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Rachbauer AM, Schneider KN, Gosheger G, Deventer N. Endoprosthetic Reconstruction of the Proximal Humerus with an Inverse Tumor Prosthesis. Cancers (Basel) 2023; 15:5330. [PMID: 38001590 PMCID: PMC10670134 DOI: 10.3390/cancers15225330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Reconstructing the proximal humerus after tumor removal is challenging due to muscle and bone loss. The current methods often result in poor shoulder function. This study assessed the long-term functional and oncological outcomes of using an inverse proximal humerus prosthesis in 46 patients with bone tumors. The results showed a mean range of motion of 62° in anteversion, 28° in retroversion, and 55° in abduction. Notably, 23 patients achieved over 90° of shoulder abduction, with an average of 140°. The median Musculoskeletal Tumor Society Score was 25. Complications included infection in two radiotherapy patients and single dislocations in seven patients. One patient with recurrent dislocations needed revision surgery. In conclusion, the use of the inverse proximal humerus prosthesis in bone tumor treatment yields excellent shoulder function and high patient satisfaction. This approach is especially beneficial for those with metastatic disease.
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Affiliation(s)
- Anna Maria Rachbauer
- Department of General Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany (N.D.)
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Singh I, Krasney L, Civatte W, Parrish W. Treatment of Epiphyseal Metastasis to the Proximal Humerus Secondary to Breast Carcinoma: A Case Report. Cureus 2023; 15:e47564. [PMID: 38022128 PMCID: PMC10666193 DOI: 10.7759/cureus.47564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Metastasis to the bone is a known risk of breast cancer, with the humerus being the most common upper extremity site of metastases, with most lesions located at the humeral diaphysis. We present a unique case of proximal humeral metastasis involving the epiphysis secondary to primary invasive ductal carcinoma in a middle-aged Caucasian female. It is important to have a high degree of suspicion for metastasis when musculoskeletal pain occurs in breast cancer patients, as it may be masked by common, degenerative conditions about the shoulder girdle. When humeral metastases involve the epiphysis, treatment options are complicated by its location, which jeopardizes the integrity of articular cartilage and the function of the shoulder girdle. External beam irradiation provides pain control in a non-invasive manner, sans surgical risks. Surgical intervention will vary depending on the characteristics of the bony lesion, but the use of endoprosthetics has emerged as the most effective option for restoring range of motion and pain control with acceptable rates of implant survival.
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Affiliation(s)
- Inderpreet Singh
- Orthopedic Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Leighann Krasney
- Orthopedic Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - William Civatte
- Orthopedic Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - William Parrish
- Orthopedic Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
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Wu K, Lin T, Lee CH. Intramedullary nailing versus cemented plate for treating metastatic pathological fracture of the proximal humerus: a comparison study and literature review. J Orthop Traumatol 2023; 24:45. [PMID: 37620629 PMCID: PMC10449752 DOI: 10.1186/s10195-023-00721-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/21/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Pathological fracture of the humerus causes severe pain, limited use of the hand, and decreased quality of life. This study aimed to compare the outcomes of intramedullary nailing and locking plate in treating metastatic pathological fractures of the proximal humerus. METHODS This retrospective comparison study included 45 patients (22 male, 23 female) with proximal humerus metastatic pathological fractures who underwent surgical treatment between 2011 and 2022. All data were collected from medical records and were analyzed retrospectively. Seventeen cases underwent intramedullary nailing plus cement augmentation, and 28 cases underwent locking plate plus cement augmentation. The main outcomes were pain relief, function scores, and complications. RESULTS Among 45 patients with mean age 61.7 ± 9.7 years, 23 (51.1%) had multiple bone metastases, and 28 (62.2%) were diagnosed with impending fractures. The nailing group had significantly lower blood loss [100 (60-200) versus 500 (350-600) ml, p < 0.001] and shorter hospital stay (8.4 ± 2.6 versus 12.3 ± 4.3 days, p < 0.001) than the plating group. Average follow-up time of the nailing group was 12 months and 16.5 months for the plating group. The nailing group had higher visual analog scale (VAS) scores than the plating group, indicating greater pain relief with nailing [7 (6-8) versus 6 (5-7), p = 0.01]. Musculoskeletal Tumor Society functional scores [28 (27-29) versus 27 (26.5-28.5), p = 0.23] were comparable between groups. No complications, local recurrence, or revision surgery were reported until the last follow-up in either group. However, one case in the plating group had a humeral head collapse and fragmentation without needing revision surgery. CONCLUSIONS Intramedullary nailing with cement augmentation is a viable option for treating proximal humerus metastatic pathological fracture, providing rigid fixation and better pain relief resulting in earlier mobility to optimize functional outcomes. Less invasive procedure with less blood loss and shorter hospital stay also benefits patients. Level of evidence Level II. Trial registration statement Not applicable.
