- Email: [email protected]
Resection or reconstruction of the clavicle
$92
296
297
J. Shoulder Elbow Surg. March/April 1996
Abstracts
SOFT-TISSUE RECONSTRUCTION AFTER TUMOR RESECTION AROUND THE SHOULDER R. Hertel, MD, F.T. Ballmer, MD, Department of Orthopaedic Surgery, University of Berne, Switzerland. Soft-tissue defects resulting from resection of musculoskeletal tumors can be related to a missing essential musculotendinous unit or to be insufficient coverage of exposed structures. For functional defects a series of muscle transfers are available. We have found the following transfers to be most usefuh teres major for substitution of the infraspinatus; Latissimus dorsi for substitution of the supraspinatus; Pectoralis major for substitution of the serratus anterior. For skin defects mainly the ipsilateral latissimus dorsi flap, the scapular and parascapular flaps were used. Other possibilities include the lateral arm flap, the medial arm flap, the dorsal deltoid flap, the serratus anterior flap and a variety of free flaps. Awareness of reconstructive options is essential to plan customized treatment sequences. We believe that i m m e d i a t e r e c o n s t r u c t i o n after a d e q u a t e t u m o r resection yields the most favourable functional and psychological results. The authors will present a series of 12 complex reconstructions of the shoulder girdle to illustrate these statements.
298
CONCEPTS OF SKELETAL RECONSTRUCTION AFTER TUMOR RESECTION AROUND THE SHOULDER R. Hertel, MD, F.T. Ballmer, MD, D e p a r t m e n t of Orthopaedic Surgery, University of Berne, Switzerland. The a u t h o r s p r e s e n t a concept for skeletal reconstruction of the shoulder girdle based on their experience of 13 patients. Four basic types of skeletal defects were: 1. segmental, extraarticular defect of the humeral shaft; 2. segmental defect of the proximal h u m e r u s including the head; 3. segmental defect of the proximal h u m e r u s and the lateral scapula; 4. loss of the entire scapula with or without proximal humeral defect. Our first choice reconstruction were: for type one defect, vascularizefl fibula. For type two defect, altograft with rotator cuff and prosthetic head. For type three defect, scapulo-humeral fusion with double vascularized fibula Struts. For type four defect, reconstruction of shoulder contour with fibular segments resting on the thorax and s u s p e n s i o n of the h u m e r u s . We have f o u n d the proposed approach based essentially on the use of vascularized grafts to yield reliable and long-lasting results. The use of allografts has been reduced to a minimum.
299
RESECTION OR RECONSTRUCTION OF THE CLAVICI~.Lj.Karevski, ~ , G.vidoevski,~, T.Nospal,MD, Z.Temelkoveki,MD. Clinic for Orthop.Surgery,University of Skopje,Rep. of Macedonia Resection of the lesion is optimal surgical treatment in different diseases of +the clavlcle,but there ere different approaches to the question of necessity of reconstruction or not,arguing that there are no differences in the functional effects of croat region.In five patients,because of different diseases (ecsinofilic granuloma, giant cell tumor) resectlon of clavicle %~e done.Defect w~s reconstructed with fibular autograft.Stabilization of clavicle was done with Kurschner needle.Postoperative Velpau dressing was used.3-month radiographic and 6-month radionuclide (Tc 99m) controls were made up to the end of the second year.The results demonstrated appearance of primary calus stabilisation of the graft recipient sides after two months.Full radiographic and clinical fusing was achieved in the fourth month.Kurschner needle was extracted after nine months.During the follow-up grafts demonstrated no changes in the first two months and partial resorption in the next six months,receiving its original size in the following two r~onths.During this period no discomfort of the patients was registered,except restriction of the loading.Clinical evaluation demonstrated perfect functional results, and no comnetic defects were present.These results have been shown in all five pati~mts.In conclusion ~ suggest all resections of clavicle,which do not include its ends, to be reconstructed with intercalary autogenous fibula bone graft as a metlx~ of choice which is clinically and esthetically superior than simply leaving it.
RESULTS OF SHOULDER ARTHROPLASTY IN NON-TUMOROUS GLENOHUMERAL DESINTEGRATION M. Pfahler, M D , * V . Lindner, MD, H.J. Refior, MD, K.P. Maurer, MD Orthop~idische Klinik u. Poliklinik LMU, Klinikum Gro&hadern, Munich.* Staatliche Orthop~dische Klinik, Munich, Germany We investigated retrospectively our patients with hemi or total shoulder arthroplasty between 4, 1 9 8 6 and 10, 1994. Indication for operation was non-tumorous glenohumeral desintegration - primary and secondary'omarthritis, humeral head necrosis and rheumatoid arthritis. We performed shoulder arthroplasty in 45 patients; 34 female (median age 66 years from 24 to 82 years) and 11 male (median age 60 years from 42 to 72 years). In 36 cases we did a hemi shoulder replacement and in 9 cases a total shoulder repPacement. The median follow up after surgery was 3 years and 9 months, For evaluation we used the Constant UCLA - and W61ker score, in the WLilker score 96 % of all patients reached a good result which was underlined by the UCLA and Constant score where patients increased their score by 50 respectively 43 percent. We saw 1 complete loosening by infection. Anarysing the poor results, we found rotator cuff deficiency in 4 cases and instability in 2 cases. In summary, 98 percent of the patients had no or slight pain. The average active flexion was 105% the average active abduction was 85 ~, the strength was satisfying but in the lower third of the Constant scale. Pain was better improved than function and function better than strength. Shoulder arthroplasty showed good and satisfying results in 87 percent. There was no difference between hemi and shoulder arthroplasty. Rotator cuff deficiency and instability are important factors for a poor result. Prognosis for shoulder arthroplasty is best for pain, followed by function and strength.
