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Bota O, Dragu A, Bönke F, Tille E, Taqatqeh F, Nowotny J. Complex Functional Posttraumatic Shoulder Reconstruction Using Shoulder Arthroplasty and a Pedicled Innervated Latissimus Dorsi Flap-A Case Report and Literature Review. Orthop Surg 2023; 15:2181-2186. [PMID: 36411538 PMCID: PMC10432418 DOI: 10.1111/os.13575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 10/09/2022] [Accepted: 10/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The shoulder joint is one of the most freely movable joints in the human body and has therefore high importance for upper limb functionality. Several techniques have been developed to replace the glenohumeral joint including humeral hemiarthroplasty, anatomical total shoulder arthroplasty, and reverse total shoulder arthroplasty, depending on the underlying pathology. For the soft tissue reconstruction, the innervated latissimus dorsi musculocutaneous flap is a reliable solution flap in shoulder and arm reconstruction. CASE PRESENTATION We present the case of a 16-year-old male patient with a complete destruction of the shoulder joint and soft tissues after ballistic trauma. We performed the reconstruction of the shoulder joint using a humeral hemiarthroplasty with a mesh fixation to the remaining glenoid. The soft tissue coverage and the restoration of the deltoid muscle function were insured with a pedicled innervated latissimus dorsi musculocutaneous flap. One year postoperatively, the patient showed a good function of the shoulder joint with an excellent aesthetical result and no pain. CONCLUSION The pedicled latissimus dorsi musculocutaneous flap can safely restore the shoulder function, while the humeral hemiarthroplasty with mesh fixation can be a reliable solution for the reconstruction of a completely destructed shoulder joint.
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Affiliation(s)
- Olimpiu Bota
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav CarusTU DresdenDresdenGermany
| | - Adrian Dragu
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav CarusTU DresdenDresdenGermany
| | - Florian Bönke
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav CarusTU DresdenDresdenGermany
| | - Eric Tille
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav CarusTU DresdenDresdenGermany
| | - Feras Taqatqeh
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav CarusTU DresdenDresdenGermany
| | - Jörg Nowotny
- University Center for Orthopedics, Trauma and Plastic Surgery, Faculty of Medicine Carl Gustav CarusTU DresdenDresdenGermany
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Muacevic A, Adler JR, Sakhre R. En Bloc Resection With Reconstruction Using a Customized Megaprosthesis in a Case of Proximal Humerus Giant Cell Tumor: A Case Report. Cureus 2023; 15:e34217. [PMID: 36852360 PMCID: PMC9958242 DOI: 10.7759/cureus.34217] [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: 01/25/2023] [Indexed: 01/28/2023] Open
Abstract
A giant cell tumor is a common, benign but locally aggressive bone tumor faced by orthopedic surgeons. The proximal humerus is a rare site of occurrence for this tumor, and the challenges posed while approaching such a case are discussed in this report of a 29-year-old male who presented with pain, swelling, and restricted motion at the left shoulder. Plain radiographs and MRI were suggestive of an aggressive giant cell tumor of the proximal humerus, which was confirmed on histopathological examination. Due to the lesion's extensive soft-tissue involvement, en-bloc resection with reconstruction was planned, but due to the COVID-19 pandemic, surgery was delayed. During the same period, the patient had trivial trauma to the same shoulder, following which the size of the lesion began increasing. The patient was operated on with en-bloc resection and reconstruction with a custom megaprosthesis; following the surgery, there was a complete resolution of pain and improvement in the range of motion. En bloc resection and replacement with a customized megaprosthesis, though technically demanding, offer a safe and cost-effective modality for limb salvage surgery for large giant cell tumors, with good functional outcomes and decreased chances of recurrence.
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Affiliation(s)
- Alexander Muacevic
- Orthopedics and Traumatology, NKP Salve Institute of Medical Sciences & Research Centre, Nagpur, IND
| | - John R Adler
- Orthopedics and Traumatology, NKP Salve Institute of Medical Sciences & Research Centre, Nagpur, IND
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Free Vascularized Fibula Salvage of Failed CPH in Pediatric Sarcoma Patients. Sarcoma 2022; 2022:6240293. [PMID: 35586727 PMCID: PMC9110248 DOI: 10.1155/2022/6240293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background Due to extended life expectancy and recent improvements in surgical techniques, limb salvage has replaced amputation as the gold standard and is now performed in 90–95% of upper extremity malignancies. However, many of these salvage procedures are associated with significant postsurgical complications. In particular, the clavicula pro humero (CPH) procedure is associated with high rates of nonunion. We present our experience with upper extremity salvage using the free vascularized fibular flap (VFF) after failure or nonunion of the original CPH procedure in the pediatric population. Methods Five patients under the age of 18 diagnosed with upper extremity sarcoma who underwent tumor resection with immediate CPH reconstruction complicated with nonunion, and subsequent revision with free VFF were included. Data on patient demographics, oncologic characteristics, surgical procedures, intraoperative details, postoperative complications, and time to graft union were recorded. Results Five patients (average age = 8.4 years; range = 5–10 years at surgery date) underwent secondary limb salvage procedure with free VFF reconstruction following failed CPH reconstruction for proximal humeral osteosarcoma (n = 4) or Ewing sarcoma (n = 1). The mean follow-up was 3.7 years. Complications occurred in five patients (100%), with three patients requiring reoperation (60%). Four patients achieved graft union (average union time = 3.7 months) and successful limb reconstruction. Four patients were alive with no local recurrence of the disease. One patient did not achieve union and was lost to follow-up. Conclusion Primary bone tumors in the pediatric population require wide surgical resection, and reconstruction often has high complication rates that can warrant further procedures. A free VFF is a viable option for upper extremity salvage after previously failed reconstructions because it provides vascularized tissue to a scarred tissue bed and allows for the replacement or augmentation of large bony defects.
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Implant cement spacer-a cost-effective solution for reconstruction of proximal humerus defects after tumor resection. J Clin Orthop Trauma 2021; 22:101574. [PMID: 34722144 PMCID: PMC8531854 DOI: 10.1016/j.jcot.2021.101574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/18/2021] [Accepted: 08/24/2021] [Indexed: 11/21/2022] Open
Abstract
The proximal humerus is a common location for both primary benign and malignant bone tumors and may require sacrificing deltoid muscles, axillary nerve and/or rotator cuff along with proximal humerus resection. Thus, post operatively shoulder movements are restricted. The main goals of reconstruction are to maintain a stable shoulder so that the function of elbow and hand can be optimized. Various reconstruction options are available after proximal humerus resection. We present our experience in using implant-cement spacers as a primary reconstruction option for limb salvage in the primary tumors of proximal humerus. All cases were retrieved from our prospectively maintained surgical database. 142 patients (96 males and 46 females) with a median age of 17.5 years (3-70 years) were operated with implant cement spacer between January 2006 and April 2019. Median follow up was 34 months (1-174 months). Functional outcome of the surgery was assessed in survivors by Musculoskeletal Tumor Society score (MSTS). Implant survival was assessed by Kaplan Meier analysis and competing risk analysis. On last follow up, out of 142 cases, 81 patients had died, 54 are alive and seven were lost to follow up. 18(13%) patients underwent revision surgery for symptomatic proximal migration, implant failure or infection. Four (2.8%) patients underwent forequarter amputation for local recurrence. The five years implant survival (IS) by Kaplan Meier analysis was 79.6% and as per competing risk analysis, the chances of implant revision are 12% and 18% at five and ten years respectively. Mean MSTS score in survivors was 71% (60-80%). Implant cement spacer is a cost-effective alternative for reconstruction of proximal humerus with revision rates and function comparable to other reconstructions in cases where deltoid, axillary nerve and/or rotator cuff are excised.
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Periprosthetic Stress Shielding of the Humerus after Reconstruction with Modular Shoulder Megaprostheses in Patients with Sarcoma. J Clin Med 2021; 10:jcm10153424. [PMID: 34362209 PMCID: PMC8347309 DOI: 10.3390/jcm10153424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 07/26/2021] [Accepted: 07/28/2021] [Indexed: 01/03/2023] Open
Abstract
(1) Background: Modular megaprosthetic reconstruction using a proximal humerus replacement has emerged as a commonly chosen approach after bone tumor resection. However, the long-term risk for revision surgery is relatively high. One factor that might be associated with mechanical failures is periprosthetic osteolysis around the stem, also known as stress shielding. The frequency, potential risk factors, and the effect on implant survival are unknown. (2) Methods: A retrospective single-center study of 65 patients with sarcoma who underwent resection of the proximal humerus and subsequent reconstruction with a modular endoprosthesis. Stress shielding was defined as the development of bone resorption around the prosthesis stem beginning at the bone/prosthesis interface. The extent of stress shielding was measured with a new method quantifying bone resorption in relation to the intramedullary stem length. All patients had a minimum follow-up of 12 months with conventional radiographs available and the median follow-up amounted to 36 months. (3) Results: Stress shielding was observed in 92% of patients (60/65). The median longitudinal extent of stress shielding amounted to 14% at last follow-up. Fifteen percent (10/65) showed bone resorption of greater than 50%. The median time to the first radiographic signs of stress shielding was 6 months (IQR 3–9). Patients who underwent chemotherapy (43/65) showed a greater extent of stress shielding compared to those without chemotherapy. Three percent (2/65) of patients were revised for aseptic loosening, and one patient had a periprosthetic fracture (1/65, 1.5%). All these cases had >20% extent of stress shielding (23–57%). (4) Conclusions: Stress shielding of the proximal humerus after shoulder reconstruction with modular megaprosthesis is common. It occurs within the first year of follow-up and might be self-limiting in many patients; however, about one third of patients shows progression beyond the first year. Still, mechanical complications were rare, but stress shielding might be clinically relevant in individual cases. The extent of stress shielding was increased in patients who underwent perioperative chemotherapy. Stress shielding can be quantified with an easy method using the stem length as a reference.
