Custom mega-prosthetic replacement for proximal humeral tumours

Proximal Humerus Reconstruction for Bone Sarcomas: A Critical Analysis

» The proximal humerus is a common location for primary bone tumors, and the goal of surgical care is to obtain a negative margin resection and subsequent reconstruction of the proximal humerus to allow for shoulder function.» The current evidence supports the use of reverse total shoulder arthroplasty over hemiarthroplasty when reconstructing the proximal humerus after resection of a bone sarcoma if the axillary nerve can be preserved.» There is a lack of high-quality data comparing allograft prosthetic composite (APC) with endoprosthetic reconstruction of the proximal humerus.» Reverse APC should be performed using an allograft with donor rotator cuff to allow for soft-tissue repair of the donor and host rotator cuff, leading to improvements in shoulder motion compared with an endoprosthesis.

What Is the Revision-free Survival of Resurfaced Allograft-prosthesis Composites for Proximal Humerus Reconstruction in Children With Bone Tumors?

BACKGROUND

Reconstruction of the proximal humerus in children who undergo bone tumor resection is challenging because of patients' small bone size and possible limb length discrepancy at the end of skeletal growth due to loss of the physis. There are several options for proximal humerus reconstruction in children, such as clavicula pro humero, free vascularized fibula grafting, massive bone osteoarticular allografting, endoprostheses, and allograft-prosthesis composites, but no consensus exists on the best method for reconstruction. Resurfaced allograft-prosthesis composites could be an alternative surgical option, but little is known about the results of this surgical technique.

QUESTIONS/PURPOSES

(1) What are the complications and what is the survivorship free from reconstruction failure associated with resurfaced allograft-prosthesis composites in a small, single-center case series? (2) What Musculoskeletal Tumor Society scores do patients achieve after reconstructions with resurfaced allograft-prosthesis composites?

METHODS

This study was a retrospective, single-arm case analysis in a single institution. We generally considered resurfaced allograft-prosthesis composites in children with malignant bone tumors involving the metaepiphysis of the proximal humerus in whom there was no evidence of joint contamination and in whom axillary nerve preservation was possible. Between 2003 and 2021, we treated 100 children (younger than 15 years) with bone tumors of the humerus. Thirty children (30%) with diaphyseal tumors (21 children) or distal tumors (9 children) were excluded. Among the potentially eligible children, 52 were not analyzed because they were treated with other procedures such as amputation, modular prostheses, cement spacers, free vascularized fibula grafting, and massive bone osteoarticular allografts. We included 18 children (26% of the potentially eligible children) who were treated with resurfaced allograft-prosthesis composites. There were 9 boys and 9 girls, with a median age of 10 years (range 4 to 15 years) at the time of diagnosis. A long stem (≥ 6 cm) in the resurfaced allograft-prosthesis composite was used in 9 children and a short stem (< 6 cm) was used in the remaining 9. One of the 18 children had a follow-up of less than 2 years. The median follow-up of the remaining 17 children was 4.7 years (range 2 to 19 years). The children' medical records were reviewed for clinical and functional outcomes. We performed a competing risk analysis to calculate the reconstruction failure-free survival of resurfaced allograft-prosthesis composites. Reconstruction failure was defined as removal of the implant or allograft because of implant loosening or breakage and allograft fracture or resorption. We analyzed the children's postoperative complications and functional outcomes at the end of the follow-up period using the Musculoskeletal Tumor Society functional scoring system.

RESULTS

The competing risk analysis revealed that reconstruction failure was 25% (95% confidence interval 7% to 40%) at 3 years, reaching a plateau. Four of 18 children underwent surgical revision with a new reconstruction. The reasons for reconstruction revision were resorption of the allograft at the proximal part (2 children) and fracture of the allograft (2 children). Reconstruction revision was performed in 3 of 9 children who underwent reconstruction with a short stem and in 1 of 9 children who underwent reconstruction with a long stem. Several children had other complications that did not result in removal of the allograft. Allograft resorption was observed in 4 of 18 children, but no additional surgical treatment was performed. Shoulder instability or subluxation was observed in 4 of 18 children, but only 1 child underwent surgery with a reverse shoulder arthroplasty without removal of the resurfaced allograft-prosthesis composite. Limited elbow motion because of plate impingement was observed in 1 child who underwent surgical cutting of the protruding distal part of the plate. Incomplete radial nerve palsy after surgery occurred in 1 child, with spontaneous resolution after 2 months. Screw loosening occurred in 2 children who underwent surgery with removal of loose screws. Two children had a nonunion at the graft-host bone junction; 1 child underwent surgery with bone grafting and refixation of the graft-host bone junction, and the other child with both nonunion and plate breakage was treated with bone grafting and refixation of the graft-host bone junction with a new plate. Among 17 children who had a follow-up longer than 2 years, the median Musculoskeletal Tumor Society functional score at the last follow-up interval was 23 of 30 (range 20 to 26); 1 child was considered to have an excellent result (functional score ≥ 26), 15 children were considered to have a good result (functional score 21 to 25), and 1 child was considered to have a fair result (functional score ≤ 20). The Musculoskeletal Tumor Society functional score did not change after excluding 4 children who underwent replacement of resurfaced allograft-prosthesis composites (24 of 30 [range 20 to 26]). The median angle of flexion of the shoulder was 40° (range 20º to 90°), and the median angle of abduction was 30° (range 20º to 90°).

