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.     

The use of cement in osteoarticular allografts for proximal humeral bone tumors

In a proximal humerus resection for a bone tumor, the use of an osteoarticular allograft is considered the best restoration of shoulder function. We retrospectively reviewed the outcomes of 31 patients who had an intraarticular resection of the proximal humerus for a bone tumor. Twenty-three of the allografts were filled with cement. The average followup was 5.3 years. Of the 31 patients with more than 24 months followup, seven had revision surgery or removal of the allograft. Kaplan-Meier analysis showed that the probability of survival of the reconstruction was 78% at 5 years. Fracture was the main complication in 11 patients (37%) of whom seven were in the noncemented group. Four of these patients had successful surgery for conversion to an allograft-prosthetic composite, whereas one patient had a new allograft. Allografts that were filled with cement had four fractures (18%); three were subchondral fractures discovered by routine CT scans. None of these patients had pain or needed revision surgery. Osteochondral allograft in proximal humerus replacement is a reliable reconstructive technique if the allograft is augmented by filling the intramedullary space with cement. Moreover, cement augmented allografts are less expensive and technically easier than allograft-prosthetic composites.     

Proximal Tibia Reconstruction After Bone Tumor Resection: Are Survivorship and Outcomes of Endoprosthetic Replacement and Osteoarticular Allograft Similar?

Background

The proximal tibia is one of the most challenging anatomic sites for extremity reconstructions after bone tumor resection. Because bone tumors are rare and large case series of reconstructions of the proximal tibia are lacking, we undertook this study to compare two major reconstructive approaches at two large sarcoma centers.

Questions/purposes

The purpose of this study was to compare groups of patients treated with endoprosthetic replacement or osteoarticular allograft reconstruction for proximal tibia bone tumors in terms of (1) limb salvage reconstruction failures and risk of amputation of the limb; (2) causes of failure; and (3) functional results.

Methods

Between 1990 and 2012, two oncologic centers treated 385 patients with proximal tibial resections and reconstruction. During that time, the general indications for those types of reconstruction were proximal tibia malignant tumors or bone destruction with articular surface damage or collapse. Patients who matched the inclusion criteria (age between 15 and 60 years old, diagnosis of a primary bone tumor of the proximal tibia treated with limb salvage surgery and reconstructed with endoprosthetic replacement or osteoarticular allograft) were included for analysis (n = 149). In those groups (endoprosthetic or allograft), of the patients not known to have reached an endpoint (death, reconstructive failure, or limb loss) before 2 years, 85% (88 of 104) and 100% (45 of 45) were available for followup at a minimum of 2 years. A total of 88 patients were included in the endoprosthetic group and 45 patients in the osteoarticular allograft group. Followup was at a mean of 9.5 (SD 6.72) years (range, 2–24 years) for patients with endoprosthetic reconstructions, and 7.4 (SD 5.94) years for patients treated with allografts (range, 2–21 years). The following variables were compared: limb salvage reconstruction failure rates, risk of limb amputation, type of failures according to the Henderson et al. classification, and functional results assessed by the Musculoskeletal Tumor Society system.

Results

With the numbers available, after competitive risk analysis, the probability of failure for endoprosthetic replacement of the proximal tibia was 18% (95% confidence interval [CI], 10.75–27.46) at 5 years and 44% (95% CI, 31.67–55.62) at 10 years and for osteoarticular allograft reconstruction was 27% (95% CI, 14.73–40.16) at 5 years and 32% (95% CI, 18.65–46.18) at 10 years. There were no differences in terms of risk of failures at 5 years (p = 0.26) or 10 years (p = 0.20) between the two groups. Fifty-one of 88 patients (58%) with proximal tibia endoprostheses developed a reconstruction failure with mechanical causes being the most prevalent (32 of 51 patients [63%]). A total of 19 of 45 osteoarticular allograft reconstructions failed (42%) and nine of 19 (47%) of them were caused by early infection. Ten-year risk of amputation after failure for endoprosthetic reconstruction was 10% (95% CI, 5.13–18.12) and 11% (95% CI, 4.01–22.28) for osteoarticular allograft with no difference between the groups (p = 0.91). With the numbers available, there were no differences between the groups in terms of the mean Musculoskeletal Tumor Society score (26.58, SD 2.99, range, 19–30 versus 27.52, SD 1.91, range, 22–30; p = 0.13; 95% CI, ?2,3 to 0.32). Mean extension lag was more severe in the endoprosthetic group than the osteoarticular allograft group: 13.56° (SD 18.73; range, 0°–80°) versus 2.41° (SD 5.76; range, 0°–30°; p < 0.001; 95% CI, 5.8–16.4).

