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

BACKGROUND: 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. QUESTIONS/PURPOSES: 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? METHODS: 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. RESULTS: 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. CONCLUSION: 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 OF EVIDENCE: Level III, therapeutic study.

Reconstruction using a frozen autograft for a skull and humeral lesion of synchronous multicentric osteosarcoma after undergoing successful neoadjuvant chemotherapy: a case report and review of the literature.

BACKGROUND: Synchronous multicentric osteosarcoma (SMOS) is a rare disease characterized by simultaneous multicentricity of intraosseous osteosarcoma without visceral involvement. SMOS, including a skull lesion, which occurs relatively rarely, and reconstruction using a frozen autograft after the excision of a lesion of SMOS has been infrequently reported previously. CASE PRESENTATION: We report an 18-year-old girl with SMOS, with lesions located in the left distal femur, right proximal humerus, and left occipital bone. Her major complaint was pain and swelling around the left knee joint. Asymptomatic lesions of the humerus and skull bone were detected on a systemic bone scan. No visceral organ metastasis was observed. A biopsy of the distal femoral lesion revealed osteosarcoma. Based on the histological findings, multiple bone lesions, and absence of visceral lesion, the clinical diagnosis of SMOS was made. After five courses of neoadjuvant chemotherapy with a regimen of doxorubicin and cisplatin, reconstruction using a tumor prosthesis following wide excision of the left distal femur was performed, and total necrosis was histologically observed in the retracted specimen. Following three cycles of adjuvant chemotherapy, tumor excision and reconstruction with a frozen autograft treated with liquid nitrogen was conducted for both lesions of the humerus and skull, rather than tumor prosthesis or synthetics, in order to retain a normal shoulder function, and to obtain a good cosmetic and functional outcome after treatment of the skull lesion. Further adjuvant chemotherapy could not be administered after the completion of the surgical treatment for all lesions because the adverse events due to chemotherapy were observed. At over 5 years after the diagnosis, she remains clinically disease-free. CONCLUSIONS: An early correct diagnosis, the proper management of chemotherapy, and surgical treatment for all lesions are essential for achieving a good clinical outcome, even in SMOS including a skull lesion. By performing reconstruction using a frozen autograft for a proximal humeral lesion and a skull lesion after confirming the good histological efficacy of neoadjuvant chemotherapy for the primary lesion, the excellent function of the shoulder joint and a good cosmetic outcome at the site of the skull lesion was acquired without complications or recurrence.

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

BACKGROUND: The treatment of severe proximal humeral bone loss (PHBL) secondary to tumor resection or failed arthroplasty is challenging. We evaluated the outcomes and complications of reconstruction with reverse shoulder-allograft prosthesis composite (RS-APC), performed with or without tendon transfer. METHODS: An RS-APC procedure was performed in 25 consecutive patients with severe PHBL (>4 cm): 12 after failed reverse shoulder arthroplasty, 5 after failed hemiarthroplasty for fracture, 6 after failed mega-tumor prosthesis placement, and 2 after tumor resection. The median length of humeral bone loss or resection was 8 cm (range, 5-23 cm). Humeral bone graft fixation was obtained with a long monobloc reverse stem and a "mirror step-cut osteotomy," without plate fixation. Nine infected shoulders underwent a 2-stage operation with a temporary cement spacer. In addition, 9 patients (36%) underwent an associated L'Episcopo procedure. The median follow-up duration was 4 years (range, 2-11 years). RESULTS: Overall, 76% of patients (19 of 25) were satisfied. In 8 patients (32%), a reoperation was needed. At last follow-up, we observed incorporation at the allograft-host junction in 96% of the cases (24/25); partial graft resorption occurred in 3 cases and severe in 1. The median adjusted Constant score was 53% (range 18-105); Subjective Shoulder Value, 50% (range 10%-95%). Additional tendon transfers significantly improved active external rotation (20° vs. 0°, P < .001) and forward elevation (140° vs. 90°, P = .045). CONCLUSIONS: (1) Shoulder reconstruction with RS-APC provides acceptable shoulder function and high rates of graft survival and healing. (2) Additional L'Episcopo tendon transfer (when technically possible) improves active shoulder motion. (3) The use of a long monobloc (cemented or uncemented) humeral reverse stem with mirror step-cut osteotomy provides a high rate of graft-host healing, as well as a limited rate of graft resorption, and precludes the need for additional plate fixation. (4) Although rewarding, this reconstructive surgery is complex with a high risk of complications and reoperations. The main advantages of using an allograft with a reverse shoulder arthroplasty (compared with other reconstruction options) are that this type of reconstruction (1) allows restoration of the bone stock, thus improving prosthesis fixation and stability, and (2) gives the possibility to perform a tendon transfer by fixing the tendons on the bone graft to improve shoulder motion.

