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Limb-Sparing Surgery for High-Grade Sarcomas of the Proximal Humerus

WITTIG, JAMES C. M.D.; KELLAR-GRANEY, KRISTEN L. B.S.; MALAWER, MARTIN M. M.D.; BICKELS, JACOB M.D.; MELLER, ISAAC M.D.

Techniques in Shoulder & Elbow Surgery: March 2001 - Volume 2 - Issue 1 - p 54-69
Technique
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HISTORICAL PERSPECTIVE

The shoulder girdle is the third most frequent site for high-grade extremity sarcomas, and the proximal humerus is the most commonly affected bone (1,2). Osteosarcoma, chondrosarcoma, and Ewing's sarcoma are the most common primary tumors arising in this location (3–6). These tumors usually originate in the metaphyseal region and present with extraosseous extension (Enneking stage IIB).

Before 1970 most patients with high-grade spindle-cell sarcomas (e.g., osteosarcomas, chondrosarcomas) involving the proximal humerus were treated with a forequarter amputation (2). In 1977 Marcove et al. (7) were the first to report limb-sparing treatment for high-grade sarcomas arising in this location. These authors reported performing an en bloc extra-articular resection that included the proximal humerus, glenoid, overlying rotator cuff, lateral two thirds of the clavicle, deltoid, coracobrachialis, and proximal biceps (long head) (Fig. 1). Local tumor control and survival rates were similar to those achieved with forequarter amputation. Resection, however, preserved a functional hand and elbow. These early oncologic results were confirmed by other surgeons, and limb-sparing surgery for high-grade sarcomas of the proximal humerus became standard treatment (5,6,8–17).

FIG. 1.

FIG. 1.

Figure 1

Figure 1

In the early experience with limb-sparing surgery, no attempt was made to reconstruct the shoulder girdle and extremities were left flail after resection (7,9,11). Patients complained of unstable extremities, poor lifting ability, and poor cosmesis. Traction neuropraxia inevitably developed, leading to pain, weakness, and sensory deficits in the hand. Patients ultimately needed to wear an external orthosis for support. In an effort to maintain shoulder motion and extremity length, and improve stability, surgeons often used an intramedullary rod as a functional spacer (12). The rod was secured into the remaining humerus and fastened proximally to a clavicle or a rib. Instability was still a problem, and hardware failure, pain, and erosion through the chest wall or skin occurred frequently. To ensure shoulder stability, other surgeons advocated arthrodesis of the remaining humerus to the scapula using either a cadaver allograft alone or an allograft plus free fibula construct (14). This method required prolonged postoperative immobilization in a shoulder spica cast and frequently failed secondary to fracture, nonunion, and infection. In addition, donor site morbidity associated with free fibula transfer was not uncommon. When a successful arthrodesis occurred, motion (rotation) below the shoulder level where most activities are performed was limited.

As the popularity of limb-sparing surgery for shoulder girdle sarcomas grew, the extent of resection necessary for various tumors, particularly the indications for an extra-articular resection, remained a matter of debate. The best method for reconstruction was also under considerable discussion. In response, Malawer et al. (3–6) developed a surgical classification system based on tumor location, extent, grade, and pathologic type (Fig. 2). The purpose of the system was to provide guidelines about the extent of resection. Extra-articular proximal humerus resection (type VB), including the abductor mechanism, was recommended for high-grade spindle-cell sarcomas with extraosseous extension. Intra-articular resection (type IA), which leaves the glenoid and scapula intact, was recommended for high-grade spindle-cell tumors that were entirely intraosseous (stage IIA) and for most round-cell sarcomas (e.g., Ewing's sarcoma, primitive neuroectodermal tumor). Malawer et al. also described techniques for reconstruction that provided for a painless, stable, yet mobile shoulder that preserved hand and elbow function and prevented traction neuropraxia.

FIG. 2.

FIG. 2.

