Aims. Clinical management of open fractures is challenging and frequently requires complex reconstruction procedures. The Gustilo-Anderson classification lacks uniform interpretation, has poor interobserver reliability, and fails to account for injuries to musculotendinous units and bone. The Ganga Hospital Open Injury Severity Score (GHOISS) was designed to address these concerns. The major aim of this review was to ascertain the evidence available on accuracy of the GHOISS in predicting successful limb salvage in patients with mangled limbs. Methods. We searched electronic data bases including PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and Web of Science to identify studies that employed the GHOISS risk tool in managing complex limb injuries published from April 2006, when the score was introduced, until April 2021. Primary outcome was the measured sensitivity and specificity of the GHOISS risk tool for predicting amputation at a specified threshold score. Secondary outcomes included length of stay, need for plastic surgery, deep infection rate, time to fracture union, and functional outcome measures. Diagnostic test accuracy meta-analysis was performed using a random effects bivariate binomial model. Results. We identified 1,304 records, of which six prospective cohort studies and two retrospective cohort studies evaluating a total of 788 patients were deemed eligible for inclusion. A diagnostic test meta-analysis conducted on five cohort studies, with 474 participants, showed that GHOISS at a threshold score of 14 has a pooled sensitivity of 93.4% (95% confidence interval (CI) 78.4 to 98.2) and a specificity of 95% (95% CI 88.7 to 97.9) for predicting primary or secondary amputations in people with complex lower limb injuries. Conclusion. GHOISS is highly accurate in predicting success of limb salvage, and can inform management and predict secondary outcomes. However, there is a need for high-quality multicentre trials to confirm these findings and investigate the effectiveness of the score in children, and in predicting secondary amputations. Cite this article: Bone Joint J 2023;105-B(1):21–28

Despite advances in reconstructive surgery, salvage of mangled extremities still requires long periods of treatment with many operations that can be taxing both to the surgeon and the patient. Attempts at reconstruction of severely shattered limbs necessitate counselling with regard to the protracted course of treatment and associated morbidity as well as problems which may require abandoning of the procedure and secondary amputation. We report the successful salvage of a severely comminuted and open fracture of the tibia in a 32-year-old man

We describe a management strategy for upper- and lower-limb fractures with associated arterial injury and report the results in 113 cases treated over a period of 18 years. Primary amputation was performed in 23 patients and of those who underwent primary vascular repair, 27 needed secondary amputation, two-thirds of them within a week of the injury. Of those requiring secondary amputation, 51.8% had ischaemia exceeding six hours, 81.4% had severe soft-tissue injury and 85.2% had type III open fractures. The patients whose limbs had been salvaged were followed up for an average of 5.6 years. The eventual outcome depended on the severity of the fracture, the degree of soft-tissue damage, the length of the ischaemic period, the severity of neurological involvement, and the presence of associated major injuries. There was a 30% incidence of long-term disability in the salvaged limbs, largely due to poor recovery of neurological function. Prompt recognition of such combined injuries is vital and requires a high index of suspicion in patients with multiple injuries and with certain fracture patterns. We recommend a multidisciplinary approach, liberal use of pre-operative angiography in upper-limb injuries and selective use of intra-operative angiography in lower-limb injuries. Stable external or internal fixation of the fractures and re-establishment of limb perfusion are urgent surgical priorities to reduce the period of ischaemia which is critical for successful limb salvage

