option in the orthopedic oncologist's armamentarium, surgeons should mind the accompanying complication rates. Allograft fractures seem to be the main issue for proximal and distal allografts, often leading to revision surgery. Intercalary allografts are mostly troubled by nonunions.

Reconstructive Science in Orthopedic Oncology

Limb salvage is widely practiced as standard of care in most cases of extremity bone sarcoma. Allograft and endoprosthesis reconstructions are the most widely utilized modalities for the reconstruction of large segment defects, however complication rates remain high. Aseptic loosening and infection remain the most common modes of failure. Implant integration, soft-tissue function, and infection prevention are crucial for implant longevity and function. Macro and micro alterations in implant design are reviewed in this manuscript. Tissue engineering principles using nanoparticles, cell-based, and biological augments have been utilized to develop implant coatings that improve osseointegration and decrease infection. Similar techniques have been used to improve the interaction between soft tissues and implants. Tissue engineered constructs (TEC) used in combination with, or in place of, traditional reconstructive techniques may represent the next major advancement in orthopaedic oncology reconstructive science, although preclinical results have yet to achieve durable translation to the bedside.

Functional Outcomes and Complications After Oncologic Reconstruction of the Proximal Humerus

BACKGROUND

No consensus exists on the best method of articular reconstruction in patients who require proximal humerus resection for the management of primary bone sarcomas, soft-tissue sarcomas extending into the bone, benign and locally aggressive primary bone tumors, and metastatic disease.

METHODS

We identified patients from two institutions who underwent wide resection of the proximal humerus along with oncologic reconstruction using osteoarticular allografts (OAs), endoprostheses, or allograft-prosthesis composites. We prospectively collected functional outcomes and retrospectively assessed complications and implant survival.

RESULTS

A total of 150 patients were included in this study. The average Disabilities of the Arm, Shoulder and Hand questionnaire score was 26 for 25 patients, of which we gathered their functional data, with no differences in physical function among the three constructional methods according to the Disabilities of the Arm, Shoulder and Hand questionnaire, upper extremity Toronto Extremity Salvage Score, upper extremity Musculoskeletal Tumor Society, and Patient-Reported Outcomes Measurement Information System scores. Overall, the survival rate of the prosthesis was >50%. A trend was noted for a higher risk of failure in the OA group secondary to the allograft fracture.

DISCUSSION

All three articular oncologic shoulder reconstructions were comparable in terms of function. This large series confirms a higher fracture rate in OAs, which explains the observed higher revision rate and apparent lower survival rate in this subgroup.

Prognosis-Based Shoulder Hemiarthroplasty After Resection of Proximal Humeral Malignancy

After wide excision of proximal humeral bony malignancy, prognosis-based reconstruction was performed at Taipei Veterans General Hospital. Bone prosthesis composite (BPC) was carried out among patients with a favored prognosis, while cement-spacer prosthesis composite (CSPC) was preserved for patients with poor prognosis. The aim of our study is to compare the clinical outcomes between the BPC and CSPC reconstruction procedures. From January 2000 to December 2014, we retrospectively reviewed the clinical outcomes of 34 patients who underwent shoulder hemiarthroplasty following wide excision of a malignant lesion of the proximal humerus, 15 of whom were treated with a BPC reconstruction and 19 cases were treated with a CSPC reconstruction. The mean postoperative follow-up was 51.9 months for the BPC group and 29.0 months for the CSPC group. At the end of the study, four patients (two in the BPC group and two in the CSPC group) developed local recurrence. Thirteen patients (1 in the BPC group and 12 in the CSPC group) had died of disease progression. The postoperative visual analogue scale score of BPC and CSPC groups was similar (P = 0.262). Functional outcome, measured using the Musculoskeletal Tumor Society score and shoulder range of motion, favored the BPC procedure (P < 0.001). The CSPC procedure, however, had less complication rate, required less operative time, and had a lower volume of intraoperative blood loss than the BPC procedure (P < 0.001). Although functional outcomes are expected to be more favorable with a BPC procedure, the CSPC procedure continues to be a safe and cost-effective shoulder hemiarthroplasty procedure for patients with low-demanding activities and when a poor disease prognosis is expected.

