Surgical Management of Metastatic Bone Disease: Humeral Lesions

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Chapter
12
Surgical Management of
Metastatic Bone Disease:
Humeral Lesions
Jacob Bickels and Martin M. Malawer
BACKGROUND
Humeral Diaphysis: Type II Metastasis
The humerus is a common site of metastatic bone disease
requiring surgery. A metastasis at that site, especially when it
involves the dominant extremity, has an immediate and profound impact on the affected individual’s ability to perform
activities of daily living. The quality of surgery, therefore, is an
important factor in restoring vital function.
■ A detailed preoperative clinical and imaging evaluation is
mandatory for defining the morphologic characteristics of the
lesion and, in turn, establishing the indications for surgical intervention, as well as distinguishing between lesions that can
be managed with curettage and cemented fixation and those
that require resection with endoprosthetic reconstruction.2,3,5,6
■ Unlike primary sarcomas of the humerus, metastatic tumors
usually have a small soft tissue component, even in the presence of extensive bone destruction. This characteristic allows
resection of bony elements only, permitting sparing of the extracortical structures, such as the joint capsule, overlying muscles, and muscle attachments, and affords the opportunity to
use them to reconstruct and preserve function (FIG 1A,B). To
this end, exposure of the proximal humerus is done by splitting the deltoid muscle rather using the deltopectoral interval,
as is done in the case of a primary sarcoma of bone, which necessitates en bloc resection of the deltoid muscle with the
tumor. Moreover, a few centimeters of upper limb shortening
following resection of bone segment has minimal impact on
function, because a slight difference in positioning of that extremity in space can easily compensate for such limb-length
discrepancy.
■ In contrast, a similar discrepancy in the lower extremities,
which require almost equal length for normal gait, would
result in an inevitable limp, the extent of which would be proportional to the shortening of the operated extremity.2
■ Because of different anatomic and surgical considerations,
surgeries around the proximal humerus (type I), humeral diaphysis (type II), and distal humerus (type III) are discussed
separately (FIG 2).1
■
■
ANATOMY
Proximal Humerus: Type I Metastasis
The proximal humerus is covered anteriorly and laterally by
the deltoid muscle.
■ The joint capsule encircles the humeral head and attaches to
the base of the anatomic neck.
■ The proximal humerus is the attachment site for the rotator
cuff muscles. The long head of the biceps muscle crosses the
anterior aspect within the bicipital groove.
■
The upper half is occupied by muscle insertions:
■ Medial aspect: teres major, latissimus dorsi, coracobrachialis
■ Lateral aspect: pectoralis major, deltoid
■ The radial nerve curves at the back from medial to lateral at
the mid-arm level.
■ The lower half is occupied by muscle origins:
■ Medial aspect: Brachialis
■ Lateral aspect: Brachioradialis
■ Neurovascular bundle along its medial aspect
Distal Humerus: Type III Metastasis
The neurovascular bundle lies along its medial aspect between the biceps and brachialis muscles.
■ The radial nerve lies along its lateral aspect between the
brachialis and brachioradialis muscles.
■
INDICATIONS
Pathological fracture
Impending pathological fracture
■ Intractable pain associated with locally progressive disease
that has shown inadequate response to narcotics and preoperative radiation therapy
■ Solitary bone metastasis in selected patients
■
■
IMAGING AND OTHER
STAGING STUDIES
Plain radiographs of the entire humerus are mandatory to
rule out synchronous metastases that may change the extent
and technique of surgery. A CT scan of the lesion will clearly
define the extents of bone destruction and soft tissue component. Total body bone scintigraphy is done to detect synchronous metastases elsewhere in the skeleton. At the conclusion of
imaging, the surgeon should be able to answer the following
questions:
■ Are there additional humeral metastases and, if there are,
can they be managed by nonoperative techniques or do they
require surgery?
■ Are there additional skeletal metastases and, if there are,
can they be managed by nonoperative techniques or do they
require surgery?
■ What is the appropriate surgery? As a rule, the tumor
curettage and cemented fixation approach is used for lesions
in which the remaining cortices allow containment of the
fixation device; otherwise, surgery involves resection of the
affected bone segment with prosthetic reconstruction.
■
1
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A
FIG 1 • A. Primary bone sarcomas
usually have considerable extension
into the soft tissues. Resection of
such tumors at the proximal humerus
would require en bloc removal of the
overlying deltoid muscle, rotator cuff
tendons, and the joint capsule.
