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Sullivan MH, Arguello AM, Barlow JD, Morrey ME, Rose PS, Sanchez-Sotelo J, Houdek MT. Comparison of reconstructive techniques for nonprimary malignancies in the proximal humerus. J Surg Oncol 2024. [PMID: 38837768 DOI: 10.1002/jso.27693] [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: 01/16/2024] [Revised: 03/20/2024] [Accepted: 05/12/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Endoprostheses (EPC) are often utilized for reconstruction of the proximal humerus with either hemiarthroplasty (HA) or reverse arthroplasty (RA) constructs. RA constructs have improved outcomes in patients with primary lesions, but no studies have compared techniques in metastatic disease. The aim of this study is to compare functional outcomes and complications between HA and RA constructs in patients undergoing endoprosthetic reconstruction for proximal humerus metastases. METHODS We retrospectively reviewed our institutional arthroplasty database to identify 66 (56% male; 38 HA and 28 RA) patients with a proximal humerus reconstruction for a non-primary malignancy. The majority (88%) presented with pathologic fracture, and the most common diagnosis was renal cell carcinoma (48%). RESULTSS Patients with RA reconstructions had better postoperative forward elevation (74° vs. 32°, p < 0.01) and higher functional outcome scores. HA patients had more complications (odds ratio 13, p < 0.01), with instability being the most common complication. CONCLUSIONS Patients with nonprimary malignancies of the proximal humerus had improved functional outcomes and fewer complications after undergoing reconstruction with a reverse EPC compared to a HA EPC. Preference for reverse EPC should be given in patients with good prognosis and ability to complete postoperative rehabilitation.
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Affiliation(s)
- Mikaela H Sullivan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jonathan D Barlow
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Tedesco NS, Mesko N, Wodajo F. The Musculoskeletal Tumor Society Clinical Practice Guideline on the Management of Metastatic Humeral Disease. J Am Acad Orthop Surg 2024; 32:e482-e488. [PMID: 38442357 DOI: 10.5435/jaaos-d-24-00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 03/07/2024] Open
Abstract
Management of Metastatic Humeral Disease is based on a systematic review of published studies surrounding the management of metastatic disease, multiple myeloma, and lymphoma limited to the humerus. This guideline contains seven action statements to assist orthopaedic surgeons, orthopaedic oncologists, physicians, and any other qualified healthcare professionals involved in the surgical management of metastatic disease of the humerus. It is also intended to serve as an information resource for decision makers, researchers, and developers of clinical practice guidelines. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development. This guideline has been endorsed by the American Academy of Orthopaedic Surgeons.
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Affiliation(s)
- Nicholas S Tedesco
- From the Department of Orthopaedic Surgery, Western University College of Osteopathic Medicine of the Pacific Northwest, Good Samaritan Regional Medical Center, Corvallis, OR (Tedesco), the Department of Orthopaedic Surgery, Case Western Reserve University Cleveland Clinic, Cleveland, OH (Mesko), and the University of Virginia School of Medicine - Inova Campus, Virginia Cancer Specialists, Fairfax, VA (Wodajo)
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West W, Moore A, Gerhardt C, Webb P, Binitie O, Lazarides A, Letson D, Joyce D. Dual plating in the metastatic distal humerus: Benefits may outweigh the risks. J Orthop 2024; 51:103-108. [PMID: 38361983 PMCID: PMC10864758 DOI: 10.1016/j.jor.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/17/2024] Open
Abstract