Two hundred and forty-one patients with extremity osteosarcoma presented to our institution between 1989 and August 2002, thirty-six of whom had a pathologic fracture. There were twenty-five limb salvage surgeries and ten primary amputations, with three limb salvage surgeries requiring secondary amputations. One patient had an unresectable tumor and was treated palliatively. At mean follow-up of 96.9 months there was one local recurrence and eighteen patients were alive without disease in the pathologic fracture group. There was no survival difference between the pathologic fracture group with no metastases at presentation and the non-pathologic fracture group with no metastases (119.4 months vs 134.3 months, log rank 0.83, p=0.36). To examine the outcome of osteosarcoma patients that present with a pathologic fracture as compared to those patients without a pathologic fracture. There was no significant difference in the rate of amputation vs limb salvage surgery in osteosarcoma patients that presented with a pathologic fracture as compared to those without. There was no difference in the two groups’ disease-free and overall survival, for those patients that presented without metastatic disease. Presentation with a pathologic fracture in osteosarcoma does not preclude limb salvage surgery and is not a prognostic indicator for decreased survival. Retrospective review of all patients presenting to our institution with extremity osteosarcoma between 1989 and August 2002. There were two hundred and forty-one patients with extremity osteosarcoma, thirty-six of whom presented with a pathologic fracture. In the pathologic fracture group, there were nineteen males and seventeen females. Twenty-five were treated with limb salvage surgery, ten required a primary amputation and one was unre-sectable. Three limb salvage surgery patients required a secondary amputation. Sevenpatients presented with metastatic disease. Twenty-eight of the thirty-six patients received (neo) adjuvant chemotherapy. At last follow-up, eighteen patients were alive no evidence of disease (51.4%), three were alive with disease, eleven were dead of disease and three were deceased from other causes. There was one local recurrence (2.8%). Mean overall survival was 119.4 months (0–147.1) for patients with a pathologic fracture and no metastasis at presentation and 134.3 months (0–172.5) for patients with no pathologic fracture and no metastasis (log rank 0.83, p=0.36)

Besides the femur and the tibia, the humerus is the third most common localisation of osteosarcoma. 78 patients with osteosarcoma of the humerus have been treated at our institution since 1934. Among these, 7 patients have been admitted before implementation of the Vienna Tumour Registry in 1968, additionally 4 patients had undergone primary surgical resection at another institution. This left 67 patients for follow-up after multi-modal therapy of humeral osteosarcoma comprising neo-adjuvant and adjuvant chemotherapy and surgical resection. (38 males and 29 females with an average age of 21.8 years, range 3.6 to 73.2 years) The subtypes of tumours observed were classic osteosarcoma in 56 patients, parostal sarcoma in 4, teleangiectatic sarcoma in 3, secondary sarcoma in 2 (one in Morbus Paget and one after radiation of a hemangioendothelioma), high-grade surface sarcoma in 1 and a humeral lesion within a multifocal osteosarcoma in 1. The localisation was foremost the proximal humerus (61) and rarely affecting the distal (5) or total bone (1). 11 patients suffered from pulmonary metastases upon primary diagnosis. In 9 cases resection alone was indicated. 9 patients underwent a resection-replantation-plasty, and in 2 patients primary amputation was performed. 46 patients were treated by resection and endoprosthetic reconstruction using ceramic prostheses (7), custom-made endoprostheses (13) or humeral HMRS modular prostheses (26). Before 1980 a non-standardised neo-adjuvant and adjuvant chemotherapy was administered in 12 patients, all patients thereafter received a chemotherapeutic regimen according to the COSS or EURAMOS-1 protocol. In 3 patients with parostal sarcoma no adjuvant therapy was indicated. The patient with multifocal osteosarcoma was treated conservatively by chemotherapy, radiation and immunotherapy by dendritic cell vaccination. The overall survival was 58% at 5 years. 23 patients died of their disease at an average of 25 months after operation (range 2 to 135 months). Average follow-up of the remaining patients was 91 months. (range 1 to 389 months). 4 patients treated before 1982 developed local tumour recurrence leading to secondary amputation in all cases, and death of disease within 12 months in 3 cases, respectively. 16 patients had to undergo one or more revisions, including secondary amputation in 2. Pulmonary metastases were observed in 15 patients, 2 patients developed skeletal metastates. After resection of metastatses, 14 patients died of disease, among them 9 patients died within 12 months after operation. Upon latest follow-up, 3 patients were alive disease-free, the patient with multifocal osteosarcoma was alive with disease 22 months after primary diagnosis. The multimodal treatment of osteosarcoma shows satisfactory oncological results. The implementation of standardised chemotherapeutic protocols has improved overall outcome