B. Bone metastases, however, usually
present with less soft tissue involvement, and their resection involves removal of bony elements with only a
thin layer of surrounding soft tissues.
B
A
B
E
F
C
D
FIG 2 • A,B. Type I humeral metastasis extending across the anatomic neck to the humeral
head. C,D. Type II humeral metastasis involving the humeral diaphysis between the
anatomic neck and the supracondylar ridges of
the humerus. E,F. Type III humeral metastasis
extending to the humeral condyles below the
supracondylar ridges. (From Bickels J,
Kollender Y, Wittig JC, et al. Function after resection of numeral metastases. Analysis of 59
consecutive patients. Clin Orthop Relat Res
2005;437:201–208, with permission.)
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Chapter 12 SURGICAL MANAGEMENT OF METASTATIC BONE DISEASE: HUMERAL LESIONS
Position and Incision
■
The patient is placed in a semilateral position, and an anterior utilitarian shoulder girdle incision is made. It begins at the junction of the inner and middle thirds of the
clavicle and continues over the coracoid process, along
the deltopectoral groove, and down the arm over the
medial border of the biceps muscle (TECH FIG 1A,B).
rasps are used to detach and reflect the periosteum and
muscle attachments from the underlying cortex (TECH
FIG 1C,D).
Tumor Removal
■
Type I metastasis
■
Using electrocautery, the rotator cuff tendons are detached from the humerus, the long head of the biceps
is cut at its insertion site around the glenoid, and the
joint capsule is opened. Osteotomy is carried out at
the required level below the surgical neck, 1 to 2 cm
below the distal margin of the tumor, and the proximal humerus can now be removed (TECH FIG 2).
Exposure
■
The deltoid muscle is divided longitudinally to expose the
humeral head and the proximal third of the humeral diaphysis. Exposure of the remaining diaphysis is achieved by
similarly dividing the brachialis muscle. Electrocautery and
A
B
C
D
TECH FIG 1 • A,B. The utilitarian shoulder incision is used for exposure of type I and II
metastases. It begins at the junction of the inner and middle thirds of the clavicle and
continues over the coracoid process, along the deltopectoral groove, and down the arm
over the medial border of the biceps muscle up to the distal arm, if required. C,D. The
deltoid and brachialis muscles are divided longitudinally to expose the humeral head
and humeral diaphysis. The periosteum is divided similarly and reflected with muscle to
expose the underlying cortex.
TECHNIQUES
TYPE I AND II METASTASES
3
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A
B
TECH FIG 2 • A–C. Resection of the type I metastatic renal cell
carcinoma seen in the plain radiograph in Figure 1C is executed by detaching the rotator cuff tendons and the long head
of the biceps and opening the joint capsule. An osteotomy is
performed and the proximal humeral segment is removed.
D. Surgical specimen.
D
■
C
Type II metastasis
■
A longitudinal cortical window with oval edges is
made just above the lesion (TECH FIG 3A). Gross
tumor is removed with hand curettes (TECH FIG 3B,C).
Curettage should be meticulous and leave only microscopic disease in the tumor cavity. It is followed by
high-speed burr drilling of walls of the tumor cavity
(TECH FIG 3D–F). Occasionally, the cortices of the involved segment are completely destroyed, leaving no
option but an intercalary resection of the affected segment. This is achieved by an osteotomy 1 to 2 cm above
and below the segment (TECH FIG 3G–I).
back into the medullary canal and fixed with interlocking screws. Alternatively, a side plate can be used
for reinforcement (TECH FIG 5C,D). If an intercalary
resection has been done, the remaining bone defect
is filled with cement (TECH FIG 5E–G).
Soft Tissue Reconstruction and
Wound Closure
■
Mechanical Reconstruction
■
■
Type I metastasis
■
A cemented prosthesis is used for reconstruction (TECH
FIG 4). The prosthetic design should allow the reattachment of rotator cuff tendons.
Type II metastasis
■
An intramedullary nail is introduced. After proper position and length are verified, the nail is partially
pulled back, and the entire tumor cavity is filled
with cement (TECH FIG 5A,B). The nail is then pushed
■
Type I metastasis
■
The rotator cuff tendons are attached to the prosthetic
head using 3-mm Dacron tapes (Deknatel, Falls River,
MA) or no. 5 Ethibond sutures (Ethicon, Somerville, NJ;
TECH FIG 6). The pectoralis major, teres major, latissimus dorsi, and coracobrachialis muscles are similarly
attached. Using the same technique, the prosthetic
head also is secured to the drill holes within the bony
elements around the shoulder joint, acromion, clavicle,
and glenoid. The second, overlying muscular layer includes the deltoid and brachialis muscles, which are sutured to cover the implant.
