ELBOW RECONSTRUCTION FOR

DISTAL HUMERUS OSTEOSARCOMA

BY USING EXTRACORPOREAL
IRRADIATION AUTOGRAFT
( TWO CASE REPORTS )

Yanuarso, A Fauzi K, Errol Untung Hutagalung

Division of Orthopaedic and Traumatology

Faculty of Medicine
University of Indonesia

• Malignant bone tumors are rare lesions :

– RSCM →1,3% of all the cancer load
(Errol UH, unpublished data, 2006)
– Mayo Clinic → 1-2%
• Osteosarcoma → the 2nd common
malignant bone tumors after multiple
myeloma Æ19%
Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143-
pp.143-95

1
• Before 1970s → the routine management
was amputations or disarticulation
→ survival rate 10-20%

• Limb salvage surgery → combination of :

– Effective chemotherapies
– Precision imaging techniques
Æ designed
g to accomplish
p removal of a
malignant tumor and reconstruction of the
limb with an acceptable oncologic,
functional, and cosmetic result
J Am Acad Orthop Surg 2003;11:25-
2003;11:25-37.

FIRST CASE
A girl, 22 yo
• History of a lump in the left distal humerus
that was getting bigger since 6 months ago
• The pain and loss of function were present
• There was no trauma

2
 Local status
Mass :
• 26 cm in circumferential
length
g ((20 cm in the
health tissue)
• Firm, tenderness, fixed
with ill-defined margin

Laboratory
• CBC : normal
• ESR : 29mm/h
• SAP : 161 u/l (40 – 150)
• LDH : 303 u/m (230–460)

Left elbow AP and lateral X-ray (January 2006) :

- Blastic and lytic lesions in the left distal humerus
- Periosteal reaction and soft tissue swelling

3
 After neoadjuvant chemotherapy
→ tumor became more sclerotic & solid

Chest X-Ray : no evidence of metastatic feature

Bone scintigraphy : increased uptake only at the left elbow
→ Neither showed no evidence of metastatic disease

4
 CT scan :
- Lytic-sclerotic lesion with irregular margin
- Thickening of cortex and periosteal
- New bone formation and good medullary cavity

Cytology examination :
Spindle cells, pleomorphic with osteoid positif

5
Clinico Pathological Conference (CPC)
• Diagnosed as conventional osteosarcoma
Æ neoadjuvant chemotherapy
• Planned for limb salvage surgery using an
extracorporeal irradiation of distal humerus

Limb Salvage Surgery

First Stage :
• Resection of the half distal
humerus that contain tumor
mass → Pathology Anatomy
Department
• Osteotomy of olecranon
• Conservation of n.radial,
n.ulnar & muscle groups,
except the part of the triceps &
brachialis attached to the
tumor mass
• The resected humerus was
sent to BATAN for irradiation
with dose 30,000 rads

6
 Second Stage :
• Reconstruction of the half
distal humerus with plate and
screw
• Olecranon fixation with TBW
• Sutured common flexor &
extensor origins to the
original sites

• Histological examination of the surgical specimen :

So much residual viable tumor cells and the tumor
classified as unresponder to the induction
chemotherapeutic agents (HUVOS 1)
• After surgery → patient was planned to received
adjuvant chemotherapy consisting of another agents

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 SECOND CASE
Woman, 30 yo
• History of recurrent lump at left distal humerus
th t was getting
that tti bigger
bi since
i 2 years ago

9 years ago 2 years ago 4 months b.a

(1997) (April 2004)

• a lump arised at • tumor was • after first

posterior distal excised operation a
portion of left lump arised
shaft humerus again at the
same site

Local Status :
Mass :
• 32 cm in circumferential
length (23 cm in the health
tissue)
• Firm, tenderness, fixed with ill-
defined margin
• No venectation

Laboratory
• CBC : normal
• ESR 30 mm/h
• SAP 192 u/l (40–150)
• LDH : 165 u/m (230–460)