CONCLUSION

Resurfaced allograft-prosthesis composites showed a high risk of complications, but not all complications resulted in removal of the reconstructed allograft. We used this technique mainly for very young children with small bones and for older children who underwent axillary nerve preservation. Although its success may be limited owing to a high risk of complications, a resurfaced allograft-prosthesis composite could be an alternative surgical option in order to preserve the bone stock and achieve good functional outcomes in very young children. We recommend using a long-stem resurfaced allograft-prosthesis composite, which may reduce the risk of complications.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Total humerus replacement with reverse shoulder design for non-oncologic indication: A case report

INTRODUCTION AND IMPORTANCE

Reconstruction of large skeletal defects pose significant challenges for orthopedic surgeons, particularly in cases of chronic skeletal defects where the surrounding structures differ substantially from the original anatomical structures, further complicating management.

CASE PRESENTATION

A 54 year old male patient presented with a large skeletal defect after osteomyelitis surgery. The treatment of choice for this case was reconstruction using a total humerus megaprosthesis. The prosthesis was custom-designed with a reversed shoulder joint and a total elbow joint, which were 3D printed using CT-Scan imaging.

CLINICAL DISCUSSION

A short-term follow-up revealed improvements for the patient in arm functionality and expectation-based satisfaction at 6 months post-surgery.

CONCLUSION

Total humerus megaprosthesis joint replacement may be a promising option for treating chronic humeral defects.

Use of LARS for soft tissue function reconstruction during tumor-type hemi-shoulder replacement achieves a good prognosis: a retrospective cohort study

BACKGROUND

Shoulder soft tissue function reconstruction during tumor-type hemishoulder replacement is an important step to restore shoulder function. This study evaluates the functional prognosis and postoperative complications of ligament advanced reinforcement system (LARS)-assisted soft tissue functional reconstruction in tumor-type hemi-shoulder replacement.

MATERIALS AND METHODS

Twenty-two patients with an average age of 37.5 ± 17.8 years diagnosed with benign invasive tumors, primary malignant bone tumors, or bone metastases were enrolled in this study. The patient's medical records (history and surgical details), histological sections, imaging files, oncological prognosis, functional prognosis, and postoperative complications were collected. The upper limb function and shoulder joint function were evaluated using the Musculoskeletal Tumor Society (MSTS) system and American Shoulder and Elbow Surgeons (ASES) scoring criteria, respectively.

RESULTS

Twenty-two patients comprising 12 males and 10 females were enrolled. Overall, 9 patients had preoperative pathological fractures. The mean lesion length was 8.6 ± 3.0 cm. The local recurrence was observed in 3 cases, including 2 cases of osteosarcoma and 1 case of MGCT. A further 4 cases had pulmonary metastasis, including 2 cases with local tumor recurrence. The average postoperative MSTS score was 25.8 ± 1.7, and the score of postoperative ASES was 85.7 ± 6.0, both of which showed satisfactory functional recovery. Two cases experienced postoperative complications requiring surgical intervention, including one periprosthetic fracture and one giant cell granuloma. Prosthesis dislocation occurred in 1 case. None of the cases of periprosthetic infection or postoperative complications resulted in implant failure.

CONCLUSIONS

LARS-assisted soft tissue function reconstruction in benign and malignant proximal humerus tumors after a tumor-type hemi-shoulder replacement is an effective technical improvement, which can effectively repair the integrity of the joint capsule to restore joint stability, provide a medium for soft tissue attachment to rebuild the muscular dynamic system, and eliminate residual dead space around the prosthesis, effectively improving limb function and reduce postoperative infection complications.

Infections of Tumor Prostheses: An Updated Review on Risk Factors, Microbiology, Diagnosis, and Treatment Strategies

Several causes contribute to the high infection rate in tumor prostheses, including extensive tissue dissection and patients' immunosuppression due to the neoplastic disease. Most of these infections develop within the first 2 years following surgery with 70% of them occurring during the first year, while they are often associated with a low pathogen burden. The pathogenesis of infections in tumor prostheses is linked to bacteria developing in biofilms. Approximately half of them are caused by Staphylococcus spp., followed by Streptococcus spp., Enterococcus spp., and Enterobacteriaceae spp., while multiple pathogens may be isolated in up to 25% of the cases, with coagulase-negative Staphylococci (CoNS) and Enterococccus spp. being the most frequent pair. Although early detection and timely management are essential for complete resolution of these challenging infections, prompt diagnosis is problematic due to the highly varying clinical symptoms and the lack of specific preoperative and intraoperative diagnostic tests. Surgical management with one- or two-stage revision surgery is the mainstay for successful eradication of these infections. The recent advances in laboratory diagnostics and the development of biofilm-resistant prostheses over the past years have been areas of great interest, as research is now focused on prevention strategies. The aim of this study is to review and consolidate the current knowledge regarding the epidemiology, risk factors, microbiology, and diagnosis of infections of tumor prostheses, and to review the current concepts for their treatment and outcomes.

