Endoprosthetic replacement of the proximal humerus

Endoprosthetic replacement of the proximal humerus has been performed in our unit on 25 occasions between 1950 and 1982. The indication for surgery was destruction of the proximal half of the humerus so extensive that the only alternatives were reconstruction or amputation. Of the patients with tumours two died from metastases, and three from unrelated causes; local recurrence necessitated amputation in two patients. Minor complications were frequent, but there were no deep infections and, after 1964, no prosthesis became loose. Active shoulder movement after operation was considerably limited, but passive movement was good and function of the elbow and hand were preserved.     

Endoprosthetic replacement of diaphyseal bone defects. Long-term results

We retrospectively studied 35 patients who underwent endoprosthetic reconstruction of diaphyseal bone defects after excision of primary sarcomas. The patients were treated between February 1979 and May 1999 and had more than 5 years follow-up. There were 22 males and 13 females and the median age at diagnosis was 29 (8–75) years. The bone defect measured a mean of 19 (10–27.6) cm. There were 29 femoral reconstructions, three tibial and three humeral. Cumulative overall survival for all patients was 65% at 10 years. Cumulative overall survival for prosthetic reconstruction, using revision surgery as an end point, was 63% at 10 years. Cumulative risk of failure of reconstruction, including infection, fracture, aseptic loosening, local recurrence and amputation, was 60% at 10 years. Tibial and humeral reconstructions fared less well than femoral. Endoprosthetic replacement is a useful method of reconstructing long intercalary defects, especially if situated in the femur.

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Résumé Nous avons étudié rétrospectivement 35 malades qui ont subi une reconstruction endoprothétique après excision diaphysaire dun sarcome primaire. Les malades ont été traités entre février 1979 et mai 1999 et avaient plus de 5 ans de suivi. Il y avait 22 hommes et 13 femmes et lâge médian au diagnostic était de 29 (8–75) ans. Le défaut osseux mesurait en moyenne 19 (10–27.6) cm. Il y avait 29 reconstructions fémorales, trois tibiales et trois humérales. La survie totale cumulative pour tous les malades était 65% à 10 ans. La survie totale cumulative pour la reconstruction prothétique, en utilisant la chirurgie de révision comme élément final, était de 63% à 10 ans. Le risque cumulatif déchec en incluant: linfection, la fracture, le démontage aseptique, la récidive locale et lamputation étaient de 60% à 10 ans. Les reconstructions tibiales et humérales sont allées moins bien que les fémorales. Le remplacement endoprothétique est une méthode utile pour reconstruire de longues pertes de substance intercalaires, surtout si elles sont situées sur le fémur.

     

Endoprosthetic replacement of the proximal tibia

We have performed endoprosthetic replacement after resection of tumours of the proximal tibia on 151 patients over a period of 20 years. During this period limb-salvage surgery was achieved in 88% of patients with tumours of the proximal tibia. Both the implant and the operative technique have been gradually modified in order to reduce complications. An initial rate of infection of 36% has been reduced to 12% by the use of a flap of the medial gastrocnemius, to which the divided patellar tendon is attached. Loosening and breakage of the implant have been further causes of failure. We found that the probability of further surgical procedures being required was 70% at ten years and the risk of amputation, 25%. The development of a new rotating hinge endoprosthesis may lower the incidence of mechanical problems. Limb salvage for tumours of the proximal tibia is fraught with complications, but the good functional outcome in successful cases justifies its continued use.     

Endoprosthetic replacement of the humerus and elbow joint

Between 1969 and 1985 26 patients with destructive lesions of the distal humerus were treated by endoprosthetic replacement; each implant was custom-made and incorporated part of the distal humerus or the entire bone as well as a hinged total elbow replacement. Recurrence occurred in three of the patients with tumours, and three prostheses were removed because of deep infection in patients with previously compound injuries of the elbow. Another three loosened without infection, but none needed revision or removal and no amputations resulted. Other complications included nerve palsies, but the only deaths were from metastases. A useful range of elbow movement, with a stable arm and good hand function, was achieved in every patient.     

