In proximal humerus reconstructions, osteoarticular massive allograft (OA) allows a biologic reattachment of tendineous structures of the host providing stability and functional recovery. Allograft-prosthesis composites (APC) are more technically demanding, but functional advantages with new prosthetic design are expected with lower fracture and failure rate with time. We compared the outcome of patients treated with OA reconstruction (group A) and patients treated with an APC (group B) after humerus resection for bone tumours.

Thirty six patients treated between 1996 and 2009 were included in the study (18 group A; 18 group B). The diagnosis was a malignant bone tumour in 28 cases, an aggressive benign bone tumour in 6 and a bone metastasis in 2. Three total humerus resections were performed (two in group A and one in group B). Three different type of prosthesis were used (conventional, reverse and resurfacing). In group A, at an average follow-up of 66 months (2-116), 16 patients were continuously disease free.

Ten patients (56%) had no complication; in 6 cases (33%) we observed a fracture of the graft and in 3 cases (17%) a pseudoarthrosis. In group B, at an average follow up of 44 months (3-164), 16 patients were continuously disease free.

Thirteen patients (72%) had no complication, in 2 cases (11%) stem loosening, in 2 cases (11%) dislocation, in 1 case pseudoarthrosis and in 1 case resorption and detachment of allograft's great tuberosity was observed. Functional outcome was evaluated using MSTS scoring system: a mean score of 24 (13-30) in group A and 23 (15-27) in group B was observed.

In our experience, proximal humerus APC showed functional results comparable to OA allograft with lower complication rate.

In conclusion, in biologic reconstruction of the proximal humerus, APC seems to provide a more reliable solution than OA allograft at long term

Aim

While the association of surgery and radiation therapy in high grade Soft Tissue Sarcoma (STS) of extremities is considered the “golden standard”, there is not international agreement regarding type, timing, overall dose of radiation, and size, site and histology of tumours to be irradiated. A similar consideration is about low grade STS. The aim of our paper is critically reconsider our experience, trough a retrospective analysis of 15 years experience. This in order to propose a perspective protocol of treatment of high and low grade STS, in order to minimize the late complication rate.

Modular endoprostheses are commonly used for reconstruction of proximal tibia defects after bone tumor resection and patellar tendon reattachment directly on the prosthesis represent an issue frequently ending in extension lag. Allograft-prosthesis composite implants theoretically provide the advantages of prosthetic implants (joint stability, mechanical resistance and long term durability) and the advantages of massive allograft reconstruction (bone stock mantainance and biologic reattachment of patellar tendon). From 1997 to 2007 19 patients (mean age: 39±16 years old) underwent proximal tibia oncologic intra-articular resection with wide margins. Primary diagnosis included giant cell tumor, osteosarcoma, chondrosarcoma and a failed osteoarticular allograft in 10, 4, 3 and 2 patients respectively. Tibial resection length was 10.4±3.4 cm in 18 knees. In one patient with chondrosarcoma the entire tibia was resected. Three patients received preoperative and postoperative chemotherapy, one only postoperative.

Reconstruction was performed with an allograft-prosthesis composite implant and direct suture of the host patellar tendon to the allograft one. Fresh frozen allograft and modular Link prosthesis were used for reconstruction. Five to six weeks of knee immobilization in extension followed the operation. A transient peroneal nerve palsy was observed in three patients. Two patients with a stiff knee underwent an open release after less than one year from index surgery. One patient had a local recurrence from osteosarcoma and underwent an above knee amputation. No patient developed distant metastasis at follow-up.

After 59±37 months none of the patients had implant revision for mechanical complications. One patient had 2-stage implant revision for deep infection. A minor allograft resorption with aseptic drain was observed in one patient who underwent surgical debridement. One other patient had a moderate allograft resorption. Knee flexion was 96±12 degrees. All the patients but two could reach complete knee extension and only two had a minor extensor lag (less than 15 degrees).

In conclusion intrarticular tibia resection and allograft-prosthesis composite replacement ensures satisfactory oncologic and functional results at a mid-term follow-up.

Sternal resection is commonly performed for primary and metastatic chest wall tumours involving the sternum or the ribs near the sternum and, in case of wide resections, it is necessary to restore the stability of the chest wall. We analyze our experience with emphasis on surgical management and survival. From 2001 to 2007, 16 patients underwent surgical resection of the sternum for malignant lesions: 10 (62.5%) primary lesions (chondorsarcoma n=8; osteosarcoma n=2) and 6 (37.5%) secondary lesions (4 local recurrence from breast cancer and 2 metastases). We performed 12 partial resections (resected area from 65 to 20 %), 2 subtotal resections (about 90% of total area) and 1 total resection. Chest wall stability was obtained by prosthetic material, rigid and non rigid, and muscolar flaps. As non rigid material we used a polytetrafluoroethylene patch (Gore-tex Dual Mesh Plus) while replacement after total sternectomy was performed using a new rigid system of mould-able titanium connecting bars and rib clips (Strasbourg Thoracic Osteosyntheses System, Medxpert, GMbH). Prosthetic material was combined in 3 cases with a latissimus dorsi muscolar flap, in 1 case with a vertical rectus abdominis muscolar flap, in 12 with a pectoralis major flap. There was no perioperative mortality or significant morbidity. All patients were extubated within 24 hours after operation. At a mean follow-up of 44.1 months (range 82–14), 5 years actuarial survival for primary tumours was 85%, while 3 years actuarial survival after resection of secondary tumours was 39% (median 20,5 months). In case of primary lesion wide resection with tumour-free margins is necessary to minimize local recurrence and to contribute to long-term survival; reconstruction with a rigid system composed of mould-able titanium bars and rib clips allows to plan extensive demolition minimizing the risk of chest wall instability. In metastatic disease surgery can provide good palliation, although survival is poor.