Platelet-rich plasma enhances the repair capacity of muscle-derived mesenchymal stem cells to large humeral bone defect in rabbits.

Mesenchymal stem cell-based therapy is a highly attractive strategy that promotes bone tissue regeneration. The aim of the present study was to evaluate the combination effect of muscle-derived mesenchymal stem cells (M-MSCs) and platelet-rich plasma (PRP) on bone repair capacity in rabbits with large humeral bone defect. Precise cylindrical bone defects of 10 mm diameter and 5 mm depth were established in rabbit humeral bones, which were unable to be repaired under natural conditions. The rabbits received treatment with M-MSCs/PRP gel, M-MSCs gel, or PRP gel, or no treatment. The bone tissue regeneration was evaluated at day 0-90 after surgery by HE morphological staining, Lane-Sandhu histopathological scoring, tetracycline detection, Gomori staining and micro-computed tomography. Beyond that, Transwell assay, CCK8 assay, Western blot analysis and ALP activity detection were performed in M-MSCs in vitro with or without PRP application to detect the molecular effects of PRP on M-MSCs. We found that the repair effect of M-MSCs group or PRP group was limited and the bone defects were not completely closed at post-operation 90 d. In contrast, M-MSCs/PRP group received obvious filling in the bone defects with a Lane-Sandhu evaluation score of 9. Tetracycline-labeled new bone area in M-MSCs/PRP group and new mineralized bone area were significantly larger than that in other groups. Micro-computed tomography result of M-MSCs/PRP group displayed complete recovery of humeral bone at post-operation 90 d. Further in vitro experiment revealed that PRP significantly induced migration, enhanced the growth, and promoted the expression of Cbfa-1 and Coll I in M-MSCs. In conclusion, PRP application significantly enhanced the regeneration capacity of M-MSCs in large bone defect via promoting the migration and proliferation of M-MSCs, and also inducing the osteogenic differentiation.

Osteochondral Reconstruction of the Capitellum.

Osteochondritis dissecans (OCD) of the capitellum is a relatively rare condition, with a higher incidence in adolescents who participate in repetitive overhead sports. The surgical treatment approach for this uncommon problem has varied from microfracture, loose body removal, abrasion chrondroplasty, lesion fixation, osteochondral allograft transplantation surgery, and osteochondral autologous transplantation surgery. The purpose of this study is to present the authors' preferred surgical technique for the treatment of unstable OCD lesions of the capitellum with osteochondral autologous transplantation surgery using autograft from the ipsilateral knee.

Reverse vascularized bone graft of the lateral distal humerus for non-union of the radial neck fracture: anatomical study and case report.

A few treatment options for radial neck non-union have been reported, including radial head excision, radial head replacement, and internal fixation with a bone graft. We describe a new treatment for radial neck non-union using a reverse vascularized bone graft of the lateral distal humerus. In the anatomical study, the posterior radial collateral artery (PRCA) was dissected in eight fresh-frozen cadaver arms. The number of branches from the PRCA to the humerus was determined, and the distances from these branches to the lateral epicondyle of the humerus were measured. We then used this information to create a reverse vascularizedhumeral bone graft, which was used to treat non-union of a radial neck fracture in a 73-year-old female. There were two to four PRCA branches (mean: 3.3) entering the bone. The distance from the branches to the lateral epicondyle of the humerus ranged from 2.5 to 10.8 cm. The mean distances from the most proximal and distal PRCA branches to the lateral epicondyle of the humerus were 7.6 cm and 3.4 cm, respectively. The case of non-union of a radial neck fracture was successfully treated with a reverse vascularized humeral bone graft. There were no major complications, and radiographs showed bony union at 8 weeks postoperatively. This procedure may become a new option for the treatment of non-union of fractures of the radial head and neck, as it enables preservation of the radial head, which is an important structure in the elbow and proximal radioulnar joints.

