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S. Bilgin (2012)
Reconstruction of proximal humeral defects with shoulder arthrodesis using free vascularized fibular graft.The Journal of bone and joint surgery. American volume, 94 13
Sho Okimatsu, H. Kamoda, T. Yonemoto, S. Iwata, T. Ishii (2016)
Effectiveness of Clavicula Pro Humero Reconstruction for Elderly Patients: Report of Two CasesCase Reports in Oncological Medicine, 2016
Li Da-sen (2005)
Reconstruction of the proximal humerus with the clavicle after tumor resectionChinese Journal of Orthopaedics
M. Clayer (2015)
A New Approach for Complex Upper Limb Revisions Utilizing the Clavicula Pro Humero Technique: A Case ReportJBJS Case Connector, 5
Y. Nishida, S. Tsukushi, Yoshihisa Yamada, Y. Kamei, K. Toriyama, N. Ishiguro (1994)
Reconstruction of the proximal humerus after extensive extraarticular resection for osteosarcoma: A report of two cases with clavicula pro humero reconstructionOncology Reports, 20
Jonathan Stevenson, R. Doxey, A. Abudu, Michael Parry, Scott Evans, F. Peart, L. Jeys (2018)
Vascularized fibular epiphyseal transfer for proximal humeral reconstruction in children with a primary sarcoma of boneThe Bone & Joint Journal, 100B
R. Wilkins, Chris Miller (2003)
Reoperation After Limb Preservation Surgery for Sarcomas of the Knee in ChildrenClinical Orthopaedics and Related Research, 1
(2020)
CA: A
Y. Kitagawa, DM Thai, P. Choong (2007)
Reconstructions of the Shoulder following Tumour ResectionJournal of Orthopaedic Surgery, 15
David Kurlander, S. Shue, G. Schwarz, A. Ghaznavi (2019)
Vascularized Fibula Epiphysis Transfer for Pediatric Extremity Reconstruction: A Systematic Review and Meta-analysisAnnals of Plastic Surgery, 82
George Quill, S. Gitelis, Timothy Morton, P. Piasecki (1990)
Complications associated with limb salvage for extremity sarcomas and their management.Clinical orthopaedics and related research, 260
Yajie Lu, Xin Xiao, Minghui Li, Guo‐jing Chen, Mengquan Huang, Chuanlei Ji, Zhen Wang, Jing Li (2021)
Use of Vascularized Fibular Epiphyseal Transfer with Massive Bone Allograft for Proximal Humeral Reconstruction in Children with Bone SarcomaAnnals of Surgical Oncology, 28
S. Tsukushi, Y. Nishida, Mitsuru Takahashi, N. Ishiguro (2006)
Clavicula Pro Humero Reconstruction after Wide Resection of the Proximal HumerusClinical Orthopaedics and Related Research, 447
M. Armangil and S. S. Bilgin (2013)
Reconstruction of proximal humeral defects with shoulder arthrodesis using free vascularized fibular graft,JBJS Essential Surgical Techniques, 3
F. Sirveaux (2019)
Reconstruction techniques after proximal humerus tumour resection.Orthopaedics & traumatology, surgery & research : OTSR, 105 1S
D. Barbier, B. Billy, P. Gicquel, S. Bourelle, P. Journeau (2017)
Is the Clavicula Pro Humero Technique of Value for Reconstruction After Resection of the Proximal Humerus in Children?Clinical Orthopaedics and Related Research®, 475
J. Benevenia, F. Patterson, Kathleen Beebe, K. Tucker, Jeffrey Moore, J. Ippolito, Steven Rivero (2015)
Results of 20 consecutive patients treated with the Repiphysis expandable prosthesis for primary malignant boneSpringerPlus, 4
Andrew Dubina, Brian Shiu, M. Gilotra, S. Hasan, D. Lerman, Vincent Ng (2017)
What is the Optimal Reconstruction Option after the Resection of Proximal Humeral Tumors? A Systematic ReviewThe Open Orthopaedics Journal, 11
Y. Tsuda, K. Tsoi, J. Stevenson, T. Fujiwara, R. Tillman, A. Abudu (2019)
Extendable Endoprostheses in Skeletally Immature Patients: A Study of 124 Children Surviving More Than 10 Years After Resection of Bone Sarcomas.The Journal of bone and joint surgery. American volume
W. Wożniak, T. Izbicki, M. Rychłowska, P. Niedzielski (1996)
Malignant humeral bone tumors in children: Excision and reconstruction with the use of rotated clavicleJournal of Surgical Oncology, 62
R. Rödl, G. Gosheger, C. Gebert, N. Lindner, T. Ozaki, W. Winkelmann (2002)
Reconstruction of the proximal humerus after wide resection of tumours.The Journal of bone and joint surgery. British volume, 84 7
Winkelmann Ww (2008)
Clavicula pro Humero - eine neue Operationsmethode für maligne Tumoren des proximalen HumerusZeitschrift für Orthopädie (ZfO), 130
G. Calvert, Jennifer Wright, J. Agarwal, Kevin Jones, Lor Randall (2015)
Is Claviculo Pro Humeri of Value for Limb Salvage of Pediatric Proximal Humerus Sarcomas?Clinical Orthopaedics and Related Research®, 473
J. Wong, J. Abraham (2014)
Upper extremity considerations for oncologic surgery.The Orthopedic clinics of North America, 45 4
N. Dubrawsky (1989)
Cancer statisticsCA: A Cancer Journal for Clinicians, 39
R. Stephenson (1962)
A and VBritish Journal of Ophthalmology, 46
MD KINAMI, I. Miyazaki, Mdi
AND T
R. Siegel, K. Miller, A. Jemal (2020)
Cancer statistics, 2020CA: A Cancer Journal for Clinicians, 70