Endoprosthetic surface replacement of the head of the humerus

The concept of an endoprosthetic surface replacement of the humeral head differs from that of stemmed endoprostheses. It is the replacement of the destroyed joint surface with reconstruction of the normal anatomy and minimal bone resection. The aim of this prospective study was to evaluate the short-term results of a newly developed cup arthroplasty (Durom-Cup) for the humeral head. In a prospective study, 39 patients with 46 Durom-Cups were evaluated preoperatively and every 3 months postoperatively. The average follow-up was 15 +/- 9 months. The group included 28 shoulders with rheumatoid arthritis, 15 joints with osteoarthritis, and 3 humeral head necroses. The Constant-score and SAS-function score were used. The Constant-score increased from 20.25 +/- 9.06 points preoperatively to 46.62 +/- 14.05 at 3 months, to 48.11 +/- 14.49 at 6 months, and to 55.25 +/- 11.6 at 9 months postoperatively. The Constant-score stayed at this level during further follow-up and was 55.81 +/- 16.31 at 12 months postoperatively. The best results were seen in the group of humeral head necroses with a Constant-score of 71.0 +/- 12.2 compared to 54.66 +/- 13.89 in the group of osteoarthritis and 56.78 +/- 13.33 in patients with rheumatoid arthritis at 12 months postoperatively. The results with the Durom-Cup are encouraging so that cup arthroplasty seems to be a good alternative to stemmed prostheses. The main advantages of the humeral head resurfacing are the bone-preserving fixation and the relatively simple surgical technique.     

Prosthetic replacement of the proximal humerus

Eighteen patients had prosthetic proximal humeral replacement with either a metal or ceramic prosthesis. Three replacements were performed for fracture nonunions, five for benign neoplasms, six for low-grade malignancies, and four for high-grade malignancies. Retention of elbow and hand function was good. In five of the 11 ceramic prostheses, failure occurred at the humeral-prosthetic junction even though it was designed for biologic fixation. Ten of 18 prostheses subluxated or dislocated. Twelve of 18 patients have had revision operations. While the revision rate in this initial series was high, valuable experience was gained for further investigations of shoulder arthroplasty.     

Endoprosthetic replacement of the distal humerus following resection of bone tumours

Between 1988 and 2006, 18 patients had a custom-made endoprosthetic replacement of the distal humerus for bone tumours at our institution. There were 11 primary malignant neoplasms, six secondary deposits, and one benign aggressive tumour. The mean follow-up was for 4.4 years (1 to 18.2). Complications occurred in nine patients and included aseptic loosening in three (16.6%), local recurrence in two (11%), infection in two (11%), neuropraxia of the radial nerve in one (5.5%) and a peri-prosthetic fracture in one (5.5%). Excision was inadequate in four patients (22%), all of which developed local recurrence and/or metastases. There were seven deaths from the primary disease after a mean of 2.3 years (1 to 5), one of whom had an above-elbow amputation for local recurrence seven months before death. The remaining six had satisfactory elbow function at their last follow-up. The 11 living patients were evaluated using the Musculoskeletal Tumour Society and Toronto Extremity Salvage scoring systems. The mean scores achieved were 76% (67% to 87%) and 73% (59% to 79%), respectively. Overall, 17 of 18 patients had significant improvement in the degree of their pain following operation. Custom-made endoprosthetic reconstruction of the elbow for bone tumours is a viable treatment in carefully selected patients. It maintains satisfactory function and provides good pain relief.     

Primary humerus head replacement in dislocated proximal humeral fracture. Indications, technique, results]

Displaced three- and four-part fractures of the humeral head detached from their blood supply are at high risk for a poor functional outcome after internal fixation. Primary prosthetic replacement can restore the pretraumatic anatomy, and early function is possible. Head replacement within 2 weeks after trauma, reapproximation of the tuberosities, and reconstruction of the rotator cuff tear establishes early stability and good functional results in up to 80%.     

Prosthetic replacement in acute fractures of the proximal humerus

The surgical treatment of selected displaced fractures of the proximal humerus with a humeral head prosthesis is a challenging procedure. Adequate knowledge of the pertinent anatomy and biomechanics of the shoulder as well as a clear roentgenographic evaluation of the displaced fracture patterns are essential. Successful prosthetic replacement requires adherence to technical factors involving soft tissue mobilization, prosthetic insertion, and tuberosity repair. Also, it is important to have a closely supervised rehabilitation program to achieve early passive motion and strengthening after fracture healing.     