This paper presents the senior author's approach to resection of high-grade sarcomas arising from the proximal humerus and his techniques of endoprosthetic reconstruction with emphasis on static and dynamic soft-tissue stabilization. Included in this paper are the authors' indications and contraindications; unique anatomic considerations as they relate to the surgical procedure and to local sarcoma growth and spread around the shoulder girdle; a new concept of a functional compartment surrounding the proximal humerus; a description of the radiologic studies necessary for preoperative planning; and the long-term oncologic and functional results based on 74 patients treated with these techniques.

The techniques in this paper have been found to be safe and reliable when performed according to our recommendations. Upper-extremity function has been maximized and complications have been minimal. At a median follow-up of 10 years, local recurrence rates have been less than 5%. All patients have been pain free with stable shoulders and essentially normal hand and elbow function. The Musculoskeletal Tumor Society Functional Score has ranged from 24 to 27 of 30 possible points. Prosthetic survival rates have been 95% to 100% and the most common complication has been the development of a transient neuropraxia.

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INDICATIONS AND CONTRAINDICATIONS

Limb-sparing resection can be performed for most (90%–95%) high-grade spindle-cell and round-cell sarcomas arising from the proximal humerus. Chemotherapy or radiotherapy or both are usually used in conjunction with surgery in these instances. The only absolute contraindications for resection are invasion or encasement of the axillary vessels and brachial plexus, chest wall invasion, extensive soft tissue and neurovascular contamination from an inappropriately placed biopsy, and infection after biopsy. Pathologic fracture is no longer considered an absolute contraindication for resection. Induction (preoperative or neoadjuvant) chemotherapy can be administered. Most tumors will demonstrate an adequate response to the chemotherapy regimen, as indicated by healing of the fracture (17,18). With a good response to chemotherapy, the tumor cells in the fracture hematoma are killed. Limb-sparing surgery usually can be performed safely in these instances without compromising survival. If the fracture does not heal and the tumor continues to progress, however, forequarter amputation is recommended.

To understand the indications and surgical guidelines for limb-sparing resection, it is necessary to review the local anatomy and biologic behavior of sarcomas arising in this area.

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Unique Anatomic Considerations

Neurovascular Structures.

To safely and adequately resect sarcomas arising from the proximal humerus, the infraclavicular brachial plexus should be exposed and all important neurovascular structures identified. The axillary vessels and brachial plexus enter the upper extremity after passing inferior to the middle third of the clavicle (Fig. 3). Subsequently, they pass medial to the coracoid process and anterior to the scapula and subscapularis muscle en route to the proximal humerus. The subscapularis and latissimus dorsi muscles separate the axillary vessels and brachial plexus from the proximal humerus. The anterior and posterior humeral circumflex vessels arise from the axillary vessels at the lower border of the subscapularis muscle and tether the axillary vessels and brachial plexus down to the proximal humerus and hence, to any tumor arising from this bone. Mobilization of the axillary vessels and brachial plexus away from the tumor therefore requires ligation of the anterior and posterior humeral circumflex vessels. The axillary nerve arises from the posterior cord of the brachial plexus and passes beneath the lower border of the subscapularis muscle with the posterior humeral circumflex vessels. It travels posteriorly along the inferior capsule and humeral neck, where most sarcomas arise. Tumors that extend beyond the bony cortices usually involve the axillary nerve, making resection of this nerve necessary in most instances. The musculocutaneous nerve, essential for elbow flexion, arises from the lateral cord of the brachial plexus and can be identified anywhere from 2 cm to 7 cm inferior to the coracoid process. The radial nerve also arises from the posterior cord of the brachial plexus and can be identified at the inferior border of the latissimus dorsi muscle.

FIG. 3.

FIG. 3.

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Functional Compartment of the Shoulder Girdle.