F. Chotel, L. Nguiabanda, P. Braillon, R. Kohler, J. Bérard, K. Abelin-Genevois (2012)
Induced membrane technique for reconstruction after bone tumor resection in children: a preliminary study.Orthopaedics & traumatology, surgery & research : OTSR, 98 3
(1975)
Cancer Incidence and Survival Among Children and Adolescents: United States SEER Program
Y. J. Avashia R. L. Shammas
Vascularized fibula-based physis transfer,Plastic and Reconstructive Surgery—Global Open, 5
Nicki Zelenski, B. Brigman, L. Levin, D. Erdmann, W. Eward (2013)
The Vascularized Fibular Graft in the Pediatric Upper Extremity: A Durable, Biological Solution to Large Oncologic DefectsSarcoma, 2013
Samuel Grinberg, Abigail Posta, K. Weber, Robert Wilson (2020)
Limb Salvage and Reconstruction Options in Osteosarcoma.Advances in experimental medicine and biology, 1257
A. Zaretski, A. Amir, I. Meller, D. Leshem, Y. Kollender, Y. Barnea, J. Bickels, T. Shpitzer, D. Ad-El, E. Gur (2004)
Free Fibula Long Bone Reconstruction in Orthopedic Oncology: A Surgical Algorithm for Reconstructive OptionsPlastic and Reconstructive Surgery, 113
Alexander Rovira, Nicolas Müller, Weiwen Deng, Chudi Ndubaku, Richmond Sarpong (2019)
Bio-inspired synthesis of xishacorenes A, B, and C, and a new congener from fuscol† †Electronic supplementary information (ESI) available. See DOI: 10.1039/c9sc02572cChemical Science, 10
D. Erdmann, Ryan Garcia, Gert Blueschke, B. Brigman, L. Levin (2013)
Vascularized Fibula-Based Physis Transfer for Pediatric Proximal Humerus ReconstructionPlastic and Reconstructive Surgery, 132
S. Onoda, M. Sakuraba, T. Asano, S. Miyamoto, Y. Beppu, H. Chuman, A. Kawai, F. Nakatani, Y. Kimata (2011)
Use of Vascularized Free Fibular Head Grafts for Upper Limb Oncologic ReconstructionPlastic and Reconstructive Surgery, 127
D. Campanacci, S. Puccini, G. Caff, G. Beltrami, A. Piccioli, M. Innocenti, R. Capanna (2014)
Vascularised fibular grafts as a salvage procedure in failed intercalary reconstructions after bone tumour resection of the femur.Injury, 45 2
and P
R. Karami, Fadi Ghieh, S. Saghieh, A. Ibrahim (2021)
The use of the fibula flap in post oncologic reconstruction of long bone in pediatric patients: A retrospective cohort study.Journal of plastic, reconstructive & aesthetic surgery : JPRAS
C. Gebert, A. Hillmann, A. Schwappach, C. Hoffmann, J. Hardes, J. Kleinheinz, G. Gosheger (2006)
Free vascularized fibular grafting for reconstruction after tumor resection in the upper extremityJournal of Surgical Oncology, 94
T. Ozaki, H. Hashizume, T. Kunisada, A. Kawai, K. Nishida, S. Sugihara, H. Inoue (2001)
Reconstruction of the proximal humerus with the clavicle after tumor resection: a case report.Clinical orthopaedics and related research, 385
F. Fitoussi, B. Ilharreborde (2015)
Is the Induced-membrane Technique Successful for Limb Reconstruction After Resecting Large Bone Tumors in Children?Clinical Orthopaedics and Related Research®, 473
M. Landau, Ido Badash, Christine Yin, R. Alluri, K. Patel (2018)
Free vascularized fibula grafting in the operative treatment of malignant bone tumors of the upper extremity: A systematic review of outcomes and complicationsJournal of Surgical Oncology, 117
Hindawi Sarcoma Volume 2022, Article ID 6240293, 7 pages https://doi.org/10.1155/2022/6240293 Research Article Free Vascularized Fibula Salvage of Failed CPH in Pediatric Sarcoma Patients 1 1 1 1 2 GiovannaPires , WhitneyD.Moss , JessicaLuo , RuyanZhang , KevinBJones , 1 1 Alvin C Kwok , and Jayant P Agarwal Division of Plastic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA Department of Orthopedics, University of Utah, Salt Lake City, UT, USA Correspondence should be addressed to Jayant P Agarwal; jay.agarwal@hsc.utah.edu Received 10 February 2022; Revised 18 April 2022; Accepted 19 April 2022; Published 9 May 2022 Academic Editor: Kanya Honoki Copyright © 2022 Giovanna Pires et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Due to extended life expectancy and recent improvements in surgical techniques, limb salvage has replaced am- putation as the gold standard and is now performed in 90–95% of upper extremity malignancies. However, many of these salvage procedures are associated with signi‹cant postsurgical complications. In particular, the clavicula pro humero (CPH) procedure is associated with high rates of nonunion. We present our experience with upper extremity salvage using the free vascularized ‹bular ”ap (VFF) after failure or nonunion of the original CPH procedure in the pediatric population. Methods. Five patients under the age of 18 diagnosed with upper extremity sarcoma who underwent tumor resection with immediate CPH reconstruction complicated with nonunion, and subsequent revision with free VFF were included. Data on patient demographics, oncologic characteristics, surgical procedures, intraoperative details, postoperative complications, and time to graft union