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Shoulder function after extensive total deltoid excision for treatment of soft-tissue sarcoma: A case report
Shoulder function after extensive total deltoid excision for treatment of soft-tissue sarcoma: A case report Toshihisa Osanai, MD, PhD, Takashi Tsuchiya, MD, PhD, Nariyuki Mura, MD, PhD, and Toshihiko Ogino, MD, PhD Yamagata, Japan
F or radical excision of a soft-tissue sarcoma, we need
to remove the tumor and the entire anatomic compartment within which it is located. Although the shoulder girdle is one of the most common primary sites of softtissue sarcomas, we could find only 1 report describing shoulder function after total deltoid excision, combined with resection of the distal clavicle and the acromion (extensive total deltoid excision).9 We report on the shoulder function of a patient after extensive total deltoid excision for treatment of a soft-tissue sarcoma of the deltoid muscle.
CASE REPORT A 28-year-old man had a 1-year history of a slowly growing mass in his left shoulder and was referred to our hospital. Physical examinations revealed an immobile, hard, elastic mass with a maximum diameter of 13 cm (Figure 1). The range of passive motion of the shoulder was limited to 50° of abduction, flexion, and extension. He had active abduction of 20°, active flexion of 30°, and active extension of 25°, with strength of 4/5 on manual muscle testing. Magnetic resonance imaging revealed a large softtissue tumor in the deltoid muscle measuring 10 ⫻ 11 ⫻ 12 cm. The tumor was adjacent to the humerus, but there was no cortical erosion or medullary involvement. T1-weighted images showed a homogeneous low-intensity lesion, and T2-weighted images showed a heterogeneous intermediateto high-intensity lesion (Figure 2, A). T1-weighted images after gadolinium injection demonstrated heterogeneous enhancement (Figure 2, B). Computed tomography scans of the chest, abdomen, and pelvis showed no abnormalities. Technetium 99m– hydroxymethylene diphosphonate bone scintigraphy revealed no abnormal uptake in the humerus. We performed an incisional biopsy, and the pathologic diagnosis was low-grade fibromyxoid sarcoma. For radical excision of the tumor, we successfully performed total deltoid excision, combined with resection of From the Department of Orthopaedic Surgery, Yamagata University School of Medicine. Reprint requests: Toshihisa Osanai, MD, PhD, Department of Orthopaedic Surgery, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan (E-mail: osanait@ med.id.yamagata-u.ac.jp). J Shoulder Elbow Surg 2007;16:e9-e12. Copyright © 2007 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2007/$32.00 doi:10.1016/j.jse.2006.04.004
Figure 1 The anterior view of the patient shows a large tumor in his left shoulder.
the distal clavicle, the acromion, and the scapular spine (Figure 3). There was no additional treatment, such as chemotherapy or radiotherapy. At the end of the fifth, tenth, fifteenth, and twentieth postoperative weeks, the patient attained active shoulder abduction of 45°, 85°, 100°, and 115° and active shoulder flexion of 75°, 90°, 105°, and 115°, respectively. Twenty months after the operation, he had active abduction of 140° (Figure 4), flexion of 145°, extension of 45°, external rotation of 75°, and internal rotation of 80°. Isometric muscle strength of shoulder abduction, flexion, and extension was measured with a handheld dynamometer (microFET; Hoggan Health Industries, West Jordan, UT). Abduction strength was 39% at 90° of abduction compared with the intact side. Flexion strength was 41% at 90° of flexion. Extension strength was 53% at 0° of extension. The time-dependent changes in the muscle strength of the shoulder are shown in Figure 5. Moreover, we examined glenohumeral joint laxity by plain radiography, which did not reveal any excess laxity. The patient could lift objects and place them unassisted without any instability of the glenohumeral joint. The postoperative Musculoskeletal Tumor Society score3 was 87%, and the patient was satisfied with the result. Twenty months after surgery, there were no metastases and no local recurrence.
