Does total humeral endoprosthetic replacement provide reliable reconstruction with preservation of a useful extremity?

Background: Controversy exists regarding the ideal method of reconstruction after proximal humeral resection and several reconstructive techniques have been reported. The reconstructive options are very limited when resection of the entire humerus is required. One option is endoprosthetic reconstruction, but there have been few published studies on the outcome of total humeral endoprosthetic reconstruction.

Questions/purposes: The purposes of this study were (1) to assess the longevity of total humerus prostheses in those patients who survived their disease; (2) to review the complications associated with this prosthesis; and (3) to assess the Musculoskeletal Tumor Society functional score in survivors.

Methods: Thirty-four patients (10 males, 24 females) with a mean age of 26 years (range, 7-86 years) were included in this study. Histological diagnosis was osteosarcoma in 15 patients, chondrosarcoma in seven, Ewing's sarcoma in seven, metastatic carcinoma in three, liposarcoma in one, and giant cell tumor of bone in one remaining patient. Twenty-nine patients had their total humeral endoprosthetic replacement for primary reconstruction, whereas the remaining five patients received their implants for failures with other reconstructive techniques. At a minimum followup of 3 months (mean, 8.2 years; range, 3 months to 29 years), 16 patients were alive with no evidence of disease, whereas 13 of the remaining 18 died with metastatic disease. Local recurrence was seen in five patients and all eventually died of disease progression.

Results: According to the Kaplan-Meier survival analysis, the cumulative 10-year implant survival rate was 90%. Periprosthetic infection was seen in four patients, postoperative radial nerve palsy in one, and proximal migration of the prosthesis in three, whereas three patients needed a change of the articular elbow bushings at a mean of 16 years after the implant insertion. The mean Musculoskeletal Tumor Society functional score of the 28 patients who survived their disease for more than 12 months after the index procedure and could therefore be functionally assessed was 83% (range, 60%-93%).

Conclusions: From this small, preliminary report, we suggest that total humeral endoprosthetic replacement may be a reasonable option of reconstruction after tumor resection. We have shown that this prosthesis preserves the function of the hand. The local recurrence rate observed suggests that careful selection of patients is crucial. Infection was our most common surgical complication, but we showed that in those who survived their tumor, this prosthesis offers a method to preserve a functional upper extremity in some patients. Further study with more patients is necessary to confirm the value of this reconstruction method.

Level Of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.