Coonrad-Morrey total elbow arthroplasty for tumours of the distal humerus and elbow

Reconstruction of the elbow with distal humerus endoprosthetic replacement after tumor resection: a systematic review of the literature and institutional case series

BACKGROUND

Distal humerus replacement (DHR) is a modular endoprosthesis mainly used for bone reconstruction after resection of primary or metastatic bone lesions. Studies on DHR failure rates and postoperative functional outcomes are scarce. We sought to assess implant survival, modes of failure, and functional outcomes in patients undergoing DHR for oncologic indications.

METHODS

A systematic review of the PubMed and Embase databases was performed. PRISMA guidelines were followed for this manuscript. Our study was registered on PROSPERO (457,260). Quality appraisal of included studies was conducted using the STROBE checklist. Prosthetic failure was assessed using the Henderson classification for megaprosthetic failures. We additionally performed a retrospective review of patients treated with a DHR for oncologic indications at a large tertiary care academic center. Weighted means were calculated to pool data.

RESULTS

Eleven studies with a total of 162 patients met the inclusion criteria. Mean follow-up was 3.7 years (range, 1.66-8 years). Henderson type 2 failures (aseptic loosening) were the most common mode of failure, occurring in 12% of cases (range, 0%-33%). Five-year implant survival was 72% (range, 49%-93.7%). Mean postoperative Musculoskeletal Tumor Society (MSTS) score was 81.1 (range, 74-84.3). In our institutional case series, 2 out of 5 patients had DHR revision for periprosthetic fracture and aseptic loosening at 16 and 27 months after surgery, respectively.

CONCLUSIONS

Distal humerus replacement is a successful reconstruction strategy for tumors of the distal humerus, with high implant survival and good to excellent functional outcomes.

Functional and Rehabilitative Outcomes of Patients Affected by Bone Cancer of the Upper Limb Treated with MUTARS Prosthesis: A Narrative Review

Megaprostheses are well-known, reliable, and effective reconstruction prostheses used in oncologic surgery for limb salvage in patients affected by primary or metastatic bone tumors. Rehabilitation plays a major role after MUTARS replacement, with the aim of improving function after surgery and maintaining the highest possible quality of life. Only a few studies have been published about the use of megaprostheses for the upper limb. The aim of this narrative review is to describe the results of functional and rehabilitative outcomes of patients affected by bone primary or metastatic bone cancer of the upper limb and surgically treated with MUTARS prostheses. A comprehensive search was conducted on PubMed and Scopus using the following MESH terms: "Mutars", "Megaprosthesis", "bone", "tumors", "metastasis", "upper limb", "rehabilitation", "outcome", "quality of life", and 10 studies were included. The most frequent oncological pathology was found to be metastases of the proximal humerus treated with modular endoprosthesis or modular reverse implants. Outcome measures used were ROM, MSTS, ASES, DASH, Constant-Murley score, Enneking score, VAS, MEP, TESS, and WOSI. Reconstruction of the proximal humerus with the MUTARS system seemed to be a valid treatment option after bone tumor resection. Rehabilitation after MUTARS surgery is very relevant, but currently, functional and rehabilitative outcomes are inadequately represented in the literature. Hence, further studies are needed to define standardized rehabilitation protocols after oncological orthopedic surgery that can be applied routinely in clinical practice.

Outcomes of management of primary benign aggressive or malignant bone tumors around the elbow by limb-salvage surgery

PURPOSE

Bone tumors around the elbow are rare, with frequently delayed diagnosis. The current study aimed to assess the functional and oncological outcomes of limb salvage surgery for primary benign aggressive or malignant bone tumors around the elbow.

METHODS

We conducted a retrospective review of patients with primary aggressive benign and malignant bone tumors around the elbow treated with limb salvage surgery between 1995 and 2020 at a single musculoskeletal oncology center. The minimum follow-up period was 24 months. Functional results were assessed using the Musculoskeletal Tumor Society (MSTS) scoring system at the last follow-up visit. Local recurrence, chest metastasis, and complications were recorded.

RESULTS

This study included 30 patients, 19 males and 11 females, with a mean age of 25.4 ± 14.2 years. The tumor location was the distal humerus (n = 21), proximal radius (n = 5), and proximal ulna (n = 4). Reconstruction was done by elbow fusion using fibular graft (n = 10), mobile endoprosthesis (n = 9), excision arthroplasty (n = 7), and extracorporeal freezing and reimplantation (n = 4). The mean follow-up period was 36.2 ± 21.3 months. The median follow-up MSTS score was 27 [Interquartile range (IQR): 26-30]. Skeletally immature patients had a significantly higher MSTS score. The rate of postoperative complications was 26.7%.

CONCLUSION

Limb salvage surgery with different reconstructive options for benign aggressive and malignant bone tumors around the elbow can achieve good functional and oncological outcomes.

LEVEL OF EVIDENCE

Level IV.

Outcomes of Humeral Allograft-Prosthetic Composites with Plate Fixation in Revision Total Elbow Arthroplasty

Background

Traditionally, the reconstruction of severe distal humeral bone loss at the time of revision total elbow arthroplasty (TEA) has used allograft-prosthetic composites (APCs) stabilized with cerclage wires or cables. We have migrated to plate fixation when revision TEA using a humeral APC is performed. This study shows the outcomes of patients treated with a humeral APC with plate fixation during revision TEA.

