Outcomes of major musculoskeletal oncological reconstructions using prolene mesh-a retrospective analysis from a tertiary referral centre

BackgroundAdequate reconstruction of the soft tissue defect following resection of bone tumors is challenging. Prolene mesh, despite being a useful tool, is not widely used due to the fear of deep infection. The aim of this study was to evaluate the functional outcome and complications of using a Prolene mesh in oncological reconstructions.MethodsA retrospective study was conducted in bone tumor patients with soft tissue reconstruction using Prolene mesh between January 2017 and June 2019. Functional evaluation was done using MSTS 93 score. Complications were recorded and were classified as mechanical (dislocation and extension lag) or biological failure (wound problems and deep infection). Comparison was performed between groups with and without biological failure to identify predictive variables.ResultsOf 116 patients, 68 were males and 48 were females, with median age of 22.5 years. Thirty nine patients had tumors of proximal tibia, 23 of proximal femur, 25 of proximal humerus, 24 of pelvis, and five tumors at other sites. Approximately two-thirds (62.9%) of our patients underwent endoprosthetic reconstruction while the rest underwent either biological or cement spacer reconstructions. Excellent or good functional outcomes were reported in 98.3% patients as per MSTS 93 scoring. Complications were noted in 22 patients (18.9%), of which 16 had biological failure, with four patients requiring debridement and mesh removal. Dislocation of prosthesis occurred in 2 patients of proximal femur replacement. Overall re-surgery rate was 5.1% (6 patients). There was no statistically significant difference between the groups with or without biological failure with respect to demographics, site of tumor, type of procedure, blood loss, duration of surgery and history of chemotherapy.ConclusionProlene mesh is a useful tool to reconstruct the soft tissue defects following bone tumor resections. It is readily available, reliable and provides reproducible results, with no added risk of wound complications.     

Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures

Background

Osteoporosis may complicate surgical fixation and healing of proximal humerus fractures and should be assessed preoperatively. Peripheral quantitative CT (pQCT) and the Tingart measurement are helpful methods, but both have limitations in clinical use because of limited availability (pQCT) or fracture lines crossing the area of interest (Tingart measurement). The aim of our study was to introduce and validate a simple cortical index to assess the quality of bone in proximal humerus fractures using AP radiographs.

Questions/purposes

We asked: (1) How do the deltoid tuberosity index and Tingart measurement correlate with each other, with patient age, and local bone mineral density (BMD) of the humeral head, measured by pQCT? (2) Which threshold values for the deltoid tuberosity index and Tingart measurement optimally discriminate poor local bone quality of the proximal humerus? (3) Are the deltoid tuberosity index and Tingart measurement clinically applicable and reproducible in patients with proximal humerus fractures?

Methods

The deltoid tuberosity index was measured immediately above the upper end of the deltoid tuberosity. At this position, where the outer cortical borders become parallel, the deltoid tuberosity index equals the ratio between the outer cortical and inner endosteal diameter. In the first part of our study, we retrospectively measured the deltoid tuberosity index on 31 patients (16 women, 15 men; mean age, 65 years; range, 22–83 years) who were scheduled for elective surgery other than fracture repair. Inclusion criteria were available native pQCT scans, AP shoulder radiographs taken in internal rotation, and no previous shoulder surgery. The deltoid tuberosity index and the Tingart measurement were measured on the preoperative internal rotation AP radiograph. The second part of our study was performed by reviewing 40 radiographs of patients with proximal humerus fractures (31 women, nine men; median age, 65 years; range, 22–88 years). Interrater (two surgeons) and intrarater (two readings) reliabilities, applicability, and diagnostic accuracy were assessed.