Purpose of the study: Advances in chemotherapy protocols over the last 20 years have considerably improved the prognosis and functional outcome in patients with osteogenic sarcoma. We report here the results of a cooperative study conducted under the auspices of the French Society of Pediatric Oncology (SFOP). Twenty-nine oncology centers participated in this retrospective national multicentric study. Materials and methods: The study included 15 .3 patients with osteogenic sarcoma of the limb who were treated by the OS87 protocol with conservative surgery between 1987 and 1994. The OS87 protocol consisted in conservative or nonconservative surgery combined with pre- and postoperative chemotherapy. The following inclusion criteria were used: age under 20 years, tumor localization in a limb (pelvis and spine excluded), no metastasis at diagnosis, biopsy proven osteogenic sarcoma. Results: Mean age at diagnosis was 13 years. The knee localization predominated (80 p. 100). 82.5 p. 100 of the patients had grade IIB disease (Enneking classification). For the 187 patients included in the protocol surgery was nonconservative in 20 p. 100 of the cases and conservative in 80 p. 100. The choice of the surgical technique (arthroplasty, allograft, autograft, resection without reconstruction) depended on the patient’s age and school situation. Data analyzed here concerned only those patients who had conservative treatment. Mean follow-up was 64 months. The actuarial survival curve plateaued at 71 p. 100 at more than 6 years. Early and late complications were numerous and variable (mechanical, infectious, local recurrence). Secondary amputation was required in 10 p. 100 of the patients. The overall functional outcome of the preserved limbs was nevertheless good with rapid restoration of self-sufficiency despite major surgery and a high number of reoperations (about 65 p. 100 of cases). Discussion: In light of the frequency and the seriousness of the complications, these results are modest. Patients and family should be advised of the risk, particularly the risk of secondary amputation which may be required early due to contaminated excision or at mid term due to major non-cancerological complications. As survival has been improved, functional capacity must be preserved for several years. This orients surgery towards more “biological” reconstruction which can provide greater longevity than arthroplasty

Purpose: Between January 1975 and December 2000, 498 cases of sarcoma of limb bones were treated by our multi-disciplinary team. Mean patient age was 27.1 years. Mean tumour size was 13.1 cm. Histology revealed osteosarcoma (n= 231), chondrosarcoma (n=118), Ewing sarcoma (n=104), MFH (n= 25), fibrosarcoma (n=12) and diverse tumours (n=8). The most frequent localisations were: femur (n=203), pelvis (n=98), tibia (n=86), humerus (n=60). Metastasis was present in 64 cases when first seen by our team. The histological resection was wide in 295 cases, marginal in 185 and contaminated in 18. Adjuvant treatment was adapted to patient age, histology and tumour localisation. Postoperative radiotherapy (34 to 50 Gy) was given for certain adults with osteosarcoma or Ewing tumours who had little histological response to preoperative chemotherapy or who had a marginal or contaminated resection. Results: Median follow-up was 12 years. Two hundred fifty-two patients were living and disease free, eight were still under treatment, and 238 had died of their disease or treatment complications. There were 35 cases of local relapse, most of them (n=26) in referred patients, particularly after insufficiently effective chemotherapy. Complications were mainly deep infections (n=42). Secondary amputation was required for 24 patients (5%). Functional outcome at last follow-up was excellent in 52% of the patients, good in 35%, fair in 7% and unsatisfactory in 6%. Outcome depended basically on tumour size and localisation and deteriorated with infectious complications and radiotherapy. Conclusion: 1. In our series, conservative surgery was performed in 95% of the cases, even for large tumours with fractures or for young children. 2. Functional outcome was better after conservative surgery: more than 85% excellent or good function. 3. Risk of local relapse was 2% for patients seen for initial diagnosis of high-grade malignant sarcoma. For patients with low-grade malignant tumours, or those who could not be given effective chemotherapy, the risk of local relapse was higher. 4. Radiotherapy improved local control for Ewing sarcomas and mesenchymatous chondro-sarcomas but its effect could not be assessed for the other tumours. As most of the secondary amputations and most of the poor functional results were observed in patients given complementary radiotherapy, this therapeutic modality, should, in our opinion, be avoided. 5. Preoperative chemotherapy being potentially dangerous for poor responders when the preoperative phase is continued too long, we advocate one month of preoperative chemotherapy for osteosarcoma and six weeks for Ewing sarcoma. This should be sufficient to allow conservative surgery (reduced tumour size) and chemotherapy (precise dose and protocols)