Although there are no truly defined anatomic compartments of the shoulder girdle, several spaces that are bound by muscle and fascia pose a barrier to tumor extension. We term such space a functional compartment. This functional compartment is biologically equivalent to a true anatomic compartment, which is based on fascial borders (19). The metaphyseal region of the proximal humerus (the epicenter for most sarcomas) is contained by the deltoid, subscapularis, and remaining rotator cuff muscles. As a sarcoma grows through the cortices of the proximal humerus, these muscles are compressed into a pseudocapsular layer. The overlying muscle fascia functions as an anatomic barrier and prevents tumor penetration. These muscles and their investing fascia therefore serve as the boundaries of the functional compartment surrounding the proximal humerus (Fig. 4). The only neurovascular structures that enter the compartment are the axillary nerve and anterior and posterior humeral circumflex vessels. As these vessels pass beneath the inferior border of the subscapularis muscle they lie against the inferior capsule and humeral neck and are frequently involved by tumor originating in this area. Because the goal of limb-sparing resection is to remove the entire tumor (wide or radical resection) and maximize local tumor control, resection must include the surrounding muscles (pseudocapsule) and neurovascular structures that are involved by tumor. Thus, for most high-grade sarcomas of the proximal humerus, the deltoid, portions of the rotator cuff, axillary nerve, and humeral circumflex vessels must be removed with the tumor to ensure an oncologically safe margin. This accomplishes a true compartmental resection.

FIG. 4.

FIG. 4.

Figure 4

Figure 4

Figure 4

Figure 4

Figure 4

Figure 4

Compartmental boundaries also protect vital structures from tumor involvement and make it possible to preserve them. The subscapularis and latissimus dorsi muscles pose a medial boundary that protects the brachial plexus and axillary vessels from involvement. These muscles also protect the overlying pectoralis major and short head of the biceps, which are important to preserve for soft-tissue coverage and elbow flexion, respectively.

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Glenohumeral Characteristics and Transarticular Involvement.

Tumors arising in the proximal humerus or scapula are more likely to contaminate the glenohumeral joint or spread to the opposing articular surface than are tumors arising adjacent to other joints such as the knee or hip (3–6,20). Mechanisms of joint involvement include direct capsular spread (subsynovial and extrasynovial), hematoma formation from pathologic fracture, and spread along the intra-articular portion of the biceps (Fig. 5A). The metaphyseal region of the proximal humerus, which is the site of origin of most high-grade sarcomas, is located a short distance (approximately 1 cm) from the glenoid and is partially intracapsular. The entire medial metaphyseal region of the proximal humerus and the glenoid are contained within the confines of the subscapularis and infraspinatus muscles. Because sarcomas grow along the path of least resistance and respect fascial boundaries, those that arise from the proximal humerus readily extend along the capsule and rotator cuff to the opposing glenoid or scapular neck, grossly and microscopically. The long head of the biceps is juxtaposed to the metaphyseal region of the proximal humerus in the biceps groove. It travels transarticularly to the opposing glenoid, thus serving as a conduit for tumor spread (Fig. 5B). Because the metaphyseal region is contained by the subscapularis and infraspinatus muscles and a portion of it is contained by the capsule, pathologic fracture with hematoma formation will disseminate tumor cells throughout the compartment and contaminate the glenoid (Fig. 5C). Intra-articular or transarticular involvement cannot always be identified with preoperative imaging studies or during surgical exploration, especially if it represents microscopic spread or if there is significant surrounding edema. To ensure a wide resection (negative surgical margin), en bloc extra-articular resection encompassing the proximal humerus, intact glenohumeral joint, and scapula to the area just medial to the coracoid is recommended for high-grade spindle-cell sarcomas with extraosseous extension. In these instances, as previously stated, the deltoid, rotator cuff, and axillary nerve also require resection. Thus the glenoid serves no purpose after resection of these muscles and, as will be discussed later, its resection facilitates medialization of the prosthetic construct and soft tissue coverage.

FIG. 5.

FIG. 5.