Methods

Between 2009 and 2019, 41 humeral APCs with plate fixation of distal humeral allograft to the native humerus were performed in the setting of revision TEA. There were 12 male patients (29%) and 29 female patients (71%), with a mean age of 63 years (range, 41 to 87 years). The mean allograft length was 12 cm. All elbows had a minimum follow-up of 2 years (mean follow-up, 3.3 years). Patients were evaluated for visual analog scale pain scores, range of motion, the ability to perform select activities of daily living, and the Mayo Elbow Performance Score (MEPS). Outcomes including reoperations, complications, and revisions were noted. The most recent radiographs were evaluated for union at the allograft-host interface, failure of the plate-and-screw construct, or component loosening.

Results

The mean postoperative flexion was 124° (range, 60° to 150°) and the mean postoperative extension was 26° (range, 0° to 90°); the mean arc of motion was 99° (range, 30° to 150°). The mean MEPS was 58 points (range, 10 to 100 points). Two surgical procedures were complicated by neurologic deficits. The overall reoperation rate was 14 (34%) of 41. Of the 33 patients with complete radiographic follow-up, 12 (36%) had evidence of nonunion at the allograft-host interface with humeral component loosening, 1 (3%) had evidence of partial union, and 1 (3%) had ulnar stem loosening.

Conclusions

Revision TEA with a humeral APC using compression plating was successful in approximately two-thirds of the elbows. Further refinement of surgical techniques is needed to improve union rates in these complex cases.

Level of Evidence

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

Elbow hemiarthroplasty with a 3D-printed prosthesis for distal humeral bone defects after tumor excision: a case report

INTRODUCTION

The distal humerus is a rare site for primary and metastatic bone tumors. Due to the scarcity of cases and lack of standardized surgical strategies, it is often difficult for surgeons to choose the right choice. The application of a 3D-printed prosthesis with hemiarthroplasty for the treatment of the distal humerus after tumor resection can be a very effective option.

CASE PRESENTATION

We present a clinical case of a 3D-printed distal humeral prosthesis for the treatment of bone defects caused by metastatic bone tumors. The preoperative evaluation was aggressively performed, and the decision was made to distal humeral hemiarthroplasty (DHH) after wide resection of the tumor segment bone. Processing of the Digital Imaging and Communications in Medicine (DICOM) data from CT scans performed after mirror conversion using CT data of the contralateral humerus, we designed a 3D-printed distal humeral prosthesis with hemiarthroplasty. After reconstruction of bone and surrounding soft tissue by the 3D-printed prosthesis combined with the LARS ligament and regular follow-up for 12 months, the patient had an MSTS-93 score of 29 and an MEP of 100, which reached a good level, and the patient was fully competent in normal daily activities.

CONCLUSIONS

Our results show that the 3D-printed modular prosthesis with hemiarthroplasty is a very effective option for cases of large elbow bone defects due to primary bone tumors or metastatic disease. However, careful preoperative preparation is required for the best outcome. Careful preoperative preparation and long-term follow-up are essential for the best outcome.

Extended deltopectoral approach for revision total elbow arthroplasty requiring humeral allograft-prosthetic composites in patients with severely compromised proximal humerus bone stock

Background

Severe humeral bone loss in the setting of failed total elbow arthroplasty (TEA) poses a particularly challenging reconstructive problem. The objective of this study was to review the rationale, indications, contraindications, and detailed surgical technique for using an extended anterior deltopectoral approach to perform a revision TEA when substantially long allografts are required in the presence of severely compromised proximal humerus bone stock.

Methods

The authors developed this exposure and reconstructive strategy for failed elbow arthroplasties where the remaining segment of proximal humerus is extremely short, which makes adequate plate fixation of an allograft-prosthetic composite (APC) to the native bone extremely challenging. From an anterior deltopectoral approach, it is possible to use dedicated long, precontoured proximal humerus locking plates to maximize fixation in any remaining proximal humerus. This exposure still makes it possible to provide adequate access to the coupling mechanism of the humeral and ulnar components for implantation of a linked elbow arthroplasty. This exposure also allows for adequate judgment of humeral length and rotation.

Pitfalls and Challenges

Crucial steps in the surgery include extending the dissection past the elbow flexion crease such that one can obtain circumferential exposure of the distal humerus. It is also important to couple the humeral and ulnar components prior to committing to the length of the APC. Special attention must be paid to gauge appropriate APC rotation and length for proper soft tissue tension. When performing fixation of the proximal humeral plate, screw purchase must be maximized in both the remaining native proximal humerus and the APC. Compression across the allograft-host interface is paramount for healing to occur.

Conclusion

An extended anterior deltopectoral approach to perform a revision TEA when very long APCs are required is a viable option to restore humeral bone stock and regain humeral stem fixation in the setting of failed TEA with extensive humeral bone loss.

Elbow hemiarthroplasty with a 3D-printed megaprosthesis for defects of the distal humerus or proximal ulna after tumour resection : a preliminary report

AIMS

The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection.

METHODS

From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients.