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D'Arienzo A, Ipponi E, Ruinato AD, De Franco S, Colangeli S, Andreani L, Capanna R. Proximal Humerus Reconstruction after Tumor Resection: An Overview of Surgical Management. Adv Orthop 2021; 2021:5559377. [PMID: 33828866 PMCID: PMC8004366 DOI: 10.1155/2021/5559377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/10/2021] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Antonio D'Arienzo
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Edoardo Ipponi
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | | | - Silvia De Franco
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Simone Colangeli
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Lorenzo Andreani
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
| | - Rodolfo Capanna
- Department of Orthopaedic and Trauma Surgery, University of Pisa, Pisa, Italy
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Hu H, Liu W, Zeng Q, Wang S, Zhang Z, Liu J, Zhang Y, Shao Z, Wang B. The Personalized Shoulder Reconstruction Assisted by 3D Printing Technology After Resection of the Proximal Humerus Tumours. Cancer Manag Res 2019; 11:10665-10673. [PMID: 31920376 PMCID: PMC6934118 DOI: 10.2147/cmar.s232051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/09/2019] [Indexed: 12/31/2022] Open
Abstract
Background The reverse shoulder arthroplasty (RSA) may be a promising alternative for proximal humerus tumours because of good postoperative shoulder function. However, the conventional reverse shoulder prosthesis can not meet individual needs and RSA has been associated with a relatively high complication rate. Therefore, implant design and surgical reconstruction technique warrant further study. Methods Between September 2015 and May 2018, 7 patients were treated via RSA after en-bloc resection of the proximal humerus tumours. A 3D-printed guiding baseplate was used to assist the implant of the 3D-printed glenoid prosthesis; a personalized humerus prosthesis was used to reconstruct the proximal humerus. The functional outcomes were assessed by range of motion (ROM) of the shoulder joint, Musculoskeletal Tumour Society (MSTS) functional score, and Toronto Extremity Salvage Score (TESS). We also analyzed tumour recurrence, metastases, and complications associated with the reconstruction procedure. Results All patients were observed for 14 to 36 months, with an average of 23.6 months. At the final follow-up, the mean MSTS score was 85.7% (range, 73.3–93.3%), and the mean TESS score was 90.0% (range, 84.1–95.9%). No instability, infection, scapular notching, loosening or fracture were observed in this series. One patient with GCT suffered from pulmonary metastasis, while one with osteosarcoma died because of pulmonary metastasis. Conclusion The 3D-printed guiding baseplate facilitated the accurate implantation of the glenoid prosthesis. The RSA based on a 3D-printed glenoid prosthesis and a personalized custom-made humerus prosthesis significantly improved the shoulder function and decreased the complication rate. Further studies of a larger scale with longer follow-up are required to validate this technology.
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Affiliation(s)
- Hongzhi Hu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
| | - Weijian Liu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
| | - Qianwen Zeng
- Department of Pediatrics, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430030, People's Republic of China
| | - Shangyu Wang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
| | - Zhicai Zhang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
| | - Jianxiang Liu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
| | - Yingze Zhang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Qiaoxi District, Shijiazhuang, Hebei, 050051, People's Republic of China, Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, Hebei 050051, People's Republic of China
| | - Zengwu Shao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
| | - Baichuan Wang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
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Guo W, Gao X, Wang D, Wang T, Tang L, Wang Y, Liu B. Quality of life of patients with proximal humerus metastasis treated with cement spacer. Cancer Manag Res 2019; 11:8499-8506. [PMID: 31572004 PMCID: PMC6756156 DOI: 10.2147/cmar.s219178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/23/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose The goal of this study was to determine whether the surgery using cement spacer could improve the quality of life of patients with proximal humerus metastasis. Patients and methods This is a retrospective study. The study included 34 patients who had been treated for proximal humerus metastasis between January 2010 and June 2014. The patients were divided into surgical and non-surgical group depending on whether they underwent cement spacer surgery. The patient’s quality of life (QOL) assessment is scheduled at five points—at the initial diagnosis (baseline) and at 1 month, 3 months, 6 months, and 9 months of follow-up. Evaluation tool is Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire. Results A total of 34 patients, including 15 patients in the surgery group and 19 patients in the non-surgery group, were enrolled in this retrospective study. In the end, 22 patients finished all evaluations, including 11 patients in the surgical group and 11 patients in the non-surgery group. At the completion of the study, 22 patients had died, including 8 patients in the surgery group and 14 patients in the non-surgery group. After surgical using the cement spacer, the QOL scores of patients at each follow-up point were significantly higher than that of preoperative scores. These scores were also higher than those of the non-surgery group. Conclusion The current study indicated that surgical treatment using the cement spacer could upgrade and maintain quality of life for patients with proximal humerus metastasis in the 9-month assessment.
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Affiliation(s)
- Wen Guo
- Department of Orthopedics, Taizhou People's Hospital, Taizhou 225300, Jiangsu, People's Republic of China
| | - Xin Gao
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Dongsheng Wang
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Tao Wang
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Liang Tang
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Yao Wang
- Orthopaedic Oncology Center, Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai 200000, People's Republic of China
| | - Bin Liu
- Department of Bone and Soft Tissue Neurosurgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning 530021, Guangxi, People's Republic of China
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Do Early Results of Proximal Humeral Allograft-Prosthetic Composite Reconstructions Persist at 5-year Followup? Clin Orthop Relat Res 2019; 477:758-765. [PMID: 30811366 PMCID: PMC6437392 DOI: 10.1097/corr.0000000000000354] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Insufficiency of the rotator cuff is a major problem after resections of proximal humeral tumors and can limit shoulder motion despite preservation of the deltoid muscle and axillary nerve. Allograft-prosthetic composite reconstruction offers one method to reattach the rotator cuff tendons and has been successful in small studies with short followup. However, data are lacking with regard to implant durability, changes in Musculoskeletal Tumor Society (MSTS) scores over time, and delayed complications with extended followup. QUESTIONS/PURPOSES (1) What is the cumulative incidence of allograft-prosthetic composite revision surgery 5 years after the procedure? (2) What are the early- and intermediate-term MSTS scores of allograft-prosthetic composite reconstruction of the shoulder? (3) What are the complications of allograft-prosthetic composite reconstruction? METHODS Twenty-one patients underwent allograft-prosthetic composite reconstruction after tumor resection of the proximal humerus between 2000 and 2015. Six patients who were lost to followup were not included. All patients had malignant or aggressive benign tumors that could be treated with a wide intraarticular approach preserving the deltoid muscle, axillary nerve, and glenoid. Cumulative incidence of implant revision was calculated with death of the patient as a competing risk. Minimum followup was 24 months (with the exception of one patient who died at 22 months), and median followup was 97 months (range, 20-198 months). The upper extremity MSTS score was used to assess function. Various complications were identified from radiographs and charts. RESULTS The cumulative risk of implant revision was 10.1% at 5 years (95% confidence interval [CI], 1.6%-28.0%). Mean MSTS scores were 86% (± SD 9%) at 1 year and 78% (± SD 13%) at 5 years (mean difference ± SD 9% ± 14%, p = 0.015). Mean active forward elevation was 101° (± SD 33°) at 1 year and 92° (± SD 34°) at 5 years (mean difference ± SD 8° ± 36°, p = 0.41). Notable adverse events included progressive radiographic superior subluxation > 1 cm after 12 months followup (12 of 21 patients), delayed union > 12 months (10 of 21 patients), resorption of the greater tuberosity (nine of 21 patients), and aseptic loosening (three of 21 patients). CONCLUSIONS At intermediate 5-year followup, allograft-prosthetic composite reconstruction of the proximal humerus has an acceptable overall MSTS score and a low incidence of implant revision, but loss of patients to followup and exclusion from the study likely make the results seem better than they actually are. The MSTS score deteriorates between 1 and 5 years. Decreased active forward elevation is not likely to be the sole reason for worsening MSTS scores. A variety of delayed complications including delayed union, resorption of the greater tuberosity, and superior subluxation occurs frequently and may contribute to overall scores. Future studies that compare allograft-prosthetic composites against other forms of reconstruction should attempt to control for possible selection bias and have sufficiently long followup to detect the deterioration of MSTS scores that occur with time. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Ogink PT, Teunissen FR, Massier JR, Raskin KA, Schwab JH, Lozano-Calderon SA. Allograft reconstruction of the humerus: Complications and revision surgery. J Surg Oncol 2018; 119:329-335. [PMID: 30517776 DOI: 10.1002/jso.25309] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/08/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES Allograft reconstruction of the humerus after resection is preferred by many because of bone stock restoration and biologic attachment of ligaments and muscles to the allograft, theoretically obtaining superior stability and functionality. Our aim was to assess the prevalence of complications and the incidence and etiology for revision surgery in humeral allograft reconstructions. METHODS We included patients 18 years and older who underwent wide resection and allograft reconstruction of the humerus for primary and metastatic lesions at our institution between 1990 and 2013. Our primary outcome measures were complications and revision surgery. We used competing risk regression to assess allograft survival. RESULTS Of the 84 patients we included, 47 patients (51%) underwent allograft reconstructions of the proximal humerus, 30 (36%) intercalary, and seven (8%) of the distal humerus. Fifty-one patients (61%) had at least one complication after surgery. Eighteen patients (21%) underwent revision surgery. The 5-year allograft survival was 71%. CONCLUSION Although allograft reconstructions of the humerus are a valuable option in the orthopedic oncologist's armamentarium, surgeons should mind the accompanying complication rates. Allograft fractures seem to be the main issue for proximal and distal allografts, often leading to revision surgery. Intercalary allografts are mostly troubled by nonunions.
