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Sullivan MH, Arguello AM, Barlow JD, Morrey ME, Rose PS, Sanchez-Sotelo J, Houdek MT. Comparison of reconstructive techniques for nonprimary malignancies in the proximal humerus. J Surg Oncol 2024; 130:64-71. [PMID: 38837768 DOI: 10.1002/jso.27693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/20/2024] [Accepted: 05/12/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Endoprostheses (EPC) are often utilized for reconstruction of the proximal humerus with either hemiarthroplasty (HA) or reverse arthroplasty (RA) constructs. RA constructs have improved outcomes in patients with primary lesions, but no studies have compared techniques in metastatic disease. The aim of this study is to compare functional outcomes and complications between HA and RA constructs in patients undergoing endoprosthetic reconstruction for proximal humerus metastases. METHODS We retrospectively reviewed our institutional arthroplasty database to identify 66 (56% male; 38 HA and 28 RA) patients with a proximal humerus reconstruction for a non-primary malignancy. The majority (88%) presented with pathologic fracture, and the most common diagnosis was renal cell carcinoma (48%). RESULTSS Patients with RA reconstructions had better postoperative forward elevation (74° vs. 32°, p < 0.01) and higher functional outcome scores. HA patients had more complications (odds ratio 13, p < 0.01), with instability being the most common complication. CONCLUSIONS Patients with nonprimary malignancies of the proximal humerus had improved functional outcomes and fewer complications after undergoing reconstruction with a reverse EPC compared to a HA EPC. Preference for reverse EPC should be given in patients with good prognosis and ability to complete postoperative rehabilitation.
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Affiliation(s)
- Mikaela H Sullivan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jonathan D Barlow
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Sanaei R, Pagel CN, Ayodele BA, Lozanovski B, Beths T, Leary M, Shidid D, Kastrati E, Elambasseril J, Bühner U, Williamson T, Ryan S, Brandt M. Reducing the prosthesis modulus by inclusion of an open space lattice improves osteogenic response in a sheep model of extraarticular defect. Front Bioeng Biotechnol 2023; 11:1301454. [PMID: 38130824 PMCID: PMC10733966 DOI: 10.3389/fbioe.2023.1301454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction: Stress shielding is a common complication following endoprosthetic reconstruction surgery. The resulting periprosthetic osteopenia often manifests as catastrophic fractures and can significantly limit future treatment options. It has been long known that bone plates with lower elastic moduli are key to reducing the risk of stress shielding in orthopedics. Inclusion of open space lattices in metal endoprostheses is believed to reduce the prosthesis modulus potentially improving stress shielding. However, no in vivo data is currently available to support this assumption in long bone reconstruction. This manuscript aims to address this hypothesis using a sheep model of extraarticular bone defect. Methods: Initially, CT was used to create a virtual resection plan of the distal femoral metaphyses and to custom design endoprostheses specific to each femur. The endoprostheses comprised additively manufactured Ti6Al4V-ELI modules that either had a solid core with a modulus of ∼120 GPa (solid implant group) or an open space lattice core with unit cells that had a modulus of 3-6 GPa (lattice implant group). Osteotomies were performed using computer-assisted navigation followed by implantations. The periprosthetic, interfacial and interstitial regions of interest were evaluated by a combination of micro-CT, back-scattered scanning electron microscopy (BSEM), as well as epifluorescence and brightfield microscopy. Results: In the periprosthetic region, mean pixel intensity (a proxy for tissue mineral density in BSEM) in the caudal cortex was found to be higher in the lattice implant group. This was complemented by BSEM derived porosity being lower in the lattice implant group in both caudal and cranial cortices. In the interfacial and interstitial regions, most pronounced differences were observed in the axial interfacial perimeter where the solid implant group had greater bone coverage. In contrast, the lattice group had a greater coverage in the cranial interfacial region. Conclusion: Our findings suggest that reducing the prosthesis modulus by inclusion of an open-space lattice in its design has a positive effect on bone material and morphological parameters particularly within the periprosthetic regions. Improved mechanics appears to also have a measurable effect on the interfacial osteogenic response and osteointegration.
