- Email: [email protected]
Reverse shoulder endoprosthesis for pathologic lesions of the proximal humerus: a minimum 3-year follow-up
ARTICLE IN PRESS J Shoulder Elbow Surg (2017) ■■, ■■–■■
www.elsevier.com/locate/ymse
ORIGINAL ARTICLE
Reverse shoulder endoprosthesis for pathologic lesions of the proximal humerus: a minimum 3-year follow-up Simon Maclean, FRCS (Tr & Orth), Shahbaz S. Malik, MSc (Orth Eng), FRCS (Tr & Orth)*, Scott Evans, FRCS (Tr & Orth), Jonathan Gregory, FRCS (Tr & Orth), Lee Jeys, FRCS (Tr & Orth) Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, Birmingham, UK Background: The Bayley Walker (Stanmore Implants, Elstree, UK) reversed polarity, linked shoulder replacement is designed to provide stable function in the treatment of a painful shoulder with poor soft tissue coverage. We reviewed the results of the prosthesis in destructive pathologic lesions of the proximal humerus at a United Kingdom tumor center. Methods: We identified 8 patients (2 men, 6 women) in our database. Clinical information and functional outcome scores were collected, including range of movement, Toronto Extremity Salvage Score, the Musculoskeletal Tumor Score. Radiographs from the last clinic follow-up were analyzed. Results: Of the 8 patients, 2 were revisions for aseptic loosening around proximal humeral endoprosthetic replacements. Indications for surgery included chondrosarcoma in 4, metastatic disease in 2, Ewing sarcoma in 1, and osteomyelitis in 1. Patients were a mean age at diagnosis of 49 years (range, 16-78 years). One patient died of metastatic disease during follow-up. Mean follow-up was 49 months (range, 36-90 months). At the latest follow-up, there was 100% survivorship using revision as the end point. There were no local recurrences. Three of 5 patients returned to their previous occupation. Neuropathic pain developed in 1 patient postoperatively, but no other postoperative complications were noted. Radiographs showed no progressive lucencies or scapula notching. Mean range of movement at final follow-up was abduction, 62°; forward flexion, 71°; and external and internal rotation, 50°. Conclusion: The Bayley Walker prosthesis gives excellent medium-term survivorship and pain relief in patients with pathologic lesions of the proximal humerus requiring wide local excision. Level of evidence: Level IV; Case Series; Treatment Study Crown Copyright © 2017 All rights reserved. Keywords: Bayley Walker prosthesis; reverse shoulder EPR; pathological lesions of the proximal humerus; reverse shoulder arthroplasty; rotator cuff arthropathy; bone tumours
IRB statement missing *Reprint requests: Shahbaz S. Malik, MSc (Orth Eng), FRCS (Tr & Orth), Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, The Woodlands, Bristol Rd S, Birmingham B31 2AP, UK. E-mail address: [email protected] (S.S. Malik). 1058-2746/$ - see front matter Crown Copyright © 2017 All rights reserved. http://dx.doi.org/10.1016/j.jse.2017.04.005
The proximal humerus is a common site of primary and secondary bone malignancy. Owing to vague symptoms and late presentation, operative intervention is usually radical and reconstruction is complex. Surgical treatment of extracompartmental bone tumors (ie, S3, S4, S5 according
ARTICLE IN PRESS 2
S. Maclean et al.
to Musculoskeletal Tumor Society [MSTS] classification)6 often requires resection of the rotator cuff. The primary orthopedic aim is curative, and the secondary aim is to relieve pain, and lastly, but importantly, to attempt to preserve function. Reconstruction options involve allograft,7 allograftprosthesis composite,1 vascularized graft,11 or prosthetic reconstruction.9 The Bayley Walker prosthesis (Stanmore Implants, Elstree, UK) is a reverse-polarity fixed-fulcrum total shoulder replacement designed for patients who may have rotator cuff arthropathy, disruption of superior coracoacromial arch, and difficult reconstruction.2 Biomechanically, the reverse polarity design allows for medialization of the center of rotation, thereby enhancing deltoid function and stability by increasing the moment arm. This is of particular importance if the proximal humerus and rotator cuff are resected or dysfunctional.11 The design of prosthesis allows it to be used in the treatment of bone tumors. The highly constrained design helps prevent subluxation of the prosthesis, particularly when radical resection involves division of the shoulder girdle muscles: the teres major, pectoralis major, and latissimus dorsi. Recent studies, however, report concern over the presence of loosening and scapula notching when reverse prostheses are used after tumor resection.3 The glenoid component of the Bayley Walker prosthesis is designed as a long hydroxyapatite (HA)-coated tapered helical screw with a larger thread pitch and depth. This maximizes bending and torsional fixation. The HA-coated glenoid plate further augments the fixation by direct transfer of part of the compressive force and the sagittal bending moment.2 A designer series has reported good results at 5 years.8 We aimed to report our independent series at an orthopedic tumor unit, focusing on implant survival, radiologic assessment, and functional outcome.
