Osteosarcoma of the proximal humerus: long-term results with limb-sparing surgery

Malawer type I/V proximal humerus reconstruction after tumor resection: a systematic review

BACKGROUND

Several reconstruction methods exist for Malawer type I/V proximal humerus reconstruction after bone tumor resection; however, no consensus has been reached regarding the preferred methods.

METHODS

We conducted a literature search on various types of proximal humerus oncologic reconstruction methods. We collected data on postoperative functional outcomes assessed based on Musculoskeletal Tumor Society (MSTS) scores, 5-year reconstruction survival rates, and complications. We calculated each reconstruction's weighted mean based on the sample size and standard errors. Complications were categorized based on the Henderson classification. Based on these integrated data, our primary objective is to propose an optimal strategy for proximal humerus reconstruction after bone tumor resection.

RESULTS

We examined various reconstruction techniques, including modular prosthesis (752 patients in 21 articles), osteoarticular allograft (142 patients in 6 articles), allograft prosthesis composites (APCs) (236 patients in 12 articles), reverse shoulder total arthroplasty (141 patients in 10 articles), composite reverse shoulder total arthroplasty (33 patients in 4 articles), claviculo-pro-humero (CPH) technique (51 patients in 6 articles), and cement spacer (207 patients in 4 articles). Weighted mean MSTS scores were: modular prosthesis (73.8%), osteoarticular allograft (74.4%), APCs (79.2%), reverse shoulder total arthroplasty (77.0%), composite reverse shoulder total arthroplasty (76.1%), CPH technique (75.1%), and cement spacer (69.1%). Weighted 5-year reconstruction survival rates were modular prosthesis (85.4%), osteoarticular allograft (67.6%), APCs (85.2%), reverse shoulder total arthroplasty (84.1%), and cement spacer (88.0%). Reconstruction survival data was unavailable for composite reverse shoulder total arthroplasty and CPH technique. Major complications included shoulder joint instability: modular prosthesis (26.2%), osteoarticular allograft (41.5%), APCs (33.9%), reverse shoulder total arthroplasty (17%), composite reverse shoulder total arthroplasty (6.1%), CPH technique (2.0%), and cement spacer (8.7%). Aseptic loosening of the prosthesis occurred: modular prosthesis (3.9%) and reverse shoulder total arthroplasty (5.7%). Allograft fracture was observed in 54.9% of patients with osteoarticular allograft.

CONCLUSION

The complication profiles differed among reconstruction methods. Weighted mean MSTS scores exceeded 70% in all methods except cement spacer, and the 5-year reconstruction survival rate surpassed 80% for all methods except osteoarticular allograft. Proximal humerus reconstruction after bone tumor resection should consider potential complications and patients' individual factors.

Endoprosthesis vs. nail-cement spacer application for reconstruction after oncologic proximal humeral resection: is there a difference in functional outcome?

Background

The proximal humerus is a common site for primary malignant and benign aggressive bone tumors, necessitating wide resection and subsequent skeletal defect reconstruction. Various reconstruction options include osteoarticular allografts, autografts, endoprosthesis, nail-cement spacer, reverse shoulder arthroplasty, and allograft-prosthesis composites. However, there is no consensus on the optimal reconstruction method. This study aims to compare functional outcomes and complications between these two methods.

Methods

A total of 40 patients with proximal humerus tumors who underwent endoprosthesis or nail-cement spacer reconstruction between March 2012 and December 2020 were included. The mean follow-up in the study was 31.37 +/- 12 months. Demographic and clinical data were collected, and functional outcomes were assessed using the Musculoskeletal Tumor Society 93 scoring system and the Disabilities of the Arm, Shoulder, and Hand questionnaire. Complications and oncological outcomes were recorded.

Results

Both groups were similar in terms of demographic and clinical variables. Endoprosthesis reconstruction demonstrated significantly better active shoulder forward flexion compared to nail-cement spacer (45.8 vs. 25.2 degrees) (P = .015). Endoprosthesis group also exhibited greater active shoulder internal rotation (68.25 vs. 63.25 degrees) (P = .004). No statistically significant differences were observed in overall functional outcomes. Complications, including radial nerve palsy and infection, were comparable between groups, with one case of spacer loosening.

Conclusion

Both endoprosthesis and nail-cement spacer reconstruction provide comparable functional outcomes and complication rates following proximal humerus tumor resection. Nail-cement spacer offers a cost-effective alternative for patients in resource-constrained settings.

Functional and oncological outcomes of patients with proximal humerus osteosarcoma managed by limb salvage

BACKGROUND

Osteosarcoma is the most common primary bone malignancy in skeletally immature patients. The proximal humerus is the third most common site of osteosarcoma. The literature shows a paucity of published data concerning the outcome of proximal humerus osteosarcoma managed by limb salvage. The purpose of this study was to answer the following questions: (1) do patients with proximal humerus osteosarcoma managed by limb salvage and neoadjuvant chemotherapy show good functional and oncological outcomes, and (2) are there any prognostic factors that are associated with better oncological and functional outcomes?