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Affiliation(s)
- Reza Sanaei
- Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, VIC, Australia
| | - Charles Neil Pagel
- Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, VIC, Australia
| | - Babatunde A. Ayodele
- Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, VIC, Australia
| | - Bill Lozanovski
- RMIT Centre for Additive Manufacturing, RMIT University, Carlton, VIC, Australia
| | - Thierry Beths
- Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, VIC, Australia
| | - Martin Leary
- RMIT Centre for Additive Manufacturing, RMIT University, Carlton, VIC, Australia
| | - Darpan Shidid
- RMIT Centre for Additive Manufacturing, RMIT University, Carlton, VIC, Australia
| | - Endri Kastrati
- RMIT Centre for Additive Manufacturing, RMIT University, Carlton, VIC, Australia
- Stryker Australia Pty Ltd., St Leonards, NSW, Australia
| | - Joe Elambasseril
- RMIT Centre for Additive Manufacturing, RMIT University, Carlton, VIC, Australia
| | | | - Tom Williamson
- RMIT Centre for Additive Manufacturing, RMIT University, Carlton, VIC, Australia
- Stryker Australia Pty Ltd., St Leonards, NSW, Australia
| | - Stewart Ryan
- Melbourne Veterinary School, Faculty of Science, The University of Melbourne, Parkville, VIC, Australia
| | - Milan Brandt
- RMIT Centre for Additive Manufacturing, RMIT University, Carlton, VIC, Australia
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Broida SE, Sullivan MH, Barlow JD, Morrey M, Scorianz M, Wagner ER, Sanchez-Sotelo J, Rose PS, Houdek MT. Oncological and functional outcomes after resection of malignant tumours of the scapula. Bone Joint J 2023; 105-B:1314-1320. [PMID: 38035605 DOI: 10.1302/0301-620x.105b12.bjj-2023-0552.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Aims The scapula is a rare site for a primary bone tumour. Only a small number of series have studied patient outcomes after treatment. Previous studies have shown a high rate of recurrence, with functional outcomes determined by the preservation of the glenohumeral joint and deltoid. The purpose of the current study was to report the outcome of patients who had undergone tumour resection that included the scapula. Methods We reviewed 61 patients (37 male, 24 female; mean age 42 years (SD 19)) who had undergone resection of the scapula. The most common resection was type 2 (n = 34) according to the Tikhoff-Linberg classification, or type S1A (n = 35) on the Enneking classification. Results The ten-year disease-specific survival was 76%. High tumour grade (hazard ratio (HR) 4.27; p = 0.016) and a total resection of the scapula (HR 3.84; p = 0.015) were associated with worse survival. The ten-year metastasis-free and local recurrence-free survivals were 82% and 86%, respectively. Total scapular resection (HR 6.29; p = 0.004) was associated with metastatic disease and positive margins were associated with local recurrence (HR 12.86; p = 0.001). At final follow-up, the mean shoulder forward elevation and external rotation were 79° (SD 62°) and 27° (SD 25°), respectively. The most recent functional outcomes evaluated included the mean Musculoskeletal Tumor Society Score (76% (SD 17%)), the American Shoulder and Elbow Score (73% (SD 20%)), and the Simple Shoulder Test (7 (SD 3)). Preservation of the glenoid (p = 0.001) and scapular spine (p < 0.001) improved clinical outcomes; interestingly, preservation of the scapular spine without the glenoid improved outcomes (p < 0.001) compared to preservation of the glenoid alone (p = 0.05). Conclusion Resection of the scapula is a major undertaking with an oncological outcome related to tumour grade, and a functional outcome associated with the status of the scapular spine and glenoid. Positive resection margins are associated with local recurrence.
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Affiliation(s)
- Samuel E Broida
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, USA
| | | | | | - Mark Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, USA
| | - Maurizio Scorianz
- Orthopaedic Oncology and Reconstructive Unit, Careggi University Hospital, Florence, Italy
| | - Eric R Wagner
- Department of Orthopedic Surgery, Emory University, Atlanta, Georgia, USA
| | | | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, USA
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Li J, Li J, Yang Y, He X, Wei X, Tan Q, Wang Y, Xu S, Chang S, Liu W. Biocompatibility and osteointegration capability of β-TCP manufactured by stereolithography 3D printing: In vitro study. Open Life Sci 2023; 18:20220530. [PMID: 36742452 PMCID: PMC9883693 DOI: 10.1515/biol-2022-0530] [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] [Received: 08/10/2022] [Revised: 09/27/2022] [Accepted: 11/02/2022] [Indexed: 01/26/2023] Open
Abstract
Beta-tricalcium phosphate (β-TCP) bioceramics have an inorganic composition similar to the human bone. While conventional methods can only produce ceramic scaffolds with poor controllability, the advancement of 3D-printing, especially stereolithography, made it possible to manufacture controllable, highly precise, micropore ceramic scaffolds. In this study, the stereolithography was applied to produce β-TCP bioceramics, while ZrO2, Al2O3, Ti6Al4V, and polyetheretherketone (PEEK) were used as controls. Phase analysis, water contact angle tests, and Micro-CT were applied to evaluate the surface properties and scaffold. Hemolytic toxicity, cell proliferation, and morphological assessment were performed to evaluate the biocompatibility. Alkaline phosphatase (ALP) level, mineralization, and qRT-PCR were measured to evaluate the osteointegration. During the manufacturing of β-TCP, no evident impurity substance and hemolytic toxicity was found. Cells on β-TCP had good morphologies, and their proliferation capability was similar to Ti6Al4V, which was higher than the other materials. Cells on β-TCP had higher ALP levels than PEEK. The degree of mineralization was significantly higher on β-TCP. The expression of osteogenesis-related genes on β-TCP was similar to Ti6Al4V and higher than the other materials. In this study, the β-TCP produced by stereolithography had no toxicity, high accuracy, and excellent osteointegration capability, thus resulting as a good choice for bone implants.