Materials and methods We searched our database, which holds prospectively gathered data on more than 35,000 patients, including more than 3800 primary bone sarcomas, to identify patients who underwent resection of the
Table I
proximal humerus for a bone sarcoma, followed by reconstruction using reverse total shoulder arthroplasty (RTSA). The data included patients’ demographics, histologic diagnosis, and any subsequent complications. The diagnosis and management of each patient was decided after a multidisciplinary discussion within our supraregional bone tumor unit. Neoadjuvant and adjuvant chemotherapy, as well as radiotherapy, were administered to sensitive cases using standard protocols. A deltopectoral approach was used in all operations. This approach has the advantage that it can be extended to allow access to the appropriate resection level while also providing an excellent view for reconstruction. The biopsy tract was excised in all cases in continuity with the tumor. The cephalic vein was mobilized and retracted laterally or medially. The pectoralis insertion on the humerus was identified, released, and tagged. The deltoid was retracted laterally, and its insertion on the humerus was detached and tagged. If required, the teres major and latissimus dorsi were released from the humerus and tagged. The axillary nerve was systematically identified beneath the subscapularis as it exits through the quadrangular space and maintained. The planned resection of the humerus was marked and a circumferential subperiosteal dissection performed at the desired level, with the brachialis reflected as required. The resection included the rotator cuff tendons and the appropriate amount of the proximal humerus. Before humeral transection, the anterior cortex of the humerus was marked with an osteotome to provide a landmark to guide the rotational placement of the implant. The triceps was subsequently released posteriorly taking care to protect the radial nerve. All patients underwent Bayley Walker reverse endoprosthetic replacement of their proximal humerus and glenoid. In cases where shoulder girdle muscles were resected from the humerus, a Trevira tube was used to reattach the tendons. This is an attachment device used in conjunction with the Bayley Walker prosthesis and manufactured from polyethylene terephthalate. There was at least partial preservation of the deltoid in all cases and preservation of the axillary nerve. Demographics and resection margins are summarized in Table I. All patients were protected in a sling for 6 weeks. Most were permitted to undergo passive range of motion exercises under physiotherapy supervision. This initially consisted of pendulum exercises. Active shoulder rehabilitation was instigated at the 6-week postoperative clinic check and only after a satisfactory shoulder radiograph was obtained. Patients subsequently underwent a gradual strengthening and range of motion program.
Patient demographics, diagnosis, resection margins, and level
Patient
Age (y)
Sex
Diagnosis
Resection margin (MSTS)
Resection level (cm)
Trevira tube used?
1 2 3 4 5 6 7 8
20 51 64 16 26 64 78 69
M F M F F F F F
Chondrosarcoma Chondrosarcoma Chondrosarcoma Ewing sarcoma Chondrosarcoma Metastases Osteomyelitis Metastases
S5 S5 S1,2,3 S4 S5 S4 S4 S4
21 12 Anatomic neck 10 11 9.5 10 10
No Yes No Yes Yes No Yes No
F, female; M, male; MSTS, Musculoskeletal Tumor Society; y; years.
ARTICLE IN PRESS Reverse shoulder endoprosthesis for humeral lesions
A
3
B
Figure 1 (A) Preoperative x-ray image of patient 6 with breast metastasis. (B) Postoperative x-ray image of patient 6 after implant of the Bayley Walker prosthesis (Stanmore Implants, Elstree, UK). Table II
Mean scores, lucency, and notching for each patient
Patient
Follow-up (mo)
TESS score (%)
MSTS score (%)
Progressive lucencies?
Scapula notching— Sirveaux grade
1 2 3 4 5 6 7 8
36 39 — 55 54 45 36 37
68.40 42.80 — 73.50 54.80 67.10 73.60 58.60
56.70 43.30 — 70.00 53.30 66.70 73.30 56.70
No No No No No Yes No No
1 0 0 0 0 1 0 0
MSTS, Musculoskeletal Tumor Society; TESS, Toronto Extremity Scoring System.
Postoperative surveillance comprised clinical examination for local recurrence, with subsequent magnetic resonance imaging on the basis of examination findings and chest radiography, with subsequent computed tomography on the basis of radiography findings for systemic disease. Each RTSA implant underwent serial plain radiographic assessment. All patients managed at our unit undergo standard postoperative sarcoma follow-up consisting of a review at 3-month intervals for the first 2 years, 6-month intervals until 5 years, and annually until 10 years after resection. Shoulder range of motion was documented, and functional assessment was performed using the MSTS scoring system and the Toronto Extremity Scoring System (TESS). Resection level was classified using the MSTS and was measured from the superior aspect of the humeral head with a mean length of 9.3 cm (range, 9.5-21 cm). According to the MSTS classification, 3 patients were S5, 3 patients were S4 (Fig. 1), and 1 patient was S1,2,3.
