Allograft-prosthetic Composites Research Articles

Allograft Prosthetic Composite (APC) for Proximal Humeral Bone Deficiency in Revision Reverse Shoulder Arthroplasty: A Technical Note and Systematic Review.

Background: Proximal humeral bone deficiency in revision shoulder arthroplasty is an emerging and challenging problem as the use of reverse shoulder arthroplasty (RSA) increases. This paper presents a technical note discussing our detailed preoperative planning steps, surgical techniques, and their rationale in carrying out the use of an allograft prosthetic composite (APC) to address proximal humeral bone deficiency in revision RSA. The outcomes of this technique are also presented. This paper also presents a systematic review to further discuss the existing literature on RSA with APCs. Methods: The preoperative surgical planning and the surgical technique employed to execute proximal humeral reconstruction using APC during revision arthroplasty are discussed in the technical note. The preliminary clinical and radiological results of five patients who underwent revision shoulder arthroplasty with proximal humeral reconstruction using APCs are presented. The PRISMA guidelines were followed to perform the systematic review. A systematic search using PubMed, Embase, and Cochrane databases was conducted. All studies involving RSA and APCs were pooled, and the data were extracted and analyzed. Results: A total of 14 studies were eligible for inclusion in the systematic review, with a total of 255 patients and a mean follow-up of 57 months. All studies in the systematic review and the patients included in the author's case series showed improvements in the level of pain, range of motion, function, and satisfaction. Graft incorporation in the systematic review was 84%. Conclusions: Based on the available literature and the results of our case series, the use of an APC construct is a viable option for proximal humeral bone deficiency in revision shoulder arthroplasty.

Proximal Humerus Reconstruction in Skeletally Immature Patients

Proximal humerus reconstruction after oncologic resection is complex, with numerous muscular attachments, proximity of critical neurovascular structures, and dynamic stability granting multidirectional motion at the glenohumeral articulation. In skeletally immature patients, additional factors increase the complexity, including remaining limb growth and humerus size. Limb length discrepancy affects the limb's esthetics and function while the humerus size can limit fixation strategies and intramedullary device use. Reconstruction options used in isolation or combination include endoprostheses, osteoarticular allografts, allograft-prosthetic composites, autografts, and arthrodesis. Unique limb salvage options to address the unique factors in young, skeletally immature patients include vascularized fibular epiphyseal transfer, claviculo pro humeri, and expandible endoprostheses. Each option has advantages and disadvantages for anticipated function, durability, shoulder stability, and complications. This review aims to aid preoperative planning and decision making for surgeons and patients undergoing proximal humerus resection and reconstruction with notable remaining growth potential.

Reverse Allograft Prosthetic-Composite Versus Endoprosthesis Reconstruction for Massive Proximal Humerus Bone Loss: A Systematic Review and Meta-analysis of Outcomes and Complications.

This systematic review and meta-analysis sought to compare the clinical outcomes after proximal humerus reconstruction with a reverse allograft-prosthetic composite (APC) versus reverse endoprosthesis. Per PRISMA guidelines, we queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of reverse APC or reverse endoprosthesis reconstruction of the proximal humerus for massive bone loss secondary to tumor, fracture, or failed arthroplasty. We compared postoperative range of motion, outcome scores, and the incidence of complications and revision surgery. Of 259 unique articles, 18 articles were included (267 APC, 260 endoprosthesis). There were no significant differences between the APC and endoprosthesis cohort for postoperative forward elevation (P = .231), external rotation (P = .634), ASES score (P = .420), Constant score (P = .414), MSTS (P = .815), SST (P = .367), or VAS (P = .714). Rate of complications was 15% (31/213) in the APC cohort and 19% (27/144) in the endoprosthesis cohort. The rate of revision surgery was 12% after APC cohort and 7% after endoprosthesis. APC-specific complications included a 10% APC nonunion/malunion/resorption rate and 6% APC fracture/fragmentation rate. Reverse APC and endoprosthesis are reasonable options for proximal humerus reconstruction. APC carries additional risks for complications, warranting evaluation of patients' healing capacity and surgeon experience. Level IV; Systematic Review. The online version contains supplementary material available at 10.1007/s43465-024-01248-7.

Graft Infections in Biologic Reconstructions in the Oncologic Setting: A Systematic Review of the Literature.