Effect of implant length variations on stress shielding in proximal humeral replacement after tumor excision under torsion: Finite element study

The proximal humerus is the most common site of occurrence of primary bone tumors in the upper limb. Endoprosthetic replacement is deemed as the preferred reconstructive option following primary resection of bone tumors. However, it has been also associated with complications such as stress shielding and aseptic loosening compromising prosthetic survival. Our objective was to conduct a finite element (FE) study to investigate the effect of varying endoprosthesis length on bone stresses as well as to quantify the extent of stress shielding across the bone length (BL) in a humerus-prosthesis assembly for proximal humeral replacement after tumor excision thereby allowing us to identify the optimal implant length with best biomechanical performance. FE models of the intact humerus and humerus-prosthesis assemblies were established where they were loaded at the elbow joint under torsion with the glenohumeral joint fixed to represent twisting. After dividing the bone into individual slices consisting of 5% BL, the maximum cortical and cancellous principal, von Mises and shear bone stresses were calculated. To measure the level of stress shielding, the percentage stress change from the intact state was evaluated across each slice. Similar stress patterns were observed between the intact state and shorter endoprosthesis compared to the longer endoprostheses. Our findings illustrated the possibility of stress shielding occurring under torsional forces with its effect increasing with implant lengthening. To conclude, we believe that using a shorter prosthesis may substantially diminish the risk of potential implant failure due to stress shielding.

Proximal Humeral Replacement With Osteoarticular Allograft Prosthetic Composite in Failed Revision Total Elbow Arthroplasty With Marked Bone Loss

Total elbow arthroplasty (TEA) procedures are becoming more prevalent with an associated increase in revision procedures. Revision TEA in the setting of marked bone loss poses a challenge for the treating surgeon. We present a viable surgical option for patients with extensive proximal humeral bone loss treated with proximal humerus osteoarticular allograft prosthetic composites prepared with intact rotator cuff, pectoralis, and deltoid soft tissue attachments along with a rehabilitative protocol and follow up. Revision techniques involving the use of strut allografts and allograft prosthetic composites have previously been described in the distal humerus, but none to our knowledge have been published regarding composite allograft replacement of the proximal humerus in in combination with a TEA.

The Use of Tumor Prostheses for Primary or Revision Reverse Total Shoulder Arthroplasty With Proximal Humeral Bone Loss

Background

During shoulder arthroplasty with substantial bone and soft tissue loss, reverse shoulder arthroplasty (RSA) with a tumor prosthesis may restore function, reduce pain, and improve implant fixation.

Methods

Thirteen adult patients undergoing RSA using a tumor prosthesis system were retrospectively reviewed. Preoperative visual analog score (VAS), single assessment numeric evaluation (SANE), American Shoulder and Elbow Surgeons (ASES) score, simple shoulder test (SST), and forward flexion were compared to latest follow up. Postoperative radiographs and complications were recorded.

Results

Mean age at surgery was 68.4 years. Eight patients had undergone at least 1 prior operation on the indicated shoulder. Six patients required wide excision of proximal humerus tumor. At mean of 34 months postoperatively, significant improvements were noted in VAS (P = .03) and ASES score (P = .04). Active forward elevation was 81.1 degrees. For all patients, postoperative radiographs demonstrated satisfactory alignment. Complications occurred in 38% of patients, with 31% requiring reoperation.

Conclusion

In cases of failed shoulder arthroplasty with excessive bone and soft tissue loss or substantial tumor burden, RSA with a tumor prosthesis can reduce pain levels and improve functional outcomes. However, forward elevation remains limited, and postoperative complications are a concern.

Proximal Humerus Reconstruction after Tumor Resection: An Overview of Surgical Management

Proximal humerus is one of the anatomical sites that are most frequently involved by bone and soft tissue malignant tumors. Alone or in association with adjuvant treatments, surgery represents the main therapeutic option to treat and eradicate these diseases. Once the first-line option, in the last decades, amputation lost its role as treatment of choice for the large majority of cases in favor of the modern limb sparing surgery that promises to preserve anatomy and-as much as possible-upper limb functionality. Currently, the main approaches used to replace proximal humerus after a wide resection in oncologic surgery can be summarized in biological reconstructions (allografts and autografts), prosthetic reconstructions (anatomic endoprostheses, total reverse shoulder prostheses), and graft-prosthetic composite reconstructions. The purpose of this overview is to present nowadays surgical options for proximal humerus reconstruction in oncological patients, with their respective advantages and disadvantages.