Open reduction and internal fixation with bone grafts for comminuted mason type II radial head fractures.

BACKGROUND: The use of bone graft for the radial head fractures has been previously described and occasionally used by other authors.This is the first paper, to my knowledge, dealing with the relevant issue about the importance that the use of an autologous bone graft can have on the radial head fractures. METHODS: From July 2010 to July 2014, 20 consecutive patients who underwent open reduction and internal fixation for a closed Mason type II radial head fracture were retrospectively reviewed. Patients with Mason type I, III, simple type II, and comminuted type II fractures treated without bone grafting were excluded. A clinical examination and radiographic evaluation were performed. The overall functional result was evaluated using the Mayo Elbow Performance Score (MEPS). The Broberg and Morrey classification was used to evaluate traumatic arthritis. RESULTS: The average follow-up duration was 31 months (range, 24-50 months). Bone union of the radial head fracture was achieved in all patients at an average of 13.5 weeks (range, 12-17 weeks). Postoperative radiographs showed no cases of postsurgical ligamentous instability, necrosis of the radial head, or internal fixation failure. The mean range of motion of the affected elbow was 128° ± 8.4° in flexion, 14.5° ± 11.1° in extension, 68.7° ± 14.1° in pronation, and 65.2° ± 18.2° in supination. The mean MEPS was 92 ± 7.9 points (range, 80-100); the outcome was excellent (90-100 points) in 13 patients and good (75-89 points) in 7 patients. The MEPS tended to be higher in patients with an isolated fracture (p = 0.016). Based on the Broberg and Morrey classification for radiographic assessment of post-traumatic arthritis, 15 elbows had no evidence of degenerative changes (grade 0), and 5 elbows had grade 1 changes. CONCLUSION: Although radial head fractures may not be amenable to internal fixation, our findings suggest that open reduction and internal fixation with an autogenous bone graft from the lateral epicondyle of the humerus provides satisfactory elbow function in patients with comminuted Mason type II radial head fractures.

Impaction autografting: bone-preserving, secure fixation of a standard humeral component.

BACKGROUND: When fixed with bone ingrowth, a tight diaphyseal press fit, or cement, the humeral component of a shoulder arthroplasty may present problems of malposition, stress shielding, or periprosthetic fracture or difficulty with removal at revision arthroplasty. We have avoided the need for these fixation methods by using impaction cancellous autografting of the humeral stem, minimizing contact between the prosthetic stem and the humeral cortex. This study presents the radiographic survivorship of impaction-autografted humeral implants using component subsidence as the primary endpoint. METHODS: We reviewed 286 primary anatomic shoulder arthroplasties having an average follow-up of 4.9 ± 2.7 years. Initial postoperative radiographs and minimum 2-year follow-up radiographs were evaluated by 3 observers to assess subsidence. RESULTS: Two different implants (Humeral Replacement Prosthesis [HRP] and Global Advantage prosthesis) were used. Of 286 stems, 267 (93.4%) had not subsided. The Global Advantage prosthesis had a subsidence-free survival rate of 98.5% at 5 years. The stiffer-stemmed HRP used early during the study had a higher rate of subsidence compared with the currently used Global Advantage stem (hazard ratio, 5.6; P = .001). Radiolucent lines of 2 mm or greater were less common for the Global Advantage prosthesis than for the HRP in each of 7 zones (P < .001). Total shoulder arthroplasty was associated with a higher rate of subsidence compared with hemiarthroplasty (hazard ratio, 2.6; P = .12). CONCLUSIONS: Impaction autografting provides a secure, durable, bone-preserving means of humeral component fixation in anatomic shoulder arthroplasty.