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Affiliation(s)
- Karl Wu
- Department of Physical Education and Sport Sciences, National Taiwan Normal University, Taipei, Taiwan
- Department of Materials and Textiles, Oriental Institute of Technology, New Taipei City, 220, Taiwan
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City, 220, Taiwan (R.O.C.)
| | - Ting Lin
- Department of Nursing, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Cheng-Han Lee
- Department of Orthopedic Surgery, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya S. Rd., New Taipei City, 220, Taiwan (R.O.C.).
- Department of Orthopedic Surgery, Nantou Hospital, Ministry of Health and Welfare, Nantou, Taiwan.
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Fiore M, Sambri A, Giannini C, Zucchini R, De Cristofaro R, De Paolis M. Anatomical and reverse megaprosthesis in proximal humerus reconstructions after oncologic resections: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2022; 142:2459-2469. [PMID: 33721053 DOI: 10.1007/s00402-021-03857-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 03/06/2021] [Indexed: 12/19/2022]
Abstract
AIM Anatomic (AN) Endoprosthesis (EPR) reconstructions of the shoulder after intra-articular proximal humerus (Malawer type 1) resections are characterized by early recovery and low complications rate. However, shoulder instability and limited mobility can occur. Reverse shoulder (RS) EPR has been introduced to improve functional outcome. The aim of this systematic review is to evaluate shoulder reconstructions with AN or RS EPR after Malawer type 1 resection, comparing complications and functional results. METHODS Through an electronic systematic search of PubMed, articles concerning EPR after shoulder Malawer type 1 resections were reviewed. Complications rate, range of motion (ROM) and functional outcome (Musculoskeletal Society Tumor Society-MSTS score) of AN and RS EPR were evaluated. RESULTS Sixteen studies were included. A similar complication rate was observed between AN and RS EPR rate (26.4% and 22.4%, respectively, p = 0.37). Soft tissue failure was the most frequent complication and cause of revision in both groups. Mean post-operative flexion and abduction ROM and MSTS scores were significantly higher in RS EPR, particularly among patients with preserved deltoid function (p = 0.013, p = 0.025 and p = 0.005, respectively). CONCLUSIONS Anatomic and reverse shoulder EPR represent safe and effective implants for shoulder reconstruction, with similar implant stability and complication rates. RS EPR significantly improves post-operative ROM and functional outcomes, especially when at least a partial function of the abductor apparatus is preserved.
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Affiliation(s)
- Michele Fiore
- IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli 1, 40136, Bologna, Italy
| | - Andrea Sambri
- Alma Mater Studiorum, University of Bologna, Bologna, Italy. .,IRCCS Policlinico di Sant'Orsola, Bologna, Italy.
| | - Claudio Giannini
- IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli 1, 40136, Bologna, Italy
| | - Riccardo Zucchini
- IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli 1, 40136, Bologna, Italy
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Ebeid WA, Eldaw S, Badr IT, Mesregah MK, Hasan BZ. Outcomes of modular endoprosthesis reconstruction versus cement spacer reconstruction following resection of proximal humeral tumors. BMC Musculoskelet Disord 2022; 23:484. [PMID: 35597987 PMCID: PMC9123671 DOI: 10.1186/s12891-022-05432-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is no agreement about the best reconstructive option following resection of proximal humerus tumors. The purpose of this study was to compare the functional outcomes of endoprosthesis reconstruction versus nail cement spacer reconstruction after wide resection of proximal humeral tumors. METHODS This retrospective comparative study included 58 patients with proximal humerus tumors who had undergone tumor resection and reconstruction with modular endoprosthesis (humeral hemiarthroplasties) or cement spacer. Medical records were reviewed for the epidemiological, clinical, radiological, and operative data. Lung metastasis, local recurrence, and complication were also reviewed. The functional outcome was evaluated using the Musculoskeletal Tumor Society scoring (MSTS) system. RESULTS Nineteen patients with a mean age of 33.4 ± 17.5 years underwent reconstruction by modular endoprosthesis, and 39 patients with a mean age of 24.6 ± 14.3 years underwent reconstruction by cement spacer. The mean MSTS score was 24.8 ± 1.1 in the endoprosthesis group and 23.9 ± 1.4 in the spacer group, P = 0.018. Complications were reported in 5 (26.3%) patients in the endoprosthesis group and 11 (28.2%) patients in the spacer group, P = 0.879. There were no statistically significant differences in the functional outcomes in both patient groups with or without axillary or deltoid resection. CONCLUSIONS Both endoprostheses and cement spacers are durable reconstructions with almost equal functional outcomes with no added advantage of the expensive endoprosthesis.
