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Endoprosthetic Reconstruction of Proximal Humerus Malignant Lesions

Preoperative Patient Care
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
Private Note

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