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Endoprosthetic Reconstruction of Proximal Humerus Malignant Lesions

Technique

D

Anterior Portion of Utilitarian Approach

1

Mark the incision

  • Incision extends from the middle third of the clavicle and passes 1 cm medial to the coracoid process,across the axillary fold and distally along the anteromedial aspect of the arm.

2

Make the skin incision

  • Follow the course of the neurovascular bundle
  • Raise medial and lateral fascia cutaneous flaps

3

Release musculature

  • Release the pectoralis major from its humeral insertion
  • Release the strap muscles from their insertion on the coracoid

4

Expose neurovascular structures

  • Dissect out the musculocutaneous nerve at the point where it enters the coracobrachialis and short head of the biceps
  • this is usually 2-7 cm inferior to the coracoid
  • Release the pectoralis minor from the coracoid
  • identify the axillary nerve and surround with vessel loops
  • Isolate and ligate the anterior and posterior humeral circumflex arteries
  • Identify the radial nerve and preserve
E

Tumor Exposure

1

Transect deep structures

  • separate the long and short heads of the biceps to expose the humerus
  • determine the site for the osteotomy
  • this is typically 3-4 cm distal to the tumor
  • transect the long head of the biceps and brachialis
  • identify the inferior border of the latissimus dorsi
  • make a fascial incision that allows one finger to pass behind the latissimus and teres major muscles several centimeters from there insertion on the humerus or scapula
  • transect these muscles using electrocautery
  • externally rotate the arm to expose the subscapularis
  • transect at the level of the coracoid process
F

Proximal Humerus Resection

1

Expose the glenohumeral joint

  • expose the joint circumferentially

2

Perform osteotomy

  • osteotomize the scapula medial to the coracoid along with the distal portion of the scapula En Bloc
  • the resected specimen should contain the proximal half of the humerus, the glenohumeral joint and the distal clavicle
G

Endoprosthetic Replacement of the Proximal Humerus

1

Use replacement to reconstruct the skeletal defect

H

Dual Suspension Technique

1

Stabilize the prosthesis

  • make drill holes in distal portion of the osteotomized clavicle and scapula at the level of the spine
  • secure the head of the prosthesis to the remaining portion of the scapula with 3-mm dacron tape
  • suspend the prosthesis mediolaterally during this part of the procedure
  • use more dynamic tape at the end of the clavicle while the the extremity os suspended in a craniocaudal direction
  • tenodese the short head of the biceps to the stump of the clavicle
I

Soft Tissue Reconstruction

1

Perform tenodesis

  • tenodese the remaining muscles to the pectoralis major and osteotomized border of the scapula with dacron tape
J

Wound Closure

1

Perform deep closure

  • use 0-vicryl for deep closure

2

Perform superficial closure

  • use 3- vicryl for subcutaneous closure
  • use 3-0 monocryl for skin

3

Place dressings

  • place in abduction orthosis

Patient Care

K

Preoperative H & P

1

Obtains history and performs basic physical exam

  • history
  • pain and function
  • past medical/surgical/social/family history
  • review of systems
  • physical exam
  • heart
  • lungs
  • extremity exam
  • range of motion
  • strength
  • sensation
  • skin changes
  • tenderness
  • screen medical studies to identify and contraindications for surgery

2

Orders basic imaging studies

  • radiographs
  • AP/lateral of the lesion
  • Joint above and below the lesion

3

Prescribe non-operative treatment

  • protected weightbearing
  • bracing
  • no intervention

4

Perform operative consent

  • describe complications of surgery including
  • Infection
  • nonunion
  • Wound complications
  • Neurovascular compromise
  • Tumor progression
  • DVT/PE
  • Pneumonia
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • IV antibiotics until drain is discontinued
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • remove dressings POD 2
  • remove drain in 3-5 days
  • appropriately orders and interprets basic imaging studies
  • check radiographs of the humerus in post op
  • appropriate medical management and medical consultation
  • Inpatient physical therapy
  • keep in abduction brace at all times

2

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
  • wound care
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • history
  • past history of cancer or radiation
  • prior treatments
  • pre-existing pain
  • smoking or chemical exposure
  • constitutional symptoms
  • fever
  • physical exam
  • notes lymph node involvement, lumps/nodules

2

Interprets basic imaging studies

  • describe the radiographic appearance
  • osteolytic
  • osteoblastic

3

Prescribes and manages nonoperative treatment

  • understand when to have the patient back to clinic for follow-up
  • understand when to order new radiographic imaging studies

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • check radiographs
  • start formal physical therapy at 4 weeks
  • gentle range of motion exercises
  • diagnose and management of early complications
  • infection
  • DVT/PE
  • wound breakdown
  • neurovascular compromise
  • hardware failure
  • postop: 4-6 week postoperative visit
  • check radiographs
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies/lab studies

  • 3D radiographic studies to include CT
  • evaluates cortical bone changes
  • MRI
  • identifies the extent of intraosseus bone tumor
  • angiography
  • determines the vascularity of the tumor
  • lab studies
  • SPEP/UPEP
  • PSA
  • other tumor markers

2

Recommends complex non-operative treatment

  • RFA or cryoablation
  • Bisphosphonates
  • Kyphoplasty or vertebroplasty

3

Nonoperative treatment

  • infection
  • wound breakdown
  • DVT/PE)

4

Pre-operative preparation and consultation

  • onc
  • rad onc
  • counseling
O

Complex Patient Care

1

Recommends appropriate biopsy including biopsy alternatives and appropriate techniques

  • understand role of open biopsy vs needle biopsy

2

Develops unique, complex post-operative management plans

3

Discusses prognosis and end of life care with patient and family

 

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