特制人工肱骨头假体置换治疗成人肱骨上端骨肿瘤

目的探讨特制人工肱骨头假体置换治疗成人肱骨上端骨肿瘤的临床价值。方法对8例肱骨上端骨肿瘤患者，个体化人工肱骨假体实施置换。结果经8—51个月随访，6例患者关节功能恢复满意，2例早期发现骨关节囊有松弛倾向，术后经过6个月功能锻炼得以稳固。结论成人肱骨上端骨肿瘤，特制人工肱骨头假体置换能达到保留肢体，术后肩关节功能恢复效果较好。     

Functional results following fractures of the proximal humerus

Summary In order to compare 1 and 3 weeks of immobilization following proximal humeral fractures a prospective controlled trial was performed in 85 patients. Clinical follow-up according to the Neer assessment system was done after 1, 3, 6, 12, and 24 months. One week of immobilization resulted in a better total score due to less pain during the first 3 months. After 6 months no difference in pain, function, or mobility was found and no further recovery of shoulder function was seen after 12 and 24 months.     

Shoulder function after prosthetic replacement of proximal humerus

Between 1973 and 1985 eighteen patients with bone tumours and two patients with comminuted fractures had their proximal humerus replaced with a custom made isoelastic hemiendoprosthesis. In 1987 a clinical and radiographical review was performed of eleven patients with a mean follow up time of seven years, range 3-10 years. Four patients had pain at rest and six patients experienced severe pain on exertion. Active range of motion was poor and constituted only half of the corresponding range of passive motion. Shoulder girdle muscles were generally weak, only one patient could keep the arm straight in a flexed or abducted position. All patients had returned to their previous occupations, but their ability to perform ADL functions was poor. Rotator cuff insufficiency was considered to be the major cause of poor shoulder function. In comparison to most other surgical alternatives in tumour cases endoprosthetic replacement of the proximal humerus appears to be a safe and reliable method. The endoprosthesis gives stability to the arm and normal elbow and hand function is preserved.     

Endoprosthetic replacement for bony metastases.

A series of 38 patients with long bone metastases treated at the Birmingham Bone Tumour Treatment Service with resection of the metastatic lesion and replacement of the bone defect with an endoprosthesis was reviewed. The majority of cases had pathological fractures due to a massive destructive lesion. Two-thirds of the patients had a solitary metastasis. Metastases from hypernephroma and breast carcinoma accounted for the majority of cases. All the patients were independently mobile after the endoprosthetic replacement and were pain free. The average survival rate after the endoprosthetic replacement was 14.7 months and this varies with the primary tumour. The indications for endoprosthetic replacement for the treatment of long bone metastases are outlined and the results and complications are discussed. It is concluded that endoprosthetic replacement for bony metastases is an effective palliative procedure for a selected group of patients.     

A bioceramic endoprosthesis for the replacement of the proximal humerus

Summary In patients with malignant tumors in the region of the shoulder, radical resection can avoid amputation in most instances. To improve the function of the arm, endoprosthetic replacement of the defect is desirable.A three-component endoprosthesis made of a bioceramic material (aluminium oxide) was designed, implanted without bone cement. Fast anchorage to bone is achieved by using a conical sleeve, fixed upon the previously conically reamed humerus shaft. A stable primary fit is always feasible. Subsequent bone in-growth into grooves inside the conical sleeve provides a permanent anchorage of the endoprosthesis.The authors experiences are based on implantations of 38 endoprostheses. The original diseases were primary malignant bone tumors in 19 patients, one case of solitary plasmocytoma and metastases into the proximal humerus in 16 patients. In two women, resection was made because of posttraumatic subcapital humeral pseudarthrosis.The follow-up study includes only those 27 cases operated on at least one year ago. 12 of the 14 patients with primary tumors have been surviving for 12–55 months (range 27.4) without signs of metastases or recurrent disease. Seven patients with metastases died of their original diseases after 7.7 months on the average.Owing to extensive resection of the shoulder musculature the mobility in the shoulder joint is considerably reduced.All the patients have good movement of the elbow joint and free function of the hand.

