A total humerus prosthetic replacement is a procedure that involves removing a tumor, usually malignant or benign aggressive, of the entire arm bone/humerus and in most instances replacing the bone with a special customizable total humerus tumor prosthesis.
The entire arm bone, called the humerus, includes the shoulder and elbow joints. The shoulder girdle consists of the proximal humerus, scapula, and clavicle. The elbow consists of your humerus, ulna, and radius bone. Common tumors that affect the humerus are various sarcomas, benign aggressive tumors, and metastatic cancers to bone. Some of these tumors include osteosarcomas, chondrosarcomas, and giant cell tumors. Limb-sparing surgery can be performed for approximately 95% of tumors arising from this part of the body. In some instances, the extremity cannot be saved, and an amputation is performed. Contraindications for saving the limb may include neurovascular invasion, infection, pathological fracture, invasion of the chest wall, extensive disease, contamination from a poorly performed biopsy, recurrent disease.
Separating all major arteries, veins, and nerves from the tumor. In rare cases a nerve (s) may need to be removed if it is involved by the bone sarcoma. Once the blood vessels and nerves are properly identified they can be retracted (moved away) and protected throughout the procedure.
Developing surgical planes (margins that are tumor free) and separating muscles that can be preserved and leaving those in continuity with the tumor that should be removed. This is based on preoperative MRI and intraoperative findings as well as the type of tumor.
Developing surgical planes (margins that are tumor free) and separating muscles that can be preserved and leaving those in continuity with the tumor that should be removed. This is based on preoperative MRI and intraoperative findings as well as the type of tumor.
Remove the tumor. There are two different types of resections and reconstructions for bone sarcomas of the proximal humerus based on whether or not the sarcoma extends outside the bone into the soft tissues or if it is entirely encased by the bone. Most of the time it extends into the soft tissues. In these cases, the sarcoma easily spreads across the joint and into the deltoid muscle. The socket (glenoid) and deltoid muscle are removed in these cases (extra-articular resection). If the tumor is contained in the bone, the deltoid and socket can be saved (intra-articular resection).
Reconstruction of the limb. There are different methods of prosthetic reconstruction in each case. In an extra-articular resection when the deltoid and socket are removed the scapula body is used as a new socket and the prosthesis is stabilized to it and the clavicle with heavy sutures. In an intra-articular resection, the deltoid is preserved, and special methods are used to stabilize the prosthesis in the socket. Again, the goal is to restore shoulder stability and have a functional hand and elbow.
The tumor prosthesis is inserted. This prosthesis is sized and built during the surgical procedure then implanted. Then the prosthesis is cemented into the bone and is safely secured in place.
Soft-tissue coverage of the prosthesis. We use your surrounding muscles to cover the prosthesis. The soft tissue coverage utilizing your muscle not only provides additional support to your prosthesis, but also helps prevent skin problems and infections after your surgery. The muscles used for this technique can include your deltoid and latissimus dorsi (“lat” muscle).
We close your incision with sutures and cover the surgical site with bandages. Multiple large drains may also be used to drain the surgical site and prevent a seroma (buildup of fluid).
After your surgery you will spend a few nights in the hospital and then will be recuperating at home. Various pain protocols and nerve blocks are used to minimize pain. Mostly all patients are very comfortable after the surgery. For the first few days you will ice the area and keep it elevated to reduce swelling. You will return to the office 2 weeks after surgery. Patients are usually kept in a sling for 6 weeks to allow the muscles to heal. The elbow is not permitted to extend beyond 45 degrees of flexion for 4 to 6 weeks to allow the biceps muscle to heal which will stabilize the prosthesis. Once cleared, you will subsequently start physical therapy. We usually prescribe specific physical therapy protocols 3 times a week for 12 weeks after surgery to gradually strengthen muscles. Strengthening with significant resistance after sufficient range of motion is achieved as determined by Dr. Wittig. There may be an ultimate weight limit imposed upon you depending on various factors.
You will be monitored periodically with X-rays over the course of 5 years. Sometimes an MRI and/or CT may be used to additionally monitor the area to make sure the tumor has not come back. You will then have follow up appointments every 4 months for the first 2 years, then every 6 months for the next 2 years, and then once a year. Since the bone integrity has been restored to full or almost full, recovery is anticipated provided the patient adheres to strict physical therapy.
Dr. James Wittig narrates a video illustrating the surgical technique for resection of a sacrococcygeal chordoma, using cryosurgery as an adjuvant therapy. | WATCH VIDEO