Results The 8 patients (2 men and 6 women) in the study (Table I) were a mean age of 49 years (range, 16-78 years) at the time of the procedure. Mean follow-up was 43 months (range, 3655 months). Two procedures were revisions: one for aseptic loosening around a previous proximal humeral replacement and the other because of a subluxing hemiarthroplasty. One patient with streptococcal osteomyelitis underwent a previ-
ous resection, and an antibiotic-loaded cement spacer was implanted 6 weeks before insertion of the Bayley Walker prosthesis. Radiologic and functional outcomes are reported in Table II. The mean TESS score was 62.7%, and the mean MSTS score was 60.0%. Three of 5 working patients returned to their previous occupation. Mean range of movement at final followup was abduction, 62°; forward flexion, 71°; and external and internal rotation, 50°. At the latest follow-up, there was 100% survivorship using revision surgery as the end point. There were no local recurrences. Neuropathic pain developed in 1 patient postoperatively, but there were no other postoperative complications. Asymptomatic signs of loosening and scapula notching were noted in 1 patient (Table II). No patients needed further procedures. One patient died of metastatic disease 8 months after an uneventful procedure.
Discussion We have shown that excellent early survivorship can be achieved using the Bayley Walker reverse endoprosthetic replacement for destructive lesions of the proximal humerus. This implant offers not only pain relief but also restoration of the joint with a replacement type that is not otherwise
ARTICLE IN PRESS 4
S. Maclean et al.
A
B
Figure 2 (A) Preoperative x-ray image of patient 3 with grade 1 chondrosarcoma. (B) Postoperative x-ray image of patient 6 after implant of the Bayley Walker prosthesis (Stanmore Implants, Elstree, United Kingdom).
available by a surface replacement in a rotator cuff–deficient shoulder.8 The mean TESS score was 62.7%, and the mean MSTS score was 60.0%. Compared with a series by Griffiths et al,8 these scores are slightly less than those in their series of 42 patients where the mean MSTS score was 72.3% (range, 53.3%-100%) and the mean TESS was 77.2% (range, 58.6%100%). The mean MSTS score in a series by Bonnevialle et al3 was 20.25 points (range, 7-29 points), whereas De Wilde et al4 reported a mean MSTS score of 90% to 96.7% in their series of 4 patients who underwent reverse shoulder arthroplasty with a Delta 3.1 (DePuy, Warsaw, IN, USA). Functional scores in our series were lower in 3 of the chondrosarcoma patients (patients 1, 2, and 5). This is unsurprising, given the greater resection margins in this cohort. By excluding these scores, the overall TESS score increased to 68.2%, and the MSTS score increased to 66.7% for the remaining 4 patients. Griffiths et al8 also showed a decrease in the MSTS score for malignant (71.4%) vs. benign cases (77.2%). Radiologic results were encouraging in our study. A low rate of loosening of either component occurred in 1 patient. This may be partly the result of successful osteointegration of the HA-coated components. A histologic analysis performed by Griffiths et al 8 of the humeral and glenoid components showed osteoid formation in direct contact with HA-coated surface. This they put down to complete osteointegration. No loosening occurred in their series. In a series by Bonnevialle et al,3 who analyzed 8 patients undergoing reverse shoulder arthroplasty for tumors of the proximal humerus, 3 patients had scapular notching, 2 patients had a radiolucent line, and 1 patient had humeral component loosening. Loosening occurred in the patient who had a long cemented humeral stem, and radiolucency was present in the standard humeral stem without any coating. This patient, however, did have radiotherapy. These last 2 patients also had glenoid spurs.
Functional results in our series are acceptable. Of 5 working patients, 3 managed to return to the same office-based jobs postoperatively. Range of movement overall was adequate but not enough to allow activities at shoulder height or above. Although partial preservation of deltoid occurred in our cohort, deltoid over-reliance and fatigue is inevitable. Encouragingly, patients retained acceptable rotational movements; however, lower range of movement was predictably found in 3 of the chondrosarcoma patients (patients 1, 2, and 5) because of greater resection margins in this cohort (Fig. 2). De Wilde et al4 also reported outcomes of reverse shoulder arthroplasty after resection of malignant proximal humeral tumors but mostly looked at the function. They reviewed 9 of 14 patients (6 patients died) at final follow-up. Three patients had benign tumor, 3 had osteosarcoma, 5 had chondrosarcomas, 2 had metastasis, and 1 had malignant synovial sarcoma. At the last follow-up, mean active abduction was 157° vs. 135° in those without muscle transfer. External rotation in the group with muscle transfer was 60° in abduction compared with 17° in the group without muscle transfer. In our series, mean range of movement at final followup was abduction, 62°; forward flexion, 71°; and external and internal rotation, 50°. In the Bonnevialle et al3 series, mean forward elevation was 122°, external rotation at the side was −2°, and internal rotation was to L4. The decreased range of abduction (less than 90°)4 is acceptable in patients as in our series where there is large resection or biologic reconstruction. One of the problems in previous series has been found with the use of humeral allograft, leading to resorption and component loosening (Table III). We found a low rate of progressive scapula notching. This may have resulted from the glenoid component being placed in a more inferior position than in previous studies. Problems have been reported with the use of autograft10,12 (fibula, clavicle) allograftprosthesis composite,7 and allograft reconstruction of the proximal humerus.1
ARTICLE IN PRESS Reverse shoulder endoprosthesis for humeral lesions Table III
5
Functional results by implant types in treatment of proximal humeral tumors and their complications
Study
Implant
Griffiths et al,8 Bayley Walker*
Patients, No.