were recorded. Results. Five patients (average age 8.4 years; range 5–10 years at surgery date) underwent secondary limb salvage procedure with free VFF reconstruction following failed CPH reconstruction for proximal humeral osteosarcoma (n 4) or Ewing sarcoma (n 1). e mean follow-up was 3.7 years. Complications occurred in ‹ve patients (100%), with three patients requiring reoperation (60%). Four patients achieved graft union (average union time 3.7 months) and successful limb reconstruction. Four patients were alive with no local recurrence of the disease. One patient did not achieve union and was lost to follow-up. Conclusion. Primary bone tumors in the pediatric population require wide surgical resection, and reconstruction often has high complication rates that can warrant further procedures. A free VFF is a viable option for upper extremity salvage after previously failed reconstructions because it provides vascularized tissue to a scarred tissue bed and allows for the replacement or aug- mentation of large bony defects. replaced amputation as the gold standard and is now per- 1. Introduction formed for 90–95% of upper extremity malignancies [2, 5, 6]. Primary bone tumors account for 6% of malignancies in the e proximal humerus is the fourth most common lo- pediatric population younger than 20 years of age, with cation for primary bone tumors [2]. In the pediatric pop- ulation, the tendency of primary malignant tumors to osteosarcoma (56%) and Ewing sarcoma (34%) being the most predominant [1]. e mainstay of treatment for both develop near the physeal growth centers of long bones malignancies includes multiagent chemotherapy punctuated presents unique challenges for reconstruction [2, 5]. Often, by wide surgical resection for local control [2]. With the the resection involves the humeral head, extensive muscu- advancement of diagnostic imaging and chemotherapy lature, rotator cu¢ tendons, and axillary nerve, which makes strategies, the 5-year survival rate for children has increased the reconstructive goals of a sustainably stable shoulder with to 60–79% [3, 4]. Due to the extended life expectancy and maximum mobility di£cult to achieve [5]. Due to skeletal improvement in surgical techniques, limb salvage has immaturity, resection of the physis prevents further growth 2 Sarcoma and can result in the development of limb length discrep- identified patients under the age of 18 diagnosed with upper ancies [5]. Reconstructive options range from metal endo- extremity sarcoma who underwent tumor resection with prosthetic implants, cadaveric allografts, and vascularized or immediate CPH reconstruction complicated by nonunion, nonvascularized autografts [2, 5]. Each option exposes the and subsequent revision surgery with free VFF. +e fol- patient to modest benefits, significant functional challenges, lowing data were recorded: patient demographics, comor- and high rates of complications. +is has resulted in a lack of bidities, primary diagnosis, malignancy location, presence of consensus amongst surgeons on the best reconstructive metastatic disease, adjuvant therapy, procedure performed, method. Ultimately, the type of reconstruction depends on vessel anastomosis, imaging, mortality, limb survival, local surgeon preference, experience, patient-specific factors (e.g., recurrence, complications, reoperations, and time to graft age, preference, and functional requirements), and tumor- union. Graft union time was determined by the visualization specific factors (e.g., size, location, and associated soft tissue of bridging callus or the obscuring of the osteotomy site at involvement) [7]. the proximal and distal ends of the fibular graft on radio- At our institution, clavicula pro humero (CPH) has been graph interpretation by an orthopedic surgeon on follow-up offered to young patients with primary bone malignancies in imaging. the proximal humerus. CPH uses native anatomy to re- construct a stable and durable proximal humerus that permits further growth and limits other donor site morbidity 2.1. Surgical Technique. All five patients originally under- [8]. Since the first description of the use of CPH for proximal went an immediate tumor resection and CPH reconstruc- humerus reconstruction in 1992 by Winkelmann [9], there tion by a senior orthopedic surgeon at our institution have been only a handful of case reports and case series (Supplemental Table 2). In all patients, the CPH recon- assessing surgical outcomes for these patients. +ese pub- struction resulted in nonunion or fracture. +e patients then lished cases have revealed that CPH can maintain shoulder underwent a salvage procedure with delayed VFF recon- stability with comparable mobility (average 75 on flexion) struction by a multidisciplinary surgical team consisting of a and superior Musculoskeletal Tumor Society (MSTS) senior plastic surgeon