Isolation, expansion and differentiation of mesenchymal stromal cells from rabbits' bone marrow / Isolamento, expansão e diferenciação de celulas tronco mesenquimais oriundas da medula óssea de coelhos

Tissue engineering has been a fundamental technique in the regenerative medicine field, once it permits to build tri-dimensional tissue constructs associating undifferentiated mesenchymal cells (or mesenchymal stromal cells - MSCs) and scaffolds in vitro. Therefore, many studies have been carried out using these cells from different animal species, and rabbits are often used as animal model for in vivo tissue repair studies. However, most of the information available about MSCs harvesting and characterization is about human and murine cells, which brings some doubts to researchers who desire to work with a rabbit model in tissue repair studies based on MSCs. In this context, this study aimed to add and improve the information available in the scientific literature providing a complete technique for isolation, expansion and differentiation of MSCs from rabbits. Bone marrow mononuclear cells (BMMCs) from humerus and femur of rabbits were obtained and to evaluate their proliferation rate, three different culture media were tested, here referred as DMEM-P, DMEM´S and α-MEM. The BMMCs were also cultured in osteogenic, chondrogenic and adipogenic induction media to prove their multipotentiality. It was concluded that the techniques suggested in this study can provide a guideline to harvest and isolate MSCs from bone marrow of rabbits in enough amount to allow their expansion and, based on the laboratory experience where the study was developed, it is also suggested a culture media formulation to provide a better cell proliferation rate with multipotentiality preservation.

A engenharia de tecidos tem sido uma técnica fundamental no campo da medicina regenerativa, uma vez que permite a criação de peças teciduais tri-dimensionais por meio da associação de células mesenquimais indiferenciadas (ou células estromais mesenquimais - CEMs) e moldes de biomateriais in vitro. Assim, muitos estudos têm sido realizados utilizando estas células oriundas de diferentes espécies animais, e os coelhos são frequentemente utilizados como um modelo animal para estudos in vivo de reparação tecidual. No entanto, a maioria das informações disponíveis sobre a coleta e caracterização de CEMs referem-se às células humanas e murinas, o que traz algumas dúvidas para pesquisadores que desejam trabalhar com coelhos em estudos de reparação de tecidos baseados em CEMs. Neste contexto, o presente estudo objetivou contribuir e aprimorar as informações disponíveis na literatura científica fornecendo uma técnica completa para o isolamento, expansão e diferenciação das MSCs de coelhos. Células mononucleares da medula óssea (CMMOs) do úmero e fêmur de coelhos foram obtidas e, para avaliar sua taxa de proliferação, três meios de cultura diferentes foram testadas, aqui referidos como DMEM-P, DMEM'S e α-MEM. As CMMOs também foram cultivadas em meios de indução osteogênico, condrogênico, e linhagens adipogênico para provar a sua multipotencialidade. Concluiu-se que as técnicas sugeridas neste estudo podem fornecer um guia para a coleta e isolamento de CEMs da medula óssea de coelhos em quantidade suficiente para permitir a sua expansão e, com base na experiência de laboratório onde o estudo foi desenvolvido, é também sugerida uma formulação de meio de cultivo para proporcionar uma melhor taxa de proliferação celular com preservação da multipotencialidade.

Bone Graft Substitute Provides Metaphyseal Fixation for a Stemless Humeral Implant.