Background: Biologic graft infection (BGI) is one of the main complications in graft reconstructions. However, very little evidence exists regarding the epidemiology of BGI, as most of the data come from sparse reports. Moreover, most of the series did not detail the treatment and outcome of graft infections. The aim of this systematic review of the literature is to provide a comprehensive data collection on BGI after oncologic resections. Methods: Three different databases (PubMed, Scopus, and Web of Science) were searched for relevant articles, and further references were obtained by cross-referencing. Results: 139 studies met the inclusion criteria. A total of 9824 grafts were retrieved. Among these, 684 (6.9%) were in the humerus, 365 (3.7%) in the pelvis, 2041 (20.7%) in the femur and 1660 (16.8%) in the tibia. Most grafts were osteoarticular (2481, 26.7%) and intercalary 2112 (22.7%) allografts. In 461 (5.0%), vascularized fibula grafts (VFGs) were used in combination with recycled autografts. Recycled grafts were reported in 1573 (16.9%) of the cases, and allograft-prosthetic composites in 1673 (18.0%). The pelvis and the tibia had the highest incidence of BGI (20.4% and 11.0%, respectively). The most reported first treatment was debridement and implant retention (DAIR) in 187 (42.8%) cases and two-stage revision with graft removal in 152 (34.8%). Very little data are reported on the final outcome specified by site or type of graft. Conclusions: This systematic review of the literature confirms a high incidence of infections in biologic reconstructions after resections of primary bone tumors. Despite DAIR being a viable attempt, in most cases, a two-stage approach with graft removal and reconstruction with endoprosthesis presented the highest chance to overcome infection, guaranteeing a reconstruction. We emphasize the need for future multicentric studies to focus on the management of infections after biological reconstructions in bone sarcomas.

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.

The Functional Outcome of Limb Salvage of Proximal Femur Tumors With Modular Endoprosthesis: A Prospective Study.

Introduction The proximal femur is a common siteforprimary bone sarcomas, includingEwing's sarcoma, chondrosarcoma, osteosarcoma, and giant celltumors (GCT). Extensive resections arechallengingto reconstruct because the size of the tumormay necessitate an extensive resection ofthefemur to achieve adequate oncologic clearance. The resection of the proximal femur can result inhip jointinstabilitydue totheloss of the strong native hipcapsule orhip abductor strength. With a wide range of reconstruction options,such asresection arthrodesis, allograft-prosthetic composite (APC),andendoprosthesis,we can achieve limb salvage with good functionaloutcomes. Objective The objective of this case series isto evaluate the clinical outcomes and complications associatedwith endoprosthesis replacement in patients with proximal femur tumors. Methods A prospective analysis was conducted with 32 patients who underwent modular endoprosthesis replacement for proximal femoral tumors at our institution. Patient data, tumor characteristics, surgicaldetails, and postoperative outcomes were collected and analyzed. Results The study involved 32 patientswho met theinclusion criteria.Theywere assessed usingthe MusculoskeletalTumor Society Score (MSTS), which showedgoodfunctional outcomesin72.84%of the patients. The study highlights the functionaloutcomes and potential complications associated with the use of modular prostheses. Conclusion Endoprosthesis replacement in proximal femur tumors is a viable treatment option, providinggood functional outcomes and an acceptable method for limb salvage, which enhances the quality of life.

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

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. 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). 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]). 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.

Allograft-Prosthetic Composite Reconstruction for Proximal Humerus Bone Loss: A Systematic Review and Meta-Analysis of Outcomes and Complications.