MATERIALS AND METHODS

The study was a retrospective case series study assessing the overall outcome of 34 patients with proximal humerus osteosarcoma. Eighteen patients were males (53%) while 16 were females. Biological reconstruction was done in 15 patients (44%), while nonbiological reconstruction was done in 19 patients. Resections were mainly intraarticular (82%). Functional outcome was assessed using the Musculoskeletal Tumor Society (MSTS) score, while oncological outcome was assessed based on local recurrence and development of chest metastasis. Comparisons between quantitative variables were done using the nonparametric Mann-Whitney test. To compare categorical data, the chi-square (χ2) test was performed. The exact test was used instead when the expected frequency was less than 5. Correlations between quantitative variables were examined using the Spearman correlation coefficient.

RESULTS

The mean MSTS score was 25.5 (range 23-29). A younger age was statistically correlated with a poorer MSTS score (P = 0.0016). Six patients out of 34 (17.6%) had local recurrence and four of them (67%) were treated by forequarter amputation. 41% of patients developed chest metastasis, and the majority of them were treated by chemotherapy (71%). In comparison with patients with osteosarcoma at other sites who were also managed in our institution, proximal humerus osteosarcoma patients showed higher incidence rates of local recurrence and chest metastasis along with lower 5-year patient and limb survivorships compared to distal femur, proximal tibia and proximal femur osteosarcoma patients.

CONCLUSION

Treatment of osteosarcoma of the proximal humerus by limb salvage and chemotherapy yields a good functional outcome. The method of reconstruction does not impact the resultant function. The 5-year survivorship of these patients is 65%. Younger patients have a better oncological outcome and an inferior functional outcome.

LEVEL OF EVIDENCE

Level IV therapeutic study.

Proximal Humerus Reconstruction for Bone Sarcomas: A Critical Analysis

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

Outcomes of Sling Procedure Using a Free Vascularized Fibular Graft After Resection of the Proximal Humerus

Background

The proximal humerus is a common site for both primary and metastatic bone tumors. Although various methods have been developed for reconstruction following resection of the proximal humerus, a consensus on which technique is best has not been established. We focused on the sling procedure using a free vascularized fibular graft (FVFG) and conducted what we believe to be the largest retrospective study of patients to undergo this surgery to date.

Methods

We retrospectively reviewed the data of 19 patients who underwent the sling procedure with use of an FVFG at our hospital between 1998 and 2022. The median age was 20 years, and the median follow-up duration was 63.1 months. Surgical data, oncological outcomes, the postoperative course, complications, and functional outcomes as measured with use of the Musculoskeletal Tumor Society (MSTS) score were thoroughly reviewed.

Results

The median operative duration was 555 minutes, and the median blood loss was 374 mL. The median length of the bone defect was 17.0 cm, and the median length of the graft was 20.0 cm. With respect to oncological outcomes, 9 patients were continuously disease-free, 9 patients had no evidence of disease, and 1 patient was alive with disease. Bone union was present in 13 of the 17 patients for whom it was evaluable. The median time to bone union was 4 months. Graft growth was observed in 2 pediatric patients. Postoperative fracture was a major complication at the recipient site. The incidence of pseudarthrosis significantly increased when the FVFG could not be inserted into the remaining humeral bone or was split in half (p = 0.002). Although a few patients demonstrated peroneal nerve palsy at the donor site, the symptom was temporary. The overall functional outcome was favorable, with an average MSTS score of 66.9%.

Conclusions

The sling procedure demonstrated a low complication rate and a favorable functional outcome overall. Therefore, we believe that this procedure is a useful reconstruction method for patients in a broad age range who have a wide defect of the proximal humerus.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of Bone and Soft Tissue Tumors of the Shoulder Girdle

INTRODUCTION

The shoulder girdle comprises the scapula, clavicle, proximal humerus, and the soft tissues surrounding these structures. Bone and soft tissue tumors are notably more prevalent in the lower extremity than in the upper extremity. However, the shoulder ranks as the third most common site for primary tumors, following the hip-pelvis and knee.

MATERIALS AND METHODS

This study conducted a retrospective examination of patients who presented with pain and swelling in the shoulder and its vicinity. The evaluation was carried out using a multidisciplinary approach by the Bone and Soft Tissue Tumors Council.

RESULTS

The study included 224 patients diagnosed with a tumoral lesion in the shoulder girdle between 2004 and 2021. Among these patients, 22 were assessed to have lesions other than tumors, while 105 (51.98%) had benign lesions, and 97 had malignant lesions. The most prevalent benign lesions were cystic bone lesions (30) and soft tissue lipomas (10). The primary form of malignant lesion was metastatic tumors (49).

CONCLUSION

Pathologies in the shoulder girdle may manifest through pain, palpable swelling, pathological fractures, or may be incidentally detected via radiological imaging. Notably, pain, hypercalcemia, and pathological fractures are significant indicators, especially in cases of bone metastases, which often follow a highly fatal course when involving long bones. The musculoskeletal system is the third most common site for metastasis, following the lungs and liver. Hence, particular attention should be directed toward metastatic concerns in the shoulder and its surrounding area.

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.

Microwave-induced hyperthermia in situ in the treatment of tumors of proximal humerus: long-term results with functionary sparing surgery

BACKGROUND

The present study aimed to evaluate the indications, feasibility, clinical effectiveness and complications of the treatment with microwave in situ inactivation followed by curettage and bone grafting assisted with internal fixation, for the proximal humerus tumors.