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Affiliation(s)
- Walid Atef Ebeid
- Department of Orthopaedic Surgery, Cairo University Faculty of Medicine, Cairo, Egypt
| | - Sherif Eldaw
- Department of Orthopaedic Surgery, Tanta University Faculty of Medicine, Tanta, Egypt
| | - Ismail Tawfeek Badr
- Department of Orthopaedic Surgery, Menoufia University Faculty of Medicine, Shebin El-Kom, Menoufia, Egypt
| | - Mohamed Kamal Mesregah
- Department of Orthopaedic Surgery, Menoufia University Faculty of Medicine, Shebin El-Kom, Menoufia, Egypt.
| | - Bahaa Zakarya Hasan
- Department of Orthopaedic Surgery, Menoufia University Faculty of Medicine, Shebin El-Kom, Menoufia, Egypt
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Megaprosthesis for Metastatic Bone Disease—A Comparative Analysis. Curr Oncol 2022; 29:3460-3471. [PMID: 35621669 PMCID: PMC9139992 DOI: 10.3390/curroncol29050279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/25/2022] [Accepted: 05/06/2022] [Indexed: 01/14/2023] Open
Abstract
Background: Megaprosthetic reconstruction is sometimes indicated in advanced metastatic bone disease (MBD) of the appendicular skeleton with large degrees of bone loss or need for oncological segmental resection. Outcome after megaprosthetic reconstruction was studied in the setting of primary bone sarcoma with high levels of complications, but it is not known if this applies to MBD. Method: We performed a comparative analysis of complications and revision surgery for MBD and bone sarcoma surgery in an institutional cohort from 2005–2019. Presented are the descriptive data of the cohort, with Kaplan–Meier (K–M) rates of revision at 1, 2 and 5 years together with a competing risk analysis by indication type. Results: Rates of revision surgery are significantly lower for MBD (8% at 1 year, 12% at 2 years), in the intermediate term, compared to that of sarcoma (18% at 1 year, 24% at 2 years) (p = 0.04). At 5 years this is not significant by K–M analysis (25% for MBD, and 33% for sarcoma), but remains significant in a competing risk model (8% for MBD, and 20% for sarcoma) (p = 0.03), accounting for death as a competing event. Conclusion: Rates of revision surgery after megaprosthetic reconstruction of MBD are significantly lower than that for primary bone sarcoma in this cohort.
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Tseng TE, Lee CC, Yen HK, Groot OQ, Hou CH, Lin SY, Bongers MER, Hu MH, Karhade AV, Ko JC, Lai YH, Yang JJ, Verlaan JJ, Yang RS, Schwab JH, Lin WH. International Validation of the SORG Machine-learning Algorithm for Predicting the Survival of Patients with Extremity Metastases Undergoing Surgical Treatment. Clin Orthop Relat Res 2022; 480:367-378. [PMID: 34491920 PMCID: PMC8747677 DOI: 10.1097/corr.0000000000001969] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 08/17/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND The Skeletal Oncology Research Group machine-learning algorithms (SORG-MLAs) estimate 90-day and 1-year survival in patients with long-bone metastases undergoing surgical treatment and have demonstrated good discriminatory ability on internal validation. However, the performance of a prediction model could potentially vary by race or region, and the SORG-MLA must be externally validated in an Asian cohort. Furthermore, the authors of the original developmental study did not consider the Eastern Cooperative Oncology Group (ECOG) performance status, a survival prognosticator repeatedly validated in other studies, in their algorithms because of missing data. QUESTIONS/PURPOSES (1) Is the SORG-MLA generalizable to Taiwanese patients for predicting 90-day and 1-year mortality? (2) Is the ECOG score an independent factor associated with 90-day and 1-year mortality while controlling for SORG-MLA predictions? METHODS All 356 patients who underwent surgery for long-bone metastases between 2014 and 2019 at one tertiary care center in Taiwan were included. Ninety-eight percent (349 of 356) of patients were of Han Chinese descent. The median (range) patient age was 61 years (25 to 95), 52% (184 of 356) were women, and the median BMI was 23 kg/m2 (13 to 39 kg/m2). The most common primary tumors were lung cancer (33% [116 of 356]) and breast cancer (16% [58 of 356]). Fifty-five percent (195 of 356) of patients presented with a complete pathologic fracture. Intramedullary nailing was the most commonly performed type of surgery (59% [210 of 356]), followed by plate screw fixation (23% [81 of 356]) and endoprosthetic reconstruction (18% [65 of 356]). Six patients were lost to follow-up within 90 days; 30 were lost to follow-up within 1 year. Eighty-five percent (301 of 356) of patients were followed until death or for at least 2 years. Survival was 82% (287 of 350) at 90 days and 49% (159 of 326) at 1 year. The model's performance metrics included discrimination (concordance index [c-index]), calibration (intercept and slope), and Brier score. In general, a c-index of 0.5 indicates random guess and a c-index of 0.8 denotes excellent discrimination. Calibration refers to the agreement between the predicted outcomes and the actual outcomes, with a perfect calibration having an intercept of 0 and a slope of 1. The Brier score of a prediction model must be compared with and ideally should be smaller than the score of the null model. A