Department of Orthopaedics and Tumor Orthopaedics, Muenster University Hospital, Muenster, Germany.
Department of Orthopaedics and Trauma, Medical University of Graz, Graz, Austria.
Clin Orthop Relat Res. 2021 Aug 1;479(8):1754-1764. doi: 10.1097/CORR.0000000000001677.
Total humeral replacement is an option to reconstruct massive bone defects after resection of locally advanced bone tumors of the humerus. However, implant survivorship, potential risk factors for implant revision surgery, and functional results of total humeral replacement are poorly elucidated because of the rarity of the procedure.
QUESTIONS/PURPOSES: We asked: (1) What is the revision-free implant and overall limb survivorship after total humerus replacement? (2) What factors are associated with implant revision surgery? (3) What is the functional outcome of the procedure as determined by the Musculoskeletal Tumor Society (MSTS) score and the American Shoulder and Elbow Surgeons (ASES) score?
Between August 1999 and December 2018, 666 patients underwent megaprosthetic reconstruction after resection of a primary malignant or locally aggressive/rarely metastasizing tumor of the long bones at our department. In all, 23% (154) of these patients had a primary tumor located in the humerus. During the study, we performed total humeral replacement in all patients with a locally advanced sarcoma, in patients with pathological fractures, in patients with skip metastases, or in patients with previous intralesional contaminating surgery, who would have no sufficient bone stock for a stable implant fixation for a single joint megaprosthetic replacement of the proximal or distal humerus. We performed no biological reconstructions or reconstructions with allograft-prosthetic composites. As a result, 5% (33 of 666) of patients underwent total humerus replacement. Six percent (2 of 33) of patients were excluded because they received a custom-made, three-dimensionally (3-D) printed hemiprosthesis, leaving 5% (31) of the initial 666 patients for inclusion in our retrospective analysis. Of these, 6% (2 of 31) had surgery more than 5 years ago, but they had not been seen in the last 5 years. Median (interquartile range) age at the time of surgery was 15 years (14 to 25 years), and indications for total humeral replacement were primary malignant bone tumors (n = 30) and a recurring, rarely metastasizing bone tumor (n = 1). All megaprosthetic reconstructions were performed with a single modular system. The implanted prostheses were silver-coated beginning in 2006, and beginning in 2010, a reverse proximal humerus component was used when appropriate. We analyzed endoprosthetic complications descriptively and assessed the functional outcome of all surviving patients who did not undergo secondary amputation using the 1993 MSTS score and the ASES score. The median (IQR) follow-up in all survivors was 75 months (50 to 122 months), with a minimum follow-up period of 25 months. We evaluated the following factors for possible association with implant revision surgery: age, BMI, reconstruction length, duration of surgery, extraarticular resection, pathological fracture, previous intralesional surgery, (neo-)adjuvant radio- and chemotherapy, and metastatic disease.
The revision-free implant survivorship at 1 year was 77% (95% confidence interval 58% to 89%) and 74% (95% CI 55% to 86%) at 5 years. The overall limb survivorship was 93% (95% CI 75% to 98%) after 1 and after 5 years. We found revision-free survivorship to be lower in patients with extraarticular shoulder resection compared with intraarticular resections (50% [95% CI 21% to 74%] versus 89% [95% CI 64% to 97%]) after 5 years (subhazard ratios for extraarticular resections 4.4 [95% CI 1.2 to 16.5]; p = 0.03). With the number of patients available for our analysis, we could not detect a difference in revision-free survivorship at 5 years between patients who underwent postoperative radiotherapy (40% [95% CI 5% to 75%]) and patients who did not (81% [95% CI 60% to 92%]; p = 0.09). The median (IQR) MSTS score in 9 of 13 surviving patients after a median follow-up of 75 months (51 to 148 months) was 87% (67% to 92%), and the median ASES score was 83 (63 to 89) of 100 points, with higher scores representing better function.
Total humeral replacement after resection of locally advanced bone tumors appears to be associated with a good functional outcome in patients who do not die of their tumors, which in our study was approximately one- third of those who were treated with a resection and total humerus prosthesis. However, the probability of early prosthetic revision surgery is high, especially in patients undergoing extraarticular resections, who should be counseled accordingly. Still, our results suggest that if the prosthesis survives the first year, further risk for revision appears to be low. Future studies should reexamine the effect of postoperative radiotherapy on implant survival in a larger cohort and evaluate whether the use of soft tissue coverage with plastic reconstructive surgery might decrease the risk of early revisions, especially in patients undergoing extraarticular resections.
