Proximal humerus allograft prosthetic composites: technique, outcomes, and pearls and pitfalls

Allograft-Prosthetic Composite Reconstruction for Proximal Humerus Bone Loss: A Systematic Review and Meta-Analysis of Outcomes and Complications

BACKGROUND

In smaller studies, allograft-prosthetic composite (APC) has been used for proximal humerus bone loss with some success, although with notable complication risk. This systematic review and meta-analysis sought to describe outcomes and complications after proximal humerus APC and how major APC complications are defined in the literature.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for articles on APC for proximal humeral bone loss secondary to tumor, fracture, or failed arthroplasty. Primary outcomes included postoperative range of motion, outcome scores (Musculoskeletal Tumor Society [MSTS], Simple Shoulder Test [SST], American Shoulder and Elbow Surgeons [ASES], Constant, visual analog scale [VAS], and subjective shoulder value [SSV]), and complication incidence. We also described individual study definitions of APC malunion/nonunion, methods of postoperative evaluation, malunion/nonunion rates, allograft fracture/fragmentation rates, and mean union time, when available. Secondarily, we compared hemiarthroplasty and reverse total shoulder arthroplasty.

RESULTS

Sixteen articles including 375 shoulders were evaluated (average age: 49 years, follow-up: 54 months). Fifty-seven percent of procedures were performed for tumors, 1% for proximal humerus trauma sequelae, and 42% for revision arthroplasty. Average postoperative forward elevation was 82° (69-94°), abduction 60° (30-90°), and external rotation 23° (17-28°). Average MSTS score was 82% (77%-87%), SST score 5.3 (4.5-6.1), ASES score 64 (54-74), Constant score 44 (38-50), VAS score 2.2 (1.7-2.7), and SSV 51 (45-58). There was a 51% complication rate with an 18% nonallograft surgical complication rate, 26% APC nonunion/malunion/resorption rate, and 10% APC fracture/fragmentation rate. Fifteen percent of nonunited APCs underwent secondary bone grafting; 3% required a new allograft; and overall revision rate was 12%. APC nonunion/malunion was defined in 2 of 16, malunion/nonunion rates in 14 of 16, fracture/fragmentation rates in 6 of 16, and mean union time (7 months) in 4 of 16 studies.

CONCLUSION

APC reconstruction of the proximal humerus remains a treatment option, albeit with substantial complication rates. In addition, there is a need for APC literature to report institutional definitions of nonunion/malunion, postoperative evaluation, and time to union for a more standardized evaluation.

LEVEL OF EVIDENCE

Level IV; systematic review. See Instructions for Authors for a complete description of levels of evidence.

Does reverse total shoulder arthroplasty with allograft-prosthesis composite (APC) have surgical benefits over hemiarthroplasty with APC in patients with tumors of the proximal humerus?

Background

The research on surgical outcomes of hemiarthroplasty and reverse total shoulder arthroplasty using allograft-prosthesis composites for the proximal humeral oncologic condition is still scarce. Therefore, this study aimed to compare surgical outcomes of shoulder joint reconstruction with hemiarthroplasty and reverse total shoulder arthroplasty using allograft-prosthesis composites for tumors of the proximal humerus.

Methods

Eleven patients underwent hemiarthroplasty or reverse total shoulder arthroplasty using allograft-prosthesis composites for tumors of the proximal humerus between July 2011 and April 2018 were reviewed. Radiographic analysis for bone union of allograft-host bone junction, implant loosening, stress shielding and shoulder dislocation or subluxation was performed. Functional outcomes were evaluated using visual analog scales for pain, range of motion, Simple Shoulder Test score and Musculoskeletal Tumor Society score. Furthermore, oncologic outcome and complications were also assessed, respectively.

Results

There were five patients with hemiarthroplasty (mean age, 23.2 years) and six patients with reverse total shoulder arthroplasty (mean age, 46.8 years, P = 0.05). Radiographically, there were no events associated with implant loosening, stress shielding and shoulder dislocation or subluxation in the two groups. There were no differences in functional outcomes between the two groups. There was no local recurrence in entire cohort. In the hemiarthroplasty group, one patient was required revision surgery to reverse total shoulder arthroplasty at postoperative 6 years due to rotator cuff dysfunction. In the reverse total shoulder arthroplasty group, one patient showed the fracture occurred at allograft-host bone junction at postoperative 6 months.

Conclusions

Surgical outcomes of hemiarthroplasty with allograft-prosthesis composites were not inferior to reverse total shoulder arthroplasty when applied in properly selected patients. The authors recommended that hemiarthroplasty with allograft-prosthesis composites could be used for young age patients without glenoid metastasis involvement, and reverse total shoulder arthroplasty with allograft-prosthesis composites could be used for patients with old age or metastatic bone tumors.