8
X-ray of left elbow AP and lateral views (May 2006) :
→ heavily mineralized mass attached by broad base to the
posterior aspect of left distal humerus and soft tissue swelling

• Chest X-Ray : no evidence of metastatic feature

• Bone scintigraphy : inceased uptake only at the left
elbow
→ No evidence of metastatic disease

9
 Review slide from first operation :
Spindle cells, minimal cytologic atypia
and rare mitotic figure, osteoid positif

Clinico Pathological Conference (CPC)

• Diagnosed
Di d as reccurrentt parosteal
t l
osteosarcoma
• Planned to limb salvage procedure
using extra corporeal irradiation
autograft
f
• Death : Nov 2007

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Limb Salvage Surgery

First Stage :
• Resection of the half distal
humerus and excision of the
tumor mass → sent to
Pathology Anatomy Dep.
• Resected humerus → BATAN
for irradiation 30,000 rads

Second Stage :
• Reconstruction of the half
distal humerus and elbow
byy fixed them into the
proximal shaft with plate
and screw
• Olecranon was fixed with
the tension band wire
• Common flexor and
extensor origins were
sutered again to the
original sites
• Radiohumeral joint was
fixed with the K wire for
temporary

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 Post-operative X rays :
Humeral shaft fixed with plate
and screw and olecranon fixed
with TBW

• Primary malignant bone tumors → rare

lesions
• Before 1970s → routine management was
consisted of transbone amputations or
disarticulation
→ dismal survival rate 10-20%
Dahlin’s bone tumors general aspects and data on 11,087 cases.1996. pp.143-
pp.143-95.
J Am Acad Orthop Surg 2003;11:25-
2003;11:25-37.

12
 Development of :
• Effective chemotherapeutic agents
• CT and MRI
Ð
Allow precise visualization of the anatomic
location of tumor and surrounding
structures
Ð
Better patient selection for spesific treatment
of limb salvage procedure
J Am Acad Orthop Surg 2003;11:25-
2003;11:25-37.

Consideration of Limb Salvage Procedure :

1. An upper extremity tumor → needs
resection of the articular portion of the
distal humerus or proximal ulna
2. Disfunction of the elbow, wrist, and hand
→ due to abundant of neurovascular
structures in this location
3. Psychological problem associated with
tradition and aesthetic
J Bone Joint Surg [Br] 1996;78
1996;78--B:652
B:652--57.

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 Limb Salvage Surgery

First Stage : Second Stage :

• Resection
R ti off th
the h
halflf di
distal
t l • Reconstruction
R t ti off ththe
humerus that contain half distal humerus with
tumor plate & screw
• Osteotomy of olecranon, • Fixation of the olecranon
• Conservation of nervus & with TBW
muscle groups, except the • Sutured the common
muscle attached to the flexor and extensor
tumor
tumor. origins to the original
• The resected humerus sites
sent to BATAN for • Radiohumeral joint was
irradiation with dose fixed with the K wire for
30,000 rads temporary

Result

I. Conventional II. Parosteal osteosarcoma

osteosarcoma Ð
Ð
1. Limb salvage surgery
1 Neoadjuvant
1. N dj t directly
chemotherapy
2. Limb salvage surgery 2. No chemotherapy before
3. Evaluation of neoadjuvant Ð
chemotherapy agents Result :
revealed to unresponder ROM of elbow joint 30-90°
group (HUVOS I) Æ change
to another chemotherapy Ð
g
agents Follow-up
Follow up :
Ð Elbow joint function
Result in 1st mo :
ROM of elbow joint 35-75°
Ð
Follow-up :
Elbow joint function

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• The management of malignant bone
tumors still presents many challenge
• Advances in imaging, chemotherapy and
reconstructive surgery can offered limb
sparing surgery
• Functional outcome and patient
satisfaction appear to be at least as good,
and probably better after reconstruction
than after ablation

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