Conclusions

Reconstruction of the proximal tibia with either endoprosthetic replacement or osteoarticular allograft appears to offer similar reconstruction failures rates. The primary cause of failure for allograft was infection and for endoprosthesis was mechanical complications. We believe that the treating surgeon should have both options available for treatment of patients with malignant or aggressive tumors of the proximal tibia. (S)he might consider an allograft in a younger patient to achieve better extensor mechanism function, whereas in an older patient or one with a poorer prognosis where return to function and ambulation quickly is desired, an endoprosthesis may be advantageous.

Level of Evidence

Level III, therapeutic study.

     

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。     

肱骨近端恶性肿瘤的保肢治疗

目的 探讨肱骨近端恶性肿瘤切除术后的重建方法。方法 36例肱骨近端恶性肿瘤,其中骨肉瘤 11例、软骨肉瘤 6例、皮质旁骨肉瘤及纤维肉瘤各 3例、原始神经外胚层瘤及恶性纤维组织细胞瘤各 2例、转移性骨肿瘤 5例、恶性骨巨细胞瘤 4例。骨肉瘤、原始神经外胚层瘤与恶性纤维组织细胞瘤患者均接受了新辅助化疗。肿瘤关节内切除 33例,关节外切除 3例。 21例采用异体半关节移植, 4例采用人工假体置换, 6例行游离锁骨移植, 5例行带骨膜血管蒂锁骨移植。结果 随访 6～ 118个月,平均 62.7个月。死亡 11例,局部复发 3例。按 Enneking功能评价标准, 21例采用异体半关节移植的患者,平均得分 24分; 4例人工假体置换的患者,平均得分 26分; 11例采用同侧锁骨重建肱骨近端的患者,平均得分 23分。结论 肱骨近端恶性肿瘤保肢手术的重建以人工假体置换和异体半关节移植为首选,儿童的保肢可选用同侧锁骨移植。保肢术后的功能与肩袖和肩外展肌的修复密切相关。     

Synthetic Mesh Improves Shoulder Function After Intraarticular Resection and Prosthetic Replacement of Proximal Humerus

BackgroundShoulder function often is limited after tumor resection and endoprosthetic replacement of the proximal humerus. This is partly attributable to the inability to reliably reattach rotator cuff tendons to the prosthesis and achieve adequate shoulder capsule repair with a metallic prosthesis. An option to attain these goals is to use synthetic mesh for the reconstruction, although the value of this method has not been well documented in the literature.Questions/purposesWe asked whether patients who had shoulder reconstruction using synthetic mesh had (1) better shoulder function; (2) improved ROM compared with shoulder reconstructions without mesh; and (3) more stable joints compared with those in patients with similar resections who had reconstructions without synthetic mesh.MethodsDuring a 5-year period, we performed 41 intraarticular resections with endoprosthetic reconstructions for malignancies in the proximal humerus meeting specified criteria to generate similarity in the study groups. Twelve patients (29%) were lost to followup before 24 months, leaving 29 patients available for review at a mean of 45 months (range, 24–70 months). This retrospective study compared 14 patients with soft tissue reconstruction that included synthetic mesh with 15 patients with soft tissue reconstruction without the use of synthetic mesh. The choice was made during consultation between the patient and surgeon, after reviewing the perceived advantages and disadvantages of each approach. A tumor band (ligament advanced reinforcement system) was used as synthetic mesh and wrapped around the prosthesis of the proximal humerus for soft tissue reconstruction in the reconstruction-with-mesh group. Study endpoints included the Musculoskeletal Tumor Society (MSTS) function scores, American Shoulder and Elbow Surgeons (ASES) score, shoulder ROM, and proximal migration of the humeral prosthesis.ResultsThe mean MSTS score for patients without synthetic mesh reconstruction was 20 ± 3 points (66%), whereas for patients with synthetic mesh reconstruction, the mean score was 24 ± 2 points (79%; p = 0.001). Patients with synthetic mesh reconstruction had a higher mean total ASES score (85 ± 1.1 points versus 72 ±1.7 points; p = 0.025), and better function for activities of daily living. They also had better ROM on mean active forward flexion (p = 0.020), abduction (p < 0.001), and external rotation (p < 0.001) than patients without synthetic mesh reconstruction. Proximal migration of the prosthesis was observed in five of 15 of patients in the group without synthetic mesh reconstruction and in none of those treated with synthetic mesh (p = 0.042).ConclusionsPatients with intraarticular resection and endoprosthetic replacement of the proximal humerus with reconstruction that included synthetic mesh had better shoulder function and ROM, and more stable joints than patients who had reconstruction without synthetic mesh. This result supports prior observations by others and it remains to be shown whether use of the ligament advanced reconstruction system is superior to other types of mesh or other types of reconstructions. Further investigation is needed but our results indicate that using mesh should be considered for patients with tumor resection and endoprosthetic replacement of the proximal humerus.