and a senior orthopedic surgeon. All functionality scores (83%) [10, 11]. However, the published patients underwent preoperative angiogram assessment of complication rates for this procedure are high, with a the upper and lower extremities for artery and vein mapping. +e prior anterior incision of the upper extremity was substantial number of documented postoperative compli- cations requiring surgical revision (Supplemental Table 1) used to access the humerus, and the dissection was carried [8, 12–20]. +e largest pediatric case series assessing post- down to the bone and the nonunion site. +e broken fixation operative outcomes following CPH for proximal humerus devices (plate and/or screws) were removed, and the non- reconstruction revealed proximal nonunion requiring re- union site debrided down to bleeding bone. In preparation vision surgery occurred in five of seven patients (71%) [19]. for the VFF, further exposure of the bone and vascular Due to the expected risks of nonunion and fracture following supply was performed. CPH, it is essential to anticipate possible revision proce- +e contralateral fibular length was measured and dures. However, since the CPH procedure itself is not marked on the skin of the posterolateral leg. +e fibula was commonly performed given the low frequency of proximal isolated in the usual fashion. Harvested diaphysis fibular humeral sarcomas, there is a paucity of literature on sec- length averaged 12.4 cm (range � 10–16 cm) (Table 1). ondary salvage procedures following CPH failure. Osteotomies were performed superiorly and inferiorly at +e vascularized fibular flap (VFF) has become the the measured length. +e peroneal vessels were identified, workhorse for segmental bony reconstruction and an option dissected to provide a leash, and then carefully clipped for salvage after failed endoprosthetic, allograft, or other and divided. Care was taken to preserve the tibial and autograft reconstructions. It has the advantages of enhanced peroneal nerves, as well as the anterior and posterior tibial rates of biologic incorporation and the ability to thrive in arteries. compromised soft tissue environments [7, 21, 22]. While In the brachium, the fibular flap was placed in appro- VFF has been described as a primary reconstruction option priate alignment alongside the clavicular graft and attached for long bone sarcomas [23] and a successful salvage pro- with bone screws to the proximal fragment of the clavicular graft and the distal fragment of the humerus. +e appro- cedure for femur reconstruction and allograft failure [24], no reports have been published on the use of VFF as a sec- priate alignment of the humerus was confirmed with fluo- ondary salvage procedure following failed CPH in pediatric roscopy. +e elbow was taken through a full range of motion patients. In this study, we retrospectively review all pediatric to ensure the graft was not blocking elbow flexion or ex- patients at our institution who underwent secondary salvage tension. In three patients (60%), allograft chips were mixed using the vascularized fibular flap (VFF) after nonunion of with demineralized bone matrix and placed at the nonunion the original proximal humerus reconstruction with the CPH site. Anastomosis was then performed between the peroneal procedure. artery of the flap and an artery of the recipient site (brachial artery, branch of the brachial artery, or circumflex humeral artery) in an end-to-end or end-to-side fashion. All venous 2. Methods anastomoses were performed in an end-to-end fashion with a venous coupler between the peroneal vein and a deep arm +is retrospective study was exempted by our institution’s Institutional Review Board (IRB00118828). Chart review vein (Table 1). An implantable Doppler was typically placed Sarcoma 3 Table 1: Free vascularized fibular flap (VFF) operative details. Was allograft Skin Original Fibula Artery Operative Estimated or DBM used # of paddle Mode of Patient defect size length Anastomosis anastomosis duration blood loss at the veins size fixation (cm) (cm) style (min) (mL) nonunion (cm) site? Peroneal to 1 10.5 16 side branch of ETS 1 — — 350 Yes Screws brachial Peroneal to ∗∗ 2 15 10 circumflex ETE 1 15 × 2.5 459 150 No Screws humeral Plate (reused from Peroneal to 3 17 15 ETS 1 10 ×1.5 710 200 No original brachial procedure), screws Peroneal to 4 15 11 side branch of ETS 1 15 × 2.5 497 50 Yes Screws brachial Peroneal to 5 8 10 circumflex ETE 1 15 × 3 462 375 Yes Screws humeral artery ∗ ∗∗ +ird revision surgery. Fourth revision surgery. ETS: end-to-side; ETE: end-to-end; —: not available. Table 2: Patient demographics and oncologic characteristics. Time to failure from Follow- Patient Sex Age Diagnosis Location Metastasis Chemo Radiation CPH operation up ∗∗ (days) 8 y Proximal 1 M 5 y 0 m Osteosarcoma No Yes No 611 3 m humerus 9 y Proximal 2 F 3 y 4 