Figure 5

Figure 5

Figure 5

Figure 5

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SURGICAL CLASSIFICATION SYSTEM

Malawer et al. (3–6) described a surgical classification scheme for resecting tumors in various regions of the bony shoulder girdle (Fig. 2). The classification system was intended to provide guidelines about the extent of bony and soft tissue resection, on the basis of anatomic location and extent of the tumor, tumor grade, and histologic type. Each of the six types of resection was assigned a number (I through VI) and was subcategorized as to whether the abductor mechanism was preserved (A) or resected (B). Type IA (intra-articular) and type VB (extra-articular) resections were recommended for tumors arising from the proximal humerus (3,5). Primary high-grade spindle-cell sarcomas (e.g., osteosarcomas, high-grade chondrosarcomas, malignant fibrous histiocytoma of bone) with extraosseous extension are most commonly treated with a type VB resection. Type IA resection (intra-articular) is recommended only for spindle-cell sarcomas that are entirely intraosseous (Enneking stage IIA) and select round-cell sarcomas (Ewing's sarcoma, primitive neuroectodermal tumor). Round-cell sarcomas usually undergo dramatic shrinkage with preoperative chemotherapy and are exquisitely radiosensitive such that residual microscopic disease after intra-articular resection can usually be eradicated with postoperative radiotherapy (21).

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PREOPERATIVE EVALUATION

Radiologic staging studies are necessary to evaluate the local and distant extent of disease and, for select primary sarcomas, the response to induction chemotherapy. Local imaging studies are crucial to determine the exact anatomic extent and thereby accurately plan the surgical procedure.

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Radiologic Evaluation

Imaging studies should include plain radiography, computed tomography (CT) of the shoulder and chest, magnetic resonance imaging (MRI) of the shoulder, bone scintigraphy, thallium scanning, angiography, and in select cases, venography.

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Plain Radiographs.

Plain radiographs of the shoulder are used to localize the anatomic origin of the tumor, formulate a differential diagnosis, and estimate tumor extent. After induction chemotherapy of an osteosarcoma, plain radiographs can be used to estimate the response of the tumor to the chemotherapeutic agents. A good response (greater than 90% tumor necrosis) is indicated by extensive tumor calcification, periosteal new bone formation, and healing of pathologic fractures (Fig. 6).

FIG. 6.

FIG. 6.

Figure 6

Figure 6

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Magnetic Resonance Imaging.

Magnetic resonance imaging is the most accurate method of determining intraosseous and extraosseous tumor extent and for detecting intraosseous and transarticular skip metastases. Proximity of the extraosseous component to the axillary and brachial vessels and brachial plexus can be determined. An appreciation of intraosseous extent is necessary to plan the osteotomy site 2-to 3-cm distal to the tumor to achieve a wide surgical margin. Standard T1-weighted, T2-weighted, and fat-suppressed images are recommended.

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Computed Tomography of the Shoulder.

Computed tomography and MRI are considered complementary studies. Both studies are routinely performed before surgery. CT is also useful for evaluating intraosseous and extraosseous extent. In instances in which there is excessive tumoral edema, which frequently occurs with Ewing's sarcoma, CT may be more accurate than MRI. Contrast-enhanced CT is particularly helpful for determining proximity of the tumor to the axillary and brachial vessels and brachial plexus. After preoperative chemotherapy of an osteosarcoma, CT characteristically shows a rimlike calcification in those tumors that have had a good response. Ewing's sarcoma typically undergoes a significant reduction in volume after induction chemotherapy that may best be depicted with a CT scan. Chest CT is most sensitive for detecting lung metastases.

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Bone Scintigraphy.

Triple-phase bone scanning provides an accurate estimate of intraosseous tumor extent and is the best test for detecting sites of bony metastases. The flow phase, which reflects tumor vascularity, and hence viability, will show diminished uptake after a good response to induction chemotherapy. The delayed phase of a bone scan may be inaccurate, because it may demonstrate increased activity secondary to reactive bone formation, in the presence of a good response.

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Thallium Scintigraphy.

Thallium 201 is a potassium analog that is actively transported by the sodium-potassium ATPase pump. A quantitative thallium scan has been useful for determining viability of bone tumors, particularly osteosarcomas. The affected side is compared with the unaffected side; a ratio less than 4:1 is consistent with greater than 90% tumor necrosis.

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Arteriography.

A shoulder arteriogram is recommended preceding resection. An arteriogram is the standard for estimating the response to preoperative chemotherapy and for determining the vascular anatomy and displacement. Viable tumors promote intense neovascularization, which appears as a tumor blush on the delayed phase of an arteriogram. A marked decrease in vascularity is associated with extensive tumor necrosis after induction treatment. Vascular anatomy, especially anomalies, can be described and aid in preoperative planning. Displacement of the axillary and brachial vessels and brachial plexus routinely occurs with extraosseous extension of proximal humerus tumors. The direction in which these structures are displaced can be determined.