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Affiliation(s)
- Paul T Ogink
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frederik R Teunissen
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julie R Massier
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kevin A Raskin
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Santiago A Lozano-Calderon
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Surgical and Functional Outcome after Endoprosthetic Reconstruction in Patients with Osteosarcoma of the Humerus. Sci Rep 2018; 8:16148. [PMID: 30410099 PMCID: PMC6224576 DOI: 10.1038/s41598-018-34397-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/12/2018] [Indexed: 11/15/2022] Open
Abstract
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.
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Shukla DR, Lee J, Mangold D, Cofield RH, Sanchez-Sotelo J, Sperling JW. Reverse Shoulder Arthroplasty With Proximal Humeral Replacement for the Management of Massive Proximal Humeral Bone Loss. J Shoulder Elb Arthroplast 2018. [DOI: 10.1177/2471549218779845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Substantial proximal humeral bone loss may compromise reverse shoulder arthroplasty secondary to limited implant support, insufficient soft tissue tension due to shortening, lack of attachment sites for the posterosuperior cuff when present, and lack of lateral offset of the deltoid. In these circumstances, use of a proximal humeral replacement may be considered. Patients/Methods Between 2012 and 2014, 34 consecutive reverse shoulder arthroplasties were performed using a proximal humeral replacement system. The indications were failed shoulder arthroplasty (15), oncology reconstruction (9), humeral malunion/nonunion (7), prior resection arthroplasty (2), and intraoperative fracture (1). All patients were included in the survival analysis. Twenty-two patients with minimum 2-year follow-up were included in analysis of clinical results. Results Among the cohort of 34 patients, there were 8 additional reoperations: humeral loosening (3), periprosthetic fracture (2), irrigation and debridement (2), and glenoid loosening (1). Humeral component loosening occurred exclusively in patients undergoing revision shoulder arthroplasty. The 4 patients had an average 3.75 prior procedures before the proximal humeral replacement. Two of the revisions were from cemented to uncemented stems. Among the 23 patients with minimum 2-year follow-up, there was significant improvement in pain scores (4.1 vs 0.6), forward elevation (31 vs 109) degrees, and 81% were satisfied. Conclusion Use of a proximal humeral replacement when performing a reverse shoulder arthroplasty in the complex setting of substantial proximal humerus bone loss provides good clinical results and a particularly low dislocation rate. However, the rate of loosening of the humeral component in the revision setting suggests that proximal humeral replacement components should be cemented when revising a previously cemented stem. IRB 16-006966.
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Affiliation(s)
- Dave R Shukla
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Julia Lee
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Devin Mangold
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Robert H Cofield
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - John W Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Barbier D, De Billy B, Gicquel P, Bourelle S, Journeau P. Is the Clavicula Pro Humero Technique of Value for Reconstruction After Resection of the Proximal Humerus in Children? Clin Orthop Relat Res 2017; 475:2550-2561. [PMID: 28699149 PMCID: PMC5599409 DOI: 10.1007/s11999-017-5438-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 06/26/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are several options for reconstruction of proximal humerus resections after wide resection for malignant tumors in children. The clavicula pro humero technique is a biologic option that has been used in the past, but there are only scant case reports and small series that comment on the results of the procedure. Because the longevity of children mandates a reconstruction with potential longevity not likely to be achieved by other techniques, the clavicula pro humero technique may be a potential option in selected patients. QUESTIONS/PURPOSES (1) How successful is the clavicula pro humero procedure in achieving local tumor control? (2) What is the frequency of nonunion? (3) What are the complications of the procedure? (4) What scores do patients achieve (on the Musculoskeletal Tumor Society (MSTS) and the Toronto Extremity Salvage Score (TESS) after this procedure? METHODS Four university hospitals performed the clavicula pro humero technique in eight children aged 8 to 18 years between June 2006 and February 2014. During that period, general indications for this approach included all reconstructions of the proximal humerus for malignant tumors in children older than 8 years. All patients were followed for a mean of 40 months (range, 25-86 months); one patient was lost to followup before 2 years. The tumor resections removed the rotator cuff muscles in all patients, glenohumeral joint in five, and deltoid muscle in three. The median length of the bone defect after resection was 20 cm (range, 7-25 cm). It was reduced to 9 cm (range, 0-17 cm) or 27% (range, 0%-64%) of the total humerus length after clavicular rotation. Direct osteosynthesis (one patient), induced membrane technique (one patient), or vascularized fibular autograft (six patients) was used to complete the defect after rotation of the clavicle if necessary. Presence of union (defined as bone healing before 10 months, as assessed by disappearance of the osteotomy on AP and lateral view radiographs), and complications were determined by chart review performed by a surgeon not involved in patient care. Function assessed by the MSTS and the TESS scores were determined by the patients with their families. RESULTS None of the patients had tumor recurrence. One patient died of pulmonary metastases before the 2-year followup. Proximal and distal bone unions were achieved before 10 months without an additional surgical procedure in two and six of seven patients, respectively. Fourteen local complications occurred resulting in nine revision operations. The main complication was aseptic proximal pseudarthrosis (five patients); other complications included one proximal junction fracture, one clavicle fracture complicated by clavicle osteolysis, one distal junction fracture, one necrosis of the skin paddle of the fibular autograft, one glenoclavicular ossification, and one distal pseudarthrosis complicated by a fracture of this distal junction. Function, as assessed by the MSTS score, was a median of 23 of 30 (range, 11-27). The median TESS score was 82% (range, 75%-92%). Shoulder ROM (median; range) in abduction, front elevation, and external and internal rotations were 70°(30°-90°), 75°(30°-85°), 10°(0°-20°), and 80°(80°-100°), respectively. Three of the seven patients reported dissatisfaction with the cosmetic appearance. CONCLUSIONS The clavicula pro humero technique achieved oncologic local control after resection and reconstruction of proximal humerus tumors in children. Although union times are approximately 2 years and some patients underwent augmentation with other grafts, it eventually provides a solid, painless, biologic, and stable reconstruction and creates a mobile acromioclavicular joint and generally good function. Nonunion of the proximal junction is the main complication of this technique. We cannot directly compare this technique with other reconstruction options, and longer followup is needed, but this may be a useful reconstruction option to consider in select pediatric patients with sarcomas of the proximal humerus. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Dominique Barbier
- Pediatric Orthopedics Department, Children’s Hospital, CHU Nancy, Rue du Morvan, 54000 Nancy, France
| | - Benoît De Billy
- Pediatric Orthopedics Department, CHRU, Hôpital Jean Minjoz, Besançon, France
| | - Philippe Gicquel
- Pediatric Orthopedics Department, Hôpital de Hautepierre, Strasbourg, France
| | - Sophie Bourelle
- Pediatric Ortopedics Department, American Memorial Hospital, Reims, France
| | - Pierre Journeau
- Pediatric Orthopedics Department, Children’s Hospital, CHU Nancy, Rue du Morvan, 54000 Nancy, France
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Chen CM, Wu PK, Tsai SW, Chen CF, Chen WM. Prognosis-Based Shoulder Hemiarthroplasty After Resection of Proximal Humeral Malignancy. Artif Organs 2017; 41:1162-1172. [PMID: 28722169 DOI: 10.1111/aor.12915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/08/2016] [Accepted: 12/13/2016] [Indexed: 01/01/2023]
Abstract
After wide excision of proximal humeral bony malignancy, prognosis-based reconstruction was performed at Taipei Veterans General Hospital. Bone prosthesis composite (BPC) was carried out among patients with a favored prognosis, while cement-spacer prosthesis composite (CSPC) was preserved for patients with poor prognosis. The aim of our study is to compare the clinical outcomes between the BPC and CSPC reconstruction procedures. From January 2000 to December 2014, we retrospectively reviewed the clinical outcomes of 34 patients who underwent shoulder hemiarthroplasty following wide excision of a malignant lesion of the proximal humerus, 15 of whom were treated with a BPC reconstruction and 19 cases were treated with a CSPC reconstruction. The mean postoperative follow-up was 51.9 months for the BPC group and 29.0 months for the CSPC group. At the end of the study, four patients (two in the BPC group and two in the CSPC group) developed local recurrence. Thirteen patients (1 in the BPC group and 12 in the CSPC group) had died of disease progression. The postoperative visual analogue scale score of BPC and CSPC groups was similar (P = 0.262). Functional outcome, measured using the Musculoskeletal Tumor Society score and shoulder range of motion, favored the BPC procedure (P < 0.001). The CSPC procedure, however, had less complication rate, required less operative time, and had a lower volume of intraoperative blood loss than the BPC procedure (P < 0.001). Although functional outcomes are expected to be more favorable with a BPC procedure, the CSPC procedure continues to be a safe and cost-effective shoulder hemiarthroplasty procedure for patients with low-demanding activities and when a poor disease prognosis is expected.
