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Rampam S, Segu H, Gonzalez MR, Lozano-Calderon SA. Complications and functional outcomes after reconstruction of the proximal humerus with allograft-prosthetic composite: a systematic review of the literature. J Shoulder Elbow Surg 2024; 33:1873-1883. [PMID: 38604399 DOI: 10.1016/j.jse.2024.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/04/2024] [Accepted: 02/17/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Allograft prosthetic composite (APC) reconstruction is performed after resection of proximal humerus tumors or failure of arthroplasty implants. There is limited literature on the postoperative outcomes of this technique. We sought to assess implant survival, failure rates, and postoperative functional outcomes after APC reconstruction of the proximal humerus. METHODS A systematic review of the PubMed and Embase databases was conducted. The study was registered on PROSPERO (ID: 448,663). The Strengthening of the Reporting of Observational Studies in Epidemiology checklist was used for quality assessment. Implant failure was determined using the Henderson classification for biological reconstruction. Functional outcome was primarily assessed using the Musculoskeletal Tumor Society score at last follow-up. RESULTS Twenty-five studies with a total of 488 patients were included. Mean follow-up in reporting studies ranged from 2.5 to 10 years. Five-year revision-free survival for implants ranged from 41% to 92%. Overall implant failure rate ranged from 9% to 54%, and reoperation rate ranged from 0% to 55%. Graft host nonunion (type 2) was the most common mode of failure, with rates ranging from 0% to 75%. The mean Musculoskeletal Tumor Society scores at last follow-up ranged from 57% to 90% across studies. A trend towards better functional outcomes was seen in patients having an APC with a reverse total shoulder arthroplasty (rTSA) compared with those with hemiarthroplasty. CONCLUSIONS APCs show promise in proximal shoulder reconstruction, with heterogeneous functional outcomes that are noninferior to other reconstruction techniques. Graft host nonunion is a common mode of failure and remains a concern in this type of prosthesis. Future studies should compare rTSA-APCs and rTSA endoprostheses while controlling for potential confounders.
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Affiliation(s)
- Sanjeev Rampam
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hitha Segu
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Marcos R Gonzalez
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Santiago A Lozano-Calderon
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Antal I, Szőke G, Szendrői M, Szalay K, Perlaky T, Kiss J, Skaliczki G. Functional outcome and quality of life following resection of the proximal humerus performed for musculoskeletal tumors and reconstruction done by four different methods. Musculoskelet Surg 2023; 107:351-359. [PMID: 36648636 PMCID: PMC10432350 DOI: 10.1007/s12306-022-00771-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 12/19/2022] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The proximal humerus is a frequent site for both primary and secondary bone tumors. Several options are currently available to reconstruct the resected humerus, but there is no consensus regarding optimal reconstruction. The aim of this retrospective study was to compare the functional outcome, complications and patient compliance following four different types of reconstructive techniques. MATERIAL AND METHODS The authors performed 90 proximal humerus resections due to primary and secondary bone tumors over the past 21 years. Four different procedures were performed for reconstruction following the resection: fibula autograft transplantation, osteoarticular allograft implantation, modular tumor endoprosthesis (hemiarthroplasty) and reconstruction of the defect with a reverse shoulder prosthesis-allograft composite. A retrospective analysis of the complications and patient's physical status was performed. Functional outcome and life quality was evaluated by using the MSTS and SF-36 scores. RESULTS The best range of motion was observed following arthroplasty with a reverse shoulder prosthesis-homograft composite followed by a fibula autograft reconstruction. Revision surgery was required due to major complications most frequently in the osteoarticular allograft group, followed by the reverse shoulder prosthesis-allograft composite group, the autologous fibula transplantation group; the tumor endoprosthesis hemiarthroplasty group had superior results regarding revision surgery (40, 25, 24 and 14% respectively). MSTS was 84% on average for the reverse shoulder prosthesis-allograft composite group, 70% for the autologous fibula group, 67% for the anatomical hemiarthroplasty group and 64% for the osteoartricular allograft group. Using the SF-36 questionnaire for assessment no significant differences were found between the four groups regarding quality of life. DISCUSSION Based on the results of our study the best functional performance (range of motion and patient compliance) was achieved in the a reverse prosthesis-allograft combination group-in cases where the axillary nerve could be spared. The use of an osteoarticular allograft resulted in unsatisfying functional results and high complication rates, therefore we do not recommend it as a reconstructive method following resection of the proximal humerus due to either primary or metastatic bone tumors. Young patients who have good life expectancy but a small humerus or intramedullar cavity reconstruction by implantation of a fibula autograft is a good option. For patients with a poor prognosis (i.g. bone metastases) or in cases where the axillary nerve must be sacrificed, hemiarthroplasty using a tumor endoprosthesis was found to have acceptable results with a low complication rate. According to the MSTS and SF-36 functional scoring systems patients compliance was nearly identical following all four types of reconstruction techniques; the underlying cause may be the complexity of the shoulder girdle. However, we recommend the implantation of a reverse shoulder prosthesis-allograft whenever indication is appropriate, as it has been demonstrated to provide excellent functional outcomes, especially in young adults.