METHODS

The clinical data of 49 patients with primary or metastatic tumor of the proximal humerus who received intraoperative microwave inactivation in situ with curettage and bone grafting in our hospital from May 2008 to April 2021 were retrospectively analyzed.

RESULTS

There were 25 males and 24 females, with an average age of 57.6 ± 19.9 years (range, 20-81). All patients were followed up for 7 to 146 months, with an average period of 69.2 ± 39.8 months. Up to the last follow-up, 14 patients died. The 5-year overall survival was 67.3%, and 5-year tumor-specific survival was 71.4%. The 5-year tumor-specific survival rates were 100% for aggressive benign tumors or low potential malignancy tumors, 70.1% for primary malignancies, and 36.9% for metastatic tumors. The average preoperative MSTS, constant-Murley and VAS scores were 16.81 ± 3.85, 62.71 ± 12.56 and 6.75 ± 2.47, which were all significantly improved at 6 weeks after operation and at the final follow-up (P < 0.05).

CONCLUSIONS

Microwave inactivation in situ and curettage and bone grafting are a feasible treatment for tumors of proximal humeral, especially for malignant tumors and metastases, without the necessity of the replacement of the shoulder, with little trauma and good upper limb function, and with low local recurrence and distant metastasis.

Three-dimensional-printed porous prosthesis for the joint-sparing reconstruction of the proximal humeral tumorous defect

Background: Tumorous bone defect reconstructions of the proximal humerus with joint sparing is a challenge. Numerous reconstruction methods have been proposed but the proximal residual humerus is commonly sacrificed because of its extremely short length. To preserve the proximal humerus and improve clinical outcomes, we designed a three-dimensional (3D) printed uncemented prosthesis with a porous structure to treat tumorous bone defects of the proximal humerus. Methods: Our analysis included seven patients treated between March 2018 and July 2019. A 3D model was established, and related data were obtained, including the diameter of the humeral head, the resection length, and the residual length. A prosthesis was designed and fabricated based on these data. Functional and oncologic outcomes were recorded, and complications and osseointegration were evaluated. Results: The mean age of the patients was 20.3 years, and the median follow-up period was 26 months. The lengths of the residual proximal humerus were 17.9 mm on average. All the patients had preserved humeral heads and most of the rotator cuff was intact. The average postoperative range of motion (ROM) of the affected shoulder was 83.8°; flexion was 82.5°, extension was 43.8°, and adduction was 16.3°. The average Musculoskeletal Tumor Society score (MSTS) was 94.3%. Good osseointegration was observed on the interface between the bone and prosthesis. Conclusion: A 3D printed porous prosthesis with cone-like structures successfully achieved joint-sparing reconstruction of proximal humeral tumorous defects with satisfying functional outcomes. The preservation of the rotator cuff and humeral head plays an essential role in the function of the shoulder joint.

En Bloc Resection With Reconstruction Using a Customized Megaprosthesis in a Case of Proximal Humerus Giant Cell Tumor: A Case Report

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.

Management of Proximal Humeral Oncologic Lesions

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.

Prosthetic Reconstruction of the Shoulder After Resection of Proximal Humerus Bone Tumor

Prosthetic reconstruction after wide resection of tumors of the proximal humerus presents a unique challenge. The shoulder is a complex articulation, and patients have high expectations for postoperative function. The goal of this study is to compare functional outcomes, oncologic outcomes, and complication rates for 2 reconstructive methods. Forty patients with proximal humeral tumors were reviewed retrospectively. Proximal humeral endoprosthesis (PHE) was used for 21 patients, and reverse shoulder arthroplasty (RSA) was used for 19 patients. Clinical results, oncologic outcomes, and complication rates were assessed. The functional outcomes of the patients were assessed with the Musculoskeletal Tumor Society scoring system (MSTS), the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and shoulder range of motion. The mean follow-up was 62±15 months. Shoulder dislocations occurred among 8 patients with PHE and 1 patient with RSA (P=.021). The other complication rates were similar for the 2 groups (P<.05). At the latest follow-up, the mean MSTS score was 68±10.3 for those with PHE and 76±7.7 for the patients with RSA (P=.72). However, the QuickDASH score was significantly better (P=.031) for those with RSA (mean, 19±6.3) compared with patients with PHE (mean, 30±4.8). Additionally, shoulder active abduction and forward flexion were significantly greater for the RSA group (P=.04 and P=.03, respectively). Five patients had local recurrence. Prosthetic reconstruction after oncologic re-section of the proximal humerus is associated with significant limitation of shoulder range of motion and a high rate of revision surgery. However, in this study, RSA was associated with fewer dislocations, improved Quick-DASH score, and greater abduction and forward flexion compared with PHE. [Orthopedics. 2022;45(6):e335-e341.].

Free Fibula Reconstruction for Bone Tumors Involving Humerus: Our Experience

Background Malignant primary bone tumors constitute only 0.2% of all malignancies in adults and approximately 5% of childhood malignancies. The humerus is a common site for malignancies like chondrosarcoma, osteosarcoma, Ewing sarcoma, and metastatic carcinomas. Management consists of multimodality treatment including chemotherapy, radiotherapy, and surgery depending on histology of the tumor and response to therapy. Reconstruction of humerus following oncological resection is a challenging procedure and the surgical options include endoprosthesis, plates, avascular bone grafts, and vascularized autologous bone using microvascular surgery.