Mesh patch and anchors can improve clinical results of prosthetic replacement after resection of primary proximal humerus malignant tumor

The purpose of this study was to evaluate the functional results, complications and related factors of prosthesis reconstruction after malignant tumor resection of primary proximal humeral, and also evaluate whether soft tissue reconstruction with mesh patch and anchors can improve clinical results. From 2002 to 2016, forty-one patients were enrolled in this study. The pathological diagnosis contained 27 cases of osteosarcoma, 7 cases of chondrosarcoma and other primary malignant bone tumors. Both mesh patch and anchors were used in the reconstruction of joint capsule and the surrounding soft tissues in 27 cases. The mean postoperative follow-up was 60.6 months. The average active abduction angle and passive abduction angle was 33.5 (5–71) degrees and 72.4 (52–104) degrees. The prosthetic humeral head displacement was over 2 cm in 5 cases (12.2%). The average MSTS score was 23.1. The overall 5-year survival rate of prosthesis was 88.2%. The length of osteotomy, whether preserving deltoid muscle, whether applying mesh patch and anchors had significant effects on the abduction angle of shoulder joint; the length of osteotomy, whether applying mesh patch and anchors had significant effects on the degree of upward displacement of prosthesis. The application of both mesh patch and anchors in prosthesis reconstruction achieved more stable result and better function of shoulder joint. To ensure the stability of shoulder joint and the firm wrapping of surrounding soft tissue are key factors affecting the postoperative function.

Comparison of reconstructive techniques following oncologic intraarticular resection of proximal humerus

INTRODUCTION

The proximal humerus is a common site of primary and metastatic disease in the upper extremity. Historically, the goal of a hemiarthroplasty reconstruction was to provide a stable platform for hand and elbow function, with limited shoulder function. Techniques utilizing a reverse endoprosthesis (endoprosthetic replacement [EPR]) and allograft-prosthetic composite (APC) have been developed; however, there is a paucity of comparative studies.

METHODS

A total of 83 (42 females, 41 males) patients undergoing an intraarticular resection of the humerus were reviewed. Reconstructions included 30 reverse and 53 hemiarthroplasty; including hemiarthroplasty EPR (n = 36) and APC (n = 17), and reverse EPR (n = 20) and APC (n = 10).

RESULTS

Reverse reconstructions had improved forward elevation (85° vs. 44°, p < .001) and external rotation (30° vs. 21°; p < .001) versus a hemiarthroplasty. Reverse reconstructions had improved American Shoulder and Elbow Surgeons scores (65 vs. 57; p = .01) and Musculoskeletal Tumor Society 93 scores (72 vs. 63; p < .001) versus hemiarthroplasty. Subluxation of the reconstruction was a common (n = 23, 27%), only occurring in hemiarthroplasty patients (EPR [n = 13, 36%] and APC [n = 10, 59%]).

CONCLUSION

The current series highlights the improved functional outcome in patients undergoing reconstruction with a reverse arthroplasty compared to the traditional hemiarthroplasty. Currently reverse shoulder arthroplasty (APC or EPR) is our preferred methods of reconstruction in this patient population.

Constrained or unconstrained shoulder replacement for musculoskeletal tumor resections?

BACKGROUND

Many options exist for reconstructing the shoulder after large bony resections of the proximal humerus. One of the more widely used is endoprosthetic replacement. Proximal migration of unconstrained hemiarthroplasty articulations may cause difficulties particularly in the setting of loss of the rotator cuff and/or deltoid musculature. To attempt to overcome these issues, a fixed-fulcrum constrained reverse shoulder replacement option may be considered.

METHODS

A retrospective review of prospectively collected data from the Queensland Bone and Soft Tissue Sarcoma Service was undertaken to compare the function, implant survivorship, and reoperation rate of constrained reverse and unconstrained hemiarthroplasty-type endoprostheses in patients with tumors.

RESULTS

We retrospectively reviewed data on 41 consecutive proximal or total humeral endoprosthetic replacements undertaken between January 2003 and July 2018. One patient was excluded as lost to follow-up prior to 24 months. There were 21 unconstrained implants and 19 constrained shoulder replacements (Stanmore Modular Endoprosthesis Tumour System with Bayley-Walker articulation). Proximal migration of the unconstrained hemiarthroplasty articulation occurred in 8 patients (38%), and dislocation or failure of the constrained mechanism occurred in 5 (26%). Reoperation for implant-related issues was required in 5 patients in the constrained group and none in the unconstrained group. Of the 18 patients alive at the time of review, 12 provided functional scores. The mean follow-up period for surviving patients was 4.2 years (standard deviation, 2.7 years), with a minimum of 2 years' follow-up. Functional scores were similar between the 2 groups.

CONCLUSION

Constrained reverse prostheses were associated with a higher reoperation rate in this series without any functional benefit compared with unconstrained hemiarthroplasty-type articulations. We favor the use of unconstrained hemiarthroplasty-type endoprostheses for reconstruction after resection of destructive lesions of the proximal humerus.

Survival, Tumor Recurrence, and Function Following Shoulder Girdle Limb Salvage at 24 to 35 Years of Follow-up

Limb salvage is the treatment of choice for malignant shoulder girdle tumors; however, there is a paucity of data examining the long-term outcome. The authors have previously reported on a cohort of patients at short- and mid-term follow-up. The purpose of this study was to report the long-term outcome of shoulder reconstruction in terms of oncological and functional outcome. The authors reviewed 53 patients who underwent a limb salvage procedure for treatment of a tumor of the shoulder girdle. At a mean of 28 years following the resection, 76% of surviving patients were contacted and administered functional outcome scores using the Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage (TESS). The 20-year survival and recurrence-free survival were 79% and 80%, respectively. Likewise, the 20-year revision survival was 75%, with a limb salvage rate of 94%. At last follow-up, the mean MSTS rating and TESS score were 75% and 85%, respectively, with 9 patients having improvement in their MSTS rating from the previous findings. Limb salvage following resection of shoulder girdle tumor resulted in acceptable means of oncological outcome and function. Some patients continued to experience improvements in functional outcome even at late (>20 years) follow-up. [Orthopedics. 2019; 42(6):e514-e520.].

