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Is claviculo pro humeri of value for limb salvage of pediatric proximal humerus sarcomas?
George T Calvert1, Jennifer Wright, Jayant Agarwal
1Sarcoma Services, Center for Children's Cancer Research, Huntsman Cancer Institute, University of Utah, 2000 Circle of Hope, Suite 4260, Salt Lake City, UT, 84112-5550, USA.
Insights
Clavicula pro humeri (CPH) reconstruction in young children with proximal humerus sarcoma achieved functional limb salvage in all patients. Nonunion was the main complication but was successfully treated, suggesting CPH is a viable option for reconstruction.
Area of Science:
- Orthopedic oncology
- Pediatric reconstructive surgery
Background:
- Proximal humerus reconstruction in young children after malignant tumor resection lacks a superior technique.
- Clavicula pro humeri (CPH) is a biologic reconstruction using the ipsilateral clavicle.
Purpose of the Study:
- Assess oncologic outcomes of CPH in pediatric patients (minimum 2-year follow-up).
- Identify complications associated with CPH.
- Evaluate Musculoskeletal Tumor Society (MSTS) functional scores post-CPH.
Main Methods:
- Retrospective review of four pediatric patients (average age 5y 11m) undergoing CPH for proximal humerus sarcoma resection.
- Inclusion criteria: children <10 years needing proximal humerus reconstruction.
- Data collected: demographics, diagnosis, tumor details, operative specifics, imaging, complications, functional outcomes.
Main Results:
- All patients survived with no evidence of disease at average 43-month follow-up.
- Two patients experienced nonunion, treated successfully with revision surgery.
- Excellent MSTS functional scores (87-90%) achieved with limited shoulder motion (30-90° forward elevation).
Conclusions:
- CPH provides functional limb salvage in pediatric proximal humerus reconstruction.
- Nonunion is the primary complication but is manageable.
- CPH is a reasonable option for children <10 years undergoing proximal humerus resection.
Background:
There are several options for proximal humerus reconstruction in young children after resection of a malignant tumor and no one technique has been definitively shown to be superior to others, leaving the decision to surgeon and patient choice. Claviculo pro humeri (CPH) is a biologic reconstruction of the proximal humerus using the patient's ipsilateral clavicle as a rotational osseous flap. CPH represents a potential option for this complicated clinical problem in very young children, but little is known about it because the indications for its use are so uncommon.
Questions/Purposes:
The purposes of this study were to (1) assess the oncologic outcomes of CPH at a minimum of 2 years in a small series of patients; (2) elicit the complications associated with this procedure; and (3) show the Musculoskeletal Tumor Society (MSTS) functional score of these patients.
Methods:
Four patients (average age, 5 years 11 months; range, 4 years 5 months to 8 years 9 months at the time of surgery) were treated with CPH for reconstruction after resection of a proximal humerus sarcoma; this represented all of the patients treated with this approach for this problem between January 2008 and April 2011 at one institution. During this period, the general indications for using CPH were the need to reconstruct a proximal humerus defect in a child younger than 10 years of age. During this time, CPH was used for all patients treated for proximal humerus sarcomas meeting these criteria. Patient demographics, diagnosis, tumor size and extent, operative details, radiographs and MRIs, complications, and functional outcomes were assessed.
Results:
All are alive with no evidence of disease at a minimum followup of 31 months (average, 43 months; range, 31-58 months). Two patients developed nonunion and underwent revision surgery. Osseous union and a stable neoshoulder articulation were ultimately obtained in all patients. Limited shoulder motion was the only functional deficit noted with forward elevation ranging between 30° and 90°. MSTS functional scores were excellent with a range of 87% to 90%.
Conclusions:
This is a rarely used procedure in North America but we achieved functional limb salvage in all four patients. Consistent with prior literature, nonunion was the major complication in this series. The two nonunions were successfully treated without interruption of chemotherapy or significant bone graft donor site morbidity. Based on these results, the authors suggest that this procedure is a reasonable reconstruction option to consider after proximal humerus resection in patients younger than 10 years of age. Further followup will be required to assess long-term results and to determine how this procedure compares with the alternatives.
Level Of Evidence:
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