RESULTS

Preparation of the prosthesis was a mean of 8.0 days (SD 1.5), during which time no patients experienced tumour progression. The mean operating time and intraoperative blood loss were 158.1 minutes (SD 67.6) and 176.9 ml (SD 187.8), respectively. All of the prostheses were implanted successfully. During a mean follow-up of 25.7 months (SD 7.8), no patients died, but four had complications (two superficial wound problems, one temporary palsy of radial nerve, and one dislocation). No aseptic loosening, structural failure, infection, heterotopic ossification, or degenerative arthritis was seen in this study. The mean flexion of the elbow was 119.6° (SD 15.9°) and the mean extension lag was 11.9° (SD 13.8°). The mean Musculoskeletal Tumor Society 93 score and Mayo Elbow Performance Score were 28.4 (SD 0.9) and 97.7 (SD 4.4), respectively.

CONCLUSION

The custom-made, 3D-printed megaprosthesis with hemiarthroplasty is a feasible option for functional reconstruction after resection of a tumour in the distal humerus or proximal ulna. Cite this article: Bone Joint J 2022;104-B(6):747-757.

Total elbow arthroplasty using an augmented reality-assisted surgical technique

BACKGROUND

Precision placement of implants in total elbow arthroplasty (TEA) using conventional surgical techniques can be difficult and riddled with errors. Modern technologies such as augmented reality (AR) and 3-dimensional (3D) printing have already found useful applications in many fields of medicine. We proposed a cutting-edge surgical technique, augmented reality total elbow arthroplasty (ARTEA), that uses AR and 3D printing to provide 3D information for intuitive preoperative planning. The purpose of this study was to evaluate the accuracy of humeral and ulnar component placement using ARTEA.

METHODS

Twelve upper extremities from human frozen cadavers were used for experiments performed in this study. We scanned the extremities via computed tomography prior to performing TEA to plan placement sites using computer simulations. The ARTEA technique was used to perform TEA surgery on 6 of the extremities, whereas conventional (non-ARTEA) techniques were used on the other 6 extremities. Computed tomography scanning was repeated after TEA completion, and the error between the planned and actual placements of humeral and ulnar components was calculated and compared.

RESULTS

For humeral component placement, the mean positional error ± standard deviation of ARTEA vs. non-ARTEA was 1.4° ± 0.6° vs. 4.4° ± 0.9° in total rotation (P = .002) and 1.5 ± 0.6 mm vs. 8.6 ± 1.3 mm in total translation (P = .002). For ulnar component placement, the mean positional error ± standard deviation of ARTEA vs. non-ARTEA was 5.5° ± 3.1° vs. 19.5° ± 9.8° in total rotation (P = .004) and 1.5 ± 0.4 mm vs. 6.9 ± 1.6 mm in total translation (P = .002). Both rotational accuracy and translational accuracy were greater for joint components replaced using the ARTEA technique compared with the non-ARTEA technique (P < .05).

CONCLUSION

Compared with conventional surgical techniques, ARTEA had greater accuracy in prosthetic implant placement when used to perform TEA.

Surgical phocomelia or phoco-reduction as a method of limb salvage for sarcomas of the upper limb: A suitable alternative to amputation

BACKGROUND

Reconstruction following resection of sarcomas of the upper extremity with methods described in the prevalent literature may not be possible in few selected cases. We describe surgical phocomelia or phoco-reduction as a method of limb salvage in such cases of extensive sarcomas of the upper limb with its functional and oncological outcomes.

METHODS

Evaluation of functional and oncological outcomes was performed for 11 patients who underwent surgical phocomelia or phoco-reduction for extensive sarcomas of the upper limb between 2010 and 2019.

RESULTS

The mean follow-up period in the study was 27.8 months. Five patients required a segmental resection including the entire humerus while six patients underwent segmental resection around the elbow with a mean resection length of 21.5 cm. Mean Musculoskeletal Tumor Society 93 score was 22 depicting a good functional outcome. Mean handgrip strength on the operated side was 62% of the contralateral side with preservation of useful hand function. Meantime to humeroulnar union was 6.7 months. Radial nerve palsy and implant failure occurred in one patient each. No patient developed local recurrence while three patients died of metastasis.

CONCLUSION

Surgical phocomelia is a prudent alternative to severely incapacitating amputations in situations where other reconstruction methods are not feasible.

Joint replacement surgery for elbow tumours: a systematic review of outcomes

BACKGROUND

Tumour resection followed by joint reconstruction is a surgical option in the appropriate patient. The evidence for such reconstructive surgery of the elbow joint is limited. The aim of this study is to review the literature to evaluate the outcomes of joint replacement surgery in tumours of the elbow.

METHODS

A systematic review of PUBMED and EMBASE databases was conducted. Case series and comparative studies reporting results after total elbow arthroplasty, modular endo-prosthetic replacement and custom prosthesis were eligible for inclusion.

RESULTS

Eleven eligible studies were identified (n = 134). At mean follow-up of 44 months, the overall revision rate was 14% and complication rate was 28%. The mean Mayo Elbow Performance Score was 75, with 56% of patients reporting good or excellent outcomes. The mean post-operative range of motion was 97°.

DISCUSSION

Elbow prosthesis reconstruction after tumour resection can provide good functional outcomes at mid-term follow-up. The complication and revision rates are comparable to other indications for elbow replacement surgery. Further prospective studies are required to compare outcomes between different elbow arthroplasty options after tumour resection.

Short-term outcomes of the Nexel total elbow arthroplasty

BACKGROUND

Third-generation total elbow arthroplasties (TEAs) have shown better mechanical characteristics than older designs. However, these results remain purely mechanical and lack clinical evidence. The purpose of this study was to evaluate clinical and radiographic outcomes of the new-generation semiconstrained Nexel TEA performed at our center.