Materials and Methods This was a single institutional, retrospective observational study conducted at a tertiary cancer center in Northeast India from June 2018 to March 2020. All the reconstructions were done with free fibular osseous flap. Postoperative outcome was measured with Musculoskeletal Tumor Society (MSTS) scoring. Data was collected from patient records and hospital online reporting system. All data were analyzed using Statistical Package for Social Sciences, version 21. Histograms were used for descriptive statistics; Spearman's correlation was run to determine the relationship between MSTS score and age. Rest of the data was checked with Mann–Whitney and Kruskal–Wallis test. A p-value less than 0.05 was considered as statistically significant at 5% level of significance.

Results Six patients were included in our study (n = 6), three of Ewing sarcoma and one each of osteosarcoma, angiosarcoma, and chondrosarcoma. Mean age was 21.7 ± 18.6 years; there was no flap necrosis in the series. One old lady developed nonunion and fracture at the native humerus in follow-up. At the end of 1 year the mean MSTS score of the series was 24.7/30. From data analysis a significant decrease in mean MSTS score was by 0.134 times (p = 0.035), been observed with increasing age. The correlation between gender and MSTS score (p = 0.325), type of tumor and MSTS score (p = 0.490), and location of the tumor and MSTS score (p = 0.351) was statistically not significant.

Conclusion Free vascularized fibular graft is an important option for bony reconstruction following tumor resection. In our small series we find it very effective for reconstruction of proximal humerus, particularly in younger patients, when microvascular expertise is present. Following a positive initial experience in humerus reconstruction with free fibular osseus flap a large study population will be considered in near future.

Efficacy and safety of a 3D-printed arthrodesis prosthesis for reconstruction after resection of the proximal humerus: preliminary outcomes with a minimum 2-year follow-up

Background

The purpose of this study was to investigate the feasibility of using a three-dimensional (3D)-printed arthrodesis prosthesis for reconstruction of the proximal humeral defect after tumor resection.

Methods

A novel proximal humeral prosthesis was designed to restore bone continuity and shoulder arthrodesis and was fabricated via 3D printing technology. Ten patients with primary malignancies in the proximal humerus underwent intra-articular resection and replacement with this prosthesis from 2017 to 2019. Baseline and operative data, oncological and prosthetic survival, and functional status were summarized.

Results

This cohort consisted of 9 males and 1 female with a mean age of 32.1 ± 16.1 years. Diagnoses included 5 cases of osteosarcoma, 3 cases of chondrosarcoma and 1 each case of undifferentiated pleomorphic sarcoma and malignant myoepithelioma. The mean operative duration, intraoperative hemorrhage and postoperative length of hospitalization were 151.5 ± 61.0 min, 410.0 ± 353.4 ml and 5.3 ± 1.9 d, respectively. The mean follow-up duration was 29.3 ± 6.4 months, with a minimum of 24 months for the surviving patients. Two patients experienced local recurrence, and four patients developed distant metastases. Detachment of the taper occurred in two patients. One was managed conservatively, and the other received amputation due to concurrent tumor recurrence. The mean MSTS-93 and ASES scores and ranges of forwards flexion and abduction were 24.9 ± 3.1, 79.4 ± 8.3, 71.3 ± 19.4°, and 61.3 ± 16.4°, respectively. The functional outcomes were independent of the preservation of the axillary nerve. Histological study of the glenoid component showed evidence of bone ingrowth at the bone-prosthesis porous interface.

Conclusion

Application of the 3D-printed arthrodesis prosthesis might be a safe and efficacious method for functional reconstruction in patients who underwent resection of the proximal humerus, especially for those without preservation of the axillary nerve.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05581-6.

Dog Models of Aging

As the most phenotypically diverse mammalian species that shares human environments and access to sophisticated healthcare, domestic dogs have unique potential to inform our understanding of the determinants of aging. Here we outline key concepts in the study of aging and illustrate the value of research with dogs, which can improve dog health and support translational discoveries. We consider similarities and differences in aging and age-related diseases in dogs and humans and summarize key advances in our understanding of genetic and environmental risk factors for morbidity and mortality in dogs. We address health outcomes ranging from cancer to cognitive function and highlight emerging research opportunities from large-scale cohort studies in companion dogs. We conclude that studying aging in dogs could overcome many limitations of laboratory models, most notably, the ability to assess how aging-associated pathways influence aging in real-world environments similar to those experienced by humans.

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

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

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

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

What sports activity levels are achieved in long-term survivors with modular endoprosthetic humerus reconstruction following primary bone sarcoma resection?

Background

The aim of the study was to assess (1) sports activity, (2) sports involving the upper extremities, (3) functional outcome and (4) sports-related complications of long-term survivors of primary malignant bone tumors of the proximal humerus.

