Elbow reconstruction after excision of proximal ulna tumors: Challenges and solutions

Abstract

Most malignant bone tumors are treated with surgical excision, adhering to oncologic principles, followed by reconstruction to preserve form and function whenever feasible. Primary bone tumors around the elbow are rare accounting for <1% of all skeletal tumors. They pose a reconstructive challenge, due to the complex interplay between the osseous & capsulo-ligamentous structures which is essential for elbow stability and function. Tumors affecting the proximal ulna are rare and reconstruction of the defects following these tumors is extremely challenging. Various reconstruction options like arthrodesis, autogenous bone grafts, allografts, re-implantation of sterilized tumor bone, pseudoarthrosis, and endoprosthesis have been tried with variable success. However, due to lack of standardization and the rarity of the site, surgeons are often in a dilemma to choose the correct option. This can lead to suboptimal functional outcomes and long-term failures. In this article, we reviewed the published literature on proximal ulnar tumors and noted the pros and cons of various reconstructive procedures. We have also attempted to formulate reconstruction recommendations based on the level of resection of proximal ulna.

Keywords: Allograft; Autograft; Biological reconstruction; Elbow function; Endoprosthetic reconstruction; Single bone forearm.

Fig. 1

Flowchart depicting the selection process methodology.

Fig. 2

Schematic diagram showing levels of proximal ulnar resections. a) Type Ia, b) Type Ib, c) Type II, d) Type III.

Fig. 3

Synovial sarcoma of forearm with ulnar involvement treated with wide excision with intercalary ulnar resection (type Ia) and reconstruction with vascularized fibular graft. a&b) pre-operative MRI showing large soft tissue sarcoma abutting ulnar cortex c) clinical picture d) specimen excised e&f) intra-operative pics before and after intercalary vascularized fibular graft g) follow-up radiograph at 1 year.

Fig. 4

Right proximal ulna Ewing's sarcoma treated with Intercalary resection (type Ib) and extra corporeal irradiation and reimplantation of tumor bone. a) Radiograph showing an aggressive lesion with periosteal reaction involving diaphysis and proximal metaphysis of ulna. b) MRI showing a lesion in Coronal STIR and c-e) T1 Axial sequences with soft tissue component. f) Post operative radiograph. g) radiograph at 18 months follow-up.

Fig. 5

Giant cell Tumor of right proximal ulna GCT treated with proximal ulna resection and radio humeral-trochlea transfer. a) Radiograph showing expansile lytic lesion with trabeculations. b) MRI showing a hypointense lesion in T1W sagittal, c&d) T2W axial images. e) Postoperative radiograph f) radiograph at 6 months follow-up.