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Venography.

A formal venogram (not the flow-through phase of an arteriogram) is a very accurate means of determining tumor resectability. A venogram provides an indirect means of assessing brachial plexus invasion or encasement. The brachial plexus, axillary vein, and axillary artery all lie in close apposition within the axillary sheath. Tumors that invade or encase the axillary sheath and thus the brachial plexus will obliterate the axillary vein because of its thin walls and its low, intraluminal pressure. The axillary artery may be displaced but is usually patent, owing to its thick walls and high intraluminal pressures. Obliteration of the vein, as seen on a venogram, indirectly suggests that the brachial plexus is involved with tumor and that the tumor is likely to be unresectable. Thus a venogram aids in surgical planning and allows informed discussions with the patient and family about the potential for a forequarter amputation. Because of the gravity of a forequarter amputation, however, the final decision regarding tumor resectability is made during surgery after brachial plexus exploration.

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Scanography.

A scanogram of the entire humerus helps determine the length of proximal humerus that will require resection. Preparation for endoprosthetic reconstruction is facilitated because the length of the components required for reconstruction can be estimated before surgery.

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Biopsy

Biopsy is a necessary step in the diagnosis of a bone tumor. To prevent biopsy-related artifacts, the biopsy should be performed after staging studies. It should be performed by the surgeon who will perform the definitive procedure or under his or her direct supervision. Inappropriately performed biopsies are a frequent cause of unnecessary amputations, post-biopsy fractures, misdiagnoses, and local recurrences. Biopsy of proximal humeral lesions should be performed through the anterior third of the deltoid. The deltopectoral interval should never be used because this may lead to tumor contamination of the neurovascular bundle.

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SURGICAL TECHNIQUE

There are three major components of a limb-sparing resection: 1) oncologic resection; 2) skeletal reconstruction; and 3) multiple muscle transfers for recreating stability and soft-tissue coverage. The goal of resection is to remove the entire tumor en bloc and thereby optimize local control. We do not recommend a flail shoulder or an arthrodesis. We recommend a method of reconstruction that provides for a painless, stable, yet mobile, shoulder that preserves elbow and hand function. It should not require prolonged postoperative immobilization and should facilitate early functional use of the extremity and prompt resumption of chemotherapy. Endoprosthetic replacement with static and dynamic methods of stabilization has successfully met these criteria. We have had 20 years of experience with this technique.

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Utilitarian Shoulder Girdle Incision

The senior author has developed one basic incision that can be used for resection of all types of shoulder girdle tumors in various locations and is referred to as the utilitarian shoulder girdle incision. It consists of three arms. The anterior arm of the incision (A) is used for exploration and mobilization of the neurovascular structures and proximal humerus resections (Fig. 7). The incision extends from the midclavicle region medial to the coracoid, across the axillary fold, and distally along the anteromedial aspect of the arm, following the neurovascular bundle. After the incision, fasciocutaneous skin flaps are raised medially and laterally to gain adequate exposure. For an extra-articular resection (Malawer type VB), the incision is extended posterolaterally over the top of the shoulder (incision B) and medially and laterally based fasciocutaneous flaps are developed. Intra-articular resections (Malawer type IA) can be performed solely through the anterior arm of the incision (incision A). Incision C can be extended for proximal humerus tumors with a large axillary component, forequarter amputations, and resection of isolated axillary tumors. Each arm of the incision results in formation of a skin flap where the base is at least the same width as the length of the flap, thus reducing the risk of skin necrosis.

FIG. 7.

FIG. 7.

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Neurovascular Exposure and Exploration

The first step in resection of a tumor arising from the proximal humerus is adequate exposure and exploration of the neurovascular structures. This ensures safety and permits isolation of structures not involved by tumor that are amenable to preservation. The neurovascular bundle is always the closest margin of resection and therefore its adequate exposure facilitates an oncologically safe dissection. Immediate exploration of the neurovascular structures also allows definitive determination of tumor resectability. The procedure can be converted to a forequarter amputation if the tumor is found to be unresectable.

