Complications Are Frequent Following Allograft Reconstruction of the Humerus

For reconstruction of the humerus after resection of a tumor, many surgeons prefer osteoarticular/intercalary allografts, partly because of their reported stability and functionality. Yet several studies have detected a much higher rate of complications, especially infections, with allografts than with endoprostheses or allograft-prosthesis composites.

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In a retrospective study, orthopaedic oncology surgeon Santiago A. Lozano-Calderon MD, PhD, research fellow Paul T. Ogink, MD, and colleagues confirmed a high rate of complications with humeral allograft reconstructions. However, fractures and nonunions, not infections, were the principal issues. The research team's report appears in the Journal of Surgical Oncology.

Study Participants and Surgical Technique

The researchers identified 84 adults who underwent wide resection and allograft reconstruction of the humerus for primary bone sarcomas, primary benign aggressive bone tumors, soft tissue sarcomas, lymphoma or metastatic lesions at Massachusetts General Hospital between 1990 and 2013 and had at least six months of follow-up. The surgical technique and approach were left to the surgeon's discretion.

About half of the cohort (56%) was male and the median age was 45. Altogether, 47 patients (51%) underwent allograft reconstructions of the proximal humerus, 30 (36%) of the intercalary region and seven (8%) of the distal humerus.

Complications

At least one complication occurred in 61% of patients, the researchers found. They say that is within the range of previous studies of more than 10 patients.

In the proximal and distal allograft groups, the most common complications were graft fractures (28% and 29% of patients, respectively) and subluxation (32% and 29%, respectively). In the intercalary allograft group, nonunion and hardware failure were the most common (both 23%).

Infection occurred in 4% of patients in the proximal group, 10% of the intercalary group and 0% of the distal group.

There were no statistically significant differences between groups regarding the overall complication rate or the rates of infection, fracture, malunion, nonunion or any other individual complication recorded. The researchers do note that the use of prior chemotherapy, which increases the risk of nonunion, was particularly common among patients with intercalary allografts (27%).

Revision Surgery and Allograft Survival

Eighteen patients (21%) required revision surgery, of whom 12 had a proximal allograft and six had an intercalary allograft. The most common reasons for revision were fracture (n=7 patients), nonunion (n=4) and infection (n=2). The median time between initial and revision surgery was 3.0 years (interquartile range, 1.6–5.4).

Fifteen patients (18%) required reoperation but no revision, most commonly for nonunion (n=5).

The five-year allograft survival rate was 71%. There were no significant differences between the proximal, intercalary and distal groups in terms of need for revision or allograft survival.

Clinical Implications

The authors conclude that when counseling patients about potential humeral allograft reconstruction, surgeons should discuss that, despite relatively high treatable complication rates, allograft survival at five years in the humerus is good. As with other reconstruction techniques the possibility of needing revision surgery years later is present. Contrary to previous belief, infection is not a clinical concern. The surgeon and treatment team should focus on surgical techniques and new implant technologies to decrease the risk of fracture and nonunion.

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