DISCUSSION Low-grade fibromyxoid sarcoma is a rare tumor currently characterized by a high rate of local, often repeated, recurrence and by lung metastases in a significant percent-
e9
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Osanai et al
J Shoulder Elbow Surg March/April 2007
Figure 2 Magnetic resonance images in the coronal and axial planes show the tumor located in the deltoid muscle: T2-weighted image (A) and T1-weighted image (B) after gadolinium injection and with chemical-shift fat suppression.
age of patients.4,5 A better prognosis is expected if the tumor is treated with aggressive surgery, because the effectiveness of chemotherapy and radiotherapy is doubtful. For radical local resection of a large soft-tissue sarcoma in the deltoid muscle, the compartment and all of its contents from the origin (clavicle, acromion, and scapular spine) to the insertion must be excised. Although soft-tissue sarcomas commonly develop in the shoulder region, only a few reports describe shoulder function after total and subtotal deltoid excision.7,9 The deltoid is a bulky muscle making up approximately 20% of the shoulder musculature, and it is the main elevator of the shoulder.2 Contrary to popular clinical belief, Howell et al6 demonstrated that both the supraspinatus and the deltoid muscles were equally responsible for generating torque during arm elevation in a lidocaine-induced axillary or suprascapular nerve palsy subject. Sharkey et al12 showed that the function of the infraspinatus and teres minor muscles was to exert force needed for arm elevation. In patients with deltoid paralysis as a result of complete axillary nerve palsy, an almost full range of movement of the shoulder can be attained.11 Abduction ability recovers gradually, and it is not until 1 year after axillary nerve injury that full abduction is possible.1 Markhede et al9 reported on excision of soft-tissue tumors in the shoulder region in 3 patients treated with total deltoid excision and 1 patient treated with extensive total deltoid excision. They con-
cluded that total deltoid excision resulted in only a slight impairment of shoulder function, but the course of functional recovery was not described in detail. In our case, the range of active shoulder flexion recovered more quickly than that of shoulder abduction, and the range of active flexion and abduction reached its plateau at the end of the twentieth postoperative month. In addition to all of the cuff muscle forces, the biceps, the coracobrachialis, and the pectoralis major muscles may produce a compensatory force needed for arm elevation in the aftermath of extensive total deltoid excision. Concerning the stabilizing role of the deltoid muscle, we could find several reports using cadaveric shoulders.8,10 In those experimental studies, inferior translation of the humeral head did not occur after removal of the deltoid muscle. Markhede et al9 described shoulder function after total deltoid excision, but they did not specifically mention stability or instability of the glenohumeral joint. In the case presented, we did not observe any excess joint laxity either clinically or radiologically. In fact, the lifting ability of the patient was enough to permit work as a farmer without fear of shoulder instability. To the best of our knowledge, this is the first report describing the course of functional recovery of the shoulder and the stability of the glenohumeral joint after extensive total deltoid excision. Extensive total deltoid excision is an oncologically safe procedure for resection of sarcomas in
Osanai et al
J Shoulder Elbow Surg Volume 16, Number 2
Figure 3 Cut surface of the excised tumor after extensive total deltoid excision. The arrowhead indicates an acromion, and the arrow indicates the partially excised brachialis muscle.
e11
Figure 4 Twenty months after the operation, the active shoulder abduction attained was 140°.
REFERENCES
Figure 5 Time-dependent changes in isometric muscle strength for shoulder abduction, flexion, and extension are demonstrated in relation to the nonoperative side.
the deltoid muscle. Because dysfunction of the shoulder after surgery was minimal in activities of daily living, the range of motion, muscle strength, and stability of the shoulder were acceptable to the patient.