Level III, therapeutic study.
在肱骨近端局部晚期骨肿瘤切除术后，全肱骨置换是重建大骨缺损的一种选择。然而，由于该手术罕见，假体的存活率、潜在的翻修手术危险因素以及全肱骨置换的功能结果仍不清楚。
问题/目的：我们提出了以下问题：（1）全肱骨置换后，假体和肢体的无翻修存活率是多少？（2）哪些因素与假体翻修手术相关？（3）功能结果如何，使用肌肉骨骼肿瘤学会（MSTS）评分和美国肩肘外科医生协会（ASES）评分来评估？
1999 年 8 月至 2018 年 12 月，我们科室对 666 例原发性恶性或局部侵袭性/罕见转移性长骨肿瘤患者进行了 Megaprosthetic 重建，其中 23%（154 例）的患者肱骨有原发性肿瘤。在研究期间，我们对所有局部晚期肉瘤患者、病理性骨折患者、跳跃转移患者或先前进行过污染性病灶内手术、无法进行稳定假体固定的单关节 Megaprosthetic 置换的患者进行了全肱骨置换。我们没有进行生物重建或同种异体-假体复合材料重建。结果，666 例患者中有 5%（33 例）接受了全肱骨置换。33 例中有 6%（2 例）因接受定制的三维打印半关节而被排除，因此 666 例患者中有 5%（31 例）被纳入回顾性分析。其中 6%（2 例）患者的手术时间超过 5 年，但在过去 5 年内未就诊。手术时的中位（四分位距）年龄为 15 岁（14-25 岁），全肱骨置换的指征为原发性恶性骨肿瘤（n=30）和复发性、罕见转移性骨肿瘤（n=1）。所有 Megaprosthetic 重建均采用单一模块系统进行。从 2006 年开始，植入的假体被银涂层覆盖，从 2010 年开始，当适当的时候，使用反向肱骨近端组件。我们对所有植入物并发症进行了描述性分析，并使用 1993 年 MSTS 评分和 ASES 评分评估了所有未行二次截肢的存活患者的功能结果。所有存活患者的中位（IQR）随访时间为 75 个月（50-122 个月），随访时间最短为 25 个月。我们评估了以下可能与假体翻修手术相关的因素：年龄、BMI、重建长度、手术时间、关节外切除、病理性骨折、先前病灶内手术、（新）辅助放化疗和转移性疾病。
1 年时无假体翻修的假体存活率为 77%（95%置信区间 58%-89%），5 年时为 74%（95%CI 55%-86%）。全肢体存活率在 1 年和 5 年后分别为 93%（95%CI 75%-98%）。我们发现，与关节内切除相比，关节外切除的患者无假体翻修存活率较低（5 年后分别为 50%[95%CI 21%-74%]和 89%[95%CI 64%-97%]）（关节外切除的亚危险比为 4.4[95%CI 1.2-16.5]；p=0.03）。由于我们分析的患者数量有限，我们无法在 5 年内检测到术后接受放疗的患者（40%[95%CI 5%-75%]）和未接受放疗的患者（81%[95%CI 60%-92%]）之间无假体翻修存活率的差异（p=0.09）。在中位（IQR）随访 75 个月（51-148 个月）后，13 例存活患者中有 9 例的 MSTS 评分中位数为 87%（67%-92%），ASES 评分中位数为 83（63-89）分，分数越高代表功能越好。
肱骨近端局部晚期骨肿瘤切除术后行全肱骨置换似乎与未死于肿瘤的患者有较好的功能结果相关，在我们的研究中，这大约占接受切除术和全肱骨假体置换的患者的三分之一。然而，早期假体翻修手术的概率很高，尤其是在接受关节外切除的患者中，应相应地对这些患者进行治疗。尽管如此，我们的结果表明，如果假体在第一年存活，进一步翻修的风险似乎较低。未来的研究应该在更大的队列中重新评估术后放疗对假体生存的影响，并评估软组织覆盖的塑料重建手术是否可以降低早期翻修的风险，尤其是在接受关节外切除的患者中。
III 级，治疗性研究。
