Background: The posterior trunk has been considered a challenging area to reconstruct following soft tissue tumor excision because of the shortage of local donor sites. The advent of innovative procedures such as perforator flaps has radically changed this perspective and offered a new approach to the problem. Methods: Upon a review of the literature and the personal experiences of the senior author, an algorithm is developed according to the most updated procedure, combined with more conventional options that maintain a role in decision-making. Results: The upper back latissimus dorsi and trapezium flap are still the most reliable approaches, while perforator flaps based either on the circumflex scapular arteries or the transverse cervical artery represent a more refined option. In the middle third, few indications remain for the reverse latissimus dorsi, while the gold standard is represented by local perforator flaps based on the posterior intercostal system. In the lower back, conventional VY advancement flaps are still a safe and effective option in the sacral area, and perforator flaps based on posterior intercostal arteries, lumbar arteries and superior gluteal arteries are the first choice in most cases. Conclusions: Using perforator flaps significantly improved soft tissue reconstruction in the posterior trunk.

(1) Background: We aim to address the following questions. What was the complication rate of vascularized fibula graft (VFG) combined with massive allograft in patients treated with joint-sparing resection around the knee for a high-grade osteosarcoma? What was the long-term survivorship of VFG free from revision and graft removal? What were the functional results as assessed by the Musculoskeletal Tumor Society (MSTS) score? (2) Methods: 39 patients treated in our unit for osteosarcoma around the knee with intercalary resection and reconstruction with VFG combined with massive allograft were included; 26 patients underwent intercalary tibial resection, while 13 underwent intercalary femoral resection. (3) Results: Mean Follow-Up was 205 months (28 to 424). Complications that required surgery were assessed in requiring surgical revision in 19 patients (49%) after a mean of 31 months (0 to 107), while VFG removal was necessary in three patients (8%). The revision-free survival of the reconstructions was 59% at 5 years and 50% at 10 to 30 years. The overall survival of the reconstructions was 95% at 5 to 15 years and 89% at 20 to 30 years. The mean MSTS score was 29.3 (23 to 30). (4) Conclusions: VFG represents an effective reconstructive option after joint-sparing intercalary resection around the knee for osteosarcoma.

Background: Treating bone sarcomas in young children, particularly in the proximal femur, is challenging because of the need to preserve growth potential, maintain joint function, and conserve bone for future revisions. In 1997, we introduced a new technique combining a vascularized fibula that preserved the proximal epiphysis to substitute for the femoral head and physis with a massive bone allograft aimed at providing a supportive scaffold for the autograft during growth. This approach initially showed promising results in both anatomic and functional restoration, but because it was a complex operation, we believed that longer term follow-up of this procedure would be helpful to judge its value as a potential reconstructive option. Questions/purposes: (1) What proportion of patients achieved allograft union; what proportion exhibited radiologic signs of vitality in the vascularized fibula, demonstrating bone growth and remodeling; what proportion avoided revision surgery; and what complications were observed with this technique? (2) What were the observed outcome scores using the Musculoskeletal Tumor Society (MSTS) score? (3) What was the status of the hip after treatment? Methods: Between 1997 and 2010, a total of 14 patients who were 6 years old or younger underwent resection of the proximal femur for a bone sarcoma in two sarcoma centers. Six patients were treated with a vascularized fibular autograft plus bulk allograft reconstruction. The median (range) length of the proximal femur resection was 13 (11 to 14) cm. During the period in question, we generally performed the vascularized fibular autograft plus bulk allograft when the acetabular diameter was < 36 mm. None of those who had the fibula autograft plus bulk allograft reconstruction were lost to follow-up before 2 years without meeting a study endpoint (revision, reoperation) or died prior to 2 years with implants intact. All six patients in the original group had either a follow-up of at least 14 years or had met a study endpoint (revision, reoperation) before that minimum surveillance duration; these patients were the focus of the current study. We noted that two patients had follow-up periods of 20 and 27 years but have not been seen in the last 5 years; they were included for survivorship analysis purposes, yet we emphasize that we cannot ascertain their current status. The median (range) follow-up was 17 (14 to 27) years. Results: Six of six patients achieved allograft union, while five of six underwent reoperations, and four of six had the graft removed as part of a revision procedure at a median (range) of 19 (7 to 40) months. Only one patient maintained the original reconstruction after 27 years, despite an epiphysiolysis that occurred 56 months after surgery, which was corrected surgically. The other five patients experienced a complication of the reconstruction at a median (range) onset at 19 (7 to 40) months after surgery. Two of the six patients had a common peroneal nerve palsy at the harvested site. Allograft union was observed a median of 8 months from the index procedure. All patients presented residual limb length discrepancy ranging from 1 to 7 cm. The median (range) MSTS score before any revision was 38% (33% to 93%). Four of the six patients underwent removal of the biological reconstruction and were reconstructed by other methods. They displayed a median (range) MSTS functional score of 88% (73% to 93%) at most recent follow-up. One of the six patients showed progressive diaphyseal hypertrophy, growth, and remodeling of the epiphysis, along with integration with the allograft, and had a final limb length discrepancy of -1 cm. The vascularized fibular epiphysis was enlarged and remodeled to provide a new femoral head and grew similar to the physis of the native femoral head in this one patient. Conclusion: Biological reconstruction using a vascularized fibula and bone allograft in young patients with proximal femur sarcoma was not a durable solution for most patients, and it resulted in frequent unplanned reoperations and revisions. Only one of six patients in this small series had a reconstruction that lasted into adulthood. Even though this was a small group of patients, the poor survival of the construct, the frequent complications, and the unpredictable results associated with it led us to discontinue its use in favor of prosthetic replacement. Level of Evidence: Level IV, therapeutic study.