We evaluated the long-term functional outcome in 118 patients treated for osteosarcoma or Ewing’s sarcoma in the extremities a minimum of five years after treatment. We also examined if impaired function influenced their quality of life and ability to work. The function was evaluated according to the Musculoskeletal Tumor Society (MSTS) score and the Toronto Extremity Salvage Score (TESS). Quality of life was assessed by using the Short Form-36 (SF-36). The mean age at follow-up was 31 years (15 to 57) and the mean follow-up was for 13 years (6 to 22). A total of 67 patients (57%) initially had limb-sparing surgery, but four had a secondary amputation. The median MSTS score was 70% (17% to 100%) and the median TESS was 89% (43% to 100%). The amputees had a significantly lower MSTS score than those with limb-sparing surgery (p < 0.001), but there was no difference for the TESS. Tumour localisation above knee level resulted in significantly lower MSTS scores and TESS (p = 0.003 and p = 0.02, respectively). There were no significant differences in quality of life between amputees and those with limb-sparing surgery except in physical functioning. Of the patients 11% (13) did not work or study. In multivariate analysis, amputation, tumour location above the knee and having muscular pain were associated with low physical function. We conclude that most of the bone tumour survivors managed well after adjustment to their physical limitations. A total of 105 are able to work and have an overall good quality of life

Aims

The aim of this study was to assess the incidence of reinfection in patients after two-stage revision of an infected megaprosthesis (MPR) implanted after resection of a bone tumour.

Aims

To evaluate mid-to long-term patient-reported outcome measures (PROMs) of endoprosthetic reconstruction after resection of malignant tumours arising around the knee, and to investigate the risk factors for unfavourable PROMs.

Purpose of Study. We intended to determine our rates of deep infection and non-union in severe open tibial fractures treated at our institution with Ilizarov frames. Methods. We retrospectively reviewed the case notes and radiographs of sixty consecutive cases of severe (Gustillo-Anderson Grade III) open fractures of the tibia treated in our tertiary referral unit with the ‘Flap and Frame’ technique. This technique involves early aggressive soft tissue and bone debridement and temporary skeletal stabilisation, followed by soft tissue coverage and then, when the soft tissues have settled, definitive skeletal stabilisation with the Ilizarov frame. The primary outcome measures were the presence of deep infection, occurence of union with the index frame, and any requirement for secondary amputation. Results. Mean average age was 43.3 years (range 16–89). None had neurovascular injuries requiring repair, while three quaters required soft tissue coverage procedures. Half of the fractures had significant bone loss following debridement, with a mean average loss of 28.1 mm (range 5–125). Mean followup was 10.3 months. The deep sepsis rate was 1.7 percent, or 5 percent including cases with significant soft tissue infection but no confirmed bone infection, with a 5 percent non-union rate. Conclusion. In our centre management of severe open fractures of the tibia treated with the ‘Flap and Frame’ technique, with Ilizarov, fixation achieves rates of deep infection and union which compare favourably with previously reported results

1. The conservative school of treatment of fractures of the tibia, which bases part of its criticism of internal fixation on the ultimate risk of amputation, does not often publish its own rates of amputation. 2. Statistics from a hospital that treats one-third of closed fractured tibiae and two-thirds of compound fractures by internal fixation are therefore put up as a basis for criticism. 3. Comparisons are made with the few available statistics in the literature of conservative treatment. 4. Almost all of the causes for secondary amputation are now curable and in recent years the number of limbs being saved is increasing

