Limb Salvage Surgery With Joint Preservation For Malignant Humeral Bone Tumors: Operative Procedures And Clinical Application

Objective: As incessant advancement of neoadjuvant chemotherapy,surgical technique,radiation therapy,and targeted therapy,limb salvage surgery has been the mainstream of surgical treatments for humeral malignant tumors.Most humeral malignant bone tumors are located on the epiphysis and/or the metaphysis.Wide resection of the tumors often requires sacrifice of the native shoulder and elbow joints based on the basic tumor-free principle for malignant bone tumors.However,some humeral malignancies occur in the metaphysis or diaphysis,making it possible to preserve the surrounding normal joints.To date,there has not been a consistent application standard for various limb salvage operative procedures with joint preservation.A series of factors,including patient age,tumor location,tumor size,soft tissue coverage,expected functional preservation,oncological outcomes and operators’ experience,may play an important role on the surgical decision-making for diaphyseal malignancies.We retrospectively analyzed clinical records of 28 patients who had undergone joint-sparing limb salvage surgery for diaphyseal humeral malignant bone tumors at our institute.The purpose of this study is to propose a selection strategy of joint-preserving operative procedures for humeral malignant bone tumors based on patient age,tumor origin,tumor location and bone strength score.In addition,we evaluated the effective of Chinese medicine in alleviating pain and improving quality of life of patients with humeral metastases.Patients and methods: The medical data of 28 patients with humeral malignancies treated at our institute from January 2010 to December 2016 were analyzed retrospectively.There were 12 male and 16 female subjects;the average age was 51 years(range,8 – 82 years)at diagnosis.There were 7 patients with primary malignant bone tumors,17 patients with metastatic bone tumors,and 4 patients with hematological malignancies.The pain degree of the affected limb was calculated using a visual analogue scale and the patients were divided into mild,moderate and severe pain groups according to their VAS score.Based on Mirels scoring system and the invasion score for evaluating the extent of bone destruction through osteosarcoma,we made some improvements and proposed the bone strength scoring system.Modified bone strength scoring which includes five factors(pain degree,tumor location,tumor lesion,localized erosion,and longitudinal destruction),was used to evaluated the bone strength of the tumor segment.Four joint-sparing surgical methods(alcohol inactivated autograft replantation with joint preservation,in situ microwave ablation,intercalary prosthetic reconstruction and intramedullary nail or steel plate osteosynthesis with adjunctive bone cement)were performed on selected patients.Evaluation of postoperative function was based on the Musculoskeletal Tumor Society scoring system for the upper extremity.We utilized chi-square test to compare count data such as gender.Measurement data were presented as mean ± standard deviation.The measurement data were treated with normality test.Mann-Whitney U test was used to compare age difference which not conformed to normal distribution.Bone strengh score and postoperative MSTS score were in conformity with the normal distribution.Two-sample t-test was used to compare patient group data such as bone strength score and postoperative Musculoskeletal Tumor Society score.A two-tailed p-value < 0.05 was considered significant.VAS score and KPS score were used to evaluate postoperative pain and quality of life of patients with humeral metastases,respectively.Results: Limb salvage surgery with joint preservation was performed on all patients.Biological reconstruction methods included alcohol inactivated autograft replantation(AAR)with joint preservation(3)and in situ microwave ablation(MA)(10).Non-biological reconstruction methods included diaphyseal prosthetic reconstruction(9)and intramedullary nail or steel plate osteosynthesis with adjunctive bone cement(6).Regular postoperative follow-up was performed on all patients.The mean followup period for the 7 patients with primary malignancies was 45 months(range,15–66 months).One patient died due to local recurrence and lung metastasis,while the remaining 6 patients(6/7,85.7%)survived without tumor recurrence.For the 21 patients with metastatic diseases,5 survived with primary tumors,with an average survival time of 25.8 months(range,9–48 months).The rest died from progression of the primary tumors.The average bone strength score for the biological reconstruction group and non-biological reconstruction group was respectively 9.7 ± 1.3 and 12.9± 1.2.A significant difference between the 2 groups(p = 0.000)was seen.The average postoperative MSTS score of the 28 patients was 26.6 ± 1.8(range,22–30).The mean MSTS score of the biological reconstruction group and non-biological reconstruction group respectively was 26.7±1.4 and 26.1± 1.7,respectively.There was no significant difference between the 2groups(p=0.358).Non-oncological complications were encountered in 3 of the 28 patients(3/28,10.7%),and included fracture and plate breakage in one patient(3.6%),aseptic loosening in another(3.6%),and radial nerve injury in yet another(3.6%).The therapeutic effect of the group of integrated traditional and western medicine was better than the effect of using simple western medicine in relieving postoperative pain and improving quality of life(p=0.000).Conclusions: Selection of the joint-sparing limb salvage operative methods should be according to patient age,tumor nature,tumor site and bone strength score.Biological reconstruction using in vitro alcohol devitalized tumor-bearing autograft replantation is applicable for diaphyseal humeral primary malignant bone tumor with a good response to chemotherapy and a low bone strength score(≤10).In situ microwave ablation followed by plate and screw fixation is suitable for diaphyseal and(or)metaphyseal humeral low-grade malignant bone tumors or metastases with a low bone strength score(≤ 10).Intercalary prosthetic reconstruction is preferred for diaphyseal humeral metastases with incomplete cortical bone and a high bone strength score(>10).Modified Taohong Siwu Decoction can relieve pain and improve quality of life of patients with metastatic tumors.