Plate-prosthesis composite reconstruction after large segmental resection of proximal humeral tumors: A retrospective comparative study

Since the standard reconstructive option after large segmental resection of proximal humeral tumors remained controversial, we designed and applied plate-prosthesis composite (PPC) for this circumstance. The purposes of the study were to: compare the functional outcome, implant survival (IS), surgical risk of PPC with those of conventional proximal humeral prosthesis (PHP); and describe the design and reconstructive procedure of PPC.Twenty patients (11 males, 9 females), who received intraarticular proximal humeral resection without preservation of abductor mechanism, were included in this study, with a mean resection length accounting for 72.5% (range, 61.9-81.8%) of whole humeral length. According to the reconstructive options, we categorized patients into PPC group (9 patients) and PHP group (11 patients). PPC was a semi-custom-made endoprosthesis, with modular proximal part same as PHP and custom-made distal part including dumpy stem and composite lateral anatomic plate for distal humerus. The mechanical prosthetic complication was defined as the imaging evidence regardless of reoperation. The IS was defined as the time from surgery to the occurrence of mechanical prosthetic complication.The mean follow-up time was 40.1 months (range, 14-129). The Musculoskeletal Tumor Society 93 scores of PPC and PHP group showed no significant difference (73.3% vs 70.0%, P = .46). Compared to PHP group, PPC group showed significantly lower mechanical prosthetic complication rates (0 vs 45.4%, P = .03) and better IS (86.0 vs 59.3 ± 21.7 months, P = .028). Moreover, the comparison of surgical time (3.2 vs 3.3 hours, P = .60), blood loss (288.9 vs 376.4 mL, P = .15) and perioperative complication rates (11.1% vs 18.2%, P = .58) between 2 groups showed no differences.For reconstruction after large segmental resection of proximal humeral tumors, PPC achieved better IS while maintained similar functional outcome compared to conventional PHP without influencing the complexity and safety of surgery.

Reverse shoulder arthroplasty after failed megaprosthesis for osteosarcoma of the proximal humerus: A case report and review of literature

The involvement of proximal humerus by Osteosarcoma is quite common, with the survival rates highly dependent on the staging of the tumor. Numerous salvage methods have been described but without any consensus. We present a case of a 17-year-old patient who had a wide excision of the tumor and underwent a mega prosthesis fixation, which underwent implant failure with the revised prosthesis subluxing. Finally, Reverse Shoulder Arthroplasty was done. Ten years follow up shows the success of the above. Salvage surgery in young patients yields good functional and cosmetic results. However, an insight into the complications associated with extended use of the mega prosthesis is needed. Prolonged survival after bone tumors is associated with surgical, medical and psychological challenges.

Surgical and Functional Outcome after Endoprosthetic Reconstruction in Patients with Osteosarcoma of the Humerus

Endoprosthetic reconstruction (EPR) is the most widely used reconstruction technique after humeral osteosarcoma (OSA). Complications are common and function is often compromised due to the premise of wide resection. In the current study we evaluated (1) the risk of complications after resection and EPR; (2) the functional outcome and how it is influenced by the preservation/resection of deltoid muscle (DM), rotator cuff (RC), axillary nerve or the type of resection (intra-/extraarticular) and (3) if the preservation/resection of DM, RC, axillary nerve or the type of resection has a negative influence on the oncological outcome. We retrospectively evaluated data of 49 patients with humeral OSA. All patients underwent resection and EPR. Complication-free survival according to the ISOLS classification was estimated by a competing risk model. Functional outcome was evaluated by range of motion (ROM) in abduction and the MSTS score. Eleven patients (22%) had at least one complication. The estimated cumulative incidence for the first complication was 18% at one year, 23% at five years, and 28% at ten years, respectively. Soft tissue failure was the most common complication. ROM and MSTS scores were significantly higher in patients where DM and RC (p = 0.043/p = 0.046) and axillary nerve (p = 0.014/p = 0.021) could be preserved. Preservation of these structures had no negative influence on the surgical margins. In conclusion, EPR is a good treatment method with an acceptable complication rate. Preservation of the abductor mechanism, when possible in the setting of obtaining negative margins, provides superior functional outcome.

Humeral metastasis of renal cancer: Surgical options and review of literature

INTRODUCTION

The humerus is the second most common long bone site of metastatic disease from renal cell carcinomas (RCC) after femur. Surgery has an important role in the treatment of these lesions due to renal cell tumor's resistance to chemotherapy and radiotherapy.

HYPOTHESIS

Prosthetic replacement is an effective and safe solution in treatment of renal humeral metastasis.