m Osteosarcoma Yes Yes No 497 1 m humerus 10 y Ewing Proximal Yes (postoperative whole lung 3 F 5 y 10 m Yes Yes 493 1 m sarcoma humerus irradiation for 8 fractions) 10 y Proximal 4 M 3 y 2 m Osteosarcoma No Yes No 287 2 m humerus 5 y Proximal 5 F 1 y 2 m Osteosarcoma No Yes No 1568 9 m humerus ∗ ∗∗ Follow-up defined as time from CPH procedure to last documented clinic follow-up visit. Time to failure from CPH operation defined as days between CPH operation and secondary salvage procedure. around the vein and secured with a hemoclip to ensure a mean age of 8.4 years old (range � 5–10 years old) at the time good venous signal. of salvage surgery. +e average time to salvage surgery from At both surgical sites, adequate hemostasis was obtained, the CPH operation was 691.2 days (range � 287–1568 days). bulb suction drains placed, and incisions closed. A skin All patients presented with primary bone tumors and the paddle was used if the overlying skin was heavily scarred or proximal humerus was the involved site in all patients pulled excessively tight to provide more malleable soft tissue (n � 5). +e pathologic diagnosis was osteosarcoma in four coverage. +e arm was immobilized in a sling and swathe, patients (80%), and Ewing sarcoma in one patient (20%). and the ankle in a fiberglass splint. Two patients (40%) presented with metastatic disease. All patients received preoperative chemotherapy. One patient received additional postoperative radiation consisting of 3. Results whole lung irradiation for 8 fractions. One patient had a 3.1. Demographics and Oncologic Characteristics. We iden- patent foramen ovale, but otherwise, no patients had any tified five pediatric patients who underwent free VFF salvage significant past medical history. +e mean follow-up time, reconstruction following failed CPH (Table 2). All of the defined as the time from the CPH procedure to the last flaps performed were osteocutaneous flaps. +e study cohort documented clinic follow-up visit, was 3.7 years consisted of two males (40%) and three females (60%) with a (range � 1.2–5.10 years) (Table 2). +ere was no local 4 Sarcoma Table 3: Postoperative course and associated complications. Postoperative Treatment of Total # of associated Time to osseous Patient Reoperation details complications complications reoperations union (months) 1 Lost Doppler signal Reoperation Venous Doppler repositioning 1 4.6 Transfusion of 1 Hypotension — — pRBC Conservative 2 Partial tissue necrosis — 0 2.9 management Skin paddle venous Skin paddle resection with 3 Reoperation — congestion advancement flap Nonunion and Planned 2 — fracture reoperation Hematoma evacuation, flap vein 4 Lost Doppler signal Reoperation 1 5.3 thrombectomy and reanastomosis Conservative 5 Radial nerve palsy — 0 1.9 management Lost to follow-up before undergoing reoperation and achieving evidence of osseus union. Exploration of the right arm fibula flap revealed venous Doppler shifted in position but artery and vein were patent on exploration. Exploration revealed thrombosis of tiny perforator vessels with widely patent flap vessels. Skin paddle resected using Bovie, and an anterior skin subcutaneous tissue advancement flap 15 × 6 cm for right arm closure. Figure 1: (a) 3 months after primary limb reconstruction with clavicula pro humero (CPH) procedure. (b) Nonunion at 9 months after original CPH procedure. (c) Subsequent fracture at 19 months after original CPH. (d) Secondary salvage procedure 24 months after CPH with onlay free vascularized fibular flap. (e) Union and remodeling of fibular flap 63 months after original CPH procedure. reoccurrence of the disease in any of the cases, and all reoperation (40%) included partial necrosis of the skin paddle patients were alive at the time of the study. treated conservatively (n � 1), and transient radial nerve palsy that resolved with conservative management (n � 1). +ere were no cases of total flap loss and no donor site compli- 3.2. Complications. All patients experienced postoperative cations. Subsequent postoperative radiographs revealed bi- complications, representing a complication rate of 100% lateral fibular bone integration at the recipient site. Since all (Table 3). Of the five patients experiencing complications, flaps were osteocutaneous flaps, we were able to clinically three (60%) required immediate reoperation. One patient assess the skin paddle viability. All the skin flaps remained required revision of the venous anastomosis for thrombosis, viable, providing further reassurance of bone survival. one required partial skin paddle excision and advancement for partial necrosis, and one required surgical re-exploration for a lost signal from a dislodged Doppler and required only 3.3. Bone Union and Functional Outcomes. Patients were repositioning of the Doppler in the operating room. +e two followed up with radiographic