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

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

Application and improvement of ipsilateral clavicle turnover during proximal humeral tumorous bone defect repair

PURPOSE

To investigate the clinical effects and complications that may arise as a result of ipsilateral clavicle turnover during tumorous bone defect repair of the proximal humerus, and to explore the feasibility of performing combined free fibula transplantation and internal fixation in reducing complications METHODS: We treated 13 patients with clavicle turnover or free fibular transplantation from September 1998 to February 2020. There were 7 males and 6 females with the average age of 26.2 years (7-50 years). The histological diagnoses were osteosarcoma in 6 patients (Enneking IIB), giant cell tumors in 3 patients (Campanacci III) and one patient each with Ewing's sarcoma (Enneking IIB), chondrosarcoma (Canceration of multiple osteochondromatosis), fibrosarcoma and metastatic cancer of bone (Bone metastasis of lung cancer). Pathological fractures were found in 7 of the 13 patients.

RESULTS

The operation was successfully performed for all 13 patients. We followed 12 patients for 18 to 274 months (average 92.7 months). For 6 patients treated with simple clavicle turnover using a short plate, the average healing time was 7 months (4-12 months). Among them, there were 3 cases of clavicle fracture and 3 cases of overturned bone healed well. For the 7 patients treated with clavicle turnover and free fibula using a long plate, the healing time was 6.7 months. However, one patient died of tumor metastasis 19 months after operation, without reversal of clavicle fracture and other complications.

CONCLUSION

Clavicle turnover is a feasible method for the treatment of tumorous bone defect of the proximal humerus. Flipping clavicle fracture is the most common complication. The application of total clavicle fixation and free fibular transplantation strengthens the flipping clavicle and reduces the risk of clavicle fracture.

Implant cement spacer-a cost-effective solution for reconstruction of proximal humerus defects after tumor resection

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.

Reconstruction for bone tumours of the shoulder and humerus in children and adolescents

Reconstructions for paediatric bone tumours of the shoulder girdle and humerus are intended to optimize placement of the hand in space. Given the longevity of paediatric survivors of sarcoma, durability is an important planning consideration. Here, I review a subset of approaches based on anatomical site with an emphasis on function and longevity. Often, biological reconstructions that combine living bone with tendon repairs and transfers best address those goals.

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

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

Complications and Survivorship of Distal Humeral Allograft Reconstruction After Tumor Resection: Literature Review and Case Series

Primary bone sarcomas of the proximal humerus represent most bone sarcomas in the upper extremity. However, limited literature exists on the survival and complications of distal humeral allograft reconstruction because of the relative rarity of disease at the distal end.

Proximal Humerus Tumors: Higher-than-Expected Risk of Revision With Constrained Reverse Shoulder Arthroplasty

BACKGROUND

The treatment of proximal humerus tumors with endoprostheses is associated with a high risk of implant-related surgical complications. Because of extensive soft-tissue resection and muscular detachment during surgery, instability is the most common serious complication. A reverse total shoulder arthroplasty with a highly constrained design is one option to mitigate instability, but few studies have reported the results of this prosthesis for proximal humerus tumor resections.

QUESTIONS/PURPOSES

(1) What are the short-term functional results of the constrained reverse total shoulder prosthesis in terms of Musculoskeletal Tumor Society (MSTS), DASH, and Constant-Murley scores and ROM values? (2) What is the frequency of revision, using a competing-risks estimator to assess implant survival, and what were the causes of the revisions that occurred? (3) What proportion of patients experienced dislocations at short-term follow-up?

METHODS

Between January 2014 and June 2017, we treated 55 patients with proximal humeral resections and reconstructions for malignant tumors. Of those, 33% (18) of patients were treated with the constrained, reverse total shoulder arthroplasty implant under study here. During that period, no other constrained reverse total shoulder implant was used; however, 13% (seven) of patients were treated with conventional (unconstrained) reverse total shoulder implants, 27% (15) had hemiarthroplasties, 15% (eight) of patients had biologic reconstructions with auto- or allografts and 13% (seven) underwent amputation. During the period in question, our general indications for use of the constrained device under study here were resection of the deltoid muscle/axillary nerve or the deltoid insertion on the humerus due to tumor invasion, or extensive rotator cuff and surrounding soft tissue resection that might result in shoulder instability. During this period, these indications were adhered to consistently. Four of 18 patients treated with the study implant died (three died with the implant intact) and none were lost to follow-up before 2 years, leaving 14 patients (seven women and seven men) for study at a median (range) follow-up of 35 months (25 to 65). Two authors evaluated the clinical and functional status of each patient with ROM (flexion, extension, internal and external rotation, abduction, and adduction) and MSTS, (range 0% to 100%), Constant-Murley (range 0% to 100%), and DASH (range 0 points to 100 points) scores. For the MSTS and Constant-Murley scores, higher percentage scores mean better functional outcome; and for the DASH score, a higher score means more severe disability. Radiographs were obtained at each visit and were used to look for signs of loosening, which we defined as progressive radiolucencies between visits, prosthetic component migration, and fragmentation/fracture of the cement. The Sirveaux classification was used to determine scapular notching. A competing risks analysis with 95% confidence intervals was performed to estimate the cumulative incidence of revision surgery, which we defined as any reoperation in which the implant was removed or changed for any reason, with patient mortality as a competing event.