Background Impending and complete pathologic fractures of the distal humerus are rare complications of metastatic cancer. Surgical treatment aims to quickly restore function and minimize pain. Plate and screw fixation (PSF) is a common method for addressing these lesions, but unlike in orthopaedic trauma, there are no clear guidelines for best management. While dual PSF theoretically provides better support and reduces the chance of reoperation due to tumor progression, single PSF is currently the more common choice. Materials and methods Between March 2008 and September 2021, 35 consecutive patients who underwent PSF for distal humerus metastasis or multiple myeloma were retrospectively reviewed. The proportion of patients who developed various postoperative complications, including infection, nonunion, deep vein thrombosis, tumor progression, and radial nerve palsy, as well as those requiring reoperation, was calculated. Mann-Whitney U test, Pearson's chi-squared, and Fisher's exact test were used to investigate differences between the single and dual PSF groups with statistical significance defined as p ≤ 0.05. Results There was no significant difference (p = 0.259) in revision rate, although 3 of 21 (14.3 %) single PSF patients required reoperation compared to 0 of 14 (0.0 %) dual PSF patients. The revisions were performed in one patient due to refracture and in two patients due to tumor progression. Although not statistically significant, a larger percentage of single PSF patients developed a postoperative complication compared to dual PSF patients [odds ratio 0.42 (95 % confidence interval 0.071 to 2.5); p = 0.431]. Single PSF did lead to shorter operative time compared to dual PSF [p < 0.001]. Conclusion Dual PSF is non-inferior to single PSF and potentially results in fewer reoperations and postoperative complications in distal humerus pathologic lesions, although it leads to longer operative time. The current study is limited by small sample size due to the rarity of distal humerus metastatic lesions.
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Affiliation(s)
- William West
- University of South Florida Morsani College of Medicine, USA
| | | | | | - Paul Webb
- University of South Florida Morsani College of Medicine, USA
| | | | | | | | - David Joyce
- Sarcoma Department, Moffitt Cancer Center, USA
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Labott JR, Heidenreich MJ, Broida SE, Mills GL, Rose PS, Houdek MT. Durability of intercalary endoprosthesis for humeral reconstruction. J Surg Oncol 2024; 129:410-415. [PMID: 37750341 DOI: 10.1002/jso.27458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 09/01/2023] [Accepted: 09/17/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION The humerus is a common site of metastases and primary tumors. For some patients with a segmental defect and/or diaphyseal cortical destruction a cemented intercalary device may provide a more reliable construct, however data on their use is limited. METHODS We reviewed 43 (28 male and 15 female) patients treated with an intercalary humeral spacer at a single tertiary referral center between 1989 and 2022. Humeral lesions were most commonly secondary to metastatic disease (n = 29, 68%), with 25 (58%) patients presenting with a pathologic fracture. Mean age and body mass index were 66 years and 27.9 kg/m2 . First generation taper joint device were used in 22 patients and second-generation lap device in 21 patients. RESULTS Following reconstruction the 2-year overall survival was 30%. Mechanical complications occurred in 11 patients, most commonly aseptic loosening (n = 6, 14%). With death as a competing risk, the cumulative incidence of mechanical failure was 28% at 2-years postoperative. Following the procedure, mean Musculoskeletal Tumor Society scores was 70% and mean shoulder elevation was 87°. CONCLUSION Reconstruction of the humeral diaphysis with an intercalary endoprosthesis provides restoration of function of the upper extremity, however, is associated with one in four patients having mechanical failure.