Mean ROM
Mean MSTS
Loosening
42
—
72.3%
None
Bonnevialle et al,3
1. Delta Xtend† 10 2. Delta3† 3. Aequalis Reversed‡
FF: 122° ER: –2° IR: L4
De Wilde et al5 2005 De Wilde et al4 2011
Delta3.1
Abd: 175°
This study
4
Complication
Dislocations (×14) 2 deep infections 67.5% 4 scapular notching Instability (×2), 1 1 loosening requiring 1 lucency disarticulation Brachial plexus injury 90%-96.7% Nil Nil
7 (without muscle Abd: 163° — 1. Delta3.1† transfer) 2. Delta CTA† 3. Delta Xtend† 4. Aequalis Reversed‡ 8 Abd: 62° 60% Bayley Walker* FF: 71° ER/IR: 50°
1 aseptic loosening 2 dislocations 1 septic loosening 1 deep infection 4 scapular notching 2 scapular notching Neuropathic pain (×1) 1 lucency Asymptomatic loosening Scapular notching (×1)
Abd, abduction; ER, external rotation; FF, forward flexion; IR, internal rotation; MSTS; Musculoskeletal Tumor Society, ROM, range of motion. * Stanmore Implants, Elstree, UK. † Depuy, Warsaw, IN, USA. ‡ Tornier, Montbonnot, France.
Conclusion 4.
We have shown good results for limb-salvage surgery for tumors of the proximal humerus. Our results have shown that survivorship and acceptable clinical and radiologic outcome can be achieved in a specialist onco-orthopedic unit using the reverse Bayley Walker prosthesis.
5.
6.
Disclaimer
7.
The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
8.
9.
References 1. Abdeen A, Hoang BH, Athanasian EA, Morris CD, Boland PJ, Healey JH. Allograft-prosthesis composite reconstruction of the proximal part of the humerus: functional outcome and survivorship. J Bone Joint Surg Am 2009;91-A:2406-15. http://dx.doi.org/10.2106/JBJS.H.00815 2. Ahir SP, Walker PS, Squire-Taylor CJ, Blunn GW, Bayley JI. Analysis of glenoid fixation for a reversed anatomy fixed-fulcrum shoulder replacement. J Biomech 2004;37:1699-708. http://dx.doi.org/10.1016/ j.jbiomech.2004.01.031 3. Bonnevialle N, Mansat P, Lebon J, Laffosse JM, Bonnevialle P. Reverse shoulder arthroplasty for malignant tumors of proximal humerus. J
10.
11.
12.
Shoulder Elbow Surg 2015;24:36-44. http://dx.doi.org/10.1016/ j.jse.2014.04.006 De Wilde LF, Boileau P, Van der Bracht H. Does reverse shoulder arthroplasty for tumors of the proximal humerus reduce impairment? Clin Orthop Relat Res 2011;469:2489-95. http://dx.doi.org/10.1007/ s11999-010-1758-x De Wilde LF, Plasschaert FS, Audenaert EA, Verdonk RC. Functional recovery after a reverse prosthesis for reconstruction of the proximal humerus in tumor surgery. Clin Orthop Relat Res 2005;430:156-62. Enneking W, Dunham W, Gebhardt M, Malawer M, Pritchard D. A system for the classification of skeletal resections. Chir Organi Mov 1990;75(Suppl):217-40. Getty PJ, Peabody TD. Complications and functional outcomes of reconstruction with an osteoarticular allograft after intra-articular resection of the proximal aspect of the humerus. J Bone Joint Surg Am 1999;81A:1138-46. Griffiths D, Gikas PD, Jowett C, Bayliss L, Aston W, Skinner J, et al. Proximal humeral replacement using a fixed-fulcrum endoprosthesis. J Bone Joint Surg Br 2011;93:399-403. http://dx.doi.org/10.1302/ 0301-620X.93B3.24421 Kumar D, Grimer RJ, Abudu A, Carter SR, Tillman RM. Endoprosthetic replacement of the proximal humerus: long-term results. J Bone Joint Surg Br 2003;85-B:717-22. http://dx.doi.org/10.1302/0301-620X .85B5.13588 Tsukushi S, Nishida Y, Takahashi M, Ishiguro N. Clavicula pro humero reconstruction after wide resection of the proximal humerus. Clin Orthop Relat Res 2006;447:132-7. van der Helm FC. The “reversed” glenohumeral endoprosthesis: the role of the rotator cuff muscles for stability and strength. J Biomech 1998;31(Suppl 1):27. Wada T, Usui M, Isu K, Yamawakii S, Ishii S. Reconstruction and limb salvage after resection for malignant bone tumour of the proximal humerus: a sling procedure using a free vascularised fibular graft. J Bone Joint Surg Br 1999;81-B:808-13.