decision curve analysis was then performed for the 90-day and 1-year prediction models to evaluate their net benefit across a range of different threshold probabilities. A multivariate logistic regression analysis was used to evaluate whether the ECOG score was an independent prognosticator while controlling for the SORG-MLA's predictions. We did not perform retraining/recalibration because we were not trying to update the SORG-MLA algorithm in this study. RESULTS The SORG-MLA had good discriminatory ability at both timepoints, with a c-index of 0.80 (95% confidence interval 0.74 to 0.86) for 90-day survival prediction and a c-index of 0.84 (95% CI 0.80 to 0.89) for 1-year survival prediction. However, the calibration analysis showed that the SORG-MLAs tended to underestimate Taiwanese patients' survival (90-day survival prediction: calibration intercept 0.78 [95% CI 0.46 to 1.10], calibration slope 0.74 [95% CI 0.53 to 0.96]; 1-year survival prediction: calibration intercept 0.75 [95% CI 0.49 to 1.00], calibration slope 1.22 [95% CI 0.95 to 1.49]). The Brier score of the 90-day and 1-year SORG-MLA prediction models was lower than their respective null model (0.12 versus 0.16 for 90-day prediction; 0.16 versus 0.25 for 1-year prediction), indicating good overall performance of SORG-MLAs at these two timepoints. Decision curve analysis showed SORG-MLAs provided net benefits when threshold probabilities ranged from 0.40 to 0.95 for 90-day survival prediction and from 0.15 to 1.0 for 1-year prediction. The ECOG score was an independent factor associated with 90-day mortality (odds ratio 1.94 [95% CI 1.01 to 3.73]) but not 1-year mortality (OR 1.07 [95% CI 0.53 to 2.17]) after controlling for SORG-MLA predictions for 90-day and 1-year survival, respectively. CONCLUSION SORG-MLAs retained good discriminatory ability in Taiwanese patients with long-bone metastases, although their actual survival time was slightly underestimated. More international validation and incremental value studies that address factors such as the ECOG score are warranted to refine the algorithms, which can be freely accessed online at https://sorg-apps.shinyapps.io/extremitymetssurvival/. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Ting-En Tseng
- Department of Medical Education, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chia-Che Lee
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | | | - Olivier Q. Groot
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chun-Han Hou
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Shin-Ying Lin
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Michiel E. R. Bongers
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ming-Hsiao Hu
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Aditya V. Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jia-Chi Ko
- Department of Medical Education, National Taiwan University Hospital, Taipei City, Taiwan
| | - Yi-Hsiang Lai
- Department of Medical Education, National Taiwan University Hospital, Taipei City, Taiwan
| | - Jing-Jen Yang
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Wei-Hsin Lin
- Department of Orthopedic Surgery, National Taiwan University Hospital, Taipei City, Taiwan
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Abbott A, Kendal JK, Hewison C, Puloski S, Monument M. Longitudinal survival trends of patients with cancer with surgically managed appendicular metastatic bone disease: systematic review. Can J Surg 2021; 64:E550-E560. [PMID: 34728520 PMCID: PMC8565884 DOI: 10.1503/cjs.015520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2020] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Advances in systemic cancer therapies have improved survival for patients with metastatic carcinoma; however, it is unknown whether these advances have translated to improved survival for patients with appendicular metastatic bone disease (A-MBD) after orthopedic interventions. We conducted a study to evaluate the trend in overall survival for patients who underwent orthopedic surgery for A-MBD between 1968 and 2018. METHODS A systematic search of Embase and Medline to identify studies published since 1968 evaluating patients treated with orthopedic surgery for A-MBD was conducted for a previously published scoping review. We used a meta-regression model to assess the longitudinal trends in 1-, 2- and 5-year overall survival between 1968 and 2018. The midpoint year of patient inclusion for each study was used for analysis. We categorized primary tumour types into a tumour severity score according to prognosis for a further meta-regression analysis. RESULTS Of the 5747 studies identified, 103 were retained for analysis. Meta-regression analysis showed no significant effect of midpoint study year on survival across all time points. There was no effect of the weighted average of tumour severity scores for each study on 1-year survival over time. CONCLUSION There was no significant improvement in overall survival between 1968 and 2018 for patients with A-MBD who underwent orthopedic surgery. Orthopedic intervention remains a poor prognostic variable for patients with MBD. This finding highlights the need for improved collection of prospective data in this population to identify patients with favourable survival outcomes who may benefit from personalized oncologic surgical interventions.
