Beyond Implant Design: Surgical Principles and Early Outcomes of Patient-Specific Scapular Reconstruction After Total Scapulectomy.

Background/Objectives: Total scapulectomy for malignant scapular tumors remains a major reconstructive challenge because resection removes the osseous framework, muscular insertions, and biomechanical support required for shoulder function. Patient-specific three-dimensional (3D)-printed implants may improve anatomical reconstruction, but the indications and surgical principles underlying successful total scapular replacement remain poorly defined. Methods: This retrospective single-center case series included the first three consecutive patients who underwent total scapulectomy followed by immediate reconstruction using a patient-specific 3D-printed scapular prosthesis between January 2024 and December 2025. Clinical, radiographic, oncological, and functional outcomes were reviewed. Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score and active shoulder range of motion. Results: The cohort included two women and one man with a median age of 53 years (range, 43-58 years). Diagnoses were chondrosarcoma in two patients and osteosarcoma in one. All tumors were Enneking stage IIB. Negative margins were achieved in all patients, and the axillary nerve and principal shoulder-girdle stabilizers were preserved in every case. Median follow-up was 13 months (range, 12-27 months). At latest follow-up, two patients had no evidence of disease and one was alive with disease after developing pulmonary metastases. The median MSTS score was 25/30 (range, 21-26). Median active elbow flexion, abduction, and forward flexion measured 88°, 80°, and 80°, respectively. Two patients experienced complications: one clavicular fracture and one aseptic wound dehiscence; neither resulted in implant failure or required revision of the reconstruction. Conclusions: Patient-specific total scapular reconstruction may provide satisfactory early radiographic and functional outcomes in carefully selected patients, although outcomes remain variable depending on individual patient and tumor characteristics. Implant design, patient selection, preservation of the axillary nerve and viable innervated shoulder-girdle musculature, and soft-tissue reconstruction should be considered complementary components of this reconstructive strategy.