Results

The correlations between radiograph measurements and local BMD (pQCT) were strong for the deltoid tuberosity index (r = 0.80; 95% CI, 0.63–0.90; p < 0.001) and moderate for the Tingart measurement (r = 0.67; 95% CI, 0.42–0.83; p < 0.001). There was moderate correlation between patient age and the deltoid tuberosity index (r = 0.65; p < 0.001), patient age and the Tingart measurement (r = 0.69; p < 0.001), and patient age and pQCT (r = 0.73; p < 0.001). The correlation between the deltoid tuberosity index and the Tingart measurement was strong (r = 0.84; p < 0.001). We determined the cutoff value for the deltoid tuberosity index to be 1.44, with the area under the curve = 0.87 (95% CI, 0.74–0.99). This provided a sensitivity of 0.88 and specificity of 0.80. For the Tingart measurement, we determined the cutoff value to be 5.3 mm, with the area under the curve = 0.83 (95% CI, 0.67–0.98), which resulted in a sensitivity of 0.81 and specificity of 0.85. The intraobserver reliability was high and not different between the Tingart measurement (intraclass correlation coefficients [ICC] = 0.75 and 0.88) and deltoid tuberosity index (ICC = 0.88 and 0.82). However, interobserver reliability was higher for the deltoid tuberosity index (ICC = 0.96; 95% CI, 0.93–0.98) than for the Tingart measurement (ICC = 0.85; 95% CI, 0.69–0.93).The clinical applicability on AP radiographs of fractures was better for the deltoid tuberosity index (p = 0.025) because it was measureable on more of the radiographs (77/80; 96%) than the Tingart measurement (69/80; 86%).

Conclusions

The deltoid tuberosity index correlated strongly with local BMD measured on pQCT and our study evidence shows that it is a reliable, simple, and applicable tool to assess local bone quality in the proximal humerus. We found that deltoid tuberosity index values consistently lower than 1.4 indicated low local BMD of the proximal humerus. Furthermore, the use of the deltoid tuberosity index has important advantages over the Tingart measurement regarding clinical applicability in patients with proximal humerus fractures, when fracture lines obscure the Tingart measurement landmarks. However, further studies are needed to assess the effect of the deltoid tuberosity index measurement and osteoporosis on treatment and outcome in patients with proximal humerus fractures.

Level of Evidence

Level IV, diagnostic study.     

Evaluation of a reconstruction reverse shoulder for tumour surgery and tribological comparision with an anatomical shoulder arthroplasty

Purpose

The functional results after reconstruction of the proximal humerus in tumour surgery are poor. Therefore, a reversed proximal humerus replacement was developed in our institution (MUTARS humerus inverse). A low degree of wear on the polyethylene is required because of the patients’ youth and demands on shoulder function. A special type of polyethylene with shock-absorbing properties has been developed to minimise polyethylene wear in the MUTARS inverse proximal humerus replacement. We compared the tribological properties of an anatomical shoulder prosthesis (CAPICA) with the new reversed proximal humerus replacement (MUTARS humerus inverse).

Methods

Both prostheses were tested up to 5 × 10⁶ cycles. Every millionth cycle the surface was inspected and a gravimetric measurement was performed. A measurement of surface roughness was done before testing and after 5 × 10⁶ cycles.

Results

In both prostheses after 5 × 10⁶ cycles there were no major defects, such as delamination, observed. In the reversed proximal humerus replacement abrasion of 28 mg/10⁶ cycles was detected. The mean abrasion of the anatomical prosthesis was 9.28 mg/ 10⁶ cycles.

Conclusion

The glenoid component of the first reversed humerus replacement (MUTARS humerus inverse) has wear properties comparable to those of normal reversed shoulder prostheses. This is important, as this type of prosthesis is used in young patients after resection of bone tumours, with a good functional outcome. It can, therefore, be expected that the revision rate due to wear will be as high as in patients with normal reversed shoulder prostheses.     

肩关节肿瘤切除和重建后的患肢功能观察

目的 肩关节肿瘤切除后,探讨不同重建方式的患肢长期功能。方法回顾性分析32例肩关节肿瘤保肢患者的临床资料。重建方式包括：8例一期肩关节融合,7例假体异体骨复合物,6例功能性间隔物,5例未行重建或悬吊术,3例假体,2例带血管蒂腓骨和1例异体骨。结果23例生存患者平均随访81个月。不同重建方式的功能评分分别为：一期肩关节融合为87％,主动运动优良,肩部有力;假体异体骨复合物为79％,间隔物为66％,未重建为85％,假体为60％和带血管蒂腓骨为73％。结论肩关节肿瘤的重建方式是根据切除范围和患者的实际需要来选择。如外展肌群无法重建,肩关节融合的功能良好,肩部有力;如果外展肌群可以重建,假体异体骨复合物功能较好。     

Osteosarcoma of the proximal humerus: long-term results with limb-sparing surgery

