The shoulder has the largest ROM in the human skeleton. In contrast with the hip, the glenohumeral joint has six degrees of freedom and a major component of the overall stability is provided by soft tissue attachments [1
]. Modern metallic endoprostheses permit the orthopaedic surgeon to reconstruct large segments of diseased bone. However, these constructs lack the soft tissue-bone interface required for function. Several studies have focused on the proximal femur to try to understand the complex relationship of tendon-bone interfaces [16
]. Osteoconductive scaffolds [53
], metallic anchors for soft tissues [20
], predetermined suture sites embedded in the metallic prostheses [50
], and coating of the prostheses with novel materials [14
], have been described to promote soft tissue ingrowth and improve function after limb salvage with endoprostheses. All of the surgical options for proximal humerus reconstruction have been associated with instability [25
], recurrent dislocation [25
], and overall poor function [36
]. In the present study, the authors describe the surgical technique using an aortograft during humerus reconstructions, the functional level and shoulder ROM of patients undergoing the procedure, and the incidence of postoperative dislocation and shoulder instability.
We acknowledge several limitations to our study. First, it is a small sample of patients. Proximal humerus reconstruction for tumors is a relatively rare surgical procedure and it is difficult to accumulate large series in a single institution. We report on 16 patients (accrual over 17 months) who underwent a proximal humerus reconstruction with the use of an aortograft mesh at a large National Cancer Institute designated cancer center. Second, we had a relatively short followup of a mean of 26 months (range 13 to 43 months). Patients with osteosarcoma have a short life expectancy (68% at 5 years) 40 and in the case of other primary tumors (such as renal cell) with metastasis to bone, the survival decreases even more to a median life expectancy of 12 months [48
]. Although only one of the patients described in this series died (13 months after the procedure), the authors believe that some of the most important functional deficits (dislocations and instability) are evident within the present study followup and adversely affect quality of life during the remaining survival [23
]. A mean followup of 26 months allows adequate time to assess soft tissue attachment, restoration of function, and occurrence of dislocations [22
]. In other series [7
] three of 36 patients (8%) presented with dislocations after proximal humeral replacements at a mean followup of 26 months (minimum followup of 6 months). Third, we lacked a control group. The authors continued using the aortograft mesh in all patients after the first procedure was performed in February of 2006. An attempt to compare the present series to previous procedures performed by the same surgeon without the use of the aortograft mesh was abandoned due to difficulty with matching of diagnoses, preoperative limb function, and number of cases available.
Kumar et al. [26
] reported on 10 patients who underwent limb salvage procedures of the upper extremity. Patients were followed for a mean of 18 months and they observed acceptable function (defined as patients free of disease and pain and able to return to occupational activities but not sports) in 30% of their patients [26
]. None of the patients described in that series was able to perform over the head activities. O’Connor et al. [37
] published the functional results of 57 patients who had a limb salvage procedure for a tumor of the shoulder girdle region. The average followup was 5.3 years (median, 4.6 years). They concluded that proximal humeral replacements produced symptomatic instability that leads to a secondary arthrodesis in some patients [37
]. Camnasio et al. [7
] reported on 37 proximal humerus reconstructions. At a mean followup of 26 months, 30.6% of patients had satisfactory functional results (compared to 74% of patients with proximal femur replacements) [7
]. Finally, Mourikis et al. [35
] concluded all reconstruction approaches to the proximal humerus, resulted in functional problems for the patient (Table ).
Several studies report the use of modified surgical techniques and new biomaterials with improved function after proximal humerus reconstruction. Wittig et al. [50
] analyzed the long-term survival and function and complications associated with limb-sparing surgery for 23 patients with osteosarcoma of the proximal humerus. In all patients, the endoprosthetic replacement was stabilized by static suspension (Dacron® tapes) and dynamic suspension (muscle transfers). At latest followup (median, 10 years), 15 patients (65%) were alive without evidence of disease. The Musculoskeletal Tumor Society upper extremity functional score ranged from 24 to 27 (80%–90%). All shoulders were stable and pain-free. The most common complication was a transient neuropraxia (n = 8) [50
]. Gosheger et al. [17
] studied 69 megaprostheses implanted with the use of a polyethylene terephthalate (Trevira®) tube to support reconstruction of the capsule and soft tissues. In cases of proximal humerus replacement (16 patients), the tube allowed for reconstruction of the capsule and refixation of the muscles. No dislocation was observed in patients with a proximal humerus endoprosthesis. They analyzed the implanted trevira tube in six patients who had revision surgery for aseptic loosening of a distal femur (one patient), revised periprosthetic fracture (one patient), amputations for local recurrence (three patients), and low-grade late infection (one patient). The histopathologic findings in those patients showed tissue ingrowth into the tube. They concluded, in soft tissue reconstruction of megaprostheses, the reattachment of soft tissues and joint capsules is essential and can be adequate with the use of biomaterials such as polyethylene terephthalate [17
Our data suggest the use of an aortograft mesh during proximal humerus reconstruction may reduce dislocations and facilitate soft tissue attachment and reconstruction after tumor resection. Our findings should prompt larger investigations to confirm the safety and clinical benefits of this straightforward surgical technique. In addition to tumor control, surgical procedures should provide an adequate quality of life with reduced complications and repeat surgery. The sleeve created by the aortograft allows for both mechanical restraint and ingrowth potential for soft tissue attachments.