The key step in exposure is the release of the pectoralis major from its humeral insertion, leaving a small portion of the insertion as a margin (Fig. 8). The musculocutaneous nerve is identified and dissected where it enters coracobrachialis and the short head of the biceps. The short head of the biceps is released from its coracoid insertion while protecting the underlying plexus and musculocutaneous nerve. The pectoralis minor is also released from the coracoid. The entire brachial plexus and axillary structures can now be visualized.

FIG. 8.

FIG. 8.

Figure 8

Figure 8

Figure 8

Figure 8

Figure 8

Figure 8

The axillary nerve, at the lower border of the subscapularis muscle, and the radial nerve, at the lower border of the latissimus dorsi muscle, are identified and marked with vessel loops. Anterior and posterior humeral circumflex vessels, which tether the plexus and axillary vessel to the tumor and proximal humerus, are isolated and doubly ligated. This step is crucial for mobilization of the neurovascular bundle away from the tumor. The axillary nerve is ligated for extra-articular resections. The latissimus dorsi and teres major are released from the proximal humerus, leaving a margin of tissue. The muscles are tagged with a suture.

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Tumor Resection

Proximal Humerus and Extra-articular Glenohumeral Resection (Type VB).

When a type VB resection (extraarticular) of the proximal humerus is indicated, the anterior incision (incision A) is extended posteriorly over the top of the shoulder and distally along the lateral border of the scapula (connected to incision B). The trapezius is released from the clavicle and scapular spine (Fig. 9). An incision using Bovie cautery is made through the rotator cuff medial to the coracoid, extending from the subscapularis and passing sequentially through the supraspinatus, infraspinatus, and teres minor muscles. Using a sagittal saw, an osteotomy is made through the lateral one third of the clavicle; through the humeral shaft, at least 2 cm distal to the anatomic extent of the tumor; and through the bony scapula medial to the coracoid. The proximal humerus is removed en bloc with the lateral portion of the scapula, intact glenohumeral capsule, overlying rotator cuff, proximal portion of the long head of the biceps tendon, and deltoid muscle. The entire functional compartment of the proximal humerus is removed, which accomplishes a true wide resection.

FIG. 9.

FIG. 9.

Figure 9

Figure 9

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Intra-articular Proximal Humerus Resection. (Type IA).

When an intra-articular resection is indicated, only the anterior incision is used (incision A). The axillary nerve is preserved. The deltoid, rotator cuff, and glenohumeral capsule are spared from resection and released from their insertions on the proximal humerus. The latissimus is also released and tagged with a suture. The long head of the biceps tendon is left attached to the glenoid. Humeral osteotomy is performed at least 2 cm distal to the tumor extent.

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Reconstruction

Extra-articular Reconstruction.

Meticulous attention to skeletal and soft-tissue reconstruction is essential to optimize results and minimize postoperative complications. A modular endoprosthetic proximal humerus is used. The prosthesis is sized during surgery, on the basis of preoperative estimations and intraoperative tension on the neurovascular structures. Sizing usually allows for shortening of 2-to 3-cm, which prevents traction on the neurovascular bundle and eases soft tissue coverage. The humerus is reamed and the largest diameter stem that allows for a 2-mm cement mantle is chosen. The prosthesis is cemented into the proximal humerus in a retroverted position so that the humeral head faces the subscapular fossa. Once the cement has cured, prosthetic stability is achieved with static and dynamic soft-tissue reconstruction.

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Static and Dynamic Soft Tissue Reconstruction.