The purpose of the current study was to analyze the long-term oncologic and functional results and complications associated with limb-sparing surgery and endoprosthetic reconstruction for 23 patients with osteosarcoma of the proximal humerus. There was one Stage IIA lesion, 18 Stage IIB lesions, and four Stage III lesions in this study group. Twenty-two patients were treated with an extraarticular resection that included the deltoid and rotator cuff and one patient was treated with an intraarticular resection that spared the shoulder abductors. In all these patients, the proximal humerus was reconstructed with a cemented endoprosthetic replacement that was stabilized via a technique of static suspension (Dacron tapes) and dynamic suspension (muscle transfers). At latest followup (median, 10 years), 15 patients (65%) were alive without evidence of disease. There were no local recurrences. Prosthetic survival was 100% for the 15 survivors. The Musculoskeletal Tumor Society upper extremity functional score ranged from 24 to 27 (80%-90%). All shoulders were stable and pain-free. Elbow and hand function were preserved in all patients. The most common complication was a transient neurapraxia (n = 8). En bloc extraarticular resection and endoprosthetic reconstruction is a safe and reliable method of limb-sparing surgery for patients with high-grade extracompartmental osteosarcoma of the proximal humerus.     

定制型肱骨近端假体结合人工补片重建肩关节的疗效分析

目的 探讨肱骨近端骨肿瘤保肢术中使用人工补片重建盂肱关节囊的手术方法及其对稳定肩关节、预防术后肱骨头脱位的效果.方法 2006年2月至2009年1月,回顾性分析接受定制型肱骨近端假体结合聚丙烯非降解性人工补片重建肩关节的患者12例,男7例,女5例;年龄21～55岁,平均38岁.肿瘤类型:骨巨细胞瘤9例,骨肉瘤1例,软骨肉瘤2例.9例骨巨细胞瘤患者中3例为Campanacci Ⅱ期,6例为Campanacci Ⅲ期;1例骨肉瘤患者为Enneking ⅡB期;2例软骨肉瘤患者均为Enneking Ⅱ A期.采用国际骨与软组织肿瘤协会(MSTS)功能评估标准评价术后肩关节功能.结果 患者均获得随访,随访时间24～52个月,平均35个月.手术出血量150～500 ml,平均254 ml;手术时间150～200 min,平均172 min.术后患者肩关节前屈20°～60°,平均41°;外展20°～70°,平均42°.MSTS评分为53%～77%,平均66%.术后无一例患者出现臂丛损伤、切口感染及假体脱位;随访期间无一例患者出现局部复发、远处转移或死亡.结论 使用聚丙烯非降解性人工补片重建盂肱关节囊可显著减少肱骨近端骨肿瘤保肢术后肱骨头假体脱位的发生,便于周围软组织的附着和长入.

Abstract：

Objective To investigate the surgical technique,postoperative function and dislocation incidence of proximal humerus reconstruction with metallic endoprostheses and polypropylene knitted nonabsorbable mesh after proximal humeral tumor resection.Methods Twenty patients with proximal humeral tumor were retrospectively reviewed.They were performed proximal humerus reconstruction with proximal humeral prosthesis and polypropylene knitted non-absorbable mesh from February 2006 to January 2009.There were 5 women and 7 men with a mean age of 38 years(range,21-55 years)at the time of surgery,and giant cell tumor in 9 patients(including Campanacci Ⅱ for 3,Campanacci Ⅲ for 6),osteosarcoma in 1(Enneking ⅡB).and chondrosarcoma in 2 (Enneking ⅡA).The operative time,blood loss,and shoulder movement postoperation were analysed.According to the assessment system by MSTS,the function of limb after surgery was assessed.Results Patients were followed clinically and radiographically for a minimum of 24 months (mean,35 months;range,24-52 months).The mean operative time was 172 min(range,150-200min).The mean blood loss was 254 ml (range,150-500 ml).There were no shoulder dislocations at final follow-up.The mean shoulder flexion was 41°(range,20°-60°)and mean shoulder abduction was 42°(range,20°-70°).The mean postoperative functional assessment score of the limb was 66%(range,53%-77%).None of the Datients had a wound infection,traction neuropraxia or died after the surgical procedure.Conclnsion The data suggests that the use of a polypropylene knitted non-absorbable mesh for proximal humerus reconstruction may reduce dislocations and facilitate soft tissue attachment after tumor resection.     