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Affiliation(s)
- Chao-Ming Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Rehabilitation and Technical Aid Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Fong Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Rehabilitation and Technical Aid Center, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
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15
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Lesenský J, Mavrogenis AF, Igoumenou VG, Matejovsky Z, Nemec K, Papagelopoulos PJ, Fabbri N. Complex surgery for locally advanced bone and soft tissue sarcomas of the shoulder girdle. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:777-786. [DOI: 10.1007/s00590-017-1999-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 06/15/2017] [Indexed: 11/24/2022]
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Meijer ST, Paulino Pereira NR, Nota SPFT, Ferrone ML, Schwab JH, Lozano Calderón SA. Factors associated with infection after reconstructive shoulder surgery for proximal humerus tumors. J Shoulder Elbow Surg 2017; 26:931-938. [PMID: 28094193 DOI: 10.1016/j.jse.2016.10.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 10/12/2016] [Accepted: 10/26/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND The main reconstruction techniques for proximal humerus tumors include osteoarticular allografts (OAs), endoprostheses (EPs), or allograft prosthetic composites (APCs). A common complication is infection, and constructs involving the use of allografts are believed to be at a higher risk of infection. Literature comparing infection rates between different modalities of reconstruction is scarce and underpowered. The study purposes were (1) to determine and compare the prevalence of infection in patients who underwent reconstruction of the proximal humerus including OAs, EPs, and APCs; (2) to identify preoperative, perioperative, and postoperative predictors of infection that might be modifiable; and (3) to present our protocol of treatment in patients with superficial and deep infections. METHODS We reviewed 150 patients of all ages with proximal humerus tumors treated by an OA, EP, or APC at 2 tertiary institutions. The prevalence of infection for each modality was calculated and compared between groups. We identified potential predictors of infection with stepwise backward multivariate Cox regression analysis. RESULTS An infection developed in 19 patients (12%): 5 of 45 (11%) in the OA group, 12 of 85 (14%) in the EP group, and 2 of 20 (10%) in the APC group (P = .740). A lower preoperative hemoglobin blood level and low preoperative albumin blood level were independently associated with infection. CONCLUSIONS We found similar infection rates compared with previously reported series. However, we did not identify a higher infection prevalence in constructs using allografts. Patients with a lower preoperative hemoglobin or albumin level are at higher risk of infection and should undergo optimization before surgery.
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Affiliation(s)
- Sjoerd Th Meijer
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA.
| | - Nuno R Paulino Pereira
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Sjoerd P F Th Nota
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Marco L Ferrone
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Brigham and Women's Hospital-Harvard Medical School, Boston, MA, USA
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
| | - Santiago A Lozano Calderón
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA
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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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The effect of cement augmentation and anteromedial plating on proximal humerus allograft reconstruction. J Orthop Sci 2017; 22:69-74. [PMID: 27680581 DOI: 10.1016/j.jos.2016.09.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/01/2016] [Accepted: 09/07/2016] [Indexed: 02/09/2023]
Abstract
BACKGROUND Limb salvage following the resection of tumor from the proximal part of the humerus, poses many challenges, and there is no consensus regarding the best reconstructive technique after proximal humerus resection. The aim of this study was to evaluate the effect of anteromedial placing of the plate in the absence of deltoid muscle and cement augmentation on the functional outcome, complication rate and survival of proximal humerus allograft reconstruction. PATIENTS AND METHODS A number of 36 osteoarticular allograft reconstructions of proximal humerus were included in final study. In 26 cases, medullary canal of the allograft was filled by cement and the complication rate and survival was compared to non-cemented allografts. In addition, anteromedial placement of plate was applied for all resection type IB (18 cases), in which the deltoid muscle was resected. The mean follow-up of patients was 46 months. RESULTS In total, 12 complications including 3 fractures, 4 resorptions, 3 infections and 2 nonunions were reported. Complication rates were significantly lower in cemented allografts (p = 0.001). Five year survival rates of cemented and non-cemented allografts were found to be 82% and 70%, respectively. The mean MSTS score was 84.9%, ranging 76-90. CONCLUSION According to our results, cement augmentation improves survival and reduces the complication rate of allografts. Moreover, our results showed that anteromedial placing of the plate in resection type IB could improve the functional outcome of allografts. However, the detailed effect of anteromedial plating should be further investigated in future studies.
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Effectiveness of Clavicula Pro Humero Reconstruction for Elderly Patients: Report of Two Cases. Case Rep Oncol Med 2016; 2016:4140239. [PMID: 27847662 PMCID: PMC5099472 DOI: 10.1155/2016/4140239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 10/03/2016] [Indexed: 11/26/2022] Open
Abstract
Clavicula pro humero (CPH) reconstruction is a method that is used after proximal humeral excision. During CPH reconstruction, the ipsilateral clavicle is rotated downward and connected to the preserved distal humerus by using plates and screws. This method is frequently used for reconstruction surgeries involving young patients and has positive outcomes. In this study, we describe two cases of CPH reconstruction that were performed on elderly individuals after wide resection of the proximal humerus; postoperative results from these surgeries were satisfactory. The average Musculoskeletal Tumor Society (MSTS) functional score after surgery was 68.5%, indicating that CPH reconstruction is suitable for not only younger but also elderly patients, particularly those over the age of 65 years.
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Schmolders J, Koob S, Schepers P, Kehrer M, Frey SP, Wirtz DC, Pennekamp PH, Strauss AC. Silver-coated endoprosthetic replacement of the proximal humerus in case of tumour-is there an increased risk of periprosthetic infection by using a trevira tube? INTERNATIONAL ORTHOPAEDICS 2016; 41:423-428. [PMID: 27830274 DOI: 10.1007/s00264-016-3329-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 10/20/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES The aim of our study was to evaluate if there is an increased risk of periprosthetic infection (PJI) in patients following replacement of the proximal humerus by using a modular tumour prosthesis in combination with a trevira tube. METHODS Thirty patients were treated by using a modular tumour endoprosthesis (MUTARS®) following intra-articular resection of the proximal humerus. Fifteen patients received treatment by using a trevira tube. In 15 further cases the use of a trevira tube was not necessary. The mean follow-up time was 26 months (range: 24 months to 84 months). Both, Enneking score and range of motion (ROM), was evaluated. Further radiographs were obtained in two planes. RESULTS The survival rate one year after surgery was 83 % and 63 % after two years. We recorded a 96 % survival of the limb two years after surgery. We also observed only one case of periprosthetic joint infection (PJI) in the entire follow-up period in one patient who received treatment with a trevira tube. The mean Enneking score was 20 points (range 8 to 26 points). ROM was equal in both study groups. In total 20 % of the treated patients (n = 6) suffered complications. CONCLUSIONS Replacement of the proximal humerus by using a trevira tube in combination with a modular tumour endoprosthesis is a safe and viable treatment option for both, bone tumours and metastases. There is no statistically significant increased risk of infection by using trevira tube even among immunosuppressed patients. LEVEL OF EVIDENCE Level 3, retrospective comparative study.
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Affiliation(s)
- Jan Schmolders
- Department for Orthopaedics und Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany.
| | - Sebastian Koob
- Department for Orthopaedics und Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Paul Schepers
- Department for Orthopaedics und Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Michael Kehrer
- Department for Orthopaedics und Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Sönke Percy Frey
- Department for Orthopaedics und Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Dieter Christian Wirtz
- Department for Orthopaedics und Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Peter Heinrich Pennekamp
- Department for Orthopaedics und Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
| | - Andreas Christian Strauss
- Department for Orthopaedics und Trauma Surgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany
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Total Humeral Endoprosthetic Replacement following Excision of Malignant Bone Tumors. Sarcoma 2016; 2016:6318060. [PMID: 27042158 PMCID: PMC4799826 DOI: 10.1155/2016/6318060] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 12/17/2015] [Indexed: 11/18/2022] Open
Abstract
Humerus is a common site for malignant tumors. Advances in adjuvant therapies and reconstructive methods provide salvage of the upper limb with improved outcomes. Reports of limb salvage with total humeral replacement in extensive humeral tumors are sparse. We undertook a retrospective study of 20 patients who underwent total humeral endoprosthetic replacement as limb salvage following excision of extensile malignant tumor from 1990 to 2011. With an average followup of 42.9, functional and oncological outcomes were analyzed. Ten patients were still alive at the time of review. Mean estimated blood loss was 1131 mL and duration of surgery was 314 minutes. Deep infection was encountered in one patient requiring debridement while mechanical loosening of ulnar component was identified in one patient. Subluxation of prosthetic humeral head was noted in 3 patients. Mean active shoulder abduction was 12.5° and active flexion was 15°. Incompetence of abduction mechanism was the major determinant of poor active functional outcome. Mean elbow flexion was 103.5° with 30.5° flexion contracture in 10 patients with good and useful hand function. Average MSTS score was 71.5%. Total humeral replacement is a reliable treatment option in restoring mechanical stability and reasonable functional results without compromising patient survival, with low complication rate.