1. Babcock JL, Wray JB. Analysis of abduction in a shoulder with deltoid paralysis due to axillary nerve injury. Clin Orthop Relat Res 1970;68:116-20. 2. Bassett RW, Browne AO, Morrey BF, An KN. Glenohumeral muscle force and moment mechanics in a position of shoulder instability. J Biomech 1990;23:405-15. 3. Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 1993;286:241-6. 4. Evans HL. Low-grade fibromyxoid sarcoma. A report of two metastasizing neoplasms having a deceptively benign appearance. Am J Clin Pathol 1987;88:615-9. 5. Folpe AL, Lane KL, Paull G, Weiss SW. Low-grade fibromyxoid sarcoma and hyalinizing spindle cell tumor with giant rosettes: a clinicopathologic study of 73 cases supporting their identity and assessing the impact of high-grade areas. Am J Surg Pathol 2000;24:1353-60. 6. Howell SM, Imobersteg AM, Seger DH, Marone PJ. Clarification of the role of the supraspinatus muscle in shoulder function. J Bone Joint Surg Am 1986;68:398-404. 7. Khruekarnchana P, Suzuki K, Fukuda H. Shoulder function after subtotal excision of the deltoid muscle and of the deltoid and infraspinatus muscles in extra-abdominal desmoid tumor: a longterm follow-up in two cases. J Shoulder Elbow Surg 2004;13: 119-22. 8. Kumar VP, Balasubramaniam P. The role of atmospheric pressure in stabilising the shoulder. J Bone Joint Surg Br 1985;67:719-21.
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Osanai et al
9. Markhede G, Monastyrski J, Stener B. Shoulder function after deltoid muscle removal. Acta Orthop Scand 1985;56: 242-4. 10. Motzkin NE, Itoi E, Morrey BF, An KN. Contribution of passive bulk tissues and deltoid to static inferior glenohumeral stability. J Shoulder Elbow Surg 1994;3:313-9.
J Shoulder Elbow Surg March/April 2007
11. Palmer SH, Ross AC. Case report. Recovery ment in patients with complete axillary nerve Surg Engl 1998;80:413-5. 12. Sharkey NA, Marder RA, Hanson PB. The contributes to elevation of the arm. 1994;12:699-708.
of shoulder movepalsy. Ann R Coll entire rotator cuff J Orthop Res
F or radical excision of a soft-tissue sarcoma, we need
to remove the tumor and the entire anatomic compartment within which it is located. Although the shoulder girdle is one of the most common primary sites of softtissue sarcomas, we could find only 1 report describing shoulder function after total deltoid excision, combined with resection of the distal clavicle and the acromion (extensive total deltoid excision).9 We report on the shoulder function of a patient after extensive total deltoid excision for treatment of a soft-tissue sarcoma of the deltoid muscle.
CASE REPORT A 28-year-old man had a 1-year history of a slowly growing mass in his left shoulder and was referred to our hospital. Physical examinations revealed an immobile, hard, elastic mass with a maximum diameter of 13 cm (Figure 1). The range of passive motion of the shoulder was limited to 50° of abduction, flexion, and extension. He had active abduction of 20°, active flexion of 30°, and active extension of 25°, with strength of 4/5 on manual muscle testing. Magnetic resonance imaging revealed a large softtissue tumor in the deltoid muscle measuring 10 ⫻ 11 ⫻ 12 cm. The tumor was adjacent to the humerus, but there was no cortical erosion or medullary involvement. T1-weighted images showed a homogeneous low-intensity lesion, and T2-weighted images showed a heterogeneous intermediateto high-intensity lesion (Figure 2, A). T1-weighted images after gadolinium injection demonstrated heterogeneous enhancement (Figure 2, B). Computed tomography scans of the chest, abdomen, and pelvis showed no abnormalities. Technetium 99m– hydroxymethylene diphosphonate bone scintigraphy revealed no abnormal uptake in the humerus. We performed an incisional biopsy, and the pathologic diagnosis was low-grade fibromyxoid sarcoma. For radical excision of the tumor, we successfully performed total deltoid excision, combined with resection of From the Department of Orthopaedic Surgery, Yamagata University School of Medicine. Reprint requests: Toshihisa Osanai, MD, PhD, Department of Orthopaedic Surgery, Yamagata University School of Medicine, 2-2-2 Iida-Nishi, Yamagata 990-9585, Japan (E-mail: osanait@ med.id.yamagata-u.ac.jp). J Shoulder Elbow Surg 2007;16:e9-e12. Copyright © 2007 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2007/$32.00 doi:10.1016/j.jse.2006.04.004
Figure 1 The anterior view of the patient shows a large tumor in his left shoulder.