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Affiliation(s)
- I Antal
- Department of Orthopedics, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary.
| | - G Szőke
- Department of Orthopedics, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - M Szendrői
- Department of Orthopedics, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - K Szalay
- Department of Orthopedics, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - T Perlaky
- Department of Orthopedics, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - J Kiss
- Department of Orthopedics, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
| | - G Skaliczki
- Department of Orthopedics, Semmelweis University, Üllői út 26, Budapest, 1085, Hungary
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Kawanami K, Kajita Y, Harada Y, Takahashi E, Deie M. Bone metastasis of proximal humerus treated by reverse shoulder arthroplasty with polyester mesh: A case report. J Orthop Sci 2023; 28:1175-1178. [PMID: 33419626 DOI: 10.1016/j.jos.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/28/2020] [Accepted: 12/01/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Katsuhisa Kawanami
- Department of Orthopaedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan.
| | - Yukihiro Kajita
- Department of Orthopaedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan.
| | - Yohei Harada
- Department of Orthopaedic Surgery, Hiroshima University, Kasumi 1-2-3 Minami-ku, Hiroshima, Japan.
| | - Emiko Takahashi
- Department of Pathology, Aichi Medical University, Nagakute, Aichi, Japan.
| | - Masataka Deie
- Department of Orthopaedic Surgery, Aichi Medical University, Nagakute, Aichi, Japan.
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4
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Hones KM, Gutowski CT, Srinivasan RC, Wright JO, King JJ, Wright TW, Fedorka CJ, Marigi EM, Schoch BS, Hao KA. Allograft-Prosthetic Composite Reconstruction for Proximal Humerus Bone Loss: A Systematic Review and Meta-Analysis of Outcomes and Complications. JBJS Rev 2023; 11:01874474-202308000-00009. [PMID: 37616466 DOI: 10.2106/jbjs.rvw.23.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
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.
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Affiliation(s)
- Keegan M Hones
- College of Medicine, University of Florida, Gainesville, Florida
| | | | | | - Jonathan O Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida
| | - Joseph J King
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida
| | - Thomas W Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida
| | - Catherine J Fedorka
- Cooper Bone and Joint Institute, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Erick M Marigi
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, Florida
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El Motassime A, Meschini C, Di Costa D, Rovere G, Matrangolo MR, De Maio F, Farsetti P, Ziranu A, Maccauro G, Vitiello R. Functional Outcomes and Shoulder Instability in Reconstruction of Proximal Humerus Metastases. Curr Oncol 2023; 30:3571-3579. [PMID: 37185385 PMCID: PMC10136526 DOI: 10.3390/curroncol30040272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/16/2023] [Accepted: 03/20/2023] [Indexed: 05/17/2023] Open
Abstract
(1) Background: Some of the goals of orthopedic surgical oncology are saving limbs and function. The humerus is the third most frequent site in primary tumors and one of the most involved sites for metastases. Prosthetic replacement with modular megaprosthesis is one of the treatment choices, but there are several types of complications, such as problems with function and pain. The aim of our study is to assess functional outcomes and shoulder instability in the reconstruction of proximal humerus metastases. (2) Methods: This is a retrospective observational study. Twenty-eight patients, with proximal humerus metastases, admitted to the department of Orthopaedics and Traumatology of our University Hospital between 2014 and 2022 were recruited. Each patient underwent resection and prosthetic replacement surgery with modular megaprosthesis. Clinical evaluation was assessed through MSTS score, WOSI index, and DASH score. (3) Results: Twenty patients were included in the study. Fairly good results, especially regarding pain, function, and emotional acceptance, were obtained in all three tests: DASH, MSTS, and WOSI. Patients who reported shoulder instability actually have worse outcomes than those who report having stable shoulders. In addition, patients with a resection >10 cm have worse outcomes than those who had a resection of 10 cm. No significant differences were found between the deltopectoral approach group and the lateral approach group. (4) Conclusions: Reconstructive surgery with megaprosthesis of the proximal humerus in patients with metastases can be considered a treatment option, especially in patients with pathological fractures or injuries with a high risk of fracture and good life expectancy. This study shows how this type of surgery affects instability, but in terms of functionality, pain, and patient satisfaction, it gives satisfactory results.
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Affiliation(s)
- Alessandro El Motassime
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Cesare Meschini
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Doriana Di Costa
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giuseppe Rovere
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Maria Rosaria Matrangolo
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Fernando De Maio
- Department of Clinical Science and Translational Medicine, Section of Orthopaedics and Traumatology, University of Rome "Tor Vergata", 00133 Rome, Italy
| | - Pasquale Farsetti
- Department of Clinical Science and Translational Medicine, Section of Orthopaedics and Traumatology, University of Rome "Tor Vergata", 00133 Rome, Italy
| | - Antonio Ziranu
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giulio Maccauro
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Raffaele Vitiello
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Orthopaedics, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, University Cattolica del Sacro Cuore, 00168 Rome, Italy
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Denissen JJPM, Koenders N, van Hinte G, Groen F, van der Wees PJ, van der Geest ICM, Dierselhuis EF. Functional outcomes after reversed shoulder megaprosthesis following resection of malignant bone tumor in the proximal humerus: a systematic review and meta-analysis. JSES Int 2023. [DOI: 10.1016/j.jseint.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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7
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Fiore M, Sambri A, Giannini C, Zucchini R, De Cristofaro R, De Paolis M. Anatomical and reverse megaprosthesis in proximal humerus reconstructions after oncologic resections: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2022; 142:2459-2469. [PMID: 33721053 DOI: 10.1007/s00402-021-03857-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 03/06/2021] [Indexed: 12/19/2022]
Abstract
AIM Anatomic (AN) Endoprosthesis (EPR) reconstructions of the shoulder after intra-articular proximal humerus (Malawer type 1) resections are characterized by early recovery and low complications rate. However, shoulder instability and limited mobility can occur. Reverse shoulder (RS) EPR has been introduced to improve functional outcome. The aim of this systematic review is to evaluate shoulder reconstructions with AN or RS EPR after Malawer type 1 resection, comparing complications and functional results. METHODS Through an electronic systematic search of PubMed, articles concerning EPR after shoulder Malawer type 1 resections were reviewed. Complications rate, range of motion (ROM) and functional outcome (Musculoskeletal Society Tumor Society-MSTS score) of AN and RS EPR were evaluated. RESULTS Sixteen studies were included. A similar complication rate was observed between AN and RS EPR rate (26.4% and 22.4%, respectively, p = 0.37). Soft tissue failure was the most frequent complication and cause of revision in both groups. Mean post-operative flexion and abduction ROM and MSTS scores were significantly higher in RS EPR, particularly among patients with preserved deltoid function (p = 0.013, p = 0.025 and p = 0.005, respectively). CONCLUSIONS Anatomic and reverse shoulder EPR represent safe and effective implants for shoulder reconstruction, with similar implant stability and complication rates. RS EPR significantly improves post-operative ROM and functional outcomes, especially when at least a partial function of the abductor apparatus is preserved.