Type II metastasis
■
The deltoid and brachialis muscles are sutured to
cover the humeral diaphysis.
TYPE III METASTASES
■
Type III metastases extend to the humeral condyles
below the supracondylar ridges. In most of these
cases, the extent of bone destruction allows tumor
curettage and reconstruction with cemented hard-
ware (the technique is described in the following section). Rarely will extensive destruction of the distal
humerus necessitate formal resection with endoprosthetic reconstruction.
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TECHNIQUES
A
B
E
D
G
C
H
F
I
J
TECH FIG 3 • A. A longitudinal cortical window with oval edges is made just above the lesion. B,C. Gross tumor is removed with
hand curettes. Curettage should be meticulous and should leave only microscopic disease in the tumor cavity. D,E. Curettage is
followed by high-speed burr drilling of walls of the tumor cavity. F. Tumor cavity following curettage and burr drilling. G. Plain
radiograph of type II thyroid carcinoma metastases. The extent of cortical destruction may does not allow curettage and burr
drilling and so intercalary resection of the affected segment is indicated. H–J. Intercalary resection is achieved by proximal and
distal osteotomies 1 to 2 cm above and below the tumor margin.
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A
B
TECH FIG 4 • Intraoperative photograph (A) and plain radiograph (B) showing a proximal humeral tumor prosthesis used for reconstruction after resection of a type I metastasis.
Position and Exposure
■
The patient is placed supine on the operating table with
the ipsilateral arm lying across the chest. A slightly curved
incision is made on the lateral aspect of the arm over the
supracondylar ridge of the elbow (TECH FIG 7A).
The distal humerus is exposed using the plane between
the brachioradialis and triceps muscles. The brachioradialis
is reflected anteriorly and the triceps posteriorly. Further
posterior reflection of the anconeus muscle combined
with detachment and anterior reflection of the common
extensor origin exposes the radial head (TECH FIG 7B).
■
A
B
Tumor Removal and Mechanical
Reconstruction
■
■
A longitudinal cortical window with oval edges is made
just above the lesion. Gross tumor is removed with hand
curettes (TECH FIG 8A), and this is followed by highspeed burr drilling (TECH FIG 8B).
An intramedullary rod is introduced through the tumor
cavity, which is then filled with cement. A reconstruction
plate along the lateral supracondylar ridge is used to
reinforce the reconstruction (TECH FIG 8C).
C
TECH FIG 5 • A. An intramedullary nail is introduced. B. After proper position and length are verified, the nail is
partially pulled back, and the entire tumor cavity is filled with cement. The nail is then pushed back into the
medullary canal and fixed with interlocking screws. Intraoperative photograph (C) and plain radiograph (continued)
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TECHNIQUES
E
D
G
F
A
B
TECH FIG 5 • (continued) (D) showing side plate reinforcement of a cemented intramedullary humeral
nail. Plain radiograph (E) and intraoperative photographs (F,G) showing side plate reinforcement of a cemented intramedullary humeral
nail following intercalary resection
of a type II metastasis. The remaining bone defect is filled with cement.
C
TECH FIG 6 • 3-mm Dacron tapes (A) or no. 5 Ethibond sutures (B) are used for securing the prosthetic head to the neighboring acromion, clavicle, and glenoid and for reattachment of the rotator cuff tendons. C. Rotator cuff tendons are sutured to
the prosthetic head.
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TECHNIQUES
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A
B
TECH FIG 7 • A. To expose a lesion at the distal humerus, the patient is placed supine on the operating table
with the ipsilateral arm lying across the chest. A slightly curved incision is made on the lateral aspect of the
arm over the supracondylar ridge of the elbow. B. The distal humerus and radial head are exposed using the
plane between the brachioradialis and triceps muscles.
A
C
B
TECH FIG 8 • A. Gross tumor is removed with hand curettes. B. Curettage is
followed by high-speed burr drilling. C. A cemented intramedullary rod that
is reinforced by a reconstruction plate along the supracondylar ridge is used
for reconstruction.