Treatment of a Humeral Metastasis with a Composite Allograft-Prosthetic Reconstruction

Abstract Background: The treatment of impending pathological fractures and symptomatic metastases involving the upper extremity articulations remains a challenge for the trauma surgeon. While the goals of treatment of bony metastases are clearly defined (early restoration of function, excellent pain control and minimal surgical trauma), these are not always easy to realize in upper extremity periarticular metastases. Case Study: A patient with a metastasis of a mediastinal nerve sheet tumor, involving the proximal 12 cm of the right humerus, including the whole head and both the tubercles, is described. A complete resection up to the level of the deltoid insertion was performed. In order to restore maximal function, the shoulder joint was reconstructed using a reversed total shoulder prosthesis. A fresh frozen cadaver proximal humerus was used as an allograft to obtain a secure stabilization of the prosthesis. Short-term results were very promising with restoration of ADL (activities of daily living) functionality within 3 months. Abduction and elevation > 100°, exorotation up to 20° and gluteal endorotation could be performed at that time. Conclusion: To the authors knowledge, this report is the first to describe reconstruction of the shoulder joint using a reversed shoulder prosthesis-allograft construction in case of a resection for malignancy.     

Proximal humerus reconstruction after tumour resection: biological versus endoprosthetic reconstruction

The purpose of this study was to compare the outcome, complications and survival of the three most commonly used surgical reconstructions of the proximal humerus after transarticular tumour resection. Between 1985 and 2005, 38 consecutive proximal humeral reconstructions using allograft-prosthesis composite (n = 10), osteoarticular allograft (n = 13) or a modular tumour prosthesis (n = 14) were performed in our clinic. The mean follow-up was ten years (1–25). Of these, 27 were disease free at latest follow-up (mean 16.8 years) and ten had died of disease. The endoprosthetic group presented the smallest complication rate of 21% (n = 1), compared to 40% (n = 4) in the allograft-prosthesis composite and 62% (n = 8) in the osteoarticular allograft group. Only one revision was performed in the endoprosthetic group, in a case of shoulder instability. Infection after revision (n = 3), pseudoarthrosis (n = 2), fracture of the allograft (n = 3) and shoulder instability (n = 4) were the major complications of allograft use in general. Kaplan-Meier analysis showed a significantly better implant survival for the endoprosthetic group (log-rank p = 0.002). At final follow-up the Musculoskeletal Tumour Society scores were an average of 72% for the allograft-prosthetic composite (n = 7, median follow-up 17 years), 76% for the osteoarticular allograft (n = 3, 19 years) and 77% for the endoprosthetic reconstruction (n = 10, 5 years) groups. An endoprosthetic reconstruction after transarticular proximal humeral resection resulted in the lowest complication rate, highest implant survival and comparable functional results when compared to allograft-prosthesis composite and osteoarticular allograft use. We believe that the surgical approach that best preserves the abductor mechanism and provides sufficient surgical exposure for tumour resection contributed to better functional results and glenohumeral stability in the endoprosthetic group.     

Epidemiology of proximal femoral fractures

IntroductionWith increasing age, the incidence of proximal femoral fractures increases steadily. Although the different treatments are investigated frequently, little is known about the seasonal variation and predisposing factors. The purpose of this study is to investigate the epidemiology, the impact of femoroacetabular impingement, as well as the presence of osteoarthritis.MethodsWe performed a retrospective review of all patients with pertrochanteric, lateral and medial femoral neck fractures between 2012 and 2019. Inclusion criteria consisted of patients older than 18 years old who presented with isolated proximal femoral fractures without any congenital or hereditary deformity. For analysis, we assessed the demographics, season at time of accident, Kellgren-Lawrence score and corner edge (CE) angle.ResultsIn total, 187 patients were identified at a mean age of 75.1 ± 12.9 years old. Females consisted of 54.5% of this cohort. Most commonly, patients tend to present in winter with pertrochanteric fractures whereas no seasonal variation was found for medial femoral neck fractures. Significant correlations between season and age (regression coefficient −0.050 ± 0.021; p < 0.05) were identified. In medial neck fractures, the Gardner score was lower and Kellgren-Lawrence score higher for both female than males (p < 0.05). Patients with lateral neck fractures were significantly younger at 68.6 ± 12.5 years old (p < 0.05). In pertrochanteric fractures, the Kellgren-Lawrence score was significantly higher at 2.1 ± 0.8 (p < 0.05) with higher CE angle at 43.0 ± 7.6° (p = 0.14).ConclusionWith increasing incidences of proximal femoral fractures, it is essential to recognize potential risk factors. This allows for development of new guidelines and algorithm that can aid in diagnosis, prevention, and education for patients.     