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Affiliation(s)
- Michele Fiore
- IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli 1, 40136, Bologna, Italy
| | - Andrea Sambri
- Alma Mater Studiorum, University of Bologna, Bologna, Italy. .,IRCCS Policlinico di Sant'Orsola, Bologna, Italy.
| | - Claudio Giannini
- IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli 1, 40136, Bologna, Italy
| | - Riccardo Zucchini
- IRCCS Istituto Ortopedico Rizzoli, via G.C. Pupilli 1, 40136, Bologna, Italy
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Ma Z, Yang Q, Liu X, Li Z. Application of allograft and absorbable screws in the reconstruction of a massive bone defect following resection of giant osteochondroma: A retrospective study. Front Surg 2022; 9:938750. [PMID: 36211287 PMCID: PMC9535078 DOI: 10.3389/fsurg.2022.938750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/29/2022] [Indexed: 11/19/2022] Open
Abstract
Background This study aims to introduce a reconstruction method of applying allografts and absorbable screws to repair large bone defects caused by the resection of giant osteochondroma. Methods A retrospective study of a series of patients who underwent the resection of giant osteochondroma reconstructed by allografts and absorbable screws was conducted from February 2020 to September 2021. Their demographic data, location site, area of bone defect, and pertinent operative details were recorded. The reconstruction modality of allografts was elaborated on. In the follow-up, radiographic images were utilized to determine bone union, and the Musculoskeletal Tumor Society score was used to evaluate postoperative limb function. Results A total of seven patients were included, including three males and four females with an average age of 16.6 ± 6.5 years. Among them, three cases of tumors occurred in the humerus and four cases occurred in the femur. The average follow-up time was 11.3 ± 3.0 months. The average area of bone defect was 25.9 ± 8.3 cm2. No complications such as infection, nonunion, and allograft bone fracture were found during the follow-up period. Six months after the operation, the average Musculoskeletal Tumor Society score was 26.4 ± 1.6, with acceptable postoperative function. Conclusions The cooperative application of absorbable screw fixation and allografts including mixed cortical bone and cancellous bone, which yielded satisfactory functional outcomes and acceptable postoperative complications, is an effective reconstruction method for a massive bone defect after the resection of giant osteochondroma.
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Affiliation(s)
| | | | - Xinyu Liu
- Correspondence: Zhenfeng Li Xinyu Liu
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Zuo D, Mu H, Yang Q, Sun M, Shen J, Wang H, Ma X, Wang C, Li C, Sun W, Cai Z. Do reverse total shoulder replacements have better clinical and functional outcomes than hemiarthroplasty for patients undergoing proximal humeral tumor resection using devitalized autograft composite reconstruction: a case-control study. J Orthop Surg Res 2021; 16:453. [PMID: 34261497 PMCID: PMC8278672 DOI: 10.1186/s13018-021-02488-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/13/2021] [Indexed: 01/16/2023] Open
Abstract
Objective To compare the efficacy and prognosis of reverse total shoulder arthroplasty (rTSA) with shoulder hemiarthroplasty (SHA) using devitalized autograft or allograft composite reconstruction after proximal humeral tumor resection. Methods We retrospectively reviewed patients who underwent SHA (32) and rTSA (20) for tumor resections of the proximal humerus from January 2014 to July 2020. The clinical results included duration of the operation, intraoperative blood loss, bone union, visual analog scale (VAS) score, shoulder range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) shoulder score, recurrence, and overall survival. Results Fifty-two patients were followed up for a mean of 30 months. Thirty-two patients were SHA with allograft-prosthetic composite (APC) reconstructions, while other 20 were rTSA with devitalized autograft-prosthetic composite reconstructions. At the end of the follow-up, 2 recurrence, 3 postoperative infections, and 4 subluxations occurred among the SHA patients. Two patients in the rTSA group had postoperative anterior dislocation and underwent revision surgery with surgical mesh, and 2 (2/20) had grade II scapular notching. The mean VAS score of the shoulder was 1.5 ± 0.8 in the rTSA group and 2.3 ± 1.2 in the SHA group (p < 0.05). The mean active forward flexion of the shoulder joint was 50.6 ± 6.0 in the SHA group and 100 ± 7.6 in the rTSA group (p < 0.05). The ASES shoulder score was 78 ± 3.0 in the rTSA group and 52 ± 5.6 in the SHA group (p < 0.05). The overall 3-year survival rate of all patients was 60.0%, and patients in the rTSA group showed better survival in terms of the mean 3-year OS than patients in the SHA group (p = 0.04). Conclusion rTSA with devitalized autograft-prosthetic composite can offer a reasonable reconstruction of the shoulder joint after Malawer type I tumor resection. Compared with patients who underwent SHA, patients who underwent rTSA present good outcomes, a better range of motion, better bone union, and no increase in instability rate in the mid-term.