Level of Evidence

Level III, therapeutic study.     

Complex segmental elbow reconstruction after tumor resection

Twenty-three patients were reviewed retrospectively to determine their oncologic and functional outcomes after resection of 15 primary or eight metastatic tumors about the elbow between 1985 and 2000. The indications for resection were dictated by the histologic features of the tumor, location of the lesion, and extent of bone destruction. A total humeral reconstruction was done in 12 patients. Of this group, an endoprosthesis was used in seven patients and a total humeral allograft with a proximal humeral prosthesis and osteoarticular elbow reconstruction (allograft-prosthetic composite) was used in five patients. Eleven additional patients had a segmental total elbow replacement after resection of the distal humerus or proximal ulna. Local disease control was achieved in 17 patients (74%). Fourteen patients presented with (48%) or had (13%) distant metastasis develop, but only eight (35%) died of their disease. Periprosthetic lysis or allograft resorption was present in five patients (22%), and two (18%) humeral components of total elbow prostheses required revision for loosening. The mean Musculoskeletal Tumor Society functional score was 23 of 30 points (77%) in the 12 living patients followed up for a mean of 46 months (range, 24-124 months). It was 83% in patients with a segmental total elbow reconstruction and 71% in patients with a total humeral reconstruction. Aggressive limb salvage of the humerus or elbow or both provides a satisfactory functional outcome without jeopardizing overall survival.     

Functional outcomes and complications of reconstruction of the proximal humerus after intra‐articular tumor resection

Objective: To evaluate functional outcomes and complications of reconstruction of the proximal humerus after intra‐articular tumor resection. Methods: Twenty‐five patients who underwent Malawer I type resection and reconstruction of the proximal humerus for treatment of malignant or invasive benign tumors from August 1999 to August 2005 were evaluated. A variety of reconstructive procedures, including modular tumor prosthesis, osteoarticular allograft, and allograft‐prosthetic composite (APC), were performed after resection of tumor. Oncological and radiographic parameters were evaluated. The modified Musculoskeletal Tumor Society (MSTS) evaluation system was used to assess limb functional outcome. Results: The study group consisted of 10 male and 15 female patients, among which there were 20 malignant and 5 benign tumors. Restoration of shoulder function was achieved with a prosthesis in 6 patients, osteoarticular allograft in 12, and allograft‐prosthesis composite in 7. At a mean of 48 months follow‐up, 2 patients had died of disease. Two patients had local recurrence and 2 had metastatic disease. On the basis of the modified MSTS functional evaluation, the mean scores were 22.50 in the modular prosthesis group, 24.58 in the osteoarticular allograft group, and 27.00 in APC group, respectively. Joint instability and subluxation were serious complications affecting shoulder function in 10 patients. Conclusion: Reconstruction of the proximal humerus is an option that provides good relief of pain and preserves manual dexterity. Functional outcomes are better for APC and allograft than for modular prosthesis, due to retention of the rotation cuff. Complications in the APC group were less than in the allograft one.     