In smaller studies, allograft-prosthetic composite (APC) has been used for proximal humerus bone loss with some success, although with notable complication risk. This systematic review and meta-analysis sought to describe outcomes and complications after proximal humerus APC and how major APC complications are defined in the literature. A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for articles on APC for proximal humeral bone loss secondary to tumor, fracture, or failed arthroplasty. Primary outcomes included postoperative range of motion, outcome scores (Musculoskeletal Tumor Society [MSTS], Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES], Constant, visual analog scale [VAS], and subjective shoulder value [SSV]), and complication incidence. We also described individual study definitions of APC malunion/nonunion, methods of postoperative evaluation, malunion/nonunion rates, allograft fracture/fragmentation rates, and mean union time, when available. Secondarily, we compared hemiarthroplasty and reverse total shoulder arthroplasty. Sixteen articles including 375 shoulders were evaluated (average age: 49 years, follow-up: 54 months). Fifty-seven percent of procedures were performed for tumors, 1% for proximal humerus trauma sequelae, and 42% for revision arthroplasty. Average postoperative forward elevation was 82° (69-94°), abduction 60° (30-90°), and external rotation 23° (17-28°). Average MSTS score was 82% (77%-87%), SST score 5.3 (4.5-6.1), ASES score 64 (54-74), Constant score 44 (38-50), VAS score 2.2 (1.7-2.7), and SSV 51 (45-58). There was a 51% complication rate with an 18% nonallograft surgical complication rate, 26% APC nonunion/malunion/resorption rate, and 10% APC fracture/fragmentation rate. Fifteen percent of nonunited APCs underwent secondary bone grafting; 3% required a new allograft; and overall revision rate was 12%. APC nonunion/malunion was defined in 2 of 16, malunion/nonunion rates in 14 of 16, fracture/fragmentation rates in 6 of 16, and mean union time (7 months) in 4 of 16 studies. APC reconstruction of the proximal humerus remains a treatment option, albeit with substantial complication rates. In addition, there is a need for APC literature to report institutional definitions of nonunion/malunion, postoperative evaluation, and time to union for a more standardized evaluation. Level IV; systematic review. See Instructions for Authors for a complete description of levels of evidence.

Two-Year Outcomes of the Reverse Humeral Reconstruction Prosthesis.

Extensive proximal humeral bone loss in the setting of shoulder arthroplasty represents a difficult challenge for the treating surgeon. Achieving adequate fixation with standard humeral prostheses can be problematic. Allograft-prosthetic composites are a viable solution for this problem, however high rates of complications have been reported. Modular proximal humeral replacement systems are another potential solution, but there is a paucity of outcome data on these implants. This study reports the two-year minimum follow-up outcomes and complications of a single system reverse proximal humeral reconstruction prosthesis (RHRP) for patients with extensive proximal humeral bone loss. We retrospectively reviewed all patients with minimum two-year follow-up who underwent implantation of a RHRP for either 1) failed shoulder arthroplasty or 2) proximal humerus fracture with severe bone loss (Pharos 2 and 3) and/or sequelae thereof. Forty-four patients met inclusion criteria (average age 68.3 ± 13.1 years). The average follow-up was 36.2 ± 12.4 months. Demographic information, operative data, and complications were recorded. Pre- and postoperative range of motion (ROM), pain, and outcome scores were assessed and compared to the MCID and SCB for primary rTSA where available. Of the 44 RHRPs evaluated, 93% (n=39) had undergone prior surgery and 70% (n=30) were performed for failed arthroplasty. ROM improved significantly in abduction by 22° (P = .006) and forward elevation by 28° (P = .003). Average pain on a daily basis and pain at worst improved significantly, by 2.0 points (P < .001) and 2.7 points (P < .001), respectively. Mean SST score improved by 3.2 (P < .001), Constant score by 10.9 (P = .030), ASES score by 29.7 (P < .001), UCLA score by 10.6 (P < .001), and SPADI score by 37.4 (P < .001). A majority of patients achieved the MCID for all outcome measures assessed (56-81%). The SCB was exceeded by half of patients for forward elevation and the Constant score (50%), and exceeded by the majority of patients for the ASES score (58%) and UCLA score (58%). The complication rate was 28%; the most common complication was dislocation requiring closed reduction. Notably, there were no occurrences of humeral loosening requiring revision surgery. This data demonstrates that the RHRP resulted in significant improvements in ROM, pain, and PROMs, without the risk of early humeral component loosening. RHRP represents another potential solution for shoulder arthroplasty surgeons when addressing extensive proximal humerus bone loss.

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

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

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

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. 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. 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. 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.