Correlation of CT Values and Bone Mineral Density in Elderly Chinese Patients with Proximal Humeral Fractures

ObjectiveTo investigate the correlation between computed tomography (CT) values and bone mineral density (BMD) in elderly Chinese patients with proximal humeral fractures.MethodsThis was a single‐center retrospective study involving 166 elderly patients with proximal humeral fractures between January and June 2015 in our hospital. Following the inclusion and exclusion criteria, 89 patients were finally enrolled in this study. The spiral CT scanning was performed on these patients, and the CT images were obtained by using MIMICS software. The CT values in axial, coronal, and sagittal images of healthy proximal humeri were measured using a circular region of interest (ROI) by Image J. The bone mineral density (BMD) of the lumbar spine and femoral neck was measured using dual‐energy X‐ray absorptiometry (DXA). Spearman rank correlation methods were used for analysis of the association between the proximal humerus average CT value (CT_Mean) and the lumbar spine as well as femoral neck BMD in patients with proximal humeral fractures, or osteoporotic patients.ResultsAmong the included 89 patients, there were 26 males and 63 females, 69% and 84% of whom were diagnosed with osteoporosis, respectively. The lumbar spine and femoral neck BMD and the CT_Mean of the proximal humerus were higher in males than females with proximal humeral fractures (P < 0.05). This gender difference was also found in the osteoporotic patient population (P < 0.05). The Spearman rank correlation method showed that the lumbar spine and femoral neck BMD was closely related to the proximal humeral CT_Mean in males (r = 0.877, P = 0.000; r = 0.832, P = 0.000; respectively) and females (r = 0.806, P = 0.000; r = 0.616, P = 0.000; respectively) with proximal humeral fractures, as well as osteoporotic male (r = 0.745, P = 0.000; r = 0.575, P = 0.000; respectively) and female (r = 0.613, P = 0.000; r = 0.629, P = 0.000; respectively) patients.ConclusionsThe CT value of the proximal humerus is a rapid and accurate method by which bone quality can be assessed in elderly patients with proximal humeral fractures. Moreover, the CT value of the proximal humerus is an alternative measurement of BMD that can guide surgeons in selecting the appropriate internal fixation material.     

人工补片肩关节囊重建防治肿瘤型人工肱骨头假体脱位

目的 探讨肿瘤型肱骨头假体置换采用人工补片行肩关节囊重建的方法和临床应用价值.方法 6例肱骨近端肿瘤患者中,初次置换4例,假体脱位翻修2例,置换时将Prolene网状补片一端固定在肩胛盂边缘关节囊上,包绕肱骨头后,另一端固定在肿瘤假体为重建肩袖预制的槽孔内,重建肩关节囊,稳定肩关节.结果 6例均获随访,时间12～28(21 2±64)个月,假体无脱位.肩关节疼痛VAS评分从术前平均7分±0 8分降至术后平均3 1分±1 1分.术后肩关节活动度前屈平均68 9°±14 7°,后伸平均27 5°±8°,外展平均72 7°±16 6°,肱骨旋转活动度平均22 5°±94°.结论 人工补片肩关节囊重建能帮助稳定肩关节,其网状结构还便于术中肩袖及肱骨驱动肌肉的重建,并使肿瘤型肱骨头假体保留良好活动度.     

Is the Combination of Convex Compression for the Proximal Thoracic Curve and Concave Distraction for the Main Thoracic Curve Using Separate-rod Derotation Effective for Correcting Shoulder Balance and Thoracic Kyphosis?