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Affiliation(s)
- Jialiang Li
- Department of Orthopedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Jiaxi Li
- Department of Orthopedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Yubing Yang
- Department of Orthopedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Xijing He
- Department of Orthopedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Xinyu Wei
- Department of Health Management, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Qinghua Tan
- Department of Orthopedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Yiqun Wang
- Department of Orthopedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Siyue Xu
- Department of Orthopedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Sue Chang
- Department of Orthopedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Weiwei Liu
- Department of Precision Medicine Group, Equipment Research Institute, National Innovation Institute of Additive Manufacturing, Xi’an, Shaanxi Province, China
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Arguello AM, Houdek MT, Barlow JD. Management of Proximal Humeral Oncologic Lesions. Orthop Clin North Am 2023; 54:89-100. [PMID: 36402514 DOI: 10.1016/j.ocl.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The proximal humerus is a common location for primary tumors, benign lesions, and metastatic disease. Advances in neoadjuvant and adjuvant therapy have allowed for limb-salvage surgery in most of the cases. There are numerous of options for surgical management of proximal humerus lesions and the decision to pursue one over another depends on factors such as age, comorbidities, pathology, location within the proximal humerus, planned resection margins/size of defect, and bone quality. Long-term outcomes for these techniques tend to be retrospective comparative studies, with recent studies highlighting the improved outcomes of reverse total shoulders.
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Affiliation(s)
- Alexandra M Arguello
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Jonathan D Barlow
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Abstract
Scapular resections are large oncologic undertakings. Due to the soft tissue coverage of the scapula, tumors are often able to be resected with a negative margin. Involvement of the brachial plexus and axillary vessels is rare, allowing for a limb-salvage surgery in most cases. Functional outcomes are based on the magnitude of resection; patients undergoing a partial scapulectomy and those with glenoid preservation demonstrate improved outcomes compared to patients undergoing a total scapulectomy or glenoid resection. Although scapular endoprosthetics are available, there is limited data to support their routine use.
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Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA.
| | - Benjamin K Wilke
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
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Theil C, Schwarze J, Gosheger G, Moellenbeck B, Schneider KN, Deventer N, Klingebiel S, Grammatopoulos G, Boettner F, Schmidt-Braekling T. Implant Survival, Clinical Outcome and Complications of Megaprosthetic Reconstructions Following Sarcoma Resection. Cancers (Basel) 2022; 14:cancers14020351. [PMID: 35053514 PMCID: PMC8773828 DOI: 10.3390/cancers14020351] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/04/2022] [Accepted: 01/08/2022] [Indexed: 12/29/2022] Open
Abstract
Simple Summary Malignant bone and soft tissue tumors are usually surgically removed with an envelope of healthy tissue as a barrier. If located in the long bones of the upper and lower extremity, this approach leads to a large bone defect commonly affecting a joint. One way to rebuild the bone defect and the neighboring joint is the use of a megaprosthesis that is anchored in the remaining bone comparable to a conventional joint replacement. In general this approach is popular as it provides early stability and allows the affected patient to begin rehabilitation early on. However, complications leading to long-term unplanned reoperation are common. This article provides an overview of current implant survival, types of complication and long-term outcomes of megaprostheses used following tumor resection. Abstract Megaprosthetic reconstruction of segmental bone defects following sarcoma resection is a frequently chosen surgical approach in orthopedic oncology. While the use of megaprostheses has gained popularity over the last decades and such implants are increasingly used for metastatic reconstructions and in non-tumor cases, there still is a high risk of long-term complications leading to revision surgery. This article investigates current implant survivorship, frequency and types of complications as well as functional outcomes of upper and lower limb megaprosthetic reconstructions.
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Affiliation(s)
- Christoph Theil
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Jan Schwarze
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Georg Gosheger
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Burkhard Moellenbeck
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Kristian Nikolaus Schneider
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Niklas Deventer
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - Sebastian Klingebiel
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada;
| | - Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA;
| | - Tom Schmidt-Braekling
- Department for General Orthopaedics and Tumor Orthopaedics, University Hospital Muenster, Albert-Schweitzer Campus 1, 48149 Muenster, Germany; (C.T.); (J.S.); (G.G.); (B.M.); (K.N.S.); (N.D.); (S.K.)
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada;
- Correspondence:
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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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