Limb-salvage reconstruction after wide resection of a malignant proximal humeral tumour
- The aim is a wide, Enneking-appropriate resection of the tumour with the biopsy tract in continuity, reconstructed with a cemented modular proximal humeral endoprosthesis. The margin is the cure — never compromise it for the sake of the reconstruction.
- The single biggest determinant of shoulder function is whether the axillary nerve and deltoid can be preserved. Preserve them and the patient may regain useful active elevation; sacrifice them and the shoulder becomes stable and painless but active abduction is lost — yet the hand and elbow remain fully functional.
- Stability and any useful motion come from the soft tissues, not the metal. The capsule, residual rotator cuff and deltoid are reconstructed to the prosthesis with a synthetic mesh (Trevira or Dacron) sleeve; a reverse or constrained design is reserved for instability that soft-tissue reconstruction cannot solve.
- Through the deltopectoral approach identify and protect the axillary nerve in the quadrilateral space, ligate the anterior and posterior circumflex humeral arteries, and guard the radial nerve in the spiral groove at the osteotomy.
- An allograft-prosthetic composite (APC) is the main alternative — it restores biological bone stock and a cuff or deltoid attachment for better potential stability and rotator function, at the cost of allograft nonunion, fracture and infection.
When & Why
Indication. A malignant tumour of the proximal humerus where limb salvage is appropriate and a wide margin is achievable: a high-grade primary sarcoma (osteosarcoma, Ewing sarcoma, chondrosarcoma) is the classic indication; selected solitary metastases or myeloma deposits with a favourable prognosis, and painful destructive metastases with impending fracture, are also reconstructed this way. The proximal humeral metaphysis is the most common away-from-the-knee site and the third most common site overall for primary bone sarcoma. Before the knife — staging sets the plan. A wide resection is only chosen after the tumour is fully defined: - MRI of the whole humerus — local extent, epiphyseal and joint involvement, extraosseous extension, the relationship to the axillary nerve in the quadrilateral space and to the deltoid, and skip lesions in the marrow.
- Systemic staging — CT chest and a bone scan or whole-body MRI/PET for metastases (and local staging of a sarcoma).
- Biopsy — image-guided, taken along the future resection route so the tract is excised en bloc; plan the definitive incision before the biopsy is done. The one decision that matters — can the abductor mechanism be saved? Read off the MRI whether the tumour respects the axillary nerve and deltoid. If it does, an abductor-sparing resection is possible and function is preserved. If the nerve or deltoid is involved, both are sacrificed with the specimen and active abduction is lost. This single decision sets the resection type, the reconstruction, and the result you counsel the patient to expect.
The default. Cemented modular stem and proximal body; mechanically reliable, immediate stability, simple and quick. No biological attachment — function is capped by whatever rotator cuff and deltoid remain, so stability depends on the mesh soft-tissue reconstruction.
A bulk allograft sleeves a prosthesis, restoring bone stock and a biological cuff and deltoid attachment for better potential stability and rotator function. The trade-off is allograft nonunion, fracture and infection.
Glenohumeral arthrodesis (or an osteoarticular allograft) for the young patient who wants power and stability over motion; rotationplasty is reserved for very extensive tumours in a child where length and growth must be preserved.
Consent specifically for instability or dislocation (the commonest problem), infection, nerve deficit (axillary, radial or musculocutaneous), limited active elevation, local recurrence, possible revision or amputation, allograft-specific risks if an APC is used, and lifelong surveillance. Setup. Beach-chair (or supine with a scapular bump), the arm free and draped to allow circumduction so the osteotomy and soft tissues can be reached. A tourniquet is usually avoided because proximal control of the axillary vessels is needed; the arm is exsanguinated only if a tourniquet is used. General anaesthesia with a regional block for postoperative pain, a cell saver on the field, antibiotics at induction, and an image intensifier available to confirm the osteotomy level and cementing.