Stemless humeral fixation has become an alternative to traditional total shoulder arthroplasty, but metaphyseal fixation may be compromised by the quality of the trabecular bone that diminishes with age and disease, and augmentation of the fixation may be desirable. The authors hypothesized that a bone graft substitute (BGS) could achieve initial fixation comparable to polymethylmethacrylate (PMMA) bone cement. Fifteen fresh-frozen human male humerii were randomly implanted using a stemless humeral prosthesis, and metaphyseal fixation was augmented with either high-viscosity PMMA bone cement (PMMA group) or a magnesium-based injectable BGS (OsteoCrete; Bone Solutions Inc, Dallas, Texas) (OC group). Both groups were compared with a control group with no augmentation. Initial stiffness, failure load, failure displacement, failure cycle, and total work were compared among groups. The PMMA and OC groups showed markedly higher failure loads, failure displacements, and failure cycles than the control group (P<.01). There were no statistically significant differences in initial stiffness, failure load, failure displacement, failure cycle, or total work between the PMMA and OC groups. The biomechanical properties of magnesium-based BGS fixation compared favorably with PMMA bone cement in the fixation of stemless humeral prostheses and may provide sufficient initial fixation for this clinical application. Future work will investigate the long-term remodeling characteristics and bone quality at the prosthetic-bone interface in an in vivo model to evaluate the clinical efficacy of this approach.

Tuberosity healing after reverse shoulder arthroplasty for acute proximal humerus fractures: the "black and tan" technique.

BACKGROUND: Reverse shoulder arthroplasty has seen increased use for management of complex proximal humeral fractures in the elderly. Recent evidence has shown that tuberosity healing leads to improved active range of motion and functional outcomes. The purpose of this study was to report on the radiographic and clinical outcomes of a consecutive series of patients having undergone reverse shoulder arthroplasty for fracture utilizing the "black and tan" method--a hybrid cementation-impaction grafting technique that uses autogenous cancellous bone graft to create an interface between the proximal cement mantle and the area of tuberosity repair. METHODS: Twenty-five patients (average age, 77 years; range, 63-88 years) were included in the analysis with a mean follow-up of 17 months. All patients underwent reverse shoulder arthroplasty for a complex proximal humerus fracture using the black and tan technique. RESULTS: The tuberosity healing rate was 88%. At final follow-up, mean active elevation was 117° ± 23°, mean abduction was 86° ± 16°, and mean external rotation was 29° ± 18°. External rotation strength averaged 4.9 ± 0.2. The Simple Shoulder Test and Single Assessment Numeric Evaluation scores averaged 7 and 76, respectively. The mean American Shoulder and Elbow Surgeons total score was 71; visual analog scale score for pain, 2; and visual analog scale score for function, 7. Of the 25 patients, 21 (84%) rated their satisfaction with the surgery as excellent or good. CONCLUSIONS: The black and tan technique together with standard suture repair and an implant with features that support tuberosity repair results in a high tuberosity healing rate with restoration of external rotation after reverse shoulder arthroplasty for fracture.

Stable fixation of the IBP humeral component implanted without cement in total elbow replacement: a radiostereometric analysis study of 16 elbows at two-year follow-up.

We determined the short-term clinical outcome and migration within the bone of the humeral cementless component of the Instrumented Bone Preserving (IBP) total elbow replacement in a series of 16 patients. There were four men and 12 women with a mean age at operation of 63 years (40 to 81). Migration was calculated using radiostereometric analysis. There were no intra-operative complications and no revisions. At two-year follow-up, all patients showed a significant reduction in pain and functional improvement of the elbow (both p < 0.001). Although ten components (63%) showed movement or micromovement during the first six weeks, 14 (88%) were stable at one year post-operatively. Translation was primarily found in the proximal direction (median 0.3 mm (interquartile range (IQR) -0.09 to 0.8); the major rotational movement was an anterior tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component continued to migrate during the second year, and one component could not be followed beyond three months because migration had caused the markers to break off the prosthesis. This study shows promising early results for the cementless humeral component of the IBP total elbow replacement. All patients had a good clinical outcome, and most components stabilised within six months of the operation.

Total sacrectomy for low-grade malignant peripheral nerve sheath tumour: a case report.

We report on a 58-year-old woman who underwent total sacrectomy and spinopelvic reconstruction for a low-grade malignant peripheral nerve sheath tumour involving the sacrum. One week later, she developed deep wound infection, and the entire spinopelvic reconstruction was removed. At the 36-month followup, the patient had no pain and was able to walk with a walking frame. There was no sign of recurrence or metastasis.

