Arthrodèse d’épaule avec fibula vascularisée après résection tumorale de l’extrémité supérieure de l’humérus: Shoulder arthrodesis with vascularized fibular graft after tumor resection of the proximal humerus

Abstract

Purpose of the study Resection of malignant tumors of the proximal humerus often requires dissection of the rotator cuffs and the deltoid muscle. There is no consensus on the ideal method for shoulder reconstruction. We report the functional outcome in a homogeneous series of eight patients treated by arthrodesis using a vascularized free fibular flap. Material and methods Eight patients were included in this study. All had an aggressive tumor of the upper humerus. Tumor resection was associated with a rotator cuff and deltoid muscle resection in all patients. All patients then underwent shoulder arthrodesis using a free vascularized fibular flap fixed with a plate. Clinical and radiological evaluation was available for six patients at mean 28 months. The Musculoskeletal Tumor Society function score was used to assess overall function of the upper limb. The cosmetic outcome and radiographic bone healing as well as hypertrophy of the fibular graft were noted. Results Active abduction and active flexion were 82° on average. All patients could bring their hand to the mouth. Circumduction was possible but limited in amplitude. The mean function score was 26.5/30 with an excellent functional outcome in all patients. The cosmetic outcome was considered poor by all patients. Radiographically, bone healing was achieved at last follow-up in all patients but there was one case of failed fusion between the fibular graft and the scapula which required secondary iliac grafting. Mean fibular graft hypertrophy was 32.8% at last follow-up. Discussion and conclusion Two reconstruction methods have been described for patients who require tumor resection of the upper humerus: reconstruction with preservation of glenohumeral joint function and shoulder arthrodesis. Many techniques have been described for each method. It is however difficult to compare the different series reported in the literature because rotator cuff and deltoid muscle resection was not systematically performed and reconstruction methods varied between patients. An analysis of the literature shows that preservation of motion of the scapular glenoid joint can give good functional results when the rotator cuff and deltoid muscle can be preserved. If they cannot, results favor shoulder arthrodesis which provides the patient with very satisfactory upper limb function. Use of a vascularized fibular flap has provided very good arthrodesis results. The patient must however be informed of the probable poor final cosmetic result.