The reconstruction of lower limb defects after oncological reconstructions is still a problem in limb salvage surgery. Large bony defects need to be treated with sound and durable reconstructions. During recent decades, the life expectancy of patients affected with cancer has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution.

From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures were relatively high. We should consider that in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure. However the new design of morse tapers have annulled these problems

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

Purpose: Femoral fracture non-unions are considered to be rare, and are usually treated successfully with exchange nailing. However, recalcitrant aseptic cases often require additional bone grafting procedures. The purpose of this study was to investigate the efficacy of BMP-7 (biological enhancement) in the treatment of recalcitrant aseptic femoral non-unions.

Material & Methods: Since 2003 a multicenter registry (bmpusergroup.co.uk) was created to collect details of BMP7 application in general, between different university hospitals across Europe. Demographic data, intraoperative details, complications, clinical outcome parameters, radiological healing, VAS pain score, EuroQol-5D, and return-to-work were prospectively recorded. Radiological healing was defined as the presence of callous in two planes over 3 cortices. The minimum follow up was 12 months.

Results: Thirty patients, who had undergone a median of 1 (1 to 5) prior revision operations, over a median period from the injury of 24 months (9 to 65), were included in this observational study. In 76.7% (23/30) the application of BMP7 was combined with a revision of the fixation. Non-union was verified in 26/30 cases (86.7%) in a median period of 6 months (range 4–10). Over 70% of these patients returned to their preinjury level of activities, the median overall health state score was 82.5 (45 to 95). No adverse events or complications were associated with the BMP7 application over the median follow-up of 30 months (12–68).

Discussion/Conclusion: This case series has verified the safety and efficacy of the use of BMP7 in a manner comparable to the scarce existing evidence on femoral non-unions. The establishment of multicenter networks and the systematic and long-term follow-up of these patients are expected to provide further information and significantly improve our understanding on this promising osteoinductive bone substitute.

Different techniques were proposed for reconstruction after distal radial resection for bone tumors. When not dealing with heavy workers or complex revision cases, a motility preserving procedure can be used. From 1999 to 2007 we performed a reconstruction with an ostearticular allograft in 18 patients.

Age of the patients ranged from 13 to 56 years. Histotypes were: giant cell tumor in 16 patients, Ewing sarcoma in 1, osteosarcoma in 1. Neadjuvant chemotherapy was used in Ewing and osteosarcoma patients. Length of resection ranged from 5 to 13 cm. An accurate host-graft capsulorraphy was performed to reestablish joint stability; no adjunctive distal radioulnar stabilization procedures were used. In one case the procedure was performed after a failed previous graft-arthrodesis; in this case also a proximal row carpectomy was performed.

Non-union of the allograft occurred in 2 cases. In one case autologous cancellous bone grafting from the iliac crest was performed. In the second case the patient due to mild symptoms has till now refused further surgery.

No septic complications occurred.

One patient presented a fracture of the allograft; a revision procedure was performed with a new allograft but also the second graft failed and an arthrodesis was performed. This was the only complete failure of our series.

Follow-up ranged from 20 to 103 months. No recurrences (local or distant) were observed. The patients were evaluated with radiographic and clinical examination. Functional evaluation was performed using ISOLS-MSTS score and a wrist-specific functional score (PRWE).

The oncological and functional results in our series highlight that a functional wrist can be restored with an osteoarticular allograft after distal radial resection for bone tumors. Deterioration of the results could occur in the long-term and thus further monitoring with a longer follow-up is needed.

The treatment of bone metastases is usually palliative and aims to achieve adequate control of pain, to prevent and resolve compression of the cord in lesions of the spine and to anticipate or stabilise pathological fractures in the appendicular skeleton. In selected cases the complete resection of an isolated bone metastasis may improve the survival of the patient. During recent decades, the life expectancy of patients affected with metastatic carcinoma has improved considerably because of advances in chemotherapy, immunotherapy, hormonal treatment and radiotherapy. This improvement requires greater reliability in the reconstructive procedure in order to avoid mechanical failure during prolonged survival of the patient. The author experience with modular megaprosthesis by Link (megasystem C) allowed us to present a rapid, effective and functional solution.