Megaendoprotheses are widely used in the reconstruction of large bone defects in orthopaedic tumour surgery. The major complications (up to 36%) are periprosthetic infections. Persisting periprosthetic infections lead to secondary amputation up to 37% of the cases. One underestimated reason for persisting infections are subpopulations of S. aureus called “small colony variants” (SCVs). Aim of this study was to evaluate that silver ions might prevent or cure a periprosthetic infection caused by SCVs. For testing the antimicrobial activity of silver-coated titanium we used a technique introduced by Bechert et al. Therefore an adhesion and proliferation assay was performed with clinical isolates of S. aureus SCV (A22616/3). We tested the adhesion and proliferation properties of S aureus SCV on stainless steel (steel), Cobalt-Chrome-Molybdenum-alloy (CoCrMo), Titan-Aluminium-Vanadium-alloy (TiAlVa) and silver-coated Titan-Aluminium-Vanadium-alloy (scTiAlVa). Adhesion of S. aureus SCV is significantly reduced on scTiAlVa vs. steel (p> 0001). We could also demonstrate that the proliferation rate of scTiAlVa vs. all tested materials is significant (p> 0001) lower. We concluded that silver-coating has an effective antimicrobial activity against S. aureus SCVs. Thus silver-coated megaendoprostheses are a good prophylaxis against persisting infections caused by S. aureus SCVs

Background. Decisions about local treatment are important in osteosarcoma treatment. The purpose of this study was to review decisions about local treatment in one centre. Methods. This was a retrospective review of the records of all patients with high-grade extremity osteosarcoma presenting to our centre between 1997 and 2008. Particular attention was paid to local control decisions. Results. 54 patients were included, 37 were male. Median age was 18 (4.1 to 71.3 years). The anatomical location was distal femur in 33, tibia in 8, humerus in 7, ankle/foot in 3, fibula in 2 and clavicle in 1. 8 (14.8%) patients had metastases at presentation. 13 (24.1%) patients underwent primary amputation, predominantly in the early years of the series. The remaining 41 patients had limb-sparing surgery, 5 of whom had microscopically positive margins. 21 of 54 (38.8%) had >90% necrosis in the resected tumour. 3 patients had poor necrosis and positive margins. These were a 70 yo intolerant of chemotherapy, who refused amputation, developed LR and metastatic disease; a 15 yo with metastatic disease, who had a secondary amputation and metastatectomy and survived and a 43 yo who developed metastases and LR on chemotherapy. 4 further patients had local recurrence after LSS. All had poor necrosis after chemotherapy but adequate margins. All developed metastatic disease and 3 have died. Overall survival was 60%. 5-year survival without metastatic disease at presentation was 65%. Conclusion. Our series is similar to other centres. Challenges include older patients, poor response to chemotherapy and metastases

We aimed to investigate the treatment and outcome of patients over 65 years of age with tibial Pilon fracture. Patients were treated by primary open reduction and internal fixation or external fixation (EF) as determined by local soft tissue conditions. Patient course, incidence of radiological osteoarthritis and functional outcome using the SF-36 questionnaire were recorded. All patients were evaluated serially until discharge from final follow-up. The mean follow-up time was 28 months (12-45). Statistical analysis was performed using Analyse-it(tm) software for Excel. In total 25 patients were studied. Two patients died before completion of treatment and were excluded from the final analysis. Therefore, 23 patients (10 male) were included with a mean age of 70.9 years (range 66-89) and a mean ISS of 10.25 (range 9-22). There were 4 grade IIIb open injuries. Three patients suffered superficial tibial wound infection. Two patients underwent early secondary amputation due to deep bone sepsis within 8 weeks of injury. One patient in the ORIF group underwent primary arthrodesis, which was subsequently revised due to non-union. 3 patients underwent secondary bone grafting to enhance healing, performed at 2, 6 and 9 weeks. 2 patients with metal work failure underwent subsequent revision of ORIF and progressed to union; the mean time to union was 33.8 weeks. At final follow-up 7 (28%) patients had radiological features of osteoarthritis but none had symptoms severe enough to warrant ankle arthrodesis. There were significant differences from the USA norm in physical function score, role physical score, and physical component score, (p< 0.01). Conclusion/Significance. In older patients local complications are relatively common and clinical vigilance must be maintained in order to allow appropriate intervention during their post-operative course. Despite the incidence of radiological post-traumatic arthrosis, none of the patients progressed to ankle fusion

