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e assessed the intermediate functional results of In patients who have a malignant bone tumour of the
W eight patients after wide resection of the
proximal humerus for malignant bone tumour. We
proximal humerus, it is often possible to carry out curative
resection which spares the limb. Reconstruction, however,
used a free vascularised fibular graft as a functional remains a problem because none of the prostheses which
spacer and a sling procedure to preserve passive are currently available adequately compensates for the
scapulohumeral movement. Scapulohumeral functional loss after amputation.
arthrodesis was not carried out. Five patients had There are two main groups of reconstructive procedures
osteosarcoma, two achondrosarcoma and one a for the proximal humerus. One involves arthrodesis and
1,2 3
malignant fibrous histiocytoma of the bone. The mean includes autogenous grafts, allografts and composite
1,4
duration of follow-up was 70 months (median, 76) for allografts. The other aims to preserve glenohumeral
4,5
the seven patients who were still alive at the time of movement using functional pacers, prostheses for
4,6,7
the latest follow-up. One patient died from the disease replacement of the proximal humerus or osteoarticular
8
12 months after surgery. There were no local allografts. The advantages and disadvantages have been
recurrences. widely discussed.
The functional results were described and graded After resection of a malignant bone tumour of the prox-
quantitatively according to the rating system of the imal humerus, we used a free vascularised fibular graft as a
Musculoskeletal Tumour Society. Our results were functional spacer, and a sling procedure to preserve scap-
2,9
satisfactory with regard to pain, emotional acceptance ulohumeral passive movement. We reviewed a consec-
and manual dexterity. Function and lifting ability utive series of eight patients who had this reconstructive
were unsatisfactory in two patients. One patient had procedure, assessing function at a mean of 63 months after
delayed union between host and graft, but this united surgery.
after six months without further surgery. Radiographs
of the shoulder showed absorption or collapse of the Patients and Methods
head of the fibula in four of the eight patients and a
fracture in another. No functional problems related to Between 1988 and 1995 five women and three men of
absorption or fracture of the head of the fibula were mean age 27 years (10 to 47) underwent this procedure
noted. There was no infection or subluxation of the (Table I). All had a primary malignant tumour of the
head. We conclude that this is a reasonably effective proximal humerus. Excluded from the study were patients
technique of limb salvage after resection of the with soft-tissue sarcomas or tumours of the clavicle, scap-
proximal humerus. ula or proximal part of the humeral diaphysis which did not
J Bone Joint Surg [Br] 1999;81-B:808-13. involve the humeral head. Patients were selected only if
Received 25 August 1998; Accepted after revision 18 November 1999 preoperative imaging had shown that a satisfactory surgical
margin could be achieved and, if metastatic disease was
present, that this was also amenable to resection. Pre-
T. Wada, MD, Assistant Professor operative studies included plane radiography of the shoul-
M. Usui, MD, Associate Professor der, MRI or CT of the region around the tumour, full body
S. Ishii, MD, Professor and Chairman
Department of Orthopaedic Surgery, Sapporo Medical University School technetium bone scanning and CT of the chest. None of the
of Medicine, S-1, W-16, Sapporo 060-8543, Japan. patients had distant metastasis at the time of operation.
K. Isu, MD, Chief of Orthopaedic Clinic There were five osteosarcomas, two chondrosarcomas and
S. Yamawaki, MD, President
Sapporo National Hospital, 4-2 Kikusui, Sapporo 030, Shiroishiku, one malignant fibrous histiocytoma (MFH) of the bone.
Japan. The surgical stage was Ib for one patient with chon-
Correspondence should be sent to Dr T. Wada. drosarcoma and IIb for the remaining seven. All patients
©1999 British Editorial Society of Bone and Joint Surgery presented with pain and a palpable mass, and two had
0301-620X/99/59430 $2.00 pathological fractures.
808 THE JOURNAL OF BONE AND JOINT SURGERY
RECONSTRUCTION AND LIMB SALVAGE AFTER RESECTION FOR MALIGNANT BONE TUMOUR OF THE PROXIMAL HUMERUS 809
Table I. Details of the eight patients who had a sling procedure for sarcoma of the proximal humerus
Graft Latissimus
Age Pathological Surgical Type of Time of length dorsi
Case (yr) Gender diagnosis staging resection* reconstruction (cm) rotation Complications
1 43 M Chondrosarcoma Ib IA Primary 22 - Delayed union
2 20 M Osteosarcoma IIb VB Secondary† 26 - None
3 10 F Osteosarcoma IIb VB Primary 15 - Absorption of the fibular head
4 17 F Osteosarcoma IIb VB Primary 20 - Absorption of the fibular head
5 30 M Osteosarcoma IIb VB Secondary‡ 25 - None
6 34 F MFH IIb IA Primary 17 - Absorption of the fibular head
7 14 F Osteosarcoma IIb VB Primary 15 Primary Absorption of the fibular head
8 47 F Chondrosarcoma IIb VB Primary 23 Secondary Fracture, absorption of the fibular head
* see text
† wide resection only was carried out at initial operation
‡ reconstruction after failed prosthetic implant
11
Table II. Functional rating system of the Musculoskeletal Tumour Society for the upper limb
Emotional Positioning of Manual Lifting
Rating Pain Function acceptance the hand dexterity ability
5 None No restrictions Enthusiastic Unlimited No limitation Normal load
4 Intermediate Intermediate Intermediate Intermediate Intermediate Intermediate
3 Modest/non-disabling Recreational restrictions Satisfied Not above shoulder Loss of fine Limited
or no pronation movements
or supination
2 Intermediate Intermediate Intermediate Intermediate Intermediate Intermediate
1 Moderate/intermediately Partial occupational Accepted Not above waist Cannot pinch Helping only
disabling restriction
0 Severe/continuously Total occupational Dislikes None Cannot grasp Cannot help
disabling restriction
We classified the extent of each resection according to was fixed to the proximal stump of the humerus with a
10
the scheme proposed by Malawer, Meller and Dunham. 3.5 mm dynamic compression plate. The tendons of biceps
The functional results were described and graded quantita- femoris and palmaris longus together with a transient
tively according to the most recent rating system of the
11
Musculoskeletal Tumour Society (Table II).