imaging (Figure 1). Four cases with postoperative complications which did not require patients (80%) achieved bony union at both ends of the Sarcoma 5 fibula, with an average time to bony union of 3.7 months attributed to the excessive local scar tissue and decreased (range � 1.9–5.3 months) (Table 3). One patient (20%) ex- blood flow from prior procedures as well as postradiation skin changes. Despite the high rate of postoperative com- perienced graft nonunion and fracture. +is patient was scheduled for planned reoperation but was ultimately lost to plications, all patients retained the salvaged limb and were follow-up prior to surgical intervention. Despite the oc- able to complete activities of daily living. Additionally, four currence of nonunion in one patient, all patients (n � 5) patients (80%) achieved bony union by four months on retained the salvaged limb. At the last clinic follow-up, all average, which is consistent with the prior literature on VFF patients (100%) demonstrated intact sensation in the reconstruction of the proximal humerus [35–37]. proximal upper extremity and well-healed surgical incisions. Additionally, all patients (100%) were able to perform 4.1. Limitations. +ere are several limitations to this study, regular activities of daily living with no pain complaints. including the retrospective nature of the study which limits Postoperative range of motion varied between patients data collection. Another limitation is the small sample size. depending on the muscular structures sacrificed during the +e rarity of bone sarcomas in any specific anatomic site in initial tumor resection (Supplemental Table 2). +ree pa- the pediatric population makes it difficult for institutions to tients (60%) were able to raise their hands to their forehead gather significant case numbers. Our study further limits the on physical exam. Active shoulder flexion for all patients number of cases as it focuses on our experiences with a ranged from 45 to 60 . +ree patients (60%) had medical secondary revisional procedure not well described in the record documentation of full function and range of motion literature. Another limitation is the average follow-up time from the elbow distally with good hand strength; the distal of 3.7 years. Although several years of follow-up time is range of motion of the other two patients was not specified. generally considered sufficient, in many pediatric recon- structive operations, the dissatisfaction with limb aesthetics 4. Discussion or length discrepancies as patients grow can often drive further operations, which is not accounted for in our rel- Primary bony tumors in the proximal humerus of pediatric atively short follow-up time. Additionally, our patients have patients are rare. +e many reconstructive options com- not yet reached skeletal maturity, and the long-term du- pounded with challenging functional goals make the deci- rability of these reconstructions is yet uncertain. sion between the surgeon and parents for the best salvage method difficult. Regardless of the type of reconstruction, complications such as nonunion and fractures warranting 5. Conclusion further procedures can be common. In previously published Primary bone tumors in the pediatric population require systematic reviews, fractures were the most common wide surgical resection, and reconstruction often has high complication of upper extremity reconstructions (35% and complication rates of nonunion or fractures that can warrant 11.7%) [21, 25]. +e most common original limb salvage further procedures. A free VFF is a viable option for upper operations in the pediatric population include vascularized extremity salvage after previously failed reconstructions fibular flap (VFF) [26–29], endoprosthesis [30, 31], induced because it provides vascularized tissue to a scarred tissue bed membrane techniques involving spacers [32, 33], and vas- and allows for the replacement or augmentation of large cularized fibular epiphyseal transfers [29, 34]. Vascularized bony defects. fibular epiphyseal transfers in particular have gained pop- ularity as a first-line treatment option due to preserved longitudinal growth potential and adequate functional Data Availability outcomes [29, 34]. Due to the expected risks of nonunion +e data are available from the authors upon reasonable and fracture following limb salvage procedures regardless of request. the initial reconstructive method selected, it is essential to anticipate possible revision procedures and document successful salvage options for this population. One previ- Disclosure ously published manuscript on pediatric sarcoma recon- +e procedures were performed at the University of Utah struction salvage was a case report (n � 1) documenting limb Hospital. salvage with a combined clavicula pro humero (CPH) and VFF procedure following infection of the