Introduction: Septic non unions are rare and often occurs after an open fracture but they might arise after an inappropriate surgical or medical treatment. Different techniques can be used for the treatment. External fixation has many advantages over other techniques particularly when bone reconstruction and/or plastic surgery are indicated although sometimes more than one surgery is necessary to restore ideal biological and mechanical conditions for healing. Material and Methods: The authors present their experience in the treatment of 38 septic non unions using a protocol which differentiates the diagnostic and therapeutic approach. External fixation can be used as a single procedure or associated to other surgical procedures in relation to the type and diffusion of the infection. Results: Bone healing and infection eradication have been obtained in 92% of the cases (35 pts). We had 3 secondary amputations (8%). In the first series of patients screw removal and replacement, for pin track infections, occurred in 40% of the cases while this percentage decreased to 4.3% when HA- coated screws were used. Conclusions: The treatment of septic non-unions needs a multidisciplinary approach to treat properly both non union and infection of bone and soft tissues. Internal fixation remains a procedure at risk because of the high rate of infection recurrence. External fixation is instead still the safer and more versatile surgical option to treat these pathologies. It nevertheless requests strict diagnostic and therapeutic protocols and a good postoperative organisation in order to shorten the healing time and to minimise the complications

Purpose: Improved surgical technique and facilities enable emergency salvage of very damaged limbs. Functional outcome after this type of conservative treatment is generally satisfactory but at the risk of more or less quiescent osteitis. In the event of chronic osteitis, the neighbouring skin can undergo malignant degeneration (squamous-cell carcinoma). The purpose of our work was to report three such transformations and discuss therapeutic indications. Material and methods: The study series included three patients with chronic osteitis of the tibia after trauma. During surveillance, several years later we observed changes in local signs: increasing pain, purulent discharge and bleeding (Rowlands triad). In each patient, biopsy led to the diagnosis of transformation to squamous-cell carcinoma. All patients were treated by above knee amputation. Results: Outcome was satisfactory with an excellent quality scar formation. The search for extension was still negative a three years follow-up. Discussion: The frequency of carcinomatous degeneration near zones of chronic osteitis varies depending on the series to 0.2% to 1.7%. This is in sort the cost of conservative treatment. Changes in the clinical presentation, Rowland’s triad, associated with modification of the bacterial flora and development of a nauseous odour are important signs which should be followed by a biopsy. The treatment of choice for most authors is amputation in order to increase patient survival. Conclusion: The desire to pursue conservative reconstruction surgery even in the most difficult cases should not mask the risk of potential malignant transformation. Secondary amputation should not be considered as a failure in these extreme clinical situations

Background. Modular endoprostheses today represent a standard treatment option in the management of musculoskeletal tumors of the lower extremities. Long-term results of these reconstructions, however, are often limited by the course of the underlying disease. We therefore report our experiences in cancer patients with megaprostheses of the lower limb after a minimum of 15 years. Materials and Methods. 62 patients, 34 men and 28 women, with a mean age of 26 years (median, 20; range, 6–83) were included in this investigation with a mean follow-up of 230 months (median, 228; range, 180–342). Endoprosthetic reconstructions of the proximal femur (11), the distal femur (28), the total femur (2) or the proximal tibia (21) were indicated for osteosarcoma (43), chondrosarcoma (5), malignant fibrous histiocytoma (3) or other tumors (11). All patients have received either a KMFTR (22) or a HMRS (40) modular prosthesis; 23 patients had a muscle flap, 14 had a fibular transposition osteotomy and 4 have received an artificial LARS ligament for soft-tissue reconstruction. Results. 7 patients (11.3%) died throughout the follow-up period, but none succumbed to primary disease. One patient (1.6%) developed a local recurrence after 31 months that was resected. Overall, 56 patients (90.3%) underwent revision of their prosthesis; 50 (80.7%) had multiple revisions up to a maximum of 12 operations (mean, 3 per patient). The median overall prosthetic survival to first revision was 40 months; the corresponding 5-, 10- and 15-year survival rates were 35.5%, 14.5% and 12.9%, respectively. 3 patients (5.4%) had an infection, 8 (14.3%) had a soft-tissue related failure, 30 (53.6%) had a mechanical or structural failure and 15 (26.8%) had an aseptic loosening. The 15-year survival rates of these respective endpoints were 87.1% for infection, 79.0% for soft-tissue related failure, 32.3% for mechanical or structural failure and 56.5% for aseptic loosening. 59 patients (95.2%) have retained their prosthesis; 2 patients (3.2%) underwent secondary amputation due to an irresolvable complication, another one (1.6%) for a second malignancy. Conclusion. Modular prosthetic reconstructions of the lower extremities have a high revision rate in the long-term, primarily due to mechanical failures. Given that patients survive their malignant disease the rate of secondary implant removal, however, tends to be low, providing satisfactory function and body integrity. Further advances in implant design, soft tissue management and infection prophylaxis are required to reduce revision rates