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ORIGINAL ARTICLE
Reverse shoulder endoprosthesis for pathologic lesions of the proximal humerus: a minimum 3-year follow-up Simon Maclean, FRCS (Tr & Orth), Shahbaz S. Malik, MSc (Orth Eng), FRCS (Tr & Orth)*, Scott Evans, FRCS (Tr & Orth), Jonathan Gregory, FRCS (Tr & Orth), Lee Jeys, FRCS (Tr & Orth) Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, Birmingham, UK Background: The Bayley Walker (Stanmore Implants, Elstree, UK) reversed polarity, linked shoulder replacement is designed to provide stable function in the treatment of a painful shoulder with poor soft tissue coverage. We reviewed the results of the prosthesis in destructive pathologic lesions of the proximal humerus at a United Kingdom tumor center. Methods: We identified 8 patients (2 men, 6 women) in our database. Clinical information and functional outcome scores were collected, including range of movement, Toronto Extremity Salvage Score, the Musculoskeletal Tumor Score. Radiographs from the last clinic follow-up were analyzed. Results: Of the 8 patients, 2 were revisions for aseptic loosening around proximal humeral endoprosthetic replacements. Indications for surgery included chondrosarcoma in 4, metastatic disease in 2, Ewing sarcoma in 1, and osteomyelitis in 1. Patients were a mean age at diagnosis of 49 years (range, 16-78 years). One patient died of metastatic disease during follow-up. Mean follow-up was 49 months (range, 36-90 months). At the latest follow-up, there was 100% survivorship using revision as the end point. There were no local recurrences. Three of 5 patients returned to their previous occupation. Neuropathic pain developed in 1 patient postoperatively, but no other postoperative complications were noted. Radiographs showed no progressive lucencies or scapula notching. Mean range of movement at final follow-up was abduction, 62°; forward flexion, 71°; and external and internal rotation, 50°. Conclusion: The Bayley Walker prosthesis gives excellent medium-term survivorship and pain relief in patients with pathologic lesions of the proximal humerus requiring wide local excision. Level of evidence: Level IV; Case Series; Treatment Study Crown Copyright © 2017 All rights reserved. Keywords: Bayley Walker prosthesis; reverse shoulder EPR; pathological lesions of the proximal humerus; reverse shoulder arthroplasty; rotator cuff arthropathy; bone tumours
IRB statement missing *Reprint requests: Shahbaz S. Malik, MSc (Orth Eng), FRCS (Tr & Orth), Department of Orthopaedic Oncology, The Royal Orthopaedic Hospital, The Woodlands, Bristol Rd S, Birmingham B31 2AP, UK. E-mail address: [email protected] (S.S. Malik). 1058-2746/$ - see front matter Crown Copyright © 2017 All rights reserved. http://dx.doi.org/10.1016/j.jse.2017.04.005
The proximal humerus is a common site of primary and secondary bone malignancy. Owing to vague symptoms and late presentation, operative intervention is usually radical and reconstruction is complex. Surgical treatment of extracompartmental bone tumors (ie, S3, S4, S5 according
ARTICLE IN PRESS 2
S. Maclean et al.
to Musculoskeletal Tumor Society [MSTS] classification)6 often requires resection of the rotator cuff. The primary orthopedic aim is curative, and the secondary aim is to relieve pain, and lastly, but importantly, to attempt to preserve function. Reconstruction options involve allograft,7 allograftprosthesis composite,1 vascularized graft,11 or prosthetic reconstruction.9 The Bayley Walker prosthesis (Stanmore Implants, Elstree, UK) is a reverse-polarity fixed-fulcrum total shoulder replacement designed for patients who may have rotator cuff arthropathy, disruption of superior coracoacromial arch, and difficult reconstruction.2 Biomechanically, the reverse polarity design allows for medialization of the center of rotation, thereby enhancing deltoid function and stability by increasing the moment arm. This is of particular importance if the proximal humerus and rotator cuff are resected or dysfunctional.11 The design of prosthesis allows it to be used in the treatment of bone tumors. The highly constrained design helps prevent subluxation of the prosthesis, particularly when radical resection involves division of the shoulder girdle muscles: the teres major, pectoralis major, and latissimus dorsi. Recent studies, however, report concern over the presence of loosening and scapula notching when reverse prostheses are used after tumor resection.3 The glenoid component of the Bayley Walker prosthesis is designed as a long hydroxyapatite (HA)-coated tapered helical screw with a larger thread pitch and depth. This maximizes bending and torsional fixation. The HA-coated glenoid plate further augments the fixation by direct transfer of part of the compressive force and the sagittal bending moment.2 A designer series has reported good results at 5 years.8 We aimed to report our independent series at an orthopedic tumor unit, focusing on implant survival, radiologic assessment, and functional outcome.