MATERIALS AND METHODS

Between 2015 and 2017, 9 Nexel TEAs were implanted in 9 patients (mean age 61 years, range 38-71). Indication for further surgery, range of motion, mean Mayo Elbow Performance Score (MEPS), Subjective Elbow Value (SEV), radiolucency lines, outcome measures that included implant survival, complications, and revisions were assessed.

RESULTS

The mean follow-up was 28 months (5-46 months). Average range of motion significantly improved from pre- to postoperation, with flexion from 120° (70°-140°) to 140° (130°-155°) and supination from 60° (0°-80°) to 80° (80°). Average MEPS improved from 33 (5-45) to 85 points (30-95). During the study period, 5 elbows (56%) experienced complications and 2 (22%) underwent revision. Aseptic humeral loosening was the main indication for revision. The survivorship rate without revision was 75% at 45 months.

CONCLUSIONS

The short-term clinical results of the Nexel TEA are satisfactory. However, an unusually high rate of complications and revisions was observed, mainly at the humeral component. Further research with longer follow-up and more patients included are needed to validate this new prosthesis.

Total elbow arthroplasty for tumors of the distal humerus and elbow

INTRODUCTION

The elbow is a rare location for primary and metastatic tumors in the upper extremity. The goal of reconstruction is to provide painless motion and stability for hand function. Total elbow arthroplasty (TEA) is commonly utilized, with either off-the-self components, modular segmental endoprosthesis, or allograft-prosthesis composites (APC). The purpose of this study was to analyze and compare commonly utilized elbow reconstructions and report outcomes of (1) patient function and (2) implant survival and complications.

METHODS

We reviewed 33 patients (18 females and 15 males) undergoing elbow arthroplasty for reconstruction of an underlying oncologic process including linked TEA (n = 22, 67%), APC (n = 9, 27%), and endoprosthesis (n = 2, 6%). The most common indication was metastatic disease (n = 17, 52%), with 24 patients (73%) presenting with a pathologic fracture.

RESULTS

Five-year implant survival was following elbow reconstruction was 88%. The mean most recent Mayo Elbow Performance Score and Musculoskeletal Tumor Society Score were 84 ± 18 and 78 ± 15%. Postoperative complications occurred in 15 elbows (45%), most commonly periprosthetic fracture (n = 5, 15%), leading to reoperation in six elbows (18%).

CONCLUSION

Although elbow arthroplasty is associated with a high incidence of complications, it provides a stable platform for upper extremity function in patients with oncologic processes of the elbow.

Triceps Insufficiency After Total Elbow Arthroplasty: A Systematic Review

BACKGROUND

The incidence of triceps insufficiency after total elbow arthroplasty (TEA) varies in the literature, and a consensus on treatment strategy is lacking. We review the incidence, the risk factors, the clinical presentation, and the diagnosis and treatment of triceps insufficiency after TEA. Based on this information, we have formulated recommendations for clinical practice.

METHODS

We performed a systematic review of the literature from January 2003 to April 2020 to identify studies that investigated triceps function following TEA by searching the PubMed, Cochrane, and Embase databases. Eligible studies (1) reported on triceps function following primary or revision TEA for every indication, regardless of technique (e.g., bone grafts), (2) included ≥6 adult patients, (3) had the full-text article available, and (4) had a minimum follow-up of 1 year.

RESULTS

Eighty studies with a total of 4,825 TEAs were included. The quality was low in 15 studies, moderate in 64 studies, and high in 1 study. The mean incidence of triceps insufficiency was 4.5%. The rates were highest in patients after revision TEA (22%), in those with posttraumatic arthritis as an indication for surgery (10.2%), and after a triceps-reflecting approach (4.9%). Most studies used the Medical Research Council scale to score triceps function, although cutoff points and the definition of triceps insufficiency differed among studies. Surgical treatment showed favorable results with anconeus tendon transfer and Achilles allograft repair when compared with direct repair.

CONCLUSIONS

The incidence of triceps insufficiency varies greatly, probably due to a lack of consensus on the definition of the term. Therefore, we recommend the guidelines for clinical practice that are presented in this article. These guidelines assist clinicians in providing the best possible treatment strategy for their patients and help researchers optimize their future study designs in order to compare outcomes.

LEVEL OF EVIDENCE

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

Humeral amputation following total elbow arthroplasty

PURPOSE

Total elbow arthroplasty (TEA) is associated with a relatively high complication rate, and exceptionally catastrophic complications might lead to amputation. The purpose of this study was to determine the incidence and aetiology of amputation performed at our institution in upper extremity limbs with a prior TEA.

METHODS

Between 1973 and 2018, 1906 consecutive TEAs were performed at our institution. Upper extremity amputation was performed in seven (0.36%) elbows with five transhumeral amputations and two shoulder disarticulations. The group consisted of five females and two males with a mean age of 64 years (range, 37-80). The index TEA had been performed for rheumatoid arthritis (n = 2), rheumatoid arthritis with acute fracture (n = 2), radiation associated nonunion (n = 2), and metastatic cancer (n = 1). Mean follow-up after amputation was three years (range, 3 months-5 years).

RESULTS

Mean time between amputation and TEA was 5 years (range, 2 months-13 years). The indications for amputation included uncontrolled deep infection in six (86%) elbows and tumor recurrence in one (14%) elbow. Only one elbow (14%) was fitted with a prosthesis. Six (86%) patients died at a mean of three years (range, 3 months-5 years) after amputation.

