Reprint requests: Dr R Bhaga PO Box 324 Extension Lenasia Cell:

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1 CASE REPORT SA ORTHOPAEDIC JOURNAL Spring 2009 / Pge 85 C ASE R EPORT Proximl humerl llogrft in trum setting R Bhg, MBBCh Registrr AA Aden FCS(SA)Orth Senior Consultnt Deprtment of Orthopedics, University of Witwtersrnd, Helen Joseph Hospitl, Johnnesurg, South Afric Reprint requests: Dr R Bhg PO Box 324 Extension Lensi Emil: rvihg@hotmil.com Cell: Astrct Proximl humerl llogrfts re usully reserved for reconstruction of the shoulder in neoplstic setting. To our knowledge it hs never een descried for use in trum setting. In this cse report, we present 30-yer-old mn involved in motor vehicle ccident (MVA) in He is right-hnd dominnt nd employed s driver. He presented initilly to peripherl hospitl, nd he sustined wht seems to e right floting shoulder injury with clvicle, scpul nd proximl humerl frctures. He ws operted there nd underwent excision of the proximl humerus. Susequently he presented to us nd stged procedure ws performed. Initilly, the clvicle ws plted nd, six weeks lter, he underwent reconstruction with proximl humerl llogrft. All rottor cuff muscles were re-ttched nd the llogrft ws secured with cement nd n intrmedullry nil. We present his pre-op nd post-op pictures s well s the function chieved. We lso present rief review of the literture. Introduction Proximl humerl llogrft reconstruction is procedure in which cdver humerus is shped nd used to replce pre-existing defect in ptient. It is reserved for ptients who hve intr-rticulr pthology of the gleno-humerl joint nd where the glenoid is still preserved. There hve een severl pulictions on its outcomes in ptients undergoing this procedure for tumour reconstruction in lim-spring surgery. However from our extensive literture serch it hs never een descried in trum setting. This is minly ecuse the need for humerl llogrft in trum is such rre occurrence. Modern prostheses nd implnts usully suffice for most frctures. Proximl humerl llogrft reconstruction is procedure in which cdver humerus is shped nd used to replce pre-existing defect in ptient SAOA poster wrd, Congress 2008, 2 nd prize

2 Pge 86 / SA ORTHOPAEDIC JOURNAL Spring 2009 CASE REPORT Figure 1: AP view of defect following initil surgery t peripherl centre Figure 4: Fresh frozen humerl llogrft Figure 2: Lterl view of ptient s shoulder Figure 3&: MRI scn of shoulder showing intct rottor cuff Figure 5: Humerl hed showing preserved rottor cuff ttchments He hd sustined proximl humerl shft frcture, mid-shft clvicle frcture nd minimlly displced frcture of the glenoid neck Cse report A 30-yer-old mle who is righthnd dominnt nd employed s driver ws involved in motor vehicle ccident (MVA) in June He ws initilly tken to peripherl hospitl for tretment. Among other injuries he lso sustined wht seemed to e floting shoulder on the right side. He hd sustined proximl humerl shft frcture, mid-shft clvicle frcture nd minimlly displced frcture of the glenoid neck (Figures 1 nd 2). He could not give us n indiction s to why he hd to undergo proximl humerl resection t the peripherl hospitl. He susequently presented to Helen Joseph Hospitl in Decemer 2007 with pinless flil right upper lim. He ws unle to use the rm in ny ctivity of work or dily living. Cliniclly, it did not seem tht he hd rchil plexus injury s ll nerves were ssessed s functionl except the suprscpulr nerve tht does not hve peripherl sensory component. Prt of the pre-opertive plnning included n MRI scn to ssess the integrity of the rottor cuff (Figure 3). The MRI reveled the infrspintus nd suscpulris folded in on the glenoid. The rottor cuff ws remrkly preserved. His deltoid lso seemed preserved. EMG/nerve conduction study ws not considered ecuse of the norml findings in the clinicl exmintion. A decision to do stged procedure ws mde. Initilly he underwent n open reduction nd internl fixtion of his clvicle with sixhole locking plte. After n uneventful procedure he returned in Ferury 2008 for the second stge of the procedure which involved the reconstruction of his proximl humerus. A requisition for fresh frozen full cdver humerus ws mde (Figure 4). The donor humerus hd to mtch the pproximte size of our ptient nd hd to e rightsided humerus.