RESULTS

At the most recent follow-up, the median (range) MSTS score was 78% (50 to 90), the DASH score was 20 (8 to 65), and the Constant-Murley score was 53% (26 to 83). The median ROM was 75° in forward flexion (40 to 160), 78° in abduction (30 to 150), 35° in internal rotation (10 to 80), and 33° in external rotation (0 to 55). Postoperatively, two of 14 patients underwent or were supposed to undergo revision surgery, and the cumulative incidence of revision surgery was 18% for both 30 and 48 months (95% CI 2 to 45). During the study period, no patients reported instability, and no dislocations occurred.

CONCLUSIONS

Our findings are concerning because the revision risk with this constrained reverse total shoulder implant was higher than has been reported by others for other proximal humerus prostheses. The highly constrained design that helps prevent instability might also transmit increased stresses to the humeral component-bone interface, therefore making it susceptible to loosening. We believe that any other implant with a similar degree of constraint will have the same problem, and changing the indications for patient selection may not solve this issue. These theories need to be tested biomechanically, but our desire is to warn surgeons that while trying to prevent instability, one might trade one complication (instability) for another: aseptic loosening.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Endoprosthetic Reconstruction of the Upper Extremity in Oncologic Surgery

In 1943, Austin Moore successfully reconstructed a proximal femur using a Vitallium endoprosthesis. This marked the first successful alternative to amputation in oncologic surgery. However, it was not until the introduction of high-resolution axial imaging and improved chemotherapeutics that the feasibility of limb salvage began to improve. Today, limb salvage surgery can be used to treat most oncologic conditions of the extremities, the most popular reconstruction option being endoprostheses. Megaprostheses use has expanded to nononcologic indications with severe bone loss, including infections, revision arthroplasty, and severe periarticular trauma and its sequelae. The proximal humerus and scapula are challenging for reconstruction, given the complex anatomy of the brachial plexus, the accompanying vascular structures, and the dynamic stabilizers of the relatively nonstable glenohumeral joint. The midhumerus is difficult because of the close location of the radial nerve, whereas the distal humerus is challenging because of the proximity of the brachial artery and its bifurcation, radial, ulnar, and median nerves, and lack of soft-tissue coverage. Despite these challenges, this review demonstrates that many series show excellent mid- to long-term results for pain relief and function restoration after megaprosthetic reconstruction of the scapula and humerus after bone resections for oncologic and nononcologic reasons.

Comparison of outcomes of 2 surgical treatments for proximal humerus giant cell tumors: a multicenter retrospective study

BACKGROUND

The incidence of giant cell tumors in the proximal humerus is low. We evaluated 2 surgical treatments for giant cell tumors of the proximal humerus and postoperative upper-extremity function.

METHODS

This study retrospectively analyzed the clinical data of 27 cases of giant cell tumors of the proximal humerus at 4 Chinese medical centers specializing in bone oncology collected between January 2002 and June 2015. All patients were followed up for more than 2 years. The surgical procedures performed for treatment included curettage in 14 patients and segmental resection in 13. The Campanacci grade, occurrence of pathologic fracture, surgical method, complications, and Musculoskeletal Tumor Society score were recorded for each cohort.

RESULTS

The recurrence rate was 7.1% in the curettage group and 15.4% in the segmental resection group. Other postoperative complications occurred in 4 patients with segmental resection, including resorption of the osteoarticular allograft in 2, subluxation of the glenohumeral joint in 1, and prosthetic loosening and exposure in 1. A significant difference in postoperative upper-extremity function was noted between the 2 groups (P < .001).

CONCLUSIONS

Postoperative upper-extremity function in the curettage group was significantly better than that in the segmental resection group. Segmental resection and reconstruction with a large segmental osteoarticular allograft were considered unadvisable. We suggest that extensive curettage should be selected to treat proximal humerus giant cell tumors as much as possible.

Reconstruction techniques after proximal humerus tumour resection

Reconstruction of the proximal humerus after tumour resection is a surgical challenge. The goal consists not only in reconstructing the resected bone segment, but also in restoring a stable and mobile shoulder. The choice of the technique depends on the status of the soft-tissues at the end of the resection. The preoperative work-up must determine the oncological goals of the resection and identify the structures that can be spared. When deltoid muscle function is preserved, a reverse prosthesis offers the best stability and mobility outcomes. The objective of this work is to describe the indications and techniques used in the various available reconstruction methods. Shoulder mobilities are restored using some of these methods and lost with others. Emphasis is put on the reverse shoulder prosthesis, with a description of its variants (standard prosthesis, cement sleeve, allograft-prosthesis composite, and massive prosthesis) and a discussion of the management of its early complications. When performing reverse shoulder arthroplasty, glenoid implant preparation and positioning are crucial to achieve stability, and humeral length restoration will govern soft-tissue tension. Latissimus dorsi tendon transfer is required to restore active external rotation if the posterior rotator cuff tendons have been removed. Allograft-anatomic prosthesis composites, osteo-cartilaginous allografts, arthrodesis, and spacer prostheses are proposed for patients in whom the local conditions preclude implantation of a reverse shoulder prosthesis.