Materials and methods We searched our database, which holds prospectively gathered data on more than 35,000 patients, including more than 3800 primary bone sarcomas, to identify patients who underwent resection of the
Table I
proximal humerus for a bone sarcoma, followed by reconstruction using reverse total shoulder arthroplasty (RTSA). The data included patients’ demographics, histologic diagnosis, and any subsequent complications. The diagnosis and management of each patient was decided after a multidisciplinary discussion within our supraregional bone tumor unit. Neoadjuvant and adjuvant chemotherapy, as well as radiotherapy, were administered to sensitive cases using standard protocols. A deltopectoral approach was used in all operations. This approach has the advantage that it can be extended to allow access to the appropriate resection level while also providing an excellent view for reconstruction. The biopsy tract was excised in all cases in continuity with the tumor. The cephalic vein was mobilized and retracted laterally or medially. The pectoralis insertion on the humerus was identified, released, and tagged. The deltoid was retracted laterally, and its insertion on the humerus was detached and tagged. If required, the teres major and latissimus dorsi were released from the humerus and tagged. The axillary nerve was systematically identified beneath the subscapularis as it exits through the quadrangular space and maintained. The planned resection of the humerus was marked and a circumferential subperiosteal dissection performed at the desired level, with the brachialis reflected as required. The resection included the rotator cuff tendons and the appropriate amount of the proximal humerus. Before humeral transection, the anterior cortex of the humerus was marked with an osteotome to provide a landmark to guide the rotational placement of the implant. The triceps was subsequently released posteriorly taking care to protect the radial nerve. All patients underwent Bayley Walker reverse endoprosthetic replacement of their proximal humerus and glenoid. In cases where shoulder girdle muscles were resected from the humerus, a Trevira tube was used to reattach the tendons. This is an attachment device used in conjunction with the Bayley Walker prosthesis and manufactured from polyethylene terephthalate. There was at least partial preservation of the deltoid in all cases and preservation of the axillary nerve. Demographics and resection margins are summarized in Table I. All patients were protected in a sling for 6 weeks. Most were permitted to undergo passive range of motion exercises under physiotherapy supervision. This initially consisted of pendulum exercises. Active shoulder rehabilitation was instigated at the 6-week postoperative clinic check and only after a satisfactory shoulder radiograph was obtained. Patients subsequently underwent a gradual strengthening and range of motion program.
Patient demographics, diagnosis, resection margins, and level
Patient
Age (y)
Sex
Diagnosis
Resection margin (MSTS)
Resection level (cm)
Trevira tube used?
1 2 3 4 5 6 7 8
20 51 64 16 26 64 78 69
M F M F F F F F
Chondrosarcoma Chondrosarcoma Chondrosarcoma Ewing sarcoma Chondrosarcoma Metastases Osteomyelitis Metastases
S5 S5 S1,2,3 S4 S5 S4 S4 S4
21 12 Anatomic neck 10 11 9.5 10 10
No Yes No Yes Yes No Yes No
F, female; M, male; MSTS, Musculoskeletal Tumor Society; y; years.
ARTICLE IN PRESS Reverse shoulder endoprosthesis for humeral lesions
A
3
B
Figure 1 (A) Preoperative x-ray image of patient 6 with breast metastasis. (B) Postoperative x-ray image of patient 6 after implant of the Bayley Walker prosthesis (Stanmore Implants, Elstree, UK). Table II
Mean scores, lucency, and notching for each patient
Patient
Follow-up (mo)
TESS score (%)
MSTS score (%)
Progressive lucencies?
Scapula notching— Sirveaux grade
1 2 3 4 5 6 7 8
36 39 — 55 54 45 36 37
68.40 42.80 — 73.50 54.80 67.10 73.60 58.60
56.70 43.30 — 70.00 53.30 66.70 73.30 56.70
No No No No No Yes No No
1 0 0 0 0 1 0 0
MSTS, Musculoskeletal Tumor Society; TESS, Toronto Extremity Scoring System.
Postoperative surveillance comprised clinical examination for local recurrence, with subsequent magnetic resonance imaging on the basis of examination findings and chest radiography, with subsequent computed tomography on the basis of radiography findings for systemic disease. Each RTSA implant underwent serial plain radiographic assessment. All patients managed at our unit undergo standard postoperative sarcoma follow-up consisting of a review at 3-month intervals for the first 2 years, 6-month intervals until 5 years, and annually until 10 years after resection. Shoulder range of motion was documented, and functional assessment was performed using the MSTS scoring system and the Toronto Extremity Scoring System (TESS). Resection level was classified using the MSTS and was measured from the superior aspect of the humeral head with a mean length of 9.3 cm (range, 9.5-21 cm). According to the MSTS classification, 3 patients were S5, 3 patients were S4 (Fig. 1), and 1 patient was S1,2,3.