Midterm outcomes allograft prosthetic composite reconstruction for massive bone loss at the elbow

BackgroundRevision of a loose total elbow arthroplasty (TEA) is challenging, particularly in the context of massive bone loss (MBL). The use of an allograft prosthetic composite (APC) at the elbow is rare, typically reserved as a salvage procedure for MBL. Thus, limited data describing the outcomes of APCs are available in current literature. HypothesisThe authors hypothesize that short to midterm clinical outcomes of APC for MBL about the elbow are satisfactory. Patients and methodsBetween 2009 and 2018, 6 APCs implanted with a semi-constrained Coonrad Morrey prosthesis were performed in 5 females and 1 male. Median patient age was 70 years (range, 49–76 years). The indication for revision was aseptic loosening in all 6 cases (6 humeral and 2 ulnar). Median follow-up was 3.5 years (range, 2–6.7 years). Functional outcomes including Mayo Elbow Performance Score (MEPS), Visual Analog Scale (VAS), range of motion (ROM), and radiographic outcomes were assessed for all patients. ResultsMedian MEPS and VAS scores were 75 (range, 40–90), and 0 (range, 0–8) at latest follow-up, respectively. Median postoperative flexion-extension and prono-supination arcs were 90̊ (range, 70–140̊) and 150 (range, 100–160̊), respectively. Allograft incorporation was noted in 5 (83%) patients; all prostheses were well-fixed. In total, 4 patients (63%) experienced 5 complications (83%) including periprosthetic fracture (n=2), ulnar neuropathy (n=1), aseptic loosening (n=1), and wound dehiscence (n=1). Two (33%) required reoperation with prosthetic retention. ConclusionElbow reconstruction using allograft prosthetic composite is a viable option for patients with MBL following TEA. The midterm functional outcomes are satisfactory with no revisions required, despite a relatively high rate of complications. Further long-term studies with larger cohorts are needed to better elucidate long-term outcomes and reasons for failure. Level of evidenceIV; therapeutic study (case series [no, or historical, control group])

What's New in Musculoskeletal Tumor Surgery.

What's New in Musculoskeletal Tumor Surgery.

Periprosthetic Postoperative Humeral Fractures After Shoulder Arthroplasty.

The increased utilization of shoulder arthroplasty, including revision procedures, combined with rises in life expectancy, is expected to translate into a substantial increase in periprosthetic humeral fractures. The evaluation and management of these fractures needs to be updated to consider fractures that complicate anatomic and reverse arthroplasties and contemporary short-stem and stemless implants. Although conservative treatment is successful in a large proportion of these fractures, several surgical reconstructive techniques are required for the management of all fracture types. Surgical options include internal fixation, graft augmentation, standard revision procedures, and occasionally complex reconstructions including modular segmental prosthesis and allograft prosthetic composites. Most studies on the outcomes of periprosthetic humeral fractures have analyzed small samples and have typically reported on anatomic total shoulders with a standard-length humeral implant. Additional research is required to optimize the management of periprosthetic postoperative humeral fractures in the era of reverse arthroplasty, short stems, and stemless arthroplasty.

Proximal Humeral Replacement With Osteoarticular Allograft Prosthetic Composite in Failed Revision Total Elbow Arthroplasty With Marked Bone Loss.

Total elbow arthroplasty (TEA) procedures are becoming more prevalent with an associated increase in revision procedures. Revision TEA in the setting of marked bone loss poses a challenge for the treating surgeon. We present a viable surgical option for patients with extensive proximal humeral bone loss treated with proximal humerus osteoarticular allograft prosthetic composites prepared with intact rotator cuff, pectoralis, and deltoid soft tissue attachments along with a rehabilitative protocol and follow up. Revision techniques involving the use of strut allografts and allograft prosthetic composites have previously been described in the distal humerus, but none to our knowledge have been published regarding composite allograft replacement of the proximal humerus in in combination with a TEA.

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

ObjectiveTo 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.MethodsWe 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.ResultsFifty-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).ConclusionrTSA 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.

Oncological and Functional Outcomes in Joint-sparing Resections of the Proximal Femur for Malignant Primary Bone Tumors.

