Updated: 10/4/2016

Endoprosthetic Reconstruction of Proximal Humerus Malignant Lesions

Preoperative Patient Care


Outpatient Evaluation and Management


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


Interprets basic imaging studies

  • describe the radiographic appearance
  • osteolytic
  • osteoblastic


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


Makes informed decision to proceed with operative treatment

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


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

Advanced Evaluation and Management


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
  • PSA
  • other tumor markers


Recommends complex non-operative treatment

  • RFA or cryoablation
  • Bisphosphonates
  • Kyphoplasty or vertebroplasty


Nonoperative treatment

  • infection
  • wound breakdown
  • DVT/PE)


Pre-operative preparation and consultation

  • onc
  • rad onc
  • counseling

Preoperative H & P


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


Orders basic imaging studies

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


Prescribe non-operative treatment

  • protected weightbearing
  • bracing
  • no intervention


Perform operative consent

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

Operative Techniques


Anterior Portion of Utilitarian Approach


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.


Make the skin incision

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


Release musculature

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


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

Tumor Exposure


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

Proximal Humerus Resection


Expose the glenohumeral joint

  • expose the joint circumferentially


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

Endoprosthetic Replacement of the Proximal Humerus


Use replacement to reconstruct the skeletal defect


Dual Suspension Technique


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

Soft Tissue Reconstruction


Perform tenodesis

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

Wound Closure


Perform deep closure

  • use 0-vicryl for deep closure


Perform superficial closure

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


Place dressings

  • place in abduction orthosis

Postoperative Patient Care


Perioperative Inpatient Management


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


Discharges patient appropriately

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

Complex Patient Care


Recommends appropriate biopsy including biopsy alternatives and appropriate techniques

  • understand role of open biopsy vs needle biopsy


Develops unique, complex post-operative management plans


Discusses prognosis and end of life care with patient and family


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