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Affiliation(s)
- Dongqing Zuo
- Department of Orthopedic Oncology, Shanghai General Hospital Affiliated with Shanghai Jiaotong University, No. 100 Haining Road, Hongkou District, Shanghai, 200080, China
| | - Haoran Mu
- Shanghai Bone Tumor Institute, Shanghai, China
| | - Qingbo Yang
- Department of Thoracic Surgery, Shanghai Tenth People's Hospital affiliated with Tongji University, 301 Yanchang Road, Shanghai, China
| | - Mengxiong Sun
- Department of Orthopedic Oncology, Shanghai General Hospital Affiliated with Shanghai Jiaotong University, No. 100 Haining Road, Hongkou District, Shanghai, 200080, China
| | - Jiakang Shen
- Department of Orthopedic Oncology, Shanghai General Hospital Affiliated with Shanghai Jiaotong University, No. 100 Haining Road, Hongkou District, Shanghai, 200080, China
| | - Hongsheng Wang
- Department of Orthopedic Oncology, Shanghai General Hospital Affiliated with Shanghai Jiaotong University, No. 100 Haining Road, Hongkou District, Shanghai, 200080, China
| | - Xiaojun Ma
- Department of Orthopedic Oncology, Shanghai General Hospital Affiliated with Shanghai Jiaotong University, No. 100 Haining Road, Hongkou District, Shanghai, 200080, China
| | - Chongren Wang
- Department of Orthopedic Oncology, Shanghai General Hospital Affiliated with Shanghai Jiaotong University, No. 100 Haining Road, Hongkou District, Shanghai, 200080, China
| | - Chuanping Li
- Department of Thoracic Surgery, Shanghai Tenth People's Hospital affiliated with Tongji University, 301 Yanchang Road, Shanghai, China.,Department of Rehabilitation, Shanghai General Hospital Affiliated with Shanghai Jiaotong University, No. 100 Haining Road, Shanghai, China
| | - Wei Sun
- Department of Orthopedic Oncology, Shanghai General Hospital Affiliated with Shanghai Jiaotong University, No. 100 Haining Road, Hongkou District, Shanghai, 200080, China.
| | - Zhengdong Cai
- Department of Orthopedic Oncology, Shanghai General Hospital Affiliated with Shanghai Jiaotong University, No. 100 Haining Road, Hongkou District, Shanghai, 200080, China
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Gautam D, Arora N, Gupta S, George J, Malhotra R. Megaprosthesis Versus Allograft Prosthesis Composite for the Management of Massive Skeletal Defects: A Meta-Analysis of Comparative Studies. Curr Rev Musculoskelet Med 2021; 14:255-270. [PMID: 33864628 PMCID: PMC8137768 DOI: 10.1007/s12178-021-09707-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW Megaprosthesis and Allograft Prosthesis Composite (APC) are the established treatment modalities for massive skeletal defects. There are a handful of studies comparing the use of megaprosthesis and APC in the management of substantial bone loss and it has always been a topic of debate regarding the superiority of one modality over the other. Therefore, we aim to compare the functional outcome and implant survivorship of each modality including complications, revision rates, amputation rate and mortality. RECENT FINDINGS The Allograft Prosthesis Composite (APC) constitutes a skeletal allograft implanted with a revision type prosthesis in it. The biological environment provided by the allograft allows attachment of the muscles and tendons imparting better stability and function. However, the literature is not kind enough with APC due to associated risk of infection, disease transmission and nonunion at the graft-host junction. The megaprosthesis (MP) on the other hand is a nonbiologic modality with better survivorship but subservient functional outcome. Infection has been a major issue in both the modalities. Advancement in metallurgy using silver coated megaprosthesis also failed to provide strong evidence in preventing infection. The functional outcome is better with APC in both the upper and lower limbs. However, the survivorship is better with megaprosthesis, especially in the upper limb when revision rates were compared between the two modalities. Deep infection and mechanical complications were significantly higher in the APC group. There was no significant difference between the two groups in terms of amputation rate, mortality, and local recurrence. LEVEL OF EVIDENCE (CEBM) 2a.
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Affiliation(s)
- Deepak Gautam
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Nitish Arora
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Saurabh Gupta
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Jaiben George
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
| | - Rajesh Malhotra
- Department of Orthopedics, All India Institute of Medical Sciences (AIIMS), New Delhi, 110029 India
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11
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Preliminary results of reconstruction of proximal humeral bone loss with a reverse total shoulder prosthesis using a modular endoprosthetic reconstruction system: a case series. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
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.