The Operation
The goal: remove the tumour with a wide margin and the biopsy tract in continuity, then reconstruct the proximal humerus with a cemented modular endoprosthesis and a mesh soft-tissue sleeve that gives the shoulder its stability. The exposure is laid out in full below (and in depth on the deltopectoral approach page) — the first steps are the approach, then the resection, then the reconstruction.
Intra-operative view of the proximal humeral resection defect with the modular cemented endoprosthesis in situ — the cemented stem in the remaining humeral diaphysis, the modular proximal body replacing the resected humeral head with the glenoid preserved, and the synthetic mesh sleeve being fashioned to reconstruct the capsule with the residual rotator cuff and deltoid reattached to it.
Context: A verified image is being sourced.
Operative sequence
- Beach chair, arm free; mark the biopsy tract (to be excised en bloc), the deltopectoral groove, the coracoid process, the clavicle and acromion, and the planned osteotomy level distal to the tumour.
- Design one incision that ellipses the biopsy tract and opens directly onto the tumour's deep margin, with room to extend proximally onto the clavicle and distally down the shaft.
- A long deltopectoral or anterolateral incision that excises the biopsy tract in continuity with the specimen.
- Extend proximally along the anterior acromion and clavicle and distally along the humeral shaft as the resection demands; the incision is the single corridor for exposure, resection and reconstruction.
- Develop the internervous plane between deltoid (axillary nerve) and pectoralis major (medial and lateral pectoral nerves), retracting the cephalic vein — usually laterally with the deltoid.
- Open the clavipectoral fascia, expose the coracoid process and the conjoined tendon (short head of biceps and coracobrachialis), and retract them medially.
- Define the axillary artery and vein and the cords of the brachial plexus; protect the musculocutaneous nerve as it passes lateral to the coracoid.
- Ligate the anterior and posterior circumflex humeral arteries.
- Identify the axillary nerve in the quadrilateral space, running with the posterior circumflex humeral artery. As planned from the MRI: if the tumour respects the nerve, preserve it (and the deltoid) for an abductor-sparing resection; if it is involved or threatened, sacrifice it en bloc with the specimen.
- Release the pectoralis major from the lateral lip of the bicipital groove, and the latissimus dorsi and teres major insertions, as the margin requires.
- Mark the humeral osteotomy 3 to 5 cm beyond the distal tumour extent as measured on MRI, and confirm the level with the image intensifier.
- Protect the radial nerve in the spiral groove posteriorly and make the cut from anterior to posterior so the nerve is never levered upon.
- For an intra-articular resection (joint uninvolved): open the capsule, divide the rotator cuff at the required margin, and deliver the proximal humerus with the attached soft tissues.
- For an extra-articular resection (joint or extraosseous extension): take the glenoid and capsule en bloc with the specimen, often through a second posterior incision — the choice is dictated entirely by tumour extension, not by ease.
- Remove the specimen with the biopsy tract in continuity, measure the resection length and the defect, and send margins for histology.
- Ream and prepare the remaining humeral diaphysis to accept the cemented stem.
- Trial the modular body segment and head to restore humeral length and retrotorsion, matching the resection length to the contralateral side.
- Cement the stem into the diaphysis with modern cementing technique, restrictors and pressurisation.
- Assemble the modular body segment and proximal humeral component, restoring length and retrotorsion so the soft tissues tension correctly.
- Fashion a synthetic mesh (Trevira or Dacron) sleeve around the proximal body to reconstruct the glenohumeral capsule.
- Reattach the residual rotator cuff and the deltoid (where preserved) to the mesh and prosthesis with non-absorbable sutures; advance and reattach pectoralis major onto the prosthesis for anterior cover and stability.
- If the deltoid was sacrificed, reconstruct a tensioned mesh sleeve to cradle the head for stability and accept poor active abduction. Reserve a constrained or reverse design for instability that meticulous soft-tissue work cannot control.
- Layered closure over drains; achieve a stable, well-covered soft-tissue envelope — this is what keeps the prosthesis reduced.
- Immobilise in a shoulder immobiliser or sling, the arm in slight abduction and neutral rotation, protecting the reconstruction while the soft tissues heal.