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Affiliation(s)
- Annalise Abbott
- From the Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alta. (Abbott, Kendal, Hewison, Puloski, Monument); the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alta. (Puloski, Monument); and the Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alta. (Monument)
| | - Joseph K Kendal
- From the Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alta. (Abbott, Kendal, Hewison, Puloski, Monument); the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alta. (Puloski, Monument); and the Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alta. (Monument)
| | - Christopher Hewison
- From the Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alta. (Abbott, Kendal, Hewison, Puloski, Monument); the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alta. (Puloski, Monument); and the Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alta. (Monument)
| | - Shannon Puloski
- From the Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alta. (Abbott, Kendal, Hewison, Puloski, Monument); the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alta. (Puloski, Monument); and the Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alta. (Monument)
| | - Michael Monument
- From the Section of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, Alta. (Abbott, Kendal, Hewison, Puloski, Monument); the McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alta. (Puloski, Monument); and the Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alta. (Monument)
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Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis. Orthop Traumatol Surg Res 2020; 106:1047-1057. [PMID: 32768275 DOI: 10.1016/j.otsr.2020.02.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17-31%), kidney (13-15%) or lung (11-24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated. HYPOTHESIS We hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients' function. MATERIALS AND METHODS Between 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30-94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively. RESULTS Seven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing. CONCLUSIONS Our initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso-epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival. LEVEL OF EVIDENCE IV, retrospective study.
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Cazzato RL, Garnon J, De Marini P, Auloge P, Dalili D, Koch G, Antoni D, Barthelemy P, Kurtz JE, Malouf G, Feydy A, Charles YP, Gangi A. French Multidisciplinary Approach for the Treatment of MSK Tumors. Semin Musculoskelet Radiol 2020; 24:310-322. [DOI: 10.1055/s-0040-1710052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AbstractSeveral interventional treatments have recently been integrated into the therapeutic armamentarium available for the treatment of bone tumors. In some scenarios (e.g., osteoid osteoma), interventional treatments represent the sole and definitive applied treatment. Due to the absence of widely shared protocols and the complex multivariate scenarios underlying the clinical presentation of the remaining bone tumors including metastases, therapeutic strategies derived from a multidisciplinary tumor board are essential to provide effective treatments tailored to each patient. In the present review, we present the multidisciplinary therapeutic strategies commonly adopted for the most frequent bone tumors.
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Affiliation(s)
- Roberto Luigi Cazzato
- Service d’Imagerie Interventionnelle, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Julien Garnon
- Service d’Imagerie Interventionnelle, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pierre De Marini
- Service d’Imagerie Interventionnelle, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pierre Auloge
- Service d’Imagerie Interventionnelle, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Danoob Dalili
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Nuffield Orthopaedic Centre, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Guillaume Koch
- Service d’Imagerie Interventionnelle, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Delphine Antoni
- Service de Radiothérapie, Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Philippe Barthelemy
- Service d’Oncologie Médicale, Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Jean Emmanuel Kurtz
- Service d’Oncologie Médicale, Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Gabriel Malouf
- Service d’Oncologie Médicale, Institut de cancérologie Strasbourg Europe (ICANS), Strasbourg, France
| | - Antoine Feydy
- Service de Radiologie, Hôpital Cochin, APHP, Université Paris V, Paris, France
| | - Yan-Philippe Charles
- Service de Chirurgie du Rachis, Hôpitaux Universitaires de Strasbourg, Fédération de Médecine Translationnelle (FMTS), Université de Strasbourg, Strasbourg, France
| | - Afshin Gangi
- Service d’Imagerie Interventionnelle, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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11