Joint-sparing resections (JSR) of the proximal femur allow for preservation of the proximal femoral growth plate and native hip joint, but whether this offers fewer complications or better function and longevity of the reconstruction remains unknown. In this study, we compared the functional outcomes of pediatric patients with bone sarcomas undergoing JSR of the proximal femur with intercalary allograft (ICA) reconstruction to those undergoing proximal femoral resections (PFR) with allograft-prosthetic composite (APC) reconstructions. We retrospectively reviewed all patients undergoing JSR with ICA reconstruction and PFR with APC reconstructions between 1995 and 2013 at a tertiary pediatric referral center. Primary outcomes included major and minor complications and secondary outcomes included the need for a secondary procedure, presence of local or distant relapse, survival status, and the presence of pain and ambulatory status (limp, assistive device, highest level of function). We assessed differences in outcomes using the Fisher exact and Wilcoxon rank-sum tests. Eight patients underwent a JSR and ICA reconstruction, while 7 patients underwent a PFR with APC reconstruction. Median patient follow-up was 60.4 months (interquartile range: 36.8 to 112.9) Patients undergoing JSR and ICA reconstruction were younger than patients undergoing PFR with APC reconstruction (7.7 vs. 11.7 y, P=0.043); however, we found no other statistically significant differences in patient demographics. There were no statistically significant differences in primary or secondary outcomes between the study groups; however, patients who underwent JSR with ICA had more major complications (62.5% vs. 42.9%, P=0.29) and a lower rate of minor complications (25% vs. 28.6%, P=0.22). Treatment of proximal femoral bone sarcomas in pediatric and adolescent patients remains a challenging enterprise. JSR with ICA reconstruction in the proximal femur, when feasible, may provide a similar function and risk of intermediate-term major and minor complications when compared with PFR with APC reconstruction. Further long-term studies are required to determine the impact of the native femoral head retention with respect to revision rates. Level III, retrospective comparative study.

Resurfaced allograft-prosthetic composite for distal femur reconstruction in children with bone tumor.

Reconstruction of the distal femur in children following resection of bone sarcoma is challenging. The main problem in children is the small size of bone and a possible limb-length discrepancy at the end of skeletal growth secondary to the loss of the physes. We reported the results of a new surgical technique for distal femur reconstruction after bone tumor resection in children. We analyzed 5 patients with distal femoral sarcomas who underwent intra-articular resection and reconstruction with resurfaced allograft-prosthetic composite at a mean follow-up of 70 months. There were 2 males and 3 females, with a mean age of 10 years (range 8-12) at the time of the diagnosis. All patients were affected by high-grade osteosarcoma. The patients' medical records were reviewed for clinical and functional outcomes as well as post-operative complications. The functional evaluation of the patients was done at the end of the follow-up using Musculoskeletal Tumor Society scoring system. The minimal follow-up was 24 months. At the last follow-up, 4 patients were continuously disease-free. We excluded one patient who died of disease secondary to lung metastases 16 months after the surgery. Complications occurred in 2 of 4 patients at 17 months and 24 months, respectively. One patient developed deep infection who required the removal of the original reconstruction and, once the infection was treated, the patient underwent reconstruction with an expandable prosthesis. An allograft fracture occurred in another of the 4 patients at 24 months after the first surgery, thus the original reconstruction was removed and the patient underwent reconstruction with modular prosthesis. In the two patients who retained the original reconstruction at the time of their latest follow-up, the mean implant survival time was 70 months. These patients had an excellent MSTS score (29.5 points) and walked without support or limitations with an active knee range of motion of > 90° and complete active extension of the knee. No degenerative changes of the articular surface of the proximal tibia and the patella were observed at the time of the last follow-up. Growth of the physis of the proximal tibia was observed in all the patients during follow-up and no angular deformity of the joint was observed. The limb discrepancy was 4 cm and 2 cm, respectively. Resurfaced allograft-prosthetic composite may represent an alternative surgical technique for distal femur reconstruction in children with bone sarcomas. Although its success is limited by high risk of complications, resurfaced allograft-prosthetic composite seems to be a viable option to preserve the bone stock and the physis of the proximal tibia in selected young patients, minimizing a potential limb-length discrepancy at the end of the skeletal growth.

What Is the Implant Survivorship and Functional Outcome After Total Humeral Replacement in Patients with Primary Bone Tumors?