The axillary nerve passes posteriorly through the quadrilateral space with the posterior circumflex humeral artery, deep to the deltoid; the radial nerve winds the spiral groove on the posterior humeral shaft and is at the osteotomy's mercy. Identify both before any bone cut. Protect the axillary nerve if it is to be spared, and make the humeral osteotomy from anterior to posterior with a retractor guarding the radial nerve in the groove. Never lever on the shaft, and never proceed without proximal control of the axillary vessels.
Preserve the deltoid and axillary nerve and the patient keeps useful active elevation; sacrifice them and you trade active abduction for a stable, painless shoulder — but the hand and elbow stay fully functional. The single sentence a viva examiner wants is: a stable shoulder, a functional hand, and limited active elevation.
Instability is the commonest failure of a proximal humeral endoprosthesis, and it is driven entirely by soft-tissue deficiency, not by the implant geometry. Hence the mesh capsule, the pectoralis advancement, and postoperative immobilisation. Reconstruct the soft tissues as meticulously as the bone, or the head will dislocate.
Aftercare & Complications
Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 | 0 to 2 weeks | Shoulder immobiliser or sling | Active hand, wrist and elbow from day 1; gentle pendulums | | 2 | 2 to 6 weeks | Sling, removed for exercise | Assisted shoulder motion where the cuff and deltoid were reconstructed; protect abduction if the deltoid was sacrificed | | 3 | 6 to 12 weeks | Sling for comfort only | Progressive active motion and light activities of daily living | | 4 | 3 to 6 months | None | Graded strengthening (limited where the abductor mechanism was sacrificed) | Functional outcome tracks abductor preservation. With the deltoid and axillary nerve preserved, most patients regain useful assisted and some active elevation; when they are sacrificed, the result is a stable, painless shoulder with MSTS scores in the region of 50 to 70 per cent of normal, a fully functional hand and elbow, and little active abduction. Aseptic loosening and implant survivorship are favourable at ten years in modern modular series, with instability and infection the dominant reasons for revision. Complications
| Complication | Recognition | Prevention | Management |
|---|---|---|---|
| Instability or dislocation | Pain, deformity, loss of contour; confirmed on radiograph | Meticulous mesh capsule and pectoralis advancement; postoperative immobilisation | Closed or open reduction; revision soft-tissue reconstruction; constrained or reverse prosthesis for recurrence |
| Infection | Wound breakdown, persistent drainage, pain, raised inflammatory markers | Prophylactic antibiotics, meticulous soft-tissue cover, minimise dead space | Debridement and antibiotics; single- or two-stage exchange; rarely amputation |
| Nerve deficit (axillary, radial, musculocutaneous) | Weakness or numbness in the relevant distribution | Identify and protect nerves before bone cuts; osteotomy anterior to posterior | Observation for neuropraxia; explore a palsy in continuity with no recovery; directed therapy |
| Local recurrence | New pain or mass; confirmed on MRI and biopsy | A wide margin at the index operation — never compromise for reconstruction | Wide re-resection or amputation; oncology review for further treatment |
| Aseptic loosening or implant failure | Pain on loading; radiographic lucency or component migration | Modern cementing technique; restored length and version for balanced soft-tissue tension | Revision of the loose component; revision megaprosthesis |
| Periprosthetic fracture | Pain and deformity after a fall or torque; radiograph around the stem | Adequate diaphyseal cement fixation; protect from falls early | Internal fixation or stem revision depending on level and stability |
| Wound breakdown or skin necrosis | Edge necrosis or exposed mesh and implant | Tension-free closure, pliable flaps, avoid a thin bridge over the prosthesis | Local wound care; plastic surgical cover (flap) for exposed hardware |
Viva & Exam Focus
DELTOIDDELTOID — order of the operation
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 19-year-old has a high-grade osteosarcoma of the proximal humerus. Describe your approach to a wide resection and the principles of reconstruction.”
