There is more than one option for proximal humerus reconstruction after oncological resection but we believe osteochondral allografts provide a good biological solution for these defects. We report three cases with different histological diagnoses and different results following such reconstruction. The aim is to highlight the advantages and disadvantages of this surgical procedure. The first case report concerns a 15-year-old boy (M.P.) with Ewing’s sarcoma of the proximal humerus. The gleno-humeral articulation and most of the rotator cuff were not involved by the disease. An allograft was used for the reconstruction after satisfactory resection. This allowed good restoration of the function quickly. At 12 months there was a fatigue fracture in the allograft, which required revision with a modular prosthesis. In another patient, a young woman (E.C.), a proximal humeral defect was reconstructed following resection of a benign lesion, fibrous dysplasia. She does not have complete restoration of function but there are no complications at 3 year follow up. The last case is a 49-year-old woman (M.M.), who had osteochondral allograft reconstruction of the proximal humerus after resection of a completely destroyed head by a giant cell tumour. She had good initial results but required revision surgery with Kuntscher nail and vancomycin was added to the cement due to infection. The biological articular reconstruction after oncological wide resection allows good functional results when rotator cuff tendons are available and allografts permit a good and fitting reinsertion. The reported early restoration of function in the young boy (case 1) has to be considered in the stress-fracture genesis. The authors consider that the lack of motion in case 2 was due to a non-aggressive and careful rehabilitation: a quite poor functional result to avoid complications. The case 3 failure is due to an infection, one of most frequent complications in allograft implants. The choice of using an osteochondral allograft must be considered as a useful alternative with prosthetic replacements.
The reconstruction of a skeletal defect after resection of a bone tumour represents a challenge for the orthopaedic surgeon. Age, site of the lesion and extension of the disease often limit the choice of surgical technique for a conservative procedure, but several options are available, mainly modular, composite or custom prostheses, massive bone allografts with or without autologous vascularised fibular grafts (AVF), and arthrodeses. An interesting reconstructive technique uses the AVF graft, with microsurgical technique, alone or associated with a massive allograft. The association of a fibular transplant with an allograft increases the mechanical strength of the reconstruction, also promoting more rapid integration. The fibula is a cortical bone and it may provide mechanical strength in the reconstruction of a large segmental bony defect if employed as a viable biological rod. In the present paper the authors discuss their experience with 17 patients treated at the Oncological Orthopaedic Unit of the G.Pini Orthopaedic Institute, for bone tumour resection and reconstruction using AVF graft, almost always combined with a bone allograft. No treatments were performed as augmentation in osteoarticular massive allografts. Subjects’ ages ranged from 7 to 66 years (mean 25.2 years). Most of the patients were referred for a diagnosis of malignancy (15 of 17 cases) and in only two patients were the tumours not aggressive. In 11 patients the AVF was transplanted immediately after tumour resection, while in the others it was used after problems of previous reconstruction. The authors report two cases of deep infection and four mechanical fractures (all healed after a period of cast immobilisation with or without bone bridging). All the AVF survived and healed with a good functional result for the patients except for two recurrences that required an amputation.