Results The 8 patients (2 men and 6 women) in the study (Table I) were a mean age of 49 years (range, 16-78 years) at the time of the procedure. Mean follow-up was 43 months (range, 3655 months). Two procedures were revisions: one for aseptic loosening around a previous proximal humeral replacement and the other because of a subluxing hemiarthroplasty. One patient with streptococcal osteomyelitis underwent a previ-
ous resection, and an antibiotic-loaded cement spacer was implanted 6 weeks before insertion of the Bayley Walker prosthesis. Radiologic and functional outcomes are reported in Table II. The mean TESS score was 62.7%, and the mean MSTS score was 60.0%. Three of 5 working patients returned to their previous occupation. Mean range of movement at final followup was abduction, 62°; forward flexion, 71°; and external and internal rotation, 50°. At the latest follow-up, there was 100% survivorship using revision surgery as the end point. There were no local recurrences. Neuropathic pain developed in 1 patient postoperatively, but there were no other postoperative complications. Asymptomatic signs of loosening and scapula notching were noted in 1 patient (Table II). No patients needed further procedures. One patient died of metastatic disease 8 months after an uneventful procedure.
Discussion We have shown that excellent early survivorship can be achieved using the Bayley Walker reverse endoprosthetic replacement for destructive lesions of the proximal humerus. This implant offers not only pain relief but also restoration of the joint with a replacement type that is not otherwise
ARTICLE IN PRESS 4
S. Maclean et al.
A
B
Figure 2 (A) Preoperative x-ray image of patient 3 with grade 1 chondrosarcoma. (B) Postoperative x-ray image of patient 6 after implant of the Bayley Walker prosthesis (Stanmore Implants, Elstree, United Kingdom).
available by a surface replacement in a rotator cuff–deficient shoulder.8 The mean TESS score was 62.7%, and the mean MSTS score was 60.0%. Compared with a series by Griffiths et al,8 these scores are slightly less than those in their series of 42 patients where the mean MSTS score was 72.3% (range, 53.3%-100%) and the mean TESS was 77.2% (range, 58.6%100%). The mean MSTS score in a series by Bonnevialle et al3 was 20.25 points (range, 7-29 points), whereas De Wilde et al4 reported a mean MSTS score of 90% to 96.7% in their series of 4 patients who underwent reverse shoulder arthroplasty with a Delta 3.1 (DePuy, Warsaw, IN, USA). Functional scores in our series were lower in 3 of the chondrosarcoma patients (patients 1, 2, and 5). This is unsurprising, given the greater resection margins in this cohort. By excluding these scores, the overall TESS score increased to 68.2%, and the MSTS score increased to 66.7% for the remaining 4 patients. Griffiths et al8 also showed a decrease in the MSTS score for malignant (71.4%) vs. benign cases (77.2%). Radiologic results were encouraging in our study. A low rate of loosening of either component occurred in 1 patient. This may be partly the result of successful osteointegration of the HA-coated components. A histologic analysis performed by Griffiths et al 8 of the humeral and glenoid components showed osteoid formation in direct contact with HA-coated surface. This they put down to complete osteointegration. No loosening occurred in their series. In a series by Bonnevialle et al,3 who analyzed 8 patients undergoing reverse shoulder arthroplasty for tumors of the proximal humerus, 3 patients had scapular notching, 2 patients had a radiolucent line, and 1 patient had humeral component loosening. Loosening occurred in the patient who had a long cemented humeral stem, and radiolucency was present in the standard humeral stem without any coating. This patient, however, did have radiotherapy. These last 2 patients also had glenoid spurs.
Functional results in our series are acceptable. Of 5 working patients, 3 managed to return to the same office-based jobs postoperatively. Range of movement overall was adequate but not enough to allow activities at shoulder height or above. Although partial preservation of deltoid occurred in our cohort, deltoid over-reliance and fatigue is inevitable. Encouragingly, patients retained acceptable rotational movements; however, lower range of movement was predictably found in 3 of the chondrosarcoma patients (patients 1, 2, and 5) because of greater resection margins in this cohort (Fig. 2). De Wilde et al4 also reported outcomes of reverse shoulder arthroplasty after resection of malignant proximal humeral tumors but mostly looked at the function. They reviewed 9 of 14 patients (6 patients died) at final follow-up. Three patients had benign tumor, 3 had osteosarcoma, 5 had chondrosarcomas, 2 had metastasis, and 1 had malignant synovial sarcoma. At the last follow-up, mean active abduction was 157° vs. 135° in those without muscle transfer. External rotation in the group with muscle transfer was 60° in abduction compared with 17° in the group without muscle transfer. In our series, mean range of movement at final followup was abduction, 62°; forward flexion, 71°; and external and internal rotation, 50°. In the Bonnevialle et al3 series, mean forward elevation was 122°, external rotation at the side was −2°, and internal rotation was to L4. The decreased range of abduction (less than 90°)4 is acceptable in patients as in our series where there is large resection or biologic reconstruction. One of the problems in previous series has been found with the use of humeral allograft, leading to resorption and component loosening (Table III). We found a low rate of progressive scapula notching. This may have resulted from the glenoid component being placed in a more inferior position than in previous studies. Problems have been reported with the use of autograft10,12 (fibula, clavicle) allograftprosthesis composite,7 and allograft reconstruction of the proximal humerus.1
ARTICLE IN PRESS Reverse shoulder endoprosthesis for humeral lesions Table III
5
Functional results by implant types in treatment of proximal humeral tumors and their complications
Study
Implant
Griffiths et al,8 Bayley Walker*
Patients, No.
