University Institute for Locomotion and Sports (iULS), Pasteur 2 Hospital, Nice, France.
University Institute for Locomotion and Sports (iULS), Pasteur 2 Hospital, Nice, France.
J Shoulder Elbow Surg. 2020 Nov;29(11):e401-e415. doi: 10.1016/j.jse.2020.03.016. Epub 2020 Jun 9.
The treatment of severe proximal humeral bone loss (PHBL) secondary to tumor resection or failed arthroplasty is challenging. We evaluated the outcomes and complications of reconstruction with reverse shoulder-allograft prosthesis composite (RS-APC), performed with or without tendon transfer.
An RS-APC procedure was performed in 25 consecutive patients with severe PHBL (>4 cm): 12 after failed reverse shoulder arthroplasty, 5 after failed hemiarthroplasty for fracture, 6 after failed mega-tumor prosthesis placement, and 2 after tumor resection. The median length of humeral bone loss or resection was 8 cm (range, 5-23 cm). Humeral bone graft fixation was obtained with a long monobloc reverse stem and a "mirror step-cut osteotomy," without plate fixation. Nine infected shoulders underwent a 2-stage operation with a temporary cement spacer. In addition, 9 patients (36%) underwent an associated L'Episcopo procedure. The median follow-up duration was 4 years (range, 2-11 years).
Overall, 76% of patients (19 of 25) were satisfied. In 8 patients (32%), a reoperation was needed. At last follow-up, we observed incorporation at the allograft-host junction in 96% of the cases (24/25); partial graft resorption occurred in 3 cases and severe in 1. The median adjusted Constant score was 53% (range 18-105); Subjective Shoulder Value, 50% (range 10%-95%). Additional tendon transfers significantly improved active external rotation (20° vs. 0°, P < .001) and forward elevation (140° vs. 90°, P = .045).
(1) Shoulder reconstruction with RS-APC provides acceptable shoulder function and high rates of graft survival and healing. (2) Additional L'Episcopo tendon transfer (when technically possible) improves active shoulder motion. (3) The use of a long monobloc (cemented or uncemented) humeral reverse stem with mirror step-cut osteotomy provides a high rate of graft-host healing, as well as a limited rate of graft resorption, and precludes the need for additional plate fixation. (4) Although rewarding, this reconstructive surgery is complex with a high risk of complications and reoperations. The main advantages of using an allograft with a reverse shoulder arthroplasty (compared with other reconstruction options) are that this type of reconstruction (1) allows restoration of the bone stock, thus improving prosthesis fixation and stability, and (2) gives the possibility to perform a tendon transfer by fixing the tendons on the bone graft to improve shoulder motion.
由于肿瘤切除或关节置换失败导致的严重肱骨近端骨缺损（PHBL）的治疗具有挑战性。我们评估了使用反肩关节异体移植物假体复合（RS-APC）进行重建的结果和并发症，包括是否进行肌腱转移。
连续 25 例严重 PHBL（>4cm）患者接受了 RS-APC 手术：12 例因反肩关节置换失败，5 例因骨折半关节置换失败，6 例因巨型肿瘤假体放置失败，2 例因肿瘤切除。肱骨骨缺损或切除的中位数长度为 8cm（范围，5-23cm）。肱骨骨移植物固定采用长的单块反向柄和“镜像台阶截骨术”，不使用钢板固定。9 例感染性肩采用 2 期手术，使用临时水泥间隔器。此外，9 例患者（36%）接受了 L'Episcopo 手术。中位随访时间为 4 年（范围，2-11 年）。
总体而言，76%（25 例中的 19 例）的患者满意。8 例（32%）患者需要再次手术。最后一次随访时，我们观察到 24/25 例（96%）异体移植物与宿主交界处有融合；3 例出现部分移植物吸收，1 例严重。调整后的 Constant 评分中位数为 53%（范围 18-105）；主观肩部评分 50%（范围 10%-95%）。附加的肌腱转移显著改善了主动外旋（20° vs. 0°，P<.001）和前向抬高（140° vs. 90°，P=.045）。
（1）使用 RS-APC 进行肩部重建可提供可接受的肩部功能和高存活率和愈合率。（2）附加的 L'Episcopo 肌腱转移（在技术上可行时）可改善主动肩部运动。（3）使用长的单块（水泥或非水泥）肱骨反向柄和镜像台阶截骨术可提供高的移植物与宿主愈合率，以及有限的移植物吸收率，并避免需要额外的钢板固定。（4）虽然令人满意，但这种重建手术复杂，并发症和再手术风险高。使用反肩关节异体移植物（与其他重建选择相比）的主要优点是这种重建（1）允许恢复骨量，从而改善假体固定和稳定性，（2）通过将肌腱固定在移植物上以改善肩部运动来进行肌腱转移的可能性。