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Functional outcome of reverse shoulder tumor prosthesis in the treatment of proximal humerus tumors. J Shoulder Elbow Surg 2016; 25:e1-6. [PMID: 26234664 DOI: 10.1016/j.jse.2015.06.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 05/29/2015] [Accepted: 06/01/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of proximal humerus tumors with reverse shoulder arthroplasty with allograft augmentation is still controversial. A tumor prosthesis represents a proven solution for such osseous defects. We investigated the functional results of patients who underwent reverse shoulder tumor prosthesis (RSTP) without the use of allograft after resection of a proximal humerus tumor. METHODS We retrospectively evaluated 10 patients with malignant proximal humerus tumors who had undergone RSTP, with a mean follow-up period of 18.2 months (range, 6-27 months). The average age of the patients was 49.4 years. The mean resection length was 10.2 cm (range, 6-16 cm). The tumor prosthesis was preferred for the humeral component. Released rotator cuff muscles were reattached to the prosthesis with nonabsorbable sutures. RESULTS The mean active forward flexion was 96° (range, 30°-160°), the mean active abduction was 88° (range, 30°-160°), and the mean active external rotation was 13° (range, 0°-20°). The mean Constant-Murley score was 53.7%. The mean Disabilities of the Arm, Shoulder, and Hand score was 26.2. The mean visual analog scale score was 1.3. The mean Musculoskeletal Tumor Society score was 78.1%. None of our patients have shown local recurrence or infection signs in the follow-up period. CONCLUSIONS Functionally satisfying results and a stable shoulder can be achieved by reverse shoulder arthroplasty without the need for an allograft. An intact abductor mechanism with a shorter resection humerus length produced good results. The treatment of malignant proximal humerus tumors with RSTP is an alternative that minimizes surgery time and complexity.
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Singh KA, Shankar V, Mohanty SP. Treatment of Non Unions of Subtrochanteric Fractures Using an Anatomical Proximal Femur Locked Compression Plate - A Prospective Study of 13 Patients. J Orthop Case Rep 2016; 6:65-8. [PMID: 27299132 PMCID: PMC5404167 DOI: 10.13107/jocr.2250-0685.381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Subtrochanteric fractures have a bimodal age distribution. They are mostly due to high violence trauma in the younger age group. They almost always require open reduction and internal fixation. Due to the increase in the emergence of native bone setters, these fractures are increasingly been managed by these spurious bone setters using native splints. As a result, non-union rate is high among such patients. These patients definitely need open reduction with internal fixation +/- bone grafting. The choice of implants used can be either a dynamic condylar screw plate (DCS) orproximal femoral nail (PFN). CASE SERIES Here we have used a surgical grade 316 L stainless steel proximal femoral anatomical locked compression plate (PF-LCP). We analyzed 13 patients with established non unions of subtrochanteric fractures treated in our centre by the use of the PF-LCP. There were 10 males and 3 females. The average age was 48.23 years. All our patients were followed up by serial radiographs at 6, 12, 18, 24 weeks and thereafter at 6 months interval. Union was achieved in 11 out of 13 patients at 12 weeks whereas two patients had delayed union which eventually healed at 18 weeks and 24 weeks. The average Harris hip score at 1 year follow-up was excellent in eight, good in four and fair in one patient respectively. CONCLUSION We conclude that in complicated non-unions, the use of PF-LCP has a definite positive role in the management of such cases.
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Affiliation(s)
| | - Vijay Shankar
- Department of Orthopaedics, Kasturba Medical College, Manipal, Karnataka, India
| | - Simanchal P Mohanty
- Department of Orthopaedics, Kasturba Medical College, Manipal, Karnataka, India
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Fujibuchi T, Matsumoto S, Shimoji T, Ae K, Tanizawa T, Gokita T, Hayakawa K. New endoprosthesis suspension method with polypropylene monofilament knitted mesh after resection of bone tumors in proximal humerus. J Shoulder Elbow Surg 2015; 24:882-8. [PMID: 25547854 DOI: 10.1016/j.jse.2014.10.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 10/08/2014] [Accepted: 10/19/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Endoprosthetic reconstruction of the proximal humerus is one of the standard procedures after resection of tumors of the proximal humerus and has been considered a reliable method to reconstruct the proximal humerus in recent reports. However, instability of the shoulder joint caused by loss of the rotator cuff and deltoid muscle function is often observed after such an endoprosthetic reconstruction. METHODS We performed the endoprosthesis suspension method with polypropylene monofilament knitted mesh. This suspension method, by which the endoprosthesis is suspended from the bone structure, was used after resection of tumors in 9 patients. We assessed postoperative stability of the shoulder joint by comparing these patients with 12 patients who underwent the conventional surgical technique, by which the mesh-wrapped endoprosthesis is attached only to soft tissue. RESULTS In radiographic and physical evaluation, 4 of the 12 patients in the soft tissue reconstruction group showed shoulder joint instability. No patient in the suspension method group showed subluxation of the humeral prosthesis. The mean shoulder flexion was 35° and 65° and the mean shoulder abduction was 40° and 40° for the soft tissue reconstruction group and the suspension method group, respectively. DISCUSSION Shoulder joint subluxation sometimes occurs because of elongation of the attached soft tissue in the conventional reconstruction with mesh, whereas no shoulder joint subluxation occurs after endoprosthetic reconstruction in the suspension method because the bone structure has no leeway for elongation. Excellent stability of our new method enables exercise of the surgical shoulder at an early stage, leading to improved range of shoulder joint motion.
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Affiliation(s)
- Taketsugu Fujibuchi
- Department of Orthopaedic Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan.
| | - Seiichi Matsumoto
- Department of Orthopaedic Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
| | - Takashi Shimoji
- Department of Orthopaedic Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
| | - Keisuke Ae
- Department of Orthopaedic Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
| | - Taisuke Tanizawa
- Department of Orthopaedic Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
| | - Tabu Gokita
- Department of Orthopaedic Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
| | - Keiko Hayakawa
- Department of Orthopaedic Oncology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Koto, Tokyo, Japan
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Wafa H, Reddy K, Grimer R, Abudu A, Jeys L, Carter S, Tillman R. Does total humeral endoprosthetic replacement provide reliable reconstruction with preservation of a useful extremity? Clin Orthop Relat Res 2015; 473:917-25. [PMID: 24801261 PMCID: PMC4317414 DOI: 10.1007/s11999-014-3635-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Controversy exists regarding the ideal method of reconstruction after proximal humeral resection and several reconstructive techniques have been reported. The reconstructive options are very limited when resection of the entire humerus is required. One option is endoprosthetic reconstruction, but there have been few published studies on the outcome of total humeral endoprosthetic reconstruction. QUESTIONS/PURPOSES The purposes of this study were (1) to assess the longevity of total humerus prostheses in those patients who survived their disease; (2) to review the complications associated with this prosthesis; and (3) to assess the Musculoskeletal Tumor Society functional score in survivors. METHODS Thirty-four patients (10 males, 24 females) with a mean age of 26 years (range, 7-86 years) were included in this study. Histological diagnosis was osteosarcoma in 15 patients, chondrosarcoma in seven, Ewing's sarcoma in seven, metastatic carcinoma in three, liposarcoma in one, and giant cell tumor of bone in one remaining patient. Twenty-nine patients had their total humeral endoprosthetic replacement for primary reconstruction, whereas the remaining five patients received their implants for failures with other reconstructive techniques. At a minimum followup of 3 months (mean, 8.2 years; range, 3 months to 29 years), 16 patients were alive with no evidence of disease, whereas 13 of the remaining 18 died with metastatic disease. Local recurrence was seen in five patients and all eventually died of disease progression. RESULTS According to the Kaplan-Meier survival analysis, the cumulative 10-year implant survival rate was 90%. Periprosthetic infection was seen in four patients, postoperative radial nerve palsy in one, and proximal migration of the prosthesis in three, whereas three patients needed a change of the articular elbow bushings at a mean of 16 years after the implant insertion. The mean Musculoskeletal Tumor Society functional score of the 28 patients who survived their disease for more than 12 months after the index procedure and could therefore be functionally assessed was 83% (range, 60%-93%). CONCLUSIONS From this small, preliminary report, we suggest that total humeral endoprosthetic replacement may be a reasonable option of reconstruction after tumor resection. We have shown that this prosthesis preserves the function of the hand. The local recurrence rate observed suggests that careful selection of patients is crucial. Infection was our most common surgical complication, but we showed that in those who survived their tumor, this prosthesis offers a method to preserve a functional upper extremity in some patients. Further study with more patients is necessary to confirm the value of this reconstruction method. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hazem Wafa
- The Royal Orthopaedic Hospital Oncology Service, The Royal Orthopaedic Hospital NHS Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - Krishna Reddy
- The Royal Orthopaedic Hospital Oncology Service, The Royal Orthopaedic Hospital NHS Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - Robert Grimer
- The Royal Orthopaedic Hospital Oncology Service, The Royal Orthopaedic Hospital NHS Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - Adesegun Abudu
- The Royal Orthopaedic Hospital Oncology Service, The Royal Orthopaedic Hospital NHS Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - Lee Jeys
- The Royal Orthopaedic Hospital Oncology Service, The Royal Orthopaedic Hospital NHS Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - Simon Carter