CONCLUSION

The results of this study highlight a low incidence of amputation after TEA. Most amputations were the direct result of TEA complications, with infection being the most common cause of amputation. Outcomes after amputation are concerning, with poor overall survival and few patients being fit for a prosthesis.

Indications and outcome in total elbow arthroplasty: A systematic review

BACKGROUND

Total elbow arthroplasty (TEA) is the established treatment for end-stage rheumatoid arthritis but improved surgical techniques have resulted in expanded indications. The aim of this study is to review the literature to evaluate the evolution of surgical indications for TEA.

METHODS

A systematic review of PubMed and EMBASE databases was conducted. Case series and comparative studies reporting results after three types of primary TEA were eligible for inclusion.

RESULTS

Forty-nine eligible studies were identified (n = 1995). The number of TEA cases published annually increased from 6 cases in 1980 to 135 cases in 2008. The commonest indication for TEA throughout the review period was rheumatoid arthritis but its annual proportion reduced from 77% to 50%. The mean Mayo Elbow Performance Score significantly improved for all indications. Three comparative studies reported statistically improved functional outcomes in rheumatoid arthritis over the trauma sequelae group. Complication and revision rates varied; rheumatoid arthritis 5.2-30.9% and 11-13%, acute fracture 0-50% and 10-11%, trauma sequelae 14.2-50% and 0-30%, osteoarthritis 50% and 11%, respectively.

DISCUSSION

TEA can provide functional improvements in inflammatory arthritis, acute fractures, trauma sequelae and miscellaneous indications. Long-term TEA survivorship appears satisfactory in rheumatoid arthritis and fracture cases; however, further research into alternative surgical indications is still required.

Endoprosthetic Reconstruction of the Upper Extremity in Oncologic Surgery

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

Radial Neck-to-Humerus Transposition for Elbow Reconstruction Following Oncologic Resection of the Proximal Ulna: A Report of Two Cases

CASE

Two young adult (aged 25 and 21 years) patients presented with sarcomas of the proximal ulna. To achieve an oncological margin, the proximal ulna required resection. Owing to the complex biomechanics of the elbow joint, reconstructive options are limited and have a high complication rate. The elbow was reconstructed with a transposition of the radial neck to the trochlea of the humerus in both patients. At over 2 years of follow-up, both patients have a stable and functional elbow.

CONCLUSIONS

Transposition of the radial neck to the trochlea of the humerus provides a biological reconstruction in this complex problem.

Megaprosthetic replacement of the distal humerus: still a challenge in limb salvage

BACKGROUND

The distal humerus is a rare location of bone tumors. Because of the complexity of the elbow joint, poor soft-tissue coverage, and proximity of nerves and vessels, resection and endoprosthetic reconstruction are demanding.

METHODS

This retrospective study evaluated the clinical results after distal humeral resection and megaprosthetic reconstruction in 12 patients with an average age of 46 years. All patient files were reviewed for clinical information, and postoperative function and patients' contentment were assessed using the Musculoskeletal Tumor Society score.

RESULTS

The predominant diagnoses were bone and soft-tissue sarcoma (n = 6), giant cell tumor (n = 2), and renal cell carcinoma metastasis (n = 2). Local recurrence was the reason for secondary amputation in all cases (n = 3). The prosthetic survival rate after surgery was 82% at 2 years and 64% at 5 years. Reconstruction failure was mainly caused by aseptic loosening of the humeral stem, occurring in 27% (n = 3), followed by aseptic loosening of the ulnar stem in 9% (n = 1) and periprosthetic infection in 9% (n = 1). The mean Musculoskeletal Tumor Society score was 24 points (range, 20-30 points). An extension lag of more than 10° was noted in 6 patients (55%).

CONCLUSION

Our results suggest that limb salvage with a distal humeral replacement can achieve good functional results in most patients, although the complication rate with special emphasis on the loosening rate of the humeral stem is high. However, limb salvage was not achieved in 27% of patients because of local recurrence.

Bone tumours around the elbow: a rare entity

Bone tumours around the elbow are rare. Even nowadays diagnostic dilemmas and delays are common. During recent decades the management and prognosis of patients with elbow bone tumours has improved significantly.Benign tumours can be treated using minimally invasive procedures, whereas malignant ones require a multidisciplinary team approach based on an adjuvant therapeutic regimen of chemotherapy, radiotherapy and limb salvage procedures.This article reviews the most commonly encountered elbow bone tumours and their management. Cite this article: EFORT Open Rev 2019;4:133-142. DOI: 10.1302/2058-5241.4.180086.

Compressive osseointegration endoprosthesis for massive bone loss in the upper extremity: surgical technique

Background

Reconstruction of large segments of bone loss can be very difficult. The use of a prestressed ingrowth implant can offer an attractive surgical option in these challenging cases.

Methods

This report describes the surgical technique in depth, combining the experience of the authors. Nuances of the technique are emphasized.

Results

Although published reports are uncommon, long-term restoration of extremity function is possible with this technology.

Conclusions

The use of compressive osseointegration endoprostheses is not yet widespread in the upper extremity, but this technology adds to the host of surgical options for managing massive bone loss and difficult revision surgery.

