Radical Resection of the Distal Humerus and Prosthetic Reconstruction

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Radical Resection of the Distal Humerus and
Prosthetic Reconstruction

• James C. Wittig, MD
• Associate Professor of Orthopedic Surgery
• Chief, Orthopedic OncologyMount Sinai Medical
  Center

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Purpose

• To describe the indications, surgical technique,
  and short term oncological and functional results
  for radical resection of the distal humerus and
  prosthetic reconstruction
• Small series of 3 patients

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Indications for this Procedure

• Primary bone sarcoma of the distal humerus
• Primary soft tissue sarcoma surrounding or
  invading the distal humerus
• Palliation for advanced metastatic carcinoma with
  severe bony destruction
• Complications related to conservative treatment
  for pathological fractures (nonunion or
  progression following radiation)

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Cases

• 52 year old male with a 9 cm high grade synovial
  sarcoma arising from the proximal flexor-pronator
  mass, surrounding the distal humerus
• 54 year old female with advanced metastatic renal
  cell carcinoma involving the distal humerus and a
  useless, painful arm/elbow treated one year
  prior with intramedullary rods at another
  institution
• 55 year old male with myeloma and a pathological
  fracture of the distal humerus who failed
  treatment with radiation and had a persistent
  nonunion treated conservatively for 4 months

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Surgical Procedure--Steps

• Tumor resection
• Dissection and mobilization of brachial vessels
• Dissection and Preservation of median, radial and
  ulnar nerves
• Preservation of biceps
• Preservation of sufficient forearm flexors and
  extensors while still maintaining an adequate
  margin
• Prosthetic reconstruction with Modular Segmental
  Distal Humerus and Total Elbow
• Soft tissue reconstruction
• Proximal transfer/rotation of forearm flexors and
  extensors with elbow flexed 60-90 degrees
  (Flexorplasty)
• Biceps tensioned appropriately Side sutured to
  triceps for full closure
• Entire prosthesis must be covered with soft tissue

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Case 1

• 52 year old male with high grade synovial sarcoma
  arising in the elbow region
• Large incisional biopsy in another country
• Preoperative chemotherapy
• Postop radiation

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MRILarge Mass Surrounding Distal Humerus
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Arteriogram to Visualize blood Vessels
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Case 2

• 54 year old female with advanced metastatic renal
  cell carcinoma involving the distal humerus
• Failed previous intramedullary fixation and
  radiation
• Presented with a 10 cm mass

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Distal Humerus Destroyed by Tumor
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Arteriogram Showed a Hypervascular Mass
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Preoperative Embolization to Cut Off Blood Supply
to Tumor
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Case 3

• 55 year old male with a nonunion of a
  pathological fracture of the distal humerus for 4
  months
• Failed previous radiation
• Poor quality bone at time of surgerynot
  appropriate for internal fixation

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Fracture Nonunion
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Metastatic Renal Cell Carcinoma
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Incision--Anteromedial
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Biceps Muscle
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Neurovascular Dissection and Mobilization Feeding
Blood Vessels to Tumor are Tied Off
Biceps Muscle
Brachial Vessels Median Nerve
Median Nerve
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Biceps Preserved
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Tumor Covered by Brachialis Muscle
Ulnar Nerve
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Radial Nerve
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Forearm Flexors and Extensors Released / Joint
Capsule Released
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Specimen Metastatic Renal Cell
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Defect
Radial Nerve
Olecranon
Ulnar Nerve
Median Nerve Brachial Vessels
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Modular Segmental Replacement with Constrained
Hinged Total Elbow
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Implantation of the Prosthesis
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Synovial Sarcoma of Elbow
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Biceps Muscle
Median Nerve Brachial Vessels
Tumor from Flexor Pronator Muscle Group
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Specimen
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Tumor Wrapped Around Distal Humerus Brachialis
Muscle Involved by Tumor
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Defect
Median Nerve/Brachial Vessels
Remaining Humerus
Biceps Muscle
Olecranon
Radial Nerve
Ulnar Nerve
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Prosthesis Inserted
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Elbow Flexion
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Soft Tissue Reconstruction
Flexorplasty of Forearm Muscles to Biceps
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Epidural Catheter into Brachial Plexus for
Bupivicaine Infusion
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X-Rays AP
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Lateral X-Ray
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Results

• Patients are maintained in a brace in flexion of
  60 90 degrees for 6 weeks then active motion
  exercises are initiated
• Patients were followed for 6 months to 14 months
• No local recurrences
• All patients had functional use of their hands
  postoperatively
• Pain was relieved in all patients
• Active ROM of Elbow was 10-90 degrees by 16-20
  weeks postoperatively
• No neuropraxias
• 1 minor wound dehiscence treated successfully
  with local dressing changes

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12 Weeks Postop Metastatic Renal Cell
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16 Weeks Postop Synovial Sarcoma
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Summary

• Reconstruction of the distal humerus with a
  cemented modular segmental distal humerus /
  constrained total elbow prosthesis is a safe and
  reliable method for reconstruction following
  radical resection of selected tumors for
  palliation or cure
• Function is optimized with soft tissue
  reconstruction and multiple muscle rotation flaps
• It is an acceptable alternative to an above elbow
  amputation or shoulder disarticulation
• Pain relief is reliable and a functional hand and
  elbow can be restored
• Complications can be minimized with careful
  attention to neurovascular dissection and soft
  tissue reconstruction
• The survival of the prosthesis awaits long term
  results

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Thank You!!
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Nonunion of Pathological Fracture of Distal
Humerus after Radiation Treatment
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