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What Is the Survival and Function of Modular Reverse Total Shoulder Prostheses in Patients Undergoing Tumor Resections in Whom an Innervated Deltoid Muscle Can Be Preserved? Clin Orthop Relat Res 2019; 477:2495-2507. [PMID: 31389894 PMCID: PMC6903840 DOI: 10.1097/corr.0000000000000899] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND After proximal humerus resection for bone tumors, restoring anatomy and shoulder function remains demanding because muscles and bone are removed to obtain tumor-free surgical margins. Current modes of reconstruction such as anatomic modular prostheses, osteoarticular allografts, or allograft-prosthetic composites and arthrodeses are associated with relatively poor shoulder function related to loss of the deltoid and rotator cuff muscles. Newer prosthetic designs like the reverse total shoulder arthroplasty (RTSA) are felt to be useful in other reconstructions where rotator cuff function is compromised, so it seemed logical that it might help in tumor reconstructions as well in patients where the deltoid muscle and its innervation can be preserved. QUESTIONS/PURPOSES In patients with a tumor of the proximal humerus that can be resected with preservation of the deltoid muscle, (1) What complications are associated with tumor resection and reconstruction with a modular RTSA? (2) What are the functional results of modular RTSA in these patients? METHODS From January 2011 to January 2018, we treated 52 patients for bone tumors of the proximal humerus. Of these, three patients were treated with forequarter amputation, 14 were treated with standard modular proximal humerus implants, seven were treated with allograft-prosthetic composites (RTSA-APC), and 28 were treated with a modular RTSA. Generally, we used anatomic modular prosthetic reconstruction if during the tumor resection none of the abductor mechanism could be spared. Conversely, we preferred reconstruction with RTSA if an innervated deltoid muscle could be spared, but the rotator cuff and capsule could not, using RTSA-APC or modular RTSA if humeral osteotomy was distal or proximal to deltoid insertion, respectively. In this study, we retrospectively analyzed only patients treated with modular RTSA after proximal humerus resection. We excluded three patients treated with modular RTSA as revision procedures after mechanical failure of previous biological reconstructions and three patients treated after December 2016 to obtain an expected minimum follow-up of 2 years. There were nine men and 13 women, with a mean (range) age of 55 years (18 to 71). Reconstruction was performed in all patients using silver-coated modular RTSA protheses. Patients were clinically checked according to oncologic protocol. Complications and function were evaluated at final follow-up by the treating surgeon (PR) and shoulder surgeon (AC). Complications were evaluated according to Henderson classification. Functional results were assessed with the Musculoskeletal Tumor Society score (range 0 points to 30 points), Constant-Murley score (range 0 to 100), and American Shoulder and Elbow Surgeons score (range 0 to 100). The statistical analysis was performed using Kaplan-Meier curves. RESULTS Complications occurred in five of 22 patients; there was a shoulder dislocation (Type I) in four patients and aseptic loosening (Type II) in one. Function in these patients on the outcomes scales we used was generally satisfactory; the mean Musculoskeletal Tumor Society score was 29, the mean Constant score was 61, and the mean American Shoulder and Elbow Surgeons score was 81. CONCLUSIONS Although this was a small series of patients with heterogeneous diagnoses and resection types, and we were not able to directly compare the results of this procedure with those of other available reconstructions, we found patients treated with RTSA achieved reasonable shoulder function after resection and reconstruction of a proximal humerus tumor. It may not be valuable in all tumor resections, but in patients in whom the deltoid can be partly spared, this procedure appears to reasonably restore short-term shoulder function. However, future larger studies with longer follow-up are needed to confirm these findings. LEVEL OF EVIDENCE Level IV, therapeutic study.
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14
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Chauhan VS, Vaish A, Vaishya R. Reverse shoulder arthroplasty after failed megaprosthesis for osteosarcoma of the proximal humerus: A case report and review of literature. J Clin Orthop Trauma 2019; 10:526-530. [PMID: 31061583 PMCID: PMC6491923 DOI: 10.1016/j.jcot.2019.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 03/19/2019] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
- V. Singh Chauhan
- Consultant Orthopedic Surgeon, Rift Valley Provincial General Hospital, Kenya
| | - Abhishek Vaish
- Attending Consultant, Indraprastha Apollo Hospitals, New Delhi, India
| | - Raju Vaishya
- Indian Cartilage Society & Arthritis Care Foundation, Senior Consultant Orthopaedic & Joint Replacement Surgeon, Indraprastha Apollo Hospitals, N Delhi, India
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15
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Ogink PT, Teunissen FR, Massier JR, Raskin KA, Schwab JH, Lozano-Calderon SA. Allograft reconstruction of the humerus: Complications and revision surgery. J Surg Oncol 2018; 119:329-335. [PMID: 30517776 DOI: 10.1002/jso.25309] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/08/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVES Allograft reconstruction of the humerus after resection is preferred by many because of bone stock restoration and biologic attachment of ligaments and muscles to the allograft, theoretically obtaining superior stability and functionality. Our aim was to assess the prevalence of complications and the incidence and etiology for revision surgery in humeral allograft reconstructions. METHODS We included patients 18 years and older who underwent wide resection and allograft reconstruction of the humerus for primary and metastatic lesions at our institution between 1990 and 2013. Our primary outcome measures were complications and revision surgery. We used competing risk regression to assess allograft survival. RESULTS Of the 84 patients we included, 47 patients (51%) underwent allograft reconstructions of the proximal humerus, 30 (36%) intercalary, and seven (8%) of the distal humerus. Fifty-one patients (61%) had at least one complication after surgery. Eighteen patients (21%) underwent revision surgery. The 5-year allograft survival was 71%. CONCLUSION Although allograft reconstructions of the humerus are a valuable option in the orthopedic oncologist's armamentarium, surgeons should mind the accompanying complication rates. Allograft fractures seem to be the main issue for proximal and distal allografts, often leading to revision surgery. Intercalary allografts are mostly troubled by nonunions.
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Affiliation(s)
- Paul T Ogink
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frederik R Teunissen
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Julie R Massier
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kevin A Raskin
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph H Schwab
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Santiago A Lozano-Calderon
- Department of Orthopaedic Surgery, Orthopaedic Oncology Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Surgical and Functional Outcome after Endoprosthetic Reconstruction in Patients with Osteosarcoma of the Humerus. Sci Rep 2018; 8:16148. [PMID: 30410099 PMCID: PMC6224576 DOI: 10.1038/s41598-018-34397-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 10/12/2018] [Indexed: 11/15/2022] Open
Abstract
Endoprosthetic reconstruction (EPR) is the most widely used reconstruction technique after humeral osteosarcoma (OSA). Complications are common and function is often compromised due to the premise of wide resection. In the current study we evaluated (1) the risk of complications after resection and EPR; (2) the functional outcome and how it is influenced by the preservation/resection of deltoid muscle (DM), rotator cuff (RC), axillary nerve or the type of resection (intra-/extraarticular) and (3) if the preservation/resection of DM, RC, axillary nerve or the type of resection has a negative influence on the oncological outcome. We retrospectively evaluated data of 49 patients with humeral OSA. All patients underwent resection and EPR. Complication-free survival according to the ISOLS classification was estimated by a competing risk model. Functional outcome was evaluated by range of motion (ROM) in abduction and the MSTS score. Eleven patients (22%) had at least one complication. The estimated cumulative incidence for the first complication was 18% at one year, 23% at five years, and 28% at ten years, respectively. Soft tissue failure was the most common complication. ROM and MSTS scores were significantly higher in patients where DM and RC (p = 0.043/p = 0.046) and axillary nerve (p = 0.014/p = 0.021) could be preserved. Preservation of these structures had no negative influence on the surgical margins. In conclusion, EPR is a good treatment method with an acceptable complication rate. Preservation of the abductor mechanism, when possible in the setting of obtaining negative margins, provides superior functional outcome.