Methods

A total of 18 patients with an endoprosthetic reconstruction for primary malignant bone sarcoma of the proximal humerus (8 male, 10 female, mean age 19.9 ± 8.4 years, range 7.8–37.4 years) with an average follow-up of 18.1 ± 7.4 years (range 6.7–29.8 years) were included. The type of sport, frequency, duration of each sport session and the University of California, Los Angeles (UCLA) activity score were assessed before surgery, at 1 year, 3 years and at the latest follow-up. Functional outcome was assessed by the Toronto extremity salvage score (TESS).

Results

The mean UCLA activity score decreased from 8.0 (±1.3, range 5–9) preoperative to 4.2 (±1.7, range 3–8) at 1‑year follow-up (p < 0.05). After 3 years it increased to 5.1 (±1.75, range 3–8) and further to 7 (±1.8, range 4–9) at the last follow-up. The mean postoperative TESS was 80.8 (±6.4, range 75.7–91.4) at the latest follow-up. Patients who were initially more active without reconstruction including a synthetic mesh were more likely to develop soft tissue complications accompanied by proximal endoprothesis migration.

Conclusion

Patients with a modular endoprosthetic reconstruction of the humerus following primary bone sarcoma resume participation in sports. Regarding the low incidence of periprosthetic infections, utilization of a synthetic mesh for reconstruction to prevent soft tissue complications in active patients should be considered.

Comparison of reconstructive techniques following oncologic intraarticular resection of proximal humerus

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Constrained or unconstrained shoulder replacement for musculoskeletal tumor resections?

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Predictors of Survival in Children with Osteogenic Sarcoma Undergoing Limb Salvage Surgery: Experience from a Tertiary Cancer Center in Rural India

Context: Osteogenic Sarcoma (OGS) is the fifth most common malignancy among adolescents aged 15–19. With multimodality therapy, the long-term survival has improved from 16% in the prechemotherapy era to around 70% in the postchemotherapy era. Aim: This study aims to determine the clinical profile and survival of children with OGS being treated with limb-salvage surgery (LSS). Subjects and Methods: This is a retrospective analysis of all cases of OGS (age ≤ 19) who underwent LSS at our center between June 2009 and February 2017. Baseline characteristics were noted and multivariate analysis was performed for various variables to identify predictors of survival. Results: Among 44 cases studied majority were boys (n = 27). Ninety-three percentage (n = 41) were adolescents. Stage 2 disease was 75% and Stage 3 disease was 25%. The estimated 3-year overall survival (OS) was 69% (95% confidence interval [CI] 55–86) and the estimated 3-year event-free survival (EFS) was 55% (95% CI = 41–74). OS was significantly improved in patients with >90% necrosis postneoadjuvant chemotherapy (NACT) when compared with <90% necrosis (3-year OS = 88% vs. 51%,P= 0.01) and in patients who received ≤4 cycles NACT versus >4 cycles (78% vs. 60%,P= 0.04). EFS was significantly better in patients without lung metastasis at presentation (61% vs. 29%,P= 0.04), Stage 2 disease (59% vs. 38%,P= 0.04) and >90% necrosis in the tumor post-NACT (69% vs. 35%,P= 0.02). Conclusion: Significant response to NACT predicted improved OS and EFS in children with OGS treated with LSS.

Antimicrobial Prophylaxis for the Prevention of Surgical Site Infections in Orthopaedic Oncology - A Narrative Review of Current Concepts

The incidence of surgical site infections (SSIs) after elective tumour orthopaedic surgery in adults is higher than non-oncologic orthopaedic surgery. Their causative microorganisms and antibiotic susceptibilities are also different from the non-oncologic cases; with no apparent predictable microbiological patterns. Clinicians continue to struggle to tailor the optimal prophylactic regimen for the very heterogeneous group of tumour patients. Many clinicians thus prolong the first-and second-generation cephalosporin agents, while a minority chooses to broaden the antimicrobial spectrum by combination prophylaxis. The variability in current practices and surgical techniques is enormous, even within the same setting. The scientific literature lacks adequate retrospective case-studies and there is currently only one prospective randomized trial. In this narrative review, we discuss various perioperative antibiotic concepts in oncologic orthopaedic surgery, including a summary of the state-to-the-art, opinions and difficulties related to the different prophylactic strategies.

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

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

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

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

Total Scapulectomy and Shoulder Reconstruction Using a Scapular Prosthesis and Constrained Reverse Shoulder Arthroplasty

Malignant tumors of the scapula are rare, and limb salvage surgery after tumor resection is challenging. The authors present a series of 6 patients who were treated by total scapulectomy and reconstruction with a custom-made scapular prosthesis and a constrained reverse shoulder arthroplasty. Postoperative oncologic and functional outcomes were assessed. The mean follow-up was 37 months (range, 9-84 months). Clear surgical margins were achieved in all patients. At the last follow-up, 4 patients showed no evidence of disease and 2 had died of systemic metastatic disease. Although shoulder function was limited, all shoulders were painless and stable and the patients retained satisfactory hand, wrist, and elbow function. [Orthopedics. 2018; 41(6):e888-e893.].

Extra-articular shoulder resections: outcomes of 54 patients

BACKGROUND

The survival of patients with tumors around the shoulder treated with extra-articular resection, the rates of reconstructions-related complications, and the function of the shoulder cannot be estimated because of limited available data from mainly small published related series and case reports.

