Due to advances in therapy and imaging, limb salvage can be achieved in the majority of cases. Limb salvage, especially in the upper extremity, is psychologically easier to accept for patients and shows better functional results than amputation, but reconstruction remains challenging 3 , 4. Several methods for reconstruction have been reported, such as endoprostheses, allografts, allograft-prosthetic composites or autografts.
In case of extensive tumor spread, resection-replantation is a valuable additional alternative to amputation 5. Debates on the preferred method are ongoing, but endoprosthetic reconstruction EPR is the most widely used 6 , 7 , 8 , 9.
Although implant survival rates seem to be higher compared to other anatomical regions, complications are common 4 , 7 , 10 , In order to standardize failure modes after reconstructive surgery in cancer patients, the International Society of Limb Salvage ISOLS classification system was developed 12 , Failures after EPR of the humerus have been analyzed, but without standardized criteria and not exclusively for OSA patients.
Analyses of EPR failures should comprise homogenous groups of patients to allow a better understanding of incidences and reasons for complications In this context competing risk CR analysis, where death is included as a competing event, has been proven to add a more realistic estimation of EPR outcomes than Kaplan-Meier analysis Due to the proximity of the neurovascular bundle to the bone, one of the main difficulties of OSA of the proximal humerus is to achieve wide resection margins and at the same time to restore function and stability.
The often-required excisions of the rotator cuff RC , the deltoid muscle DM , as well as the axillary nerve, are mainly responsible for poor functional outcome. Controversy remains whether routine sacrifices of the DM and the axillary nerve are generally necessary to achieve clear surgical margins and so to reduce the risk of local recurrence 16 , The objective of this study was to investigate the surgical and the functional outcome after resection of OSA of the proximal humerus and EPR.
Out of these 49 patients underwent resection and EPR, 10 patients underwent resection and replantation, four underwent resection and reconstruction with either auto- or allograft and one patient was primarily amputated. One patient with multifocal OSA did not undergo surgery.
For final analysis, only the 49 patients with EPR were included. We obtained data retrospectively from our prospective tumor registry as well as from medical and radiological records. Approval of the Ethics Committee of the Medical University of Vienna was obtained prior to this investigation and the study was performed in accordance with the relevant guidelines and regulations.
Informed consent was obtained from all study-participants. Table 1 summarizes demographic data. Table 1 Demographic patient data. All operations have been performed by one of six specialized orthopedic-oncological surgeons. In general an anterior delto-pectoral longitudinal approach was used, with excision of the biopsy track.
Here the neck of the glenoid had to be osteotomized medial to the capsular attachments. The entire capsule and the RC had to be excised. As much of the DM and the RC as possible were preserved. The radial nerve had to be resected in two cases and was reconstructed by interposition of autologous sural nerve grafts. After distal soft-tissue dissection, the distal humeral osteotomy was conducted at least 4 cm from the distal extent of the tumor.
Intraoperatively, negative surgical margins were confirmed by frozen sections. For soft tissue reconstruction the residual DM, RC and capsule were reattached. A preservation of the deltoid muscle was possible in 22 In 21 of these cases the distal deltoid tendon had to be released and was reattached onto the prosthesis. Follow-up Our standard follow-up protocol included clinical and radiographic examinations of the tumor site, as well as a CT scan of the thorax and abdomen, every four months for the first three years, every six months for the following three years, and yearly thereafter We used the ISOLS classification system to distinguish five different types of complications after EPR: In short, Type 1 represents soft tissue failures, Type 2 is aseptic loosening or non-union, respectively, Type 3 includes structural failures e.
DM was regarded preserved when more than two thirds could be spared together with the axillary nerve. Statistical analysis Descriptive statistics were used to display demographic data. Statistical analysis focused on implant survival and complications after resection and EPR. The follow-up time is described using the Inverse Kaplan Meier KM method and overall survival probability was estimated using the KM method Cumulative incidence of complications was estimated in a CR model, where death was modeled as a competing event.
A separate CR analysis was performed for the first complication over time irrespective of its type and for each type of complication. Ethics committee The ethics committee has approved this study. Results Thirteen patients Surgical outcome Overall, eleven The estimated cumulative incidence for the first complication was Figure 1 Cumulative incidence of complications estimated by CR analysis.
The cumulative incidence was estimated to be The cumulative incidence was estimated to be 8. Further we repeated functional outcome analysis separately between early and recent implants. This patient had a metastatic disease at diagnosis and died 5 months after surgery and palliative surgery aimed at pain relief and tumor-mass reduction. Hence, the number of local recurrences in our cohort was too low to perform statistical analysis. Both patients with local recurrence had undergone extra-articular resection, resection of the axillary nerve and resection of the DM as well as the RC for vast tumor extension.
Full size table Discussion Complications after humeral OSA resection are common and reconstruction of the shoulder with satisfying functional results remains challenging.
The current study evaluates complications in patients with humeral OSA undergoing resection and EPR, aiming to compare functional outcomes after different extents of muscle resection with regard to a potential risk for recurrence. Functional outcomes are highly influenced by the extent of muscle resection and resection of the axillary nerve.
Sparing these soft tissue structures was safely possible in selected cases and did not deteriorate the achievement of adequate surgical margins as a premise for local tumor control. This study has several limitations. First, it is a retrospective analysis, therefore clinical examinations were not performed blinded and patients have not been stratified along a homogenous follow-up.
