Bone tumors are infrequent within the scapula. Total scapulectomy with massive allograft reconstruction represents an attractive alternative to amputation when the whole scapula is invaded with tumor and the neurovascular bundle can be preserved during tumor resection. We report a case of resection of the scapula and proximal humerus for recurrent osteosarcoma with massive allograft reconstruction of the scapula and proximal humerus. A 22-year-old male patient was seen in February 1992 for a pathological fracture of the proximal left humerus. In July 1992, a resection of the proximal end of the humerus followed by a reconstruction with osteochondral allograft and nail osteosynthesis was performed. The postoperative course was uneventful. In September 2009, 17 years later, the patient presented with a huge tumor developed at the level of the scapula. There was no vascular or neurological symptom. Plain radiography showed an expansive osteolytic mass. CT scan demonstrated scapular and proximal humerus invasion. An extended assessment revealed the presence of two pulmonary nodules. The biopsy confirmed the recurrence of osteosarcoma. The indication of a resection of both the left scapula and the 1992 allograft which was completely invaded at its proximal portion and the complete reconstruction of the scapula and the proximal humerus with allograft was made. One year postoperatively, we note a favourable outcome in terms of musculoskeletal functions. Despite two resection surgeries of pulmonary nodules and chemotherapy treatments, the patient developed new lung metastases and an unfavourable outcome. Although shoulder function was almost completely eliminated following surgery, preservation of elbow, wrist and finger motion resulted in an acceptable level of postoperative limb function. This reconstruction appears to be an attractive technique to be used in similar cases. The necessity of a reliable tissue bank with quality allografts in sufficient number is paramount.
Proximal humerus is the first location of primary tumors of the upper limb and the fourth for all primary malignancies [
Amputation was the usual treatment in the past but its use had been greatly reduced due to in-depth preoperative assessment using cutting-edge imaging modalities, the effectiveness of adjuvant chemotherapy and the progress of surgical reconstruction techniques [
Reconstruction techniques of the proximal humerus sarcoma are well known [
A 22-year-old male patient was seen in February 1992 for a pathological fracture of the proximal left humerus. The biopsy found a low grade osteosarcoma. Full body CT scanning did not reveal other locations and scintigraphy excluded the presence of metastasis. Magnetic resonance imaging made before and after chemotherapy showed a relatively poor response to chemotherapy. In July 1992 a resection of the proximal end of the humerus followed by a reconstruction with osteochondral allograft and nail osteosynthesis was performed. The postoperative course was uneventful.
In September 2009, 17 years later, as part of a study on the reconstruction of the proximal humerus with osteochondral allograft, the patient presented with a huge tumor developed at the level of the scapula. This mass significantly increased in size in the last six months (
Ethical consideration: Informed consent was obtained from a patient. Agreement was obtained from the local ethical committee of the institution (registration number NCT02355301; 2015/26JAN/025).
The proximal humerus is a common site for primary malignant bone tumors. Limb-spearing surgery is currently the rule. Technically, resection is difficult due to the proximity of the brachial plexus and axillary vessels [
The functional result of conservative treatment of tumors of the shoulder girdle depends on the preservation of the glenoid, the deltoid muscle and tendons of the rotator cuff and neurovascular structures [
which are the glenohumeral arthrodesis, the humeral prosthesis (with or without allograft), reversed prosthesis and massive allografts [
When proximal humerus and the entire scapula are both invaded, as was the case of our patient, scapula and proximal humerus reconstruction options are limited. Scapular osteoarticular allograft reconstruction after scapular tumors resection are rarely reported and limited. After resection of the entire scapula, the glenohumeral joint or proximal humerus is damaged; the remaining humerus can be suspended from clavicle or ribs. However, the trend has been reconstruction with a scapular prosthesis in order to obtain better functional and cosmetic
results. Every method has its advantages and disadvantages so that there is no optimal reconstructive strategy [
The use of osteoarticular allograft in oncology surgery is well known with good functional outcome [
There uses remains attractive, however, there are still limiting factors, such as the necessity of a reliable tissue bank with quality allografts in sufficient number is paramount [
On the one hand, they must not overshadow osteocartilaginous resorption and associated fractures. Long term complications include pseudarthrosis and fractures. Before 12 months, they are related to huge fragility due to screw holes. After 12 months, complications are constraint fractures and after 24 months, they are stress fractures. After 48 months, complications are related to massive allograft resorption [
Regarding the reconstruction of soft tissue, the deltoid muscle plays the most important role in stability and shoulder function. It was partially sacrificed in our patient. The capsule acts as a joint stabilizer. However, to restore shoulder function and maintain the stability of the shoulder, the rotator cuff, especially the supraspinatus muscle, should also be preserved as much as possible. Careful preparation of the supraspinatus and infraspinatus and their nerve supply are required to obtain a satisfactory outcome of the reconstruction.
The main aim musculoskeletal malignancies resection is tumor remission, and secondly the need to preserve the limb and its function, and aesthetic concerns. The main objective of the reconstruction is to create a functional member which is acceptable to the patient [
Our patient continued to develop lung metastases. This could be explained by delays in consultation. Functionally, flexion/extension of the elbow and wrist were normal. The abduction was 30˚, internal rotation allows moving the left hand to D10, which is required for most activities of daily living and personal hygiene.
The reconstruction of the scapula and the proximal humerus by a massive osteoarticular allograft can be an oncologic safety procedure with an acceptable complication rate. Osteoarticular allografts have the advantage of being anatomical, theoretically rehabitable and allow easier tendon reinsertion than on a prosthetic metal surface. They restore bone stock and provide immediate shoulder stability. The necessity of a reliable tissue bank with quality allografts in sufficient number is paramount. Functional and oncological outcomes are related to the timing of consultation period and periarticular structures invasion.
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AlidouTraoré,KarimTribak,BrahimaDoukouré,Daouda KanatéSoumaro,Slim AlbanMbende,Sidi YayaTraoré,Rebecca EvaBoka,ChristianDelloye, (2015) Shoulder Reconstruction with Massive Scapular-Proximal Humerus Osteoarticular Allograft after Total Scapulectomy for Proximal Humerus Osteosarcoma Recurrence. Open Journal of Orthopedics,05,390-399. doi: 10.4236/ojo.2015.512052