From June 2001 to December 2007 225 patients have been operated with a megaprosthesis C for tumoral resection. The new megaprosthesis C by Link represents a wide-ranging system that can afford a large variety of reconstructions in the inferior limb, from very short replacement of 5 cm in proximal femur, to a total femur and proximal tibia replacement. Modularity is represented by 1 cm increase in length. The different options of cemented and not cemented stem may be used with intraoperative decision. In cemented stem a rough collar seals the osteotomy and prevents polyethylene debris from entering the femoral canal by inducing a scar tissue around the stem entrance (so-called purse-string effect). Moreover in patients with solitary lesions and very good prognosis an allograft-prosthesis composite can be performed with improved clinical results on walking and function. Of the 225 patients that underwent tumoral resection and reconstruction with a modular megaprosthesis approximately 43% (97 cases) were operated for metastatic disease. Among these cases 55 cases were proximal femoral recontructions, 39 cases were distal femoral reconstructions and 3 cases were proximal tibial reconstructions. All cases were performed with cemented stems. We experienced a 7% of postoperative infections, 2% of dislocations of proximal femoral prosthesis and 3% of mechanical failures. While infections and dislocation rates were in the average for this surgery, mechanical failures seemed relatively high. However in patients with relatively long resections and muscle deficiency the mechanical stress exerted on the prosthesis can explain this kind of mechanical failure.

Proximal tibia reconstruction after oncologic resection is challenging due to bone stock and extensor mechanism restoration.

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 midterm follow-up.

Different techniques were proposed for reconstruction after distal radial resection for bone tumors. When not dealing with heavy workers or complex revision cases, a motility preserving procedure can be used. From 1999 to 2007 we performed a reconstruction with an ostearticular allograft in 18 patients.

Age of the patients ranged from 13 to 56 years. Histotypes were: giant cell tumor in 16 patients, Ewing sarcoma in 1, osteosarcoma in 1. Neadjuvant chemotherapy was used in Ewing and osteosarcoma patients. Length of resection ranged from 5 to 13 cm. An accurate host-graft capsulorraphy was performed to reestablish joint stability; no adjunctive distal radioulnar stabilization procedures were used. In one case the procedure was performed after a failed previous graft-arthrodesis; in this case also a proximal row carpectomy was performed.

Non-union of the allograft occurred in 2 cases. In one case autologous cancellous bone grafting from the iliac crest was performed. In the second case the patient due to mild symptoms has till now refused further surgery.

No septic complications occurred.

One patient presented a fracture of the allograft; a revision procedure was performed with a new allograft but also the second graft failed and an arthrodesis was performed. This was the only complete failure of our series.

Follow-up ranged from 20 to 103 months. No recurrences (local or distant) were observed. The patients were evaluated with radiographic and clinical examination. Functional evaluation was performed using ISOLS-MSTS score, a wrist-specific functional score (PRWE) and a comprehensive evaluation of upper arm function score (DASH).

The oncological and functional results in our series highlight that a functional wrist can be restored with an osteoarticular allograft after distal radial resection for bone tumors. Deterioration of the results could occur in the long-term and thus further monitoring with a longer follow-up is needed.

Radiofrequency ablation (RFA) is a relatively new technique to produce cell death by radiowaves (460– 480 kHz) caused by an alternating current emitted from the tip of a needle electrode and causing local ions vibration producing heat. In orthopaedic fields RFA has been proposed for the treatment of osteoid osteoma and painful metastases.

Methods: 121 patients with a clinical and radiographic accerted osteoid osteoma have been treated with percutaneous radiofrequency ablation at our institutions from 1998 till December 2005. Average age of the patients was 23 years. Preoperative symptoms lasted 10 months on average. The osteoid osteoma was localized at the limbs in 111 cases, at the pelvis in 4 cases and at the spine in 6 cases.

Results: At follow up we had 3 cases of recurrences and 2 fair results with a total of 5 unsuccessful cases. The fair results were due to a mistake of radiological indication and one case of ineffectively ablation. We observed 3 cases of skin burns in tibia with superficial infections: 2 cases resolved without treatment while the latter case showed initial bone infection and needed surgical revision.

Conclusion: Percutaneous RFA of osteoid osteoma proved to be a successful treatment in more than 95% of the cases with a low complication rate.

Ankle arthrodesis is considered a valid reconstructive option after bone tumor resection of the distal tibia, distal fibula and of the talus. The purpose of the present study was the review of author’s experience in ankle arthrodesis for bone tumors with the employ of bone grafts.

Over the last 15 years, 17 ankle arthrodesis were performed in author’s Institution for oncological pathologies. Average age at the time of surgery was 41 years (4–75). Twelve patients had a malignant tumor (3 osteosarcoma, 2 fibrosarcomas, 1 Ewing sarcoma, 1 emangioendotelioma, 1 condrosarcoma, 1 pleomorphic sarcoma, 1 adamantinoma and 2 metastases from renal carcinoma) and 5 patients had a benign tumor (4 giant cell tumors, 1 condroblastoma). In 13 cases the tumor involved the distal tibia, in 2 cases the distal fibula and in 2 cases the talus. In 15 patients we performed a tibiotalar arthrodesis and in 2 patients (tumors of the talus) a tibiocalcaneal arthrodesis.