- The Royal Orthopaedic Hospital Oncology Service, The Royal Orthopaedic Hospital NHS Trust, Bristol Road South, Birmingham, B31 2AP UK
| | - Roger Tillman
- The Royal Orthopaedic Hospital Oncology Service, The Royal Orthopaedic Hospital NHS Trust, Bristol Road South, Birmingham, B31 2AP UK
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Calvert GT, Wright J, Agarwal J, Jones KB, Randall RL. Is claviculo pro humeri of value for limb salvage of pediatric proximal humerus sarcomas? Clin Orthop Relat Res 2015; 473:877-82. [PMID: 25057117 PMCID: PMC4317444 DOI: 10.1007/s11999-014-3814-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There are several options for proximal humerus reconstruction in young children after resection of a malignant tumor and no one technique has been definitively shown to be superior to others, leaving the decision to surgeon and patient choice. Claviculo pro humeri (CPH) is a biologic reconstruction of the proximal humerus using the patient's ipsilateral clavicle as a rotational osseous flap. CPH represents a potential option for this complicated clinical problem in very young children, but little is known about it because the indications for its use are so uncommon. QUESTIONS/PURPOSES The purposes of this study were to (1) assess the oncologic outcomes of CPH at a minimum of 2 years in a small series of patients; (2) elicit the complications associated with this procedure; and (3) show the Musculoskeletal Tumor Society (MSTS) functional score of these patients. METHODS Four patients (average age, 5 years 11 months; range, 4 years 5 months to 8 years 9 months at the time of surgery) were treated with CPH for reconstruction after resection of a proximal humerus sarcoma; this represented all of the patients treated with this approach for this problem between January 2008 and April 2011 at one institution. During this period, the general indications for using CPH were the need to reconstruct a proximal humerus defect in a child younger than 10 years of age. During this time, CPH was used for all patients treated for proximal humerus sarcomas meeting these criteria. Patient demographics, diagnosis, tumor size and extent, operative details, radiographs and MRIs, complications, and functional outcomes were assessed. RESULTS All are alive with no evidence of disease at a minimum followup of 31 months (average, 43 months; range, 31-58 months). Two patients developed nonunion and underwent revision surgery. Osseous union and a stable neoshoulder articulation were ultimately obtained in all patients. Limited shoulder motion was the only functional deficit noted with forward elevation ranging between 30° and 90°. MSTS functional scores were excellent with a range of 87% to 90%. CONCLUSIONS This is a rarely used procedure in North America but we achieved functional limb salvage in all four patients. Consistent with prior literature, nonunion was the major complication in this series. The two nonunions were successfully treated without interruption of chemotherapy or significant bone graft donor site morbidity. Based on these results, the authors suggest that this procedure is a reasonable reconstruction option to consider after proximal humerus resection in patients younger than 10 years of age. Further followup will be required to assess long-term results and to determine how this procedure compares with the alternatives. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- George T. Calvert
- Sarcoma Services, Center for Children’s Cancer Research, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Suite 4260, Salt Lake City, UT 84112-5550 USA ,Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT USA
| | - Jennifer Wright
- Sarcoma Services, Center for Children’s Cancer Research, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Suite 4260, Salt Lake City, UT 84112-5550 USA ,Department of Pediatrics, University of Utah, Salt Lake City, UT USA
| | - Jayant Agarwal
- Division of Plastic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT USA
| | - Kevin B. Jones
- Sarcoma Services, Center for Children’s Cancer Research, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Suite 4260, Salt Lake City, UT 84112-5550 USA ,Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT USA
| | - R. Lor Randall
- Sarcoma Services, Center for Children’s Cancer Research, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Suite 4260, Salt Lake City, UT 84112-5550 USA ,Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT USA
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Bonnevialle N, Mansat P, Lebon J, Laffosse JM, Bonnevialle P. Reverse shoulder arthroplasty for malignant tumors of proximal humerus. J Shoulder Elbow Surg 2015; 24:36-44. [PMID: 24927883 DOI: 10.1016/j.jse.2014.04.006] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 03/31/2014] [Accepted: 04/08/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reverse shoulder arthroplasty (RSA) provides an alternative for shoulder girdle reconstruction after wide transarticular resection of the proximal humerus for malignant tumor. The aim of this study was to evaluate midterm outcomes of this therapeutic option. METHODS Ten patients with RSA were included and reviewed with 24 months of minimum follow-up. Proximal resection of malignant tumor included the "V" deltoid insertion in 4 patients. The humeral stem was coated (with an allograft in 2 patients and a cement mantel in 3) or left uncoated (5 patients). RESULTS At a mean follow-up of 42 months, among 8 prosthesis available for evaluation (2 patients died), the Constant and Murley score averaged 52 points, the 11-item version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score averaged 29.5 points, the Subjective Shoulder Value averaged 58%, and the Musculoskeletal Tumor Society score averaged 20.25 points. Mean forward active elevation reached 122°, external rotation at side was -2°, and internal rotation was to L4. Three prostheses were unstable. The involvement of "V" deltoid insertion at surgery trended to worsen the clinical outcome. Atrophy of the anterior deltoid occurred in most of patients who had a previous transdeltoid biopsy. Radiographic evaluation found 1 stem loosening, 1 stem at risk, and 3 scapular notches without glenoid loosening. CONCLUSION Use of RSA after resection of a malignant tumor of the proximal humerus seems to be an acceptable option to preserve function. However, radiographic evolution is worrisome, and long-term study remains necessary to validate this therapeutic option with follow-up.
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Affiliation(s)
- Nicolas Bonnevialle
- Service d'Orthopédie-Traumatologie, Centre Hospitalier Universitaire de Toulouse-Purpan, Toulouse, France.
| | - Pierre Mansat
- Service d'Orthopédie-Traumatologie, Centre Hospitalier Universitaire de Toulouse-Purpan, Toulouse, France
| | - Julie Lebon
- Service d'Orthopédie-Traumatologie, Centre Hospitalier Universitaire de Toulouse-Purpan, Toulouse, France
| | - Jean-Michel Laffosse
- Service d'Orthopédie-Traumatologie, Centre Hospitalier Universitaire de Toulouse-Purpan, Toulouse, France
| | - Paul Bonnevialle
- Service d'Orthopédie-Traumatologie, Centre Hospitalier Universitaire de Toulouse-Purpan, Toulouse, France
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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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Improvement of the shoulder function after large segment resection of the proximal humerus with the use of an inverse tumour prosthesis. INTERNATIONAL ORTHOPAEDICS 2014; 39:355-61. [PMID: 25326856 DOI: 10.1007/s00264-014-2560-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Active shoulder function after segmental tumour resection of the proximal humerus and endoprosthetic reconstruction is regularly compromised, while the overall arm function allows a satisfying use in daily activities. The main functional problem remains the loss of huge parts of the shoulder girdle musculature and its bony attachment. In revision arthroplasty inverse shoulder implants can improve the active range of motion significantly in comparison to anatomical shaped prostheses. The aim of this study was to investigate if these promising experiences are transferable to reconstructions after tumour resection of the proximal humerus by using a modular inverse tumour prosthesis. METHODS In this study we observed the functional and oncological results of 18 inverse proximal humerus endoprosthetic replacements (IPHP) with the MUTARS system (Implantcast®) after resection of benign (1x giant cell) and malignant (11x primary bone sarcoma, 5x bone metastasis of carcinoma) bone tumours. Mean age at operation was 42 years. The mean postoperative follow-up was 33 months (range ten to 120). RESULTS Resection margins were wide in 13 and marginal in five patients. Mean reconstruction length was 15.1 cm (range 6-25 cm). Mean operation time was 191 minutes. The axillary nerve was mostly preserved in 78 % (n = 14). At latest follow-up the patients presented a medium MSTS-score of 24.6/30. The mean active arm abduction in the shoulder joint was 78° and 88° active arm elevation for patients with intact axillary nerve function, but significantly reduced for the four patients with compromised deltoid function. One patient needed a surgical revision due to a deep implant infection. CONCLUSIONS The IPHP offers a significant improvement of active shoulder function in patients in whom the axillary nerve can be preserved in comparison to anatomically-shaped implants. However, for patients without any deltoid function there is no benefit regarding an improved active range of motion using an IPHP.
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Abstract
It was estimated that more than 3000 people would be diagnosed with a primary bone or joint malignancy and more than 11,000 people would be diagnosed with a soft tissue sarcoma in 2013. Although primary bone and soft tissue tumors of the upper extremity are infrequent, it is imperative that the clinician be familiar with a systematic approach to the diagnosis and treatment of these conditions to prevent inadvertently compromising patient outcome. With advances in chemotherapy, radiotherapy, tumor imaging, and surgical reconstructive options, limb salvage surgery is estimated to be feasible in 95% of extremity bone or soft tissue sarcomas.
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Affiliation(s)
- Justin C Wong
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1025 Walnut Street, Room 516, College Building, Philadelphia, PA 19107, USA
| | - John A Abraham
- The Rothman Institute of Orthopaedics, Thomas Jefferson University Hospital, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107, USA.
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Outcome after reconstruction of the proximal humerus for tumor resection: a systematic review. Clin Orthop Relat Res 2014; 472:2245-53. [PMID: 24469551 PMCID: PMC4048415 DOI: 10.1007/s11999-014-3474-4] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/14/2014] [Indexed: 01/31/2023]
Abstract
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.