BackgroundPosterior correction of the proximal thoracic curve in patients with adolescent idiopathic scoliosis has been recommended to achieve shoulder balance. However, finding a good surgical method is challenging because of the small pedicle diameters on the concave side of the proximal thoracic curve. If the shoulder height can be corrected using screws on the convex side, this would appear to be a more feasible approach.Questions/purposesIn patients with adolescent idiopathic scoliosis, we asked: (1) Is convex compression with separate-rod derotation effective for correcting the proximal thoracic curve, shoulder balance, and thoracic kyphosis? (2) Which vertebrum is most appropriate to serve as the uppermost-instrumented vertebra? (3) Is correction of the proximal thoracic curve related to the postoperative shoulder balance?MethodsBetween 2015 and 2017, we treated 672 patients with scoliosis. Of those, we considered patients with elevated left shoulder, Lenke Type 2 or 4, or King Type V idiopathic scoliosis as potentially eligible. Based on that, 17% (111 of 672) were eligible; 5% (6 of 111) were excluded because of other previous operations and left-side main thoracic curve, 22% (24 of 111) were excluded because they did not undergo surgery for the proximal thoracic curve with only pedicle screws, 21% (23 of 111) were excluded because the proximal thoracic curve was not corrected by convex compression and separate rod derotation, and another 3% (3 of 111) were lost before the minimum study follow-up of 2 years, leaving 50% (55 of 111) for analysis. During the study period, we generally chose T2 as the uppermost level instrumented when the apex was above T4, or T3 when the apex was T5. Apart from the uppermost-instrumented level, the groups did not differ in measurable ways such as age, sex, Cobb angles of proximal and main thoracic curves, and T1 tilt. However, shoulder balance was better in the T3 group preoperatively. The median (range) age at the time of surgery was 15 years (12 to 19 years). The median follow-up duration was 26 months (24 to 52 months). Whole-spine standing posteroanterior and lateral views were used to evaluate the improvement of radiologic parameters at the most recent follow-up and to compare the radiologic parameters between the uppermost-instrumented T2 (37 patients) and T3 (18 patients) vertebra groups. Finally, we analyzed radiologic factors related to shoulder balance, defined as the difference between the horizontal lines passing both superolateral tips of the clavicles (right-shoulder-up was positive), at the most recent follow-up.ResultsConvex compression with separate-rod derotation effectively corrected the proximal thoracic curve (41° ± 11° versus 17° ± 10°, mean difference 25° [95% CI 22° to 27°]; p < 0.001), and the most recent shoulder balance changed to right-shoulder-down compared with preoperative right-shoulder-up (8 ± 11 mm versus -8 ± 10 mm, mean difference 16 mm [95% CI 12 to 19]; p < 0.001). Proximal thoracic kyphosis decreased (13° ± 7° versus 11° ± 6°, mean difference 2° [95% CI 0° to 3°]; p = 0.02), while mid-thoracic kyphosis increased (12° ± 8° versus 18° ± 6°, mean difference -7° [95% CI -9° to -4°]; p < 0.001). Preoperative radiographic parameters did not differ between the groups, except for shoulder balance, which tended to be more right-shoulder-up in the T2 group (11 ± 10 mm versus 1 ± 11 mm, mean difference 10 mm [95% CI 4 to 16]; p = 0.002). At the most recent follow-up, the correction proportion of the proximal thoracic curve was better in the T2 group than the T3 group (67% ± 10% versus 49% ± 22%, mean difference 19% [95% CI 8% to 30%]; p < 0.001). In the T2 group, T1 tilt (6° ± 4° versus 6° ± 4°, mean difference 1° [95% CI 0° to 2°]; p = 0.045) and shoulder balance (-14 ± 11 mm versus -7 ± 9 mm, mean difference -7 mm [95% CI -11 to -3]; p = 0.002) at the most recent follow-up improved compared with those at the first erect radiograph. The most recent shoulder balance was correlated with the correction proportion of the proximal thoracic curve (r = 0.29 [95% CI 0.02 to 0.34]; p = 0.03) and change in T1 tilt (r = 0.35 [95% CI 0.20 to 1.31]; p = 0.009).ConclusionUsing the combination of convex compression and concave distraction with separate-rod derotation is an effective method to correct proximal and main thoracic curves, with reliable achievement of postoperative thoracic kyphosis and shoulder balance. T2 was a more appropriate uppermost-instrumented vertebra than T3, providing better correction of the proximal thoracic curve and T1 tilt. Additionally, spontaneous improvement in T1 tilt and shoulder balance is expected with upper-instrumented T2 vertebrae. Preoperatively, surgeons should evaluate shoulder balance because right-shoulder-down can occur after surgery in patients with a proximal thoracic curve.Level of EvidenceLevel III, therapeutic study.     

Postoperative radial nerve palsy in humeral shaft nonunion reconstruction: Can the lateral paratricipital approach prevent this common complication?