The bone defect after resection was reconstructed with: cortical structural autografts from controlateral tibia and autologous bone chips from iliac crest in 5 patients; cortical structural autografts from controlateral tibia + cortical structural allografts + autologous bone chips from iliac crest in 2 patients; cortical structural allografts + autologous bone chips from iliac crest in 2 patients; structural autografts in 4 patients; autogenous vascolarized fibula in 4 patient with cortical allograft in 3 cases and autograft in 1 case. Stabilization was obtained by intramedullary anterograde nailing in 8 patients, plate in 2, two or multiple screws in 7 (including two tibiocalcaneal arthrodesis).

Three patients died before this review (1, 1.5, 7 years after surgery: 1 Ewing sarcoma, 2 patients with metastases from kidney cancer). Follow-up for alive patients ranged from 14 to 146 months (average 53). Two local recurrences were observed, in a Ewing sarcoma in 1 case and in a giant cell tumor in 1 case. One patient is alive with lung metastases but no signs of local recurrence. In all patients but one the arthrodesis healed successfully. In one case a deep infection occurred (with wound dehiscence) and the arthrodesis did not heal. Complications included 1 deep infection, 1 superficial infection of the donor site (controlateral leg) and 1 fracture of the controlateral tibia (donor site of cortical autograft) treated with plaster cast. Three patients underwent a secondary surgical procedure: two partial hardware removals and one myocutaneous sural flap.

The low rate of local recurrence (1/5 in benign tumors and 1/12 in malignant tumors) and the high percentage of bone union (16 out of 17) together with the satisfactory functional outcome showed that ankle arthrodesis with bone grafts can be an oncologically safe and a meccanically successful procedure in bone tumor surgery.

The reconstruction of large bone segments is a major goal in orthopaedic surgery. Autologous cancellous bone is recognized as the most biologically active graft material, but autologous bone harvest is associated with significant morbidity and founds its limit in the available quantity. Biomaterials or allografts do not encounter these limitations, but have no osteogenic and limited osteinductive potential. In order to enhance tissue regeneration and healing we have tried to obtain a graft with osteconductive, inductive and osteogenic properties. The day before operation 350 cc of autologous blood is donated from the patient and centrifuged to obtain a platelet-rich plasma. Bone marrow is aspirated from the posterior iliac crests with the patient under spinal anaesthesia and is processed to increase its stem cell content. The structural scaffold used is morcellized cancellous bone provided from our Bone Bank. At operation bone is mixed with bone marrow buffy coat and Platelet Rich Plasma in a sterile glass becker with addition of CaCl2 till clot formation to produce a gel-like component that is handled easily. We have utilized this technique from November 2000 till January 2004 for 68 patients: 41 of these patients required healing of large bone defects: 22 males and 19 females. Fresh bone marrow alone was used for a percutaneous injection in 11 cases; open surgery with autologous growth factors, bone marrow buffy coat and allograft was used in 30 patients. The radiological and clinical results showed early healing of the defects treated with this technique and no complications related to the procedure at an average follow up of 23 months (3–40).

Aims: Massive allografts have been widely employed to replace skeletal defects after bone tumour resection. They have major advantages but the major concern is the long term behaviour of the implant. The aim of the present study was to evaluate the incidence of complications in allograft reconstruction and to describe the new techniques to decrease their rate. Methods: The present series includes 68 patients with 70 massive allografts operated from 1996 to 2002. 35 were males and 35 females with an average age of 31 years (4–79). The massive allograft was used as osteoarticular reconstruction in 28 cases, composite in 28, intercalary in 10, knee arthrodesis reconstruction in 3 and scapular replacement in one case. In 7 cases a vascularized fibula was associated. The femur was involved in 23 cases, the humerus in 16 and the tibia in 17, the pelvis in 7, the radius in 3, the scapula in 2 and patella and a finger in 1 case. Results: Infection rate on 68 cases was 6% (4 cases). All infections healed after surgical revision. Two patients were lost at fu and 10 patients have less than 12 months of fu. The 58 patients left have an average fu of 34 months (12–71). Among these patients 45% had one or more complications treated surgically and 2/3 of the cases healed. Non union rate was 12% and fracture rate 5%. Conclusion: Allograft reconstruction showed a high rate of complications. Almost half of the patients (45%) presented one or more complications which required surgery in 40% of cases. Aggressive antibiotic perioperative regimen and adequate soft tissue coverage of the graft may reduce the risk of infections. Biologic augmentation with vascularized grafts, bone marrow and/or growth factors may reduce non union rate. Cement filling of the graft and composite implant (with prosthesis association) have been introduced in order to decrease the risk of diaphyseal and articular fractures.