肢体大块骨缺损的大段同种异种骨关节移植

作者为３５例四肢恶性肿瘤切除后的骨缺损患者进行了大段同种异体骨移植重建，其中男性２３例，女性１２例。股骨下端和胫骨上端占６８．５％。骨肉瘤占４０％。所有病例均经术前、术后化疗。植骨材料来源于该院综合骨库。作者强调充分的术前准备，仔细选择匹配移植骨段，手术中注意设计骨膜油套和软组织袖套以利于骨愈合。本组病例随访５个月￣１０年，平均３年，其中无病存活者２５例，死亡６例，带病存活４例。部分患者于术后２年     

Osteoarticular and Total Elbow Allograft Reconstruction With Severe Bone Loss

Osteoarticular allograft reconstruction is an option in patients with massive periarticular elbow bone loss secondary to tumor surgery or trauma. Our consecutive series consisted of 18 patients with tumors and one patient with trauma. Reconstruction consisted of 16 hemiarticular allografts and three total elbow osteoarticular allografts; patients had a minimum followup of 2 years (mean, 9.9 years; range, 2-12 years). For patients who had hemiarticular allografts, 14 of 16 were able to return to their preoperative level of occupational function, with one patient experiencing failure of the allograft from infection. For the three patients who had total elbow allograft reconstructions, all had degenerative changes develop after surgery and two of the allografts failed. Complications occurred in six of 19 patients. Hemiarticular elbow allograft reconstruction is useful for limb salvage with massive bone loss. Total elbow allograft reconstructions have a high failure rate in the mid-term. LEVEL OF EVIDENCE: Level IV, therapeutic study.     

Do irradiated osteo-articular recycled tumor autografts still hold promise for biological joint reconstruction? Our experience with acetabular and proximal ulna ECRT

BackgroundJoint reconstruction following resection of malignant bone tumors is challenging in itself in spite of several options in hand. Ability to restore joint anatomy, function and mobility while achieving optimal oncological outcomes are the requirement of reconstructions today. While biological reconstructions (allograft or recycled tumor autografts) following tumor bone surgery are popular for intercalary resections not involving the joint, their use for osteo-articular reconstructions are associated with concerns over cartilage and joint health. We have used extracorporeal radiation therapy (ECRT) and re-implantation of the osteoarticular segment as a size matched recycled tumor autograft reconstruction after complex acetabular and proximal ulnar resections; owing to the lack of significantly superior reconstruction alternatives in these locations and also review the current literature on other biological/non-biological reconstruction options.Questions/purposes(1) What are the oncological, reconstruction and functional outcomes with osteo-articular reconstruction using ECRT and re-implantation of recycled tumor autograft for the acetabulum and olecranon? (2) Is there an evidence of cartilage loss, joint damage or avascular necrosis resulting from irradiation of the articular autograft?Methods19 patients with primary bone tumors underwent limb salvage surgery with en-bloc resection and reconstruction using the resected articular tumor bone after treating it with extra-corporeal irradiation of 50–60Gy. These included 16 acetabular and 3 proximal ulnar. While all patients were included for oncological assessment; minimum follow-up of 24 months was considered for final outcome assessment of function and joint status.ResultsMSTS scores of the 16 acetabular reconstruction patients with minimum 2 years follow-up was 87% (26/30). Neither delayed union, non-union at osteotomy sites nor was any fractures reported in the irradiated graft. There was no local recurrence within the irradiated graft and only 1 patient required graft excision for uncontrolled infection. All 3 patients of proximal ulna reconstruction achieved healing and full range of movement of the elbow. Scores of MSTS: 100% (30/30), MEPS: 100 and DASH: zero was achieved. Two patients developed osteonecrosis of the femoral head; one requiring a joint replacement and one awaiting replacement. One patient of acetabular reconstruction has joint space narrowing on radiographs with mild clinical symptoms.ConclusionsExtracorporeal radiotherapy and re-implantation after osteo-articular resection is an oncologically safe option offering promising outcome in our small series. The availability of size-matched graft, thus avoiding inherent problems of allograft also provides a better economic option over endoprosthesis and its associated complications in select sites. The results can deteriorate over time that may require secondary reconstructive procedures like joint replacement.Level of evidenceLevel IV, Therapeutic Study.     