original mega- prosthetic reconstruction [18]. +e literature on pediatric Conflicts of Interest proximal humerus reconstruction is limited, and elaboration on further procedures has rarely been described, aside from Dr. Agarwal is a consultant for an unrelated project with the previously mentioned case report. We aimed to fill this Don Joy Orthopedics. Dr. Jones has contracts with the gap in the literature by reporting our experience with VFF National Cancer Institute and National Institute of Health salvage of failed CPH proximal humerus reconstruction. and is a Connective Tissue Oncology Society Board member. All five (100%) of our patients experienced complica- +e other authors certify that they have no commercial tions, with three (60%) needing further operations (patients associations (e.g., consultancies, stock ownership, equity 1, 3, and 4). +e reoperations occurred in the immediate interest, patent/licensing arrangements, etc.) that might pose postoperative period. +e high rate of complications may be a conflict of interest in connection with the submitted article. 6 Sarcoma [15] S. Tsukushi, Y. Nishida, M. Takahashi, and N. Ishiguro, Supplementary Materials “Clavicula pro humero reconstruction after wide resection of the proximal humerus,” Clinical Orthopaedics and Related Supplemental Table 1: literature search of proximal humerus Research, vol. 447, pp. 132–137, 2006. reconstruction with CPH procedure and associated com- [16] Y. Kitagawa, D. +ai, and P. Choong, “Reconstructions of the plications. Supplemental Table 2: initial tumor resection and shoulder following tumour resection,” Journal of Orthopaedic CPH reconstruction operative details. (Supplementary Surgery, vol. 15, no. 2, pp. 201–206, 2007. Materials) [17] Y. Nishida, S. Tsukushi, Y. Yamada, Y. Kamei, K. Toriyama, and N. Ishiguro, “Reconstruction of the proximal humerus References after extensive extraarticular resection for osteosarcoma: a report of two cases with clavicula pro humero reconstruc- [1] L. A. G. Ries, M. A. Smith, J. G. Gurney et al., Cancer Incidence tion,” Oncology Reports, vol. 20, no. 5, pp. 1105–1109, 2008. and Survival Among Children and Adolescents: United States [18] M. Clayer, “A new approach for complex upper limb revisions SEER Program 1975-1995, National Cancer Institute, utilizing the clavicula pro humero technique,” JBJS Case Bethesda, MD, USA, 1999. Connector, vol. 5, no. 4, p. e114, 2015. [2] J. C. Wong and J. A. Abraham, “Upper extremity consider- [19] D. Barbier, B. De Billy, P. Gicquel, S. Bourelle, and ations for oncologic surgery,” Orthopedic Clinics of North P. Journeau, “Is the clavicula pro humero technique of value America, vol. 45, no. 4, pp. 541–564, 2014. for reconstruction after resection of the proximal humerus in [3] R. L. Siegel, K. D. Miller, and A. Jemal, “Cancer statistics, children?” Clinical Orthopaedics and Related Research, 2020,” CA: A Cancer Journal for Clinicians, vol. 70, no. 1, vol. 475, no. 10, pp. 2550–2561, 2017. pp. 7–30, 2020. [20] S. Okimatsu, H. Kamoda, T. Yonemoto, S. Iwata, and T. Ishii, [4] R. M. Wilkins and C. M. Miller, “Reoperation after limb “Effectiveness of clavicula pro humero reconstruction for preservation surgery for sarcomas of the knee in children,” elderly patients: report of two cases,” Case Reports in Onco- Clinical Orthopaedics and Related Research, vol. 412, logical Medicine, vol. 2016, Article ID 4140239, 6 pages, 2016. pp. 153–161, 2003. [21] M. J. Landau, I. Badash, C. Yin, R. K. Alluri, and K. M. Patel, [5] S. Z. Grinberg, A. Posta, K. L. Weber, and R. J. Wilson, “Limb “Free vascularized fibula grafting in the operative treatment of salvage and reconstruction options in osteosarcoma,” Ad- malignant bone tumors of the upper extremity: a systematic vances in Experimental Medicine & Biology, vol. 1257, review of outcomes and complications,” Journal of Surgical pp. 13–29, 2020. Oncology, vol. 117, no. 7, pp. 1432–1439, 2018. [6] G. Quill, S. Gitelis, T. Morton, and P. Piasecki, “Complica- [22] N. Zelenski, B. E. Brigman, L. S. Levin, D. Erdmann, and tions associated with limb salvage for extremity sarcomas and W. C. Eward, “+e vascularized fibular graft in the pediatric their management,” Clinical Orthopaedics and Related Re- upper extremity: a durable, biological solution to large on- search, vol. 260, pp. 242–250, 1990. cologic defects,” Sarcoma, vol. 2013, Article ID 321201, [7] C. Gebert, A. Hillmann, A. Schwappach et al., “Free vascu- 7 pages, 2013. larized fibular grafting for reconstruction after tumor resec- [23] R. A. Karami, F. M. Ghieh, S. S. Saghieh, and A. E. Ibrahim, tion in the upper extremity,” Journal of Surgical Oncology, “+e use of the fibula flap in post oncologic reconstruction of vol. 94, no. 2, pp. 114–127, 2006. long bone in pediatric patients: a retrospective cohort study,” [8] G. T. Calvert, J. Wright, J. Agarwal, K. B. Jones, and