296
297
J. Shoulder Elbow Surg. March/April 1996
Abstracts
SOFT-TISSUE RECONSTRUCTION AFTER TUMOR RESECTION AROUND THE SHOULDER R. Hertel, MD, F.T. Ballmer, MD, Department of Orthopaedic Surgery, University of Berne, Switzerland. Soft-tissue defects resulting from resection of musculoskeletal tumors can be related to a missing essential musculotendinous unit or to be insufficient coverage of exposed structures. For functional defects a series of muscle transfers are available. We have found the following transfers to be most usefuh teres major for substitution of the infraspinatus; Latissimus dorsi for substitution of the supraspinatus; Pectoralis major for substitution of the serratus anterior. For skin defects mainly the ipsilateral latissimus dorsi flap, the scapular and parascapular flaps were used. Other possibilities include the lateral arm flap, the medial arm flap, the dorsal deltoid flap, the serratus anterior flap and a variety of free flaps. Awareness of reconstructive options is essential to plan customized treatment sequences. We believe that i m m e d i a t e r e c o n s t r u c t i o n after a d e q u a t e t u m o r resection yields the most favourable functional and psychological results. The authors will present a series of 12 complex reconstructions of the shoulder girdle to illustrate these statements.
298
CONCEPTS OF SKELETAL RECONSTRUCTION AFTER TUMOR RESECTION AROUND THE SHOULDER R. Hertel, MD, F.T. Ballmer, MD, D e p a r t m e n t of Orthopaedic Surgery, University of Berne, Switzerland. The a u t h o r s p r e s e n t a concept for skeletal reconstruction of the shoulder girdle based on their experience of 13 patients. Four basic types of skeletal defects were: 1. segmental, extraarticular defect of the humeral shaft; 2. segmental defect of the proximal h u m e r u s including the head; 3. segmental defect of the proximal h u m e r u s and the lateral scapula; 4. loss of the entire scapula with or without proximal humeral defect. Our first choice reconstruction were: for type one defect, vascularizefl fibula. For type two defect, altograft with rotator cuff and prosthetic head. For type three defect, scapulo-humeral fusion with double vascularized fibula Struts. For type four defect, reconstruction of shoulder contour with fibular segments resting on the thorax and s u s p e n s i o n of the h u m e r u s . We have f o u n d the proposed approach based essentially on the use of vascularized grafts to yield reliable and long-lasting results. The use of allografts has been reduced to a minimum.
299
RESECTION OR RECONSTRUCTION OF THE CLAVICI~.Lj.Karevski, ~ , G.vidoevski,~, T.Nospal,MD, Z.Temelkoveki,MD. Clinic for Orthop.Surgery,University of Skopje,Rep. of Macedonia Resection of the lesion is optimal surgical treatment in different diseases of +the clavlcle,but there ere different approaches to the question of necessity of reconstruction or not,arguing that there are no differences in the functional effects of croat region.In five patients,because of different diseases (ecsinofilic granuloma, giant cell tumor) resectlon of clavicle %~e done.Defect w~s reconstructed with fibular autograft.Stabilization of clavicle was done with Kurschner needle.Postoperative Velpau dressing was used.3-month radiographic and 6-month radionuclide (Tc 99m) controls were made up to the end of the second year.The results demonstrated appearance of primary calus stabilisation of the graft recipient sides after two months.Full radiographic and clinical fusing was achieved in the fourth month.Kurschner needle was extracted after nine months.During the follow-up grafts demonstrated no changes in the first two months and partial resorption in the next six months,receiving its original size in the following two r~onths.During this period no discomfort of the patients was registered,except restriction of the loading.Clinical evaluation demonstrated perfect functional results, and no comnetic defects were present.These results have been shown in all five pati~mts.In conclusion ~ suggest all resections of clavicle,which do not include its ends, to be reconstructed with intercalary autogenous fibula bone graft as a metlx~ of choice which is clinically and esthetically superior than simply leaving it.
RESULTS OF SHOULDER ARTHROPLASTY IN NON-TUMOROUS GLENOHUMERAL DESINTEGRATION M. Pfahler, M D , * V . Lindner, MD, H.J. Refior, MD, K.P. Maurer, MD Orthop~idische Klinik u. Poliklinik LMU, Klinikum Gro&hadern, Munich.* Staatliche Orthop~dische Klinik, Munich, Germany We investigated retrospectively our patients with hemi or total shoulder arthroplasty between 4, 1 9 8 6 and 10, 1994. Indication for operation was non-tumorous glenohumeral desintegration - primary and secondary'omarthritis, humeral head necrosis and rheumatoid arthritis. We performed shoulder arthroplasty in 45 patients; 34 female (median age 66 years from 24 to 82 years) and 11 male (median age 60 years from 42 to 72 years). In 36 cases we did a hemi shoulder replacement and in 9 cases a total shoulder repPacement. The median follow up after surgery was 3 years and 9 months, For evaluation we used the Constant UCLA - and W61ker score, in the WLilker score 96 % of all patients reached a good result which was underlined by the UCLA and Constant score where patients increased their score by 50 respectively 43 percent. We saw 1 complete loosening by infection. Anarysing the poor results, we found rotator cuff deficiency in 4 cases and instability in 2 cases. In summary, 98 percent of the patients had no or slight pain. The average active flexion was 105% the average active abduction was 85 ~, the strength was satisfying but in the lower third of the Constant scale. Pain was better improved than function and function better than strength. Shoulder arthroplasty showed good and satisfying results in 87 percent. There was no difference between hemi and shoulder arthroplasty. Rotator cuff deficiency and instability are important factors for a poor result. Prognosis for shoulder arthroplasty is best for pain, followed by function and strength.