Limb salvage has become the most important treatment for patients with malignant bone tumors of the lower limb. Reconstruction with endoprosthesis of the proximal femur and distal femur and proximal tibia is now the most common solution. The data of 180 consecutive patients with malignant bone tumors of the lower limbtreated between 4/1987 and 11/1998 were reviewed. The average follow up is of four years.

129 patients had surgery for primary bone sarcoma, six for aggressive GCT and 45 for metastatic carcinoma. 63 patients were reoperated for different complications. The main complications were: local recurrences in 10 patients, infection in 12 patients and mechanical complications in 35 patients. 28 patients were operated two times and 24 patients more than two times.

14 patients have undergone amputation: six because of local recurrences, four because of infection, and two for post-surgical ischemia.

Eight of the 12 infections occurred after a re-operation.

35 patients had mechanical complications: 14 patients were reoperated to replace the polyethylene bushings in of the first model of HMRTS prosthesis (Howmedica), five patients had ruptures of the femoral stem, three patients suffered mobilization of the tibial stem and two of the femoral stem, six patients required a patella prostheses for local pain.

Two patients had acetabulum wear and three had hip dislocation.

In our experience endoprosthesis reconstruction after resection of bone tumors of the lower limb is a feasible procedure for limb salvage. We must consider that more than 30% of these patients will be re-operated for different complications and that 50% of infections occours after a new surgical procedure.

Conservative treatment of neoplastic bone lesions in paediatric patients may require the sacrifice of growth cartilage with subsequent hypometria or axial deviation of the lower limb.

Segmental reconstructions can be made using acrylic cement and intramedullary nailing or allograft. In case of involvement of the joint, reconstruction can be performed with prosthesis or arthrodesis.

These reconstruction techniques can lead to a progressive deformity associated with shortening of the limb.

The resolution of legs discrepancy and axial defects in survived patients often requires more than one surgical procedure.

In our Institute, the patients affected by aforementioned defects, are treated with axial or circular external fixator at completed skeletal growth.

This paper refers complications and outcomes in five patients treated:

1st case. Male, 10 years: osteosarcoma of the distal femur healed with residual shortening of 8 centimeters.

– We proceeded with a double level lengthening (proximal femur and proximal tibia) using Ilizarov technique.

The results obtained in our patients show that the use of the external fixator increases the quality of life in long-term survivors.

EH of bone is a rare vascular neoplasm, subtype of hemangioendothelioma, characterized by mesenchimal cells that have an epithelioid endothelial appearance. There are different kinds of EH: the benign epithelioid hemangioma, and the malignant epithelioid angiosarcoma.

This tumors can occurs in soft tissue, lung, liver and bones and often are multicentric.

EH generally involve the bone of the spine and lower limb and is very rare in the upper limb and the hands. The main symptom is pain; pathological fracture may occur in aggressive lesions.

Radiographically the EH is a ostelytic lesion with variable peripheral sclerosis, cortical destruction and periosteal new bone.

Treatment of EH is curettage and local adjuvants in benign lesion, en bloc resection in the low-grade forms and wide or radical surgery in the high-grade forms. Radiation therapy is suggest in inoperable situations.

In the present report we describe the clinical features, the oncological treatment and the reconstructive solutions of two cases of EH of the hand treated in the Orthopedic Oncological Center of Gaetano Pini Institute of Milan. Both cases had multiple locations in the carpus, metacarpus and phalanges. The involvement of more joints caused a delayed diagnosis (> 1 year). Exer-esi and reconstruction of several segments of the wrist and hand has led to considerable technical difficulties resolved with the collaboration of the microsurgeon and plastic surgeon.

Introduction: Infection following major orthopaedic oncological surgery is a serious complication and every precaution should be taken to avoid it.

One potential source of infection is the biopsy procedure, particularly when is carried out of a referring centre. In fact up to 30 per cent of patients with soft tissues problems following a biopsy is reported. As an infected biopsy may make subsequent limb preservation surgery impractical, the greatest care should be taken in carrying out the biopsy.

The implantation of foreign materials (prostheses, grafts, acrilic cement, metallic devices, etc) as the duration of the surgical procedure, intraoperative bleeding, possible deep haematomas, presence of drains, increase the risk of infection. Also the importance of haematogenous spread from other sites of infection to joint pros-thesis is well estabilished.

Materials and methods: In this paper the Authors present their experience regarding septic complications after orthopaedic oncologie surgery. From 1988 to 2002, 143 patients underwent a major surgery for the treatment of skeletal neoplasms (wide resection and reconstruction employing modular or composite prostheses, osteoarticular or intercalary allografts, acrylic cement and osteosynthesis devices, major spinal surgery, internal hemipelvectomy, etc).

Results: The patients were followed-up to detect the presence of a septic complication. Also patient’s files were revised to evaluate paramethers related to infection as bleeding, duration of surgery, postoperative fever, neutropenia, ESR and CRP, antibiotic prophylaxis, etc. The overall infection rate was approximately to 15 per cent.

Conclusions: Immunosuppression from previous chemotherapy may predispose the patient to infection which may be occult, but which must be diligently sought.

It has to be also emphasized that if at any stage the patient has had local radiotherapy, the tissues may be fibrosed and avascular and unable to combat local infection effectively.

The Authors retain that the infection after major orthopaedic oncologie surgery could represent a serious threat to the implant and to the limb. The importance of meticolous asepsis practised at every stage has to be emphasized, together with prolonged use of prophylactic antibiotic, specially in immunosuppressed patients or chemotherapy.

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.