Long-term survival of proximal humerus allografts for reconstruction following resection of malignant bone tumours.

We previously reported early favourable results concerning allograft use in proximal humerus reconstruction following malignancy. We now present the long-term follow-up of patients who underwent tumour resection with massive humeral allograft reconstruction. This is a retrospective review of 8 consecutive patients who underwent massive proximal humeral allograft for primary or secondary bone tumours. The median age at first surgery was 41 years; the median followup is 11.1 years. The overall revision rate of the allografts was 75%. A total of 10 revision procedures were required in this cohort. Five-year survival for implants was 44%; at ten years no implants were intact. Five-year survival for patients was 88%; it was 60% at ten years. In our experience, proximal humerus allograft reconstruction was associated with a high complication rate and resulted in multiple revision procedures in the long-term. We no longer perform or recommend this procedure.

Reverse total shoulder arthroplasty for the management of failed shoulder arthroplasty with proximal humeral bone loss: is allograft augmentation necessary?

BACKGROUND: Patients undergoing revision shoulder arthroplasty frequently have deficient proximal humeral bone stock. Proximal humeral allograft has been recommended to augment reverse total shoulder arthroplasty (RTSA) to improve stability and function. This study reports the results of RTSA without proximal humeral allograft in patients with proximal humeral bone loss secondary to failed shoulder arthroplasty. MATERIALS AND METHODS: From 2005 to 2008, 251 patients were enrolled in a prospective RTSA cohort study. Significant humeral bone loss was demonstrated in 15 of 56 undergoing revision for failed arthroplasty. Average age was 67 years. Average bone loss measured 38.4 mm (range, 26-72 mm). Patients were followed up for a minimum of 2 years with American Shoulder and Elbow Surgeons (ASES), Subjective Shoulder Value (SSV), Constant Score (CS), and visual analog scale (VAS) pain scores, as well as self-reported satisfaction and radiographs. RESULTS: Patients demonstrated significant improvement in mean CS (23.0 to 44.2), ASES (38.2 to 68.3), ASES activities of daily living (7.0 to 15.9), SSV (19.2 to 75.8), and VAS pain (4.6 to 1.6) scores. Thirteen of 15 patients reported satisfaction (87%). Range of motion improved in forward flexion (38.3° to 103.2°) and external rotation (-0.5° to 11.9°). Radiographs demonstrated notching in 3 patients (20%), no humeral subsidence or loosening, and prosthetic fracture of 1 modular humeral stem. CONCLUSIONS: Use of RTSA for failed shoulder arthroplasty and deficient humeral bone stock provides a significant clinical benefit without the need for allograft augmentation. Monoblock humeral component use may diminish risk for prosthetic fracture.

Induced membrane technique for reconstruction after bone tumor resection in children: a preliminary study.

AIM: Segmental long-bone defect due to tumor resection remains a challenge to treat. The induced membrane technique is a new alternative for biological reconstruction. During the first stage, a cement spacer is inserted after bone resection and stabilisation. The cement spacer is removed during a second stage procedure performed after chemotherapy, and cortico-cancellous bone autograft was placed in the biological induced chamber. The aim of this study was to assess preliminary results in eight children. PATIENTS AND METHODS: This prospective study included six girls and two boys, with a mean age of 12.1 years (range 9.5 to 18) and treated for a mean 15 cm defect (range 10 to 22 cms) due to resection of osteosarcoma (n=4), Ewing sarcoma (n=3) and low grade sarcoma. All patients except one, were given pre- and postoperative chemotherapy. Surgery was performed for three patients with a distal femur tumor, two patients with a proximal tibial tumor and three patients who had proximal humerus, shaft of humerus and fibular tumors. Fixation was mainly performed with locking compression plate (n=4) and locked nail (n=2). The mean operating times for first and second step procedures were 4.8 and 4h respectively. The healing process was radiologically assessed. RESULTS: After a mean follow-up of 21.6 months (15 to 30), all patients were free of disease and seven had bony union. For the lower limb reconstructions, full weight bearing was possible after a mean of 116 days (range 90 to 150) following the second stage. Mean time to bone union was 4.8 months (1.5 to 10). The early Musculoskeletal Tumor Society (MSTS) score was 25.2/30 (range 20-30). Complications were: non-union (n=1), paradoxical graft resorption (n=1) requiring graft revision. CONCLUSION: This two stage procedure reduces the operating time during the first stage and it also reduces early complications. Rapid bone union is objectively obtained despite major bone resection and the patients receiving chemotherapy. SIGNIFICANCE: The induced membrane technique could be an excellent alternative for biological reconstruction after tumor resection in children.