Modular megaprosthesis reconstruction for oncological and non-oncological resection of the elbow joint

BACKGROUND

Reconstruction of large bone defects around the elbow joint is surgically demanding due to sparse soft tissue coverage, complex biomechanics and the close proximity to neurovascular structures. Modular megaprostheses are established reconstruction tools for the elbow, but only small case series have been reported in the literature.

METHODS

Thirty-six patients who underwent reconstruction of the elbow joint with a modular megaprosthesis were reviewed retrospectively. In 31 patients (86.1%), elbow replacement was performed after resection of a bone tumour, whereas five non-oncological patients (13.9%) underwent surgery because of a previous failed elbow reconstruction. Functional outcome, rate of complications and oncological results were considered as primary endpoints.

RESULTS

The mean follow-up was 25 months. The average achieved Mayo Elbow Performance Score (MEPS) was 77.08 (range 40-95) and the average Musculoskeletal Tumor Society (MSTS) score was 22.9 (range 8-30). Six complications (16.7%) were observed: two radial palsies, one temporary radial nerve dysfunction, one ulnar palsy, one disassembling of the articular prosthesis component and one deep infection necessitating the only implant removal. The overall 5-year survival rate of the patients was poor (25.1%) because of rapid systemic progression of the oncological disease in patients with metastatic lesion. However, the 5-year survival rate of the implant was very satisfactory (93%).

CONCLUSIONS

Modular megaprosthesis is a reliable and effective reconstruction tool in large bone defects around the elbow joint. The complication rates are lower than seen in osteoarticular allografts and allograft-prosthesis composites while the functional outcome is equal. In palliative situations with metastatic disease involving the elbow, modular megaprosthesis enables rapid recovery and pain relief and preserves elbow function.

Total elbow arthroplasty for primary and metastatic tumor

BACKGROUND

Prostheses can be used in elbow reconstruction in both primary and metastatic lesions. Several authors have reported their experience with different types of implant, but not with modular prostheses.

HYPOTHESIS

Limb salvage using an elbow prosthesis is effective in obtaining good functional results and reliable local tumor control.

MATERIAL AND METHODS

Forty-seven patients treated at the Rizzoli Institute for elbow neoplasm from 1990 to 2012 were evaluated. There were 30 primary tumors (64%), 24 bone tumors and 6 soft tissue sarcomas, and 17 bone metastases. Elbow reconstruction used a modular prosthesis in 25 patients and a standard prosthesis in 22. Reconstruction was primary in 30 patients and secondary in 17.

RESULTS

At last control, 15 (32%) were dead of disease (DOD) at a mean follow-up of 35 months, 12 (25%) were alive with disease (AWD) at a mean follow-up of 29 months, 19 (40%) showed no evidence of disease (NED) at a mean follow-up of 80 months. Early complications were related to unexpected neurological damage, observed in 12 patients (25%): in 5 cases the deficit resolved in a mean 6 months; in the others, no or only partial recovery was observed. Two implants (4%) developed infection: 1 was treated with antibiotic therapy, and the other required implant revision. One implant showing cement extrusion was revised. In 3 patients (6%) radiography showed a radiolucent halo around the stem (2 humeral, 1 ulnar); no measures were taken, as the patients were completely asymptomatic at every follow-up. In 3 patients (6%) partial resorption of the allograft was observed on X-ray, but remained unchanged at last follow-up, without pain or functional impairment. Seven local recurrences (15%) were observed, at a mean of 16 months after surgery; 5 were treated by resection and/or radiotherapy, and 2 by amputation. Mean functional scores on MEPS and MSTS were respectively 84% and 22/30 (73%).

CONCLUSIONS

Elbow prostheses provided better function in primary than in metastatic tumor. Elbow prosthesis reconstruction after tumor resection is a viable option both for primary and secondary bone neoplasms.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

IV, retrospective study.

Pre-operative templating in total elbow arthroplasty: not useful

PURPOSE

Total elbow arthroplasty (TEA) is a definitive surgical procedure for treating rheumatoid arthritis and (posttraumatic) osteoarthritis of the elbow and is also useful in comminuted elbow fractures. Pre-operative digital templating may theoretically improve the surgical implantation of TEA, but reliability and predictive values of templating are unknown. The aim of this study was to determine the intra- and inter-observer reliability and the validity of pre-operative digital templating for TEA.

MATERIALS AND METHODS

All pre-operative plain anterior-posterior and lateral calibrated elbow radiographs from patients who underwent TEA in our center from 2008 to June 2014 were reviewed. Two independent assessors templated implant sizes using digital overlays twice. Intra- and inter-observer reliability were evaluated with Cohen's kappa. Two experienced elbow surgeons reviewed post-operative radiographs for evaluation. The predictive value of templating was the percentage of the correctly templated sizes, with the optimal implant size as the reference standard.

RESULTS

Twenty-one cases were included. Intra-observer reliability was substantial to almost perfect (κ = 0.61 and κ = 0.90) for humeral implants, moderate to substantial (κ = 0.54 and κ = 0.73) for ulnar implants. Inter-observer reliability was substantial (κ = 0.67) for humeral implants and moderate (κ = 0.60) for ulnar implants. The predictive value was 53 % for both implants.

CONCLUSIONS

Pre-operative digital templating for TEA is a reliable method to plan implant sizes. However, the predictive value is low.

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.