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Affiliation(s)
- Joshua R Labott
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark J Heidenreich
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Samuel E Broida
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Gavin L Mills
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter S Rose
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Chen BK, Tai TH, Lin SH, Chen KH, Huang YM, Chen CY. Intramedullary Nail vs. Plate Fixation for Pathological Humeral Shaft Fracture: An Updated Narrative Review and Meta-Analysis of Surgery-Related Factors. J Clin Med 2024; 13:755. [PMID: 38337449 PMCID: PMC10856436 DOI: 10.3390/jcm13030755] [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: 11/26/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Pathological humeral shaft fracture (PHSF) is a frequently observed clinical manifestation in the later stages of tumor metastasis. Surgical interventions are typically recommended to alleviate pain and restore functionality. Intramedullary nail fixation (INF) or plate fixation (PF) is currently recommended for the treatment of PHSF. However, there is still no standard for optimal surgical treatment. Thus, we conducted a meta-analysis comparing the clinical outcomes of INF with PF for PHSF treatment. (2) Methods: We conducted searches in databases, such as Scopus, EMBASE, and PubMed, for studies published prior to May 2023. In total, nine studies with 485 patients were reviewed. (3) Results: There were no significant differences noted in the incidence of fixation failure, local recurrence, wound complication or overall complication. However, the INF group demonstrated a significantly lower incidence of postoperative radial nerve palsy than the PF group (OR, 5.246; 95% CI, 1.548-17.774; p = 0.008). A subgroup analysis indicated that there were no statistically significant differences in fixation failure or local recurrence among subgroups categorized by the design of intramedullary nail. (4) Conclusions: Considering the short life expectancy of end-stage patients, the choice of surgical method depends on the patient's individual condition, fracture and lesion patterns, the surgeon's experience, and comprehensive discussion between the surgeon and patient.
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Affiliation(s)
- Bing-Kuan Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (B.-K.C.); (T.-H.T.); (S.-H.L.)
- Division of General Medicine, Department of Medical Education, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
| | - Ting-Han Tai
- School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (B.-K.C.); (T.-H.T.); (S.-H.L.)
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
| | - Shu-Hsuan Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (B.-K.C.); (T.-H.T.); (S.-H.L.)
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
| | - Kuan-Hao Chen
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
- Graduate Institute of Biomedical Materials and Tissue Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
| | - Yu-Min Huang
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
| | - Chih-Yu Chen
- School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; (B.-K.C.); (T.-H.T.); (S.-H.L.)
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (K.-H.C.); (Y.-M.H.)
- International Ph.D. Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei 11031, Taiwan
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Singh I, Krasney L, Civatte W, Parrish W. Treatment of Epiphyseal Metastasis to the Proximal Humerus Secondary to Breast Carcinoma: A Case Report. Cureus 2023; 15:e47564. [PMID: 38022128 PMCID: PMC10666193 DOI: 10.7759/cureus.47564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 12/01/2023] Open
Abstract
Metastasis to the bone is a known risk of breast cancer, with the humerus being the most common upper extremity site of metastases, with most lesions located at the humeral diaphysis. We present a unique case of proximal humeral metastasis involving the epiphysis secondary to primary invasive ductal carcinoma in a middle-aged Caucasian female. It is important to have a high degree of suspicion for metastasis when musculoskeletal pain occurs in breast cancer patients, as it may be masked by common, degenerative conditions about the shoulder girdle. When humeral metastases involve the epiphysis, treatment options are complicated by its location, which jeopardizes the integrity of articular cartilage and the function of the shoulder girdle. External beam irradiation provides pain control in a non-invasive manner, sans surgical risks. Surgical intervention will vary depending on the characteristics of the bony lesion, but the use of endoprosthetics has emerged as the most effective option for restoring range of motion and pain control with acceptable rates of implant survival.