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17
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Gautam D, Malhotra R. Megaprosthesis versus Allograft Prosthesis Composite for massive skeletal defects. J Clin Orthop Trauma 2018; 9:63-80. [PMID: 29628687 PMCID: PMC5884048 DOI: 10.1016/j.jcot.2017.09.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 09/20/2017] [Indexed: 02/09/2023] Open
Abstract
Massive skeletal defects are encountered in the setting of tumors necessitating excision, failed total hip arthroplasty with periprosthetic bone loss, periprosthetic fracture, complex trauma, multiple failed osteosynthesis and infection. Reconstruction of the segmental defects poses a tremendous challenge to the orthopaedic surgeons. The goal of osseous reconstruction of these defects is to restore the bone length and function. Currently the most commonly employed methods for reconstruction are either a megaprosthesis or an Allograft Prosthesis Composite (APC). Megaprosthesis, initially created for the treatment in neoplastic pathologies are being used for the non-neoplastic pathologies as well. The longevity of these implants is an issue as majority of the patients receiving them are the survivors of oncologic issue or elderly population, both in which the life expectancy is limited. However, the early complications like instability, infection, prosthetic breakage and fixation failure have been extensively reported in several literatures. Moreover, the megaprostheses are non-biological options preventing secure fixation of the soft tissue around the implant. The Allograft Prosthesis Composites were introduced to overcome the complications of megaprosthesis. APC is made of a revision-type prosthesis cemented into the skeletal allograft to which the remaining soft tissue sleeve can be biologically fixed. APCs are preferred in young and low risk patients. Though the incidence of instability is relatively low with the composites as compared to the megaprosthesis, apart from infection, the newer complications pertaining to APCs are inevitable that includes non-union, allograft resorption, periprosthetic fracture and potential risk of disease transmission. The current review aims to give an overview on the treatment outcomes, complications and survival of both the megaprostheses and APCs at different anatomic sites in both the upper and lower limbs.
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Affiliation(s)
| | - Rajesh Malhotra
- Corresponding author at: Room No 5019, Department of Orthopedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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18
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Chen CM, Wu PK, Tsai SW, Chen CF, Chen WM. Prognosis-Based Shoulder Hemiarthroplasty After Resection of Proximal Humeral Malignancy. Artif Organs 2017; 41:1162-1172. [PMID: 28722169 DOI: 10.1111/aor.12915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/08/2016] [Accepted: 12/13/2016] [Indexed: 01/01/2023]
Abstract
After wide excision of proximal humeral bony malignancy, prognosis-based reconstruction was performed at Taipei Veterans General Hospital. Bone prosthesis composite (BPC) was carried out among patients with a favored prognosis, while cement-spacer prosthesis composite (CSPC) was preserved for patients with poor prognosis. The aim of our study is to compare the clinical outcomes between the BPC and CSPC reconstruction procedures. From January 2000 to December 2014, we retrospectively reviewed the clinical outcomes of 34 patients who underwent shoulder hemiarthroplasty following wide excision of a malignant lesion of the proximal humerus, 15 of whom were treated with a BPC reconstruction and 19 cases were treated with a CSPC reconstruction. The mean postoperative follow-up was 51.9 months for the BPC group and 29.0 months for the CSPC group. At the end of the study, four patients (two in the BPC group and two in the CSPC group) developed local recurrence. Thirteen patients (1 in the BPC group and 12 in the CSPC group) had died of disease progression. The postoperative visual analogue scale score of BPC and CSPC groups was similar (P = 0.262). Functional outcome, measured using the Musculoskeletal Tumor Society score and shoulder range of motion, favored the BPC procedure (P < 0.001). The CSPC procedure, however, had less complication rate, required less operative time, and had a lower volume of intraoperative blood loss than the BPC procedure (P < 0.001). Although functional outcomes are expected to be more favorable with a BPC procedure, the CSPC procedure continues to be a safe and cost-effective shoulder hemiarthroplasty procedure for patients with low-demanding activities and when a poor disease prognosis is expected.