The value of computer-assisted navigation for bone reconstruction after tumor resection

This study was designed to evaluate the use of computer-assisted navigation with computed tomography (CT) images for bone reconstruction after resection in malignant bone tumor treatment. Forty-five patients with malignant bone tumors were recruited for this study. CT scan images in a computer-assisted navigation system were used to assist during the osteotomy, the pairing with allografts, and the monitoring of the allograft and joint lines to perform joint reconstruction. Our results show that osteotomy and allograft pairing were successful in all patients. The average duration of the osteotomy procedures was 46.8±12.3 min; and the average pairing time was 32.5±9.8 min. The anatomical registration points and the three-dimensional virtual CT images were successfully matched. The average error of registration was 0.36±0.09 mm. Also, the range of tumor resection and allograft osteotomy were successfully paired, with an average error of 0.11±0.03 mm. No complications such as unequal limbs length or joint deformities occurred after reconstruction. The average follow-up time was 11.6±3.9 months. The tumor recurrence rate was 11.1% (5/45) and the survival rate 95.6% (43/45). The average healing time for the allograft and host bone was 5.5±1.2 months and no unexpected internal fixations, fractures or joint collapses occurred. The average knee joint functionality MSTS score was 25.5±6.6 points. No significant differences were found in the length of tumor resection, rate of negative incision margin, duration of osteotomy or of pairing, registration error or allogeneic bone and defect matching error averages between those patients with tumor recurrence and those without it (p>0.05). Based on our results, the computer-assisted navigation system for bone reconstruction after malignant tumor resection allows for high precision during osteotomy, delivers a high success rate of pairing, results in great limb function and low complication rates, and is thus a highly successful and safe approach benefiting bone cancer patients.

What is the Optimal Reconstruction Option after the Resection of Proximal Humeral Tumors? A Systematic Review

Purpose:

The proximal humerus is a common location for both primary and metastatic bone tumors. There are numerous reconstruction options after surgical resection. There is no consensus on the ideal method of reconstruction.

Methods:

A systematic review was performed with a focus on the surgical reconstructive options for lesions involving the proximal humerus.

Results:

A total of 50 articles and 1227 patients were included for analysis. Reoperation rates were autograft arthrodesis (11%), megaprosthesis (10%), RSA (17%), hemiarthroplasty (26%), and osteoarticular allograft (34%). Mechanical failure rates, including prosthetic loosening, fracture, and dislocation, were highest in allograft-containing constructs (APC, osteoarticular allograft, arthrodesis) followed by arthroplasty (hemiarthroplasty, RSA, megaprosthesis) and lowest for autografts (vascularized fibula, autograft arthrodesis). Infections involving RSA (9%) were higher than hemiarthroplasty (0%) and megaprosthesis (4%).

Postoperative function as measured by MSTS score were similar amongst all prosthetic options, ranging from 66% to 74%, and claviculo pro humeri (CPH) was slightly better (83%). Patients were generally limited to active abduction of approximately 45° and no greater than 90°. With resection of the rotator cuff, deltoid muscle or axillary nerve, function and stability were compromised even further. If the rotator cuff was sacrificed but the deltoid and axillary nerve preserved, active forward flexion and abduction were superior with RSA.

Discussion:

Various reconstruction techniques for the proximal humerus lead to relatively similar functional results. Surgical choice should be tailored to anatomic defect and functional requirements.

The effect of cement augmentation and anteromedial plating on proximal humerus allograft reconstruction

BACKGROUND

Limb salvage following the resection of tumor from the proximal part of the humerus, poses many challenges, and there is no consensus regarding the best reconstructive technique after proximal humerus resection. The aim of this study was to evaluate the effect of anteromedial placing of the plate in the absence of deltoid muscle and cement augmentation on the functional outcome, complication rate and survival of proximal humerus allograft reconstruction.

PATIENTS AND METHODS

A number of 36 osteoarticular allograft reconstructions of proximal humerus were included in final study. In 26 cases, medullary canal of the allograft was filled by cement and the complication rate and survival was compared to non-cemented allografts. In addition, anteromedial placement of plate was applied for all resection type IB (18 cases), in which the deltoid muscle was resected. The mean follow-up of patients was 46 months.

RESULTS

In total, 12 complications including 3 fractures, 4 resorptions, 3 infections and 2 nonunions were reported. Complication rates were significantly lower in cemented allografts (p = 0.001). Five year survival rates of cemented and non-cemented allografts were found to be 82% and 70%, respectively. The mean MSTS score was 84.9%, ranging 76-90.