3 CASE REPORT SA ORTHOPAEDIC JOURNAL Spring 2009 / Pge 87 Figure 6: Ptient supine with previous surgicl incision Figure 7: Humerl llogrft shped to mtch defect Figure 9: Rottor cuff re-ttched Figure 10: Allogrft in plce Figure 8: Allogrft in plce with cement nd n intrmedullry nil with spirl lde It ws lso impertive tht the llogrft would e supplied with the rottor cuff ttchments to fcilitte rettchment (Figure 5). The ptient ws positioned supine nd drped. The previous surgicl incision ws used (Figure 6). Therefter, the delto-pectorl intervl ws identified. Intr-opertively, the individul rottor cuff muscles were identified nd isolted with non-sorle sutures. The defect of the humerus ws identified nd the humerl llogrft ws then shped ccording to this defect to fit in with the humerl shft (Figure 7). The llogrft ws secured to the humerl shft with cement nd n intrmedullry nil. The nil extended through the entire medullry cnl. In ddition, spirl lde which locked into the nil, ws pssed through the humerl hed (Figure 8). It ws importnt to otin the correct version of the donor humerl hed to the recipient humerl shft. The rottor cuff muscles were re-ttched using nonsorle sutures (Figures 9 nd 10). The rottor cuff nd cpsule were rettched in position of 30 of externl rottion. The proportionl cover of the hed of humerl llogrft y the donor nd recipient tendons ws in fvour of the ltter. The deltoid ws preserved nd the skin pproximted. A drin ws plced for period of 24 hours nd the ptient immoilised in sling post-opertively. Immedite post-opertive rdiogrphs were stisfctory (Figure 8). The ptient mde n uneventful recovery with no immedite complictions. He ws dischrged on rehilittion progrmme to strengthen the rottor cuff nd deltoid. At the six-week follow-up he presented with some superficil wound sepsis which ws treted with iodine dressings. At the six-month follow-up (Figures 11 nd 12) the ptient ws very stisfied with the procedure nd his rnge of movement. He ws le to chieve 30 of externl rottion, 30 of forwrd elevtion nd 10 of duction (Figure 12).