the distal clavicle, the acromion, and the scapular spine (Figure 3). There was no additional treatment, such as chemotherapy or radiotherapy. At the end of the fifth, tenth, fifteenth, and twentieth postoperative weeks, the patient attained active shoulder abduction of 45°, 85°, 100°, and 115° and active shoulder flexion of 75°, 90°, 105°, and 115°, respectively. Twenty months after the operation, he had active abduction of 140° (Figure 4), flexion of 145°, extension of 45°, external rotation of 75°, and internal rotation of 80°. Isometric muscle strength of shoulder abduction, flexion, and extension was measured with a handheld dynamometer (microFET; Hoggan Health Industries, West Jordan, UT). Abduction strength was 39% at 90° of abduction compared with the intact side. Flexion strength was 41% at 90° of flexion. Extension strength was 53% at 0° of extension. The time-dependent changes in the muscle strength of the shoulder are shown in Figure 5. Moreover, we examined glenohumeral joint laxity by plain radiography, which did not reveal any excess laxity. The patient could lift objects and place them unassisted without any instability of the glenohumeral joint. The postoperative Musculoskeletal Tumor Society score3 was 87%, and the patient was satisfied with the result. Twenty months after surgery, there were no metastases and no local recurrence.
DISCUSSION Low-grade fibromyxoid sarcoma is a rare tumor currently characterized by a high rate of local, often repeated, recurrence and by lung metastases in a significant percent-
e9
e10
Osanai et al
J Shoulder Elbow Surg March/April 2007
Figure 2 Magnetic resonance images in the coronal and axial planes show the tumor located in the deltoid muscle: T2-weighted image (A) and T1-weighted image (B) after gadolinium injection and with chemical-shift fat suppression.
age of patients.4,5 A better prognosis is expected if the tumor is treated with aggressive surgery, because the effectiveness of chemotherapy and radiotherapy is doubtful. For radical local resection of a large soft-tissue sarcoma in the deltoid muscle, the compartment and all of its contents from the origin (clavicle, acromion, and scapular spine) to the insertion must be excised. Although soft-tissue sarcomas commonly develop in the shoulder region, only a few reports describe shoulder function after total and subtotal deltoid excision.7,9 The deltoid is a bulky muscle making up approximately 20% of the shoulder musculature, and it is the main elevator of the shoulder.2 Contrary to popular clinical belief, Howell et al6 demonstrated that both the supraspinatus and the deltoid muscles were equally responsible for generating torque during arm elevation in a lidocaine-induced axillary or suprascapular nerve palsy subject. Sharkey et al12 showed that the function of the infraspinatus and teres minor muscles was to exert force needed for arm elevation. In patients with deltoid paralysis as a result of complete axillary nerve palsy, an almost full range of movement of the shoulder can be attained.11 Abduction ability recovers gradually, and it is not until 1 year after axillary nerve injury that full abduction is possible.1 Markhede et al9 reported on excision of soft-tissue tumors in the shoulder region in 3 patients treated with total deltoid excision and 1 patient treated with extensive total deltoid excision. They con-
cluded that total deltoid excision resulted in only a slight impairment of shoulder function, but the course of functional recovery was not described in detail. In our case, the range of active shoulder flexion recovered more quickly than that of shoulder abduction, and the range of active flexion and abduction reached its plateau at the end of the twentieth postoperative month. In addition to all of the cuff muscle forces, the biceps, the coracobrachialis, and the pectoralis major muscles may produce a compensatory force needed for arm elevation in the aftermath of extensive total deltoid excision. Concerning the stabilizing role of the deltoid muscle, we could find several reports using cadaveric shoulders.8,10 In those experimental studies, inferior translation of the humeral head did not occur after removal of the deltoid muscle. Markhede et al9 described shoulder function after total deltoid excision, but they did not specifically mention stability or instability of the glenohumeral joint. In the case presented, we did not observe any excess joint laxity either clinically or radiologically. In fact, the lifting ability of the patient was enough to permit work as a farmer without fear of shoulder instability. To the best of our knowledge, this is the first report describing the course of functional recovery of the shoulder and the stability of the glenohumeral joint after extensive total deltoid excision. Extensive total deltoid excision is an oncologically safe procedure for resection of sarcomas in
Osanai et al
J Shoulder Elbow Surg Volume 16, Number 2
Figure 3 Cut surface of the excised tumor after extensive total deltoid excision. The arrowhead indicates an acromion, and the arrow indicates the partially excised brachialis muscle.