CONCLUSION

According to our results, cement augmentation improves survival and reduces the complication rate of allografts. Moreover, our results showed that anteromedial placing of the plate in resection type IB could improve the functional outcome of allografts. However, the detailed effect of anteromedial plating should be further investigated in future studies.

Proximal humeral osteoarticular allografts: technique, pearls and pitfalls, outcomes

Allograft transplantation is a biologic reconstruction option for massive bone defects after resection of bone sarcomas. This type of reconstruction not only restores bone stock but it also allows us to reconstruct the joint anatomically. These factors are a major concern, especially in a young and active population.We are describing indications, surgical techniques, pearls and pitfalls, and outcomes of proximal humeral osteoarticular allografts, done at present time in our institution.We found that allograft fractures and articular complications, as epiphyseal resorption and subchondral fracture, are the main complications observed in proximal humerus osteoarticular allograft reconstructions. Nevertheless, only fractures need a reconstruction revision. Joint complications may adversely affect the limb function, but for this reason, an allograft revision is rarely performed.

Proximal humerus allograft prosthetic composites: technique, outcomes, and pearls and pitfalls

The proximal humerus is the second most common location of primary bone sarcomas and a frequent location of benign locally aggressive primary osseous tumors. In contrast to other locations, tumors in this region impose significant challenges for local control and reconstruction. This is due to glenohumeral joint anatomic characteristics such as lack of intrinsic stability and dependence on dynamic and static stabilizers. In addition, the close proximity of the axillary nerve and axillary vascular bundle places these at risk of resection when attaining local control. Allograft prosthetic composites (APCs) of the proximal humerus are one of the methods for mobile reconstruction. This modality presents lower fracture rates when compared to osteoarticular allografts and lower rates of subluxation and instability than endoprosthesis. Recent literature documents a trend for superior functional outcome at comparable complication rates. APC reconstruction is an important tool in the orthopedic oncologist armamentarium.

Conference report on the 28th annual meeting of the European Musculo-Skeletal Oncology Society, 29 April-1 May 2015, Athens

The 28th Annual Meeting of the European Musculo-Skeletal Oncology Society was organised in Athens by the local host Professor Papagelopoulos and his team. The main objective of the meeting was to focus on recent advances in the diagnosis and treatment of bone and soft tissue sarcomas. The interdisciplinary nature of the meeting was of great value—surgeons, oncologists, pathologists, radiologists, and basic researchers discussed new strategies in the war on sarcoma. This report will highlight the major findings of this successful meeting.

Results of the proximal humerus endoprosthetic reconstruction after tumour resection

The purpose of the study was to evaluate the results of surgical reconstructions of the proximal humerus after transarticular tumour resection, compare the functional results with the results of shoulder arthroplasty in patients with extensive damage of the proximal humerus of non-neoplastic origin. Material and methods. Between 2001 and 2013 38 proximal humeral reconstructions were performed in our clinic: using monopolar endoprostheses - 26 (68%) and modular systems with reversible head -12 (32%). The control group included 46 patients with extensive lesions of the proximal humerus of non-neoplastic origin, operated in our clinic in the period from 2006 to 2012. Term follow-up of patients ranged from 7 months to 9 years. Assessment of functional results was carried out in a period from six months to one year. Results. The seven-year survival according the Kaplan - Meier method for patients with primary malignant tumors of the proximal humerus (25 patients) was 77%. In the study group the average value of functional outcome MSTS score was 77.7%. Unipolar prosthesis showed a bad result, both in the control (61,3% MSTS, 60,7 Neer) and in the main (67,7% MSTS, 61,1 Neer) study groups. Conclusion. Currently the method of choice which doesn’t impair the oncologic component of treatment patients with shoulder neoplastic lesions is its replacement with modular reversible systems in combination with additional soft tissue fixation.

Upper extremity considerations for oncologic surgery

It was estimated that more than 3000 people would be diagnosed with a primary bone or joint malignancy and more than 11,000 people would be diagnosed with a soft tissue sarcoma in 2013. Although primary bone and soft tissue tumors of the upper extremity are infrequent, it is imperative that the clinician be familiar with a systematic approach to the diagnosis and treatment of these conditions to prevent inadvertently compromising patient outcome. With advances in chemotherapy, radiotherapy, tumor imaging, and surgical reconstructive options, limb salvage surgery is estimated to be feasible in 95% of extremity bone or soft tissue sarcomas.