4 Pge 88 / SA ORTHOPAEDIC JOURNAL Spring 2009 CASE REPORT Figure 11&: AP nd lterl view of shoulder t six months following surgery Figure 12&: Post-opertive rnge of movement t six months This limited rnge of ctive movement indictes wek rottor cuff muscles, nd the ptient ws encourged to continue rehilittion. He ws unle to return to his pre-morid level of ctivity ut hd etter outcome compred to fter his first surgicl procedure. Discussion Proximl humerl llogrft reconstruction is very chllenging procedure. The min ims of this procedure re to replce the rticulr surfce, to retin sufficient muscle to e le to position the rm in spce nd to restore length of the rm. 1 Restortion of length is lso importnt to enle the upper lim muscles round the shoulder to function t the correct tension. It is lso vitl to improve shoulder function s well s to preserve elow nd hnd function. 2 Another chllenge to the surgeon is to otin correct version of the prosthesis nd tension on the rottor cuff to restore internl nd externl rottion to functionl rnge. Alterntives for ptients with proximl humerl defects include the use of prosthesis. 3-5 However, this prosthesis hs to e custom-mde to compenste for the defect of the proximl humerl shft. With prosthesis there is risk of The min ims re to replce the rticulr surfce, to retin sufficient muscle to e le to position the rm in spce nd to restore length of the rm stress shielding t the humerlprosthesis interfce, 3 nd there re no ntomicl ttchment sites for the rottor cuff. 4,5 These ttchments provide for greter stility nd restortion of function. Also the llogrft provides for more nturl nd ntomicl fitment. 4 There is lso the question of longevity of prosthesis especilly if used in young ptient. 1 Another lterntive is to perform n rthrodesis of the shoulder. 1,3,5 With the rthrodesis either n utogrft or llogrft is still required to compenste for the osseous defect. A vsculrised or free fiulr grft is used nd this is ssocited with ll the moridities relted to the donor site, e.g. peronel nerve dmge. The fiul, long with its proximl rticulr crtilge, cn lso e used to recrete n rticulr surfce; however the rnge of movement chieved is unstisfctory. 1 A fiulr llogrft cn lso e used ut this crries the sme risks nd side effects of proximl humerl osteorticulr llogrft. 1 There is lso n inherent high risk of frcture of these fiul grfts even though n utogrft hs etter chnce of eing incorported. The movement in ptients with n rthrodesis then shifts from gleno-humerl rticultion to the scpulothorcic one. O Connor et l in their cse series found tht these ptients hd superior rnge of movement compred to ptients undergoing proximl humerl replcement with prosthesis or spcer. 3 A spcer cn lso e used ut these ptients do not regin shoulder function. 3 The osteorticulr llogrft with ttched tendons however cn lso hve numer of complictions. These include the risk of disese trnsmission, nonunion nd one resorption. 4 The llogrft is lso t risk for frcture nd it is preferle to use fixtion tht spns the entire length of the one. 1 Furthermore, the recipient tendons might not hel to the donor tendons s the lood supply of the one ed where the tendons re ttched is precrious. There is lso high rte of infections in these ptients. 1 There is usully n initil host response to the grft, which wlls off the grft nd cretes ded spce which forms nidus for cteri. Other fctors which ply role re tht usully these procedures re long nd involve extensive dissection which could predispose to infection. 1

5 CASE REPORT SA ORTHOPAEDIC JOURNAL Spring 2009 / Pge 89 Another compliction tht ws noted in the literture is high rte of suchondrl frcture nd collpse. O Connor et l hve suggested n llogrft-prosthesis composite. 3,5 There my e more literture produced on this in the future. However it is vitl to reiterte tht ll of this work hs come from ptients with tumour reconstruction who re very different from trum ptients. The min im in tumour ptients is to ensure tht ll pthologicl tissue is removed. Trum ptients hve higher functionl demnd nd different expecttions. Conclusion Although this type of humerl frcture is rre occurrence, it is still wise for the trum surgeon to consider n osteorticulr llogrft s n option in ptient with mssive one loss injuries. References 1. Gehrdt MC, Roth YF, Mnkin HJ. Osteorticulr llogrfts for reconstruction in the proximl prt of the humerus fter excision of musculoskeletl tumor. J Bone Joint Surg Am 1990;72: Rödel RW, Gosheger G, Geert C, Lindner N, Ozki T, Winkelmnn W. Reconstruction of the proximl humerus fter wide resection of tumours. J Bone Joint Surg Br 2002:84-B: O Connor MI, Sim FH, Cho EYS. Lim slvge for neoplsms of the shoulder girdle Intermedite reconstructive nd functionl results. J Bone Joint Surg Am Decemer 1996;78-A(12): Borjin A, Nzem K, Yssine H. Complictions of mssive llogrfts reconstruction for one tumors. J Reserch in Medicl Sciences July & Aug 2006;.11(4): Getty P, Peody T. Complictions nd functionl outcomes of reconstruction with n osteorticulr llogrft fter intr-rticulr resection of the proximl spect of the humerus. J Bone Joint Surg Am August 1999;81- A(8): SAOJ Chr Pulictions wishes ll delegtes nd memers of the trde ttending the 55 th SAOA Congress richly rewrding experience nd n opportunity to mke nd strengthen links with their orthopedic collegues.