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Dubina A, Shiu B, Gilotra M, Hasan SA, Lerman D, Ng VY. What is the Optimal Reconstruction Option after the Resection of Proximal Humeral Tumors? A Systematic Review. Open Orthop J 2017; 11:203-211. [PMID: 28458733 PMCID: PMC5388785 DOI: 10.2174/1874325001711010203] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/02/2017] [Accepted: 01/20/2017] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew Dubina
- University of Maryland - Orthopaedics, Baltimore, MD, USA
| | - Brian Shiu
- University of Maryland Medical Center - Orthopaedics, Baltimore, MD, USA
| | - Mohit Gilotra
- University of Maryland Medical Center - Orthopaedics, Baltimore, MD, USA
| | - S Ashfaq Hasan
- University of Maryland Medical Center - Orthopaedics, Baltimore, MD, USA
| | - Daniel Lerman
- University of Maryland Medical Center - Orthopaedics, Baltimore, MD, USA
| | - Vincent Y Ng
- University of Maryland Medical Center - Orthopaedics, 110 S. Paca St, 6th Floor, Baltimore, 21201, MD, USA
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12
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Treatment for long bone metastases based on a systematic literature review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:205-211. [PMID: 27650452 DOI: 10.1007/s00590-016-1857-9] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 09/09/2016] [Indexed: 01/27/2023]
Abstract
PURPOSE To provide treatment guidelines for patients with long bone metastatic disease based on a systematic review of the literature and to propose an algorithm to guide orthopedic surgeons in decision-making for these patients. MATERIALS AND METHODS We performed a computerized literature search in MEDLINE, EMBASE and Scopus for studies on patients with long bone metastases. We used the key words "long bones", "metastasis" and "treatment" for published studies that evaluated any treatment for long bone metastases. The articles found were then studied to determine the accuracy of surgical treatments for long bone metastases in every anatomic location, regardless of cancer type, stage and grade of the oncologic disease. Guidelines inferred from this literature review were collected, and an algorithm was proposed. RESULTS There was no clear evidence to support excision of a long bone metastatic lesion at the same surgical setting with internal fixation or prosthetic reconstruction. However, en bloc resection of an isolated bone metastasis may have a beneficial effect on survival. The life expectancy of the patients should be considered for any surgical treatment. Internal fixation preferably with reconstruction nails is indicated for meta-diaphyseal lesions; their rate of mechanical failure and complications ranges from 2 to 22 %. Prosthetic reconstruction is indicated for extensive lytic lesions or pathologic fractures in a meta-epiphyseal locations; their rate of mechanical failure and complications ranges from 3.7 to 35 %. Most of the internal fixation-related complications occur more than 1 year after treatment, in contrast to prosthetic reconstruction-related complications that may occur earlier. CONCLUSIONS Intramedullary nail fixation or prosthetic reconstruction should be chosen on the basis of the location of the lesion, the extent of bone destruction and the stability of the construct to outlast the expected life of the patient. Implant-related complication is similar but may occur earlier with prosthetic reconstructions.
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13
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Wang B, Wu Q, Liu J, Yang S, Shao Z. Endoprosthetic reconstruction of the proximal humerus after tumour resection with polypropylene mesh. INTERNATIONAL ORTHOPAEDICS 2014; 39:501-6. [PMID: 25416123 DOI: 10.1007/s00264-014-2597-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 11/04/2014] [Indexed: 01/12/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the functional outcomes and complications of endoprosthesis-PPP mesh composite reconstruction after bone tumour resection of the proximal humerus. METHODS We retrospectively analysed 18 patients treated in our department with endoprosthesis-PPP mesh composite reconstruction after bone tumour resection of the proximal humerus between March 2005 and October 2010. Sixteen patients (16/18) were followed up for 56 months (range, 30-96 months). The pre- and post-operative pain severity was assessed according to a 10-cm visual analogue scale (VAS). The clinical results of functional improvement were assessed by Musculoskeletal Tumour Society (MSTS) score at the time of final follow-up. Moreover, we also analysed complications associated with the reconstruction procedure. RESULTS Most patients experienced some alleviation of pain two weeks after the reconstruction surgery. The mean MSTS upper extremity functional outcome score at the time of final follow-up was 20 (66.7 %, range, 16-27). Mean shoulder abduction was 36° (range, 18-125°) and mean shoulder flexion was 39° (range, 21-120°). Local recurrence occurred in only one patient (6.25 %), aseptic prosthesis loosening occurred in one patient (6.25 %) and anterior subluxation occurred in one patient (6.25 %). CONCLUSIONS The capsule reconstruction on the basis of PPP mesh can significantly reduce the recurrence rate of glenohumeral joint instability, which may offer an alternative for the capsule reconstruction after bone tumour resection of the proximal humerus.