Background/Objectives: Spino-plastic surgery describes a specialized, multidisciplinary approach to addressing various spinal pathologies. The field is the innovative product of a multidisciplinary collaboration between plastic and reconstructive, orthopedic, and neurosurgery. Over the last few decades, this collaboration has borne promising surgical techniques and treatment plans geared toward restoring form, function, and aesthetics in patients with a variety of spinal conditions, including failed fusions, pseudoarthrosis, and the need for oncologic reconstruction. This paper explores the application of spino-plastic surgery in the context of post-sarcoma resection reconstructions, focusing on the efficacy in addressing the unique challenges posed by extensive tissue loss and structural deformities. Methods: Our study reviews a series of cases wherein spino-plastic techniques were utilized in patients with sarcomas of the spine and adjacent structures. We also discuss the technical considerations, including preoperative planning, intraoperative challenges, and overall patient care, that are crucial for the success of spino-plastic procedures. Results: The outcomes demonstrate significant improvements in patient mobility, pain reduction, and overall quality of life. Most notably, spino-plastic surgical techniques help facilitate the restoration of functional anatomy by leveraging vascularized bone grafts and muscle flaps, thereby enhancing long-term stability and reducing the risk of complications such as nonunion or infection. Conclusions: Spino-plastic collaboration represents a pivotal advancement in oncologic treatment, spinal care, and reconstructive surgery, offering new hope for patients undergoing post-sarcoma reconstruction. Further research and refinement of the techniques will only expand their application and improve outcomes for a broader range of patients in the future.

Background/Objectives: EnBloc resections of bone tumors of the spine are very demanding as the target to achieve a tumor-free margin specimen (sometimes impossible due to the extracompartimental tumor extension) is sometimes conflicting with the integrity of neurological functions and spine stability. Methods: The surgical treatment of a huge multi-level chordoma of the thoracic spine with unusual extension is reported. Anteriorly, the tumor widely invaded the mediastinum and displaced the aorta; on the left side, it expanded in the subpleuric region; posteriorly, it was uncommonly distant 13 mm from the posterior wall. Results: EnBloc resection is largely performed for primary bone tumors of the spine and many reports have been published concerning brilliant solutions to difficult issues of surgical anatomy. One of the major challenges is still the compatibility between oncological and functional requirements. Conclusions: Oncological staging, careful imaging analysis, a multidisciplinary surgical team, and utilization of the most recent technologies like navigation and robotics have made an oncologically appropriate EnBloc resection of a multi-level chordoma of the thoracic spine possible without affecting the continuity of the spinal canal and without any involvement of its content by an original “L”-shaped osteotomy.