Mean ROM
Mean MSTS
Loosening
42
—
72.3%
None
Bonnevialle et al,3
1. Delta Xtend† 10 2. Delta3† 3. Aequalis Reversed‡
FF: 122° ER: –2° IR: L4
De Wilde et al5 2005 De Wilde et al4 2011
Delta3.1
Abd: 175°
This study
4
Complication
Dislocations (×14) 2 deep infections 67.5% 4 scapular notching Instability (×2), 1 1 loosening requiring 1 lucency disarticulation Brachial plexus injury 90%-96.7% Nil Nil
7 (without muscle Abd: 163° — 1. Delta3.1† transfer) 2. Delta CTA† 3. Delta Xtend† 4. Aequalis Reversed‡ 8 Abd: 62° 60% Bayley Walker* FF: 71° ER/IR: 50°
1 aseptic loosening 2 dislocations 1 septic loosening 1 deep infection 4 scapular notching 2 scapular notching Neuropathic pain (×1) 1 lucency Asymptomatic loosening Scapular notching (×1)
Abd, abduction; ER, external rotation; FF, forward flexion; IR, internal rotation; MSTS; Musculoskeletal Tumor Society, ROM, range of motion. * Stanmore Implants, Elstree, UK. † Depuy, Warsaw, IN, USA. ‡ Tornier, Montbonnot, France.
Conclusion 4.
We have shown good results for limb-salvage surgery for tumors of the proximal humerus. Our results have shown that survivorship and acceptable clinical and radiologic outcome can be achieved in a specialist onco-orthopedic unit using the reverse Bayley Walker prosthesis.
5.
6.
Disclaimer
7.
The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
8.
9.
References 1. Abdeen A, Hoang BH, Athanasian EA, Morris CD, Boland PJ, Healey JH. Allograft-prosthesis composite reconstruction of the proximal part of the humerus: functional outcome and survivorship. J Bone Joint Surg Am 2009;91-A:2406-15. http://dx.doi.org/10.2106/JBJS.H.00815 2. Ahir SP, Walker PS, Squire-Taylor CJ, Blunn GW, Bayley JI. Analysis of glenoid fixation for a reversed anatomy fixed-fulcrum shoulder replacement. J Biomech 2004;37:1699-708. http://dx.doi.org/10.1016/ j.jbiomech.2004.01.031 3. Bonnevialle N, Mansat P, Lebon J, Laffosse JM, Bonnevialle P. Reverse shoulder arthroplasty for malignant tumors of proximal humerus. J
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Shoulder Elbow Surg 2015;24:36-44. http://dx.doi.org/10.1016/ j.jse.2014.04.006 De Wilde LF, Boileau P, Van der Bracht H. Does reverse shoulder arthroplasty for tumors of the proximal humerus reduce impairment? Clin Orthop Relat Res 2011;469:2489-95. http://dx.doi.org/10.1007/ s11999-010-1758-x De Wilde LF, Plasschaert FS, Audenaert EA, Verdonk RC. Functional recovery after a reverse prosthesis for reconstruction of the proximal humerus in tumor surgery. Clin Orthop Relat Res 2005;430:156-62. Enneking W, Dunham W, Gebhardt M, Malawer M, Pritchard D. A system for the classification of skeletal resections. Chir Organi Mov 1990;75(Suppl):217-40. Getty PJ, Peabody TD. Complications and functional outcomes of reconstruction with an osteoarticular allograft after intra-articular resection of the proximal aspect of the humerus. J Bone Joint Surg Am 1999;81A:1138-46. Griffiths D, Gikas PD, Jowett C, Bayliss L, Aston W, Skinner J, et al. Proximal humeral replacement using a fixed-fulcrum endoprosthesis. J Bone Joint Surg Br 2011;93:399-403. http://dx.doi.org/10.1302/ 0301-620X.93B3.24421 Kumar D, Grimer RJ, Abudu A, Carter SR, Tillman RM. Endoprosthetic replacement of the proximal humerus: long-term results. J Bone Joint Surg Br 2003;85-B:717-22. http://dx.doi.org/10.1302/0301-620X .85B5.13588 Tsukushi S, Nishida Y, Takahashi M, Ishiguro N. Clavicula pro humero reconstruction after wide resection of the proximal humerus. Clin Orthop Relat Res 2006;447:132-7. van der Helm FC. The “reversed” glenohumeral endoprosthesis: the role of the rotator cuff muscles for stability and strength. J Biomech 1998;31(Suppl 1):27. Wada T, Usui M, Isu K, Yamawakii S, Ishii S. Reconstruction and limb salvage after resection for malignant bone tumour of the proximal humerus: a sling procedure using a free vascularised fibular graft. J Bone Joint Surg Br 1999;81-B:808-13.