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Affiliation(s)
- Baichuan Wang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China,
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14
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Janssen SJ, Teunis T, Hornicek FJ, Bramer JAM, Schwab JH. Outcome of operative treatment of metastatic fractures of the humerus: a systematic review of twenty three clinical studies. INTERNATIONAL ORTHOPAEDICS 2014; 39:735-46. [PMID: 25398471 DOI: 10.1007/s00264-014-2584-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 10/24/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE This systematic review aims to provide an overview of functional outcome and complications after surgery for metastatic humerus fractures. METHODS A literature search was performed in September 2013 using the Pubmed, Embase and Cochrane database. We included 23 studies reporting on 29 treatment arms: intramedullary nailing (19 studies, 596 cases), plate-screw fixation (five studies, 150 cases), endoprosthetic reconstruction (three studies, 81 cases), and diaphysis prosthesis (two studies, 82 cases), totalling 909 fractures. There were 414 pathological and 56 impending fractures. In 439 cases the type of fracture was not specified. Four studies reported functional outcome. RESULTS Average Musculoskeletal Tumor Society score ranged from 64 to 79 (three studies, 100 patients) after intramedullary nailing, was 90 (one study, 24 patients) after plate-screw fixation, and 73 (one study, 30 patients) after endoprosthetic reconstruction. Re-operation rate varied from 0 to 10 % after intramedullary nailing (overall 4.4 %), 5-14 % after plate-screw fixation (overall 9.3 %), 14-16 % after diaphysis prosthesis (overall 14.6 %), and 0-6 % after endoprosthetic reconstruction (overall 2.5 %). Systemic complication rate varied between 0 and 26 % after intramedullary nailing (overall 2.2 %), between 0 and 6 % after plate-screw fixation (overall 4.8 %), was 0 % after endoprosthetic reconstruction, and varied between 0 and 16 % after diaphysis prosthesis (overall 9.7 %). CONCLUSIONS Reported complication rates help surgeons inform their patients and could aid in surgical decision making. Functional outcome, pain and quality of life were poorly reported. Patient reported outcomes are therefore an important direction for future research.
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Affiliation(s)
- Stein J Janssen
- Department of Orthopaedic Surgery Orthopaedic Oncology Service, Massachusetts General Hospital - Harvard Medical School, Room 3.946, Yawkey building, 55 Fruit Street, Boston, MA, 02114, USA,
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15
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Kapur RA, McCann PA, Sarangi PP. Reverse geometry shoulder replacement for proximal humeral metastases. Ann R Coll Surg Engl 2014; 96:e32-5. [PMID: 25245723 DOI: 10.1308/003588414x13946184903964] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The management of skeletal metastases can be challenging for the orthopaedic surgeon. They represent a significant source of pain and disability for cancer patients, adding to the morbidity of their condition. Treatment is directed at the alleviation of symptoms and the restoration of function. Metastatic involvement of the proximal humerus can be especially debilitating, having the potential to cause severe pain and loss of function. We present a report of three such cases where reverse geometry proximal shoulder replacement was used to provide a pain free functional range of movement in patients with concomitant rotator cuff disease. In all cases, significant symptomatic relief was achieved postoperatively with preservation of upper limb function. No surgical complications were noted. It is our belief that this novel surgical strategy provides a valuable and effective option for the management of proximal humeral metastatic disease in the rotator cuff deficient patient.
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Affiliation(s)
- R A Kapur
- Leeds Teaching Hospitals NHS Trust, UK
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16
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Kundu ZS, Gogna P, Gupta V, Kamboj P, Singla R, Sangwan SS. Proximal humeral reconstruction using nail cement spacer in primary and metastatic tumours of proximal humerus. Strategies Trauma Limb Reconstr 2013; 8:149-54. [PMID: 23925868 PMCID: PMC3800512 DOI: 10.1007/s11751-013-0172-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 07/29/2013] [Indexed: 01/12/2023] Open
Abstract
Limb salvage surgery for malignant tumours of proximal humerus is an operative challenge, where the surgeon has to preserve elbow and hand functions and retain shoulder stability with as much function as possible. We treated 14 consecutive patients with primary malignant or isolated metastasis of proximal humerus with surgical resection and reconstruction by nail cement spacer. There were 8 females and 6 males, with a mean age of 28.92 years (range 16-51 years) and a mean follow-up of 30.14 months (range 12-52 months). The diagnosis was osteosarcoma in 8 patients, chondrosarcoma in 4 patients and metastasis from thyroid and breast carcinoma in 1 patient each. One of our patients had radial nerve neuropraxia, 1 developed inferior subluxation and 3 developed distant metastasis. Two patients died of disease and one developed local recurrence leading to forequarter amputation, leaving a total of 11 patients with functional extremities for assessment at the time of final follow-up which was done using the Musculoskeletal Tumour Society (MSTS) score. Though we were able to preserve the elbow, wrist and hand functions in all patients, the abductor mechanism, deltoid muscle and axillary nerve were not salvageable in any of cases. The mean MSTS score at the time of final follow-up was 19.09. Thus, proximal humeral reconstruction using nail cement spacer is a technical simple, cost-effective and reproducible procedure which makes it a reliable option in subset of patients where the functions around the shoulder cannot be preserved despite costlier prosthesis.