Three-millimeter Dacron tapes are passed through the scapula (horizontal suspension) and clavicle (vertical suspension) and then through manufactured holes in the prosthetic neck. These are used for static suspension of the prosthesis. The pectoralis minor is sutured to the subscapularis muscle to protect the neurovascular bundle. Muscle transfers are performed for dynamic suspension (Fig. 10). The pectoralis major is sutured with 3-mm Dacron tapes to holes in the prosthesis, lateral border of scapula and the remaining rotator cuff (horizontal dynamic suspension) and short head of the biceps to the clavicle (vertical dynamic suspension). An additional portion, 1-to 2-cm, of the lateral border of the scapula may be removed to allow for mobilization of sufficient rotator cuff and to aid with muscle coverage. The trapezius is mobilized from its insertions onto the clavicle and scapular spine and advanced to the pectoralis major, covering the prosthesis. The latissimus is transferred around the posterolateral border of the prosthesis and attached with the arm slightly externally rotated so that it may function as an external rotator (replacing the resected infraspinatus and teres minor muscles). It is tensioned at full stretch. All muscles are sutured to each other and to holes in the prosthesis with No. 0 braided, nonabsorbable suture. The entire prosthesis must be covered with muscle to ensure adequate suspension and soft-tissue coverage.

FIG. 10.

FIG. 10.

Figure 10

Figure 10

Figure 10

Figure 10

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Intra-articular Reconstruction.

A modular endoprosthetic proximal humerus is appropriately sized and cemented into the remaining humerus maintaining proper retroversion (approximately 30°–45°). Static reconstruction is accomplished with a 40-mm Gore-Tex aortic graft (Fig. 11). The glenohumeral joint capsule and the rotator cuff are closed over the Gore-Tex aortic graft. The deltoid and pectoralis major are attached to the prosthesis and to each other with No. 0 braided, nonabsorbable suture. The deltoid and pectoralis are attached to the prosthesis and tenodesed to each other with No. 0 braided, nonabsorbable suture. The short head of the biceps is reattached to the pectoralis major if unable to reattach to the coracoid. All other muscles are appropriately transferred and reattached to the prosthesis and each other as described above.

FIG. 11.

FIG. 11.

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Closure

Large-bore closed-suction drains are placed for postoperative drainage—preferably a chest tube connected to low continuous suction. This is important to prevent development of a hematoma or seroma, which could lead to swelling, venous congestion, and subsequent skin necrosis. The skin is closed in layers. A sterile, bulky dressing is applied with the elbow in 45° of flexion.

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POSTOPERATIVE MANAGEMENT

In-patient Hospital Care

Edema can result in venous congestion and ultimately skin necrosis and infection. For this reason, edema control is crucial in the early postoperative period. Patients are covered, from hand to shoulder, with a bulky dressing and Ace bandage and are maintained at bed rest with elevation for 3 to 4 days. Drains are then removed and dressings are changed. Ace bandages are reapplied over the new dressings for at least 2 weeks. The arm is immobilized with the elbow in slight flexion to decrease tension on the biceps attachment and facilitate healing. Active and passive range of motion exercises of the hand and wrist are encouraged to help decrease edema and prevent stiffness.

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Rehabilitation

The upper extremity is placed in a sling for 2 to 4 weeks. Active flexion of the elbow is permitted immediately. The elbow is allowed extension only while the patient is lying in bed, gravity assistance only, to allow cleansing the antecubital space and to prevent stiffness. Active shoulder shrugs with the trapezius are initiated within 48 hours. At 6 weeks, pendulum exercises for the shoulder and active range of motion exercises for the elbow are permitted. Elbow and shoulder strengthening is initiated at 3 months and gradually progressed over the next 6 months. Resistance exercises are restricted to a maximum of 10 pounds.

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Postoperative Follow-up

Patients are followed up closely for development of local recurrence and systemic metastases as well as for prosthetic complications. They are followed up every 3 months for the first 2 years with clinical examination, radiographs of the extremity, and a chest CT. After 2 years, they are followed up every 6 months and at 5 years they are followed up at least yearly.

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RESULTS

Oncologic Results

We treated 74 patients with high-grade sarcomas of the proximal humerus with resection and endoprosthetic reconstruction between 1979 and 1998 (40 osteosarcomas, 29 chondrosarcomas, 3 Ewing's sarcomas, 2 other). Our results (Table 1) are based on a median follow-up of 10 years; all survivors have been followed for at least 2 years. Local recurrence was less than 5% for the entire group. No patient has required a secondary forequarter amputation. Survival rates have varied depending on the type of tumor and on whether metastatic disease was present at the time of diagnosis.

