Is the Clavicula Pro Humero Technique of Value for Reconstruction After Resection of the Proximal Humerus in Children?

Abstract

Background: There are several options for reconstruction of proximal humerus resections after wide resection for malignant tumors in children. The clavicula pro humero technique is a biologic option that has been used in the past, but there are only scant case reports and small series that comment on the results of the procedure. Because the longevity of children mandates a reconstruction with potential longevity not likely to be achieved by other techniques, the clavicula pro humero technique may be a potential option in selected patients.

Questions/purposes: (1) How successful is the clavicula pro humero procedure in achieving local tumor control? (2) What is the frequency of nonunion? (3) What are the complications of the procedure? (4) What scores do patients achieve (on the Musculoskeletal Tumor Society (MSTS) and the Toronto Extremity Salvage Score (TESS) after this procedure?

Methods: Four university hospitals performed the clavicula pro humero technique in eight children aged 8 to 18 years between June 2006 and February 2014. During that period, general indications for this approach included all reconstructions of the proximal humerus for malignant tumors in children older than 8 years. All patients were followed for a mean of 40 months (range, 25-86 months); one patient was lost to followup before 2 years. The tumor resections removed the rotator cuff muscles in all patients, glenohumeral joint in five, and deltoid muscle in three. The median length of the bone defect after resection was 20 cm (range, 7-25 cm). It was reduced to 9 cm (range, 0-17 cm) or 27% (range, 0%-64%) of the total humerus length after clavicular rotation. Direct osteosynthesis (one patient), induced membrane technique (one patient), or vascularized fibular autograft (six patients) was used to complete the defect after rotation of the clavicle if necessary. Presence of union (defined as bone healing before 10 months, as assessed by disappearance of the osteotomy on AP and lateral view radiographs), and complications were determined by chart review performed by a surgeon not involved in patient care. Function assessed by the MSTS and the TESS scores were determined by the patients with their families.

Results: None of the patients had tumor recurrence. One patient died of pulmonary metastases before the 2-year followup. Proximal and distal bone unions were achieved before 10 months without an additional surgical procedure in two and six of seven patients, respectively. Fourteen local complications occurred resulting in nine revision operations. The main complication was aseptic proximal pseudarthrosis (five patients); other complications included one proximal junction fracture, one clavicle fracture complicated by clavicle osteolysis, one distal junction fracture, one necrosis of the skin paddle of the fibular autograft, one glenoclavicular ossification, and one distal pseudarthrosis complicated by a fracture of this distal junction. Function, as assessed by the MSTS score, was a median of 23 of 30 (range, 11-27). The median TESS score was 82% (range, 75%-92%). Shoulder ROM (median; range) in abduction, front elevation, and external and internal rotations were 70°(30°-90°), 75°(30°-85°), 10°(0°-20°), and 80°(80°-100°), respectively. Three of the seven patients reported dissatisfaction with the cosmetic appearance.

Conclusions: The clavicula pro humero technique achieved oncologic local control after resection and reconstruction of proximal humerus tumors in children. Although union times are approximately 2 years and some patients underwent augmentation with other grafts, it eventually provides a solid, painless, biologic, and stable reconstruction and creates a mobile acromioclavicular joint and generally good function. Nonunion of the proximal junction is the main complication of this technique. We cannot directly compare this technique with other reconstruction options, and longer followup is needed, but this may be a useful reconstruction option to consider in select pediatric patients with sarcomas of the proximal humerus.

Level of evidence: Level IV, therapeutic study.

Fig. 1A–B

These intraoperative views show (A) the clavicle in anatomic position and (B) its verticalization through a lateral pivot point corresponding to the acromioclavicular joint after clavicle osteotomy on its medial third.

Fig. 2A–D

In Patient 1, the reconstruction used an induced membrane technique [19] after resection of 70% of the total length of the humerus and rotation of the clavicle. This technique needs two steps shown on these postoperative radiographs: Step 1 is filling the gap with bone cement to induce a membrane as shown on these (A) lateral and (B) AP radiographs; and Step 2 is iliac bone grafting after removal of the cement, as shown on these (C) AP and (D) lateral radiographs.

Fig. 3A–B

In Patient 3, the reconstruction used vascularized fibular autograft after resection of 60% of the total length of the humerus and rotation of the clavicle as shown on these (A) lateral and (B) AP radiographs.

Fig. 4

In Patient 8, the reconstruction did not use interposition material after resection of 7 cm of the total length of the humerus and rotation of the clavicle because the length of the clavicle was sufficient to fill the bone defect.

Fig. 5A–B

Five of our patients had aseptic proximal junction pseudarthrosis as shown on the (A) AP and (B) lateral radiographs of the shoulder for Patient 4.

Fig. 6A–B

Osteolysis of the proximal part of the rotated clavicle of Patient 1 (reconstruction by clavicula pro humero technique and the induced membrane technique) appeared at 6 months after posttraumatic fracture, as shown on these (A) AP and (B) lateral radiographs.

Fig. 7

In Patient 7 an unexpected glenoclavicular ossification occurred at 2 months after reconstruction of the proximal humerus by clavicula pro humero technique.

Fig. 8A–H

Clavicula pro humero reconstruction of the shoulder shows (A) the at-rest position, (B) active abduction, (C) forward flexion, (D) hand-to-mouth function, (E) external rotation, (F) internal rotation, (G) hand-to-contralateral shoulder position, and (H) use of a keyboard.