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Affiliation(s)
- Chao-Ming Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Rehabilitation and Technical Aid Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Fong Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Rehabilitation and Technical Aid Center, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
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19
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Bus MPA, van de Sande MAJ, Taminiau AHM, Dijkstra PDS. Is there still a role for osteoarticular allograft reconstruction in musculoskeletal tumour surgery? a long-term follow-up study of 38 patients and systematic review of the literature. Bone Joint J 2017; 99-B:522-530. [PMID: 28385943 DOI: 10.1302/0301-620x.99b4.bjj-2016-0443.r2] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 11/11/2016] [Indexed: 11/05/2022]
Abstract
AIMS To assess complications and failure mechanisms of osteoarticular allograft reconstructions for primary bone tumours. PATIENTS AND METHODS We retrospectively evaluated 38 patients (28 men, 74%) who were treated at our institution with osteoarticular allograft reconstruction between 1989 and 2010. Median age was 19 years (interquartile range 14 to 32). Median follow-up was 19.5 years (95% confidence interval (CI) 13.0 to 26.1) when 26 patients (68%) were alive. In addition, we systematically searched the literature for clinical studies on osteoarticular allografts, finding 31 studies suitable for analysis. Results of papers that reported on one site exclusively were pooled for comparison. RESULTS A total of 20 patients (53%) experienced graft failure, including 15 due to mechanical complications (39%) and three (9%) due to infection. In the systematic review, 514 reconstructions were analysed (distal femur, n = 184, 36%; proximal tibia, n = 136, 26%; distal radius, n = 99, 19%; proximal humerus, n = 95, 18%). Overall rates of failure, fracture and infection were 27%, 20%, and 10% respectively. With the distal femur as the reference, fractures were more common in the humerus (odds ratio (OR) 4.1, 95% CI 2.2 to 7.7) and tibia (OR 2.2, 95% CI 1.3 to 4.4); infections occurred more often in the tibia (OR 2.2, 95% CI 1.3 to 4.4) and less often in the radius (OR 0.1, 95% CI 0.0 to 0.8). CONCLUSION Osteoarticular allograft reconstructions are associated with high rates of mechanical complications. Although comparative studies with alternative techniques are scarce, the risk of mechanical failure in our opinion does not justify routine employment of osteoarticular allografts for reconstruction of large joints after tumour resection. Cite this article: Bone Joint J 2017;99-B:522-30.
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Affiliation(s)
- M P A Bus
- Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - M A J van de Sande
- Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - A H M Taminiau
- Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - P D S Dijkstra
- Leiden University Medical Center, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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20
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Dubina A, Shiu B, Gilotra M, Hasan SA, Lerman D, Ng VY. What is the Optimal Reconstruction Option after the Resection of Proximal Humeral Tumors? A Systematic Review. Open Orthop J 2017; 11:203-211. [PMID: 28458733 PMCID: PMC5388785 DOI: 10.2174/1874325001711010203] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/02/2017] [Accepted: 01/20/2017] [Indexed: 11/22/2022] Open
Abstract
Purpose: The proximal humerus is a common location for both primary and metastatic bone tumors. There are numerous reconstruction options after surgical resection. There is no consensus on the ideal method of reconstruction. Methods: A systematic review was performed with a focus on the surgical reconstructive options for lesions involving the proximal humerus. Results: A total of 50 articles and 1227 patients were included for analysis. Reoperation rates were autograft arthrodesis (11%), megaprosthesis (10%), RSA (17%), hemiarthroplasty (26%), and osteoarticular allograft (34%). Mechanical failure rates, including prosthetic loosening, fracture, and dislocation, were highest in allograft-containing constructs (APC, osteoarticular allograft, arthrodesis) followed by arthroplasty (hemiarthroplasty, RSA, megaprosthesis) and lowest for autografts (vascularized fibula, autograft arthrodesis). Infections involving RSA (9%) were higher than hemiarthroplasty (0%) and megaprosthesis (4%). Postoperative function as measured by MSTS score were similar amongst all prosthetic options, ranging from 66% to 74%, and claviculo pro humeri (CPH) was slightly better (83%). Patients were generally limited to active abduction of approximately 45° and no greater than 90°. With resection of the rotator cuff, deltoid muscle or axillary nerve, function and stability were compromised even further. If the rotator cuff was sacrificed but the deltoid and axillary nerve preserved, active forward flexion and abduction were superior with RSA. Discussion: Various reconstruction techniques for the proximal humerus lead to relatively similar functional results. Surgical choice should be tailored to anatomic defect and functional requirements.
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Affiliation(s)
- Andrew Dubina
- University of Maryland - Orthopaedics, Baltimore, MD, USA
| | - Brian Shiu
- University of Maryland Medical Center - Orthopaedics, Baltimore, MD, USA
| | - Mohit Gilotra
- University of Maryland Medical Center - Orthopaedics, Baltimore, MD, USA
| | - S Ashfaq Hasan
- University of Maryland Medical Center - Orthopaedics, Baltimore, MD, USA
| | - Daniel Lerman
- University of Maryland Medical Center - Orthopaedics, Baltimore, MD, USA
| | - Vincent Y Ng
- University of Maryland Medical Center - Orthopaedics, 110 S. Paca St, 6th Floor, Baltimore, 21201, MD, USA
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Aurégan JC, Pietton R, Bégué T, Anract P, Biau D. Effect of anatomic site and irradiation on the rates of revision and infection of allograft-prosthesis composites after resection of a primary bone tumor: a meta-analysis. Arch Orthop Trauma Surg 2016; 136:1371-80. [PMID: 27515453 DOI: 10.1007/s00402-016-2549-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Allograft-prosthesis composite reconstruction after resection of a primary bone tumor may have theoretical advantages, such as restoration of bone stock and soft tissue attachments. However, the reported results of APC of different anatomical sites differ widely. We conducted a meta-analysis to estimate the revision and infection rates associated with allograft-prosthesis composite (APC) reconstructions after resection of a primary bone tumor. We looked for variables, such as anatomic sites and irradiation of the allograft, associated with these outcomes. MATERIALS AND METHODS We searched Medline, EMBASE, and Cochrane Library. The primary outcome was the revision rate, and the secondary outcome was the infection rate. Random effects meta-analyses of single proportions were used to estimate pooled rates of events. Meta-regression models were built to assess the effect of moderators on relevant both outcomes. RESULTS Thirty-one studies were included: 9 about acetabulum APC, 9 about proximal femur APC, 4 about proximal tibia APC, and 9 about proximal humerus APC. The revision rates ranged from 16 % (95 % CI 10-25 %) for proximal humerus to 38 % (95 % CI 26-52 %) for acetabulum, and were significantly different between anatomic sites (p = 0.028). The infection rates ranged from 8 % (95 % CI 4-16 %) for proximal humerus to 23 % (95 % CI 16-33 %) for proximal tibia and 23 % (95 % CI 15-35 %) acetabulum APCs, and were significantly different between anatomic sites (p = 0.008). Finally, we found that irradiation of the allograft was significantly associated with revision rates (p = 0.033) and infection rates (p < 0.001). CONCLUSIONS Results of an APC reconstruction after resection of a primary malignant bone tumor vary significantly between anatomic sites and after irradiation of the allograft.