“The tumour involves the deltoid and the axillary nerve must be sacrificed. What functional result do you counsel the patient to expect, and how do you reconstruct for it?”
Indication
- High-grade primary sarcoma (or selected metastasis) of the proximal humerus where limb salvage is appropriate and a wide margin is achievable
- Proximal humerus is the most common away-from-the-knee site of bone sarcoma
Staging and the key decision
- MRI (local extent, joint, neurovascular, deltoid), CT chest, biopsy along the resection route
- The decision: preserve or sacrifice the axillary nerve and deltoid — it sets function
Exposure
- Deltopectoral or extended approach
- Protect the axillary, radial and musculocutaneous nerves; ligate the circumflex humeral arteries
Resection
- Wide margin, biopsy tract in continuity, osteotomy 3 to 5 cm beyond tumour
- Intra-articular unless joint extension demands an extra-articular specimen
Reconstruction
- Cemented modular endoprosthesis with a mesh soft-tissue sleeve
- Allograft-prosthetic composite is the main alternative
- Constrained or reverse design only for instability
Outcome
- Function tracks deltoid and axillary preservation
- Stable shoulder, functional hand, limited active elevation
- Instability is the commonest complication
Background & Evidence
Epidemiology. The proximal humeral metaphysis is the most common site of primary bone sarcoma away from the knee and the third most common overall, after the distal femur and proximal tibia. Osteosarcoma and Ewing sarcoma dominate in adolescents and young adults; chondrosarcoma, metastatic carcinoma (breast, renal, thyroid, lung, prostate) and myeloma are the lesions of older adults. The same modular reconstruction is used for selected metastatic deposits with a reasonable prognosis and for impending pathological fracture. Pathoanatomy. Tumours arise in the proximal metaphysis and extend into the epiphysis (once the physis closes), the greater and lesser tuberosities, the rotator cuff and deltoid attachments, and along the medullary canal. Three relationships decide the operation: involvement of the glenohumeral joint (intra-articular versus extra-articular resection); involvement of the deltoid and the axillary nerve in the quadrilateral space (abductor-sparing versus abductor-sacrificing); and distal marrow extension (the osteotomy level). The anterior and posterior circumflex humeral arteries are ligated; the axillary artery and vein and the brachial plexus lie proximal and must be controlled before any resection.
| Type | Capsule and joint | Abductor (deltoid plus axillary nerve) | Expected function |
|---|---|---|---|
| I | Intra-articular | Preserved | Best — useful active abduction possible |
| II | Intra-articular | Sacrificed | Stable and painless; poor active abduction |
| III | Extra-articular (glenoid en bloc) | Preserved | Useful abduction possible if cuff and deltoid are reconstructed |
| IV | Extra-articular | Sacrificed | Stable; minimal active abduction |
| Total humeral resection | Glenohumeral joint and elbow both reconstructed | Variable | Functional hand; elbow via a hinged prosthesis |
References
A system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system
- The MSTS functional scoring system for limb-salvage reconstruction — the standard metric used to report outcome after proximal humeral endoprosthetic replacement.
- Scores pain, function, emotional acceptance and limb-specific parameters, enabling comparison across reconstruction types.
Dislocation of the proximal humeral endoprosthetic replacement
- Instability and dislocation are the commonest mode of failure of a proximal humeral endoprosthesis.
- Risk tracks the extent of rotator cuff and deltoid sacrifice, making meticulous soft-tissue reconstruction the key to prevention.
Endoprosthetic reconstruction for malignant tumors of the proximal humerus
- Modular endoprosthetic reconstruction of the proximal humerus is durable and reliable for limb salvage.
- Functional outcome is governed by preservation of the deltoid and axillary nerve; active elevation is limited when the abductor mechanism is sacrificed.
Reconstruction of the proximal humerus after tumour resection — endoprosthesis versus allograft-prosthetic composite
- An allograft-prosthetic composite restores biological bone stock and a cuff and deltoid attachment for better potential stability and rotator function than a prosthesis alone.
- The trade-off is allograft-specific morbidity — nonunion, fracture and infection.