MATERIAL AND METHODS

Fifty-six patients affected by RCC bone metastases of the humerus that underwent a surgical reconstruction were rewised. Thirty-five lesions were localized on proximal third, 12 on the shaft, 9 on distal third. Among proximal 29 were treated with resection and endoprosthetic replacement and 6 with plate and cement. Six diaphyseal lesions were stabilized with intramedullary nailing, 5 with plate and cement and 1 with an intercalary prosthesis. Regarding distal lesions, 7 elbow prostheses and 2 plates and cement were used.

RESULTS

The average age was 63years. Metastasis was single in 55% of cases, and in 45% metachronous. A pathologic fracture (PF) occurred in 64% of cases. Only 9% of patients had a mechanical complication, 7% an infection and 5% neurological deficit. A local recurrence occurred in 14% of patients. An implant failure has been observed in 10 patients, 5 for mechanical complications, 2 for infections and 3 for local recurrence; of these 7 were treated with a prosthesis and 3 with plate and cement. The mean value of MSTS score was 64%, 63% and 59% respectively in patients with proximal, diaphyseal and distal humerus metastases.

DISCUSSION

Solitary and metachronous bone metastases have a longer survival. Disease-free interval>2years is another important prognostic factor. Reconstruction with a modular prosthesis is recommended in proximal and distal third. Instead in diaphyseal lesions a closed reduction and fixation with intramedullary locked nailing are preferred. When surgical indications are correctly followed, good oncologic and functional outcomes are obtained, leading to markedly improvement of patients' quality of life.

RETROSPECTIVE STUDY

Level of evidence: IV.

What is the Optimal Reconstruction Option after the Resection of Proximal Humeral Tumors? A Systematic Review

Purpose:

The proximal humerus is a common location for both primary and metastatic bone tumors. There are numerous reconstruction options after surgical resection. There is no consensus on the ideal method of reconstruction.

Methods:

A systematic review was performed with a focus on the surgical reconstructive options for lesions involving the proximal humerus.

Results:

A total of 50 articles and 1227 patients were included for analysis. Reoperation rates were autograft arthrodesis (11%), megaprosthesis (10%), RSA (17%), hemiarthroplasty (26%), and osteoarticular allograft (34%). Mechanical failure rates, including prosthetic loosening, fracture, and dislocation, were highest in allograft-containing constructs (APC, osteoarticular allograft, arthrodesis) followed by arthroplasty (hemiarthroplasty, RSA, megaprosthesis) and lowest for autografts (vascularized fibula, autograft arthrodesis). Infections involving RSA (9%) were higher than hemiarthroplasty (0%) and megaprosthesis (4%).

Postoperative function as measured by MSTS score were similar amongst all prosthetic options, ranging from 66% to 74%, and claviculo pro humeri (CPH) was slightly better (83%). Patients were generally limited to active abduction of approximately 45° and no greater than 90°. With resection of the rotator cuff, deltoid muscle or axillary nerve, function and stability were compromised even further. If the rotator cuff was sacrificed but the deltoid and axillary nerve preserved, active forward flexion and abduction were superior with RSA.

Discussion:

Various reconstruction techniques for the proximal humerus lead to relatively similar functional results. Surgical choice should be tailored to anatomic defect and functional requirements.

Synthetic mesh improves shoulder function after intraarticular resection and prosthetic replacement of proximal humerus

BACKGROUND

Shoulder function often is limited after tumor resection and endoprosthetic replacement of the proximal humerus. This is partly attributable to the inability to reliably reattach rotator cuff tendons to the prosthesis and achieve adequate shoulder capsule repair with a metallic prosthesis. An option to attain these goals is to use synthetic mesh for the reconstruction, although the value of this method has not been well documented in the literature.

QUESTIONS/PURPOSES

We asked whether patients who had shoulder reconstruction using synthetic mesh had (1) better shoulder function; (2) improved ROM compared with shoulder reconstructions without mesh; and (3) more stable joints compared with those in patients with similar resections who had reconstructions without synthetic mesh.

METHODS

During a 5-year period, we performed 41 intraarticular resections with endoprosthetic reconstructions for malignancies in the proximal humerus meeting specified criteria to generate similarity in the study groups. Twelve patients (29%) were lost to followup before 24 months, leaving 29 patients available for review at a mean of 45 months (range, 24-70 months). This retrospective study compared 14 patients with soft tissue reconstruction that included synthetic mesh with 15 patients with soft tissue reconstruction without the use of synthetic mesh. The choice was made during consultation between the patient and surgeon, after reviewing the perceived advantages and disadvantages of each approach. A tumor band (ligament advanced reinforcement system) was used as synthetic mesh and wrapped around the prosthesis of the proximal humerus for soft tissue reconstruction in the reconstruction-with-mesh group. Study endpoints included the Musculoskeletal Tumor Society (MSTS) function scores, American Shoulder and Elbow Surgeons (ASES) score, shoulder ROM, and proximal migration of the humeral prosthesis.

RESULTS

The mean MSTS score for patients without synthetic mesh reconstruction was 20 ± 3 points (66%), whereas for patients with synthetic mesh reconstruction, the mean score was 24 ± 2 points (79%; p = 0.001). Patients with synthetic mesh reconstruction had a higher mean total ASES score (85 ± 1.1 points versus 72 ± 1.7 points; p = 0.025), and better function for activities of daily living. They also had better ROM on mean active forward flexion (p = 0.020), abduction (p < 0.001), and external rotation (p < 0.001) than patients without synthetic mesh reconstruction. Proximal migration of the prosthesis was observed in five of 15 of patients in the group without synthetic mesh reconstruction and in none of those treated with synthetic mesh (p = 0.042).