Advances in segmental endoprosthetic reconstruction for extremity tumors: a review of contemporary designs and techniques

BACKGROUND

Improved understanding and advances in treatment regimens have led to increased longevity among patients diagnosed with extremity soft tissue sarcomas. Limb salvage techniques and implants have improved and continue to evolve to accommodate the increasing demands and survival of these patients.

METHODS

The current report is a review of the literature for recent advancements in techniques, implant design, and outcomes in the field of limb salvage therapy using segmental megaprostheses for the treatment of extremity sarcomas. We report on our experience in this field utilizing a classification system of failure mechanisms to outline to discuss current controversies in management.

RESULTS

Five mechanisms of failure have been identified: soft-tissue failure, aseptic loosening, structural failure, infection, and tumor progression. Infection was the most common mode of failure in our series, accounting for 34% of cases. Soft-tissue failure occurred most commonly in the joints that depend heavily on periarticular muscles and ligaments for stability due to their high degree of functional range of motion. We observed a 28% soft-tissue failure rate about the shoulder and hip, aseptic loosening accounted for 19% of implant failures, and structural failure was seen in 17% of cases. Seventeen percent of cases failed due to tumor progression, an etiology that is defined by biological factors, surgical technique, and adjuvant therapies.

CONCLUSIONS

Surgical techniques and megaprosthesis designs are constantly changing in order to meet the challenge of increasing functional demands and longevity in this unique patient population. A classification system defined by treatment failure etiologies provides the framework for discussion of current controversies in limb salvage therapy as well as a guide for advancement and potential solutions in this challenging arena.

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.

Use of endoprosthetic diaphyseal replacement: a novel approach to management of extensive metastatic tumor of the midshaft radius

We report the first use of an endoprosthetic diaphyseal replacement after the excision of a midshaft radial tumor. We present a rare case of a solitary midshaft radial metastasis in a 72-year-old gentleman who was treated 8 years earlier for primary renal cell carcinoma by radical nephrectomy. Follow-up for this patient was 25 months after implant insertion and at the latest review was pain-free. Functional scores for the elbow (using the Mayo Elbow Performance Score) and the wrist (using the Mayo Wrist Score) were 80 and 60, respectively, both out of 100. Use of a midshaft radial endoprosthesis provides a good functional outcome and symptom relief after extensive tumor resection, with regard to functional outcome and symptom relief.

Image-based navigation improves the positioning of the humeral component in total elbow arthroplasty

HYPOTHESIS

Implant alignment in total elbow arthroplasty (TEA) is a challenging and error-prone process using conventional techniques. Identification of the flexion-extension (FE) axis is further complicated for situations of bone loss. This study evaluated the accuracy of humeral component alignment in TEA. We hypothesized that an image-based navigation system would improve humeral component positioning, with navigational errors less than or approaching 2.0 mm and 2.0 degrees .

MATERIALS AND METHODS

Implantation of a modified commercial TEA humeral component was performed with and without navigation on 11 cadaveric distal humeri. Navigated alignment was based on positioning the humeral component with the aid of a computed tomography (CT)-based preoperative plan registered to landmarks on the distal humerus. Alignment was performed under 2 scenarios of bone quality: (1) an intact distal humerus, and (2) a distal humerus without articular landmarks.

RESULTS

Navigation significantly improved implant alignment accuracy (P < .001). Navigated implant alignment was 1.2 +/- 0.3 mm in translation and 1.3 degrees +/- 0.3 degrees in rotation for the intact scenario. For the bone loss scenario, navigated alignment error was 1.1 +/- 0.5 mm and 2.0 degrees +/- 1.3 degrees . Non-navigated alignment was 3.1 +/- 1.3 mm and 5.0 degrees +/- 3.8 degrees for the intact scenario and 3.0 +/- 1.6 mm and 12.2 degrees +/- 3.3 degrees for the bone loss scenario.

DISCUSSION

Image-based navigation improves the accuracy and reproducibility of humeral component placement in TEA. Implant alignment errors for the navigated alignments were below the target of 2.0 degrees and 2 mm that is considered standard for most navigation systems. Non-navigated implant alignment error was significantly greater for the bone loss scenario compared with the intact scenario.

CONCLUSIONS

Implant malalignment may increase the likelihood of early implant wear, instability, and loosening. Improved implant positioning will likely lead to fewer complications and greater prosthesis longevity.

Segmental resection and replantation have a role for selected advanced sarcomas in the upper limb

Although limb salvage surgery for primary sarcoma of the upper limb is a standard procedure, it often is technically challenging. We asked whether segmental resection and replantation would provide (1) local control and long-term survival and (2) useful limb function in patients who had advanced primary malignant and aggressive tumors of the upper limbs. We retrospectively reviewed six patients treated with this procedure when a wide resection around the tumor could not be achieved with other limb-salvage procedures. Diagnoses included osteosarcoma (two), Ewing's sarcoma (one), leiomyosarcoma (one), and giant cell tumor (two). Four patients had displaced pathologic fractures. Minimum followup was 40 months (mean, 164 months; range, 40-214 months). All but one patient remained disease-free; the patient with Ewing's sarcoma died from the disease 40 months after surgery. The average functional score at last followup was 20 points. The mean grasping and pinching power of the operative hand were 66% and 72% of the contralateral side, respectively. Two patients had complications: one had wound dehiscence that subsequently healed and one had radial nerve palsy that recovered spontaneously by 3 months. Segmental resection and replantation may have a role in selected cases for treatment of advanced primary sarcoma or aggressive giant cell tumor of the upper limb as partial limb salvage.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Custom-made prosthesis replacement for reconstruction of elbow after tumor resection

HYPOTHESIS

The options for reconstruction after excision of a tumor around the elbow are technically difficult and limited.