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PEARLS AND PITFALLS
Type I and II Metastases
■ Adequate imaging of the entire humerus—decision on tumor curettage, intercalary resection, or
Preoperative
resection with endoprosthetic reconstruction
Intraoperative
■
Use the utilitarian shoulder incision.
Wide exposure of the tumor cavity using properly positioned and large cortical window
■ Meticulous curettage and burr drilling
■ Reconstruction with cemented hardware
■ If endoprosthetic reconstruction was done: (1) secure the prosthetic head to the surrounding bony elements to ensure shoulder stability; and (2) reattach the rotator cuff tendons to the prosthetic head to
allow shoulder function
■
Postoperative
■
Immobilize the shoulder for 3 weeks and only then allow range of motion exercises
Type III Metastases
■
Adequate exposure of the distal humerus
Meticulous curettage and burr drilling
■ Reconstruction with cemented hardware
■ Early postoperative mobilization of the elbow joint
■
POSTOPERATIVE CARE
Type I and II Metastases
Continuous suction is required for 3 to 5 days, and perioperative intravenous antibiotics are continued until the drainage
tubes are removed. If endoprosthetic reconstruction was done,
the shoulder is immobilized in a sling for 3 weeks. During that
time, the rehabilitation program emphasizes range of motion
(ROM) of the elbow, wrist, and fingers with gravity assistance.
Gradual passive and active ROM of the shoulder is then started,
with emphasis on forward flexion, abduction, and shrugging.
■ If tumor curettage has been carried out, ROM exercises
should be practiced without delay. Once the wound has healed,
usually 3 to 4 weeks after surgery, patients are referred to adjuvant radiation therapy. Radiation therapy usually is not required in patients who have undergone proximal humerus
resection with endoprosthetic reconstruction.
■
Type III Metastases
The wound is closed over suction drains. Continuous suction is required for 3 to 5 days, and perioperative intravenous
antibiotics are continued until the drainage tubes are removed.
■ Passive and active ROM exercises of the elbow joint are initiated when the suction drains are removed.
■ Once the wound has healed, usually 3 to 4 weeks after
surgery, the patient is referred to adjuvant radiation therapy.
Radiation therapy usually is not required, however, for patients who have undergone distal humerus resection with endoprosthetic reconstruction.
■
OUTCOMES
Most patients who undergo resection of a humeral metastasis experience immediate relief of their metastasis-related
pain. Patients who had a type II metastasis and who have undergone either curettage or intercalary resection have better
ROMs and superior functional outcome than those who underwent proximal or distal humeral resection with endoprosthetic reconstruction.
■
Bickels et al.2 reported that overall total function in their
56 patients (95%) who had undergone resection of a humeral
metastasis was over 68% of full normal upper extremity function, which is the mean functional outcome score after reconstruction of the upper extremity.4
■
COMPLICATIONS
Thromboembolic complications, deep wound infections,
and prosthetic loosening (rare)
■ Proximal humeral prosthetic dislocation, from poor securing to the adjacent bones and inadequate soft tissue coverage
■ Decreased ROM around the shoulder, due to poor attachment of the rotator cuff tendons to the prosthesis
■ Decreased elbow ROM after surgery around distal humerus
lesions
■ Local tumor recurrence of less than 5% if adjuvant tumor
removal was done adequately and adjuvant radiation therapy
was administered.
■
REFERENCES
1. Bickels J, Kollender Y, Wittig JC, et al. Function after resection of
humeral metastases. Analysis of 59 consecutive patients. Clin Orthop
Relat Res 2005;137:201–208.
2. Bickels J, Wittig JC, Kollender Y, et al. Limb-sparing resections of the
shoulder girdle. J Am Coll Surg 2002;194:422–435.
3. Eckardt JJ, Kabo JM, Kelly CM, et al. Endoprosthetic reconstructions
for bone metastases. Clin Orthop Relat Res 2003;415(Suppl):
s254–262.
4. Enneking WF, Dunham W, Gebhardt MC, et al. A system for functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. Clin Orthop Relat Res
1993;286:241–246.
5. Flemming JE, Beals RK. Pathologic fractures of the humerus. Clin
Orthop Relat Res 1986;203:258–260.
6. Harrington KD, Sim FH, Enis JE, et al. Methylmethacrylate as an adjuvant in internal fixation of pathological fractures: Experience with
three hundred and seventy-five cases. J Bone Joint Surg Am 1976;
58A:1047–1055.