Endoprosthetic Reconstruction of Proximal Humerus Malignant Lesions

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TECHNIQUE VIDEO
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TECHNIQUE STEPS
 
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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
G

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
H

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
I

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
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Endoprosthetic Replacement of the Proximal Humerus

1

Use replacement to reconstruct the skeletal defect

K

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
L

Soft Tissue Reconstruction

1

Perform tenodesis

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

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
Postoperative Patient Care
 

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