Osteoarticular Reconstruction Research Articles

Functional Laboratory Assessment After Oncologic Shoulder Joint Resections

A laboratory evaluation was undertaken to assess the shoulder range of motion and distal strength after oncologic resection and reconstruction involving the shoulder joint and to compare these functional parameters based on potentially important variables. Inclusion in the study was limited to 32 patients with bone tumors of the proximal humerus or scapula treated surgically by resection of the shoulder joint including the proximal humerus from 1976 through 1992. Active shoulder range of motion and isometric elbow extension and forearm supination strength are significantly less after surgery in patients with greater amounts of bony resection and with resection of the deltoid. Patients who had a modified Tikhoff-Linberg resection were able to achieve 10 degrees to 15 degrees greater shoulder motion in each direction than were patients who had the classic procedure including complete scapulectomy. However, elbow flexion and extension strength and forearm pronation strength were greater for the patients with the classic resection. Osteoarticular allografts as a reconstructive alternative provide as a group the best shoulder motion and overall distal upper extremity strength, but these reconstructions were performed only when the rotator cuff muscles and deltoid were able to be reconstructed. Diminishing elbow strength was seen with longer followup in the patients with osteoarticular reconstructions, corresponding temporally to subchondral collapse observed on radiographs. Range of shoulder motion except rotation was just as good for allograft vascularized fibular arthrodeses as for the osteoarticular allografts, but strength was significantly less with the arthrodeses.

Massive allografts in the treatment of osteosarcoma and Ewing sarcoma in children and adolescents.

A retrospective review was performed of the results of all allograft reconstructions that had been done after the resection of an osteosarcoma or an Ewing sarcoma in a skeletally immature patient between 1982 and 1989 at The Hospital for Sick Children in Toronto. There were twenty-six patients. Six reconstructions were intercalary, sixteen were resection arthrodeses, three followed resection of a bone segment including the epiphysis (osteoarticular reconstruction), and one was a replacement of the entire humerus. Resection arthrodesis about the knee was performed with a smooth intramedullary rod and with one growth plate left intact. Six procedures were performed in the upper extremity. Excluding the patients who died, the average duration of follow-up was five years and three months. Twenty-one of the twenty-six patients had reached skeletal maturity at the time of follow-up. Eighteen (69 per cent) of the patients had a good or excellent result, four (15 per cent) had a fair result, and four had a failure. Twenty patients (77 per cent) had at least one complication (other than a limb-length discrepancy), and fourteen (54 per cent) sustained at least one fracture of the allograft. Fifteen patients who had had a reconstruction in the lower extremity had survived with survival of the allograft at the time of the latest follow-up. A limb-length discrepancy of at least two centimeters developed in nine of the fifteen patients. Five were managed with a contralateral epiphyseodesis, and one of them had an unsuccessful attempt at limb-lengthening as well. The patients who had a limb-length discrepancy of more than three centimeters at the time of follow-up had been significantly younger (p < 0.05) at the time of the reconstruction than those who had a smaller discrepancy. Three allografts (12 per cent), two of which were implanted early in the series, became infected. Soft-tissue coverage is of paramount importance for the prevention of infection, and we now routinely perform primary muscle (gastrocnemius or latissimus dorsi) transfers when dealing with an inadequate muscle envelope. Twelve patients were followed for more than four years (average, six years and seven months); they had no complications other than increased limb-length discrepancy and one subluxation of the shoulder after the first four years following the reconstruction. Although the rate of complications is higher than in adults, allograft reconstruction remains a useful option for the management of skeletally immature individuals.(ABSTRACT TRUNCATED AT 400 WORDS)

The use of a bone allograft for reconstruction after resection of giant-cell tumor close to the knee.

The results of bone-allograft reconstruction after the resection of giant-cell tumor close to the knee were reviewed in fifty-two patients (fifty-five allografts), who had been followed for a mean of seven years (range, two to twenty-four years). One giant-cell tumor was graded as stage 1; twenty, as stage 2; and thirty-one, as stage 3. Three reconstructions were repeated transplants that were done after the failure of a previous transplant. Ten allograft reconstructions were intercalary and were combined with an arthrodesis of the knee, and forty-five were osteoarticular. Major complications included infection (after three reconstructions), resorption of the graft (six), collapse of the articular surface (two), fracture (two), and recurrence (one). According to the criteria described by Mankin et al. for functional analysis, forty-two (76 per cent) of the extremities had a result that was considered to be excellent or good. Radiographic evaluation according to the system of the Musculoskeletal Tumor Society showed a mean score of 72 per cent for osteoarticular reconstructions, and of 86 per cent for intercalary reconstructions.

Reconstruction for defects of the proximal part of the femur using allograft arthroplasty.

One of the most difficult problems in orthopaedic oncology is reconstruction after resection of a tumor of the proximal end of the femur. In order to achieve a wide margin about a primary or secondary malignant neoplasm of bone, it is often necessary to resect not only the hip joint and fifteen or more centimeters of the proximal part of the femur, but also the surrounding envelope of soft tissue. In some patients, little is left but the sciatic and femoral nerves and vessels. Since 1971, we have done reconstructions in forty-four patients, using an allograft and an implant or else an osteoarticular graft alone to replace the proximal end of the femur. Twenty-eight of these reconstructions were performed in patients who had had a malignant tumor and were followed for two to fifteen years postoperatively. Fifteen of the patients had only an osteoarticular graft, and thirteen had an allograft and a prosthesis (nine Austin Moore, two bipolar, and two long-stem total hip replacements). The average length of the femoral segment was 18.4 centimeters; the longest one measured thirty-one centimeters. Using an evaluation system of functional end-results that includes failures as a result of recurrence of the tumor, we recorded approximately 70 per cent excellent and good results for both groups. When the two failures that were due to recurrence of the tumor were omitted from the statistics (in order to evaluate the allograft procedure more fully), the successful results increased to about 80 per cent. In general, the patients who had an osteoarticular reconstruction fared less well than did those who had an allograft and a prosthesis, but the series were not quite comparable. The major complications were metastases in nine patients (five of whom died), infection in five, and fracture of the allograft in six. Restoration of the reconstruction was possible for most of the patients who had a problem that was not related to the tumor, and only one patient required an amputation for recurrent tumor. Despite the many difficulties, we think that an allograft, with or without a prosthetic implant, should be given primary consideration as a means of reconstruction of the limb when resection of a tumor necessitates resection of a long segment of the proximal end of the femur.