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

BACKGROUND

Tumors of the appendicular skeleton commonly affect the proximal humerus, but there is no consensus regarding the best reconstructive technique after proximal humerus resection for tumors of the shoulder.

QUESTIONS/PURPOSES

We wished to perform a systematic review to determine which surgical reconstruction offers the (1) best functional outcome as measured by the Musculoskeletal Tumor Society (MSTS) score, (2) longest construct survival, and (3) lowest complication rate after proximal humerus resection for malignant or aggressive benign tumors of the shoulder.

METHODS

We searched the literature up to June 1, 2013, from MEDLINE, EMBASE, and the Cochrane Library. Only studies reporting results in English, Dutch, or German and with followups of 80% or more of the patients at a minimum of 2 years were included. Twenty-nine studies with 693 patients met our criteria, seven studies (24%) were level of evidence III and the remainder were level IV. Studies reported on reconstruction with prostheses (n = 17), osteoarticular allografts (n = 10), and allograft-prosthesis composites (n = 11). Owing to substantial heterogeneity and bias, we narratively report our results.

RESULTS

Functional scores in prosthesis studies ranged from 61% to 77% (10 studies, 141 patients), from 50% to 78% (eight studies, 84 patients) in osteoarticular graft studies, and from 57% to 91% (10 studies, 141 patients) in allograft-prosthesis composite studies. Implant survival ranged from 0.38 to 1.0 in the prosthesis group (341 patients), 0.33 to 1.0 in the osteoarticular allograft group (143 patients), and 0.33 to 1.0 in allograft-prosthesis group (132 patients). Overall complications per patient varied between 0.045 and 0.85 in the prosthesis group, 0 and 1.5 in the osteoarticular graft group, and 0.19 and 0.79 in the prosthesis-composite graft group. We observed a higher fracture rate for osteoarticular allografts, but other specific complication rates were similar.

CONCLUSIONS

Owing to the limitations of our systematic review, we found that allograft-prosthesis composites and prostheses seem to have similar functional outcome and survival rates, and both seem to avoid fractures that are observed with osteoarticular allografts. Further collaboration in the field of surgical oncology, using randomized controlled trials, is required to establish the superiority of any particular treatment.

The principles and applications of fresh frozen allografts to bone and joint reconstruction

Fresh frozen allograft reconstruction has been used for a long time in massive bone loss in orthopedic surgery. Allografts have the advantage of being biologic reconstructions, which gives them durability. Despite a greater number of complications in the short term, after 5 years these stabilize with high rates of survival after 10 years. The rate of early complications and the need for careful management in the first years has led the orthopedic surgeon to the use of other options. However, the potential durability of this reconstruction makes this one of the best options for younger patients with high life expectancy.

Treatment and outcome of malignant bone tumors of the proximal humerus: biological versus endoprosthetic reconstruction

Background

The purpose of this study was to compare the outcome, complications and survival of the commonly used surgical reconstructions of the proximal humerus after intrarticular tumour resection in our hospital.

Methods

Between 1998 and 2010, 41 consecutive proximal humeral reconstructions using prosthesis (group P, n = 25) or recycled pasteurized autograft combined with non-vascularised fibula autograft (group B, n = 16) were performed.

Results

The mean follow-up was 57.7 months. Fourteen patients (8 patients in group P and 6 in group B) died during the follow-up period, the disease-specific survival of patients in group P was 74.5% at 5 years and in group B was 67.0%. Local recurrences were occurred in 3 cases (12.0%) in group P and 2 (12.5%) in group B. Pulmonary metastases were observed in 4 patients (16.0%) in group P and 4 (25.0%) in group B. There was no significant difference in the incidence of local recurrence, pulmonary metastasis or death of disease. Revisions were indicated in 9 patients (36.0%) in group P and 5 (31.25%) in group B. Thought the incidence of revisions was higher in group P, there was no significant difference in these two groups. The Kaplan-Meier 5-year implant survival estimates, with revision for any reason as the end point, were 80.6% and 68.8% for group P and group B, respectively. The mean MSTS Score was 63.6% in group P and 63.0% in group B. These differences were not statistically significant.

Conclusions

The study could show that prosthetic reconstruction and reconstruction with recycled pasteurized autograft are similar in terms of their local recurrence and metastasis, while the incidence of revisions was higher for patients with prosthetic reconstruction.