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Affiliation(s)
- Zile Singh Kundu
- Department of Orthopaedics and Rehabilitation, PGIMS, 2/11-J Medical Enclave, Rohtak, 124001 Haryana India
| | - Paritosh Gogna
- Department of Orthopaedics and Rehabilitation, PGIMS, 2/11-J Medical Enclave, Rohtak, 124001 Haryana India
| | - Vinay Gupta
- Department of Orthopaedics and Rehabilitation, PGIMS, 2/11-J Medical Enclave, Rohtak, 124001 Haryana India
| | - Pradeep Kamboj
- Department of Orthopaedics and Rehabilitation, PGIMS, 2/11-J Medical Enclave, Rohtak, 124001 Haryana India
| | - Rohit Singla
- Department of Orthopaedics and Rehabilitation, PGIMS, 2/11-J Medical Enclave, Rohtak, 124001 Haryana India
| | - Sukhbir Singh Sangwan
- Department of Orthopaedics and Rehabilitation, PGIMS, 2/11-J Medical Enclave, Rohtak, 124001 Haryana India
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Ruggieri P, Mavrogenis AF, Casadei R, Errani C, Angelini A, Calabrò T, Pala E, Mercuri M. Protocol of surgical treatment of long bone pathological fractures. Injury 2010; 41:1161-7. [PMID: 20947077 DOI: 10.1016/j.injury.2010.09.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Long bone pathological fractures in patients with primary and metastatic bone tumours are difficult to treat and their management may alter the prognosis of the disease and jeopardize survival. The aim of this article was to review the relevant studies reporting on the management of tumour patients with pathological fractures of the long bones, to discuss the most suitable approach in these patients, to highlight specific treatment recommendations, and finally based on this analysis and our clinical practice, to propose a treatment algorithm for decision making and treatment.
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Affiliation(s)
- Pietro Ruggieri
- Department of Orthopaedics, Istituto Ortopedico Rizzoli, University of Bologna, Bologna, Italy.
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Piccioli A, Maccauro G, Rossi B, Scaramuzzo L, Frenos F, Capanna R. Surgical treatment of pathologic fractures of humerus. Injury 2010; 41:1112-6. [PMID: 20828692 DOI: 10.1016/j.injury.2010.08.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This study evaluates different operative treatment options for patients with metastatic fractures of the humerus focusing on surgical procedures, complications, function, and survival rate. From January 2003 to January 2008, 87 pathological fractures of the humerus in 85 cancer patients were surgically treated in our institutions. Histotypes were breast (n=21), lung (n=14), prostate (n=5), bladder (n=4), kidney (n=13), thyroid (n=7), larynx (n=1), lymphoma (n=5), myeloma (n=8), colon-rectum (n=1), melanoma (n=1), testicle (n=1), hepatocellular carcinoma (n=1) and unknown tumours (n=3). Lesions of the proximal epiphysis were treated with resection and endoprosthetic replacement (n=30). The remaining 57 fractures were stabilized with antegrade unreamed intra-medullary locked nailing without (9 cases) or with resection and use of cement (48 cases). The function of the upper limb was assessed using the Musculo-Skeletal Tumor Society (MSTS) rating scale and survival rate was retrospectively analysed. The mean survival time of patients after surgery was 8.3 months. Complications of endoprosthetic replacement recorded included disease relapse (n=3), soft tissue infection (n=2) and palsy of musculocutaneous nerve (n=1) whereas, for intra-medullary locked nailing there were three cases of soft tissue infection and one case of radial nerve palsy. The mean MSTS score at follow-up was 73% for endoprosthesis and 79.2% for locked intra-medullary nailing. Endoprosthetic replacement of the proximal humerus provides a good function of the upper limb, a low risk of local relapse with a low complication rate at follow-up. Unreamed nailing provides immediate stability and pain relief, minimum morbidity and early return of function.
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Affiliation(s)
- Andrea Piccioli
- Unit of Orthopedic Oncology, CTO Hospital, Via San Nemesio 21, 00145 Rome, Italy.
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