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Liu T, Zhang Q, Guo X, Zhang X, Li Z, Li X. Treatment and outcome of malignant bone tumors of the proximal humerus: biological versus endoprosthetic reconstruction. BMC Musculoskelet Disord 2014; 15:69. [PMID: 24607200 PMCID: PMC3975708 DOI: 10.1186/1471-2474-15-69] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2013] [Accepted: 02/28/2014] [Indexed: 11/18/2022] Open
Abstract
Background The purpose of this study was to compare the outcome, complications and survival of the commonly used surgical reconstructions of the proximal humerus after intrarticular tumour resection in our hospital. Methods Between 1998 and 2010, 41 consecutive proximal humeral reconstructions using prosthesis (group P, n = 25) or recycled pasteurized autograft combined with non-vascularised fibula autograft (group B, n = 16) were performed. Results The mean follow-up was 57.7 months. Fourteen patients (8 patients in group P and 6 in group B) died during the follow-up period, the disease-specific survival of patients in group P was 74.5% at 5 years and in group B was 67.0%. Local recurrences were occurred in 3 cases (12.0%) in group P and 2 (12.5%) in group B. Pulmonary metastases were observed in 4 patients (16.0%) in group P and 4 (25.0%) in group B. There was no significant difference in the incidence of local recurrence, pulmonary metastasis or death of disease. Revisions were indicated in 9 patients (36.0%) in group P and 5 (31.25%) in group B. Thought the incidence of revisions was higher in group P, there was no significant difference in these two groups. The Kaplan-Meier 5-year implant survival estimates, with revision for any reason as the end point, were 80.6% and 68.8% for group P and group B, respectively. The mean MSTS Score was 63.6% in group P and 63.0% in group B. These differences were not statistically significant. Conclusions The study could show that prosthetic reconstruction and reconstruction with recycled pasteurized autograft are similar in terms of their local recurrence and metastasis, while the incidence of revisions was higher for patients with prosthetic reconstruction.
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Affiliation(s)
| | - Qing Zhang
- Department of Orthopaedics, the Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, P,R, China.
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Ruggieri P, Mavrogenis AF, Mercuri M. Quality of life following limb-salvage surgery for bone sarcomas. Expert Rev Pharmacoecon Outcomes Res 2014; 11:59-73. [DOI: 10.1586/erp.10.91] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Wu X, Wang W, Meng C, Duan D, Xu W, Liu X, Wang H, Yang S. Functional outcome of limb-salvage surgery with shoulder abduction brace for bone tumors around the shoulders. J Surg Oncol 2014; 109:714-20. [PMID: 24395023 DOI: 10.1002/jso.23555] [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: 12/02/2013] [Accepted: 12/13/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND The current trend is toward salvage of the extremity after tumor excision without compromising the extent of resection for bone tumor around the shoulders. OBJECTIVES The aim of this study was to evaluate functional outcome of patients treated with limb-salvage surgeries combined with shoulder abduction braces. METHODS Thirty-six patients with bone tumors around the shoulders, who had limb-sparing resection and reconstruction performed with a shoulder abduction brace, were retrospectively reviewed. Allograft transplantation and rigid internal fixation was performed in 22 patients and artificial prosthetic replacement was performed in 14 patients. Functional evaluation was performed based on the Musculoskeletal Tumour Society (MSTS) scoring system. RESULTS The overall survival was 78.8% (26/33) at 2 years. The mean final functional score was (81.2 ± 19.6%). The MSTS of patients treated by allograft transplantation and prosthetic replacement were (79.4 ± 15.3%) and (81.9 ± 18.1%), respectively. The MSTS scores differed only slightly between these two groups (P > 0.05). All the patients regained good ROM of the shoulder joints. CONCLUSIONS Satisfactory functional outcomes can be obtained by limb-salvage surgery for bone tumor around the shoulder. Postoperatively shoulder crutches with shoulder abduction brace are encouraged as the aid of reconstruction of shoulder joint function.
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Affiliation(s)
- Xinghuo Wu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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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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Allograft reconstruction for the treatment of musculoskeletal tumors of the upper extremity. Sarcoma 2013; 2013:925413. [PMID: 23476115 PMCID: PMC3586508 DOI: 10.1155/2013/925413] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 12/26/2012] [Accepted: 01/18/2013] [Indexed: 11/20/2022] Open
Abstract
In comparison with the lower extremity, there is relatively paucity literature reporting survival and clinical results of allograft reconstructions after excision of a bone tumor of the upper extremity. We analyze the survival of allograft reconstructions in the upper extremity and analyze the final functional score according to anatomical site and type of reconstruction. A consecutive series of 70 allograft reconstruction in the upper limb with a mean followup of 5 years was analyzed, 38 osteoarticular allografts, 24 allograft-prosthetic composites, and 8 intercalary allografts. Kaplan-Meier survival analysis of the allografts was performed, with implant revision for any cause and amputation used as the end points. The function evaluation was performed using MSTS functional score. Sixteen patients (23%) had revision surgery for 5 factures, 2 infections, 5 allograft resorptions, and 2 local recurrences. Allograft survival at five years was 79% and 69% at ten years. In the group of patients treated with an osteoarticular allograft the articular surface survival was 90% at five years and 54% at ten years. The limb salvage rate was 98% at five and 10 years. We conclude that articular deterioration and fracture were the most frequent mode of failure in proximal humeral osteoarticular reconstructions and allograft resorption in elbow reconstructions. The best functional score was observed in the intercalary humeral allograft.
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Shin SH, Jeong HJ, Han I, Cho HS, Kim HS. Osteosarcoma and chondrosarcoma of the shoulder: site-specific comparative analysis. Orthopedics 2013; 36:e179-85. [PMID: 23380012 DOI: 10.3928/01477447-20130122-20] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Osteosarcoma and chondrosarcoma compose most of the primary malignancies of the shoulder. The literature lacks site-specific comparative analyses of these 2 major shoulder sarcomas. The purposes of this study were to describe the different characteristics of the 2 major sarcomas near the glenohumeral joint, examine differences in treatment outcomes, and evaluate the functional outcomes of limb salvage surgery. Thirty-two patients with osteosarcoma or chondrosarcoma who underwent a wide resection including the glenohumeral joint were enrolled in this study. The characteristics of tumor development and treatment, oncologic and functional outcomes, and factors affecting outcomes were compared between groups and with the literature. The results showed shoulder osteosarcoma developing similarly to the literature reports, whereas chondrosarcoma tended to be of a high histologic grade. Nonetheless, the osteosarcoma group had a poorer overall 5-year survival rate (53.0%) than the chondrosarcoma group (85.7%) or those in previous reports. The osteosarcoma group had a tendency toward a worse 5-year metastasis-free survival rate than the chondrosarcoma group (35.4% vs 75.0%, respectively), although the 5-year local recurrence-free survival rate was not significantly different between the 2 groups (75.0% vs 87.5%, respectively). Histologic grade, surgical stage, and chemotherapy affected the oncologic outcomes in univariate analysis, although not a single factor was independent in multivariate analysis. The functional outcomes were not significantly affected by clinical characteristics or surgical methods in patients who had undergone a wide resection including the glenohumeral joint.
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Affiliation(s)
- Seung Han Shin
- Department of Orthopaedic Surgery, Seoul National University Hospital, Seoul, Korea
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Wang Z, Guo Z, Li J, Li XD, Sang HX. Functional outcomes and complications of reconstruction of the proximal humerus after intra-articular tumor resection. Orthop Surg 2012; 2:19-26. [PMID: 22009903 DOI: 10.1111/j.1757-7861.2009.00058.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate functional outcomes and complications of reconstruction of the proximal humerus after intra-articular tumor resection. METHODS Twenty-five patients who underwent Malawer I type resection and reconstruction of the proximal humerus for treatment of malignant or invasive benign tumors from August 1999 to August 2005 were evaluated. A variety of reconstructive procedures, including modular tumor prosthesis, osteoarticular allograft, and allograft-prosthetic composite (APC), were performed after resection of tumor. Oncological and radiographic parameters were evaluated. The modified Musculoskeletal Tumor Society (MSTS) evaluation system was used to assess limb functional outcome. RESULTS The study group consisted of 10 male and 15 female patients, among which there were 20 malignant and 5 benign tumors. Restoration of shoulder function was achieved with a prosthesis in 6 patients, osteoarticular allograft in 12, and allograft-prosthesis composite in 7. At a mean of 48 months follow-up, 2 patients had died of disease. Two patients had local recurrence and 2 had metastatic disease. On the basis of the modified MSTS functional evaluation, the mean scores were 22.50 in the modular prosthesis group, 24.58 in the osteoarticular allograft group, and 27.00 in APC group, respectively. Joint instability and subluxation were serious complications affecting shoulder function in 10 patients. CONCLUSION Reconstruction of the proximal humerus is an option that provides good relief of pain and preserves manual dexterity. Functional outcomes are better for APC and allograft than for modular prosthesis, due to retention of the rotation cuff. Complications in the APC group were less than in the allograft one.
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Affiliation(s)
- Zhen Wang
- Department of Orthopaedics, Xijing Hospital, the Fourth Military Medical University, Xi'an, China.
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[Endoprosthetic reconstruction of the proximal humerus in malignoma]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2012; 24:174-85. [PMID: 22752327 DOI: 10.1007/s00064-011-0078-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The aim of the operation is local tumor control in malignant primary and secondary bone tumors of the proximal humerus. Limb salvage and preservation of function with the ability to lift the hand to the mouth. Stable suspension of the arm in the shoulder joint or the artificial joint. INDICATIONS Primary malignant bone tumors of the proximal humerus or the scapula with joint infiltration but without involvement of the vessel/nerve bundle. Metastases of solid tumors with osteolytic defects in palliative or curative intention or after failure of primary osteosynthesis. CONTRAINDICATIONS Tumor infiltration of the vessel/nerve bundle. Massive tumor infiltration of the soft tissues without the possibility of sufficient soft tissue coverage of the implant. SURGICAL TECHNIQUE Transdeltoid approach with splitting of the deltoid muscle. Preparation and removal of the tumor-bearing humerus with exposure of the vessel/nerve bundle. Ensure an oncologically sufficient soft tissue and bone margin in all directions of the resection. Cementless or cemented stem implantation. Reconstruction of the joint capsule and fixation of the prosthesis using a synthetic tube. Soft tissue coverage of the prosthesis with anatomical positioning of the muscle to regain function. POSTOPERATIVE TREATMENT: Immobilization of the arm/shoulder joint for 4-6 weeks in a Gilchrist bandage. Passive mobilization of the elbow joint after 3-4 weeks. Active mobilization of the shoulder and elbow joint at the earliest after 4-6 weeks.
