Publication de Nicole Delepine : Total humeral replacement for sarcoma. Considerations about 2 cases

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Publié sur : 25th annual meeting european musculoskeletal oncology society - bologne italie - 2012
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Total humeral replacement for sarcoma. Considerations about 2 cases
Gérard Delepine, Fabrice Delepine, Markovska, Nicole Delepine

Total humeral replacement for sarcoma. Considerations about 2 cases



Objectives


With effective chemotherapy the gold standard for limb salvage is wide resection. Consecutively primary total humeral resection is nowadays rarely indicated. Two cases, one with very long follow up permit us to consider the aspects of reconstruction.

humeral resection


Case 1, 1986/3


A 35 year old man consult us for pain in the left arm. Ct showed a tumour invading the whole humerus.
Open biopsy confirms a low grade fibrosarcoma.

tumour invading the whole humerus


Case 1, 1986/6


Total humeral resection was performed.
Reconstruction used an allograft armed with nail and cement.

Total humeral resection


Case 1, 1987


- 1 year Follow up.
- A sub capital fracture of the allograft compelled us to put an humeral head prosthesis on the nail.

humeral head prosthesis on the nail


Case 1, 1993


- 7 years Follow up
- resorption of proximal allograft resuted in fracture of the nail.
- Reconstruction used a an humeral prosthesis with long stem inserted into the allograft.

humeral prosthesis


Case 1, 2003


- 17 years follow up
- Heavy pains and instability of arm appeared with the loosening of the prosthesis due to the progessive resorption of allograft.

progessive resorption of allograft


2003


- We performed a total humeral prosthesis with
- an elbow hinge prosthesis
- and a constained shoulder component.

humeral prosthesis


2012/02 (25 years Follow up)


- Patient in first remission is cured.
- According to Enneking's score function is rated good
- Patient works as police officer.

Case 2 January 2010


- a boy of 17
- comes for a pathological fracture of the proximal part of right humerus.
- Without biopsy he is treated by nailing from the elbow.

pathological fracture


Case 2 June 2010


- 6 months Follow up
- The fracture healed
- But pain and bone swelling increased.

fracture healed


Case 2. 2010/12


- 1 year Follow up
- An open biopsy shows a telangectasic osteosarcoma.
- As nailing disseminated the tumour throughout the diaphysis, extratumoral surgery necessitated total humerus resection
- with resection of axillary nerve.

telangectasic osteosarcoma


Case 2


Replacement used a composite prosthesis with an upper humeral long stem prosthesis inserted in an wide elbow custom made prosthesis locked with a high dose Vancomycine loaded acrylic cement (8 grams of vancomycine in 80 grams of metacrylate).

composite prosthesis


Post operative dislocation of shoulder compelled to re operate.
To put a constrained component of the shoulder prosthesis (after completion of chemotherapy).

shoulder prosthesis


Case 2, 2012/02


- 2 year follow up
- the patient is in first remission.
- Esthetical aspect of limb is nice.
- According to Enneking's score function is rated good.

remission


Comments


Despite the technical difficulties total humeral replacement give much better function than forequarter amputation of upper limb.
Adding high dose Vancomycine may help in decreasing the infection risk.

Conclusions


These observations plea for primary reconstruction by humeral prosthesis rather than by allograft.
We prefer a composite prosthesis more flexible
A constrained shoulder prosthesis seems necessary.





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