应用假体翻修大段异体骨保肢失败后的功能重建

目的探讨应用组合式假体翻修大段异体骨感染或骨折的疗效。方法回顾性研究了美国迈阿密大学医学院和中山大学附属第一医院骨肿瘤科共22例肩关节或膝关节周围肿瘤的患者,大段异体骨保肢失败后,应用肿瘤型假体重建肢体功能。最初诊断包括骨肉瘤11例、软骨肉瘤4例、恶性纤维组织细胞瘤3例、骨巨细胞瘤2例、恶性血管内皮瘤1例和鼻咽癌转移瘤1例。发病部位包括股骨远端15例、肱骨近端3例和胫骨近端4例。结果异体骨失败原因包括:骨折14例、感染6例、持久不愈合1例、合并骨折和感染1例。异体骨移植后平均随访154.2(63～293)个月,假体翻修后平均随访73.4(24～234)个月。90.9%(20/22)的患者最终肢体功能良好,MSTS功能评分为76.5%(60%～93.3%)。81.8%(18/22)的患者假体翻修手术成功,在翻修失败的患者中,1例肱骨近端肿瘤患者为了改善功能经历了多次翻修手术,另1例股骨远端的患者,异体骨移植失败假体翻修后,由于假体近端松动而进行二次翻修——全股骨置换术,另外2例股骨远端的患者翻修后合并感染和骨折而截肢。结论异体骨重建因骨折或感染失败后,再次行假体翻修重建肢体功能是可靠的,并发症较低。翻修技术会影响重建肢体的功能。对于异体骨感染的患者,建议分期翻修重建肢体功能。     

Complications and functional outcomes of reconstruction with an osteoarticular allograft after intra-articular resection of the proximal aspect of the humerus.

BACKGROUND: The purpose of this study was to evaluate the functional outcome and the complications of reconstruction with an osteoarticular allograft in patients who had had intra-articular resection of the proximal aspect of the humerus. METHODS: Sixteen patients who had had intra-articular resection and reconstruction of the proximal aspect of the humerus for the treatment of a tumor between 1986 and 1996 were evaluated. The length of the resected part of the humerus ranged from eight to 27.5 centimeters. The resections were classified as either S34A or S345A resections of the shoulder girdle on the basis of the Musculoskeletal Tumor Society classification system. Reconstruction was performed with use of a nonirradiated, frozen osteoarticular allograft with intact capsular and rotator cuff attachments. Dual orthogonal dynamic compression plates were used for internal fixation of the allograft to the host bone. The oncological parameters that were evaluated included survival of the patient, local recurrence, and metastasis. The radiographic parameters included time to union, stability of the joint, fracture of the allograft, and fragmentation of the epiphysis of the allograft (subchondral collapse). Survival of the graft was assessed with Kaplan-Meier survival analysis. The modified Musculoskeletal Tumor Society evaluation system was used to assess functional outcome. RESULTS: At a median of forty-seven months (range, fourteen to 130 months) after the operation, fourteen of the patients in the study group were free of disease and two had died of disease. No patient had local recurrence or nonunion. Late complications included four fractures of the allograft and one infection of the graft. A Kaplan-Meier survival curve demonstrated a 68 percent rate of survival of the allograft at five years. Instability of the glenohumeral joint in the form of ptosis and anterior subluxation was noted in three patients, and dislocation of the glenohumeral joint was seen in eight patients. On the basis of the modified Musculoskeletal Tumor Society functional evaluation, the mean score at the most recent follow-up evaluation (at a mean of thirty-four months) was 70 percent. This score was lower than the mean score of 81 percent at a mean of fourteen months. All patients had normal manual dexterity and had mild or no pain at the most recent follow-up evaluation. However, all had restriction of recreational activities or partial disability in addition to limitations with regard to placement of the hand and the ability to lift. CONCLUSIONS: Reconstruction of the proximal aspect of the humerus with an osteoarticular allograft is an option that provides good relief of pain and preserves manual dexterity. However, in our study, function was limited by impairment of elevation of the shoulder and hand as well as by decreased strength of the shoulder. There was an extremely high rate of complications, including joint instability, fracture of the allograft, and infection of the allograft. We no longer routinely perform this reconstruction at our institution.     