Journal of Plastic, Reconstructive & Aesthetic Surgery, vol. 74, L. R. Randall, “Is claviculo pro humeri of value for limb no. 10, pp. 2504–2511, 2021. salvage of pediatric proximal humerus sarcomas?” Clinical [24] D. A. Campanacci, S. Puccini, G. Caff et al., “Vascularised Orthopaedics and Related Research, vol. 473, no. 3, pp. 877– fibular grafts as a salvage procedure in failed intercalary re- 882, 2015. constructions after bone tumour resection of the femur,” [9] W. Winkelmann, “Clavicula pro Humero—eine neue Oper- Injury, vol. 45, no. 2, pp. 399–404, 2014. ationsmethode fur ¨ maligne Tumoren des proximalen Hu- [25] D. E. Kurlander, S. Shue, G. S. Schwarz, and A. M. Ghaznavi, merus,” Zeitschrift fur ¨ Orthopadie ¨ und ihre Grenzgebiete, “Vascularized fibula epiphysis transfer for pediatric extremity vol. 130, no. 03, pp. 197–201, 1992. reconstruction,” Annals of Plastic Surgery, vol. 82, no. 3, [10] A. Dubina, B. Shiu, M. Gilotra, S. A. Hasan, D. Lerman, and pp. 344–351, 2019. V. Y. Ng, “What is the optimal reconstruction option after the [26] D. Erdmann, R. M. Garcia, G. Blueschke, B. E. Brigman, and resection of proximal humeral tumors? A systematic review,” L. S. Levin, “Vascularized fibula-based physis transfer for Open Orthopaedics Journal, vol. 11, no. 1, pp. 203–211, 2017. pediatric proximal humerus reconstruction,” Plastic and [11] F. Sirveaux, “Reconstruction techniques after proximal hu- Reconstructive Surgery, vol. 132, no. 2, pp. 281e–287e, 2013. merus tumour resection,” Orthopaedics and Traumatology: [27] S. Onoda, M. Sakuraba, T. Asano et al., “Use of vascularized Surgery & Research, vol. 105, no. 1, pp. S153–S164, 2019. free fibular head grafts for upper limb oncologic recon- [12] W. Wozniak, ´ T. Izbicki, M. Rychlowska, and P. Niedzielski, struction,” Plastic and Reconstructive Surgery, vol. 127, no. 3, “Malignant humeral bone tumors in children: excision and pp. 1244–1253, 2011. reconstruction with the use of rotated clavicle,” Journal of Surgical Oncology, vol. 62, no. 3, pp. 183–185, 1996. [28] R. L. Shammas, Y. J. Avashia, A. E. Farjat et al., “Vascularized fibula-based physis transfer,” Plastic and Reconstructive [13] T. Ozaki, H. Hashizume, T. Kunisada et al., “Reconstruction of the proximal humerus with the clavicle after tumor re- Surgery—Global Open, vol. 5, no. 5, Article ID e1352, 2017. [29] J. D. Stevenson, R. Doxey, A. Abudu et al., “Vascularized section,” Clinical Orthopaedics and Related Research, vol. 385, pp. 170–175, 2001. fibular epiphyseal transfer for proximal humeral recon- struction in children with a primary sarcoma of bone,” Bone & [14] R. W. Rodl, ¨ G. Gosheger, C. Gebert, N. Lindner, T. Ozaki, and W. Winkelmann, “Reconstruction of the proximal humerus Joint Journal, vol. 100-B, no. 4, pp. 535–541, 2018. [30] J. Benevenia, F. Patterson, K. Beebe et al., “Results of 20 after wide resection of tumours,” Journal of Bone & Joint Surgery, British Volume, vol. 84, no. 7, pp. 1004–1008, 2002. consecutive patients treated with the Repiphysis expandable Sarcoma 7 prosthesis for primary malignant bone,” SpringerPlus, vol. 4, no. 1, p. 793, 2015. [31] Y. Tsuda, K. Tsoi, J. D. Stevenson, T. Fujiwara, R. Tillman, and A. Abudu, “Extendable endoprostheses in skeletally immature patients,” Journal of Bone and Joint Surgery, vol. 102, no. 2, pp. 151–162, 2020. [32] F. Chotel, L. Nguiabanda, P. Braillon, R. Kohler, J. Berard, ´ and K. Abelin-Genevois, “Induced membrane technique for re- construction after bone tumor resection in children: a pre- liminary study,” Orthopaedics and Traumatology: Surgery & Research, vol. 98, no. 3, pp. 301–308, 2012. [33] F. Fitoussi and B. Ilharreborde, “Is the induced-membrane technique successful for limb reconstruction after resecting large bone tumors in children?” Clinical Orthopaedics and Related Research, vol. 473, no. 6, pp. 2067–2075, 2015. [34] Y. Lu, X. Xiao, M. Li et al., “Use of vascularized fibular epiphyseal transfer with massive bone allograft for proximal humeral reconstruction in children with bone sarcoma,” Annals of Surgical Oncology, vol. 28, no. 12, pp. 7834–7841, [35] M. Armangil and S. S. Bilgin, “Reconstruction of proximal humeral defects with shoulder arthrodesis using free vascu- larized fibular graft,” JBJS Essential Surgical Techniques, vol. 3, no. 2, p. e8, 2013. [36] S. S. Bilgin, “Reconstruction of proximal humeral defects with shoulder arthrodesis using free vascularized fibular graft,” Journal of Bone and Joint Surgery, vol. 94, no. 13, p. e94, 2012. [37] A. Zaretski, A. Amir, I. Meller et al., “Free fibula long bone reconstruction in orthopedic oncology: a surgical algorithm for reconstructive options,” Plastic and Reconstructive Sur- gery, vol. 113, no. 7, pp. 1989–2000, 2004.
Sarcoma – Hindawi Publishing Corporation
Published: May 9, 2022
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