Humerus/surgery; Joint Prosthesis* Male; Middle Aged; Necrosis;
Routine blood investigations were normal. Plain radiographs of left humerus showed a permeative, destructive lesion involving the upper and middle one third with pathological fracture (Fig. 1A). Chest radiograph was normal. Magnetic resonance imaging revealed altered marrow signal intensity in the diaphysis and proximal metaphysis of left humerus. There was a large soft tissue component which was hypointense on T1, heterogeneously hyperintense on T2 and STIR images (Fig. 1B). He underwent an incisional biopsy. The histopathological (HPE) diagnosis was Ewing’s sarcoma. Immunohistochemistry showed positivity for CD99 and Bcl-2. Positron emission tomographic scans demonstrated no evidence of pulmonary metastasis. The tumour was staged as IIB according to Musculoskeletal Tumour Society Staging.
He underwent four cycles of neoadjuvant chemotherapy with Vincristine, Adriamycin and Cyclophosphamide (VAC). Even though clinically and radiologically the tumour showed features of regression, post chemotherapy MRI revealed presence of residual tumour (Fig. 1 C, D).
He underwent radical excision of the tumour (Malawer type 1 resection) . The defect was reconstructed with custom made acrylic prosthesis (Fig. 2A, B). The entire tumour mass and the margins were sent for biopsy.
Humerus prosthesis - STROOT; JEROME H.
A 51 year old lady who had undergone total thyroidectomy and received a complete course of I131 ablation therapy for follicular carcinoma of thyroid five years ago presented with painful swelling over her right upper arm for past three months. The swelling was gradually increasing in size. At the time of presentation the pain was severe enough to disturb her sleep and activities of daily living. On examination, there was a diffuse swelling extending from the shoulder to middle one third of arm. The swelling was tender, firm in consistency with abnormal mobility.
Routine blood investigations and thyroid function tests were within normal limits. Plain radiographs of right humerus showed an expansile lytic lesion causing complete destruction of the head, neck and proximal half of right humerus. (Fig. 3A) MRI revealed a large expansile, lytic lesion which was hyperintense on T2 and iso to hyperintense on T1 image. There was a breach in the cortex circumferentially with infiltration into muscles of proximal arm. (Fig. 3B)
Posteriorly, the lesion was seen to abut the radial nerve. Contrast enhanced computerised tomographic scan of chest showed multiple cannon ball type of metastasis. (Fig. 3C)
Radical excision of tumour (Malawer type 1 resection) was done and the upper end of humerus was reconstructed with a custom made barium sulphate loaded acrylic prosthesis. (Fig. 4)
The biopsy was positive for metastatic follicular carcinoma of thyroid. Postoperatively, patient developed transient radial nerve paralysis which slowly recovered. She was completely free of pain and by four weeks had satisfactory shoulder, elbow and hand function.
N2 - Background: Limb salvage following resection of a tumor in the proximal part of the humerus poses many challenges. Reconstructive options are limited because of the loss of periarticular soft-tissue stabilizers of the glenohumeral joint in addition to the loss of bone and articular cartilage. The purpose of this study was to evaluate the functional outcome and survival of the reconstruction following use of a humeral allograft-prosthesis composite for limb salvage. Methods: An allograft-prosthesis composite was used to reconstruct a proximal humeral defect following tumor resection in thirty-six consecutive patients at one institution over a sixteen-year period. The reconstruction was performed at the time of a primary tumor resection in thirty cases, after a failure of a reconstruction following a previous tumor resection in five patients, and following excision of a local recurrence in one patient. The mean duration of followup of the living patients was five years. Glenohumeral stability, function, implant survival, fracture rate, and union rate following the reconstructions were measured. Functional outcome and implant survival were analyzed on the basis of the amount of deltoid resection, whether the glenohumeral resection had been extra-articular or intra-articular, and the length of the humerus that had been resected. Results: One patient sustained a glenohumeral dislocation. Deltoid resection (partial or complete) resulted in a reduced postoperative range of motion in flexion and abduction but had no effect on the mean Musculoskeletal Tumor Society score. Extra-articular resections were associated with lower Musculoskeletal Tumor Society scores. All patients had either mild or no pain and normal hand function at the time of final follow-up. The overall estimated rate of survival of the construct, with revision as the end point, was 88% at ten years. There were three failures due to progressive prosthetic loosening that necessitated removal of the construct. Four patients required an additional bone-grafting procedure to treat a delayed union of the osteosynthesis site. Conclusions: An allograft-prosthesis composite used for limb salvage following tumor resection in the proximal part of the humerus is a durable construct associated with an acceptable complication rate. Deltoid preservation and intraarticular resection are associated with a greater range of shoulder motion and a superior functional outcome, respectively. Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Elbow Disarticulation and Transhumeral Amputation: Prosthetic ..
simpler, less expensive and hence more suitable in developing countries where most of the patients cannot afford a modular endoprosthesis.
Cement nail prosthesis where a Kuntcher’s nail wrapped in bone cement and used as a spacer has been described in the literature . We utilized a similar concept where custom made acrylic prosthesis shaped according to the anatomy of the proximal humerus was used. For preparation of this prosthesis an approximate size of the humeral head and its length was calculated from the radiographs of the normal side. An age and sex matched dry humerus specimen of similar size belonging to the same side was procured from the Anatomy Department. Length of the humerus to be resected was determined from preoperative MRI. A negative mould was prepared using the dry humerus specimen. The prosthesis was fabricated out of acrylic material using the negative mould. A humeral interlocking nail was incorporated into the acrylic prosthesis. Three holes were drilled into the proximal end of prosthesis for attachment of rotator cuff muscles and the entire construct was gas sterilized. After resection of tumour, the medullary canal of distal humerus was reamed for introduction of nail. Reamed material was sent for HPE examination.
Bone cement was packed into the canal and the nail was locked following insertion. The rotator cuff muscles were anchored to the prosthesis through the premade holes. Using this technique a satisfactory range of shoulder movements was obtained. Both cases were pain free following surgery with good upper limb function.
Patent US6406496 - Humerus head prosthesis - Google …
For preparation of this prosthesis an approximate size of the humeral head and its length was calculated from the radiographs of the normal side. An age and sex matched dry humerus specimen of similar size belonging to the same side was procured from the Anatomy Department. Length of the humerus to be resected was determined from preoperative MRI. A negative mould was prepared using the dry humerus specimen. The prosthesis was fabricated out of dental acrylic material using the negative mould. A humeral interlocking nail was incorporated into the acrylic prosthesis. Three holes were drilled into the proximal end of prosthesis for attachment of rotator cuff muscles and the entire construct was gas sterilized. After resection of tumour, the medullary canal of distal humerus was reamed for introduction of nail. Reamed material was sent for HPE examination. Bone cement was packed into the canal and the nail was locked following insertion. The rotator cuff muscles were anchored to the prosthesis through the premade holes.