The use of large allografts for tumor reconstruction and salvage of the failed total hip arthroplasty

Large bone defects have become a more common orthopedic problem in recent year. This is due to the increased enthusiasm for limb salvage surgery as a technique to manage patients with primary bone tumors and for patients who have had multiple joint arthroplasties with subsequent bone loss. One technique that has proven successful for this difficult problem is the use of fresh frozen allografts to reconstruct these skeletal defects. From January 1981 until January 1987, 60 large fragment fresh frozen allografts were used for skeletal reconstruction. These grafts were divided into three basic groups: intercalary, 15; osteoarticular, 16; and allograft-prosthetic composite, 29. The diagnoses included 43 bone tumors, 16 failed total hip arthroplasties, and one traumatic bone loss. The average patient age was 39.7 years and had an average follow-up period of 24 months. The average length of allograft was 12.4 cm. Using the Enneking Functional Evaluation System, the final functional analysis revealed excellent or good results in 86% of the patients and fair or poor results in 14% of the patients. Roentgenological union at the allograft-host bone junction was achieved in 90% of the patients in a mean time of 5.8 months after surgery. An additional three patients obtained union after autogeneic bone grafting. At the time of follow-up evaluation, 92.3% of the patients were free of tumor; they had no local recurrences. The use of fresh frozen allografts represents an acceptable alternative for the reconstruction of large skeletal defects. One can expect good or excellent function for the majority of patients. The best functional results were obtained with the intercalary allografts and the allograft-prosthetic composites.     

Massive bone allograft reconstruction in high-grade osteosarcoma

From 1986 to 1994, 112 bone allograft reconstructions were performed in patients with high-grade osteosarcoma in whom neoadjuvant chemotherapy was administered. The allograft reconstruction was used in arthrodesis in 44 cases (41 knees, three ankles), as an intercalary graft in 39 (28 femurs, 11 tibias), as an osteoarticular graft in 22 (three proximal and/or distal humeri, six distal femurs, 13 proximal tibias), and as an allograft and prosthesis composite in seven (two proximal humeri, one proximal femurs, four proximal tibias). In 20 patients an autologous vascularized fibula was used to augment the allograft. Functional results were excellent or good in 74% of the patients after the primary surgery, and in 83% of the patients after secondary surgery. Complications include delayed union (49%) and fracture (27%), although there were no cases of deep infection. The incidence of delayed union, but not infection or fracture, was increased by the use of chemotherapy.     

Allograft reconstruction for bone sarcoma of the tibia in the growing child

The outcome of tibial allograft reconstruction after resection of a tumour is inconsistent and has a high rate of failure. There are few reports on the use of tibial allografts in children with open growth plates. We performed 21 allograft reconstructions (16 osteoarticular, five intercalary) in 19 consecutive patients between seven and 17 years of age. Two had Ewing's sarcoma, one an adamantinoma and 16 osteosarcoma, one with multifocal disease.Five patients have died; the other 14 were free from disease at the time of follow-up. Six surviving patients (eight allograft reconstructions) continue to have good or excellent function at a mean of 59 months (14 to 132). One patient has poor function at 31 months. The other seven patients have a good or excellent function after additional procedures including exchange of the allograft and resurfacing or revision to an endoprosthesis at a mean of 101 months (43 to 198). The additional operations were performed at a mean of 47 months (20 to 84) after the first reconstruction.With the use of allograft reconstruction in growing children, joints and growth plates may be preserved, at least partially. Although our results remain inconsistent, tibial allograft reconstruction in selected patients may restore complete and durable function of the limb.