METHODS

We studied 54 patients with tumors around the shoulder treated with extra-articular shoulder resections and proximal humeral megaprosthetic reconstructions from 1985 to 2012. Mean tumor volume was 549 cm³, and the mean length of the proximal humeral resection was 110 mm. Mean follow-up was 7.8 years (range, 3-21 years). We evaluated the outcomes (survival, metastases, recurrences, and function) and the survival and complications of the reconstruction.

RESULTS

Survival of patients with malignant tumors was 47%, 38%, and 35%, at 5, 10, and 20 years, respectively. Rates for metastasis and local recurrence were 60% and 18.5%, respectively. Survival was significantly higher for patients without metastases at diagnosis, tumor volume <549 cm³, and type IV resections. Survival of reconstructions was 56% at 10 years and 48% 20 years. Overall, 19 patients (35.2%) experienced 30 complications (55.5%), the most common being soft tissue failures that required subsequent surgery without, however, implant removal. The mean Musculoskeletal Tumour Society score was 25 points, without any significant difference between the types of extra-articular resections.

CONCLUSION

Tumor stage and volume as well as type of resection are important predictors of survival of patients with malignant tumors around the shoulder. Survival of the reconstructions is satisfactory; nevertheless, the complication rate is high. The Musculoskeletal Tumour Society score is similar with respect to the type of resection.

Is it safe to preserve the deltoid when resecting the proximal humerus for a primary malignant bone tumour? A comparative study

AIMS

Resection of the proximal humerus for the primary malignant bone tumour sometimes requires en bloc resection of the deltoid. However, there is no information in the literature which helps a surgeon decide whether to preserve the deltoid or not. The aim of this study was to determine whether retaining the deltoid at the time of resection would increase the rate of local recurrence. We also sought to identify the variables that persuade expert surgeons to choose a deltoid sparing rather than deltoid resecting procedure.

PATIENTS AND METHODS

We reviewed 45 patients who had undergone resection of a primary malignant tumour of the proximal humerus. There were 29 in the deltoid sparing group and 16 in the deltoid resecting group. Imaging studies were reviewed to assess tumour extension and soft-tissue involvement. The presence of a fat rim separating the tumour from the deltoid on MRI was particularly noted. The cumulative probability of local recurrence was calculated in a competing risk scenario.

RESULTS

There was no significant difference (adjusted p = 0.89) in the cumulative probability of local recurrence between the deltoid sparing (7%, 95% confidence interval (CI) 1 to 20) and the deltoid resecting group (26%, 95% CI 8 to 50). Patients were more likely to be selected for a deltoid sparing procedure if they presented with a small tumour (p = 0.0064) with less bone involvement (p = 0.032) and a continuous fat rim on MRI (p = 0.002) and if the axillary nerve could be identified (p = 0.037).

CONCLUSION

A deltoid sparing procedure can provide good local control after resection of the proximal humerus for a primary malignant bone tumour. A smaller tumour, the presence of a continuous fat rim and the identification of the axillary nerve on pre-operative MRI will persuade surgeons to opt for a deltoid resecting procedure. Cite this article: Bone Joint J 2017;99-B:1244-9.

Composite reverse shoulder arthroplasty can provide good function and quality of life in cases of malignant tumour of the proximal humerus

PURPOSE

Management of proximal humeral tumours remains a surgical challenge. No study to date has assessed the quality of life scores following the composite reverse shoulder arthroplasty for this indication. We, therefore, evaluated function and quality of life following reconstruction with allograft for malignant tumour of the humerus.

METHODS

A series of six cases of humeral tumour treated by a single surgeon in a single centre was reviewed after a mean follow-up of 5.9 years. The tumours included two chondrosarcomas, one plasmocytoma and three metastases. Resection involved bone epiphysis, metaphysis and diaphysis in five cases (S3S4S5A) and epiphysis and metaphysis in one case (S3S4A). For reconstruction, an allograft composite reverse shoulder arthroplasty was used in all the cases. Outcomes were assessed with range of motion, the QuickDash score and the Short Form 12 (SF-12) Health Survey. Radiographs assessed osseointegration and complications.

RESULTS

At the final follow-up, the mean shoulder range of motion were respectively 95°, 57° and 11° for forward flexion, abduction and external rotation. Mean QuickDASH score improved from 28 to 41 and VAS-pain scores improved from 5.1 to 2.3. The post-operative MSTS score was 73% and the Constant score was 46.1/100. The SF-12 PCS and MCS scores were also improved, respectively from 44.4 and 39.7 to 45.5 and 56.1. The mean satisfaction score was 8.1/10.

CONCLUSIONS

Composite reverse shoulder arthroplasty is a viable alternative for reconstruction after resection of malignant humeral tumour. Although total tumour resection was the most important objective, the functional and quality of life scores were satisfactory.

Total Humeral Endoprosthetic Replacement following Excision of Malignant Bone Tumors

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.

New endoprosthesis suspension method with polypropylene monofilament knitted mesh after resection of bone tumors in proximal humerus

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.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoprosthetic reconstruction of the proximal humerus after tumour resection with polypropylene mesh

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.

Upper extremity considerations for oncologic surgery

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.