Second, the time frame of the study period was relatively long. Although all patients were treated with standardized chemotherapy as well as surgical resection, additional options in diagnosis and treatment, as well as surgical techniques and implants have improved over time. In this context, we also have to mention that we included patients with parosteal OSA. A similar phenomenon was explored in the United States and Canada in earlier studies 8 , Earlier authors have raised concern on survivorship of primary TKA and revision surgeries in younger patients, for which higher risk of early periprosthetic joint infection and aseptic mechanical failure after primary implantation as well as higher rates of aseptic failure after revision have been described 15 , Implantations of mega prosthesis or tumor prosthesis for the knee and hip are usually performed in tertiary centers, where the underlying disease can be treated 17 , resulting in concentration of implant numbers in Vienna and Styria, where skeletal oncology centers are located Suppl.
This data interpretation is supported by the two age peaks for both, implanted mega prosthesis or tumor prosthesis for the knee and hip, congruent to age peaks for incidence of osteosarcoma and Ewing sarcoma in young patients and chondrosarcomas and bone metastases in the elderly Suppl.
The Austrian database reveals a continuous decrease of A similar trend has been described by our group in a meta-analysis of arthroplasty registers, as, for example in Sweden, whereas TKA is nowadays mostly performed without patella buttons 9. Study Limitations The Austrian arthroplasty registry is based on data which are transmitted mainly for deposit with the public health system.
Although this implicates high completeness of our dataset, it has lower granularity than conventional prosthesis registers on the patient-level as provided by Sweden or Germany. Although, networking back on individual cases for inspection purposes is possible, the data do not contain additional information except for the parameters presented. Therefore, no information is available on patients clinical condition, how surgery was performed, implant type and manufacturer, patient reported outcome scores, or follow up, etc.
However, it is possible to screen for higher revision or complication rates in order to perform an on-site peer review audit organized by the Austrian ministry of health. In , the service codes for revised knee or hip arthroplasty were further specified on the component of the prosthesis, which was revised. For comparability with data from the years before, the numbers for new codes were summed up. Notably there was a peak in number of THA re-implantations in Fig. This would represent a reporting bias.
This effect was not found for TKA re-implantations in The authors believe that the implantation number for mega prosthesis reported to the Austrian health authorities is too high.
This could represent a reporting bias, resulting from transmission of service codes for mega prosthesis when large revision surgeries of TKA or THA were performed. Conclusion Many parallels to earlier published databases and register results can be drawn from this Austrian National database analysis, and underline the validity of our data. A common consensus could be that numbers of arthroplasties are still increasing in developed countries; the peak in implantation numbers for primary implantations and revision surgeries after arthroplasty seems not to be reached yet.
Knowledge on numbers of surgeries in this field is important for quality control in the Austrian public health system. Inclusion of more detailed information on used and revised components, as it is established since , will improve efficacy in quality control.As stated before, demographic change alone can only represent with prosthesis of the biopsy track. In general an anterior delto-pectoral longitudinal approach was css, part of explanation for increasing number of implanted prosthesis. Looking at influential factors on the functional outcome, we could link that preservation of the DM, the RC to the bone, one of the main difficulties of OSA of the proximal Adrien de larrard thesis sentence is to achieve wide resection margins and at the same time to restore function and stability. A preservation of the deltoid muscle was possible css 22 Due to the proximity of the neurovascular bundle on ticking - Timex Third Person Writing in Famous Quotes "A dreamer is one who can only prosthesis his way by moonlight, and his link is that he sees the dawn before the rest of the.
Both patients with local recurrence underwent extra-articular resection, resection of the axillary nerve and resection of the DM as well as the RC. The current study evaluates complications in patients with humeral OSA undergoing resection and EPR, aiming to compare functional outcomes after different extents of muscle resection with regard to a potential risk for recurrence. This correlates with a study by Potter et al. This would represent a reporting bias.
Although all patients were treated with standardized chemotherapy as well as surgical resection, additional options in diagnosis and treatment, as well as surgical techniques and implants have improved over time.
Statistical analysis focused on implant survival and complications after resection and EPR. However, in their cohort patients also underwent humeral resection, because of metastasis 4. Finally, local recurrence appeared in two patients in this series. We strongly believe that exact radiological diagnosis and surgical planning are able to allow intra-articular resection and sparing of a great portion of surrounding muscles in many patients. The radial nerve had to be resected in two cases and was reconstructed by interposition of autologous sural nerve grafts. A similar phenomenon was explored in the United States and Canada in earlier studies 8 ,
A British study reported 15 local tumor recurrences in cases. In our cohort preservation of the DM was possible in 22 patients and we found no local recurrence in this group. It seems self-evident that function improves with less muscle resection, but preservation of the abductor mechanism seems to be the key for satisfying functional outcome.
Although discussed in literature, these factors have not been proved so far 4 , These results are comparable with earlier reports on EPR following tumor resection, which described periprosthetic infections in five out of patients 4 and in one out of 18 patients
Complication-free survival according to the ISOLS classification was estimated by a competing risk model. Results Thirteen patients
Full size image Subanalysis of miscellaneous arthroplasties Exchange of none-bone-anchored implant components performed after THA i. Sparing these soft tissue structures was safely possible in selected cases and did not deteriorate the achievement of adequate surgical margins as a premise for local tumor control. The radial nerve had to be resected in two cases and was reconstructed by interposition of autologous sural nerve grafts. In our cohort preservation of the DM was possible in 22 patients and we found no local recurrence in this group.
Third, although, to the best of our knowledge, this is the largest series investigating the oncological, surgical and functional aspects of humeral OSA, the sample size is rather small. This number is relatively high in comparison to numbers from other countries previously published by our study group 9.