MATERIALS AND METHODS

We retrospectively reviewed 25 patients who underwent custom-made endoprosthetic reconstruction after tumor resection near the elbow between 1998 and 2007.

RESULTS

At final follow-up, 14 patients (56%) were alive, and 11 (44%) had died of their disease. Local recurrence was encountered in 4 patients (16%). Complications occurred in 6 patients (24%), including vascular injury, neurapraxia of the radial nerve, and aseptic loosening in 4. The average Musculoskeletal Tumor Society 93 score was 23.9 points, and the average Mayo Elbow Performance score was 82 points. Pain was relieved in all patients, although some limitations of lifting ability were reported. Ten patients had an arc of elbow motion of more than 100 degrees after reconstruction.

CONCLUSIONS

In most patients, local tumor resection and prosthetic reconstruction of the elbow can be done with oncologic safety, and provides good function with low rates of complications.

Role of an anterior flange on cortical strains through the distal humerus after total elbow arthroplasty with a latitude implant

PURPOSE

Anterior flanges have been added to the humeral components of some total elbow arthroplasty systems to improve load transfer to the humerus and thereby reduce stress shielding in an effort to decrease the incidence of loosening. Either a wedge of bone or bone cement is placed between the anterior surface of the humerus and the flange. The purpose of this study was to quantify the cortical strains in the humerus as a function of these implantation options.

METHODS

Five cadaveric distal humeri were fitted with bending strain gauges at 2 levels on the diaphysis and axial strain gauges at 1 level. Each specimen was subjected to cantilevered bending and axial compressive loads. Subsequently, a humeral prosthesis was inserted, and testing was repeated with 3 materials behind the flange: no graft (simulating an implant with no flange), a wafer of cancellous bone, and a block of bone cement.

RESULTS

The presence of an anterior flange had no significant effect on load transfer through the distal humerus regardless of graft material. This was found to be consistent for both bending and axial loading modes at all gauge levels; however, the supporting collar effect of the implant may have influenced axial compression results.

CONCLUSIONS

These results suggest that for the Latitude humeral component studied, the placement of bone or bone cement behind the anterior flange may not influence the cortical strains in the distal humerus under bending loads. However, a flange may still influence cortical strains using another implant with different geometric and material properties than the currently studied design.

The effect of anatomic landmark selection of the distal humerus on registration accuracy in computer-assisted elbow surgery

Incorrect selection of the flexion-extension axis of the elbow may be an important cause of failure following total elbow arthroplasty. Axis selection can be improved by locating it on a pre-operative image and registering the image to the subject intra-operatively. However, registration is dependent on the availability of anatomic landmarks that may be distorted or absent because of tumors, arthritis, dislocations, or fractures. This study determined the anatomic landmarks required to register surface data accurately to a pre-operative image of the distal humerus. Registration error for landmarks unlikely to be compromised by severe bone loss was 1.1 +/- 0.2 mm in translation and 0.4 +/- 0.1 degrees in rotation. These results suggest that a close alignment of a pre-operative image with intra-operative surface data can be achieved using only a relatively small portion of the distal humerus that is readily available to the surgeon, and unlikely to be compromised, even in the setting of significant articular bone loss.

Wide en bloc extra-articular excision of the elbow for sarcoma with complex reconstruction

We describe a consecutive series of five patients with bone or soft-tissue sarcomas of the elbow and intra-articular extension treated by complex soft tissue, allograft bone and prosthetic joint replacement after wide extra-articular en bloc excision. All had a pedicled myocutaneous latissimus dorsi rotation flap for soft-tissue cover and reconstruction of the triceps. Wide negative surgical margins were obtained in all five patients. No local wound complications or infections were seen. There were no local recurrences at a mean follow-up of 60 months (20 to 105). The functional results were excellent in four patients and good in one. Longer term follow-up is necessary to confirm the durability of the elbow reconstruction.

Endoprosthetic replacement of the distal humerus following resection of bone tumours

Between 1988 and 2006, 18 patients had a custom-made endoprosthetic replacement of the distal humerus for bone tumours at our institution. There were 11 primary malignant neoplasms, six secondary deposits, and one benign aggressive tumour. The mean follow-up was for 4.4 years (1 to 18.2). Complications occurred in nine patients and included aseptic loosening in three (16.6%), local recurrence in two (11%), infection in two (11%), neuropraxia of the radial nerve in one (5.5%) and a peri-prosthetic fracture in one (5.5%). Excision was inadequate in four patients (22%), all of which developed local recurrence and/or metastases. There were seven deaths from the primary disease after a mean of 2.3 years (1 to 5), one of whom had an above-elbow amputation for local recurrence seven months before death. The remaining six had satisfactory elbow function at their last follow-up. The 11 living patients were evaluated using the Musculoskeletal Tumour Society and Toronto Extremity Salvage scoring systems. The mean scores achieved were 76% (67% to 87%) and 73% (59% to 79%), respectively. Overall, 17 of 18 patients had significant improvement in the degree of their pain following operation.

Custom-made endoprosthetic reconstruction of the elbow for bone tumours is a viable treatment in carefully selected patients. It maintains satisfactory function and provides good pain relief.