constrained shoulder replacement
DESCRIPTION
TRANSCRIPT
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Constrained (Rotator Cuff Substituting) Total Scapula Prosthesis Following
Tumor Resection
James C. Wittig, MD
Jacob Bickels, MD
Kristen Kellar-Graney, BS
Martin Malawer, MDWashington Cancer Institute, Washington DC
National Cancer Institute, NIH
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Background
• Shoulder Girdle: 3rd most common site for sarcoma
• Most common tumors of the scapula:• Ewing’s sarcoma
• Osteosarcoma
• Chondrosarcoma
• Metastatic Hypernephroma/Lung CA
• Periscapular Sarcomas
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Treatment
Limb-Sparing Resection
• Tikhoff-Linberg Type Resection (extraarticular total scapulectomy)
• Intra-articular Total Scapulectomy
Ewing’s Sarcoma
Humeral Head
Clavicle
Glenoid
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Anatomic Reconstruction• Restores the scapula with a metallic
endoprosthesis
• 23 pts total scapula resection; 15 prosthetic replacements
• Utilizes the remaining periscapular muscles for soft tissue reconstruction
• Restoration of both Glenohumeral and Scapulothoracic mechanisms
• Restores Muscle Force Couples
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Scapular Design• Non-Constrained Components (Earlier Versions;
n=12)Modular Proximal
Humerus
Superior Border
Axillary Border
Gore-tex Aortic Graft
Dacron Tape
Sutured to Scapula Neck
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Non-Constrained 10 yr Follow-UP
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Constrained Component
Why Designed??• Improve stability• Mechanically restore
rotator cuff function more efficiently(gore-tex elastic)
• Ease surgical reconstruction
Prevents Superior Humeral Migration!
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Constrained ComponentsBody• Down-sized • Holes for myodesis• Vacant area
Glenoid• Bipolar hip• Captured polyethylene
liner
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Constrained Total Scapula
***SNAP FIT DESIGN***
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MotionHoles for Myodesis of Periscapular Muscles
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Purpose
• To describe the indications and surgical technique for total scapular prosthetic reconstruction following tumor resection
• Report preliminary functional results and complications with constrained total scapula reconstruction
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Indications Muscle Force Couples
• Required: Periscapular Muscles and Axillary Nerve
• Trapezius
• Deltoid
• Latissimus
• Rhomboids
• Serratus Anterior
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Patient Demographics• Three Patients (all males)• Ages: 13 yrs, 16 yrs, 26 yrs• Follow-up: 7 mos, 15 mos, 20 mosDiagnoses: • Recurrent High Grade OS –Scapula Neck• Ewing’s Sarcoma• Undifferentiated HG Soft Tissue Sarcoma—
Subscapularis with invasion of the Scapula***All received induction chemo• Function assesed according to MSTS System
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Patient Demographics
• 26 y.o. male
• Navy S.E.A.L.
• 9x7x11 cm mass
• Anterior surface of scapula/subscapularis
• High grade undifferentiated sarcoma
• Multiple pulmonary nodules
• DOD at 7 mos post-op
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Extensive Necrosis Post-Chemo
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Ewing’s Sarcoma
• 17 y.o. male with a Ewing’s sarcoma of the right scapula
• Good response to induction chemo
• Complete resolution of soft tissue component
• AWD at 15 mos
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Pre-Chemo MRI
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Pre-Chemo CT
Tumor
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Post-Chemo CT
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Recurrent Osteosarcoma• 13 y.o. boy• Telangiectatic OS of
proximal humerus• Tx in Macedonia with
intraarticular resection and recon with fibula
• Local recurrence along inferior scapular neck
• Failure of hardware• ANED at 20 months
Fibula
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Surgical Procedure
• Resection: combined anterior and posterior approach
• Neurovascular bundle explored and mobilized
• Tumor explored
• Required muscles preserved, when feasible
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Reconstruction
• Prosthesis placed close to midline
• Pocket between Serratus Anterior and Rhomboids
• All other periscapular muscles transferred and tenodesed
• Latissimus mobilized
• Proximal humerus snapped into place (Gore-tex)
• Entire prosthesis covered with soft tissue
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Soft Tissue Reconstruction
Prosthesis Placed Between Serratus Anterior and Rhomboids
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Muscle Force Couples
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Entire Prosthesis Covered
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Intraoperative View
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Intraoperative View
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Postoperative AP
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Postoperative Lateral
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Postoperative Axillary
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Postoperative Function
MSTS Score: 24-27/30 (Consistent Results)
Pain: 5 (All pain free)
Hand Dexterity: 5 (Normal)
Emotional Acceptance: 5 (All enthused)
Lifting Ability: 3-4 (Normal at side of body)
Hand Positioning: 3-4 (Hand above shoulder)
Function/Activities: 3-4 (Athletic restrictions)
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Function• All shoulders stable
• Functional hand and elbow
• Scapular protraction, retraction and elevation intact
(Assist in stabilizing extremity when carrying objects)
• No complications
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Conclusions
• Total scapula prosthetic reconstruction appears to be a safe and reliable method for anatomically reconstructing the shoulder girdle following total scapulectomy
• The following periscapular muscles must be preserved for soft tissue coverage and reconstruction of the muscle force couples (Deltoid, Trapezius, Rhomboids, Serratus Anterior, Latissimus) and axillary nerve
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Conclusions
• It permits reconstruction of the glenohumeral and scapulothoracic mechanisms, both functionally important
• Constrained components ease reconstruction
• Further follow-up is necessary to determine if the constrained versions provide an improvement in function over non-constrained versions
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Reconstruction Options
Non Anatomic Methods• Glenohum and Scapulothor
Mechanisms Not Reconstr• No Recon—Flail Shoulder• I.M. Rod or Spacer• Attach Humerus to Clavicle
or Rib
Problems:• Unstable Extremity• Poor Lifting Ability• Remaining Periscapular
Muscles Not Utilized• Chronic Traction
Neuropraxia• Pain• Frequent Complications• Hardware Failure
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Indications
• Primary high grade and select low grade scapula sarcomas
• Periscapular soft tissue sarcomas invading the scapula
• Select metastatic carcinomas with extensive scapular destruction and a soft tissue component, especially radioresistant lesions