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Emori M, Kaya M, Sasaki M, Wada T, Yamaguchi T, Yamashita T. Pre-operative selective arterial embolization as a neoadjuvant therapy for proximal humerus giant cell tumor of bone: radiological and histological evaluation. Jpn J Clin Oncol 2012; 42:851-5. [PMID: 22689917 DOI: 10.1093/jjco/hys090] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The management of giant cell tumor of the proximal humerus that extends to the joint is challenging. Here, we report a case of proximal humerus giant cell tumor with cortical bone destruction extending to the shoulder joint. Pre-operative selective arterial embolization induced peripheral tumor ossification. Subsequently, the lesion was removed by intralesional curettage, and the cavity was filled with cement. Macroscopically, the inner wall of the cavity was found to be lined with a thick fibrous membrane. Histologically, massive fibrosis and resultant remodeling of the destroyed cortical bone were induced, which was consistent with the peripheral ossification on the plain radiograph. We believe that selective arterial embolization can be an effective neoadjuvant therapy for giant cell tumors of the extremities, especially for tumors with large cortical defects or joint involvement.
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Affiliation(s)
- Makoto Emori
- Department of Orthopedic Surgery, Sapporo Medical University School of Medicine, West 16, South 1, Sapporo 060-8543, Japan.
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Puri A, Gulia A. An inexpensive reconstruction method after resection in tumors of the proximal humerus with extensive involvement of the diaphysis. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2011; 5:44-6. [PMID: 21897583 PMCID: PMC3157097 DOI: 10.4103/0973-6042.83196] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Limb salvage is now the norm for a large majority of malignant bone tumors. The proximal humerus is the third most common site for the occurrence of malignant tumors of bone. In tumors of the proximal humerus with large volume disease, extensive involvement of the diaphysis is not infrequent. Resection may often extend as far as the distal metaphysis in order to obtain adequate oncologic margins. A very small distal stump of bone poses unique challenges in reconstruction where conventional reconstruction modalities may be difficult to apply. We describe the use of a customised plate to reconstruct these defects which offers an inexpensive, easy to use, durable reconstruction option. It provides adequate shoulder and arm stability and ensures excellent hand and elbow motion with good functional results.
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Affiliation(s)
- Ajay Puri
- Department of Orthopedic Oncology, Tata Memorial Hospital, Mumbai, India
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Abstract
BACKGROUND Normal function of the upper limb is seldom restored after limb-sparing surgery for tumors of the proximal humerus. The literature suggests superior shoulder function is achieved in the short term with reverse total shoulder arthroplasty compared to other techniques when performed for conditions with rotator cuff deficiency. It is unclear whether this superiority is maintained when reverse total shoulder arthroplasty is performed for tumors. QUESTIONS/PURPOSES When performed for tumors, we determined whether reverse total shoulder arthroplasty restores function and improves motion, the complications associated with the surgery, and whether reverse total shoulder arthroplasty with autologous grafting is associated with bone resorption. PATIENTS AND METHODS We retrospectively reviewed 14 patients who had undergone reverse total shoulder arthroplasty for tumors of the proximal humerus. Four patients died, leaving nine patients for review. The surviving patients were evaluated clinically and radiographically. The minimum followup was 0.6 years (mean, 7.7 years; range, 0.6-12 years). RESULTS At last followup, mean active abduction was 157° and mean functional Constant-Murley score was 76%. One patient had a deep infection and one developed a loose prosthesis; both were treated with single-stage exchange. At last followup, both patients had reasonable function without evidence of infection or loosening. Radiographic graft resorption was seen in all but one patient. CONCLUSIONS Our observations suggest, at medium-term followup, reverse total shoulder arthroplasty is a reasonable option for tumors of the proximal humerus. It has low morbidity, restores a mean active abduction of 157°, and limits the impairment of activities of daily living. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Natarajan M, Sameer M, Kunal D, Balasubramanian N. Custom-made endoprosthetic total humerus reconstruction for musculoskeletal tumours. INTERNATIONAL ORTHOPAEDICS 2011; 36:125-9. [PMID: 21796334 DOI: 10.1007/s00264-011-1316-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 06/24/2011] [Indexed: 12/01/2022]
Abstract
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.
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Proximal humerus reconstruction after tumour resection: biological versus endoprosthetic reconstruction. INTERNATIONAL ORTHOPAEDICS 2010; 35:1375-80. [PMID: 21085956 PMCID: PMC3167452 DOI: 10.1007/s00264-010-1152-z] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 10/19/2010] [Accepted: 10/25/2010] [Indexed: 11/28/2022]
Abstract
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.
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Yang Q, Li J, Yang Z, Li X, Li Z. Limb sparing surgery for bone tumours of the shoulder girdle: the oncological and functional results. INTERNATIONAL ORTHOPAEDICS 2010; 34:869-75. [PMID: 19701633 PMCID: PMC2989017 DOI: 10.1007/s00264-009-0857-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 07/28/2009] [Accepted: 07/28/2009] [Indexed: 10/20/2022]
Abstract
It is a great challenge to spare the upper limb with a malignant or invasive benign bone tumour of the shoulder girdle. We retrospectively analysed 35 patients with bone tumours of the shoulder girdle treated with various limb salvage procedures. The tumours included 25 primary malignancies, three metastases and seven giant cell tumours which involved the proximal humerus in 21 patients, scapula in 12 and clavicle in two. The reconstruction procedures included eight prosthetic replacements, four devitalised tumorous bone grafts, three osteoarticular allografts, two autogenous fibular grafts, one intramedullary cemented nail, three Tikhoff-Linberg procedures, two replantation of shortened arms, and four humeral head suspensions. Six partial scapulectomies and two lateral clavicectomies needed no bone reconstruction. With an average follow-up of 71 months, local recurrences occurred in four cases and systemic metastases in six. Nine patients died and 23 remained disease free. The five year Kaplan-Meier survival rate of 28 patients with malignancies was 69.5%. The average Musculoskeletal Tumour Society (MSTS) functional score was 77% (range 40-100%) in all patients.
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Affiliation(s)
- Qiang Yang
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, Jinan, 250012 People’s Republic of China
| | - Jianmin Li
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, Jinan, 250012 People’s Republic of China
| | - Zhiping Yang
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, Jinan, 250012 People’s Republic of China
| | - Xin Li
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, Jinan, 250012 People’s Republic of China
| | - Zhenfeng Li
- Department of Orthopaedic Surgery, Qilu Hospital of Shandong University, Jinan, 250012 People’s Republic of China
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Raiss P, Kinkel S, Sauter U, Bruckner T, Lehner B. Replacement of the proximal humerus with MUTARS tumor endoprostheses. Eur J Surg Oncol 2010; 36:371-7. [DOI: 10.1016/j.ejso.2009.11.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 10/20/2009] [Accepted: 11/02/2009] [Indexed: 10/20/2022] Open
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Conservative treatment of Campanacci grade III proximal humerus giant cell tumors. Clin Orthop Relat Res 2009; 467:1355-9. [PMID: 18987923 PMCID: PMC2664411 DOI: 10.1007/s11999-008-0583-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 10/03/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED 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.
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Potter BK, Adams SC, Pitcher JD, Malinin TI, Temple HT. Proximal humerus reconstructions for tumors. Clin Orthop Relat Res 2009; 467:1035-41. [PMID: 18820983 PMCID: PMC2650043 DOI: 10.1007/s11999-008-0531-x] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2008] [Accepted: 09/09/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED The optimal method for reconstructing the proximal humerus in patients with tumors is controversial. To determine functional outcomes and complication rates after different types of reconstructions, we reviewed a consecutive series of 49 patients who underwent proximal humerus resection and osteoarticular allograft (17 patients), allograft-prosthetic composite (16), or endoprosthetic (16) reconstruction. Operative indications included primary malignancies (24 patients), metastatic disease (19), and benign aggressive disease (six). Implant revision was more common after osteoarticular reconstruction (five of 17) than after allograft-prosthetic composite (one of 16) or endoprosthetic (zero of 16) reconstructions. At a minimum followup of 24 months (median, 98 months; range, 24-214 months) in surviving patients, Musculoskeletal Tumor Society functional scores averaged 79% for the allograft-prosthetic composite, 71% for the osteoarticular allograft, and 69% for the endoprosthetic reconstruction cohorts. Shoulder instability was associated with abductor mechanism compromise and was more common after endoprosthetic reconstruction. Allograft fractures occurred in 53% of patients receiving osteoarticular allografts. We recommend allograft-prosthetic composite reconstruction for younger patients with primary tumors of bone and endoprosthetic reconstruction for older patients with metastatic disease. Because of the unacceptable complication rate, we do not recommend osteoarticular allograft reconstruction for routine use in the proximal humerus. LEVEL OF EVIDENCE Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Benjamin K Potter
- Musculoskeletal Oncology, University of Miami Miller School of Medicine, Miami, FL, USA.
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