Proximal humerus reconstruction after tumour resection: biological versus endoprosthetic reconstruction

The purpose of this study was to compare the outcome, complications and survival of the three most commonly used surgical reconstructions of the proximal humerus after transarticular tumour resection. Between 1985 and 2005, 38 consecutive proximal humeral reconstructions using allograft-prosthesis composite (n = 10), osteoarticular allograft (n = 13) or a modular tumour prosthesis (n = 14) were performed in our clinic. The mean follow-up was ten years (1–25). Of these, 27 were disease free at latest follow-up (mean 16.8 years) and ten had died of disease. The endoprosthetic group presented the smallest complication rate of 21% (n = 1), compared to 40% (n = 4) in the allograft-prosthesis composite and 62% (n = 8) in the osteoarticular allograft group. Only one revision was performed in the endoprosthetic group, in a case of shoulder instability. Infection after revision (n = 3), pseudoarthrosis (n = 2), fracture of the allograft (n = 3) and shoulder instability (n = 4) were the major complications of allograft use in general. Kaplan-Meier analysis showed a significantly better implant survival for the endoprosthetic group (log-rank p = 0.002). At final follow-up the Musculoskeletal Tumour Society scores were an average of 72% for the allograft-prosthetic composite (n = 7, median follow-up 17 years), 76% for the osteoarticular allograft (n = 3, 19 years) and 77% for the endoprosthetic reconstruction (n = 10, 5 years) groups. An endoprosthetic reconstruction after transarticular proximal humeral resection resulted in the lowest complication rate, highest implant survival and comparable functional results when compared to allograft-prosthesis composite and osteoarticular allograft use. We believe that the surgical approach that best preserves the abductor mechanism and provides sufficient surgical exposure for tumour resection contributed to better functional results and glenohumeral stability in the endoprosthetic group

Reconstructive options in pelvic tumours

<b>Background:</b> Pelvic tumours present a complex problem. It is difficult to choose between limb salvage and hemipelvectomy. <b> Method:</b> Forty three patients of tumours of pelvis underwent limb salvage resection with reconstruction in 32 patients. The majority were chondrosarcomas (20 cases) followed by Ewing sarcoma. Stage II B was the most common stage in malignant lesions and all the seven benign lesions were aggressive (B3). Surgical margins achieved were wide in 31 and marginal in 12 cases. Ilium was involved in 51&#x0025; of cases and periacetabular involvement was seen in 12 patients. The resections done were mostly of types I &#x0026;II of Enneking&#x2032;s classification of pelvic resection. Arthrodesis was attempted in 24 patients. Customized Saddle prosthesis was used in seven patients and no reconstruction in 12 patients. Adjuvant chemotherapy was given to all high-grade malignant tumours, combined with radiotherapy in 7 patients. <b> Results:</b> With a mean follow up of 48.5 months and one patient lost to follow up, the recurrence rate among the evaluated cases was 16.6&#x0025;. Oncologically, 30 patients were continuously disease free with 7 local recurrences and 4 deaths due to disseminated disease and 2 patients died of other causes. During the initial years, satisfactory functional results were achieved with prosthetic replacement. Long-term functional result of 36 patients who were alive at the time of latest follow up was satisfactory in 75&#x0025; who underwent arthrodesis and in those where no reconstruction was used. We also describe a method of new classification of pelvic resections that clarifies certain shortcomings of the previous systems of classification. <b> Conclusion:</b> Selection of a procedure depends largely on the patient factors, the tumour grade, the resultant defect and the tissue factors. Resection with proper margins gives better functional and oncological result

HIV-1 Vpr inhibits the maturation and activation of macrophages and dendritic cells in vitro

Human immunodeficiency virus-1 (HIV-1) Vpr encodes a 14 kDa protein that has been implicated in viral pathogenesis through in vitro modulation of several host cell functions. Vpr modulates cellular proliferation, cell differentiation, apoptosis and host cell transcription in a manner that involves the glucocorticoid pathway. To better understand the role of HIV-1 Vpr in host gene expression, similar to9600 cellular RNA transcripts were assessed for their modulation in primary APC after treatment with a bioactive recombinant Vpr (rVpr) by DNA micro-array. As an extracellular delivered protein, Vpr down-modulated the expression of several immunologically important molecules including CD40, CD80, CD83 and CD86 costimulatory molecules on MDM (monocyte-derived macrophage) and MDDC (monocyte-derived dendritic cells). Maturation of dendritic cells (DC) is known to result in a decreased capacity to produce HIV due to a post-entry block of the HIV-1 replicative cycle. Based on the changes observed in the gene array, we analyzed maturation of DC generated from monocytes in tissue culture as influenced by Vpr. We observed that Vpr-treated immature MDM and MDDC were unable to acquire high levels of costimulatory molecules and failed to develop into mature DC, even in the presence of maturation signals. These studies have importance for understanding the interaction of HIV with the host immune system