Treatment of segmental bone and soft-tissue defects of the forearm with the free osteocutaneous lateral arm flap.

BACKGROUND: Complex defects of the forearm often require microvascular reconstruction with osteocutaneous free flaps to salvage the limb. In this review, we report our experience with the use of the free osteocutaneous lateral arm flap to reconstruct such defects in four patients. METHODS: Three male patients with osseous defects of the ulna and one defect of the radius with associated soft-tissue defects were treated with a free osteocutaneous lateral arm flap between 2004 and 2007. The indications for the procedure included posttraumatic osteitis (3) and bone with soft-tissue defects after trauma (1). We evaluated the patients with respect to postoperative results by evaluating the range of motion, pain, strength, and score on the disabilities of the arm, shoulder, and hand questionnaire. Donor-site morbidity was also documented. RESULTS: The average length of segmental bone defects was 5.75 cm. The average dimension of the skin paddle was 99.5 cm. The average duration of follow-up was 43.3 months. All bone flaps healed without nonunion; the fasciocutaneous flaps healed without complications. No problems related to microanastomoses were found. Functional results were very satisfactory; disabilities of the arm, shoulder, and hand questionnaire scores showed a median of 5.8 (0-10.8). All patients had returned to their preinjury occupations. CONCLUSION: This analysis demonstrates that the free osteocutaneous lateral arm flap is an effective treatment for combined segmental osseous and soft-tissue defects of the forearm that are caused by osteitis and trauma.

Cemented humeral surface replacement for a locked posterior fracture-dislocation: a case report.

Posterior fracture-dislocations of the shoulder are uncommon and challenging lesions. We present the case of a 76-year-old male patient who sustained a locked posterior humeral head fracture-dislocation during a convulsion. Because more than 40% of the articular surface was involved, preserving the head was not possible. We treated the fracture with a cemented humeral surface replacement. The patient demonstrated good shoulder function and no instability on short-term follow-up. Surface replacement may be a valuable treatment option for fracture-dislocations of the shoulder with articular surface involvement.

Biological reconstruction using massive bone allograft with intramedullary vascularized fibular flap after intercalary resection of humeral malignancy.

BACKGROUND: Reconstruction after excision of the humeral malignancy is a challenging issue for the reconstructive surgeon. The combined use of a fibular flap and allograft can provide a reliable reconstructive option. This article describes the authors' experience with this technique for the treatment of segmental bone defects after resection of humeral malignancy. METHODS: From 2005 to 2008, seven patients that had intercalary resection of humeral malignancy underwent reconstruction with an allograft and vascularized fibula construct. Patients were examined clinically and radiographically. RESULT: The average age at time of operation was 16.7 years. The mean follow-up time was 27.7 months. The average length of the resected humeral segment was 10.6 cm and that of the fibula flap was 13.1 cm. The average time of union of fibula was 20.7 weeks and for union of allograft was 26.3 weeks. Incorporation of the fibula into the allograft was seen in three patients. There were no allograft fractures and no infections. Three patients had surgery-related complications including a temporary radial nerve paralysis in 1, wound dehiscence in 1, and clawed toes in 1. The MSTS average score was 95.2% at final follow-up. CONCLUSIONS: Intramedullary fibular flaps in combination with massive allografts provide an excellent option for reconstruction of large bony defects after humeral malignancy extirpation. The viability of the fibula is a cornerstone in success of reconstruction that prevents allograft nonunion and result in decreased time to bone healing, leading to earlier patient recovery and return of function.