Authors: Michiel A J van de Sande P D Sander Dijkstra Antonie H M Taminiau
Publish Date: 2010/11/18
Volume: 35, Issue: 9, Pages: 1375-1380
Abstract
The purpose of this study was to compare the outcome complications and survival of the three most commonly used surgical reconstructions of the proximal humerus after transarticular tumour resection Between 1985 and 2005 38 consecutive proximal humeral reconstructions using allograftprosthesis composite n = 10 osteoarticular allograft n = 13 or a modular tumour prosthesis n = 14 were performed in our clinic The mean followup was ten years 1–25 Of these 27 were disease free at latest followup mean 168 years and ten had died of disease The endoprosthetic group presented the smallest complication rate of 21 n = 1 compared to 40 n = 4 in the allograftprosthesis composite and 62 n = 8 in the osteoarticular allograft group Only one revision was performed in the endoprosthetic group in a case of shoulder instability Infection after revision n = 3 pseudoarthrosis n = 2 fracture of the allograft n = 3 and shoulder instability n = 4 were the major complications of allograft use in general KaplanMeier analysis showed a significantly better implant survival for the endoprosthetic group logrank p = 0002 At final followup the Musculoskeletal Tumour Society scores were an average of 72 for the allograftprosthetic composite n = 7 median followup 17 years 76 for the osteoarticular allograft n = 3 19 years and 77 for the endoprosthetic reconstruction n = 10 5 years groups An endoprosthetic reconstruction after transarticular proximal humeral resection resulted in the lowest complication rate highest implant survival and comparable functional results when compared to allograftprosthesis composite and osteoarticular allograft use We believe that the surgical approach that best preserves the abductor mechanism and provides sufficient surgical exposure for tumour resection contributed to better functional results and glenohumeral stability in the endoprosthetic groupLimb salvage following tumour resection about the proximal humerus in the adult patient poses significant surgical challenges as it is often limited by surgical loss of surrounding functional soft tissue stabilisers of the glenohumeral joint Although studies have emphasised the possibility of deltoid muscle and axillary nerve sparing without compromising oncological surgical margins transarticular tumour resections including part of the deltoid muscle and rotator cuff are frequently reported 1 2 3 4 In the adult patient functional reconstruction after transarticular proximal humeral resection is most frequently performed using either osteoarticular allograft OA endoprosthesis EP or a combination of both 4 5 6 As a broad range of functional results and complication rates are reported for all three the choice for one or the other remains one of surgical experience time set and local preference 2 4 6 7 8 Mid and longterm complications such as fracture subchondral collapse and infection are however reported less frequently in prosthetic reconstructions Conversely glenohumeral instability is considered to be less frequent in patients with a somewhat more biological repair However in both OA and allograftprosthesis composite APC reconstruction instability caused by rotator cuff dysfunction is reported to be between 5 and 19 of cases compared to between 11 and 31 after endoprosthetic reconstruction EPR 4 7 9 Again an intact abductor mechanism was associated with increased glenohumeral stability Historical cohort studies comparing different surgical options both concluded that APC is favoured above EPR in young patients as functional results are somewhat better but in the older patient EP is preferred for its superior implant survival 4 6 7This retrospective cohort series compares three surgical options EP OA and APC for implant and resectionrelated outcome parameters to determine which type of reconstruction after primary transarticular resection could in the long term lead to optimal functional results patient and implant survival Additionally we hypothesised that optimal functional results can be achieved when the deltoid muscle including the axillary nerve is left unharmed using a new deltoidpreserving surgical approachBetween 1985 and 2007 37 consecutive proximal humeral reconstructions using either APC n = 10 OA n = 13 or a modular tumour prosthesis n = 14 were performed in our clinic A total of 33 patients underwent limb salvage resection for a primary bone tumour 9 benign and 24 malignant and four for metastatic disease The histological diagnosis was osteosarcoma in ten Ewing’s sarcoma in two highgrade chondrosarcoma in 11 giant cell tumour in eight and malignant fibrous histiocytoma MFH and aneurysmatic bone cyst in one Patients with metastatic disease were treated with EP in three cases and APC in one Primary bone lesions as described above were evenly divided between all three groupsWe retrospectively analysed all medical records for patient characteristics age at diagnosis diagnosis surgical treatment and approach duration of followup integrity of abductor mechanism humeral resection length measured from the tip of the greater tuberosity cortical destruction resection margins adjuvant treatment postoperative complications oncological parameters including overall survival and local or systemic relapse Eventfree and implant survival are described using a KaplanMeier analysis Functional assessment at the time of final followup was assessed using the Musculoskeletal Tumour Society MSTS functional scores for patients still in followup the MSTS score range between 0 and 30 is presented here as a percentage raw score/30 10 The shoulder abductor mechanism was considered compromised when the rotator cuff or axillary nerve was sacrificed and/or greater than 50 of the deltoid muscle was resected 7
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