TABLE 1

TABLE 1

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Functional Results

All patients had functional use of the extremity within 6 to 12 weeks. There was no prolonged immobilization period and patients returned to activities of daily living fairly rapidly. Kaplan-Meier survival analysis estimates 95% to 100% prosthetic survival at 10 years for all patients who underwent reconstruction with a modular proximal humerus replacement (Fig. 12C).

FIG. 12.

FIG. 12.

Figure 12

Figure 12

Figure 12

Figure 12

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Type VB Reconstruction.

All patients are pain-free and have stable shoulders (Fig. 12A and B). No patient requires a brace. Elbow and hand function are virtually normal, and all patients can carry out activities of daily living. The Musculoskeletal Tumor Society Score ranged from 24 to 27 of 30 possible points (80%–90%). Points were deducted on all patients because of restrictions in recreational activities and inability to abduct the shoulder above 90°. Abduction and forward flexion of the shoulder are 30° to 40° for most patients. Shoulder abduction is mostly secondary to scapulothoracic motion with some assistance from the trapezius transfer to the prosthesis. Forward flexion is initiated by the pectoralis major. Active internal rotation is normal because the pectoralis major muscle has been preserved. External rotation varies from −15° to neutral secondary to the latissimus dorsi transfer. Biceps motor strength for all patients is at least grade 4+. Patients can carry loads of similar weight compared with the contralateral extremity. Although we limit the maximum amount of weight to 10 pounds, many patients are noncompliant. The true benefit of this procedure over an arthrodesis is its ability to preserve motion (rotation) below the shoulder level where most activities are performed. It also does not require prolonged postoperative immobilization and is associated with fewer postoperative complications than an arthrodesis.

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Type IA Reconstruction.

Shoulder strength after intra-articular resection with rotator cuff and deltoid preservation is slightly better. The degree of abduction and forward flexion achieved depends largely on strengthening the deltoid and rotator cuff. Active abduction ranges between 30° and 60°. All shoulders are pain-free and stable, and all patients have normal hand and elbow function.

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Complications

The most common complication is development of a transient nerve palsy. In our series of 74 proximal humeral resections and reconstructions, 9 patients (12%) had transient nerve palsies. All resolved within 6 months to a year. This most likely occurred secondary to traction, postoperative swelling, and occasionally an inappropriately drained hematoma. It should be emphasized that many of the patients are predisposed to nerve problems because of the neuropathic effects of preoperative chemotherapy and also from chronic pressure placed on the brachial plexus before surgery by tumors with significant extraosseous components. Postoperative chemotherapy may also prolong recovery. Skin necrosis and wound infection occurred in fewer than 2% of patients; aseptic loosening of the prosthesis occurred in 1% to 2%. There have been no shoulder dislocations and no evidence of prosthetic instability. No patient has required a forequarter amputation to treat a complication.

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CONCLUSION

The proximal humerus is a frequent site of origin for high-grade sarcomas. Limb-sparing resection is often technically challenging because of the large size of tumors arising in this location and their proximity to the neurovascular bundle. We describe a surgical approach that accomplishes a safe exposure of the neurovascular structures and ensures an adequate resection. A type VB resection (extra-articular) is recommended for high-grade spindle-cell sarcomas with extraosseous extension and a type IA resection (intra-articular) is advised only for those spindle-cell sarcomas that are entirely intraosseous and for select round-cell sarcomas. Local tumor control has been excellent. Endoprosthetic reconstruction provides a durable, long-lasting construct. Static and dynamic stabilization ensures shoulder stability and optimizes elbow and hand function. Complications have been minimal.

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Acknowledgment:

This paper is dedicated to our mentor and friend, Dr. Ralph C. Marcove, who was first surgeon to report limb-sparing surgery for high-grade sarcomas arising from the shoulder girdle.

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© 2001 Lippincott Williams & Wilkins, Inc.