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Zusammenfassung Bei Patienten mit malignen Tumoren in der Schulterregion kann durch radikale Resektion eine Amputation fast immer umgangen werden. Zur Funktionsverbesserung des operierten Arms ist die Implantation einer Endoprothese wünschenswert.Es wurde eine 3teilige Endoprothese aus einem biokeramischen Material (Aluminiumoxid) entwickelt, die ohne Knochenzement implantiert wird. Eine feste Verankerung im Knochen wird durch Verwendung einer konischen Hülse, die auf dem vorher konisch zugearbeiteten Oberarmschaft befestigt wird, ermöglicht. Ein stabiler Primärsitz ist immer möglich. Das späatere Einwachsen in Rillen innerhalb der konischen Hülse verankert die Endoprothese dauerhaft.Die Autoren haben bisher in 38 Fällen Endoprothesen implantiert. Als Grunderkrankung fanden sich primär maligne Knochentumoren bei 19 Patienten, 1 Patient mit solitärem Plasmozytom und Metastasen im proximalen Humerus bei 16 Patienten. Bei 2 Frauen erfolgte die Operation wegen posttraumatischer, subkapitaler Humeruspseudarthrose.Die Nachuntersuchungsstudie enthält nur jene 27 Fälle, bei denen der Beobachtungszeitraum mindestens 1 Jahr beträgt. 12 der 14 Patienten mit primär malignen Knochentumoren iiberleben derzeit zwischen 12 und 55 Monaten (durchschnittlich 27,4 Monate) ohne Anzeichen von Metastasen oder Lokalrezidiven. 7 Patienten mit Metastasen starben nach durchschnittlich 7,7 Monaten an ihrer Grunderkrankung.

     

Endoprosthetic replacement of the ankle joint

Endoprosthetic replacement of the ankle joint is considered to be a modern alternative of the well-tried fusions of the joint. We try to explain indications and limits of alloarthroplasty in comparison to arthrodesis. The recent technical evolution will be presented: starting with the two-component-("first generation") and leading to the three-component ("second generation") designs, Suitable for cemented and cementless implantation as well. Results of three-component endoprostheses in the literature and our own experiences with implants of both generations especially regarding the time of survival will be discussed. Basing on the actual knowledge, we try to deduce a prognosis of the future way of ankle replacement.     

人工半肩关节置换治疗高龄肱骨近端粉碎性骨折的临床研究

目的 探讨人工半肩关节置换治疗高龄肱骨近端粉碎性骨折的疗效.方法 2004年1月至2007年2月,对42例高龄肱骨近端Neer三、四部分骨折患者行人工半肩关节置换术,术中修复受损的肩袖.重建大、小结节,术后根据Neer康复原则进行早期功能锻炼.结果 42例患者术后获10～28个月(平均12.7个月)随访,疼痛明显缓解.肩关节功能应用ASES评分系统进行评价:优11例,良24例,可4例,差3例,优良率为83.3%.42例患者均未出现假体松动,3例术后出现肩关节假体上移,1例上举轻度受限,4例出现大、小结节吸收.结论 对于高龄肱骨近端Neer三、四部分骨折,可选择人工半肩关节置换.     

人工肱骨头置换治疗肱骨近端粉碎性骨折

目的探讨人工肱骨头置换治疗肱骨近端粉碎性骨折的疗效及技术要点。方法2001年1月至2004年6月，对21例肱骨近端四部分骨折患者行人工肱骨头置换术，男12例，女9例；年龄45-72岁，平均64．6岁。患者均于受伤后2周行人工肱骨头置换术，使用单极人工肱骨头假体骨水泥固定。68个国人肱骨近端骨标本，男36个，女32个；年龄41-58岁，平均47．9岁；均无骨性疾病。分别测量肱骨头后倾角和肱骨头最高点至大结节最高点的垂直距离。结果术后随访1．5-5年，平均3．9年。X线片显示，肱骨头假体位置均满意，2例术后假体近端周围即出现透亮带，但临床无松动迹象。16例患者无疼痛，4例偶感肩部疼痛，1例时常伴肩部疼痛。所有患者上肢肌力均基本正常，日常活动无困难。按Neer评分标准，优7例，良11例，可3例，优良率86％。评价为可的3例中，2例患者上举受限，经理疗和功能锻炼后症状无明显改善；1例患者肩部上举疼痛，服用非甾体抗炎药结合理疗后疼痛好转，对日常生活和睡眠无明显影响。无肩部感染、肩关节不稳、神经损伤等并发症。国人肱骨近端骨标本的肱骨头后倾角，左侧26．59°±1．36°，右侧26．85°±1．61°；肱骨头最高点至大结节最高点的垂直距离：左侧（6．63＋1．13）mm，右侧（6．80＋1．02）mm。结论应用人工肱骨头置换术治疗肱骨近端四部分骨折疗效满意。术中大结节和肩袖的重建是术后关节功能好坏的重要因素。将假体安放于恰当的位置（人工肱骨头的最高点至肱骨大结节最高点的垂直距离应为6-8mm，人工肱骨头的后倾角应在30°-35°）及适当的早期功能锻炼是手术成功的关键。