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interscapulothoracic resection of tumours of shoulder with a note on reconstruction

We retrospectively reviewed the outcomes of 33 consecutive patients who had undergone an extra-articular, total or partial scapulectomy for a malignant tumour of the shoulder girdle between 1 July 2001 and 30 September 2013. Of these, 26 had tumours which originated in the scapula or the adjacent soft tissue and underwent a classic Tikhoff-Linberg procedure, while seven with tumours arising from the proximal humerus were treated with a modified Tikhoff-Linberg operation. We used a Ligament Advanced Reinforcement System for soft-tissue reconstruction in nine patients, but not in the other 24. The mean Musculoskeletal Tumor Society score (MSTS) was 17.6 (95% confidence interval (CI) 15.9 to 19.4); 17.6 (95% CI 15.5 to 19.6) after the classic Tikhoff-Linberg procedure and 18.1 (95% CI 13.8 to 22.3) after the modified Tikhoff-Linberg procedure. Patients who had undergone a LARS soft-tissue reconstruction had a mean score of 18.6 (95% (CI) 13.9 to 22.4) compared with 17.2 (95% CI 15.5 to 19.0) for those who did not. The Tikhoff-Linberg procedure is a useful method for wide resection of a malignant tumour of the shoulder girdle which helps to preserve hand and elbow function. The method of soft-tissue reconstruction has no effect on functional outcome.

Targeted imaging of α(v)β(3) expressing sarcoma tumor cells in vivo in pre-operative setting using near infrared: a potential tool to reduce incomplete surgical resection

Tumor size and location along with efficacy of pre-operative imaging are limiting factors for optimal surgical excision for osteosarcoma. Our general hypothesis is that targeting αvβ3 integrin-rich osteosarcoma neoangiogenesis should provide improved delivery of diagnostic compounds and assist surgeons intra operatively using near-infrared imaging techniques. We evaluated in an orthotopic metastatic osteosarcoma in rats the potential of AngioStamp™ targeting αvβ3 integrins and detected intra operatively by near infrared (NIR) illumination (Fluobeam™) as a novel, intra operative imaging technique. To determine the potential of this association in improving tumor and metastasis detection, we compared the quality and sensitivity of tumor/metastasis margin delineation and tumor resection using intra-operative NIR imaging to the ones guided by pre-operative imaging (i.e., MRI subsequently confirmed by histopathological analysis). Chemotherapy being essential in osteosarcoma treatment, we evaluated the capacity of AngioStamp™ to specifically localize to the tumor after chemotherapy treatment. We showed a significantly lesser extent of healthy tissue resection after surgical excision when assessing tumor margin intra operatively using AngioStamp™/Fluobeam™ association compared to pre-operative MRI post-operatively confirmed by histopathological analysis (p<0.01). Importantly, intra-operative NIR illumination of lungs revealed more metastases than were detected by CT Scan or under intra-operative white light examination (p<0.01). Importantly, chemotherapy did not alter AngioStamp™ tumor specific targeting nor the sensitivity of tumor detection. Our preclinical data confirm the potential of intra-operative imaging for improved primary tumor and lung metastasis excision. Based on these promising results, we now propose to evaluate this approach as a mean to improve surgical excision while maintaining tumor control in other sarcoma or tumors overexpressing αvβ3 integrins.

Functional outcome of limb-salvage surgery with shoulder abduction brace for bone tumors around the shoulders

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.

Autologous double-barrel vascularized fibula bone graft for arthrodesis of the shoulder after tumor resection

INTRODUCTION

Arthrodesis of the shoulder is a straightforward and established alternative to reconstruct the shoulder function after tumor resection of the proximal humerus. In most cases, some kind of intercalary bone graft is used to bridge the bony defect. However, due to low stability of a single fibula autograft and disadvantages of exogenous graft material when performing combined allo- and autograft reconstruction, efforts to develop new surgical techniques, with the intention to lower the complication rates, are ongoing.

MATERIALS AND METHODS

We present a detailed description of the surgical technique and the outcome of three patients with osteosarcomas of the proximal humerus, which were treated with tumor resection and autologous double-barrel vascularized fibula bone graft for arthrodesis of the shoulder. The construct was stabilized using a 4.5-mm pelvic reconstruction plate positioned on the scapular spine and the lateral aspect of the humerus.

RESULTS

A wide surgical margin was achieved in all patients. Two of them could be reintegrated and are able to work with excellent shoulder function. In one patient, who developed metastasis, a deep infection under chemotherapy 16 months after index surgery complicated the postoperative course.

CONCLUSION

The fibula's unique dual endosteal and periosteal blood supply makes it effective as a double-barrel bone graft for major long bone defects, which requires extra bone volume to prevent fractures until bone hypertrophy occurs. Additional bone and scar formation between the two struts are believed to provide a stable and long lasting construct, as seen in our patients.

Functional outcomes and complications of reconstruction of the proximal humerus after intra-articular tumor resection

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.

Limb salvage in osteosarcoma using autoclaved tumor-bearing bone

BACKGROUND

Tumor prostheses currently give the best short- and medium-term results for limb-salvage reconstruction procedures in the treatment of bone tumors. However, in developing countries, the cost of a tumor prosthesis is beyond the reach of much of the population. We report the use of autoclaved tumor-bearing bone in 10 patients, as an affordable alternative to the use of prostheses.

