Cemented-augmented fixation of metastatic humeral lesions without segmental bone loss results in reliable outcomes

Abstract

Background: Treatment of metastatic lesions to the humerus is dependent on patient's pain, lesion size and location, and post-operative functional goals. Surgical options include plate or nail fixation [open reduction internal fixation (ORIF)], or endoprosthetic replacement (EPR), with cement augmentation. The objective of this study was to perform a single institution retrospective analysis of outcomes by method of reconstruction, tumor volume, and pathologic diagnosis.

Methods: The records of 229 consecutive patients treated surgically for appendicular metastatic disease from 2005-2018 at our musculoskeletal oncology center were retrospectively reviewed following institutional review board (IRB) approval. Indications for surgical treatment at the humerus included patients who presented with impending and displaced pathologic fractures.

Results: Sixty patients (34 male, 26 female) with a mean age of 62.9±12.2 were identified who were treated surgically at the proximal (n=21), diaphyseal (n=29), or distal (n=10) humerus. Forty-nine (82%) patients presented with displaced pathologic fractures. The remaining eleven patients had a mean Mirels score of 9.5. There was no difference in overall complication rate between EPR or ORIF [4/36 (11%) versus 2/24 (8%); P=0.725]. Mean Musculoskeletal Tumor Society (MSTS) scores were 83% for both EPR and ORIF, with no differences in subgroup analyses at the proximal, diaphyseal, or distal humerus. Patients with cortical destruction on anterior posterior (AP) and lateral imaging were at increased risk for mechanical failure [2/6 (33%) versus 0/18 (0%), P=0.015].

Conclusions: In conclusion, when pathologic pattern permits, cement-augmented fixation allows for stabilization of pathologic bone, while minimizing risk of soft-tissue detachment, while EPR resulted in similar outcomes in patients with more extensive bone destruction. Increased tumor volume was associated with lower MSTS scores.

Keywords: Metastatic disease; bone tumors; humerus; upper extremity.

Figure 1

A 58-year-old male with a pathologic fracture secondary to Multiple Myeloma, with retained bone stock at humeral head. Treated with curettage, cementation, and plate fixation. Immediate post-operative and 1-year post-operative X-rays shown. Note placement of screws in cement to enhance construct strength.

Figure 2

A 66-year-old male with functional pain due to solitary renal cell carcinoma (RCC) lesion. Embolization of vascular tumors such as RCC is recommended to help with hemostasis. Immediate post-operative and 8 years post-op imaging showed following hemiarthroplasty. Despite some proximal migration and pseudo-acetabularization of the shoulder joint, the patient retained a Musculoskeletal Tumor Society (MSTS) functional outcome score of 80%.

Figure 3

A 65-year-old male with renal cell carcinoma (RCC), treated with plate fixation. In these cases, effort was made to maximize the strength of this load bearing construct by filling all screw holes. Immediate post-operative and 3-year post-operative imaging shown.

Figure 4

A 63-year-old male with renal cell carcinoma. X-ray and CT imaging show segmental destruction of bone and a lesion spanning 13 cm of bone. This patient also underwent ORIF of an impending pathologic femur fracture and was made weightbearing as tolerated immediately post operatively. Immediate and 1-year post-operative imaging shown.

Figure 5

An 80-year-old female with metastatic colon cancer at the distal humerus. X-rays and CT show bi-columnar involvement prior to fixation with 90-90 plating.

Figure 6

A 62-year-old female with metastatic breast cancer at the diaphyseal and distal humerus, who underwent resection and distal humeral replacement. Immediate and 18-month follow-up imaging shown.

Figure 7

A 58-year-old male with metastatic renal cell carcinoma (RCC), initially treated with an intramedullary nailing and referred to our institution with severe bone loss and loss of fixation and stability proximally. Limb salvage was attempted with a proximal humeral replacement.