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Affiliation(s)
- Jean-Charles Aurégan
- Department of Orthopedic Surgery and Traumatology, Antoine Béclère Hospital, AP-HP, Paris Sud University, 157 rue de la Porte de Trivaux, 92140, Clamart, France.
| | - Raphaël Pietton
- Department of Orthopedic Surgery and Traumatology, Antoine Béclère Hospital, AP-HP, Paris Sud University, 157 rue de la Porte de Trivaux, 92140, Clamart, France
| | - Thierry Bégué
- Department of Orthopedic Surgery and Traumatology, Antoine Béclère Hospital, AP-HP, Paris Sud University, 157 rue de la Porte de Trivaux, 92140, Clamart, France
| | - Philippe Anract
- Department of Orthopedic Surgery and Traumatology, Cochin Teaching Hospital, AP-HP, Paris Descartes University, INSERM U1153, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - David Biau
- Department of Orthopedic Surgery and Traumatology, Cochin Teaching Hospital, AP-HP, Paris Descartes University, INSERM U1153, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France
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22
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King JJ, Nystrom LM, Reimer NB, Gibbs CP, Scarborough MT, Wright TW. Allograft-prosthetic composite reverse total shoulder arthroplasty for reconstruction of proximal humerus tumor resections. J Shoulder Elbow Surg 2016; 25:45-54. [PMID: 26256013 DOI: 10.1016/j.jse.2015.06.021] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 06/12/2015] [Accepted: 06/22/2015] [Indexed: 02/01/2023]
Abstract
BACKGROUND Proximal humerus reconstructions after resection of tumors are challenging. Early success of the reverse shoulder arthroplasty for reconstructions has recently been reported. The reverse allograft-prosthetic composite offers the advantage of improved glenohumeral stability compared with hemiarthroplasty for proximal humeral reconstructions as it uses the deltoid for stability. METHODS This article describes the technique for treating proximal humeral tumors, including preoperative planning, biopsy principles, resection pearls, soft tissue tensioning, and specifics about reconstruction using the reverse allograft-prosthetic composite. Two cases are presented along with the functional outcomes with use of this technique. Biomechanical considerations during reconstruction are reviewed, including techniques to improve the deltoid compression force. RESULTS Reported instability rates are less with reverse shoulder arthroplasty reconstruction as opposed to hemiarthroplasty or total shoulder arthroplasty reconstructions of tumor resections. Reported functional outcomes are promising for the reverse allograft-prosthetic composite reconstructions, although complications are reported. CONCLUSION Reverse allograft-prosthetic composites are a promising option for proximal humeral reconstructions, although nonunion of the allograft-host bone junction continues to be a challenge for this technique.
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Affiliation(s)
- Joseph J King
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Lukas M Nystrom
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Chicago, Maywood, IL, USA
| | | | - C Parker Gibbs
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Mark T Scarborough
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL, USA.
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23
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Lozano-Calderón SA, Chen N. Proximal humerus allograft prosthetic composites: technique, outcomes, and pearls and pitfalls. Curr Rev Musculoskelet Med 2015; 8:324-33. [PMID: 26420311 PMCID: PMC4630233 DOI: 10.1007/s12178-015-9306-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The proximal humerus is the second most common location of primary bone sarcomas and a frequent location of benign locally aggressive primary osseous tumors. In contrast to other locations, tumors in this region impose significant challenges for local control and reconstruction. This is due to glenohumeral joint anatomic characteristics such as lack of intrinsic stability and dependence on dynamic and static stabilizers. In addition, the close proximity of the axillary nerve and axillary vascular bundle places these at risk of resection when attaining local control. Allograft prosthetic composites (APCs) of the proximal humerus are one of the methods for mobile reconstruction. This modality presents lower fracture rates when compared to osteoarticular allografts and lower rates of subluxation and instability than endoprosthesis. Recent literature documents a trend for superior functional outcome at comparable complication rates. APC reconstruction is an important tool in the orthopedic oncologist armamentarium.
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Affiliation(s)
- Santiago A Lozano-Calderón
- Department of Orthopaedic Surgery, Musculoskeletal Oncology Service, Beth Israel Deaconess Medical Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Neal Chen
- Department of Orthopaedic Surgery, Hand and Upper Extremity Service Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Lun DX, Hu YC, Huang HC. Management of great vessels and nerves in limb-salvage surgery for bone and soft tissue tumors. Orthop Surg 2013; 5:233-8. [PMID: 24254445 DOI: 10.1111/os.12066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 08/25/2013] [Indexed: 01/13/2023] Open
Abstract
In recent years, limb-salvage surgery has gradually replaced amputations and become one of the main treatment strategies for patients with bone and soft tissue tumors of the extremities. The goals of tumor resection in limb-salvage surgery are to reduce the recurrence rate and preserve as much limb function as possible. However, depending on the size and specific location of the tumor, large neurovascular bundles may be involved. In addition, management of large nerves and vessels can make wide marginal resection more difficult. Sites where these problems commonly arise include the sciatic and tibial common peroneal nerve, artery and vein in the lower limbs.
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Affiliation(s)
- Deng-xing Lun
- Department of Spine Surgery, Weifang People's Hospital, Weifang City, Shandong Province, China
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