e11
Figure 4 Twenty months after the operation, the active shoulder abduction attained was 140°.
REFERENCES
Figure 5 Time-dependent changes in isometric muscle strength for shoulder abduction, flexion, and extension are demonstrated in relation to the nonoperative side.
the deltoid muscle. Because dysfunction of the shoulder after surgery was minimal in activities of daily living, the range of motion, muscle strength, and stability of the shoulder were acceptable to the patient.
1. Babcock JL, Wray JB. Analysis of abduction in a shoulder with deltoid paralysis due to axillary nerve injury. Clin Orthop Relat Res 1970;68:116-20. 2. Bassett RW, Browne AO, Morrey BF, An KN. Glenohumeral muscle force and moment mechanics in a position of shoulder instability. J Biomech 1990;23:405-15. 3. Enneking WF, Dunham W, Gebhardt MC, Malawar M, Pritchard DJ. A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res 1993;286:241-6. 4. Evans HL. Low-grade fibromyxoid sarcoma. A report of two metastasizing neoplasms having a deceptively benign appearance. Am J Clin Pathol 1987;88:615-9. 5. Folpe AL, Lane KL, Paull G, Weiss SW. Low-grade fibromyxoid sarcoma and hyalinizing spindle cell tumor with giant rosettes: a clinicopathologic study of 73 cases supporting their identity and assessing the impact of high-grade areas. Am J Surg Pathol 2000;24:1353-60. 6. Howell SM, Imobersteg AM, Seger DH, Marone PJ. Clarification of the role of the supraspinatus muscle in shoulder function. J Bone Joint Surg Am 1986;68:398-404. 7. Khruekarnchana P, Suzuki K, Fukuda H. Shoulder function after subtotal excision of the deltoid muscle and of the deltoid and infraspinatus muscles in extra-abdominal desmoid tumor: a longterm follow-up in two cases. J Shoulder Elbow Surg 2004;13: 119-22. 8. Kumar VP, Balasubramaniam P. The role of atmospheric pressure in stabilising the shoulder. J Bone Joint Surg Br 1985;67:719-21.
e12
Osanai et al
9. Markhede G, Monastyrski J, Stener B. Shoulder function after deltoid muscle removal. Acta Orthop Scand 1985;56: 242-4. 10. Motzkin NE, Itoi E, Morrey BF, An KN. Contribution of passive bulk tissues and deltoid to static inferior glenohumeral stability. J Shoulder Elbow Surg 1994;3:313-9.
J Shoulder Elbow Surg March/April 2007
11. Palmer SH, Ross AC. Case report. Recovery ment in patients with complete axillary nerve Surg Engl 1998;80:413-5. 12. Sharkey NA, Marder RA, Hanson PB. The contributes to elevation of the arm. 1994;12:699-708.
of shoulder movepalsy. Ann R Coll entire rotator cuff J Orthop Res