BackgroundPostoperative radial nerve palsy (RNP) is a well-known complication of nonunion reconstruction of the humerus. The purpose of the current study is to determine if the surgical approach for nonunion reconstruction of the humerus influences the rate of postoperative radial nerve palsy.MethodsA retrospective case-control study of all humeral shaft and extraarticular distal humerus nonunion reconstructions performed between January 1, 2004, and August 31, 2021, was conducted. Patients included were over 18 years of age, had a non-pathologic humerus fracture nonunion and had intact radial nerve function prior to nonunion reconstruction. Exclusion criteria consisted of nonunions involving the proximal humerus, intraarticular fractures, and reconstructive treatment procedures with either intramedullary nail or external fixation methods. Perioperative variables were recorded and analyzed in regard to the development of postoperative RNP. A subgroup analysis was performed to assess the interaction of significant variables on the development of postoperative RNP.ResultsThe overall rate of postoperative RNP in this series was 6/53 (11%). However, no cases of postoperative radial nerve palsy were observed in patients who underwent nonunion reconstruction with a lateral paratricipital approach. A new RNP was seen in 4/9 (44%) of those patients who underwent a triceps splitting approach, which was significantly higher than those utilizing either an anterolateral approach (2/28, 7%) or a lateral paratricipital approach (0/16, 0%, p = 0.007).Discussion and conclusionOur data suggests that the lateral paratricipital exposure decreases the risk of radial nerve injury with nonunion reconstruction of the humerus. The lateral paratricipital exposure offers the benefit of radial nerve exploration, decompression, neurolysis and protection prior to fracture manipulation and instrumentation. This study shows conventional approaches may predispose patients to a high rate of postoperative RNP, similar to that in the literature.     

What Are the Functional Results and Complications From Allograft Reconstruction After Partial Hemipelvectomy of the Pubis?

BackgroundIn patients undergoing hemipelvectomies including resection either of a portion of the pubis or the entire pubis from the symphysis to the lateral margin of the obturator foramen while sparing the hip (so-called Dunham Type III hemipelvectomies), reconstructions typically are not performed given the preserved continuity of the weightbearing axis and the potential complications associated with reconstruction. Allograft reconstruction of the pelvic ring may, however, offer benefits for soft tissue reconstruction of the pelvic floor and hip stability, but little is known about these reconstructions.Questions/purposes(1) What is the postoperative functional status after allograft reconstruction of Type III pelvic defects? (2) What are the rates of hernia, infection, and hip instability?MethodsIn this case series, we reviewed all patients with Type III pelvic resections (with or without anterior acetabular wall resections) who underwent allograft reconstruction between 2005 and 2013 at one center (N = 14). During the period in question, reconstruction was the general approach used in patients undergoing these resections; during that time, three other patients were treated without reconstruction as a result of either surgeon preference or the patient choosing to not have reconstruction after a discussion of the risks and benefits. Of the 14 patients treated with reconstruction, complete followup was available at a minimum of 1 year in 11 (other than those who died before the end of the first year; median, 19 months; range 16–70 months among those surviving), one was lost to followup before a year, and two others had partial telephone or email followup. Patient demographics, disease status, functional status, and complications were recorded. For a portion of the cohort (four patients) later in the series, we used a novel technique for anterior acetabular wall reconstruction using the concave cartilaginous surface of a proximal fibula allograft; the others received either a long bone (humerus or femur) or hemipelvis graft. Seven patients died of disease; two had local recurrence, and five died of metastatic disease.ResultsAll patients remained ambulatory Pain at 12 months after surgery was reported as none in five, mild in two, moderate in two, and severe in one. Operative complications included infection in two, symptomatic hernia in one, hip instability in one, dislocated total hip arthroplasty on the first postoperative day in one, and graft failure in one.ConclusionsAllograft reconstruction after Type III pelvic resections can provide functional reconstruction of the pelvic ring, pelvic floor, and, in certain patients with partial anterior acetabular resections, the resected anterior acetabulum. This has implications in preventing the occurrence of hernia and hip instability in this patient population that is classically not reconstructed, although longer-term outcomes in a larger number of patients would help to better delineate this because infection, hernia, hip instability, and graft nonunion still remain concerns with this approach. The most important unanswered question remains whether, on balance, any benefits that may accrue to these patients as the result of reconstruction are offset by a relatively high likelihood of undergoing secondary or revision surgery.

Level of Evidence

Level IV, therapeutic study.