METHODS

This is a case series of 10 patients (mean age 19 years) with osteosarcoma who were treated at our hospital from 1998 to 2008, and followed up for a mean of 35 months (range 14 to 8). The femur was involved in six cases, the humerus in three cases, and the ulna in one case. The mean length of the autoclaved bone was 150 mm (range 60-210).

RESULTS

Bone union occurred in seven patients over an mean duration of 12 months (range 8-17). Three patients had non-union. Two of these had associated implant failure, with one of them also developing chronic infection, and the third is still being followed up. Two other patients had local recurrence.

CONCLUSION

The use of autoclaved tumor grafts provides an inexpensive limb-salvage option without sacrificing appropriate oncologic principles. A painless and stable limb is achievable, and the use of this technique can be further refined.

Custom-made endoprosthetic total humerus reconstruction for musculoskeletal tumours

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evolution of surgical treatment for sarcomas of proximal humerus in children: retrospective review at a single institute over 30 years

BACKGROUND

Proximal humerus, although a common site for primary bone sarcomas, finds scant mention in literature as far as options and outcome of reconstruction in the skeletally immature skeleton are concerned. Reconstruction after resection of proximal humeral sarcomas in the immature skeleton poses specific challenges to the surgeon, and there has been a definite evolution of these techniques over the decades. We studied the evolution and compared the outcome of various techniques for such reconstruction over 3 decades at a single institution.

METHODS

All 61 children younger than 13 years of age and treated for a primary sarcoma of the proximal humerus at Department of Musculoskeletal Oncology, Rizzoli Orthopedic Institute, from 1976 to 2006 were studied for techniques of resection and reconstruction, complications, surgical procedures needed during follow up, and functional and radiologic outcomes during and at final follow-up. The functional outcomes after various procedures were compared using the Musculoskeletal Tumor Society scoring system.

RESULTS

A definite trend from amputation in the first decade, to the use of nonbiological reconstruction (endoprostheses, K nail cement spacer) in the second and biological reconstruction (vascular proximal fibula autograft, osteoarticular allograft, and allograft prosthesis composite) in the third decade was seen. There was a trend of improvement in the functional outcome over the 3 decades, although the complication rates and the need for repeated surgical procedures remained a major problem in all the techniques.

CONCLUSIONS

Reconstruction of proximal humerus after resection for sarcomas is a challenging task. Although endoprostheses do have a definite role to play in reconstruction of proximal humerus in children, the use of biological techniques in well-selected patients is being carried out more often now than before, as is reflected in this series, with a potentially improved functional outcome.

LEVEL OF EVIDENCE

Level III-Retrospective comparative study.

Proximal and total humerus reconstruction with the use of an aortograft mesh

BACKGROUND

The shoulder is commonly affected by primary and metastatic tumors. Current surgical techniques for complex shoulder reconstruction frequently result in functional deficits and instability. A synthetic mesh used in vascular surgery has the biological properties to provide mechanical constraint and improve stability after tumor related shoulder reconstruction.

QUESTIONS/PURPOSES

We describe (1) surgical technique using a synthetic mesh during humerus reconstructions; (2) functional level defined as shoulder ROM of patients undergoing the procedure; (3) incidence of postoperative dislocation and shoulder instability; and (4) complications associated with the use of the device.

METHODS

We retrospectively reviewed 16 patients with proximal humerus replacements reconstructed with a synthetic mesh from February 2006 to July 2008. Patients were followed clinically and radiographically for a minimum of 13 months (mean, 26 months; range, 13-43 months).

RESULTS

There were no shoulder dislocations at the latest followup. The mean shoulder flexion was 43° (range, 15°-170°) and mean shoulder abduction of 38 (range, 15°-110°). The mean operative time was 121 minutes (range, 80-170 minutes) and the mean blood loss was 220 mL (range, 50-750 mL). One patient had a superficial wound infection and none a deep infection requiring removal of the graft or prosthesis.

CONCLUSIONS

The data suggest the use of a synthetic vascular mesh for proximal humerus reconstruction may reduce dislocations and facilitate soft tissue attachment and reconstruction after tumor resection.

Infection following Bone Tumor Resection and Reconstruction with Tumoral Prostheses: A Literature Review

Bone resection is the choice treatment of malignant bone tumors. Tumor prosthesis is one of the most common solutions of reconstruction following resection of bone tumor located to the metaphysis of long bones. Periprosthetic infections are a frequent complication of limb-salvage surgery which is largely due to prolonged and repeated surgeries, as well as to the immunocompromised condition of these patients due to neoplastic treatment. Furthermore, the large exposure of tissues during this type of surgery and the dissection across vascular distributions also contributes to the high risk of infection. The authors reviewed the literature discussing the incidence of infections of tumor prosthesis implanted following resection of bone tumors, taking into account the different sites of implantation. In the English literature, the highest risk of infection which led to limb amputation was observed after proximal tibia resection and this difference was considered to be due to the poor condition of soft tissue and also after pelvic resection due to huge dead space after sarcoma resection not filled by implant. Independent of the location, the management of infected prosthesis is similar. That is, after one or more attempts at debridement and antibiotic therapy, it consists of implant removal and insertion of a new implant in a one- or two-stage procedure, with a decreased risk of failure with the two-stage procedure.