CONCLUSIONS

Patients with intraarticular resection and endoprosthetic replacement of the proximal humerus with reconstruction that included synthetic mesh had better shoulder function and ROM, and more stable joints than patients who had reconstruction without synthetic mesh. This result supports prior observations by others and it remains to be shown whether use of the ligament advanced reconstruction system is superior to other types of mesh or other types of reconstructions. Further investigation is needed but our results indicate that using mesh should be considered for patients with tumor resection and endoprosthetic replacement of the proximal humerus.

Results of the proximal humerus endoprosthetic reconstruction after tumour resection

The purpose of the study was to evaluate the results of surgical reconstructions of the proximal humerus after transarticular tumour resection, compare the functional results with the results of shoulder arthroplasty in patients with extensive damage of the proximal humerus of non-neoplastic origin. Material and methods. Between 2001 and 2013 38 proximal humeral reconstructions were performed in our clinic: using monopolar endoprostheses - 26 (68%) and modular systems with reversible head -12 (32%). The control group included 46 patients with extensive lesions of the proximal humerus of non-neoplastic origin, operated in our clinic in the period from 2006 to 2012. Term follow-up of patients ranged from 7 months to 9 years. Assessment of functional results was carried out in a period from six months to one year. Results. The seven-year survival according the Kaplan - Meier method for patients with primary malignant tumors of the proximal humerus (25 patients) was 77%. In the study group the average value of functional outcome MSTS score was 77.7%. Unipolar prosthesis showed a bad result, both in the control (61,3% MSTS, 60,7 Neer) and in the main (67,7% MSTS, 61,1 Neer) study groups. Conclusion. Currently the method of choice which doesn’t impair the oncologic component of treatment patients with shoulder neoplastic lesions is its replacement with modular reversible systems in combination with additional soft tissue fixation.

Outcome after reconstruction of the proximal humerus for tumor resection: a systematic review

BACKGROUND

Tumors of the appendicular skeleton commonly affect the proximal humerus, but there is no consensus regarding the best reconstructive technique after proximal humerus resection for tumors of the shoulder.

QUESTIONS/PURPOSES

We wished to perform a systematic review to determine which surgical reconstruction offers the (1) best functional outcome as measured by the Musculoskeletal Tumor Society (MSTS) score, (2) longest construct survival, and (3) lowest complication rate after proximal humerus resection for malignant or aggressive benign tumors of the shoulder.

METHODS

We searched the literature up to June 1, 2013, from MEDLINE, EMBASE, and the Cochrane Library. Only studies reporting results in English, Dutch, or German and with followups of 80% or more of the patients at a minimum of 2 years were included. Twenty-nine studies with 693 patients met our criteria, seven studies (24%) were level of evidence III and the remainder were level IV. Studies reported on reconstruction with prostheses (n = 17), osteoarticular allografts (n = 10), and allograft-prosthesis composites (n = 11). Owing to substantial heterogeneity and bias, we narratively report our results.

RESULTS

Functional scores in prosthesis studies ranged from 61% to 77% (10 studies, 141 patients), from 50% to 78% (eight studies, 84 patients) in osteoarticular graft studies, and from 57% to 91% (10 studies, 141 patients) in allograft-prosthesis composite studies. Implant survival ranged from 0.38 to 1.0 in the prosthesis group (341 patients), 0.33 to 1.0 in the osteoarticular allograft group (143 patients), and 0.33 to 1.0 in allograft-prosthesis group (132 patients). Overall complications per patient varied between 0.045 and 0.85 in the prosthesis group, 0 and 1.5 in the osteoarticular graft group, and 0.19 and 0.79 in the prosthesis-composite graft group. We observed a higher fracture rate for osteoarticular allografts, but other specific complication rates were similar.

CONCLUSIONS

Owing to the limitations of our systematic review, we found that allograft-prosthesis composites and prostheses seem to have similar functional outcome and survival rates, and both seem to avoid fractures that are observed with osteoarticular allografts. Further collaboration in the field of surgical oncology, using randomized controlled trials, is required to establish the superiority of any particular treatment.

Functional outcome of limb salvage surgery with mega-endoprosthetic reconstruction for bone tumors

BACKGROUND

The use of a mega-endoprosthesis has become the method of choice for reconstruction after bone tumors. In this study, we sought to determine the functional outcome and complications associated with mega-endoprosthesis.

METHODS

A retrospective review of the charts of 16 patients who had undergone resection of bone tumors followed by reconstruction with mega-endoprosthesis between 2006 and 2011 was performed. Functional evaluation was based on the Musculoskeletal Tumor Society (MSTS) scoring system. Complications of the procedures were also analyzed.