Parosteal osteosarcoma is an uncommon tumour. Different methods of surgical treatment have been reported. Aim of this study was to investigate differences in outcome after biological and prosthetic reconstruction. Since August 1969, 28 patients have been treated at our institution. Average age was 26 years, range 15 to 59 years. Patient data was retrospectively reviewed within the prospective database of the Vienna Tumour Registry. Average follow-up was 133.9 months, range 8.4 to 382.6 months. Two patients died of disease 8.4 and 81.4 months after operation, respectively, another patient died due to unrelated causes 330.4 months postoperatively. All surviving patients were followed for a minimum of 3.6 months. Location of the lesion was the distal femur (19), proximal humerus (four), proximal tibia (three), mid-diaphyseal and proximal femur (one each). In 12 patients endoprosthetic reconstruction was indicated. Biological reconstruction was performed in 11 patients. Three patients underwent rotationplasty, two patients were amputated. Eight of 12 patients with endoprostheses have been revised, five have had multiple revisions. Causes for revision were bushing wear (four), aseptic loosening (four), infection (three) and periprosthetic fracture (one). There was no local recurrence in the endoprosthetic group. Two of 11 patients with biological reconstruction underwent revision due to pseudarthrosis and femoral fracture, respectively. There were two cases of local recurrence requiring secondary amputation. Two patients with rotationplasty underwent revision for wound healing disturbance and thrombectomy, respectively. Three patients developed lung metastases, leading to death of disease in two cases of amputation and rotationplasty. One patient with endoprosthetic reconstruction was alive 129.0 months after pulmonary metastasectomy. Functional outcome was satisfactory in all patients; there were no significant differences between patients with endoprosthetic or biological reconstruction. Biological reconstruction showed less revisions compared to endoprostheses, however, exact preoperative planning is required to obtain clear margins of resection

Purpose: Primary bone tumours situated at the distal end of the humerus are exceptional and observed in only 1% of the cases. Reconstruction at this level is often difficult due to the wide bone resection. Choosing a massive prosthesis is an interesting method allowing correct carcinological and functional results. We report a series of ten patients who underwent reconstruction of the lower end of the humerus between 1970 and 2001 with a massive prosthesis after tumour resection. Material and methods: This series included four men and six women, mean age 51 years (15–76). Eight patients had primary bone tumours and two had secondary bone lesions. Mean follow-up was 79 months (9–372). The custom-made constrained hinge prosthesis composed of chromium-cobalt and titanium was cemented. Regular clinical and radiological follow-up data were recorded. The Henneking score and the Toronto Extremity Survival Score (TESS) were used to assess functional outcome. Results: Three patients underwent revision for aseptic loosening of the humeral component at 48, 56 and 366 months with problem of polyethylene insert wear for two of them. There were no infctions or local recurrences and no secondary amputations. The posterior or anterolateral approach was used for humeral resection (mean 153 mm, 63–160 mm). Postoperatively, three patients developed transient palsy (one radial and two ulnar) which regressed. Four patients died from metastasis and had a satsifactory prosthesis result at time of death. The mean TESS was 73% (29–93%) at last follow-up. Discussion: Although this is a small series, the long-term results appear to indicate that reconstruction of the lower extremity of the humerus with a massive prosthesis is a satisfactory option for this rare tumour localisation