Total humeral replacement is an option to reconstruct massive bone defects after resection of locally advanced bone tumors of the humerus. However, implant survivorship, potential risk factors for implant revision surgery, and functional results of total humeral replacement are poorly elucidated because of the rarity of the procedure. We asked: (1) What is the revision-free implant and overall limb survivorship after total humerus replacement? (2) What factors are associated with implant revision surgery? (3) What is the functional outcome of the procedure as determined by the Musculoskeletal Tumor Society (MSTS) score and the American Shoulder and Elbow Surgeons (ASES) score? Between August 1999 and December 2018, 666 patients underwent megaprosthetic reconstruction after resection of a primary malignant or locally aggressive/rarely metastasizing tumor of the long bones at our department. In all, 23% (154) of these patients had a primary tumor located in the humerus. During the study, we performed total humeral replacement in all patients with a locally advanced sarcoma, in patients with pathological fractures, in patients with skip metastases, or in patients with previous intralesional contaminating surgery, who would have no sufficient bone stock for a stable implant fixation for a single joint megaprosthetic replacement of the proximal or distal humerus. We performed no biological reconstructions or reconstructions with allograft-prosthetic composites. As a result, 5% (33 of 666) of patients underwent total humerus replacement. Six percent (2 of 33) of patients were excluded because they received a custom-made, three-dimensionally (3-D) printed hemiprosthesis, leaving 5% (31) of the initial 666 patients for inclusion in our retrospective analysis. Of these, 6% (2 of 31) had surgery more than 5 years ago, but they had not been seen in the last 5 years. Median (interquartile range) age at the time of surgery was 15 years (14 to 25 years), and indications for total humeral replacement were primary malignant bone tumors (n = 30) and a recurring, rarely metastasizing bone tumor (n = 1). All megaprosthetic reconstructions were performed with a single modular system. The implanted prostheses were silver-coated beginning in 2006, and beginning in 2010, a reverse proximal humerus component was used when appropriate. We analyzed endoprosthetic complications descriptively and assessed the functional outcome of all surviving patients who did not undergo secondary amputation using the 1993 MSTS score and the ASES score. The median (IQR) follow-up in all survivors was 75 months (50 to 122 months), with a minimum follow-up period of 25 months. We evaluated the following factors for possible association with implant revision surgery: age, BMI, reconstruction length, duration of surgery, extraarticular resection, pathological fracture, previous intralesional surgery, (neo-)adjuvant radio- and chemotherapy, and metastatic disease. The revision-free implant survivorship at 1 year was 77% (95% confidence interval 58% to 89%) and 74% (95% CI 55% to 86%) at 5 years. The overall limb survivorship was 93% (95% CI 75% to 98%) after 1 and after 5 years. We found revision-free survivorship to be lower in patients with extraarticular shoulder resection compared with intraarticular resections (50% [95% CI 21% to 74%] versus 89% [95% CI 64% to 97%]) after 5 years (subhazard ratios for extraarticular resections 4.4 [95% CI 1.2 to 16.5]; p = 0.03). With the number of patients available for our analysis, we could not detect a difference in revision-free survivorship at 5 years between patients who underwent postoperative radiotherapy (40% [95% CI 5% to 75%]) and patients who did not (81% [95% CI 60% to 92%]; p = 0.09). The median (IQR) MSTS score in 9 of 13 surviving patients after a median follow-up of 75 months (51 to 148 months) was 87% (67% to 92%), and the median ASES score was 83 (63 to 89) of 100 points, with higher scores representing better function. Total humeral replacement after resection of locally advanced bone tumors appears to be associated with a good functional outcome in patients who do not die of their tumors, which in our study was approximately one- third of those who were treated with a resection and total humerus prosthesis. However, the probability of early prosthetic revision surgery is high, especially in patients undergoing extraarticular resections, who should be counseled accordingly. Still, our results suggest that if the prosthesis survives the first year, further risk for revision appears to be low. Future studies should reexamine the effect of postoperative radiotherapy on implant survival in a larger cohort and evaluate whether the use of soft tissue coverage with plastic reconstructive surgery might decrease the risk of early revisions, especially in patients undergoing extraarticular resections. Level III, therapeutic study.

Proximal humerus reconstruction in orthopedic oncology.

Proximal humeral reconstructive options following radical resection of proximal humeral primary and metastatic bone malignancies have evolved over time. With the relatively recent advent of the reverse total shoulder (RTSA), this technique has been increasingly employed in this setting over hemiarthroplasty techniques. An array of options, including proximal humeral allograft-prosthetic composites (including both RTSA and hemiarthroplasty), megaprostheses, and osteoarticular allografts, is reviewed from the perspective of their indications, techniques, complications, and published results. An extensive case-based pictorial presentation illustrates these options.