RESULTS

Eight men and eight women at an average age of 36.7 years were included in the study. The tumor involved lower limb in 14 patients and upper limb in 2 patients. The average MSTS functional score was 72.3 ± 15. Excellent results were achieved in six patients, good in five, moderate and fair in two each and poor in one. Complications occurred in eight patients. Two patients had aseptic loosening of the femoral component of total knee replacement. Flap necrosis occurred in two patients, both of whom required latissimus dorsi free flap for coverage of total knee prosthesis. One patient underwent revision of femoral component subsequent to knee dissociation. Local recurrence of tumor, patellar tendon rupture and foot drop occurred in one patient each.

CONCLUSION

Mega-endoprosthetic reconstruction in limb salvage provides good functional outcome in patients with bone tumors.

Infected tumor prostheses

Infection of tumor prostheses has been a major concern because of the extensive soft tissue dissection, long operating times, and patients' immunosuppression by cancer and adjuvant treatments. Infections most often present within 2 years postoperatively, with approximately 70% of postoperative deep infections presenting within 12 months after surgery. They are typically low organism burden infections, the pathogenesis of which is related to bacteria growing in biofilms. Staphylococci are the most common pathogens involved in prosthetic joint infections, accounting for approximately 50% of infections overall, followed by streptococci, enterococci, Enterobacteriaceae species, Pseudomonas aeruginosa, and anaerobe species. Multiple pathogens may be isolated in approximately 25% of cases, with the most common combination being coagulase-negative Staphylococcus and group-D Streptococcus. Early diagnosis and appropriate treatment are necessary. However, diagnosis may be challenging because clinical symptoms are highly variable and numerous preoperative and intraoperative diagnostic laboratory tests are nonspecific. In most cases, a 1- or 2-stage revision surgery is necessary for eradicating the megaprosthetic infection. Prevention of infection is important. The future will see technical advances for infections of tumor prostheses in areas such as microbiological diagnostics and biofilm-resistant prostheses.

Custom-made endoprosthetic total humerus reconstruction for musculoskeletal tumours

PURPOSE

We analysed 11 patients with malignant musculoskeletal tumours of the humerus who underwent limb salvage surgery with total humeral custom endoprosthesis from 1990 to 2009.

METHODS

There were six male and five female patients, with a mean age of 17 years. The most common diagnosis was osteosarcoma. The average follow-up period was 66 months, with the maximum being 180 months. Functional and oncological outcomes were analysed.

RESULTS

The one and five year cumulative survival (Kaplan-Meier method) rates were 90.9% and 77.9 %. The average Musculoskeletal Tumour Society Score (MSTS) was 80%. Two patients died due to metastasis. One patient had a forequarter amputation for local recurrence. The procedure provides fast recovery and relatively good restoration of elbow function, whereas active shoulder movements remain limited

CONCLUSION

Total humeral custom endoprosthetic replacement represents a viable treatment option in indicated patients, providing reliable and reasonable function of the upper limb, with a low complication rate.

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.

Conservative treatment of Campanacci grade III proximal humerus giant cell tumors

Management of large giant cell tumors of the proximal humerus is controversial because wide resection with reconstruction results in a poor functional outcome for most patients. We retrospectively reviewed the cases of six patients with Campanacci Grade III giant cell tumors of the proximal humerus to determine the feasibility of avoiding en bloc resections for large giant cell tumors in this location. We evacuated the tumor through curettage and then used burring (unless the remaining cavity was thinned and at risk for fracture) and phenolization, followed by packing of the defect with allograft cancellous bone. The mean age of the patients at surgery was 30 years, and the minimum followup was 2.5 years (mean, 5.6 years; range, 2.5-9.7 years). One of the six patients had local recurrence 1.2 years postoperatively and was treated with repeat intralesional surgery with no additional recurrence 5 years later. No other patient required additional treatment, had pulmonary metastases develop, or had progression to osteoarthritis. The mean Musculoskeletal Tumor Society and Toronto Extremity Salvage Score functional scores at last followup were 26 of 30 (range, 21-30) and 95% (range, 90%-100%), respectively. These functional scores are higher than reported scores for patients with segmental resection and reconstruction of the proximal humerus.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Functional outcome following endoprosthetic reconstruction of the proximal humerus

BACKGROUND

The proximal humerus is a common site for tumors, either metastatic or primary. Thus it is a frequent site of intervention in musculoskeletal oncology surgery. We looked at the use of endoprosthetic reconstructions in surgical intervention for tumors of the proximal humerus.

METHODS

A review of our database from 1990 to 2005 revealed 83 proximal humeral endoprosthetic reconstructions following an intra-articular, deltoid muscle, and axillary nerve sparing resection. Medical records and radiographs were reviewed to determine shoulder range of motion, MSTS scores, and any complications. The median patient age was 55 years (range, 13-80). The mean follow-up was 30 months (range, 1-199).

RESULTS

Mean active abduction was 41 degrees (range, 10-90 degrees) and mean active forward flexion was 42 degrees (range, 5-115 degrees). The mean MSTS score was 63% (range, 40-83%). Implant-related complications included 2 deep infections and 22 patients with proximal migration of the prosthesis. No prostheses loosened. Only 2 required removal (1 for infection and 1 for progression of metastatic disease).

CONCLUSIONS

A proximal humeral endoprosthesis provides a durable reconstruction with a relatively low complication rate. Although it provides a stable platform for elbow and hand function, actual shoulder function is limited.