The mean length of follow-up was 63 months. One
patient died from lung metastases 12 months after surgery.
The mean length of follow-up for the seven surviving
patients was 70 months (median, 76; range 32 to 91).
All five patients with osteosarcoma and the one with
MFH of the bone had systemic chemotherapy, both pre-
operatively and postoperatively. Neither of the two patients
with chondrosarcoma had chemotherapy.
Oncological and reconstructive procedure. A wide surgi-
cal margin was achieved in all eight patients. We carried
out either an intra-articular resection of the proximal
humerus with the abductor mechanism intact (type IA) or
an extra-articular humeral and glenoid resection with the
abductor mechanism disrupted (type VB).
A free vascularised fibular graft was inserted as a func-
tional spacer, using a sling procedure in six patients who
had primary resection, in one in whom a replacement
proximal humeral prosthesis had failed, and in one who had
resection without reconstruction. The mean duration of the
operation was 7.4 hours (5.5 to 11) and the mean blood loss
was 1131 ml (635 to 1634). The mean length of the graft
was 20.4 cm (15 to 26).
Sling procedure. An appropriate length of free vascu- Fig. 1
larised fibula, including the head, was harvested from the Diagram of the operative procedure, reproduced with permission of
ipsilateral or contralateral leg. The distal end of the fibula Medical View Inc.
Fig. 3a Fig. 3b
Table III. Functional and oncological results for the eight patients after the sling procedure for sarcoma of the proximal
humerus
Functional evaluation
Length of
follow-up Emotional Positioning Manual Lifting Overall
Case (mth) Pain Function acceptance of hand dexterity ability (%) Prognosis*
1 90 5 3 5 3 5 4 83 CDF
2 12 (30)† 5 2 3 3 5 3 70 DOD
3 91 5 3 4 4 5 4 83 CDF
4 90 5 3 4 4 5 4 83 CDF
5 76 (191)† 5 3 3 4 5 3 77 CDF
6 64 5 3 3 4 5 3 77 CDF
7 49 5 3 4 4 5 4 83 CDF
8 32 4 2 4 3 5 2 67 NED
* CDF, continuous disease-free; NED, no evidence of disease; DOD, died of disease
† indicates follow-up period after wide resection of the tumour
No longitudinal growth of the fibular graft occurred in lifting ability. In one patient (case 2) the sling procedure
either of the two patients (cases 3 and 7) with open was carried out 18 months after wide resection of the
12
epiphyses at the time of surgery. tumour. Marked preoperative elbow contracture could not
Oncological evaluation. Six patients remained free from be relieved. In another (case 8) the short head of biceps
disease at a mean of 74 months (median, 73) after surgery. could not be preserved because of involvement of the
One patient (case 2) with osteosarcoma died from the tumour leading to poor function and lifting ability.
disease 12 months after operation. A patient with chon- Complications. Radiographs of the shoulder showed
drosarcoma (case 8) developed a lung metastasis and was absorption or collapse of the head of the fibula in five of the
successfully treated by thoracotomy. There were no local eight patients (Fig. 2c) and one had a fracture of the head.
recurrences. Neither of these complications caused functional problems.
Reconstruction. Functional data were available for all One patient (case 8) with a disrupted deltoid muscle had
eight patients (Table III). The mean overall functional pain and irritation of the skin over the acromion. This was
rating was 79% (67 to 83). With regard to pain, emotional successfully treated by a latissimus dorsi flap, which pro-
acceptance and manual dexterity, the results were rated as vided adequate muscle coverage for the acromion and head
satisfactory with a score of 3.0 points or more in all of the fibula. There was no superficial or deep infection.
patients. In two (cases 2 and 8), they were unsatisfactory Subluxation or dislocation of the head was not seen. No
with a score of less than 3.0 points as regards function and problems were encountered at the donor site.
VOL. 81-B, NO. 5, SEPTEMBER 1999
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