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Affiliation(s)
- Inderpreet Singh
- Orthopedic Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - Leighann Krasney
- Orthopedic Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - William Civatte
- Orthopedic Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
| | - William Parrish
- Orthopedic Surgery, University of Pittsburgh Medical Center Pinnacle, Harrisburg, USA
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Tat J, Bodansky D, Sheth U, Ung Y, Whyne C, Nam D. Predicting Pathological Fractures at Metastatic Humeral Lesions. JB JS Open Access 2023; 8:e22.00070. [PMID: 37123507 PMCID: PMC10132712 DOI: 10.2106/jbjs.oa.22.00070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
The humerus is the second most common site of metastatic disease involving long bones, yet it is still unclear which patients are at high risk for a fracture and may require prophylactic surgical fixation. The goal of this study was to assess the validity of the Mirels score to predict fractures of metastatic lesions in the humerus. Methods We performed a retrospective electronic chart review of patients with humeral metastases at our institution (2005 to 2021), with 188 patients meeting the inclusion criteria. Sixty-one of the patients developed a fracture during follow-up. The metastatic humeral lesions were scored according to the Mirels rating system and additional radiographic criteria (cortical breach, location within the humerus, number of lesions). The predictive value of each Mirels score cutoff for fracture was assessed using sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and multivariate logistic regression. Survivorship until fracture was analyzed for each Mirels score cutoff using Kaplan-Meier curves and the log-rank test. Significance was set at p < 0.01. Results There were no significant differences in age, sex, side of the lesion, type of malignancy, and radiation dose between the groups with and without fracture (all p > 0.01). A Mirels score of ≥8 points had the best predictive profile, with sensitivity of 83.6%, specificity of 79.5%, and AUC of 0.82 (95% confidence interval [CI], 0.75 to 0.88, p < 0.01). A logistic regression model also demonstrated that a Mirels score of ≥8 (odds ratio = 5.8, 95% CI = 1.9 to 18.2, p < 0.01) and a cortical breach (odds ratio = 21.0, 95% CI = 5.7 to 77.2, p < 0.01) were significant predictors of pathological fracture. No other radiographic characteristics were found to be significant predictors of fracture. Conclusions This study indicated that a Mirels score of ≥8 points had the best predictive profile for anticipating fractures at a metastasis in the humerus. This is in contrast to the traditional Mirels definition of an impending pathological fracture that is used for the lower extremity, a score of ≥9. Additionally, the presence of a cortical breach was a significant predictor of fracture risk. Level of Evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jimmy Tat
- Sunnybrook Orthopaedic Upper Limb (SOUL), Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David Bodansky
- Sunnybrook Orthopaedic Upper Limb (SOUL), Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Ujash Sheth
- Sunnybrook Orthopaedic Upper Limb (SOUL), Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yee Ung
- Department of Radiation Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Cari Whyne
- Sunnybrook Orthopaedic Upper Limb (SOUL), Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Orthopaedic Biomechanics Lab, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Diane Nam
- Sunnybrook Orthopaedic Upper Limb (SOUL), Division of Orthopaedic Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Arguello AM, Houdek MT, Barlow JD. Management of Proximal Humeral Oncologic Lesions. Orthop Clin North Am 2023; 54:89-100. [PMID: 36402514 DOI: 10.1016/j.ocl.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The proximal humerus is a common location for primary tumors, benign lesions, and metastatic disease. Advances in neoadjuvant and adjuvant therapy have allowed for limb-salvage surgery in most of the cases. There are numerous of options for surgical management of proximal humerus lesions and the decision to pursue one over another depends on factors such as age, comorbidities, pathology, location within the proximal humerus, planned resection margins/size of defect, and bone quality. Long-term outcomes for these techniques tend to be retrospective comparative studies, with recent studies highlighting the improved outcomes of reverse total shoulders.
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Affiliation(s)
- Alexandra M Arguello
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Jonathan D Barlow
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Stochastic PCA-Based Bone Models from Inverse Transform Sampling: Proof of Concept for Mandibles and Proximal Femurs. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11115204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Principal components analysis is a powerful technique which can be used to reduce data dimensionality. With reference to three-dimensional bone shape models, it can be used to generate an unlimited number of models, defined by thousands of nodes, from a limited (less than twenty) number of scalars. The full procedure has been here described in detail and tested. Two databases were used as input data: the first database comprised 40 mandibles, while the second one comprised 98 proximal femurs. The “average shape” and principal components that were required to cover at least 90% of the whole variance were identified for both bones, as well as the statistical distributions of the respective principal components weights. Fifteen principal components sufficed to describe the mandibular shape, while nine components sufficed to describe the proximal femur morphology. A routine has been set up to generate any number of mandible or proximal femur geometries, according to the actual statistical shape distributions. The set-up procedure can be generalized to any bone shape given a sufficiently large database of the respective 3D shapes.
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